Strange experience yesterday, feedback please...

[LovingLearning]

First, I didn't get into any difficulty or trouble. Phew. LOL. But this experience has me a bit baffled...

I'm a second semester student, doing a med/surg rotation on a trauma/neuro floor. I am utterly loving it...it can get really hairy, but hey, that's all right. Yesterday was one of those hairy days, though...and I ended up getting 'talked to' by my instructor.

I had two patients, both who discharged before I got on the floor. So I picked up two more, and then ended up giving one to another student. So then I got a third, who was comfort care/DNR/DNI. His family was there, and I did my assessment and charted. While I was charting, the fire alarm went off...and locked down the elevators.

No big deal, right? Except, it was during shift change, and half of the student nurses were downstairs taking a break, half the RNs were trying to get up to the floor, and the RNs on the floor were off-floor, waiting to give report to their replacements who were stuck downstairs. Our instructor was downstairs, too...and he doesn't have a cell phone.

So this one patient had both her regular nurse going off shift, and her student nurse was on break. This patient was reporting 10/10 of pain, and I was one of three SNs on the floor (we normally have 9). I chased down her RN(literally...quite literally), and told the RN. Who looked at me, said "well, I want to go home. I'll let the other RN deal with it." The other RN was NOT on the floor, but this RN was not going to even check the chart for PRNs for the patient. And since she wasn't my patient, I had no real idea what was going on. I grabbed the chart, looked at what was up (chest tube placement this afternoon, only motrin given 4 hours earlier, mets Ca brain/lung), and there was no order for anything stronger than motrin.

Long story short, I went to the RN again, asked what I could do, and she just told me again "I'm going home. Let the next RN deal with it." I'm sorry; the patient is in incredible pain, crying, muscle guarding, grimacing, praying out loud to die, freaking her kids...and my instructor and her SN were stuck downstairs, her RN wants to go home...so after checking my two patients, I went to the charge nurse.

I explained what was going on (she was also stuck because of the fire alarm), and told her I can't take phone orders. She said to page the Dr. on call, explain what was happening, that I was an SN, and that I couldn't do phone orders...and see what the Dr. said. Well, I did it, and the Dr. was on the floor (but another wing), and came right over to get the order written so we had something we could give. All this time, I'm back and forth to the pt's room, asking her to hang on, I was working on the meds, just hang tight, and reassuring her children that I was working on things as fast as I could. Ended up having an NA walk the order to the pharmacy because our fax machine was down...and about 20 minutes later, the meds were in the pyxis. The fire alarm had ended, elevators were working again, my instructor came back to the whirlwind, and I had him let me into the pyxis and we got the meds into the pt and 30 minutes later she was reporting 2/10. YAY. I gave report to the new RN, and filled in the SN as to what had happened, and went back to my pts (who were all just fine...).

After our shift ended, my instructor asked if he could talk to me. He wanted to know what the heck had happened that I was med-passing to a patient who wasn't mine, how come I'd called the Dr for an order, et cetera. I explained everything to him, and asked if I was in trouble.

He looked at me and said "you're doing what we are teaching you to do...patients are first, their comfort is priority, and I would've done the same thing." I was relieved...but then he said "but the problem is, you have to let the RN go home when it's time...they look unorganized if they work unauthorized overtime, and we are a 24-hour hospital, and the new RN should've done it." I reiterated the issues (fire alarm, people stuck up and down stairs, et cetera), and he said "no, you did the right thing...I would've done the same. But just be cautious about that in the future; you don't want the RNs to look bad for not getting things done in time."

Like I said, it was strange...I completely get his feedback, I understand the rationale. But I also had a patient in 10/10, whose nurse was not willing to do anything even though she was stuck upstairs during a fire alarm, and didn't even want to start the process of getting meds for the pt. because she wanted to go home. My instructor did say "if I had been up here, what would you have done?" and I told him "of course I'd've gone to you, but since you weren't, I went to the charge nurse." He then asked what I'd've done if the charge nurse had said to wait and relax, and I said I'd've just waited and relaxed...but the charge nurse told me what to say to the Dr., so I was able to adhere to the SN status and issues, as well as take care of the issue at hand.

Again, I got into no trouble...and my patient and her family were so appreciative. Even said something to our instructor about how caring I was. So again, no problems, but definitely strange.

