Nurse Assistant Dumps Urine in the Sink! As Outrageous as it Seems…or Not?

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Beth Boynton, RN, MS

There’s no way that I’m going to say that dumping a patient’s urine in their sink is ok!  BUT,  I will say there may be underlying issues that would lead to this behavior.  Sound a little crazy?  Check out this letter I received from a nurse manager about dealing with this situation with one of her staff.  What would you do?  What do you think of my response?

Dear Beth, I need your help understanding a recent event at our hospital in which I tried to do the right thing and it turned out wrong.

I am the team leader of a very busy surgical floor. Due to one surgeon’s prominence in his field, we care for a lot of post-op single and double knee replacements. Over the past year or so we have had complaints from this surgeon’s patients about the poor nursing care they received, some specific to pain management and some to simple lack of basic nursing attention and care. The surgeon has met with us several times and has been quite adamant that he wants these complaints to stop. One of the strategies we developed was to hold individual staff accountable if they were the source of the complaint and act quickly to correct it.

So here’s my problem. Last week, a patient recovering from bilateral knee replacement  complained to the surgeon that the nursing assistant emptied the urine from her catheter bag into the sink in her room instead of the toilet in the adjoining bathroom… He, of course, stormed into my office with a litany of complaints about the “incompetent” nursing staff. I must say I was pretty upset and embarrassed and assured the surgeon that I would see to it that that never happened again.

I found the aide at once and reprimanded her for her actions. “How will we ever stop these complaints when you do something as stupid as that?”
Having taken action to rectify the patient’s complaint and admonish the aide, felt I had managed the situation appropriately.

Much to my dismay, the next day the patient reported to me that the aide in question came into her room and said, “Well, you caused a lot of trouble for me yesterday, didn’t you?” I was so shocked and upset by this total lapse in professional behavior. Here I had taken steps to fix the situation and it had backfired, and backfired back on the patient!

Please help me understand what I did wrong, and how I could have avoided such damaging repercussions.

Signed, Confused

Dear Confused,

When I hear about errors or actions that are so shocking, I have to catch myself from jumping on what I’ll call “the blame bandwagon.” For example, incidents of “wrong-site” surgeries are outrageous. Yet, not only are they in the news at an alarming frequency, they are repeatedly the most common Sentinel Event listed on The Joint Commission’s Web site. So I wonder, what else is going on here? I don’t have a simple “right” way to address this situation, but I do have some insights that will help to shed light on possible underlying problems.

First, consider all the different blaming that is going on via indirect and accusatory feedback. The patient complains to the surgeon about the nursing assistant, the surgeon complains to you and then you are in charge of addressing the nursing assistant. Terms such as “incompetent” and “stupid” are pretty inflammatory, and as such, are more likely to aggravate defensiveness and resentment.

Second, where is there any attempt to learn more about the situation? Nowhere along this communication channel does there seem to be a place for finding out why the nursing assistant did such a thing, clarifying the patient’s report, or validating the patient’s concern without being judge and jury. Ultimately, it is inappropriate to use the sink as a toilet. But, finding out what was going on for the nursing assistant at the time would give you a chance to hear her side of the story, review, and, if necessary, educate about related expectations, and work to address peripheral issues if need be. It may seem hard to imagine a scenario that would explain such behavior, but is it possible that she was responding to an alarm, or there was an issue with the plumbing in the patient’s bathroom, or she was already running late and on probation because of overtime issues? Approaching the nursing assistant with more curiosity and less blame would help you understand more about the situation, build your relationship with her, support collaborative problem-solving, and, perhaps, provide information about other issues that should be addressed.

Third, I am curious about the bigger picture involving this surgeon and his perceptions of poor nursing care. Is the nursing care any different for his patients and if so, why? Does he have different expectations? Does he invite criticism of the nurses? If his expectations are high, perhaps this is a chance to improve care for all patients on this floor. Is there adequate staff for the heavy physical work with orthopedic patients? I think it may be important to look for opportunities to use his feedback to improve care overall, but would be careful about doing anything different just for him. All patients deserve the best care and that should be what we are striving for regardless of who the physician is. This focus should help to make solutions less personal and more about quality of care versus pleasing or displeasing the physician

Fourth, given the current conditions, it was probably unwise to have the nursing assistant caring for the patient following the reprimand. The patient is vulnerable, and the assistant resentful. Although I can envision a unit where the assistant might be encouraged to apologize to the patient, I think it is crucial for a shift in addressing the overall conflict first.

