Responding to Mary's comments: In what ways do you think this situation would have changed for the better had you really taken the time to find out what the underlying situation was? I wonder if the situation would have changed if you took the time to listen. Do you think that would have gotten him more agitated? Do you truly think it was your "instinct" to let him go AMA?
I think that my frustration level (not to mention the patients frustration level) would have been reduced if I'd had the time earlier in the shift to sit down and talk with him. If I'd found out his concerns at that time I could have called his friend earlier and that may have reduced his anxiety so that he could have slept. If he'd been asleep I would have had more time to spend with my other patients, alleiving their anxiety! I don't think he would have become more agitated, but that is a possibility. He was very tense and maybe wouldn't have been so ready to share his feelings with me earlier in the shift.
Was it really my instinct to let him go AMA? No, but you know how your mind works when you're frustrated and irritated? It would have been the easy way out, for me at least. As I said before, then my night would have run a lot smoother! But that's not the point of nursing care. Our focus is not on what will make things easier for us, it's what is best for our patients.
And, on that note: nurses are notoriously bad at caring for themselves. Look at our pay scales, our staffing issues, our general health! I think that most of that arises from our tendency to always take care of others. We feel we don't have the time to take care of ourselves, and we push our needs to the background. How many shifts have you skipped your meal break? How many shifts have you spent where you didn't even get to sit down or take a bathroom break? Some mornings I'll be driving home, wiggling in the car seat and realizing that the last time I voided was before I left home for work the night before! None of that is good for our bodies, our minds, or our souls. Reflective practice gives us a chance to look at situations once the immediate stress of the situation is over. It lets us really think about what our choices were and how a different choice may have led to a different outcome. It also gives us a chance to care for ourselves, mentally and emotionally, by releasing some of our emotions, thoughts, frustrations and irritations that might fester if not given a place and time for release.
Monday, May 26, 2008
Monday, May 19, 2008
Week 7
Beth's comment: When you say that you WANTED to let him go ama, I'm wondering if this is really the case, or whether, given the pressure you're under to stay on task, you did not feel you really had the choice of providing appropriate nursing care. How much of that consternation is caught up in institutional, and economic constraints? I wonder if you would have reacted differently in a work setting in which your priority was to give supportive care, and in which you were supported in doing so.
You're right. I didn't WANT him to go AMA, but looking forward in my mind I could see that my whole night was going to be caught up in dealing with this patient. I'd end up staying late the next morning in order to finish the tasks I had to complete, and then I'd hear about the OT at some point... and I didn't want to deal with that stress! If he'd left it would have been a quick chart notation and on to the rest of the night. That would have been good for my time schedule but it would not have been good for the patient.
I think 99% of the consternation is caused by institutional and economic constraints. Productivity is the new byword at my hospital and to be productive you have to be efficient. Supportive care is not efficient, it's time consuming and can't be done when one has 6, 7, or 8 patients to care for in an 8 hour period.
Now, on to this weeks assigned post: another reflective framework. This time I will be using the Stephenson Model (2000).
1. What was my role in this situation?
I was the primary nurse for the patients care
2. Did I feel comfortable or uncomfortable? Why?
Hmm... as far as basic nursing goes, I felt quite comfortable. I've been doing this job long enough that I have the tasks and the basics down quite well. As far as this patients attitude and his wanting to leave, I felt uncomfortable. It's tough to break out of your normal plan of doing things. I'm going to see this patient, then that one, I'm going to do my charting, do my other tasks, pass meds, etc. When confronted with a situation that is outside the norm, your comfort level is reduced.
3. What actions did I take?
Well, I tried to talk to him, then when that didn't work I finally capitulated and took him outside to smoke.
4. How did I and others act?
I feel that we all acted appropriately. Even though inside my head I may have been thinking "go ahead and leave, you idiot!" I never stated anything like that nor did I show my irritation on my face. I remained outwardly calm and spoke calmly and rationally with the patient.
5. Was it appropriate?
Yes, my outward actions were very appropriate. My inward feelings may not have been, however.....
6. How could I have improved the situtation for myself, the patient?
For both myself and the patient I could have tried harder to find out what the underlying problem was. With careful questioning I would have found out why he was stressed about his "stuff" and that explained why he wanted to leave so badly. Instead I kept harping on his medical condition, not paying as much attention to the holistic aspects of care.