What would you have done, and what is your opinion about what I did? I am wondering if I indeed overstepped a boundary, but my instructor assured me I hadn't and that he'd've done the same thing...but it was just...strange.

As a final note, my patients were all doing well during this time, so no worries that I had ignored their needs. And the other SN didn't have any problems with me helping while she was on break.

Just interested in your feedback. Thanks in advance...

Best-

Lovin' Learning

[9livesRN, BSN, RN]

It is scarry, i am so affraid of doing something that i am not supose to... cant risk NS, but i cant let some 10/10 because it is all about the client....

I would have done the same thing, and maybe even ask my instructor to talk to the nurse...

yeah, no overtime i get it, but as a nurse or NS... i would stay, give the med, report to charge nurse, why was I on the floor after my shift...

the night nurse, should consider patient care first, than she could report and do whatever was necessarry to explain why she was on the floor

prioritize!

1- patient

2- documentation

and i don't think the charge nurse would be mad, since 20 bucks on overtime is beter then a negligence charge or something like that, r/t unnecessary pain!

[hpygrl01]

Just be careful in the future. As a student nurse myself, I KNOW FOR A FACT my butt would have been chewed out for doing what you did. I cannot pass meds/call docs/etc. w/out my instructor being present. I'm not even allowed to be standing in front of the med cart if another nurse needs it. My intructor said we are always on the graciousness of the hospital staff. The nurse in this case was wrong, but w/out your instructor, I would have told the charge nurse you could not call the doc or be involved anymore until your instructor came. Then the charge nurse would have definitly taken care of it.

You just happend to have a good instructor. Next time, you may not be so fortunate. I do applaud your efforts though.

[LovingLearning]

Let me clarify a few things...in my first post, Daytonite, I stated clearly that my instructor let me into the pyxis, and that he was aware something was afoot, but didn't have all the details but enough of them to know what was going on (in general). HE was the one who let me into the med room, took the meds out of pyxis, and did the Q&A. The Charge Nurse herself gave me the instruction to call the Dr., I didn't just grab up the phone and start dialing; I am not allowed to take phone orders, and was uncomfortable with it...so she stood there with me while I dialed a pager.

We are allowed to interact with the Drs...as a matter of fact, it's encouraged. I had two different dealings with Drs today - one ortho, and one oncology. They didn't get upset that a student nurse was doing the job she was supposed to be doing; and my staff RN was with me the whole time. So maybe it's different elsewhere, and it sure was different last semester, but this semester, we're expected to be interacting with the Drs at the level we're at.

Tonight, the charge nurse from last night asked for my help with a delicate situation...I was happy to oblige (with my instructor's full approval). That instance itself told me that she didn't mind what happened yesterday...and that it was not an issue, no complaints had been made, and that I had not acted impetuously. I can't help but think that if it's perceived that a student nurse is accidentally 'outshining' a staff nurse by taking the time to do something which she was unwilling to do, then it's not the student's problem, it's the staff nurse's issue. And since the charge nurse was the next in the chain of command, I don't think there was any real issue going to her for instruction, either. As for telling the staff RN to do her job...I just can't imagine that saying anything along those lines would've changed a thing...not to mention that I am unsure of all the rules (and the culture) to actually do more than ask her twice to take care of the patient, and she refused both times. So what else was I supposed to do? I went up for direction...and got it.

Upshot of this is that I've learned something, and that I've also put the patient's comfort first. No one's complained, there's been no crisis, it was just an odd situation all the way round...and while I understand the concerns and caution voiced in this thread, as my instructor said last night, "you're doing what we're teaching you to do...patient comfort comes first." HE'S not upset, the charge nurse isn't upset, and the patient felt better in the end.

As for me, we had two code blues and two behavior team calls tonight, and I helped do post mortem care for the first time (and immediately afterward ran for the bathroom and brought up my lunch...). I'm bushed. I don't mean to come across upset, as I'm not...I'm just a wee bit too tired tonight to communicate perfectly, and 5 am will come early and fast. I know you understand how that is...

Thanks again for all the feedback - I really do appreciate it, and it's all a learning experience.

Best-

Lovin' Learning

[caliotter3]

I think that you did a good job in taking care of this patient. What I find strange is that your instructor gave you the baloney about making the offgoing nurse look late. Not an appropriate point to be making to a student.

