Terrible clinical day, nurses don't seem to care.

AlabamaBelle · Apr 27, 2009

I haven't read all the posts, but here's my 0.02:

I work in Peds ICU. We have been able to reduce the use of restraints, but we still have to use them. Toddlers just don't get that that ETT, a-line, cvl, NDT, and various assorted other invasive lines are necessary to getting well. Neither does that teen who took a bad hit to the head is delirious and defies max sedation settings. And if the child/teen is on ECMO, those two big honking metal cannulas are mighty necessary to life. Some of our neuro kids can't be sedated because the meds do cloud the neuro exam.

And then there are those people that no matter how many times you explain/re-orient them, they can't retain that information. My patient yesterday was begging to have his NGT out, but because he still didn't have optimal neurological function and possible difficulty with swallowing. I explained and explained to him the reasons, as did the MDs, but he still begged to have it out.

There's nothing like having to wake your attending in the wee hours of the morning to let him/her know that the patient pulled the ETT and needs to be re-tubed.

And now, we face budgetary constraints. I love having and teaching students in our unit, but those "3 minute" explanations pile up over the course of the day. You won't see it, but I'll be there at least an hour after my shift to get my charting done. As of May 3, our staff will have to justify why we're there after our 12 hour shift is completed. If we don't fill out the form, we won't get paid that extra time.

I'm 4 years out of school (I was an older student), so I still remember the "ideal" world we got in school. Reality is so much different. I strive every day to be a caring nurse, and from patient/family feedback, I am succeeding. I saw a lot in CNA training and clinicals that disturbed me, but now make sense.

Yes, we also use "gallows" or some inappropriate humor. We are surviving in a difficult setting. The humor is more therapeutic than crying (I also look better laughing than crying).

My mother is a terminal cancer patient. I can assure you that she's never going to be left alone in a hospital. All 3 of her daughters are nurses as well as 1 granddaughter. No restraints will be used because we will be at her bedside. I'm afraide we may be "one of those families" the nurses may not like!

Try to keep your caring attitude!

leslie :-D · Apr 27, 2009

i think the fact that this particular student was making an effort to spend extra time with the patient and make her more comfortable would certainly give her legitimate access to the chart.

do you?

i'm still not seeing "a need to know" situation, that would justify her using the chart.

leslie

**canoehead, BSN, RN** · Apr 27, 2009

I think that if she is providing care/comfort (reorienting, repositioning) then she needs to know dietary status, possible reasons for the confusion, contraindications for various physical positioning.

I know she could ask the assigned nurse, which would remove the NEED to see the chart, but so could every onther health professional, and everyone asking the nurse is not common or sensible practice. If she looked up fluid status and found the woman was merely fluid restricted she could intervene differently as opposed to NPO. If there was a procedure coming up, and then the NPO status was going to be lifted repeating that information to the patient might help.

Those are just examples.

Rascal1 · Apr 28, 2009

I think that if she is providing care/comfort (reorienting, repositioning) then she needs to know dietary status, possible reasons for the confusion, contraindications for various physical positioning.
I know she could ask the assigned nurse, which would remove the NEED to see the chart, but so could every onther health professional, and everyone asking the nurse is not common or sensible practice. If she looked up fluid status and found the woman was merely fluid restricted she could intervene differently as opposed to NPO. If there was a procedure coming up, and then the NPO status was going to be lifted repeating that information to the patient might help.
Those are just examples.

Wow, thank you that is well put. In addition, because we live in a constant flux of change,I personally would direct the student to please check the chart for any possible changes. I can still hear my/our instructors asking us (back in the dinosaur days), "Did you check the chart?" ...

talaxandra · Apr 28, 2009

I love having and teaching students in our unit, but those "3 minute" explanations pile up over the course of the day.

Exactly! It's time consuming enough explaining everything to the students you're working with, let alone a random student who happens to be passing by one of your patients (however well intentioned, compassionate and concerned s/he might be).

One of the problems is that the less experience you have the less aware you are of the totality of what's going on, meaning that you can see the confused, thirsty, distressed but safe patient and not see that the nurse caring for that patient also has three active fires that need putting out. I often have periods where I just don't have the literally three minutes needed to explain something, particularly to someone who I don't think has a need to know.

I think that if she is providing care/comfort (reorienting, repositioning) then she needs to know dietary status, possible reasons for the confusion, contraindications for various physical positioning.

