Refusing a Clinical assignment

babyNP., APRN · Jun 28, 2012

I can think of an excellent reason why not to take a patient on...if you don't feel safe. I am a NICU RN and occasionally float to PICU. I have only ever taken care of infants as a RN and if I don't feel safe with the assignment that they have given to me, I speak up. I haven't refused an assignment yet, but I'm ready to do so if I felt that I couldn't take care of the patient properly and feel no qualms about it--that's just safe care and I would hope someone would do the same for me if my child was being taken care of a NICU RN who had no idea what to do with a school age child.

But there can be ways around it...I got assigned a 12 year old once who was trach'd, g-tubed, essentially dead, but parents couldn't let their child go. Charge RN asked me if this was okay and I asked her if she would be my resource to do things like trach care/turning/etc. The day went by and while I pretty much disliked it from the word go, I felt that I had enough resources around to give the child safe care. Now...give me a kid on multiple drips that I've never heard of and field trips to various parts of the hospital while on a vent I don't know how to work? um...nope.

wooh, BSN, RN · Jun 28, 2012

I have never crushed a time release drug. Isn't there a danger you can OD the pt? Once you crush it, it's no longer extended release? I would think a patch would be better. Anything but crushing a time release. I would seriously have to consult with a PharmD before doing that.
Just curious. Is this really done? I was always taught this is a no no, but I haven't practiced in a while.

Yup, it's really done. Not regularly, but yep, it's done.

My only question that no one was able to answer was why not give the guy an immediate release crushed up rather than the extended release in a smaller dose.

Hospital formularies for the win! If an immediate release alternative isn't available, which often it isn't, you do what you gotta do.

Katie71275 · Jun 28, 2012

Our instructors usually pick patients for us or they get with the nursing sup and find good patients for us to get a good learning opportunity from.

That way, this situation doesn't really come up unless there is some other reason.

KelRN215, BSN, RN · Jun 28, 2012

I have never crushed a time release drug. Isn't there a danger you can OD the pt? Once you crush it, it's no longer extended release? I would think a patch would be better. Anything but crushing a time release. I would seriously have to consult with a PharmD before doing that.
Just curious. Is this really done? I was always taught this is a no no, but I haven't practiced in a while.

In nursing school, they teach you that you cannot crush "enteric coated" or timed release drugs. In practice, working in a pediatric hospital, I did it every.single.day. Some newer meds ONLY come in one formulation and that formulation is enteric coated. How are you supposed to get said medication into a 2 year old without crushing it?

I'll give you a few examples- all pill formulations of Depakote are "delayed release" and most, other than sprinkle caps, are enteric coated. Say you have a G-tube dependent toddler admitted for initiation of the ketogenic diet who takes Depakote TID. You cannot give liquid medications on the ketogenic diet because of the glucose content so all medications need to be changed to pill formulation. The child cannot take the sprinkles because he's NPO and the sprinkles can't be given down a G-tube. That leaves you ONE option- you crush the enteric coated pills.

Another example- a few years ago, a new anticonvulsant called Banzel (rufinamide) was introduced. When it first came out, it only existed in tablet formulation and it was enteric coated. Any time a new med like this comes out, neurologists get excited that this is finally going to be the med to control the seizures of all their patients with intractable epilepsy so they start prescribing it like mad. The only way to get pills into many small children and G-tube dependent patients is to crush them, so you do- even if it's not officially recommended. This particular medication is now available as a suspension but if you have a kid on it starting the keto diet, you may very well be in the same situation you were in with scenario #1 and will be right back to crushing it.

If I had a nursing student who outright refused to give a med just because "enteric coated meds aren't supposed to be crushed" instead of asking for rationale and trying to figure out WHY we're doing this, I probably wouldn't react so well.

As far as the OP's question goes... I am struggling to think of what situation you would come across in nursing school that would justify refusing to care for a patient. You wouldn't do skills you weren't comfortable doing on your own but then you wouldn't refuse the assignment, you'd ask for help.

sapphire18 · Jun 28, 2012

I'll give you a few examples- all pill formulations of Depakote are "delayed release" and most, other than sprinkle caps, are enteric coated. Say you have a G-tube dependent toddler admitted for initiation of the ketogenic diet who takes Depakote TID. You cannot give liquid medications on the ketogenic diet because of the glucose content so all medications need to be changed to pill formulation. The child cannot take the sprinkles because he's NPO and the sprinkles can't be given down a G-tube. That leaves you ONE option- you crush the enteric coated pills.