In summarizing, one strategy that you might consider for addressing the overall issue of complaints would be to gather information from the surgeon, staff, and other physicians. What, if any, are the weak areas of nursing care on this unit? What are the priorities, and what do staff need in order to carry them out? This will help to build a team around improving care as opposed to reacting to complaints from a particular physician.

In addition, training and practice in giving and receiving constructive feedback for yourself and staff would help to ensure more positive outcomes when such situations occur.

By the way, Viki Kind, MA will be hosting an interview with me on Feb 23, 2012 at 12noon EST.  Join us for more dynamic conversation about “Improving Communication in Hospitals”!  More info

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6 Responses to Nurse Assistant Dumps Urine in the Sink! As Outrageous as it Seems…or Not?

  1. susan says:

    As a LNA/MA I agree with Beth about the terms “Stupid” and Incompetent” No one wants to hear those words directed towards them. That could have probably been handled more wisely. Trust me when I say that the team leader got the short end of that stick, the story all LNAs under her will end up remembering is that a fellow LNA was called “stupid” by the boss. Having said that, disposing of urine in a sink is unacceptable even more so in front of a patient. The bigger problem I see in this situation is the aid going back to the patient with problem! Its very easy to gripe to the wrong people , in the wrong place (believe me, Ive been spoken to for it myself!) I never would however bring it to a patient. That is the bigger issue this team leader needs to find a way to speak with her aid about.

    • Beth Boynton says:

      Hi Susan,

      I think you make an excellent point and agree that the aid’s interaction with the patient afterwards is a serious issue. Especially since there is a power struggle and the patient is in a very vulnerable place. Although it is a gray area, I would consider it a possible example of emotional abuse and as you say, ‘the team leader needs to speak with the aid.’ This is why training and skills in giving and receiving constructive feedback are so important and ultimately connected to patient safety. Often this kind of feedback is very hard to give and receive.

      I can envision something like:
      Team Leader: “I have to talk with you about a concern I have with your comments to patient X and want to speak with you in private. It will take about 10 minutes and I am available now or at the end of your shift”.

      …then later….

      “Mrs. X told me that you said ‘“Well, you caused a lot of trouble for me yesterday, didn’t you?”. I want you to understand that this kind of comment is threatening and abusive and I will not tolerate it. What do you have to say?”

      It is hard to predict what the aid might say. S/he may deny it or say s/he was just kidding or was referring to something totally different. It is also important to consider that the patient’s perspective may not be the total truth. The goal of this conversation does not have to be to find the total truth, (although it can be part of the process), but to set a clear expectation and to provide teaching about what is and isn’t ok. From here it can be a judgement call regarding discipline for the LNA. I might tend to give the benefit of the doubt for a first offense and be a hawk watching for any similar behaviors.

      I also think that assigning the LNA to this patient after this complaint makes the Team Leader’s judgement questionable. Without addressing the conflict it could be a set-up for this type of interaction and sheds light on leadership’s contribution. In an ideal world with a staff that has lots of communication training and practice there might be an opportunity for the team leader or someone from HR to facilitate a conversation between the LNA and Patient. An apology and explanation may go a long way to improving the patient’s and LNAs experience. Again, a judgement call.

      There is lots going on here, don’t you think? Your comments are most appreciated!!!
      Beth

  2. Niamh says:

    I want get into the nursing field bcuaese it is my ultimate goal to make a living by showing genuine compassion to people one-on-one. I also found out that my grandmother always wanted to be a nurse but couldn’t bcuaese of being a full-time stay at home mom and not having enough money, so it would almost be like fulfilling a legacy! Do you find much time for your personal life as a nurse? Is it hard to not take work home with you at the end of the night?

  3. Registered says:

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    • admin says:

      Thanks for your feedback and sign-up, Verna. Please say more about your question re: an earlier submission. I’d be happy to elaborate. Beth

      • Jorge says:

        I was inspired wntchiag RN’s work and observing how many seem to enjoy their job! I have a bachelors degree in business administration, but I want to go back to undergrad after graduate school to earn a BSN. I want to have all: A BSN, a BBA and a MBA. My goal is to work full-time as a trauma nurse in the state of Maryland, and work part-time as a mgmt consultant. I’m not sure how to balance the two, but I believe where there is a will, there is a way! Prestin, Maryland

What are your thoughts?