7. What can I change in the future?
I can think more holistically when a patient is obviously unhappy about something. If it's not their medical care or condition I can try to find out what the problem is and if there is anything I can do to fix it. If nothing else, I can listen.
8. Do I feel as if I have learned anything new about myself?
Yes, I feel that I learned to not always give in to my instincts. Had I done so, that patient would have left that night. By acting with patience and compassion I found out more about my patient than I had by acting with instinct.
9. Did I expect anything different to happen? What and Why?
Yes, I did expect that this patient would go back to his room and continue to be a problem (prior to me taking him outside). I probably expected this because it had been his pattern since I had come on shift.
10. Has it changed my way of thinking any way?
Yes, it's reminded me that each patient is a person with their own feelings and issues, and that just by listening I can sometimes make a difference. It's not all about schedules and time, it's about making the patients feel comfortable both mentally and physically.
11. What knowledge from theory and research can I apply to this situation?
Holistic care. Don't focus only on the physcial. Reach out to each patient holistically and evalute them holistically.
12. What broader issues, for example: ethical, political, or social, arise from this situation?
Lets see...
political- the awful state of health care and insurance in the US today. This patient had no insurance and was a charity care case.
ethical- not only could I not keep him there if he really wanted to leave, but also the ethical issue of me taking him outside to smoke when smoking is bad for you.
social- he was essentially homeless, staying at a local hotel that charges by the week, with no transportation and few friends in the immediate area. He was an admitted ETOH abuser with a serious medical condition that he had not only no concept of its severity but no resources to help him recover his health.
13. What do I think about these broader issues?
I think that without immediate serious reform the US healthcare system is going to be losing its battle in the coming years with the advent of the aging baby boomer population. The work force is aging while the population needing care is ballooning rapidly. Resources are limited and expensive and at some point decisions will have to be made about who will benefit most from care with other people left hanging.
You're right. I didn't WANT him to go AMA, but looking forward in my mind I could see that my whole night was going to be caught up in dealing with this patient. I'd end up staying late the next morning in order to finish the tasks I had to complete, and then I'd hear about the OT at some point... and I didn't want to deal with that stress! If he'd left it would have been a quick chart notation and on to the rest of the night. That would have been good for my time schedule but it would not have been good for the patient.
I think 99% of the consternation is caused by institutional and economic constraints. Productivity is the new byword at my hospital and to be productive you have to be efficient. Supportive care is not efficient, it's time consuming and can't be done when one has 6, 7, or 8 patients to care for in an 8 hour period.
Now, on to this weeks assigned post: another reflective framework. This time I will be using the Stephenson Model (2000).
1. What was my role in this situation?
I was the primary nurse for the patients care
2. Did I feel comfortable or uncomfortable? Why?
Hmm... as far as basic nursing goes, I felt quite comfortable. I've been doing this job long enough that I have the tasks and the basics down quite well. As far as this patients attitude and his wanting to leave, I felt uncomfortable. It's tough to break out of your normal plan of doing things. I'm going to see this patient, then that one, I'm going to do my charting, do my other tasks, pass meds, etc. When confronted with a situation that is outside the norm, your comfort level is reduced.
3. What actions did I take?
Well, I tried to talk to him, then when that didn't work I finally capitulated and took him outside to smoke.
4. How did I and others act?
I feel that we all acted appropriately. Even though inside my head I may have been thinking "go ahead and leave, you idiot!" I never stated anything like that nor did I show my irritation on my face. I remained outwardly calm and spoke calmly and rationally with the patient.
5. Was it appropriate?
Yes, my outward actions were very appropriate. My inward feelings may not have been, however.....
6. How could I have improved the situtation for myself, the patient?
For both myself and the patient I could have tried harder to find out what the underlying problem was. With careful questioning I would have found out why he was stressed about his "stuff" and that explained why he wanted to leave so badly. Instead I kept harping on his medical condition, not paying as much attention to the holistic aspects of care.
7. What can I change in the future?
I can think more holistically when a patient is obviously unhappy about something. If it's not their medical care or condition I can try to find out what the problem is and if there is anything I can do to fix it. If nothing else, I can listen.
8. Do I feel as if I have learned anything new about myself?
Yes, I feel that I learned to not always give in to my instincts. Had I done so, that patient would have left that night. By acting with patience and compassion I found out more about my patient than I had by acting with instinct.
