Student Attempted IV 7 Times

[ChickenHealer]

Not sure where to post this but I saw something today in clinical that was just eating me up. My school has an agreement with a few clinical sites to allow students to return to clinical early, and I saw something today that made me very uncomfortable. A nurse allowed myself and another student to go into her (sedated) patient's room, and offered to let us start an IV. IV insertion is strictly prohibited and the clinical coordinator specifically told us not to even attempt it, as it can result in "major consequences". I told this to the nurse, but my classmate decided to try to insert the IV anyway. The classmate poked the patient 1, then 2, then 3.... until the nurse finally stopped her, at 7 attempts. 7 insertions, including one on a different site which was not cleaned. 

The school's clinical coordinator showed up on site about 30 minutes after the event, and she asked me if we had gotten to do any IVs. I had the feeling that she knew about it, and I told her about my classmates IV attempts. It turns out that she had no idea about the event, she just happened to show up and ask. She was angry at me for reporting it and told me not to tell anyone about it, or there would be consequences. The student and I are paired to go into the ED this week, and she was going on about how she hopes that we'll have more tries at starting IVs and that she'll make sure I can do it next.

I have no idea what to do. I feel that if I report it further, the clinical coordinator will do something to take it out on me. I can't stop thinking about how that patient was sedated and didn't have any idea a student was involved in their care, the potential pain, or the risk of infection from all of those repeated insertions, including a site that wasn't cleaned at all. 

[PoodleBreath]

Just curious about how much time it would take to do seven attempts. Was the ICU nurse with the student the whole time? Seems like it would take up a good chunk of time for a busy nurse.

 

[Hoosier_RN, MSN]

3 hours ago, MunoRN said:

In terms of consenting specifically for a student to perform a procedure I've worked in one place where that was the rule, but other than that patients haven't been able to decline who is doing the procedure, if they decline to allow a student to place an IV then they've declined the IV.

I was in the hospital after a procedure once. I had a student first day, and I had been asked by the clinical instructor if said student could do x, y, z, etc. I consented. The poor little gal was rough and did some damage. The next day, when the instructor came in to report that student would be back in to do care, I declined, which was well within my rights to do, as I had already discussed with the hospital department manager. I got my care from the staff that was assigned to do so. Unfortunately,  because of what the youg lady did, I ended up requiring another procedure. She was in her 3rd semester, so she should have known basic wound care ?‍♀️

[MunoRN, RN]

56 minutes ago, Hoosier_RN said:

I was in the hospital after a procedure once. I had a student first day, and I had been asked by the clinical instructor if said student could do x, y, z, etc. I consented. The poor little gal was rough and did some damage. The next day, when the instructor came in to report that student would be back in to do care, I declined, which was well within my rights to do, as I had already discussed with the hospital department manager. I got my care from the staff that was assigned to do so. Unfortunately,  because of what the youg lady did, I ended up requiring another procedure. She was in her 3rd semester, so she should have known basic wound care ?‍♀️

And I completely get being leery of having a student provide your care, and even just deciding to decline a procedure all together as a result.  

But I don't really agree that patients should be able to choose who provides their care.  Of course every patient would rather have the most experienced and most proficient nurses and doctors caring for them, but that experienced and proficient nurse only got to that point because the patients before you let them gain that experience and proficiency.  As a result, I tend to agree with facilities I've worked at that don't allow the option, it's either the student or nothing.

[Guest856929]

The 7 attempts notwithstanding, I think you are a little troublemaker and you should only stick your nose where the aroma won't offend you. You are a student, do what you are supposed to learn and mind your business. 

[Hoosier_RN, MSN]

23 minutes ago, MunoRN said:

And I completely get being leery of having a student provide your care, and even just deciding to decline a procedure all together as a result.  

But I don't really agree that patients should be able to choose who provides their care.  Of course every patient would rather have the most experienced and most proficient nurses and doctors caring for them, but that experienced and proficient nurse only got to that point because the patients before you let them gain that experience and proficiency.  As a result, I tend to agree with facilities I've worked at that don't allow the option, it's either the student or nothing.

