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

[SilverBells]

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. 

[anewsns]

This whole thought process is interesting to me. Is the nursing care on the other unit just more complex ? Most of the time they just assign people to the appropriate for their condition with the expectation that the nurses have training for that specific unit. Regardless, my gut is that it doesn’t have that much to do with you. (Edited after this point after reading more of the thread.) I feel like she’s just non compliant and a complainer and it’s easy to burn out on those patients. You are WAY overthinking most of this. Sounds like you gotta take charge of the situation instead of just reacting to events and putting out fires and worrying about intelligence. 

[LibraNurse27, BSN, RN]

On 4/13/2021 at 11:40 AM, TriciaJ said:

Sometimes when we stop trying to cure people and take the time to really listen, we will learn fascinating things.

Yes! It took me a while to learn this. It doesn't help to try to convince pts to do PT, get up, lose weight, stop drinking, stop doing drugs, etc if they have no intention to do so. You can educate, and ask what they gain from these behaviors, and if they have any desire to get help for whichever issue it is. If they say no, I definitely don't want to quit doing meth, I know exactly how it affects my CHF, and I'm never going to take bumex, I stop bothering them.

I give the bumex and do the fluid restrictions, low sodium diet, etc while they're admitted, knowing they'll go home and do meth, eat salty food, drink tons of Gatorade, and be re-admitted next month. It sucks and it's frustrating, but you can't blame yourself or take on others' problems. You can just let them know you're there to listen if that's all they want, and if they change their mind and would like education or help, give you a call!

[RN4567, BSN]

If your unit needs a break from this patient, I think it is OK to move her to a different unit.   For patients that are non compliant with Dr’s orders, all we can do is educate them and document, document, document.   You are not failing this patient.   Self care is a must for you and your entire unit. 

[PoodleBreath]

Is there a doctor in the house?

[SilverBells, BSN]

15 minutes ago, PoodleBreath said:

Is there a doctor in the house?

Only once a week.  Otherwise, all communications are done either via virtual/telehealth visit or on the phone. 

On 4/16/2021 at 11:47 AM, RN4567 said:

If your unit needs a break from this patient, I think it is OK to move her to a different unit.   For patients that are non compliant with Dr’s orders, all we can do is educate them and document, document, document.   You are not failing this patient.   Self care is a must for you and your entire unit. 

Seems like the facility itself needed a break from this patient.  She was declined after she was referred back to us for a fifth time due to her history of noncompliance with recommendations. 

[SilverBells, BSN]

On 4/14/2021 at 3:13 AM, brandy1017 said:

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.

 

Logically, I understand that she's contributing to her own issues.  She has chronic pain and has been taking narcotics for years, so it's probably not ever going to be realistic to expect her to cut down any.  She spends most of her time sleeping, despite staff encouragement to at least get out of bed for meals.  Often refused therapy, which would have helped with physical mobility.  She even occasionally refused recommended bowel medications, despite knowing she has a history of bowel obstructions.  On top of that, she apparently had adhesions, as you mentioned.  While some of my colleagues feel that her hospitalizations are almost "inevitable," it still doesn't sit well with me to have the same patient hospitalized four times in 1 month.  I always feel I should have done more, but never really know what that "more" should have been.  Nobody else really does, either. 

Yes, I can be a bit of a perfectionist along with lacking in confidence at times.  In my mind, any patient that comes to me should get better and go home in a short period of time, not decline and be re-hospitalized repeatedly even though I logically know that sometimes people's bodies just don't always work that way.  I double check each medication or treatment order I enter at least 8 times each to avoid making any errors.  It's possible I contact the provider too often, just to make sure that I am not missing anything. I also put any patients I'm worried about on extra monitoring (such as vital signs every 3 hours, even when that is generally not realistic in a SNF setting due to large patient assignments) to make sure that if anything is wrong, they are seen sooner rather than later.   With that said, I also forget that most of the patients I care for are older, and so recovery will be slower, if not impossible, in some cases.  At the same time, I continue most of my habits because they have allowed me to catch changes in patient conditions before it has become too late. 