She was walking past the room and went in because the patient seemed distressed. A cleaner can reorientate ("you're in the hospital, dear"), a visiting neighbour can ask about dietary status ("Mrs Brown wants a glass of water, nurse"), but they don't get access to the history, and I don't think the OP does in this case, either. If I hear an IV alarming and investigate that doesn't give me enough status to access the file. If I put a flush through, hang a new flask, turn it off, or suspect it's infiltrated I might be able to look at the relevant chart but still don't have grounds to access the history. If I have a question ("is there fluid running or just a med?"), or need to relay information ("the IV tissued and needs to be resited") I talk to the nurse caring for the patient, who does have legitimate access.

"Every other health professional" involved with the patient's care has a legitimate reason to look at the history. A student allocated other patients, who happens to pass by and is (entirely benevolently) concerned does not.

nursemike, ASN, RN · Apr 28, 2009

We were told very clearly that we can not look at the chart of patients who are not ours. We were told it was a HIPAA violation.

Regardless of what any of us think, the student is prudent to follow the instructions of the instructor and the facility hosting the clinical experience. And really, since the patient was not assigned to the student, the student's scope of practice is that of any stranger off the street. Listen and nod sympatheticly, sure. Much more than that, call the assigned caregiver.

wooh, BSN, RN · Apr 28, 2009

I can still hear my/our instructors asking us (back in the dinosaur days), "Did you check the chart?" ...

Yes, on the patients that were assigned to us, not random patients on the floor.

cherrybreeze, ADN, RN · Apr 28, 2009

a nursing student, because they are "more caring" (cough) than someone else and therefore on their own deciding to spend more time in that room with that patient than what they have to, or with their own assigned patient (whose chart they can read) does not mean they have a right to nose around in their record. the op basically became a visitor in that room, based on her role, and her own patient assignment. until her clinical instructor or a nurse on staff at that facility decided that she was a part of the team taking care of that patient, it wasn't any of her business, whether or not she chose to make it so on her own. her assumption of the situation was that her presence was necessary. she isn't in a position to make that decision. i'm not saying it was bad of her to want to spend time with a patient, that part is great. however, if you want to talk about the rules and regulations, she still did not have the right to access this patient's medical info. look at it another way ~ a "sitter" (and it varies of course by facility, some places have this as an actual position, and they are minimally trained; they often are not even cna's) would not be able to, either, even though they are involved in patient care, because they are not trained to interpret that information.

i hope my medical records don't end up near people that think this way. in your way of thinking, anyone that "cares enough" about my condition has a right to find out about it, and they simply do not.

cherrybreeze, ADN, RN · Apr 28, 2009

I hope I didn't seem to imply that I think hideously inappropriate remarks among nurses are always a bad thing. What happens in the Med Room stays in the Med Room, and in moderation gallows humor and even a little venting can be a way of defusing the negative feelings we're bound to have, from time to time. But I think we're in general agreement that a little goes a long way.

I think we are in general agreement, yes. :)

NO doubt that there will be the nurse that takes that humor a bit too far, or doesn't have the ability to reign it back in when appropriate. That's the tough part.

I only wanted to convey the other side, since I hate to think that at some point, in passing, I may have made such a remark and had it taken the wrong way, KWIM? I care very much for the people that I take care of, and it bothers me to think that someone may misread the humor my colleagues and I use as NOT caring. The two are certainly not mutually exclusive (and at this point I'm just talking, nursemike, it's obvious that it's a point you understand :specs: ).

nursemike, ASN, RN · Apr 28, 2009

I think we are in general agreement, yes. :)
NO doubt that there will be the nurse that takes that humor a bit too far, or doesn't have the ability to reign it back in when appropriate. That's the tough part.
I only wanted to convey the other side, since I hate to think that at some point, in passing, I may have made such a remark and had it taken the wrong way, KWIM? I care very much for the people that I take care of, and it bothers me to think that someone may misread the humor my colleagues and I use as NOT caring. The two are certainly not mutually exclusive (and at this point I'm just talking, nursemike, it's obvious that it's a point you understand ).