9. Did I expect anything different to happen? What and Why?
Yes, I did expect that this patient would go back to his room and continue to be a problem (prior to me taking him outside). I probably expected this because it had been his pattern since I had come on shift.
10. Has it changed my way of thinking any way?
Yes, it's reminded me that each patient is a person with their own feelings and issues, and that just by listening I can sometimes make a difference. It's not all about schedules and time, it's about making the patients feel comfortable both mentally and physically.
11. What knowledge from theory and research can I apply to this situation?
Holistic care. Don't focus only on the physcial. Reach out to each patient holistically and evalute them holistically.
12. What broader issues, for example: ethical, political, or social, arise from this situation?
Lets see...
political- the awful state of health care and insurance in the US today. This patient had no insurance and was a charity care case.
ethical- not only could I not keep him there if he really wanted to leave, but also the ethical issue of me taking him outside to smoke when smoking is bad for you.
social- he was essentially homeless, staying at a local hotel that charges by the week, with no transportation and few friends in the immediate area. He was an admitted ETOH abuser with a serious medical condition that he had not only no concept of its severity but no resources to help him recover his health.
13. What do I think about these broader issues?
I think that without immediate serious reform the US healthcare system is going to be losing its battle in the coming years with the advent of the aging baby boomer population. The work force is aging while the population needing care is ballooning rapidly. Resources are limited and expensive and at some point decisions will have to be made about who will benefit most from care with other people left hanging.
Monday, May 12, 2008
Week 6
Hey you guys, I don't have any comments to incorporate!!!
I have been thinking about this incident though, and here are my current thoughts.
I still think that I did the right thing with this patient. I know smoking is bad, blah, blah blah and some people might think that I was allowing the patient to manipulate me, but in my mind getting to the root of why he wanted to leave the hospital was vital. By giving in to his want to go outside and smoke, I put myself into a "bargaining" position which led him to feel he "owed" me an explanation.
As it turned out, he was discharged the next day anyway, low platelet count and all. I don't know if that was at his request or not, and that really doesn't matter. At the time I was caring for him he was an inpatient with a potentially fatal diagnosis and I was the nurse in charge of his care. I think that I handled the situation fairly well and I wouldn't change anything about the experience.
I have been thinking about this incident though, and here are my current thoughts.
I still think that I did the right thing with this patient. I know smoking is bad, blah, blah blah and some people might think that I was allowing the patient to manipulate me, but in my mind getting to the root of why he wanted to leave the hospital was vital. By giving in to his want to go outside and smoke, I put myself into a "bargaining" position which led him to feel he "owed" me an explanation.
As it turned out, he was discharged the next day anyway, low platelet count and all. I don't know if that was at his request or not, and that really doesn't matter. At the time I was caring for him he was an inpatient with a potentially fatal diagnosis and I was the nurse in charge of his care. I think that I handled the situation fairly well and I wouldn't change anything about the experience.
Wednesday, May 7, 2008
Week 5
The framework I am using is based on Doane, G. and Varcoe, V. (2005). Family Nursing as Relational Inquiry. Developing Health-Promoting Practice.
This situation occurred recently at work. This patient was a 42 year old man who was originally admitted for ETOH overdose and epistaxis (nosebleed). As his labs came back it was determined that his platelet count was 66 on admit, and had dropped to 43by the time I was assigned to his care (a normal platelet count is 150,000 - 450,000). Quite obviously, this guy was at serious risk of bleeding to death. However, he didn't seem to absorb this. He kept ripping out his IV lines, tearing off his cardiac monitor and wandering out of his room partially dressed, telling the staff he needed to go "check on my stuff, I'm going to be pissed if it's gone". I should add that by this time (day 5 of his hospitalization) he was no longer officially detoxing... that process had occurred mostly during the 3 days he spent ventilated in the CCU. When first assigned to him I was neutral on the situation, I'd just had 7 days off and didn't "know" any of the patients. During report nothing was said that would make me think he was going to be a "problem", in fact he'd slept most of the previous shift. I started my assessments with other patients who appeared to be less stable and figured I'd leave sleeping beauty till last for assessment. Of course, as I leave another patients room after assessing them, my patient is standing out in the hall dressed in a pair of jeans and a very bloody hospital gown.
