Patient rights v. Clinical instructor?

[studentnurse0383]

Last week, my clinical instructor and a fellow student got into, well, let's call it a discussion, regarding bathing our assigned patients. In this case, this student's patients was A&0x3 and completely independent. He refused, even after encouragement and rationale for hygiene was given, to bathe or have his linens changed. When the clinical instructor heard this from the student, she said she didn't care and it was a requirement of each day that we bathe our patients and change their linens. She stated that we should not ask, we should demand and state that we WILL be assisting/giving our pt their bath and changing their linens. IF the patient refuses, tell them it is our job and we have to do it and that it WILL be done. I understand the importance of hygiene and comfort and what a lack of can do to a patient's immune system and overall well being, as do my fellow students and we are NOT above assisting our pts. If the patient asks for a bath or says yes to one, we will give it in a heart beat. My question is: Is it a violation of their rights if we "force" them to bathe? Can we be found guilty of any sort of abuse as students if we are following the instruction of our clinical instructor? We are second semester (out of 5) RN students if this makes a difference and we are currently doing our clinicals on an Oncology ward in a hospital. Thanks for your opinions. :-)

[LouisVRN, RN]

I have to say I agree, and there would be no way i would be forcing a patient to do anything. I would have to emphasize that it is especially important to encourage oncology patients to bathe daily to prevent infection.

[Cul2]

Did anyone ask the patient why he didn't want a bath? If so, what was his reason?

[Nccity2002, MSN, RN]

Uhh...I don't know... Are you sure there isn't more to the story??

[DLS_PMHNP, MSN, RN, NP]

Assault- threatening to do something, against their will

Battery- actually doing something to someone, against their will. Touching, grabbing, etc.

I hope your CI knows a good lawyer.

Ridiculous. Sorry you have to deal with this nonsense.

[studentnurse0383]

Thank you to everyone for your replies.:heartbeat To those who made it a point to mention the importance of using the right verbage, being assertive, encouraging and explaining the rationale- The last two were done. The first two, I cannot be sure. She very well may have walked into the room and asked nicely if he would like to have a bath. I can assure you that we know the importance of hygiene, especially for the immunocompromised. We understand that it can be detrimental to their health. All of us are very willing to assist with/give a bath and change linens. And, yes, if our patient refuses, we are willing (and have) to help a fellow student give a bath to his/her patient. We have all learned that you, as a nurse, not only help your patient during this process, but you can also do a skin assessment, a ROM assessment and more, not to mention the extreme value of therapeutic touch.

Again, thank you to everyone for your opinions, advice, help, and kind words! I love that I can turn to this site to gather some insight and advice.

[canoehead, BSN, RN]

If a patient flat out refuses I agree, that's the end of it. BUT...most of the time when someone refuses bathing they mean "not right now," or "I don't feel well enough to do it." So how do you deal with that? (This is what your instructor should be teaching you.) Do the bath in pieces. Every couple hours you can wash another body part, starting with breakfast.

Before or after meals provide basin and water to wipe off hands and face. Toothbrush and paste afterwards- don't insist. Just say "if and when you need it." With a smile. Offer to do their teeth for them too.

They are likely to get food or something on themselves, or maybe you just offer a fresh top. Walk in with a johnnie and a hot wet facecloth, and wash their back. Don't offer- say "I'm just going to wash your back for you, that'll make you feel a little fresher." You don't need soap on extremities or the back unless there's visible grime, it's drying. Someone that doesn't want to be washed might accept a back rub with lotion.

Give them a cloth when they change their johnny to do their pits. Lots of antibacterial soap, and just dry the pits, don't rinse, for a less stinky patient.

They've got to get out of bed for something during the day, physio, meals, tests, so do up the bed then. If not you can notice the various stains and wrinkles and provide fresh linen prn. By the end of the day you'll have a mostly fresh bed.

If you assist them to the commode you've got an easy opening to wash their hoo-hoo. Wash instead of toilet paper, but you have to be johnny-on-the-spot with the washcloth, and be gentle. Keep a stash closeby, this is a high priority moment. Be sneaky enough and you'll get thighs and buttocks.

Take 5 minutes for a "spa treatment" for their feet. Make a big deal out of it, with basins to soak in, towel to rest their wet feet, and lotion. Some people can't tolerate direct touch on their feet so drizzle hot water with a washcloth if need be. Lots of antibacterial soap. (destinkify!)

So you never actually do a bath, and you never use the word "wash," to the fermenting patient. The sickest patients will appreciate not having to face a whole bath at once. You've also taken away the procedure feel from the bedbath, it just feels like their nurse is really attentive and trying to make them as comfortable as possible. Our patients get tested and procedured out, the TLC approach gives them back some kind of control. Some days the bath is the only thing your patient has the power to say "no" to. We've got to respect that, and also make them feel cared for.

