Courage at the Bedside

Something new students/new nurses struggle with is feeling courageous at the bedside. It can be scary to walk into a new environment, have a patient with a medical condition you’re not familiar with, or even just talk to a patient AT ALL.

The definition of courage is “the ability to do something that frightens you”. Being courageous does not mean being unafraid. It means being afraid and doing the thing anyway. And it’s something we have to cultivate as nurses because our patients are counting on us as their advocates.

In this article, we’ll explore how to have courage at the bedside when it comes to getting comfortable invading patients’ personal space, speaking up for patients, advocating, directing care, setting boundaries, and what to do next when you just don’t know what to do.

Invading your patients’ space

One way new nurses and students struggle with courage is feeling timid in invading people’s personal space. This is really evident first thing in the morning when we go in to take vital signs (VS) at 0700 and patients may still be asleep. Or when we need to conduct a full head to toe assessment (HTT) and we’re not used to getting in there and getting so personal with others. 

First things first, it takes PRACTICE. Get comfortable doing vital signs and performing a head to toe assessment on people of all shapes, ages and medical backgrounds. Take advantage of each opportunity to assess patients when you’re in clinicals and build that confidence up.

If you’re really nervous about invading your patients’ space, start off with baby steps. Talking with your patient is a lot easier than diving right into a full HTT assessment, so start there.  Plus, you can assess quite a bit about your patient just by talking to them. If it’s morning, ask them how they slept the night before, introduce yourself, share your goals for the day,and/or ask them what their goals are. Ask about pain and assess for orientation. By the time you do all those things, it will be a lot easier to get in closer and start doing more hands-on assessments. 

Remind yourself of your role. As the nurse, you are this patient’s advocate. It is your duty to recognize changes in condition so you can catch them early and report them to the MD as needed. You can’t do your job unless you get in there and get personal with your patients.

This also comes into play when you look at the thoroughness of your assessments. Sometimes new students or even new nurses may feel timid about asking for the patient’s participation. For example, can you get a feel for lung sounds by listening on the front? Of course. Is it better to listen on the front and the back? Absolutely! What if the patient is asleep? Many students and nurses feel uncertain about waking a patient to take vitals or perform an assessment and may worry that they’re bothering the patient.

Again, think about your role. It is your job to assess this patient…not just watch them sleep. And sometimes, patients’ aren’t just sleeping…they’re over-sedated or have high CO2 levels or they’ve had a stroke or are septic. If any of those things are happening, don’t you want catch it early? YES. In fact, you have a duty to catch it early. Failure to rescue is a big problem in healthcare and it happens when nurses either fail to assess or fail to act on abnormal findings. The jury is not going to take “the patient was sleeping and I didn’t want to bother them” as a viable reason why you didn’t assess a patient.

Still feeling uneasy about getting in there? See how it feels to take YOUR feelings out of it. When you feel afraid or timid about getting in there and assessing the patient,  you’re making it about you. I guarantee you that if the patient is having something going wrong, they aren’t thinking at all about how nervous or hesitant you are…they want an advocate! They want you to catch the abnormal finding so something can be done about it. Patients want to feel cared for and one way we do that is with our timely and thorough assessments.

Now what about the cranky patient who is refusing things like vital signs and assessments? Yes, this can happen. Here’s what to do in that situation: 

• Educate – Sometimes patients don’t understand the rationale behind vital signs or physical assessments. By explaining that you are monitoring their progress and watching for complications, many patients who were previously refusing will agree. Sometimes the patient might refuse VS because they’re in a lot of pain and just don’t want to be bothered. If this happens, you can explain that in order to give pain medication you have to know what their baseline VS are. When patients realize you are trying to keep them safe AND intervene to address their problem, they will agree. 
• Give options – A lot of times patients refuse care in the clinical setting as a way to retain some sense of control at a time when they are feeling a loss of control. By giving them options, you help them assert their sense of autonomy. “Bob, I need to conduct your HTT assessment. Would you like to do that now or after breakfast?” Or “Janis, would you like your BP measured on your right arm or your left?” or “Larry, I want to take a look at that wound on your sacrum. I can do that now or in a few minutes when you get up with the physical therapist…which would you prefer?”
• Get creative – Some patients are just downright non-participatory and this can make doing a full assessment really difficult. If this happens, assess as much as you can through casual observation. Talking with the patient can usually reveal if the patient is oriented, you can observe if their speech is clear, and how alert they are. You can observe skin color, see diaphoresis if present, and when you touch the patient to help them with reposition, you can feel the temperature of the skin. Get as much data as you can just by interacting with the patient. If they won’t consent to a full HTT, decide what data you need the MOST and ask the patient if you can assess those things. For example, if your patient is there for a respiratory problem, asking them if you can listen to their lungs would be really important, but maybe you can skip listening to bowel sounds for now. Of course, if the patient refuses, even after receiving education, then you move on to the next step. 
• Document document document. – Any refusals should be documented in the EHR AND you’ll want to let the physician know when they come by on rounds that the patient refused a full physical assessment. 