Regarding the depakote sprinkles, just wondering why this is? I'm pretty sure that I've seen this done. :confused:

Also, not judging anybody who does this (and I've never worked in peds so I'm talking adults here)- but I would never crush a time-release medication. Just not good practice in my opinion. It's no longer time-release once crushed and we don't know exactly how the absorption would be altered.

KelRN215, BSN, RN · Jun 28, 2012

Regarding the depakote sprinkles, just wondering why this is? I'm pretty sure that I've seen this done.
Also, not judging anybody who does this (and I've never worked in peds so I'm talking adults here)- but I would never crush a time-release medication. Just not good practice in my opinion. It's no longer time-release once crushed and we don't know exactly how the absorption would be altered.

They clog the tube and get stuck in the syringe. With depakote, you're monitoring drug levels so you know whether or not the patient is therapeutic. And I've had PLENTY of patients getting crushed enteric coated depakote whose levels are perfectly acceptable and who have decent seizure control.

Double-Helix, BSN, RN · Jun 28, 2012

I can think of an excellent reason why not to take a patient on...if you don't feel safe.

As the primary RN, yes it makes sense to refuse an assignment if you don't feel you can give safe care. But as a student, not so much. Students are at clinical as to learn skills they don't yet know how to perform and to gain experience. As a student, if your faced with an uncomfortable situation that you aren't familiar with, you should ask questions, ask to observe first, ask for supervision, look up the medications, etc. but to refuse an assignment is to deny yourself the opportunity to learn new and potentially important nursing skills. If a student doesn't feel safe they should ask for help- not run away.

wooh, BSN, RN · Jun 28, 2012

If I had a nursing student who outright refused to give a med just because "enteric coated meds aren't supposed to be crushed" instead of asking for rationale and trying to figure out WHY we're doing this, I probably wouldn't react so well.

Yup. Especially since it was in nursing school that I learned that yes, GASP!!, you CAN crush extended release meds.

And ketogenic diets, as magical as they are, are such a pain at med time, 3/5 of this pill, 2/9 of that pill, never can they get a whole or a half or a quarter pill!!

But it's not just peds, adults too. Adults that can't swallow pills or altogether can't swallow.

It's amazing how nursing students will come to clinicals and just assume that the staff nurse there missed the day of nursing school when you learned to never this or never that. Obviously they're just practicing completely rogue by crushing the extended release pill! They should OBVIOUSLY do something else, even if something else isn't available!

Cali22 · Jun 28, 2012

I think that would be a problem if you just don't feel like dealing with a particular patient because of a certain medical condition. As a student you are there to learn.

OB-nurse2013, BSN, RN · Jun 28, 2012

Yup. Especially since it was in nursing school that I learned that yes, GASP!!, you CAN crush extended release meds.
And ketogenic diets, as magical as they are, are such a pain at med time, 3/5 of this pill, 2/9 of that pill, never can they get a whole or a half or a quarter pill!!
But it's not just peds, adults too. Adults that can't swallow pills or altogether can't swallow.
It's amazing how nursing students will come to clinicals and just assume that the staff nurse there missed the day of nursing school when you learned to never this or never that. Obviously they're just practicing completely rogue by crushing the extended release pill! They should OBVIOUSLY do something else, even if something else isn't available!

We did it at clinical, crushed coated meds.

I only had one incidence where I knew we ahd been taught a different technique for doing something, which I knew was a new clinical protocol. I had a really great experience with my nurse all day, she was wonderfully experienced and taught me a lot so I was comfortable telling her that we had learned to skip this one step in a particular skill. She asked me why and I told her the why they changed it, the rationale and evidence. She said it was fine to do it the new way and was wonderful. If I didn't feel that comfortable with her I would have kept my mouth shut though :)

BrandonLPN, LPN · Jun 28, 2012

As a student, you should NEVER assume your textbook knowledge overrides the knowledge of an experienced nurse. Just remember the saying, "a LITTLE knowledge is a dangerous thing"

chevyv, BSN, RN · Jun 28, 2012

If you crush an extended release med, then isn't the pt getting the full dose right away? I had a pt who would chew her extended release pain meds and I would let her know that she could not do that as she was getting a large dose right away. I was always afraid I would have to code her one day......

Is this not accurate? If it's not, then why have extended release at all? Can anyone clear up my muddled thinking?