[Purple_Scrubs, BSN, RN]

Honestly, when I was a 2nd semester student I don't think I would have had the guts to do what you did. I have to give you major credit for that! Go you!

[RochesterRN-BSN, BSN, RN]

I am sorry but I don't think that as a student or fellow RN that we should never step up to the plate and get something done that a lazy slacking nurse is not. To say that you should NEVER try to outshine the assigned nurse or make her look like she is not doing her job.....that is a little out of wack I think. Sometimes a nurse is NOT doing her job. period. and what? the rest of the people around her should not step up to the plate, step in, and get the patients needs met as they have been neglected. All because we don't want to make it LOOK like she is not doing her job......suprise she ISN'T doing her job. I am there for the patients and not to make bad nurses look good when they are not! Sorry. I have worked with nurses that have such a bad attitude and are so lazy that some things would never get done if left to her!!! Sometimes it just in the approach....saying,"you know what, I totally understand that you are exhausted and are ready to get out of here! That's fine....I am totally free and would be happy to help out here so that this patient can get what she needs without having to wait for the next nurse...." and so on. Yes as a student you will be limited in what you can do but once working you can do this--I have. Most of the time I have never had a bad reaction. I just feel like yes we have assignments but to really work as a productive team I view all the patients on the floor as everyones....in the sense of if the assigned nurse is not READILY available its up to all the others to cover until she/he is available.

[Daytonite, BSN, RN]

To say that you should NEVER try to outshine the assigned nurse or make her look like she is not doing her job.....that is a little out of wack I think. Sometimes a nurse is NOT doing her job. period. and what? the rest of the people around her should not step up to the plate, step in, and get the patients needs met as they have been neglected. All because we don't want to make it LOOK like she is not doing her job......suprise she ISN'T doing her job.

If you want to have good relationships with the people you work with you might want to re-think that.

It also involves the hospital's Liability Insurance coverage. Worst case scenario (that's not what happened here) is that something goes wrong, the patient ends up getting injured, sues, the hospital hasn't got a leg to stand on, everybody looses and the patient goes home with a big payday.

You guys need to remember that before you went to clinicals you were told the rules that you had to follow. Please remember that when you are in training to be RNs you are also in training to be future leaders. Leaders have responsibility not only to the patients they care for, but also to the employers and other employees they work for. If you don't follow rules and procedures and it leads to a facility failing there will be no place for you to do your fine nursing care. Contrary to what you may believe, rules were not made to be broken.

[RochesterRN-BSN, BSN, RN]

Sorry but I have no intentions to "rethink" anything here. When we are more concerned about covering a lazy nurses reputation then we are about putting patients needs first then the system has a big problem. And if a group of nurses on a shift works as a team this stuff doesn't usually happen-- I am not there to make friends--yeah great if I do-- but I am there to take care of patients.

[LovingLearning]

Daytonite said

You guys need to remember that before you went to clinicals you were told the rules that you had to follow. Please remember that when you are in training to be RNs you are also in training to be future leaders. Leaders have responsibility not only to the patients they care for, but also to the employers and other employees they work for. If you don't follow rules and procedures and it leads to a facility failing there will be no place for you to do your fine nursing care. Contrary to what you may believe, rules were not made to be broken.

I don't know which rules I broke?

I asked the staff rn twice to help the patient, and asked her what I should do to start the process. She declined to either give me instructions or to take care of the patient herself. I went up the chain of command in a situation I was unfamiliar with and I didn't let a patient suffer. The staff RN went home. My instructor let me into pyxis. I gave the pt the vicodin and she reported 2/10 in 30 minutes.

I followed school protocol...patient care comes first. I followed the charge nurse's directions in getting ahold of the Dr in the absence of my instructor. I did as we are taught...interacted with the Dr as appropriate (very little, in fact). Since the fax was down, the NA took the oder (as usual) to the pharm. Pharm put it into pyxis. The patient got her meds. No one complained, or was even upset. My instructor wanted all the details just in case - as I would, if the roles were reversed.

Leaders, to me, are those folks who step in and deal with a problem when it arises if no one else is doing it. Leaders set an example. Leaders go to their leaders when there's a situation they don't know how to handle. Leaders take responsibility and action when the situation calls for it.

