I work PRN at a local psychiatric hospital. Every shift I work I drop in to an unfamiliar patient population and rarely have a stable crew of coworkers. The vast majority of the time I have to take stock of who I'm working with and what the patient situation is. I'm a little unpopular at this hospital because I frown on patient abuse and engage in deescalation early rather than trying to goad a patient into violence so we can call a code and have a little fun.
I do not like to go hands-on with patients. If it is necessary, if someone's health and safety are in imminent danger, then I am quick to react and will go all the way to ensure the safety of all present. However, the threshold is very high and the circumstances must be extreme before I will force compliance. I have a great deal of compassion for the suffering of patients who are afflicted with mental illness.
Tonight, I was told by a regular staff LPN that, "I'm the med nurse, I don't know where XYZ paperwork is." She normally assumes a shadow organization charge nurse position when float staff are on duty, so this was probably a passive-aggressive attempt to put me in my place. That doesn't bother me much, but the problem is that the taxi arrived for the patient and I needed to know where the discharge paperwork is located. I saw the carbons in the patient's chart, but I didn't know where the originals were. This patient is free to go and I'm held up. I don't think that is professional workplace behavior. I found the paperwork 20 minutes later in the patients' packed belongings, but it would have been nice to be told where the regular charge nurse would have put the paperwork.
The other incident involved a charge nurse on another unit who wanted me to ambulate a patient. I have no problem ambulating a patient. That's part of what nurses do. However, I'm being called from another unit to perform this task when there are two nurses and two techs on their unit. Why me? I was told that it's because I'm a big guy and this patient has fallen at least twice a day for several days.
If this patient has a history of falls this recently, then why are we ambulating him? Patient reported a broken patella 2nd to a sports injury. Cold extremities, possibly overmedicated and nodding out on oxycontin and oxycodone, reporting lower extremity weakness, and barefoot. I don't think this is good judgment. All my questions were rebuffed that this patient needs to be ambulated.
I gave it a shot. I got him some grippy-bottomed socks, and had him do some upper body exercise in the wheelchair for a bit to get his blood pumping. He did OK with return demonstrations and seemed to be possibly able to ambulate a short distance. I socked him up, locked the chair, and had him stand. Wobbly and painful, but able to rise on his own. That's a good sign. I had him follow the wall on a short piece of the hallway, which he was able to navigate with prompting and assistance before "my knees are buckling" so I swooped in with the wheelchair and scooped him up. Pt immediately nodded off.
For some reason, this charge nurse seems to have authority on the unit above/beyond the norm. She had no gait belt, no 2:1 staff to help if he fell, and it kind of seemed like she was bullying me into performing this task.
I don't have a problem with work, but I do have a problem with being set up to swallow an incident report.
I do not like to write up my coworkers, but I also don't like being taken advantage of.
Give me some feedback. I need to take stock of this set of circumstances and figure out a course of action. I'm going to be back for the next couple of days and will be floating between these two units with these staff, so I want to put a game plan together. Part of me wants to set boundaries and drive appropriate behavior, and part of me wants to go along and get along. Both are important. It's a balancing act, so I don't want to go too far in either direction.
Oct 27, '12
I don't think there's any grounds to write them up. You can't really write up passive-aggression, and they didn't make you ambulate that patient. You agreed to it. If you're uncomfortable doing something, just say no. You just need to call them on their behavior when they're being passive-aggressive.
And, I'm shocked that you're not popular because you don't like to psychologically abuse patients. Not shocked that you're not popular because of this, shocked that abuse is normal behavior at that facility. That, you can report if people are intentionally getting a rise out of patients. If they're just not good at their job or are impatient, then they need some education on how to be effective in their job. Messing with someone who is so vulnerable is just insidious.
Doesn't sound like a particularly great place to work.
Oct 27, '12
If he's a big guy, with a high fall risk, you need to set the limits. Say you'll be happy to help them, but you aren't going to do it alone, and since you don't know the patient, the other person from that unit needs to take the lead.
Oct 28, '12
I would not try and write your coworkers up, that will not help you win them over. In regards to ambulating the pt from the other unit, I would have assessed the situation and refused. Especially if nobody offered to asssist you. A well written progress note should have been enough to cover your butt. Good luck with that crew, they sound delightful.
Oct 29, '12
I would set boundries. IF that patient falls while you are ambulating him, with no gait belt, no anything, then that is an issue. If the patient has had falls, were they checked out at the local ED? All this could come back and bite your butt--after all, you are the one who is ambulaing him and "charge told me to" doesn't stand up in court. Ask to see the order. What was assessed by the primary care nurse regarding his ambulation? Ask to see the chart--does he have a current patella fx? Is it being treated? If he can not walk, then into the local ED to get an x-ray and treatment for the knee, physical therapy for the knee--in the pysch hospital is not a place to be able to become a Physical Therapist. And I would say "I will not ambulate a patient without a specific order. The patient is unsafe to ambulate, due to no gait belt, bare feet, and mental status." Period. If there's an order, and you put some grippy socks and a gait belt, and you have a tech follow you in a wheelchair, and it doesn't work, "this patient is having knee pain, lower body weakness, and an inability to ambulate. You need to get an order for follow-up". One of the biggest pet peeves I have is that just because someone is mentally ill doesn't mean they are cognitively challenged!!
As far as the discharge--I would be sure that whomever I get report from, I would ask if the paperwork has been complete and where the patient's copies are, and if there's anything left to do for discharge. If the discharging nurse is still on the floor, then I would ask her directly.
Being quite "type A" as a nurse myself, I use that as my "explaiination" to fellow nurses who look at me like I have 3 heads when I ask for information, to see orders, to not "take someone's word for it".
"Being a nurse for as many years as I have, I need to see orders. My type A is in overdrive.......SEEEEE aren't you glad I don't work on this floor full time?!?!?!" It is in your approach. You have a practice to which you do (and SHOULD) adhere to. It is within the norm on how a nurse should practice. Be confident in that. If you are suspecting that things are happening that shouldn't be ie: a patient with a broken knee cap is not being treated for it, instead they are attempting to have him ambulate without treatment but a boatload of pain meds, then I would put in a report regarding that. Not specifically an incident report, but a report that something needs to change in the patient safety realm of things. And be careful floating to another floor. "I have a patient assignment today that prevents me from leaving the floor." Which is what your charge SHOULD have told the nurse who called to begin with.
Nov 5, '12
Thank you all for the feedback. You have some good suggestions. As much as I hate to admit it, filing incident reports is the only way to communicate to the administration of the hospital. There is no "management" layer. There is a shift supervisor, but no management. As much as I used to dislike dealing with management, I've found that not having any management to deal with is the bitter apple.
Can I see the order? Why is your unit not capable of performing this task? Has the patient received treatment for his fx patella? Good questions, and they are very relevant. I'm still a new nurse, so this is good food for thought.
Nov 5, '12
ALWAYS ask to see the order. That is your direction in what the MD is asking be done, as opposed to what someone's idea of keeping the patient busy may be. And be sure that this particular patient has a knee imobilizer and a walker. And a gait belt. In other words, everything the patient needs to ambulate safely, and you to be doing things the correct way.
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