Refusing a Clinical assignment

[SheldonCooperPHD]

As students, do we have the right to refuse to participate in any given clinical assignment or proceedure? For example, if you are assigned a patient or order you are not comfortable with can you decline? Being "green" and nervous we all have to put in our chops, I get that, but what if it is an area we are really not ready for? What happens if we refuse?

[BrandonLPN, LPN]

I did refuse an order while in clinicals my very first semester. The patient was a sweet 90+ lady who was getting extended release morphine. Crushed. I refused to crush the med. The nurse was annoyed when I explained to her that I would not crush this medication and why I would not do it. My instructor stood behind me and told the nurse if she thought it was safe to give the med that way then she should do it herself. The nurse did give the med, but by noon speech therapy was there to do a swallow study to see if it was safe to give the patient pills or if she needed to be changed to liquids. It felt great to advocate for my patient and even better that my instructor stood up for me!

I feel like I must play devil's advocate here.

Don't assume you know more than a staff nurse as a student. She's passed more pills than you can dream. I'm sure she knows ER pills weren't *manufactured* to be crushed. But it's very probable that the doctor knew the pill was being crushed and was fine with it. Heck, maybe he *wanted* her to get the full dose quicker. Think about it, if they switch to the same dose of morphine in liquid form (as you suggested they were going to) how would *that* be extended release?

Once you actually become a nurse, you will see that from time to time doctors order medications to be administered in ways that were never officially "recommended" in any drug handbook. Did you know doctors in rare instances order for end of life pts to get certain pills administered rectally? Not suppositories, but actual pills! You won't find that in your drug book!

[BrandonLPN, LPN]

And, I must say, I would be furious at a clinical instructor that came into *my* place of work and insinuated that I was administering my medications wrong. I had students at my facility last month watching me pass meds. The clinical instructor told her students (right in front of me) that I had "bad practice" because I didn't crush and give EACH PILL separately through a g tube! Give me a break! I complained to my ADON and that instructor is no longer allowed at our facility.

[llg, PhD, RN]

As you can see from the above posts, a lot depends on the individual situation. There are times when it is appropriate to say, "I will not do that," but it takes good judgment to know when and how to do that effectively. If you are asked to do something you truly feel is unsafe for the patient, you are obligated to take your concern to the appropriate person above you in the chain of command and get the issue resolved before you act. However, if you are just "uncomfortable" because you don't have a lot of experience, it's usually best to ask for help, rather than outright refuse to do something the patient needs.

Also ... if you are one of those people who can't (or is not willing) to ever do anything you are not totally "comfortable" with, you need to think seriously about your career options. In nursing -- and in many other careers -- we often find ourselves in situations that are unfamiliar or stressful. We can't always be "comfortable" as we work. Learning to use good judgment and continuing to work in spite of being a little "uncomfortable" is required to succeed on the job.

You need to learn to distinguish between those situations that require you to get help ... or report up the chain of command ... etc. and those situations where it is best to just "suck it up" and do what you need to do in spite of your discomfort. That comes with experience and through having discussions such as this one with experienced nurses.

Good question.

[LobotRN, BSN, RN]

Wow, this one ("refusal") can be a slippery slope in terms of your relationship with your clinical instructor AND how they view you. In general, try to avoid ever saying, "I don't know how to do X" and then not saying anything else. Kind of makes it appear that you aren't ready or didn't even try to get ready. Its all in the phrasing. I would tweak it a little and try to say something more along the lines of, "I have read over the procedure guidelines and also the clinical indications in our med-surg text, but haven't actually performed X with a patient yet. Since this is my first time, can I talk through with you first how I think it should be done before actually doing this? I want to make sure I am safe with the the patient and procedure."

Then get in there and do it. Everyone's gotta learn at some point, or how the heck will IVs get started, foley's placed, wounds re-packed, traction applied, drips titrated, the phlebostatic axis correctly located, new hip pts transferred from bed to chair?

:)

[nynursey_]

While I think this is sound advice to be on the safe side for patient care, a very wise nursing instructor told me that "I don't know," or any variation of the phrase can be suicide to a nursing instructor. This says to the nursing instructor that you didn't care enough to look up the procedure or prepare for the clinical assignment, and as a student, you don't ever want to appear unprepared.

Maybe a better phrase would be, "I'm having difficulty recalling how to do ...., could we walk through it first?"

:) Just my two cents!

[nynursey_]

A good response is "I'm not familiar with that care or procedure or equipment, can I watch you do it and then I'll do it next time?" Or...."I'm not sure how to do that - can you go with me and make sure I'm doing it right."

While I think this is sound advice to be on the safe side for patient care, a very wise nursing instructor told me that "I don't know," or any variation of the phrase can be suicide to a nursing instructor. This says to the nursing instructor that you didn't care enough to look up the procedure or prepare for the clinical assignment, and as a student, you don't ever want to appear unprepared.

Maybe a better phrase would be, "I'm having difficulty recalling how to do ...., could we walk through it first?"

:) Just my two cents!

[Pepper The Cat, BSN, RN]

I had a student refused to give a Coumadin because the INR was "elevated". It was 2.4.

Pt had Atrial Fib.

I tried to help her think through the reason the INR was elevated and she just repeating to me "Normal INR is 1.0. This is 2.4. Its elevated".

So - before you "refuse" to do something, think it through long and hard.

Also, remember once you are in the real world you may not be able to refused to take care of someone. So the earlier you learn to deal with difficult situations, the better.

[sapphire18]

Can you elaborate on why you would feel uncomfortable with a particular assignment? The only situation that I can think of that would be even close, is assisting in an abortion, and last time I checked, students aren't involved in those.

[FORTHELOVEOF!!!!]

It really depends on why you want to refuse. If you are just nervous about a procedure or condition then NO don't refuse, use your instructor and nurse as a resource so that you can LEARN to become comfortable. There is always something that will scare the poo out of you in clinicals, those things you WANT to do while being monitored, you wouldn't want to be set free after you get your license and run into something you refused to do in clinicals and BAM, real life just slapped you in the face and you HAVE to deal with it. Now if you are African American and your patient is a racist skinhead, then I think that would be a valid reason to refuse, but not because you are nervous or scared about something, those things you should beg to do while still in school. IMO of course :)

[Mandychelle79, ASN, RN]

As a second semester student I refused one patient. The pt was being tested for TB. Had we been at the main hospital we did clinicals at I would have had no problem providing care because I had been sized for the appropriate PPE, however at this hospital I had not been sized and they didnt use the same PPE as the main hospital so I felt that I couldnt not keep myself safe. The instructor understood and assigned me someone else.

[LynnLRN]

I would not refuse. It is important to step out of our comfort zone. Plus, nobody would let you make a mistake so it is the perfect time to take something you are not comfortable with. If you do not deal with the uncomfortable situation now while you have someone standing over you it will happen later when you are alone. Everything is scary and hard until you do it and then it becomes second nature. I wouldn't turn down anything.

[sdlane]

If I felt uncomfortable I would not refuse, I would just ask for help to make sure everything gets done safely.