For me, being asked to take care of a very delicate situation yesterday by the same charge nurse from the day before spoke of her confidence and trust in my judgment...additionally, my staff RN asked me to come with her for emotional support during a procedure she was uncomfortable with. Apparently, with the charge nurse and the RN I was assigned to, they're comfortable with me. And my instructor didn't see fit to write me up, discipline me, or admonish me in any way other than what he did in the parking lot after hours.

So I'm not sure which rules I broke.

Best-

Lovin' Learning

[Daytonite, BSN, RN]

i don't know which rules i broke?

ask your instructor.

i followed school protocol...patient care comes first.

if that were true your instructor wouldn't have taken you aside later to talk with you. i think you need to talk with your instructor more about this.

leaders, to me, are those folks who step in and deal with a problem when it arises if no one else is doing it. leaders set an example. leaders go to their leaders when there's a situation they don't know how to handle. leaders take responsibility and action when the situation calls for it.

leaders also make sure that policies and procedures are enforced and followed when others don't want to do that. otherwise, the animals run the zoo. that is part of taking responsibility.

for me, being asked to take care of a very delicate situation yesterday by the same charge nurse from the day before spoke of her confidence and trust in my judgment...additionally, my staff rn asked me to come with her for emotional support during a procedure she was uncomfortable with. apparently, with the charge nurse and the rn i was assigned to, they're comfortable with me. and my instructor didn't see fit to write me up, discipline me, or admonish me in any way other than what he did in the parking lot after hours.

a staff charge nurse asked you to do something that one of her staff nurses should have done? is that what you are saying? did that require approval of your instructor first? why would a staff

rn

need a student to accompany them for

emotional support during a procedure she was uncomfortable with

?

that doesn't sound normal. in fact, it sounds dangerous on the part of this staff nurse to me. they could have, at any time, turned to you and asked you to take over. is that allowed without your instructor being present? does your instructor even know something like this happened? you may not have been written up, disciplined, or admonished--yet--because your instructor is still investigating this incident and wanting to get all his facts correct as well as consulting with his supervisor on how to deal with this. it is what i would do in the situation to make sure i was being fair.

when we are more concerned about covering a lazy nurses reputation then we are about putting patients needs first then the system has a big problem. and if a group of nurses on a shift works as a team this stuff doesn't usually happen--i am not there to make friends--yeah great if i do-- but i am there to take care of patients.

it is not a student nurse's job to be concerned about covering for lazy nurses or their reputations. teamwork does not mean doing everyone else's job when they fail to do it. read your rules for behavior at the clinical site. your clinical instructor is your supervisor and is in charge of your behavior and what you do.

[ladymedik]

I cannot believe the attitude of the nurse who was only concerned about going home. I understand the "overtime issue", but my goodness!!! Who are we serving? If my family member were in pain, and a nurse was heard to say, "I want to go home, let someone else deal with it" , I would hope the hospital would let that nurse go home permanently! I applaud your resourcefulness and caring. Don't let the politics of hospitals take that away from you.

[ReinventingMyselfAgain, MSN, RN]

As an instructor, I have to say that for the most part, I agree with Daytonite's points.

Did you 'break any rules' per se? Technically, no (of course, depending on what your schools/instructor's rules are). I personally like to know of any interactions that the students are having with the docs. I do encourage them to communicate with them. Most of them are petrifued to do so (2nd semester as well), and I usually need to go through a walk-through of what they are going to say to them.

The two things I think that would really concern me (if you had been under my watch during this situation) is that this was not your patient, and maybe... just maybe, there might have been something you did not know about this patient when obtainining the order. You did look in the chart, but honestly, as a second semester student, could you honestly say you were armed with enough info to call the doc? Allergies, contraindications, history of what works/doesn't work for the pt, etc? If you were, (especially at that hour, at the beginning of the shift) then you are a phenominal student (and I do not mean that sarcastically).

My other concern is that your instructor left you on the unit to provide care in your absence. I know, there was a fire alarm. This, obviously is out of your control. But as an instructor, I very rarely leave their site.

I am personally a more easy going instructor (IMO, and the opinions of my students :wink: ). But I have a couple of colleagues that would have hit the roof.