is "beating around the bush" common in nursing?

chachh, BSN, RN · Dec 8, 2009

Sorry you have had some disappointments. Should a med be pushed faster than recommended? Probably not. And according to guidelines definitely not. Does it happen often? You bet. Should a sterile field be broken? Definitely not. Does it happen? I bet more than we realize. Are nurses human? Busy sometimes? Trying to manage patients with different accuities and take care of them the best they can? Most of the time. My advice is to learn what kind of nurse you want to be and do the best job you know you can. I bet in a few years you won't be pushing a 1ml vial of morphine over 4-5 minutes, but maybe not quite as fast as 2 seconds. (and by the way, I have been made fun of by the crises team for pushing morphine over 1 minute in a central line, and pushing atropine on a totally alert patient with hr in the 50's over a minute.) Just live and learn and don't judge to harshly or quickly until you walk a mile......(but that doesn't mean to EVER endanger you patients!) Hope this helps (haven't slept yet)

VegRN · Dec 8, 2009

First of all, are they pushing the medication into a running IV line? or are they pushing it into an IV that was capped a second ago? If they are pushing it into a running IV line, I would say in some cases it is ok to push it all in at once because it can take several minutes to get to the patient if the IV fluid is running at a slow rate. Also, as far as lasix goes, I am extra careful about pushing this med since it is nephrotoxic. Anything more than 40mg I run it as a secondary in a 50ml piggyback because I just don't have time to stand there and push it slow.

I believe what you are seeing is nurses in a time crunch taking short cuts. I am not saying it is right but I think that they are doing the best they can. I would recommend talking to your instructor about it. I think she/he could provide some insight and support to you. Also, you will find out when you enter the real world that a lot of things are not done by the book. You learn how to do things by the most perfect standards in school and when you get out in practice, you will have to decide how you will practice and what shortcuts you will be willing to take. I guarantee everyone takes shortcuts, some small, some big. I bet that even now, your practice is not perfect (do you swab your stethoscope with an alcohol wipe in between each and every patient? Do you wash your hands after caring for a patient and then wash them again when you go to take care of the next patient each and every time?)

Emergency RN · Dec 8, 2009

You think that's bad? LOL... The sad part is, I've seen or heard of nurses doing things that go way beyond bad practice or nursing sloppiness. Examples would include stealing from patients, diversion of narcotics, sexual abuse, racial discrimination, assault and battery of patients, documentation of fabricated vital signs & notes, medications charted but never given; shall I go on? Some of these "colleagues" were arrested, a few fired or disciplined, but the bulk of them that I've witnessed over the quarter century were never brought up to answer for anything. Like any other field of endeavor; Nursing has its good, its bad, and some god awful ugly. What's being practiced is imperfect nursing by imperfect nurses, in a less than perfect world.

When you witness something that is suboptimal, learn to pick your battles. My line stops when a patient may come to harm; that is one line that I don't let myself, or anyone else cross, at least not if I'm a witness to it. As for everything else? My advice would be to give a helpful nudge, a neutral suggestion, or just a shake of your head and walk away; you're not going to save the world, and tomorrow has battles yet to come.

Welcome to nursing.

SteffersRN87, BSN, RN · Dec 8, 2009

I worked with a nurse tech once that made up blood sugars! And, of course she didn't make then all under 150. It was widely known and management did nothing.

~Mi Vida Loca~RN, ASN, RN · Dec 8, 2009

We just got done doing injections in school and we are taught to inject 10 seconds per 1mL and after done wait 10 seconds to withdraw. So for a 2mL injection the needle is in the patient for 30 seconds. This seems like SUCH A LONG time practicing, for Returns we have to count it out and can't count fast. I have never had an injection last more then 2-3 seconds. Our instructors say that it's new evidenced based practice that this way is more effective along with the z tracking and stuff.