PS If a patient refuses any part of this you immediately agree and go away. Try again later, on another body part, but ask first "is it OK if I..." Give them control. Also, tell them you will keep offering things, to make sure they are cared for, but they are free to say no anytime. Make sure do you keep offering, so they know you are still willing.

[AJPV]

Can you say "assault and battery"? That langauge, as inconvenient and annoying as it may be to your instructor, is exactly the language that lawyers, judges, juries, and state boards of nursing use for this type of behavior. Yes, you need to be assertive in a way with your language and "strongly suggest" hygiene interventions. But you need to be careful. Even if you don't lay a finger on your patient, if your language can be construed as a threat or if that patient would reasonably conclude that they could be subjected to physical interventions unwillingly, you can still be found guilty.

[BeenThereDoneThat74, MSN, RN]

As the OP describes this situation, it seems utterly ridiculous. We cannot force a patient to do ANYTHING; this includes meds, vitals, and actually staying in the hospital. All we need to do is document our interactions, and follow the chain of command. Obviously in this case, the CI is the next rung on the chain. The problem is, SHE should have intervened. It was mentioned that the student suggest "show me how it's done". I agree completely. Because what this really means is "I want to hear the patient refuse to you". Maybe the CI can convince him, maybe he can't. I've been there and done that countless times (not with bathing). And the reality is, sometimes when the instructor comes in and has a more confident demeanor (and maybe isn't reading the action of a medication off of an index card), it just sounds more convincing. I had an instance this semester where it did not work (a patient was refusing IV abx for a serious cellulitis). I was right there the whole time (since it was a med pass) and the student did a good job with the teaching. But my 2 cents didn't make a difference. Oh well...

Now, here's me playing devil's advocate (b/c I've been there and done that with this too). Many instructors go in with an "absolute" mentality, and here's the reason: almost every semester (since I do not teach 101, which is full of hygiene experiences), I get one student who is brave enough to utter the question "Do we still have to do AM care" (as if it's a rite of passage qwhile crossing over to the next course). My answer: it a patient needs it, you'll do it. (note, I am not obsessed with the AM care issue, but I'll be damned if one of my students leaves a patient dirty and I have to hear about it from staff, while the student is holding up the wall in the hallway). Often times this is translated as "Prof ___ doesn't make us do AM care" (I kid you not). So depending on my group of students and the situation, I may not give that open response. I learned early on that some students cannot handle grey area when it comes to rules and protocols.

Here's the other thing: there are a number of students who (dare I say) are looking to do as little as possible. I see the nonverbals when a patient NEEDS to be cleaned (let's face it, it's NOT fun). Or maybe they're not comfortable with the hygiene issue. Or maybe they are afraid. The easiest excuse in the world is "patient refused" (vitals, meds, anything that may require some effort or an inconvenience to the patient). I am not at all suggesting this was the case with this student. But if this CI has been teaching forever, she's heard every excuse (as have I, and have not been teaching forever), she may be tired of it. Sometimes it takes a few clinical days to filter out who the excuse-makers are. I had one one semester whom I gave the benefit of the doubt after the first excuse (because she seemed like a nice girl). Then I saw a pattern. Lots of excuses. Turned out she was a lovely girl; just lazy.

[healthstar, BSN, RN]

Wow! Patients rights for sure and I would say to my instructor I won't force my patient to do anything they don't want to. If the situation gets worse I would go and talk to the dean.

[AlwaysTired]

Get a copy of the hospitals patient rights policy (don't they all have one?) and slip it under her door.

[Riseupandnurse]

Well, yes, the instructor handled it wrong. But I agree with nurse educate and will add my 2 cents that it is very difficult for students to step into the nursing role and out of the "social" role; that's part of learning to be a nurse and takes experience. After years of teaching clinicals, I have found that about half of my students' patients don't get bathed because of the students' social hesitation, whereas almost all of the NAs' patients get bathed. It's all in how you go about it and approach the patient. The instructor needs to teach by example. She is probably caught in the middle between the students and the facility's expectations and frustrated.

[Esme12, ASN, BSN, RN]

As a patient, you have certain rights. Some are guaranteed by federal law, such as the right to get a copy of your medical records, and the right to keep them private. Many states have additional laws protecting patients, and healthcare facilities often have a patient bill of rights.

An important patient right is informed consent. This means that if you need a treatment, your health care provider should give you the information you need to make a decision.

Many hospitals have patient advocates who can help you if you have problems. Many states have an ombudsman office for problems with long term care. Your state's department of health may also be able to help.

Not that I am a fan of wikipedia but......

http://en.wikipedia.org/wiki/U.S._Patients'_Bill_of_Rights

http://www.hhs.gov/ociio/regulations/patient/index.html

What is up with people these days:uhoh3:......