Clinicals: Be a patient advocate, anger the nurse you shadow...

[Josh L.Ac.]

So in my first week of my new rotation, I got invited by a NP to watch a patient's abdominal aortic aneurysm stint repair that was scheduled for the following day. I talked to my supervisor and got assigned to that patient for the next day. I go through the chart at the end of my shift and prepare for the next day.

When I arrive at 6:30 the next day, I notice new orders that were faxed in from the surgeon. I've never had a pre-op patient, so I was confused by some of the orders [iV fluid change and mucomyst 1200 mg PO, both to improve renal blood flow since the patient had same renal issues] and looked for the nurse that I had the day before [she admitted the patient while I finished up with some of her other patients] to get some clarification. She tells me she is pulled to do an orientation on a new hire and I'll have a new nurse. Sigh.

I look around for the new nurse for about 15 minutes to no avail, so I find my supervisor to help me go over the new orders. My supervisor works in the ER so she isn't familiar with some of the pre-op protocols, but then the nurse walks up and she says she will explain the protocols later. Great.

Later rolls around and she focuses more on the pre-op paperwork checklist. I still have a question about two of the orders and my supervisor happens to walk up when I ask the nurse about the orders. She says she has already taken care of it, and repeats this when my supervisor asks for clarification on the two orders. So I go back to the computer and see that the two orders are still not in the computer. I go back and see that the IV bag is still NS and the new bag is nowhere to be found, which I bring [again] to the attention of the nurse. She finally tells me to fax down the orders to the pharmacy, which I do. After about 30 minutes, the new bag is still not up and I remind the nurse again that the bag was supposed to be changed several hours ago and the patient's surgery time is rapidly approaching. She says she'll wait for the bag to come up and walks off. [edit: this whole process took about 4 hours]

So my supervisor comes back up and asks if I'm done with my patient and if I would like to go down to the ER for an hour, and I reply that everything is done sans the new IV bag. We look at the orders again and she decides to talk to the nurse one more time. She's taking a new admit so my supervisor decides to get answers from one of the nurses she is friends with, who happens to be the charge nurse. My supervisor asks for clarification on the two orders and the charge nurse immediately stands up and walks briskly to the nurses station. She starts going through paperwork and starts grilling me on everything I had done that day. Then she grabs the patients chart, sees that that new IV bag is still not up, then finds my nurse. She proceeds to rip the nurse a new one and tells her to call down to pharmacy and get the bag up here ASAP. Then she tells her she has to call the doctor, tell him that IV fluids haven't been changed, and ask him if the surgery needs to be rescheduled. Then the nurse glares at me as the charge nurses basically explains that this mistake started with the unit secretary (didn't enter all the new orders / medications but signed off that she had), the night nurse for not getting clarification on the order, and my nurse for not seeing the problem and fixing it.

I try to talk to the nurse several minutes later to tell her thanks for helping me out today but she is on the phone with the surgeon, so I give her a wave...which was not warmly received.

Great. I have seven more weeks on the floor. I hope the nurse realizes that mistakes are inherent and that hopefully someone else will catch ours and we will catch their's.

I'm an accelerated option student. Since we all have previous degrees and are older, the faculty doesn't worry too much about how well we can handle all the coursework in a shorter amount of time. But compared to our traditional option companions at our school, we get less clinical exposure, which does worry the faculty that we might not be able to apply our knowledge clinically. So the faculty has told us to keep asking questions if we don't understand something, which we all tend to do. This whole situation started because I didn't understand two of the orders and I kept asking questions. After the fact, my supervisor said that this was part of being a patient advocate. She then told all of us to go with our gut when in doubt.

This made me feel warm and fuzzy because the entire time I felt like I was watching a foreign movie with subtitles I didn't understand.

[jov]

my supervisor said that this was part of being a patient advocate. She then told all of us to go with our gut when in doubt.

This made me feel warm and fuzzy because the entire time I felt like I was watching a foreign movie with subtitles I didn't understand.

It's been my experience that advocating for anyone, regardless of how noble it sounds, is generally an unpleasant experience. That's why other people don't do it.

[GardenDove]

You sound like you have a pretty good grasp on things, and will probably be an excellent nurse.

[locolorenzo22, BSN, RN]

That's the rub... being an advocate as a student usually results in friction with a licensed RN as they don't like to be caught not doing their job...don't worry, odds are, next time you have that nurse, she'll be paying a little closer attention.....

[Anjann, RN]

I say you did a good job! We had a couple experiences like that where our nurse instructor had to step in because of a patient's condition and we really needed help walking that fine line between helping out, and ticking off your mentor. I say, If you see a train wreck coming, don't just stand there and let it hit you because someone else is not taking you seriously. Later it will be YOUR license on the line and advocacy should be encouraged anyway. What if that pt. had gone down to the OR because you were hesistant to say anything? Believe me, if it came down to who dropped the ball that day, guess where the fingers would be pointing? so I would have done the same thing. Being thorough is critical to being a good nurse! Maybe you could show up with a box of donuts or power bars or something next time around to try and patch things up?

Now, before I get slammed, I will back up and add that the great majority of the time the shadow nurses are excellent at what they do, happy to have a student and to be passing on their wisdom and are wonderful sources of useful info and tips you can't get in the classroom!

So thanks to all the nurses that were patient enough to take us on and help us learn!

[Josh L.Ac.]

Thanks for all the comments. This actually was the first time I had any negative experience to report from my clinicals in terms of interactions with the staff. I did the learn the lesson to be on the lookout for missed orders and to be more proactive.

I really can't take too much credit though, since I stumbled upon the missed order because I was not familiar with the pre-op protocols.