Control Issues

by jadelpn Guide

The feeling of loss of control by patients is one of the more challenging issues a nurse can face in pursuit of caring for a patient. In the novel "The Lazarus Project" one quote comes to mind-- "There are moments in life when it is all turned inside out--what is real becomes unreal, what is unreal becomes tangible, and all your levelheaded efforts to keep a tight control are rendered silly and indulgent.

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    Control Issues

    It is an effort for any nurse to be able to do what is needed for a patient, while keeping in mind that the patient has a need and a want to be in charge of their own care. I fondly call this "patient directed care".

    To say that nurses are undeniably busy to the point of almost overworked is a huge understatement. We have a great deal of pressure to chart on time, give meds on time, assess, give prn's, and the list goes on and on. Most often, with that little voice in one's head continuing to repoeat "smile, introduce, as about pain, what can I do for you...." and the numerous other "key questions" that are supposed to make a patient feel as if they are well cared for.

    To put another thought process out there, is it ever feasible to let a patient lead their care, within some guidelines that are subtly put forth by the nurse? For example, "Today, our goal is to get you walking. I KNOW, sounds scary, right? What I would like to try first is to get you into the chair. Would you like to do that now, or after breakfast?" Or, "We need to get you into a shower. CNA Xyz is here today, and she is AWESOME, will be just like a spa!! Think about what time you would like to do that, she is here until 3, so I will send her in to discuss this with you".

    If we make patients part of their own healing process, given a couple of viable options, can nurses get to the goal that they need to get to for their patients? Can nurses be able to timeline activities so that it is not 5 minutes before the end of one's crazy shift and THEN a patient wants to ambulate, shower, have a long discussion about their 58 year marriage, or perseverate on how they will "never feel any better?" Yes, sometimes this is all unavoidable. And we all have patients who are impossible to please, who's loss of control is so acute that they will not do ANYTHING, EVER and FORGET IT. Get me my dilaudid and leave me alone types. That takes thinking outside of the box, with a number of more disciplines than just yourself. One wonders that with the push to not re-admit, if something will change in the discharge process to ever make it any different.

    Most notably, chronic pain sufferers are one of the more difficult to reach goals with. Pain is exceedingly real. Few can imagine, who have not had chronic pain, what it is like, topped off with being not in control, scared of their function, a circle that never ends for the patient. (and seemingly for the nurse). There is a real need for a number of pain management clinics that can and do take a whole health approach to how specifically someone is to function. That is definetely something that should be brought up for inservices, what the hospital's policy is, what it can be, what is should be.

    Putting bandaids on an issue (unless there's a cut involved) is never the long term solution. As nurses, we can get involved in a policy change within your unit and/or your hospital to brainstorm solutions to how to balance the expectations of practice, and the patient's need to control portions of their care. Is this a realistic option?
    Last edit by Joe V on May 28, '13
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  4. About jadelpn

    jadelpn joined Nov '08 - from 'Massachusetts'. Age: 48 jadelpn has '25' year(s) of experience and specializes in 'ER, Med Surg'. Posts: 2,654 Likes: 4,549; Learn more about jadelpn by visiting their allnursesPage

    6 Comments so far...

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    I think these are valid points and are something to strive for. I know every day-heck-most days won't be like this but it is a self-goal that I find admirable and something to strive for.

    Chronic pain is an impossible dilemma on both sides of the bed. Trust me, patients feel the frustration of health care workers as well as their own. The fear of not being believed and being "abandoned" when "we have tried everything and REALLY you are still in pain" is a recipe for disaster and a loop that is very hard to break.

    Nicely written!
    canoehead and jadelpn like this.
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    Quote from jadelpn
    "We need to get you into a shower. CNA Xyz is here today, and she is AWESOME, will be just like a spa!! Think about what time you would like to do that, she is here until 3, so I will send her in to discuss this with you"
    This is where it crosses the line.
    I'm a nurse, not a beautician.
    I will do my very best to make you comfortable and keep you safe, but it will NOT be like a spa.