I will agree to disagree, especially if the care given is invasive. No one ever answered if this IV was necessary and ordered. OP also noted that some areas that were cannulated weren't cleaned. Infection risk. I think in the case of anything invasive, a patient has the right to refuse, especially in a case like this where the student was blindly sticking a patient, and did so 7 times. I'm not sure how a prudent nurse was watching her, to allow 7 attempts

[Guest856929]

33 minutes ago, MunoRN said:

And I completely get being leery of having a student provide your care, and even just deciding to decline a procedure all together as a result.  

But I don't really agree that patients should be able to choose who provides their care.  Of course every patient would rather have the most experienced and most proficient nurses and doctors caring for them, but that experienced and proficient nurse only got to that point because the patients before you let them gain that experience and proficiency.  As a result, I tend to agree with facilities I've worked at that don't allow the option, it's either the student or nothing.

7 attempts is not inexperience and lack of proficiency, it is incompetence, if not ineptitude. It is wise to know one's limitations and when to seek guidance. If the patient needed two IV's, the ICU nurse could've shown the student how to do 1 then let the student watch and do the next one. See one, do one, teach one, wash, rinse, repeat. It is as such that repetition yields excellence and proficiency. 

[Guest856929]

8 hours ago, carti said:

eh in the ICU, there is no such thing as having too much IVs especially when we have like 3-4 different IV antibiotics ordered with other stuff as well.  A sedated patient maxed out on profofol probably won't even feel a pinch but 7 tries cmon thats still too much and overboard.

If you can't work with 3 PIVs to fit what's ordered, then maybe it's time to get a PICC line. 

[MunoRN, RN]

1 hour ago, Hoosier_RN said:

I will agree to disagree, especially if the care given is invasive. No one ever answered if this IV was necessary and ordered. OP also noted that some areas that were cannulated weren't cleaned. Infection risk. I think in the case of anything invasive, a patient has the right to refuse, especially in a case like this where the student was blindly sticking a patient, and did so 7 times. I'm not sure how a prudent nurse was watching her, to allow 7 attempts

I completely agree with the right to refuse, but not to refuse all staff but the most proficient if that isn't indicated.

 

51 minutes ago, cynical-RN said:

7 attempts is not inexperience and lack of proficiency, it is incompetence, if not ineptitude. It is wise to know one's limitations and when to seek guidance. If the patient needed two IV's, the ICU nurse could've shown the student how to do 1 then let the student watch and do the next one. See one, do one, teach one, wash, rinse, repeat. It is as such that repetition yields excellence and proficiency. 

What I got from the OP's (somewhat cryptic) description is that there were two "attempts" with one attempt involving multiple sticks.  Personally I would agree that each stick is a separate attempt, my technique is that if I don't get straight into the vein then I'm done, unless I could tell which way the vein rolled and feel confident that the vein isn't going to move further and then re-aim and attempt to cannulate the vein.  I seem to be in the minority in that view though as many if not most nurses, including vascular access nurses will do far more pulling back and 're-aiming', re-sticking, or just plain rooting around and consider that all to be within a single attempt.

[LC0929, ASN, RN, EMT-B]

On 1/19/2021 at 9:24 PM, ChickenHealer said:

Not sure where to post this but I saw something today in clinical that was just eating me up. My school has an agreement with a few clinical sites to allow students to return to clinical early, and I saw something today that made me very uncomfortable. A nurse allowed myself and another student to go into her (sedated) patient's room, and offered to let us start an IV. IV insertion is strictly prohibited and the clinical coordinator specifically told us not to even attempt it, as it can result in "major consequences". I told this to the nurse, but my classmate decided to try to insert the IV anyway. The classmate poked the patient 1, then 2, then 3.... until the nurse finally stopped her, at 7 attempts. 7 insertions, including one on a different site which was not cleaned. 

The school's clinical coordinator showed up on site about 30 minutes after the event, and she asked me if we had gotten to do any IVs. I had the feeling that she knew about it, and I told her about my classmates IV attempts. It turns out that she had no idea about the event, she just happened to show up and ask. She was angry at me for reporting it and told me not to tell anyone about it, or there would be consequences. The student and I are paired to go into the ED this week, and she was going on about how she hopes that we'll have more tries at starting IVs and that she'll make sure I can do it next.

