Healthcare Trend: Does Patient Satisfaction Kill?

Posted on April 10, 2012 by Megen

I read this post on the Emergency Physicians Monthly blog and subsequently chased down the abstract for the referenced article, “The Cost of Satisfaction: A National Study of Patient Satisfaction, Health Care Utilization, Expenditures, and Mortality” (Arch Intern Med 2012;5:published ahead of print). I have repeatedly stated my personal opinion that patient satisfaction does not good medicine make, but this is a for-real study in a respected, peer-reviewed journal. According to the abstract, the study found that patients with the greatest satisfaction scores

  • Visited emergency departments less
  • Had more inpatient admissions
  • Spent more money both overall and on prescriptions
  • Were more likely to die

Fewer ED visits surprised me and the higher mortality surprised me. If you’re satisfied, shouldn’t that mean you’re getting every test you could imagine and more? All the drugs you want? It makes logical sense to me that a patient would feel greater satisfaction with a physician if he or she were admitted more often to the hospital and took more medications, because that would say to many patients “I’m being taken seriously. My feelings of illness have been validated.” But why is this killing them?

The EP Monthly blog post has several believable theories, such as physicians prescribing unnecessary treatments just to make patients happy. The example Dr. Sullivan provides is a simple one: doctors prescribe antibiotics for viruses to get patients to be quiet and go away. Is this harmless? Well…maybe not. One can easily extrapolate from this tiny example: what of patients who have multiple unneeded radiological diagnostic tests? What of those who experience reactions from unmanaged polypharmacy? I’m not talking about street-drug users. I’m talking about iatrogenic harm, straight up and neat.

I did not pay for the entire Archives of Internal Medicine article, so I rely on Dr. Sullivan’s analysis of it, but it sounds as if the authors of the original study sliced and diced the data to see if they could make the numbers show that sicker patients (who would have been more likely to die anyway) skewed the outcomes, but no. In interpreting studies such as this one, one also has to recall that correlation is not causation, but at the very least more studies need to be done, and quickly, because if a mystery variable has cropped up that is increasing patient mortality along with patient satisfaction, we in healthcare have a very big problem on our hands.

Sullivan asks whether new headlines will run along the lines of “HCAPS [sic] kill?” He asks, “How will administrators refute a plaintiff attorney’s allegation that they encouraged doctors to order discretionary testing that was detrimental to their patients’ interests in order to increase hospital profits?” This is strong, heady stuff, but not, I think, out of the realm of possibility.

This is a wrench in the spokes that I did not see coming mixed in with all the other healthcare reform issues zinging around. I anticipated that nurses would be expected to develop a flair for being waitresses and maids even more than we are and to put up with increasingly unacceptable behavior from patients, but I did not anticipate that the emphasis on patient satisfaction would go so far as to precipitate their deaths. And perhaps it has not. This boulder has only begun to roll down the hill. The trend is something nurses need to watch, however. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) affects our bottom line and our patients’ health, which is reason enough for me.

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Judge Not, Lest Your Patients Die

Posted on April 6, 2012 by Megen

I wrote earlier this week about triage and the huge responsibility that nurses have in that process, which can ultimately boil down to the decision of who lives and who dies. That post started me thinking on the larger issue of judgmentalism in nursing, and fortuitously that issue is in the news lately regarding a patient named Anna Brown.

Anna Brown died from pulmonary emboli because multiple medical personnel took a gander at her and her ankle pain, decided she was your run-of-the-mill homeless drug-seeker, and had her arrested and sent off to jail. That not being the recommended treatment for blood clots in your legs that lodge in your lungs, she died. Whoops.

Lawsuits are no doubt whirling around over that one, and I bet the nurses and physicians in that ER have some major ‘splaining to do. Bloggers are writing about the heinousness of the situation, but I have yet to read a post that doesn’t include some variation of “but I’ve done that too.” Self-reflection is an integral part of being a good nurse, so I thought about it. Have I done that? I don’t think I’ve made decisions that actually had fatal outcomes, but am I judgmental? Yes. I don’t like to be that way, and I definitely don’t like admitting it in public, but I will admit it because this case or something similar could easily happen to any nurse, including me, so we all need to be thinking about it.