Advocating for your patients at the bedside

Another area that requires courage is patient advocacy and speaking up for them. This usually means calling the MD to report a change in condition or request something that is needed for the patient. 

If this scares you, first realize that the consequences of NOT calling are FAR WORSE than the discomfort you feel about calling. Even if the person on the call is rude or hangs up on you. You’re doing your job by advocating for the patient. Maybe you’re scared because you’re not sure HOW to communicate or worried you’ll look dumb if you don’t know how to answer a question. Take a deep breath because this one is easy. You’re going to prepare before you call. And you’re going to use SBAR so that your communication is succinct and clear and efficient. 

Part of that preparation is anticipating what questions will be asked…so have that data ready to go. And, if you can include that information in your SBAR, that’s even better. Remember SBAR stands for Situation, Background, Assessment and Recommendation.

Calling about a patient with low BP – what might the MD want to know? They probably want to know about LOC, I/O, and HR, so you would work that into your SBAR. Also, have their chart at the ready so you can quickly find answers to other questions as they come up.

For a full breakdown of SBAR communication, listen to episode 328 and episode 147.

Setting boundaries at the bedside

A final area where novices can struggle is with setting boundaries. This can be with a patient who is acting inappropriately, rude, hitting on you, trying to manipulate you, trying to take up all of your time (either with repeated requests or endless conversation), or trying to get you to do EVERYTHING for them when they’re capable themselves. There are a lot of ways the people we work with can show a lack of boundaries and that’s why it’s vital that YOU set them. 

Setting boundaries comes down to professional, polite, and clear communication. And then sticking with the boundaries you set. 

In the case of the patient who is being rude, I would first seek to understand. For example, “You seem angry this morning, Bob. What’s causing your frustration…is there something I can do to help?

Beyond that, it’s boundary setting time, ”Bob, you’re clearly frustrated or angry about something. I will ask that you not take it out on me as I am here as your advocate and am only trying to help you.”

Or maybe Bob is hitting on you every time you’re in the room. “Your behavior and language are unacceptable. If you continue to make suggestive remarks I will need to find another nurse to work with you today.”

Or what if Bob is just non-stop chatty and even though he’s super sweet you’ve got things to do! “Bob, I’d love to hear more about your grandkids’ cat’s health issues but right now I need to finish getting your vitals and perhaps we can chat more about this later on this afternoon.”

Or what if Bob is waaay too needy. “Bob, I’ve noticed you keep calling me in here to help you with things you are capable of doing yourself. Why is that?” Sometimes, asking someone to explain their behavior really makes them stop and think. Perhaps he was just unaware of it, feeling vulnerable, or not sure if he is even supposed to move. You’d be surprised how many patients ask me after surgery, “Can I sit up? Can I move around?” YES! If bob says something like “I just like having you do things for me” then you can say something like, “I need to see that you are improving…and being independent is a big part of that. Can you at least try to be independent before you call next time? I’ll be in once per hour to check on you…so if you still need help, I’ll be happy to help you at that time. 

Asking for help takes courage too

Another way new nurses and students feel fear is when they don’t know what to do…let’s say your patient’s heart rate shoots up to 220 and their blood pressure drops to 82/45. That can be pretty scary! Or, you try to wake the patient and they won’t wake up…or the patient codes. All very scary things. 

First off, it’s always okay to ask for help. When you need help, ask for it. Get the charge nurse, call a RR, call the MD, call a code blue…do what you need to do to get other people in there to help. 

And something I always advise nurses to do is to plan ahead for the worst case scenario. When you get report on your patient…think about the worst things that could happen to them based on their condition and then quickly think through what you would do. 

Surgical patient who’s on a PCA who stops breathing….what would you do? Manually bag ‘em and get someone to bring you Narcan. 

Patient who had orthopedic surgery who develops sudden chest pain, SOB and dropping O2 sats? Sit ‘em up, apply oxygen, call a RR or the MD because you suspect pulmonary embolism. 

A patient with a cardaic history complains of a severe squeezing pain in their chest? Get some oxygen on them…call the MD, get a 12-lead and set of VS, and anticipate giving nitroglycerin….

Tell yourself you KNOW what to do, even if knowing what to do is getting extra help. 

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