I'm sorry if this is long. I don't know how to start my story. But I will try my best to give a good summary of what happened.
I've been a nurse for only 7 months. I'm working on a Tele Floor, and in this particular night I received an admission, patient has multiple fractures (hip and hand) due to a fall. The patient was put on NPO for a surgery the following day. That night, a family member (who is a nurse and works at the same hospital, different floor) came to visit. Everything went well, she went home after a few hours since she had to work the following day.
That night I kept asking the patient if he's doing okay, and if he is having any pain. I must have done this more than 10 times. His response was "I have pain, but I'm okay right now. It's not really bad as long as I don't move a lot." I told him I can give him pain medicine but he keeps refusing them. So what I did was to reposition and tried to keep him as comfortable as possible. This particular patient needed a few units of blood, and I had to hang them that night. So I had to sit with him multiple times, and most of my time must have been spent with him. And in those times I kept assessing his comfort and offering pain medicine and he kept refusing. And I told him that if he ever changes his mind, to just let me know. The charge nurse knows all about these since she had to witness the blood and she knows the patient was refusing the pain medicine.
Around 0645 in the morning before shift change, he told me he was having a really bad headache. I told him I can give him the pain medicine to take care of the headache. And he finally said yes. He was on NPO so I can only given him Morphine since that was the only pain medicine IV ordered, and it was for 2 mg. As I was drawing this, my charge nurse told me "Oh by the way, the family told me to just give him 1 mg he is afraid it will make him loopy". I said "the order was only for 2 mg, do you wanna call the doctor so we can have it changed?" And she said "That's fine, just give him 2 mg." So I did, and he was fine. Nothing "loopiness" happened. I gave report, and I thought my day was done. I was preparing to go home when the family came and wanted to talk to me. I told her he was doing okay, and he got his blood, and finally said yes to the pain medicine this morning. She got really upset because I let the patient go without pain medicine for 12 hours. She said the reason why he didn't want it because it makes him loopy and she said she told the charge nurse before she left to give him 1 mg to at least help with the pain. So I told her he kept refusing it, the charge nurse told me to give him 2 mg. She then asked for the day shift nurse.
I got a call from my nurse manager. This call came right after I got off work and I was literally running to the airport trying to catch a flight. I missed the flight and was so frustrated (the next flight leaves at 6pm, which meant I will miss an important family event). The phone rang, and my nurse manager told me she wanted to talk to me about a complaint by a nurse from another floor about her family member not getting pain medicine. She told me the nurse came to her and was very upset. She just wanted to know my side of the story. I was already pumped with adrenalin from running, plus the frustrations of missing the flight, and now this! I don't know if I told the story in a very calm way. But I tried to as much as possible. She told me she understand my side but she doesn't want the other floors to have this impression about our floor, that we don't take care of our patient's pain. She said I should have investigated more on why the patient doesn't want pain medicine. It's not a valid reason that I just accept when a patient says he's okay as long as he doesn't move a lot. And I explained to her that I repositioned him to make him comfortable and that I can't force pain medicine to someone who doesn't want it. I also told her that the charge nurse never informed about the family member's request until I was already drawing the morphine that morning. I should take this as a learning experience, and not to ignore someone's pain next time. She told me again that the family member was quite upset and she doesn't want this reputation on our floor.
So here's the part that really bothers me. I feel like I've stained my floor's reputation, and other nurses must think very negatively of me now. I can't stop thinking about it. I've had many other horrible families before but I've always tried to be the best nurse to their family and satisfy their expectations. I just couldn't get over the fact that a complaint was filed against me directly to the nurse manager. I'm very anxious to go back to work. It's already stressful as it is, but this one is adding to my stress big time.
Total BS ... the patient's family member needs to recognize that if she wants specific orders/doses for the patient she needs to talk with the physician - otherwise back off ... and your manager must not be very busy if this went to the top of her priority list first thing in the morning.
The only thing you might mentally file away in your patient verbiage repertoire is to ask patients who appear to be in pain and certainly have a good reason to be in pain (multiple fxs) "is there a reason you don't want anything to relieve the pain?" There are a surprising number of people who are concerned meds will be "too strong" or cause nausea or have some other negative association with meds. Having this conversation actually reinforces their autonomy, as they get to clearly state their reason, and you get to provide some education that addresses their concerns. The choice is still theirs to make -- a win-win all around.
Specializes in Pain, critical care, administration, med.
I think overall you did a good job. A couple of things to think about. When the patient said his pain is good when he doesn't move was a opportunity to discuss why pain medication would be helpful. Also digging into why he was refusing it. Many patients have misinformation and its our role to clear that up. Once a patient has been assessed and educated appropriately we have done our job. Ensure detailed documentation of the discussion and education as well as the interventions you did provide.
Pain management is huge and many of us lack the knowledge needed to care for our patients.
Thank you for all your responses. All of you have been very supportive. I do agree and I'm taking it as a learning experience that if a patient is in pain, I need to dig deeper and need to assess and reassess and give education if necessary.
You did nothing wrong. Your patient is an adult and has the right to make decisions for himself. The nurse family member was way out of line and inappropriate as was your nurse manager.
