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.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
On 4/11/2021 at 7:07 PM, 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.
Okay, here's what's happening: the other unit is keeping her happy. They let her stay in bed and they feed her pain medication. If any complications are brewing no one knows, because they are keeping her happy. You might think that is not a good way to practice nursing, because it isn't. You have concerned yourself with the whole person and her overall wellbeing. They are keeping her happy and keeping themselves less stressed.
I'm with you on this. I couldn't sleep at night wondering what's brewing on my watch. It is really not to this patient's advantage to be on the other unit. However, when she is on your unit and you aren't keeping her happy, she has to complain enough to get sent back to the ER.
Here is my motto: Do not work harder on anyone's behalf than they are willing to work for themselves. Provide constant education and encouragement for this patient and of course, document that you did so. But give her her pain meds and don't make it your personal mission to get her out of bed. It's her life and up to her to decide how to live it. You can only do so much, and there are a lot of factors working against you.
It's not easy to let things go when you care about people. It's a balancing act. Hang in there and just do the best for her that you can.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
17 hours ago, SilverBells said:
However, on the flip side...doesn't it make more sense to assign the more complex patients to the more intelligent nurse/manager?
Nope. Because you are working to become the more intelligent nurse. I don't think it's "taking advantage" of your colleague to pick his brain. If he's not just following the path of least resistance (read my previous post, it may ring true or NOT) then there is undoubtedly much to learn from him.
I also second the previous posters who said this is a highly complex patient and you may never get her to the point that you'd like her to be. The combination of physical complications and her whole psychological make-up can create quite the ball of wax.
Have you ever just pulled up a chair at her bedside and asked her how's she doing? Tell her you can see this has been a huge ordeal for her; does she ever feel discouraged? Then just listen to what she tells you. Sometimes when we stop trying to cure people and take the time to really listen, we will learn fascinating things.
Nope. Because you are working to become the more intelligent nurse. I don't think it's "taking advantage" of your colleague to pick his brain. If he's not just following the path of least resistance (read my previous post, it may ring true or NOT) then there is undoubtedly much to learn from him.
I also second the previous posters who said this is a highly complex patient and you may never get her to the point that you'd like her to be. The combination of physical complications and her whole psychological make-up can create quite the ball of wax.
Have you ever just pulled up a chair at her bedside and asked her how's she doing? Tell her you can see this has been a huge ordeal for her; does she ever feel discouraged? Then just listen to what she tells you. Sometimes when we stop trying to cure people and take the time to really listen, we will learn fascinating things.
It's unfortunate, but I agree that it may be challenging, if not impossible, to obtain the physical and mental balance that I am hoping to achieve with this patient. This is where, as you mentioned, her goals of care come in and I'm not sure that anyone has really spoken with her about what is most important to her. While it is important for me to keep my patients out of the hospital if at all possible, maybe comfort is more important to her, and as long as she can receive temporary pain relief, she is willing to accept the risk of having to return to the hospital based on consequences. Something to look into if she does return. It wouldn't be the first time where the goals a patient has for themselves don't necessarily align with my goals as a nurse.
It's possible, then, that her hospitalizations are more so related to her complex medical status and her goals of care for herself rather than any lack of intelligence on my part. This doesn't mean that it wouldn't be worth it to reach out to my colleague, as I do believe he is highly intelligent and has good nursing judgment. At the same time, he's probably not as "perfect" as I make him out to be, as he's actually made several mistakes of moderate significance this past week. He is still new to his role, so maybe overwhelming him with such a patient wouldn't be the right thing. Not to mention that if she does go over to that other unit the same issues could return regardless.
If she does return, and she does come back to my unit, at least I know ahead of time that she is medically complex. Instead of trying to pawn her off to someone else (by using "lack of intelligence" on my part as an excuse) the better option may be to simply focus on her goals of care by asking what is most important to her. The next step would be to not take any future hospitalizations personally if they result from choices she has made.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
24 minutes ago, SilverBells said:
If she does return, and she does come back to my unit, at least I know ahead of time that she is medically complex. Instead of trying to pawn her off to someone else (by using "lack of intelligence" on my part as an excuse) the better option may be to simply focus on her goals of care by asking what is most important to her. The next step would be to not take any future hospitalizations personally if they result from choices she has made.
I actually agree with your whole post, I just pared it down for space. I'm sure you already know that the hardest situations are the ones we learn the most from. It's clear to me that you are thinking about this from all angles and I think you're on the right track. What you learn from this situation will probably give you tools to handle many complex situations in the future.
Specializes in Psych, Addictions, SOL (Student of Life).
13 hours ago, SilverBells said:
Any suggestions on how to boost one’s natural intelligence appreciated. With that said, this patient deserves a manager who already has this
Well the fact that you got licensed tells us that you are smart. But I usually do CEUs in subject that I know I could do better from Join a professional practice organization. I'm sure there must be a national association of LTC/Rehab nurse. IWhen I did OB/GYL I belonged to AWHOON which aims to improve the nurses practice and ensure better patient outcomes and the CEUs were free.
Now that I doing Psych the the assocation of psychiatric nurses. I get free CEUs every month pluse I got a cool tote bag and sweatshirt. Two years ago I went to their conference and did a week long conference to enhance my understanding of issues reacrding the LGBTQ community. It was extremely eye-opening esperience.
So just go for it you don't need to work 18-20 hours day. Also going to conferences it a way to meet, smart, educated in you demographic.