My first response was “heck no, I’m not judgmental.” My parents raised me to be liberal and accepting of all religions, skin colors, and sexual orientations. They left out acceptance of all body odors, choices of street corner residences, and propensities toward violence against healthcare workers. They failed also to teach tolerance for obvious and frequent abuse of the healthcare system for reasons of boredom, hypochondria, or desire for narcotics. These things are all difficult to truly accept without judgment. I try, and usually there is some part of every patient or every patient’s story that I can identify with and dredge compassion up from that one thing. Usually if I have that, I can avoid a truly reprehensible moral stance. But it is challenging. Anyone who judges nurses for being judgmental has not been exhausted from treating truly sick people only to have a high homeless person who has already been there six times that week screaming in the triage bay for pain medication and threatening to punch the nurse if he doesn’t get it. Right now.

But does that make it OK to judge people or, more relevantly, to deny them medical treatment on the basis of the judgment? Nope. That lady should have had a medical screening examination in accordance with EMTALA just like everyone else. I don’t know whether she did or not. I’m just using her case as a jumping-off point because it’s recent in my mind.

What is the answer? The healthcare system cannot survive if we treat everyone with a full workup who makes up wild stories. We as nurses have to make judgment calls because that’s part of our job. That puts us squarely in the middle of a paradox. We must make judgment calls to triage patients and treatment decisions, yet we must do this without being morally judgmental. I don’t have an answer, other than this case should serve to cause all nurses to search their own consciences and see if they have room for improvement.

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Triage: When You Are the Sorting Hat

Posted on April 3, 2012 by Megen

I triage a lot. I don’t like it. The triage nurse has to be able to use x-ray–vision assessment skills and ask the right questions in a circus environment while juggling about 20 balls and keeping a bird’s-eye view of an entire ER. People get really mad in ER waiting rooms. It is maddening to have to wait when you’re sick. I hate even waiting in line at the grocery store. I get it. But it’s worse when you’re sick, especially when you see people going ahead of you. I explain at least a dozen times a night that we see patients in the order of severity of illness and not in the order of arrival, but sometimes sick people don’t look that sick to the untrained eye.

Triage (“sorting”) doesn’t occur only in emergency rooms, though. Any nurse who has more than one patient and one task has to sort through everything and decide what goes first, and everyone and everything else, by definition, has to wait. That means every nurse has to be a wizard at those x-ray–vision assessment skills and knowing which questions to ask to figure out who is sickest and who needs treatment first. We are all sorting hats! But most people get irritated at having to wait, especially because we can’t exactly say, e.g., “You have to wait on your warm blanket because I have one man who is having trouble breathing and another lady having chest pains.” It’s just not good customer care to effectively tell patients, “Other people are sicker than you.” It makes it sound as if they are less important. It’s a difficult issue.

Sometimes triage issues are much worse than just deciding who gets the first warm blanket. Sometimes we have to shift into disaster triage. Ask the nurses and doctors in Joplin, MO. Sometimes we have to totally reverse everything in our instincts and education and NOT treat the sickest patients first. Sometimes we have to reverse into utilitarian triage—save the most people. Do the greatest good for the most patients. That means leaving the sickest patients untreated and probably dying. I have not yet had to do this, but I have to think about it periodically during various educational modules and certifications. If it’s hard to explain to someone why he has to wait for a cup of pudding, how hard is it to explain to someone why you’re going to have to let her die? How do people react? Do they understand? It’s impossible to put myself into the situation of the triager or the patient, having been in, thankfully, neither situation in a real disaster thus far in my career. But any nurse at any time could be faced with just this situation, because disaster, unfortunately, can strike at any time.

