Have you ever requested a patient be removed from your workload?

[SilverBells, BSN]

For many of us, we encounter patients that we don't necessarily enjoy caring for.  But, as nurses, we do our jobs and we care for them in such a way that they are able to go home. 

What happens, then, when we are given a patient that we can't care for? It has nothing to do with not wanting to be the person's nurse and more so to do with the fact that we know we aren't the right person to care for this patient.  

Here's an example.  I've had a patient on my unit who has been hospitalized 4 times or once a week since she was admitted 1 month ago.  Despite my best efforts and frequent communication with the providers, she declines anyway.  No matter what I do, we end up having to send her to the emergency room.  However, she was admitted to our facility before (a couple of months prior, maybe) and was on a different unit.  She did not go to the ER once when she was on the other unit.  I'm tempted to suggest that if we do accept her back once she is medically stable that she be admitted to the other unit and not mine.  In my opinion, I have continuously failed this patient.  I also feel that by repeatedly reassigning her to my caseload, the facility is also failing her.  I might be wrong, but I'm wondering if she might do better with a different nurse overseeing her care.  

Anyone else ever been in this situation? What do you do when you are repeatedly assigned a patient you aren't capable of caring for? 

Please note: I am asking this question for the good of the patient.  If I knew what to do for this person, I would.  I really do think it's time that someone else oversee her care so she can receive the treatment she needs.  It would help me sleep better at night knowing that she's in the right hands, which I feel aren't my own. 

[MunoRN, RN]

If your concern is that there is something different or lacking about the care you're providing to this patient, compared to other unit, then it would make more sense to figure out what that is address it, since it's unlikely that would only affect this particular patient. 

Why are they being hospitalized so frequently?  Is the other unit just less likely to send the patient out to the hospital or is the patient's condition truly deteriorating more on your unit that the other unit?  In what way is the patient's condition worsening while on your unit?  Is that deterioration avoidable or unavoidable?

[SilverBells, BSN]

3 minutes ago, MunoRN said:

If your concern is that there is something different or lacking about the care you're providing to this patient, compared to other unit, then it would make more sense to figure out what that is address it, since it's unlikely that would only affect this particular patient. 

Why are they being hospitalized so frequently?  Is the other unit just less likely to send the patient out to the hospital or is the patient's condition truly deteriorating more on your unit that the other unit?  In what way is the patient's condition worsening while on your unit?  Is that deterioration avoidable or unavoidable?

Basically, she's being sent out for repeated complications related to gastric bypass surgery.  I'm not sure why she was never sent out on the other unit, because she'd also had the surgery then.  But she's constantly having abdominal pain, nausea, vomiting and bowel obstructions.  Her symptoms never seem to improve no matter what medications we give her.  I have no idea what we are doing wrong.  

I do question myself, though.  From my perspective, it always seems like I am sending more patients out to the ER than other nurses, including my management colleagues.  This past week, 3 patients went to the ER and all of them were mine.  I am not sure if I am simply getting more sick patients, am more responsive to concerns, or if I am somehow lacking in my job.  It is hard to know what is going on at the other unit or what the other nurses are doing to better manage their patients' care because their documentation is often quite lacking.  They may be caring for their patients well, but you'd never know it from their lack of progress notes.  I may ask them what they are doing to keep their patients in the facility since their return-to-hospital rate appears to be lower than mine.  

One reason I would like to see this patient on the other unit is because I truly believe the manager overseeing that unit is a stronger nurse clinically than I am myself.   It wouldn't surprise me that if this patient was admitted over there she would stay there until it was time to go home from therapy.  On the other hand, if she were to go back to the ER from that other unit, it could provide some reassurance that this patient is simply just sick.  With that said, I want to find out what he is doing that I am not.  His documentation is lacking at times, but I wonder what he is doing all day that it seems that nobody is being transferred to the ER.  Maybe he has a better approach to things than I do. 

 

[SilverBells, BSN]

As a side note: It doesn't help that this patient likes her narcotic pain medications around the clock and likes to spend most of her time in bed, which are probably contributing to some of her issues.  No matter what you do for her, you're in the wrong.  If you don't give her the pain medications she requests, she'll complain.  If you do, you're probably contributing to her bowel issues.  Also, even if you provide her with the ordered pain medications she has, she'll complain and request an even higher dose.  You can't win. 

[MunoRN, RN]

31 minutes ago, SilverBells said:

Basically, she's being sent out for repeated complications related to gastric bypass surgery.  I'm not sure why she was never sent out on the other unit, because she'd also had the surgery then.  But she's constantly having abdominal pain, nausea, vomiting and bowel obstructions.  Her symptoms never seem to improve no matter what medications we give her.  I have no idea what we are doing wrong.  

I do question myself, though.  From my perspective, it always seems like I am sending more patients out to the ER than other nurses, including my management colleagues.  This past week, 3 patients went to the ER and all of them were mine.  I am not sure if I am simply getting more sick patients, am more responsive to concerns, or if I am somehow lacking in my job.  It is hard to know what is going on at the other unit or what the other nurses are doing to better manage their patients' care because their documentation is often quite lacking.  They may be caring for their patients well, but you'd never know it from their lack of progress notes.  I may ask them what they are doing to keep their patients in the facility since their return-to-hospital rate appears to be lower than mine.  

One reason I would like to see this patient on the other unit is because I truly believe the manager overseeing that unit is a stronger nurse clinically than I am myself.   It wouldn't surprise me that if this patient was admitted over there she would stay there until it was time to go home from therapy.  On the other hand, if she were to go back to the ER from that other unit, it could provide some reassurance that this patient is simply just sick.  With that said, I want to find out what he is doing that I am not.  His documentation is lacking at times, but I wonder what he is doing all day that it seems that nobody is being transferred to the ER.  Maybe he has a better approach to things than I do. 