    It will be like a hospital, which you're in, by the way. And I also have five other "customers", so you might have to wait and negotiate for your slot at the mud bath because your neighbor down the hall won't stop trying to die on me.

    While I appreciate what this article is trying to convey, there is a fine line between ensuring patient safety/comfort and catering to patient whims, which is pretty much what healthcare for nurses is becoming thanks to Press Ganey and the like.
    canoehead, Ir15hd4nc3r_RN, gswifty, and 2 others like this.
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    Quote from SoldierNurse22
    This is where it crosses the line.
    I'm a nurse, not a beautician.
    I will do my very best to make you comfortable and keep you safe, but it will NOT be like a spa.

    It will be like a hospital, which you're in, by the way. And I also have five other "customers", so you might have to wait and negotiate for your slot at the mud bath because your neighbor down the hall won't stop trying to die on me.

    While I appreciate what this article is trying to convey, there is a fine line between ensuring patient safety/comfort and catering to patient whims, which is pretty much what healthcare for nurses is becoming thanks to Press Ganey and the like.
    And I do not disagree. But for most, CNA's are gifted in the art of having patients do things that as nurses, we can often not.
    Some units are run under the "if you can get up and shower you can go home" still others are "I am not here to shower a patient". I get that. However, because we are all forced to fall under a certain level of ancillary care in order to keep our jobs (hence the dreaded Press Gainey) as well as no re-admits, certain key words, phrases, documentation to get reimbursed so that we are able to keep our jobs, something has got to give.
    I really, really detest a press gainey outcome run unit. I also am not a beautician. I think that if a patient believes their whims are being met, whilst balancing what I have to do to keep them safe and well--then the balance.
    This stuff keeps growing and is showing no signs of going away. Customer service models abound--and with all due respect, that is not what a lot of nurses went to school for. But it is here, it is real, and we all have to come to some sort of decision on how to deal with all of it effectively.
    Ir15hd4nc3r_RN and NRSKarenRN like this.
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    What's wrong with showering a patient? And why is your model's necklace tunneling into her subclavian?
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    Quote from SoldierNurse22
    This is where it crosses the line.
    I'm a nurse, not a beautician.
    I will do my very best to make you comfortable and keep you safe, but it will NOT be like a spa.

    It will be like a hospital, which you're in, by the way. And I also have five other "customers", so you might have to wait and negotiate for your slot at the mud bath because your neighbor down the hall won't stop trying to die on me.

    While I appreciate what this article is trying to convey, there is a fine line between ensuring patient safety/comfort and catering to patient whims, which is pretty much what healthcare for nurses is becoming thanks to Press Ganey and the like.
    Disagree w/ SoldierNurse22. I don't believe that most Pts will receive the impression that a hospital shower will ACTUALLY be "just like a spa." I believe jadelpn is correct in her idea of gently pushing Pts towards an outcome. This "just like a spa" comment is correctly directed to make the Pt smile (no one believes it will be a spa experience), get them in a good mood, nudge them towards activity. Not to be condescending towards Pts, but it's like a teacher creating a cheery mood w/ her students to get them to do some task. It's bright to create this supportive atmosphere while also providing limits (e.g., the Pt gets some choice in WHEN he'll do it - as long as it's before 3pm. And if you're afraid that they'll wait until 2:59, then tell them that the aide leaves at 2PM to give yourself some leeway. Then they call for the shower at 1:59 pm, still 61 minutes before the aide leaves for the day.)
    Ir15hd4nc3r_RN likes this.
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    Thank you for mentioning pain control in your article and sending out a reminder that pain is "exceedingly real" for patients. I am disheartened by the number of healthcare workers (from phlebotomists to nurses and everyone in-between) who feel it is acceptable to make PASSING judgments on the validity of a patient's complaint of pain, without any real knowledge of their history or any personal experience living with that patient's illness or condition.


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