Thank goodness for this website! I am a brand new nurse and just starting working 2 days ago. I can picture myself doing the same exact thing as you Alex87 if I were presented with this situation. I learned something from reading your post and it's responses. Hopefully I can refer to this incident if it were to ever happen to me. It is reassuring and heartwarming to read such supportive posts from fellow nurses. The suggestions given were nonjudgmental and insightful. I hope that you're able to really recognize the fact that you did the best that you could and move on from this incident. Good luck in the future!
I don't think you did anything wrong in honoring the patient's refusals. BUT...
I've taken care of lots of elderly folks with painful conditions, and this is a common concern.
When a patient has a very painful condition, such as a hip fracture, and continues to refuse pain medication, I think it is reasonable for the nurse to investigate why. If the person gives the reason that they are concerned about altered mental status (i.e. feeling "loopy"), then that concern needs to be validated and also addressed. Maybe that person has had morphine before and had a bad experience. Maybe a different analgesic would be in order. Maybe it's just a dose related concern, and you could get an order to give a smaller amount.
I might say something like "I understand your concerns and respect them, but I can see that you're hurting, and I think it's important you get a good night's sleep. How about if I give you just a teeny tiny dose? Just enough to take the edge off the pain but not enough to make you loopy? Does that sound reasonable?" They still might refuse, but most of the time they don't, because I have addressed their concerns and I'm offering a reasonable solution.
Then I pray with everything I've got that they don't get loopy!
I think that your NM has a point that just accepting your patient's refusal when they are clearly in pain, without investigating what might be behind the refusal is reasonable behavior to question. However, with you being a new nurse, I think this is behavior that your charge nurse should have modeled for you instead of throwing you under the bus.
I think you should take this as a lesson learned about how you can do better for your patients next time, but I don't think you should internalize it as much as you are. You haven't "stained" anybody's reputation. You're just a new nurse who is still learning.
How I would approach this with my NM is that I would sincerely tell her "I see how I could have handled this better, I have learned something, and I will do better next time". And then next time, do better.
But quit beating yourself up. Nursing is hard enough as it is, especially when you're new.
You have gotten valuable advice all around. I think you did a good job taking care of your patient and have hopefully learned how to improve. ITA that yourNM did a TERRIBLE job of handling this. It sounds like her concern is more for the floor's reputation than the actual care the patients receive. I also agree that you do not have to answer your phone. Let them leave a VM and you can call when you are ready. We should all be continually learning and growing. Let the fears and bad feelings from this encounter go and strive to continually give each patient your best.
You did nothing wrong. But I hear this too often..."I don't like pain medicine, I don't want to take that stuff," etc.. Or a patient is laying there barely moving and says they have no pain after surgery.
What I tell such patients is....."Your body cannot heal when it is fighting off the pain. Your pain receptors are using up all your bodies energy. (I don't know if this is 100% medically true but I to believe there is some truth to it.) If you are in such pain you cannot move around you will not breath deeply and get pneumonia. I am going to give you (not.... "do you want"...) a tiny amount of morphine...it is the same amount I would give a 2 year old child."
Then if he still said "no." I would quote the whole conversation in my nurses notes.
take a deep breath.....you were in the right. You cannot force a patient to take a medication against their will. It seems like the nurse manager doesnt do well in any "conflict" situation. Mind your Ps and Qs...as was said, make sure your resume is updated and handy just in case
PS....I also tell them if they are not moving around because of pain they will get constipated. So their choice is a tiny dose of pain medicine now or an enema in a few days. Be serious, but say it with a smile.
If one of my coworkers was trash talking because he/she had a family member on another floor, and the nurse didn't given pain meds for 12 hours because the patient was refusing them...I would be concerned about what the problem was. I have patients that refuse pain meds all the time because they don't like feeling out of it or drowsy. As far as I'm concerned, as long as they're A&Ox3, it's entirely their decision. In fact, you or the hospital could get sued if you went and pushed morphine even if the patient didn't want it!!
Like others have said, competent adults have the right to refuse meds, etc. From what you wrote, I can't see that you did anything wrong. Also, the phone call from your manager could have waited. He or she could have simply looked at your charting if the family member had concerns about how you addressed pain.
I have had family/friends come find me at the desk to ask me to do something or the other for a patient (give pain meds, switch a consulting doctor, etc). If the patient is A&O, I simply walk back into the room and say to the patient "So-and-so asked me to get you pain meds (or whatever). Do you want something for pain?". I've gotten many a dirty look, but it usually takes care of the issue.
Altra, BSN, RN
6,255 Posts
Total BS ... the patient's family member needs to recognize that if she wants specific orders/doses for the patient she needs to talk with the physician - otherwise back off ... and your manager must not be very busy if this went to the top of her priority list first thing in the morning.
The only thing you might mentally file away in your patient verbiage repertoire is to ask patients who appear to be in pain and certainly have a good reason to be in pain (multiple fxs) "is there a reason you don't want anything to relieve the pain?" There are a surprising number of people who are concerned meds will be "too strong" or cause nausea or have some other negative association with meds. Having this conversation actually reinforces their autonomy, as they get to clearly state their reason, and you get to provide some education that addresses their concerns. The choice is still theirs to make -- a win-win all around.