I actually have been caught crossing the line from tongue-in-cheek to foot-in-mouth, and I gotta admit, I've never really regretted the remark I didn't make. Well, not nearly as much, anyway.

nursemike, ASN, RN · Apr 28, 2009

Early in my med-surg clinicals, I had a patient who was probably terminal and very anxious to talk to someone. I think my tasks for the day were assessment and ADLs. I'm not sure we were even passing meds, yet. He had a number of concerns, and told me about them at such length that it was almost all I could do to get him assessed. As my clinical time was nearing an end, his staff nurse came in, and she asked, rather pointedly, rather giving a bath wasn't part of my duties for the day. By then, of course, I was out of time, but I took the point that I was going to need to learn how to get my work done while I listened.

Later, after post-conference, I was kneeling at the nurses' station, gathering info for my careplan, when the same nurse noticed me kneeling next to her and asked if I was about to propose to her. I told her I was begging forgiveness for not getting my bath done, then told her how he'd kept saying that I was the only one who cared enough to listen to him and yada,yada,yada, and she said, "Yeah, he's right about that." I didn't interpret her to mean that she really didn't care. I believe she meant that she'd already heard it several times and couldn't spend a couple of hours a day listening again. Then both she and another nurse who was nearby agreed that there were times when there were more important things than smelling bad for a day. Next time I had him, he got his bath.

It was embarrassing, at the time, but I learned some good things, that day. As a working nurse, I have more than one patient, and lots of tasks that have to be done, more than a few of which may be life-sustaining. On the other hand, there are still times when the most important intervention I can do is to pull up a chair and just listen. Balancing all my patients' various needs is a continuous challenge, and I still end up charting an hour past my shift once in awhile because of that, but I'm learning every day how to prioritize my care. Part of that, I have to admit, is setting firmer limits than I did as a student, even though that can feel a little hard-hearted, at times. Real-life nursing isn't all flowers and rainbows. On the other hand, it can be very satisfying when you can look back on a shift where you've saved a life, kept someone else's pain under reasonable control, cheered some else up a little, and fluffed a couple of pillows, and you're only twenty minutes late getting out. It isn't how I imagined it would be when I was a first-year student, but in some ways, it can be much better. I wish the OP much success in finding that balance. For me, after almost four years as a nurse, it remains a work in progress, but I see the best nurses I know dealing with some of the same challenges, and I tell myself that when I've been a nurse for twenty years, I'll be as good at it as they are. Of course, I'll be 68, by then. I fear that may slow me down, a little...

nerdtonurse?, BSN, RN · Apr 28, 2009

I look at it this way -- if I'm going to touch you, I'm going to look at your chart (who knows if the person who had them before had put up the NPO sign, or if the pt took off their DNR bracelet). Moreover, at night, I make sure I know the DNR status of everyone on my hall, whether they are my pt or not. I hear the telemetry tech yell, "Asystole 238!" That's not the time to go find a chart. And providing patient care IS allowable under HIPAA. That's my hospital, that's my hall, and anybody on that floor can become my patient in an emergency.

Yes, HIPAA is the 800 pound gorilla in the room. However, a lot of bosses beat folks over the head with things the law doesn't actually cover. if you read the actual law http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/adminsimpregtext.pdf

164.514 states that health information is not covered as protected information IF the following data is not released:

No names of pt or family members

No address

No employer

Any geographic information smaller than the state

Location of treatment

Type of treatment or disease

Any date -- birthday, admission, etc., -- EXCEPT IF THE PT'S OVER 90 - then you can say how old they are.

Picture, fingerprint "biometric identifiers"

SS#, any insurance number, license number including professional licenses, driver's licensing, etc., IP addresses

AND -- here's the kicker -- that data must be released in such a way that identification of a specific individual is possible to an outside entitiy.

So, according it HIPAA, it's completely legal to come home and tell your hubby, "If that CHF jerk tells me he's going to report me for not bringing him a 2 liter Pepsi one more time, I'm going to scream." There's no way he could pick up the telephone and call the CHF jerk in question. If I come home and tell him, "Mr. Smith in East 324 is a pain in the TAIL." he could pick up the phone, call the hospital, and ask to speak to Mr. Smith in East 324 -- I've identified the specific individual, and I've violated HIPAA.

So, if a health professional writes a book, and writes about Mr. Smith but calls him Mr. Jones, and changes the age by a year, turns a plumber into an electrician, doesn't mention where the person was other than saying they were in Nevada or California, then you're not blowing up HIPAA. Believe me, before I EVER started posting, I learned what I could say, and what I couldn't.

And for Pete's sake, don't read the law and attempt to operate heavy machinery, it will put you to sleep....