Triage is an underemphasized, undertaught skill in both nursing education and in actual on-the-job orientation and training. It is formally taught in the ER, but it should be done for all nurses. We all need to be able to know the system for triage and be able to implement it, and by that I mean be able to implement our facility policy and be able to personally do it. We have to be emotionally prepared, as much as possible, to do what needs to be done. No nurse likes or wants to feel mean or leave any patient in pain, but we are all sorting hats, like it or not. At some point, probably in our very next shift, we are going to make a decision that leaves one patient in discomfort at the expense of another one who is in more discomfort.

And as I said, I don’t like this part of my job. It feels like playing God sometimes. Maybe that is why nurses don’t like to talk about disaster triage; we don’t like to remember that it is we who decide, literally, who lives and who dies. Fortunately, most triage decisions are informal ones implemented minute-by-minute at the bedside and not full-out disaster triage decisions. But every nurse should theoretically be prepared for a call for all hands on deck and a need for disaster triage. Are you?

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Should Nurses Lie?

Posted on March 29, 2012 by Megen

Should I lie? This is a question that I, at least, was raised to always respond to as “no.” My parents even told me what most parents do: “if you tell the truth, you won’t get in as much trouble.” I never found that to be the case, but I suppose that’s why children are not as honest as they’re reported to be.

But now we’re adult professional nurses and not children who broke the vase. Will we get in trouble if we tell the truth? In the best of all possible worlds, if we tell the truth, we won’t get in as much trouble, but just as when we were children, we don’t live in that world. When would we lie? Or stretch the truth? And when would that maybe even be beneficial?

Situation 1: A young (say, 35-year-old) patient with an imminently terminal oncologic illness arrives in your zone for admission. She is moaning in pain, pale, and not oriented to time. Vitals are as follows: BP 70/45, HR 135, temperature 103F, SpO2 98% on room air, respirations 25 per minute. Fifteen minutes later, despite ongoing fluid challenge, her BP is 70/44. The patient grabs your hand and asks, “Is this it? Am I going to die soon?” What do you say?

Situation 2: A patient is receiving an elective procedure, and the physician makes an error that causes a stop in spontaneous circulation. ACLS algorithms are followed, and the patient returns to consciousness and asks you how the procedure went. What do you say?

Situation 3: A teenaged male patient is brought in by ambulance in full arrest after an unknown downtime. He is dusky centrally and peripherally with a core body temperature of 94F. He has had several trips through the ACLS asystole algorithm with no return of spontaneous circulation or shockable rhythm. You are assigned to be the family liaison. They ask how he is. What do you say?

I could go on, but these are amalgams of situations I’ve seen, and each time I’ve been stymied. Do I say what I think? Usually not. But how does a nurse validate the patient’s or family’s feelings or suspicions without exposing the institution to possible liability? And how much does the factor of causing something to happen by implanting the idea come in to play?

Situation 1: If I agree with my patient that she is in fact probably going to die soon, will she because I reinforced her thoughts, or have I validated her and comforted her during her inevitable death?

Situation 2: Do I disclose the code to the patient, or do I hedge? (In this situation, in reality, I would be on the phone with risk management before the Amidate wore off.)

Situation 3: Ask the physician running the code what to tell the family members. They know there should be a nurse liaison. Tell the family that Dr. So-and-So reports thus-and-such. But in these situations, is it really kind to instill hope? I trend toward implying they should prepare for the worst. Is that wrong? I don’t know. I do this a lot, working in an ER, and some families seem to want to hope for the best and some trend toward hoping for realism. Nurses can gauge reactions to some extent on the basis of what the family exudes, but generally these are high-tension time-sensitive situations. I go with what I would want to know. Is my family member going to make it or not? How bad is it? Should we go in now to see him or her before it’s too late? These are nitty-gritty situations. I go with nitty-gritty honesty, delivered as compassionately as possible.

What do you do? If you are a student and haven’t run across these situations, think about it. What will you do?