I wouldn't say I highly dislike this patient. However, the fact that she continues to have issues that I haven't been able to resolve stresses me out. She keeps getting sent back to the hospital, so I feel like I've continously failed her. She'll come back from the hospital and I'll do everything I can to keep her out, but she always ends up going back. Maybe she is simply a very sick patient but I also feel it couldn't hurt to see how she does under another manager. I trust my colleague's judgment enough that if he were to send her in, something truly is wrong. I also have faith he might be able to do a better job keeping her at the facility
You aren't failing her. She if refusing to follow medical advice to move more and stop the pain meds. If its been over a month since surgery, she shouldn't still need them anyway, unless she has become addicted to them. I've read it's not uncommon for complications with gastric bypass, about 1/3 will have issues. She may be eating too much or mixing eating and drinking leading to vomiting and pain. She could have adhesions, scar tissue, although it may be too early for that.
I've seen all those complications with the few bypass patients I've cared for. I had a coworker with a failed bypass and although she lost weight initially she couldn't keep it off and also had constant pain and vomiting and was hospitalized with recurrent obstructions. I've taken care of a pt that would become dehydrated and need IV fluids who was fine with that. She was happy with the results and didn't think anything of needing her monthly "tuneup". I had a patient that went into liver failure and died after her second failed gastric bypass. She blamed the Dr for not realizing she was eating improperly in the first place. She developed NASH from the massive weight loss and eventually died.
I think you are a perfectionist and also due to your lack of confidence go above and beyond with your patients and may be catching issues early and getting them to the ER before they crash and burn. Does your nursing home have a Dr or NP on the premises that could assess the pt?
When I was a new nurse I was afraid of missing something so would call the doctors over every little thing. They were very patient and understanding, but when the pt needed the ICU they would transfer them. I had a jealous coworker who insinuated I was doing something to cause this as to why so many of my patients were transferred to the ICU. The reality was I was being given sicker patients, always up for first admit etc, and also was hypervigilant so I caught things early. A couple times I saved patient's lives by catching a PE in a pt misdiagnosed as PNA and another pt with a bleed from a heparin drip.
What type of facility do you work at? Is the other unit you're talking about for higher acuity patients? And I totally get the frustration of seeing a patient completely ignore medical advice and seem to only want narcotics. It's only natural that we get slightly annoyed with people who seem to not be taking their health seriously, but sadly, it's not fun to follow medical advice when you want to eat what you want and get pain meds when you want. I totally understand your worry that her non-compliance will somehow reflect poorly on you as a nurse, but we can't make people do what they don't want to. I would make extra sure to document the education you're providing and then her activities (with no judgment, of course, just the facts). And as other people have said, if you think the pain meds are contributing to the obstructions, then I would definitely speak to the doctor about that. Maybe even look in her records to see if there's a correlation between stomach issues and pain meds.
Specializes in Psych, Addictions, SOL (Student of Life).
1 hour ago, lmichelle25 said:
What type of facility do you work at? Is the other unit you're talking about for higher acuity patients? And I totally get the frustration of seeing a patient completely ignore medical advice and seem to only want narcotics. It's only natural that we get slightly annoyed with people who seem to not be taking their health seriously, but sadly, it's not fun to follow medical advice when you want to eat what you want and get pain meds when you want. I totally understand your worry that her non-compliance will somehow reflect poorly on you as a nurse, but we can't make people do what they don't want to. I would make extra sure to document the education you're providing and then her activities (with no judgment, of course, just the facts). And as other people have said, if you think the pain meds are contributing to the obstructions, then I would definitely speak to the doctor about that. Maybe even look in her records to see if there's a correlation between stomach issues and pain meds.
I've never asked for a patient to be moved from my assignment. I did ask for a day on another unit today after two long days with a very aggressive patient who knocked me on my Donkey's behind.
It was a lovely day on the Co-ED adult unit where most of the patients were pretty grateful even though some had really negative body odor. Just one more reason to wear an KN95 all day.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
6 minutes ago, FolksBtrippin said:
This reminds me of when my kids didn't want to be asked to do chores so they just did them poorly.
Saying that the other guy is smarter is a copout. It might even be sexist.
Learn more if you think the problem is your lack of knowledge. You're not a dummy. I can tell. I have an idiot radar.
I agree with the above. Stop saying others are "better, smarter, prettier" whatever. Fix what you can control and let go of the rest but stop comparing yourself already, OP!
Specializes in Neurosciences, stepdown, acute rehab, LTC.
Yea , we do it a fair amount on my unit. I don’t think you need a reason except that you need a break. They kept giving me this one guy because I tend to do well with behavioral patients but I had him too much and he was too loud and he simply gave me a headache every time so I just said I didn’t want to take him back anymore. Most of us only do it once in a while if we’re totally burnt out on a patient. We’re only human.
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TriciaJ, RN
4,328 Posts
Okay, here's what's happening: the other unit is keeping her happy. They let her stay in bed and they feed her pain medication. If any complications are brewing no one knows, because they are keeping her happy. You might think that is not a good way to practice nursing, because it isn't. You have concerned yourself with the whole person and her overall wellbeing. They are keeping her happy and keeping themselves less stressed.
I'm with you on this. I couldn't sleep at night wondering what's brewing on my watch. It is really not to this patient's advantage to be on the other unit. However, when she is on your unit and you aren't keeping her happy, she has to complain enough to get sent back to the ER.
Here is my motto: Do not work harder on anyone's behalf than they are willing to work for themselves. Provide constant education and encouragement for this patient and of course, document that you did so. But give her her pain meds and don't make it your personal mission to get her out of bed. It's her life and up to her to decide how to live it. You can only do so much, and there are a lot of factors working against you.
It's not easy to let things go when you care about people. It's a balancing act. Hang in there and just do the best for her that you can.