"Hey W, what are you doing?" I call as I hurry over to his side. "I'm going to the ER" he replies. I'm looking at him thinking, why???? I'm busy (I have 5 other patients) and I can feel my stress level rising. "What'cha going to the ER for?" I say. "To get this fixed" he tells me, as he holds up his left arm, blood dripping steadily off of it onto the floor from his former IV site. "I can fix that for you here" I say, taking his right arm and trying to guide him back to his room. "Nope, I know them" he states as he heads off down the hall. I trot after him, talking a mile a minute, my attempts to get him back into his room futile as he swings into the ER, which is REALLY busy this particular evening. By now I'm frustrated. Everyone in the ER is looking at us as I try to explain what's going on. I catch the looks between a couple of ER nurses and interpret them to be saying, "sheesh, these Med-Surg nurses cannot control their patients", and I start to feel embarrassed. Finally one of the other nurses takes pity on me and helps me talk W back into his room.
I get him cleaned up, another IV started, (hospital regulations state only 2 pokes per nurse, it took 4 nurses before one of us could get a 2nd IV started), check the protocol and give him a healthy dose of lorazepam for agitation and anxiety. After taking his vitals and assessing him I check the clock. It's been 2 hours settling this guy down and I still have the rest of my patients to see, not to mention my charting, MAR checks, tele strips, etc..... needless to say I'm waaaay behind schedule and feeling frustrated, distressed and downright angry.
A couple of hours later and it starts all over again, but this time he wants to leave, go home and check on his "stuff". After a lengthy talk with me explaining over and over that he has a potentially lethal platelet count and could seriously bleed to death, it turns out that he really wants to go outside and have a cigarette. I don't have time for this but neither does anyone else.... so I capitulate and tell him I'll take him outside if he'll go back to bed afterwards and try to get some sleep. He agrees and sits down in a wheelchair for me to give him a ride.
We go out and as I stand waiting for him to finish smoking I'm literally steaming. My night is shot, it'll be a miracle of I get out on time in the morning, I'm tired, my feet hurt, and I'm spending my break watching this guy smoke. Can you say stressed out???? But then, he started to talk. "I appreciate your taking me out here. I haven't had a cigarette since I came in and I've really been wanting one" he tells me. "It's ok, but don't forget you promised to lay down and rest when we go back in" I say. "I remember", he sighs, "I've been having trouble relaxing because I'm worried that my stuff will be gone when I go back to my room". "I've been staying in a motel down the street and I don't know if they'll kick me out after a week of not paying the bill" he tells me. "Can you call someone to check on it for you?" I ask. "I can't call my friend from the room, it's long distance" he replies. I offer to call his friend for him and he actually smiles at me. "If you could do that I promise I'll lay down and behave" he says. All this poor guy wanted was for someone to go check on his stuff. I did as I told him I would, getting the number for his friend and calling and leaving a message for them. He held up his end of the bargain and laid down and behaved for the rest of my shift.
I'd felt frustration, anger, embarrassment, stress and more during this situation. Most of these emotions were contextual, and I think most of them were what most nurses would feel in the same situation. They did inform me of what other shifts probably felt while trying to take care of this particular patient, and they helped me decide how to relate this incident to the next shift, explaining to them that this patient was not bent on being non compliant, but he was concerned about his belongings and if they would take a few minutes to see if the message I left was answered then he would probably relax and allow his treatment to go forward.
In reflection, I didn't listen to my feelings during the situation. Had I done so, I probably would have let this patient leave the hospital AMA and go wandering down Highway 2 at 4 in the morning. Instead, I bit my tongue, put my work on hold and took the patient outside to smoke. By doing so I showed him that I cared how HE felt, I listened to his story, I empathized with his feelings and I did my best to alleviate his concerns. I think that most nurses value their patients feelings though often we don't have time to validate those feelings. By making the time for this patient I did the right thing, even though it put me behind on my other work.
This situation occurred recently at work. This patient was a 42 year old man who was originally admitted for ETOH overdose and epistaxis (nosebleed). As his labs came back it was determined that his platelet count was 66 on admit, and had dropped to 43by the time I was assigned to his care (a normal platelet count is 150,000 - 450,000). Quite obviously, this guy was at serious risk of bleeding to death. However, he didn't seem to absorb this. He kept ripping out his IV lines, tearing off his cardiac monitor and wandering out of his room partially dressed, telling the staff he needed to go "check on my stuff, I'm going to be pissed if it's gone". I should add that by this time (day 5 of his hospitalization) he was no longer officially detoxing... that process had occurred mostly during the 3 days he spent ventilated in the CCU. When first assigned to him I was neutral on the situation, I'd just had 7 days off and didn't "know" any of the patients. During report nothing was said that would make me think he was going to be a "problem", in fact he'd slept most of the previous shift. I started my assessments with other patients who appeared to be less stable and figured I'd leave sleeping beauty till last for assessment. Of course, as I leave another patients room after assessing them, my patient is standing out in the hall dressed in a pair of jeans and a very bloody hospital gown.