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Trend: Dress Codes for Nurses

Posted on March 27, 2012 by Megen

I get uniform catalogs all the time in the mail. I used to page through them eagerly, looking at the prints and adorable gathered tops and the bottoms with flared legs and various slits, pockets, and loops. When I was a CNA, I worked on a floor where we were allowed to wear any scrubs we wanted, so I had a collection of neon green solid scrubs, matched solid pants and cute patterned tops (with gathers and ribbons and puffed sleeves), and a rainbow of other plainer outfits. My philosophy was, if I’m going to spend my days wiping people’s bottoms, I should look cute doing it. It’s only fair. Buying scrubs of any kind has become more of a chore and less of a thrill as time has marched on, but since they comprise the bulk of my wardrobe, it’s still a consideration.

Since I became an RN, I have worked in hospitals with dress codes, so I’m now on my third wardrobe of scrubs. Dress codes seem to be more common. I’m reading on Twitter that more and more hospitals are implementing them, much to the chagrin of nurses who, like me, have rather large collections of scrubs that don’t meet the criteria. Nurses who work in places with dress codes, though, by and large come around to defending them. Why? It takes the guesswork out of deciding what to wear, but also, depending on how the policy works, it can be better for patients.

There are different kinds of dress codes. Mostly they’re split into dressing by department or dressing by specialty. I’ve worked in both kinds of hospitals, and although I chafed at first at dressing by specialty, I came to like it. RNs dressed in one color, CNAs dressed in another color, and all ancillary staff wore whatever scrubs they wanted. At first blush, that seems unfair, but in practice it worked out really well because patients could tell at a glance who was entering their room. The hospital orientation packet even explained the dress code. That way, no one accidentally asked the housekeeper for a repeat dose of morphine or asked the RN to empty the trash can. Patients get worn out and exasperated trying to figure out who people are when everyone who enters the room is wearing scrubs and there’s no rhyme or reason to it. An RN/CNA dress code split removes the guesswork. In a perfect world, anyone who walked in would announce his or her credentials, but they don’t, and let’s face it—many of our patients don’t remember anyway.

The dress code–by-department idea does nothing to solve any of these problems. I suppose it’s meant to show esprit de corps or something, but in practice it just means you have fewer choices deciding what scrubs to buy. The best I can say for it is that all my scrubs automatically match. My closet is a sea of royal blue and black. If I’m feeling particularly gothy, I can dress in black from head to toe including my shoes, so I guess that’s groovy. But I liked the other hospital that had legitimate patient care–related reasons for making me buy yet another set of scrubs. I guess I don’t really care as long as I don’t have to wear a white top and skirt and soft-soled lace-up white shoes and hose, right?

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Reasons to Get Specialty Certification

Posted on March 23, 2012 by Megen

A few days ago, March 19, was annual Certified Nurses Day (there is even a Web page). Apparently, this is the birthday of Gretta Styles, a nurse who really plugged specialty certification; apparently, it needs more plugging, because I never heard of Certified Nurses Day until my Director of Nursing sent out an e-mail to congratulate all of us who have specialty certifications. It’s nice to have some reinforcement because in general, I don’t think people give specialty certification the kudos it deserves.

What is it? Specialty certification means you study and take an enormously long and difficult exam, and if you pass you get a certificate and extra letters after your name indicating that, theoretically, you possess more and deeper knowledge than your average nurse in that field. Generally, you cannot sit for the exam unless you have a certain amount of experience in that specialty area.

Voluntarily studying? Yes. Some specialty areas require certification (chemotherapy nurses must have it in my hospital), and if that’s the case your employer may help you by sending you to classes and paying for it, but even if they help you out financially there is a great deal of butt-to-chair preparation. These are board exams, complete with all the esoteric far-out-there subject material we all know and love from the NCLEX.

Why do it? If it’s required, you have to. Otherwise, there are actually many intangible benefits (“intangible” because you likely will not get a raise, recognition, or anything more than your board certification designation on your badge from your employer).