 

Does the patient return from the hospital in a better condition than before they went?  The full library of charting from their hospital stay would be a chore to go through, but did the discharge summary at least say what they had done to cause an improvement in the patient?

 

22 minutes ago, SilverBells said:

As a side note: It doesn't help that this patient likes her narcotic pain medications around the clock and likes to spend most of her time in bed, which are probably contributing to some of her issues.  No matter what you do for her, you're in the wrong.  If you don't give her the pain medications she requests, she'll complain.  If you do, you're probably contributing to her bowel issues.  Also, even if you provide her with the ordered pain medications she has, she'll complain and request an even higher dose.  You can't win. 

If the patient is being repeatedly sent to the hospital for non-mechanical small-bowel obstructions (obstructions due to immotility) then I would consider opiate pain medications to be an absolute contraindication.  The patient will not like that, but continuing to give a medication that is causing the condition that is resulting in the pain you are trying to treat isn't going to help things.  I would suggest to the patient that they need to better clarify their goals of care, if they want to get better then no opiates, if they just want to be comfortable then we can continue to give opiates until the inevitable bowel perforation occurs in which case we'll give even more opiates, but a curative approach would be off the table.

[SilverBells, BSN]

55 minutes ago, MunoRN said:

Does the patient return from the hospital in a better condition than before they went?  The full library of charting from their hospital stay would be a chore to go through, but did the discharge summary at least say what they had done to cause an improvement in the patient?

 

If the patient is being repeatedly sent to the hospital for non-mechanical small-bowel obstructions (obstructions due to immotility) then I would consider opiate pain medications to be an absolute contraindication.  The patient will not like that, but continuing to give a medication that is causing the condition that is resulting in the pain you are trying to treat isn't going to help things.  I would suggest to the patient that they need to better clarify their goals of care, if they want to get better then no opiates, if they just want to be comfortable then we can continue to give opiates until the inevitable bowel perforation occurs in which case we'll give even more opiates, but a curative approach would be off the table.

She always returns back feeling better than she was, but it never lasts long. 8 days of no hospitalization is actually a good record for her lately.  Notes from the hospital are always very vague in regards to their interventions. 

I agree that a goals of care conversation needs to occur. She always states she wants everything done to get her better but is consistently non compliant with recommendations.  I still also think that if she does come back, it would be wise to transfer her to the other unit to see how she does there.  I think she needs a manager with a substantial amount of intelligence and skill and I believe my colleague has more to offer than I do.  I feel we are doing her a disservice keeping her in my unit and worry about her continuing to decline.  Continuing to accept her and putting her under my care seems to be unwise.  

[MunoRN, RN]

40 minutes ago, SilverBells said:

She always returns back feeling better than she was, but it never lasts long. 8 days of no hospitalization is actually a good record for her lately.  Notes from the hospital are always very vague in regards to their interventions. 

I agree that a goals of care conversation needs to occur. She always states she wants everything done to get her better but is consistently non compliant with recommendations.  I still also think that if she does come back, it would be wise to transfer her to the other unit to see how she does there.  I think she needs a manager with a substantial amount of intelligence and skill and I believe my colleague has more to offer than I do.  I feel we are doing her a disservice keeping her in my unit and worry about her continuing to decline.  Continuing to accept her and putting her under my care seems to be unwise.  

Putting aside the consistent oddity of your topics, I would agree that at this point the best option might be to put the patient on the other unit, see if they do better, then look at what they did differently.  

[Emergent, RN]

Maybe a nurse from your unit is diverting this patient's opiate medication, leading to the gastrointestinal symptoms that accompany opiate withdrawal. 

[Tenebrae, BSN, RN]

I currently work in acute pysch, and yes I have had patients that I struggle to care for. I have one at the moment who seems to know exactly how to stick the knife in (metophorically speaking), and being in a fragile headspace at the moment I may ask my senior not to be asisgned to them for a week. 

The question I ask you is 'Do you leave your job after caring for this patient and feel that you have done the best job you can do?"

This patient sounds incredibly complex, as someone who has been through gastric bypass surgery many of those GI symptoms could be simply a result of eating too much of the wrong food, too quickly. I know for me eating too much sugar gives me major diarhoea, if I eat too much protein and starch too quickly I will end up with major nausea and often end up vomitting. 

As a nurse you don't have to heal the world, you just have to be able to leave your job each day with the knowledge you have done the best job you can. Your level of control litterally ends at your finger tips. We can educate up the wahzoo however if a patient is non compliant it really is like trying to put out a forrest fire by spitting on it.

And focus on good self care for you

[SilverBells, BSN]

9 hours ago, MunoRN said:

Putting aside the consistent oddity of your topics, I would agree that at this point the best option might be to put the patient on the other unit, see if they do better, then look at what they did differently.  

Thank you.  Now to convince upper management they should put this patient on the other unit should she return.. or maybe just not accept her back if they receive a referral for her....

[FolksBtrippin, BSN, RN]

There are some good reasons to remove yourself as the nurse. Maybe its because I work in Psych, but here are some I can think of:

The patient is in love with you or has another boundary issue that he or she does not have with another nurse.

You know the patient outside of work and feel that it would be a conflict. 

Your reason does not seem to me to be a good one. If you think the other nurse (manager?) Is clinically more competent or smarter or has better skills then you should ask his advice. 

Also, I feel like you are beating around the bush. What is really going on here? What do you really think the problem is? Are you thinking that your coworkers are being neglectful and not sending legitimate problems to the ER? Or do you think you are overdoing the ER because of a lack of confidence? 

[FolksBtrippin, BSN, RN]

Or... maybe you just really dislike this patient. Stop beating around the bush and tell us what the problem is.