I have no idea what to do. I feel that if I report it further, the clinical coordinator will do something to take it out on me. I can't stop thinking about how that patient was sedated and didn't have any idea a student was involved in their care, the potential pain, or the risk of infection from all of those repeated insertions, including a site that wasn't cleaned at all. 

What I find extremely disheartening is the fact that the “instructor” or “staff preceptor” is COMPLETELY RESPONSIBLE for this.  What’s even worse is that if this student has the potential of being a good nurse, they are being completely robbed of an acceptable education.  I’d transfer out of that program as fast as possible.  

[Guest856929]

1 hour ago, MunoRN said:

I completely agree with the right to refuse, but not to refuse all staff but the most proficient if that isn't indicated.

 

What I got from the OP's (somewhat cryptic) description is that there were two "attempts" with one attempt involving multiple sticks.  Personally I would agree that each stick is a separate attempt, my technique is that if I don't get straight into the vein then I'm done, unless I could tell which way the vein rolled and feel confident that the vein isn't going to move further and then re-aim and attempt to cannulate the vein.  I seem to be in the minority in that view though as many if not most nurses, including vascular access nurses will do far more pulling back and 're-aiming', re-sticking, or just plain rooting around and consider that all to be within a single attempt.

So if you stick a patient and don't get flashback, then you advance or redirect, you count that as 2 sticks? or if you get flashback then lose it because the IV is advanced too far then you retract back and redirect and get the catheter in place that would be 2 sticks? I don't think so albeit I cringe when I see someone digging around blindly. If the needle comes out of the skin, that is one attempt. 

[MunoRN, RN]

6 minutes ago, cynical-RN said:

So if you stick a patient and don't get flashback, then you advance or redirect, you count that as 2 sticks? or if you get flashback then lose it because the IV is advanced too far then you retract back and redirect and get the catheter in place that would be 2 sticks? I don't think so albeit I cringe when I see someone digging around blindly. If the needle comes out of the skin, that is one attempt. 

I don't think this has any commonly agreed on definition, but in my experience students or new nurses will often deem repeatedly advancing the catheter as multiple "attempts".

And in my experience there are many nurse who would consider withdrawing the needle to where the tip is out of the skin to be no different than withdrawing it to where the tip is micrometers from the surface of the epidermis.  Not saying I agree with that.

[ChickenHealer]

On 1/21/2021 at 10:54 AM, trytounderstand said:

Remember you are the patient's advocate and if you are witnessing something that should not be happening it is your responsibility to take care of that patient.    

Yes, I completely agree. I saw a few people commented similar things- I did speak up about it. I told the nurse that this isn't something that we should be doing. I spoke up when the site wasn't cleaned, I spoke up and told the nurse that she should take over. And when it ended, I reported it to someone higher up. I keep seeing people post that I should have been a better advocate- I'm really not sure what more I could have done in the moment, unless someone was expecting me to physically intervene. I posted it here, horrified, nervous, and exhausted, looking for further advice on what to do, and most of what I got was essentially, either that I was lying, or that I should just get my nose out of it and do what I know is right in my own practice, which I do. 

 

On 1/21/2021 at 7:37 PM, Wuzzie said:

 

This opened up the horrifying thought that some people are actually allowing others to practice IV starts on defenseless patients just for the sake of practice. I don’t care how sedated the patient is this is entirely, morally and ethically wrong and must not be allowed to continue. 

This is another point that I completely agree with. As I said, I reported the event and I spoke up to the nurse and student involved. I never once touched the patient myself and I absolutely would never have done something like this my self. I've had family sedated in the ICU. It's uncomfortable to see people talk about how they think patients shouldn't be able to refuse a student, as I thought care was supposed to involve the patient's choice. To answer a previous post- Yes the patient DID need another IV site inserted.

Sorry. I've been working 16 hour shifts and was a little too run down to hop on and check the replies after I posted my follow up.