  • Board certification instills personal confidence. If you put the time and effort into really hunkering down and learning that far-out stuff you need to know to pass, it can only add to your sense of “I know what I’m doing.”
  • Board certification instills patient confidence. Patients often ask me what “all those letters after your name” mean. Most are clearly impressed by the discovery that I’m board certified in emergency medicine, because if you’re sick, you want the most qualified nurses taking care of you, don’t you?
  • Board certification increases employer confidence. Say you’re a nurse manager, and on your desk sit two résumés. Both nurses have the same number of years of experience in your field, both possess all the required certifications, and both come highly recommended by colleagues. One has taken the trouble to pursue and obtain board certification and maintain it. Which do you pick? Right. That extra effort says, “I care deeply about my profession and this particular area of it, and I will take the time to ensure I’m the best I can be.”
  • Board certification may keep you from endangering your license. This is actually a dubious claim backed only at this point by hearsay from the Amanda Trujillo case:

    “‘…the BON decided to issue a notice of charges, so Amanda’s case will be set for an evidentiary hearing,’ reported Chimene Hawes, a supporter of Trujillo’s who lives in Phoenix, on Facebook, Tuesday, March 20, 2010. ‘The board read all the ‘allegations’ in open meeting. They also stated that Amanda is representing to the public that she is an end-of-life specialist, for which she has no certification.’”

    Still, if you ever find yourself in a position where your competency is challenged, it’s nice to whip out the “actually, I AM an expert in this field” card.

  • Board certification lays out similarities to physicians’ training and credentialing. Patients understand what it means because much is made of a doctor being board-certified in such-and-such. It just makes nursing that much more respectable to the physicians we work alongside, in addition to the public eye.
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“It’s Not My Job”

Posted on March 20, 2012 by Megen

As busy nurses, we sometimes forget being new, either to a job or to nursing itself, and we adopt the mindset that mentoring or even helping someone out is not our job. It’s not in our job description, is it? I haven’t read mine lately, because I have plenty of other soporific late-night reading, but I don’t think it is. There’s the adage about nurses eating their young, too. It seems to be a fact that experienced nurses not only fail to help new nurses, but also actively sabotage them. Why? I don’t know. I will continue to blog about it and talk about it in hopes that change will gather momentum, though. The “it’s not my job” mentality hurts everyone. Here’s an example that shows how.

We have a lot of new grads in my department right now. It’s a common nightshift scenario—a lot of experienced nurses quit all at once, and no experienced nurses were banging at the door begging for nightshifts, so here we are. I was working alongside one recently and heard later that she was afraid to ask me for help. I even offered to help her and she said no, so I assumed she didn’t need any. Patient care did not suffer, but still, aghast, I tracked her down and talked to her about it. She reported that one reason for her trepidation was having heard “it’s not my job to teach you that” from other nurses. (Another one was that I intimidate her intrinsically; nurses, don’t let other nurses do this to you! The only way to find out whether your colleagues are approachable is…wait for it…to approach them.)

I told her that was not the case because if a nurse doesn’t know how to do something and no one will help her, it puts the patient in danger. Patient advocacy and ensuring patient advocacy ARE our job, last I checked. Ergo, it IS our job to teach new nurses. I told her that if she asks for help and is refused or belittled, it is the other nurse’s issue and not hers. Now granted, there are times when I am too busy to help or have some other reason, but that is wildly different from “it’s not my job.” She looked unconvinced, so apparently these are not common ideas.

It is vital that inexperienced nurses feel confident asking questions and that, if they don’t, they learn perseverance and do it anyway. Those of us who are more experienced owe it to the next wave of nurses to help out and also to be role models. They will treat their neophytes as they have been treated, as has been the case throughout nursing history, which is why nurses are still eating their young after all these years.

There are limits, of course. We cannot carry the new nurse’s load. We cannot cover for a colleague who is truly not competent or who repeatedly makes dangerous errors. We cannot let our own patient load suffer because we are spending so much time mentoring a new nurse. If those things are happening, the department may need to rethink its orientation system, actually. At any rate, please, please, never refuse to help another nurse because it’s not your job. Patient care is our job, and nurses perform patient care, so helping nurses is helping patients, and that is our job.