I'm nervous the first time I give an injection, the Pt. is probably going to think I have no clue what I am doing as I am sitting their waiting all this time lol

suanna · Dec 8, 2009

I can see both sides of this debate but a side note about Lasix. You push it slowly because it is OTOTOXIC-(ears). A patient can end up with permanent deafness from one dose pushed too fast! Hospitals have thier own policy for IVP lasix but I never push more than 20mg/min. If the patient c/o ringing in thier ears-STOP and evaluate exactly how badly your patient needs IVP Lasix. Is there another alternative you could ask the doc for?

jjjoy, LPN · Dec 9, 2009

When we asked instructors about the many questionable practices we saw as students, we were simply told that 1) we use the experience to clairfy what kind of nurse we didn't want to be and 2) not be concerned with anyone's practice but our own. As students, we might be accused of not being fit for nursing if we pushed a med a few seconds too quickly, even while watching nurses push the same med much, much quicker over and over again. How confusing is that?! School *explicitly* taught that this or that was the ONLY RIGHT way to do something, no ifs ands or buts, that there was never *any* justification for variation. What if you can't find time to do x? Then you need to make time! What if the proper supplies aren't available? Then you need to get those supplies!

Shouldn't nursing students be warned that their practice will not always be by-the-book and that that by itself doesn't make them a bad nurse? That, in fact, nurses have to find ways to accept they will be giving imperfect nursing care? Shouldn't they be given some guidance on how to evaluate shortcuts that they see others making and/or that they might be considering for themselves? Guidance on not just how to prioritize "what first", but also on dealing with the practical issue that items lower on the prioritization list might keep getting pushed down the list as more high priority issues continually arise throughout a shift?

Jules A, MSN · Dec 9, 2009

Shouldn't nursing students be warned that their practice will not always be by-the-book and that that by itself doesn't make them a bad nurse? That, in fact, nurses have to find ways to accept they will be giving imperfect nursing care? Shouldn't they be given some guidance on how to evaluate shortcuts that they see others making and/or that they might be considering for themselves? Guidance on not just how to prioritize "what first", but also on dealing with the practical issue that items lower on the prioritization list might keep getting pushed down the list as more high priority issues continually arise throughout a shift?

I enjoyed your thoughtful post. Much of the short cuts that imo are not a danger or caused by laziness are learned by experience. Someone that is skilled at something can make a quick judgement call based on instinct so I just don't think there can be hard and fast guidelines. If you use all the questions you have typed here and research the situation as well as seeking input from the more expreienced nurses you will learn your own style.

FWIW I've heard more than one green nurse acting as if their knowledge is superior, that experienced nurses who are not doing things "the way we were taught in school" are lazy or sloppy and offering up their opinions about things like their uneducated thoughts that we over medicate our psych patients. Bottom line is that there will be nurses practicing in ways you will never be comfortable so you will need to develop your own style and live up to your priorities. "The way we learned in school" isn't even always consistent between instructors and different schools and only as current as your leader's knowledge. I'd urge new nurses show a bit of restraint and hold their harsh judgements until they actually have some experience to back it up. You'll get far more support from your peers by being humble, imo.

shrimpchips, LPN · Dec 9, 2009

thanks for your replies, everyone :heartbeat:

Virgo_RN, BSN, RN · Dec 9, 2009

What do you mean by "beating around the bush"? I'm not certain I understand how the title of your post relates to the content at all.

Anyway, my drug guide says to push Lasix at a rate of 1-2 minutes for each 40mg or fraction thereof. Lasix has no vasoactive properties, so it won't bottom out BP if you push it too quickly. Effects on BP have to do with volume depletion, which would be more dose dependent.

My drug guide also says to push Morphine at 4-5min for each 15mg or fraction thereof. Common practice, however, is to push it over at least one minute.

In the real world, sometimes common practice deviates from the guidelines. When in nursing school, however, you practice by the book.

When one does deviate from the guideline, it's essential that they understand the rationale for the existing guidelines, and the implications associated with deviation from them. But this is something you should NEVER do while in nursing school.

CuriousMe · Dec 10, 2009

Shouldn't nursing students be warned that their practice will not always be by-the-book and that that by itself doesn't make them a bad nurse? That, in fact, nurses have to find ways to accept they will be giving imperfect nursing care? Shouldn't they be given some guidance on how to evaluate shortcuts that they see others making and/or that they might be considering for themselves? Guidance on not just how to prioritize "what first", but also on dealing with the practical issue that items lower on the prioritization list might keep getting pushed down the list as more high priority issues continually arise throughout a shift?

We were warned. We were counseled to not challenge the RN, but to bring up any concerns with our clinical instructor on the floor with us. We'd then have a conversation (instructor and student) about what we saw, possible reasons for it, context of what else was happening, concerns about what could result, etc.