I grabbed my trusty CNA to help me, who was equally motivated. He was a big, strong guy that I trusted. I trusted him too much, actually. I let my trust in another person’s capabilities cloud my nursing judgment. I wanted to use a lift to get the man to the chair, but the CNA insisted he could handle him, as he’d be caring for him for days now. He was so confident (and strong!) that I decided to follow his lead.
We got the patient, who had left hemiparesis, to the side of the bed. It was tough. When he could barely hold himself up, I again thought to myself, “We really should just use the lift…” and said that to the CNA.
“No, no, that’ll take too long to get everything and it’s just a pivot and turn,” he said. I begrudgingly agreed. It would take a long time to get everything; it really was just a stand, pivot and sit situation. So I thought.
We stood him up and he was dead weight. He unexpectedly moved his right leg just enough to throw us both off balance and out of control. It was a scary three seconds. We communicated, readjusted and got him to the chair.
I made sure to discuss with the CNA how big of a deal that could have been and how we should have approached that situation. It was really important to convey a sense of urgency and concern, because while it was he who convinced me to get the patient up with him, I was ultimately accountable for the situation. I was that patient’s nurse and team leader with that CNA. I made sure to apologize to the CNA for not leading appropriately.
The patient was so happy to be up in the chair, out of that darn bed finally, but he looked like he would just slide right out. I sat in the room with him for a while to make sure he could hold himself up in the chair. I was a little concerned, but not overtly. I decided to chat with my BFFs in the physical therapy department about the best way to handle this. Thankfully, they were already on their way to work with him.
I charted in his room until they arrived, just to keep an eye on him.
After I explained my blunder to them, they said that after they saw him yesterday, they knew he wasn’t ready for sitting in a chair. He didn’t have the core strength to hold himself up to prevent sliding straight out. If I had closely read their note first, I would have been aware of this fact. I watched them work with him and had a new appreciation for the physical therapy department. The physical therapy student seamlessly and safely got the man back in bed by correctly positioning the chair and utilizing appropriate technique and body mechanics. And he did so without any assistance. I was super impressed.
That could have been bad. He could have fallen, all because I didn’t listen to my instincts. I let my need to get things done quickly cloud my ability to appropriately judge the situation and didn’t even think to read the physical therapy note from yesterday that would have further confirmed my nurse sixth sense that was telling me to stop and reassess.
I learned a few things from this situation.
First, always trust your instincts. That nurse sixth sense is there for a reason, and I should have listened to it.
Second, when you’re not sure about getting a patient up, always read the physical therapy note. See how tough it was for them, how many people they used and their recommendations. They are a wealth of knowledge, as this is their expertise.
And finally, always follow up with your team. If others were involved in a situation that could have been bad but thankfully wasn’t, don’t let that moment fly by. That is a crucial teaching moment. Immediately own up to your mistake in the situation and discuss what you could have done better as a team leader and how you believe the situation should have occurred.