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Functioning in the Midst of Fear

Posted on March 15, 2012 by Megen

Dealing with life-and-death issues (especially the death ones) inspires fear. Nurses can kill people by accident, and we always know that in the backs of our minds. That’s the big, bad fear. But there are other things to be afraid of. In the healthcare climate lately, we fear being laid off with no warning or being written up for trifles (followed by being fired for being written up). We fear physical violence from our patients; we fear lateral violence from our colleagues. We worry we will make mistakes on the job that compromise our patients’ care even if they are not life-threatening ones. It can feel as if we are always walking on eggshells for some or all of these reasons.

Yet still we have to pull it together and act. Nurses do not have the option of holding back and letting someone else take the hit. If your patient falls to the ground and has stopped breathing, you do not have time for fear. You can be afraid later. If you fail to step up to the plate and do what is required for any given situation that scares you, patients will go without care. Here, for example, are things that routinely scare me:

  • Violent patients. I hate getting hit, kicked, and spit on.
  • Coworkers I know are angry with me. I’d rather avoid the situation.
  • Telling a physician I am reluctant to carry out an order because it seems inappropriate for the patient’s condition. I fear blowups and yelling.
  • Starting heparin and insulin drips. I don’t know why, but I’m just always terrified I’m going to make a terrible error. Fears don’t have to be rational.
  • Failing to hit the “sync” button on the Lifepak when necessary (sometimes you can learn from others’ mistakes).
  • Missing a sick patient in triage.

Every nurse has a different list, but we all have them. It’s important to know your stumbling blocks and recognize them for what they are (“I’m afraid of this thing” is a powerful statement), because then you can confront them and do your job. I constantly deal with violent patients, triage, and start drips of dangerous drugs. I make doctors and other coworkers mad without meaning to. There is just no way to function without being afraid of anything (and if you are not afraid of anything about your job, you probably need to rethink what you’re doing).

So the first step is realizing what scares you. It can be as “silly” as “I fear dropping NG tubes because I’m bad at it.” It can be as serious as being afraid your patient will die. Whatever. Label the fear(s). Then consider the adage “courage is not the absence of fear; it is being afraid and taking action anyway.” Fear does not preclude action. You can be scared out of your wits and function totally competently.

I’ll repeat that, because it seems vaguely important: you can be scared out of your wits and function totally competently.

Fear is a feeling, not a barrier to successful behavior. Next, deliberately put yourself in the situations you fear. When they don’t kill you, usually the fear will diminish bit by bit. Finally, remember that you can always ask for help. If codes scare you, take ACLS. If death scares you, ask colleagues how they handle patient deaths. If interpersonal conflict scares you, explore resources for learning to handle it. Above all, try not to deny the fear, because nothing will hinder successful nursing like bluster and overconfidence.

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Save Time on the Floor

Posted on March 13, 2012 by Megen

Nurses, when was the last time you had a leisurely shift with plenty of time to do what you needed to? Probably quite a while, if ever. Being a successful nurse these days entails being a time-management ninja. Hospitals are increasing responsibilities for the nurses they have and/or not replacing nurses who leave, so again here we go with the more-with-less theme. It isn’t enough to know every lab value under the sun, understand every disease process for every patient who walks through the door, and write award-winning clinical notes. You also must do these things quickly, efficiently, accurately, and flexibly.

Quickly. Get faster at stuff. If it is a technical skill you are slow at, practice. Does it take you a half hour to start an IV? Are you still charting an hour after the rest of your coworkers have gone home? Practice may not make you perfect, but it will make you faster.

Efficiently. By “efficiently,” I mean figure out how to do the things that matter while leaving out the things you can reasonably and competently leave out. Learn the art of the focused assessment, for example. This may not apply appropriately to your practice area, but often it can, and this particularly applies to reassessment. Why is the patient there? Focus on that. Don’t do the whole thing again. One of my nursing school instructors used to say, “For heaven’s sake, don’t give them any more problems than they came in with.” Also, be more efficient by clustering your tasks. If you have meds to give at 0700, 0800, and 0900, give them all at 0800 (or whatever your facility’s boundary is for medication-administration windows), assuming it is safe and reasonable to do so—you don’t want to mess around with pre-meal medications and insulin, for example. Cluster your trips around your department. It’s amazing how much time gets wasted by the “I forgot something” syndrome. If you’re grabbing stuff to venture to the far side of the department, take a few seconds to make sure you have all the widgets and geegaws you need for all the patients you have down there. Efficiency.