"Hey W, what are you doing?" I call as I hurry over to his side. "I'm going to the ER" he replies. I'm looking at him thinking, why???? I'm busy (I have 5 other patients) and I can feel my stress level rising. "What'cha going to the ER for?" I say. "To get this fixed" he tells me, as he holds up his left arm, blood dripping steadily off of it onto the floor from his former IV site. "I can fix that for you here" I say, taking his right arm and trying to guide him back to his room. "Nope, I know them" he states as he heads off down the hall. I trot after him, talking a mile a minute, my attempts to get him back into his room futile as he swings into the ER, which is REALLY busy this particular evening. By now I'm frustrated. Everyone in the ER is looking at us as I try to explain what's going on. I catch the looks between a couple of ER nurses and interpret them to be saying, "sheesh, these Med-Surg nurses cannot control their patients", and I start to feel embarrassed. Finally one of the other nurses takes pity on me and helps me talk W back into his room.
I get him cleaned up, another IV started, (hospital regulations state only 2 pokes per nurse, it took 4 nurses before one of us could get a 2nd IV started), check the protocol and give him a healthy dose of lorazepam for agitation and anxiety. After taking his vitals and assessing him I check the clock. It's been 2 hours settling this guy down and I still have the rest of my patients to see, not to mention my charting, MAR checks, tele strips, etc..... needless to say I'm waaaay behind schedule and feeling frustrated, distressed and downright angry.
A couple of hours later and it starts all over again, but this time he wants to leave, go home and check on his "stuff". After a lengthy talk with me explaining over and over that he has a potentially lethal platelet count and could seriously bleed to death, it turns out that he really wants to go outside and have a cigarette. I don't have time for this but neither does anyone else.... so I capitulate and tell him I'll take him outside if he'll go back to bed afterwards and try to get some sleep. He agrees and sits down in a wheelchair for me to give him a ride.
We go out and as I stand waiting for him to finish smoking I'm literally steaming. My night is shot, it'll be a miracle of I get out on time in the morning, I'm tired, my feet hurt, and I'm spending my break watching this guy smoke. Can you say stressed out???? But then, he started to talk. "I appreciate your taking me out here. I haven't had a cigarette since I came in and I've really been wanting one" he tells me. "It's ok, but don't forget you promised to lay down and rest when we go back in" I say. "I remember", he sighs, "I've been having trouble relaxing because I'm worried that my stuff will be gone when I go back to my room". "I've been staying in a motel down the street and I don't know if they'll kick me out after a week of not paying the bill" he tells me. "Can you call someone to check on it for you?" I ask. "I can't call my friend from the room, it's long distance" he replies. I offer to call his friend for him and he actually smiles at me. "If you could do that I promise I'll lay down and behave" he says. All this poor guy wanted was for someone to go check on his stuff. I did as I told him I would, getting the number for his friend and calling and leaving a message for them. He held up his end of the bargain and laid down and behaved for the rest of my shift.
I'd felt frustration, anger, embarrassment, stress and more during this situation. Most of these emotions were contextual, and I think most of them were what most nurses would feel in the same situation. They did inform me of what other shifts probably felt while trying to take care of this particular patient, and they helped me decide how to relate this incident to the next shift, explaining to them that this patient was not bent on being non compliant, but he was concerned about his belongings and if they would take a few minutes to see if the message I left was answered then he would probably relax and allow his treatment to go forward.
In reflection, I didn't listen to my feelings during the situation. Had I done so, I probably would have let this patient leave the hospital AMA and go wandering down Highway 2 at 4 in the morning. Instead, I bit my tongue, put my work on hold and took the patient outside to smoke. By doing so I showed him that I cared how HE felt, I listened to his story, I empathized with his feelings and I did my best to alleviate his concerns. I think that most nurses value their patients feelings though often we don't have time to validate those feelings. By making the time for this patient I did the right thing, even though it put me behind on my other work.
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