As far as having an NP or doctor in the house, they are only physically available once a week.  Otherwise, everything is done through telehealth visits and phone calls.  There's about a 50% chance you'll reach a provider who is helpful and a 50% chance you'll make contact with a provider who is irritated about being notified regarding any patient concerns.  Therefore, everything is based on my own assessments, and I still feel as if there is much about patient care that I do not know.  Thus, I don't always feel comfortable taking patients back if they are known to frequently decline. 

 

[SilverBells, BSN]

On 4/15/2021 at 2:09 PM, 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 can see how saying that someone else is smarter might be seen as a copout, but I am wondering how recognizing someone else's talent for nursing could be seen as "sexist" just because this person happens to be male? If it makes you feel better, I would also say my DON also highly intelligent and competent. Both of them have a "knack" for knowledge and nursing skill that I don't necessarily see in myself.   Nothing to do with gender.  I just happen to be very good at recognizing the strengths, talents, and gifts in people.  

[FolksBtrippin, BSN, RN]

22 hours ago, SilverBells said:

I can see how saying that someone else is smarter might be seen as a copout, but I am wondering how recognizing someone else's talent for nursing could be seen as "sexist" just because this person happens to be male? If it makes you feel better, I would also say my DON also highly intelligent and competent. Both of them have a "knack" for knowledge and nursing skill that I don't necessarily see in myself.   Nothing to do with gender.  I just happen to be very good at recognizing the strengths, talents, and gifts in people.  

If you say it's not sexist then it's not sexist. It might have been. Some women internalize a feeling that men are smarter and know more than them. It's pretty common. 

I still think there's something you're not saying. It's my hunch and I know my strengths. 

?

[Kooky Korky, BSN, RN]

On 4/17/2021 at 3:10 PM, SilverBells said:

Logically, I understand that she's contributing to her own issues.  She has chronic pain and has been taking narcotics for years, so it's probably not ever going to be realistic to expect her to cut down any.  She spends most of her time sleeping, despite staff encouragement to at least get out of bed for meals.  Often refused therapy, which would have helped with physical mobility.  She even occasionally refused recommended bowel medications, despite knowing she has a history of bowel obstructions.  On top of that, she apparently had adhesions, as you mentioned.  While some of my colleagues feel that her hospitalizations are almost "inevitable," it still doesn't sit well with me to have the same patient hospitalized four times in 1 month.  I always feel I should have done more, but never really know what that "more" should have been.  Nobody else really does, either. 

Yes, I can be a bit of a perfectionist along with lacking in confidence at times.  In my mind, any patient that comes to me should get better and go home in a short period of time, not decline and be re-hospitalized repeatedly even though I logically know that sometimes people's bodies just don't always work that way.  I double check each medication or treatment order I enter at least 8 times each to avoid making any errors.  It's possible I contact the provider too often, just to make sure that I am not missing anything. I also put any patients I'm worried about on extra monitoring (such as vital signs every 3 hours, even when that is generally not realistic in a SNF setting due to large patient assignments) to make sure that if anything is wrong, they are seen sooner rather than later.   With that said, I also forget that most of the patients I care for are older, and so recovery will be slower, if not impossible, in some cases.  At the same time, I continue most of my habits because they have allowed me to catch changes in patient conditions before it has become too late. 

As far as having an NP or doctor in the house, they are only physically available once a week.  Otherwise, everything is done through telehealth visits and phone calls.  There's about a 50% chance you'll reach a provider who is helpful and a 50% chance you'll make contact with a provider who is irritated about being notified regarding any patient concerns.  Therefore, everything is based on my own assessments, and I still feel as if there is much about patient care that I do not know.  Thus, I don't always feel comfortable taking patients back if they are known to frequently decline. 

 

The devil with provider irritation.  They get paid a pretty penny and they can dang well earn it.  You work for your bread, don't you?  How dare you let some doctor get by with treating you badly.

As for the patient you've been discussing, it looks like she is out of your hair - at least for now.  You are likely not the only person she has ever frustrated.  

She sounds like a pain and you can rest easy, I think, knowing you tried to help her.  You can't force her, you can only do your best, which it sounds like you did.  

Do you need a doctor's order to send someone to the ER?  If so, the doctors apparently agreed with you that she should have been sent.  

You remind me of me.

Go in peace.