Accurately. Rushing often means making mistakes, so here is another opportunity to live in a nursing paradox: you have to be faster while not making any mistakes (in a perfect world). Rushing can lead to feeling flustered, which can lead to more rushing, which can lead to errors. The best way to avoid this cascade is to keep a cool head under fire. Refuse to get rattled. Don’t skimp on patient-safety issues or take shortcuts for vital things; efficiency will not matter if in the end you have “efficiently” given the wrong patient medication because you skipped scanning a bracelet or double-checking your MAR.

Flexibly. All these tips I just wrote? Be willing to toss them out the window at a moment’s notice. The ability to change your plan on a dime and seamlessly proceed with plan B will save scads of time because you have not committed yourself to plan A to the point that you’re not sure how to reconnoiter. Always recall that sometimes spending more time will save time in the long run, also. Perhaps, for example, you do need to spend a half hour starting an IV—you could get a rickety one in quickly, but you could spend some quality time with warm blankets and voodoo to get the larger-bore catheter in that will survive your patient’s entire hospital stay and allow the acidic antibiotics you’re sure she’ll need. In this case, flexibility demands that you do spend extra time up front to save time later.

Nurses are time-management superheroes. Experts say that humans can do only thing at a time, but I don’t think they’ve visited your average hospital lately.

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“Have You Done This Before?”

Posted on March 9, 2012 by Megen

I had a student recently, and before she dropped an NG tube, our patient asked her, “Have you done this before?” She looked at me with a big thought bubble containing a question mark hanging over her head. That answered the question for the patient, who said, “Forget it. YOU do it [pointing at me].” I did it. Because anytime any patient needing an NG tube comes in when I’m there, I will somehow end up doing it. But that’s another topic.

This topic is the inescapable one that to learn how to perform procedures, nursing students have to practice them on real people. There always must be a first time on a first patient. We don’t like to think of our patients as guinea pigs, because our credo is to put patient advocacy and safety first, and if we were to truly advocate for our patients then the nurse most expert in the procedure at hand would always do it. That is not possible.

We must therefore live in paradox to train new nurses, and the subject is sticky. Do we just have the student attempt the procedure without discussing it with the patient first, or do we explain that this is a student nurse who has never performed the procedure before and ask the patient’s permission? What is the best way to handle it? What is the most ethical way to handle it? When I was in nursing school, my instructors said to respond “I’ve been trained in this procedure” when patients asked if we’d done the thing before. I never liked that because it dodges the question. Most of my preceptors in school instructed me to announce, “My name is Megen, I’m your student nurse, and I’ll be starting your IV,” without further preamble. That’s fine until the patient asks if you’ve done it before.

Another aside: the issue is not limited to student nurses. As an RN, I’ve had to do procedures for the first time, too. But it’s always an issue for student nurses. What to do?

  • Have a game plan. I dropped the ball by not having one with my student. Discuss how you will present the procedure to the patient and how you will answer questions about it beforehand. Having ready answers will increase the patient’s confidence.
  • Don’t lie. If the patient asks if you’ve done this before and you haven’t, say no. Please don’t use the “I’ve been trained in this procedure” dodge. A surprising number of patients appreciate an honest, “No, but I have been trained to do it and my preceptor is here to assist me” and will agree.
  • Fake it ’til you make it. Enter the room exuding confidence in your skills and announce that you will be inserting an NG tube or an IV or whatever. Don’t announce that you will be “trying” to do it. Walking through the steps with your preceptor before you go in helps.
  • Know your limitations. If you get lost, say so. If you need your preceptor to step in, say so.
  • Thank your patient. He or she has just helped you become a better nurse.
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