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.