How do I keep integrity

[Iwander]

I am still a new nurse and yet I am already falling prey to being burnt out quickly with patients, being tempted to take shortcuts, and actually questioning my own character. Today I had a patient that exhausted me and when she had discharge orders I was so ready for her to leave. She thanked me at the end, told me to thank the night shift nurses except for one whom she criticized, and was wishing me happy holidays. I was thrown off by her criticizing the other nurse and I don't want to ever throw my coworkers under the bus, so I didn't know how to respond and just apologized and stood there awkwardly. Earlier in the day I had let her take some of her home meds that were discontinued (diuretics), whereas nurses prior had lectured her on the importance of not doing it. I finally found out the reason the MD had temporarily discontinued the diuretic was due to a low sodium level, but her potassium level was fine and she was not symptomatic. In my mind I agreed with her that it was important to keep taking it. Then, I got ready to transport her so she could be picked up and go home. I was so relieved to not take care of her anymore. Then I found out, she didn't have a ride. I was unsure what the policy was but I was pretty sure I'm not supposed to let a patient leave and drive on their own. She had had narcotics that same day. But I just let her go. She said (manipulative/lying, or truth?) that the doctor knew she had no one (in her life) and was driving on her own, and that a previous nurse had let her go. I wheel chaired her awkwardly to an area near her car, but out of anxiety that I would get in trouble, I asked her to walk to her car the rest of the way saying "I'm not sure what I'm allowed to do". She said "Don't worry, your responsibility stops as soon as I leave the hospital building." So here are multiple things wrong with this picture:

1. I should have called the MD or someone to let them know she insisted on taking her diuretic, and can it be re-ordered
   
2. I should have quickly found out if she had a ride available before acting upon transport plans at all.
   
3. I should have notified the charge nurse or someone when I found out she didn't have a ride, turned around, and wheeled her back to our unit.
   
4. I should have never never let her go when she had taken a pain pill that day.
   
5. Surely cameras saw me and I might get in trouble for this later.
   
6. I should have been clear on the hospital policy about a patient driving on their own (if they haven't taken any safety compromising drugs).
   
7. I should have never never compromised my integrity, ethics, and what was right for fear of the patient manipulating me/opinions of me, for convenience, for being burnt out, for needing to tend to my other patients, for a doctor yelling at me, etc etc etc.
   
8. Yet here I am this fresh in my career and I already find that I compromised what was right, that I was willing to lie if need be, and that if I'm not careful it could become a bad habit. How can I be so burnt out this quickly that I'm already a bad nurse.
   
9. Not to mention the whole category of medication administration, and the high integrity I must uphold but fail to at times.
   
10. I had to confess that, and was wondering if any of you catch yourselves with this attitude. How do you motivate yourself to continue with good character or cleanse yourself of your actions and maintain integrity? If my character were very good I wouldn't even have to ask that question.
    

[NICUmiiki, DNP, NP]

4. I work in an ED. We people leave on their own 4 hours after taking a narc. I don't know how long it was since your patient took hers, but it was most likely ok.

[Gooselady, BSN, RN]

You had a difficult patient that would have had me tearing my hair out.

YES. What went through your head, all your choices you made, including the wrong ones, are completely understandable.

Best of all, you made an excellent list of what went wrong and where, and what should have happened instead. That's what impresses me the most. Not that you effortlessly did everything right the first time (especially with such a demanding patient and your level of experience) but that you are humble and dedicated enough to good patient care to look honestly at your mistakes.

Allowing her to take her dc'd diuretics was the major 'no no', no matter how much she insisted or what her labs were. We can't make those kinds of decisions. Not halting the discharge because she had no 'ride' might also be a mistake you made, probably was if you were to review hospital policy about such things.

The 'biggest' mistake is what caused all of this chaos in the first place. I didn't see where you asked for help, feedback or 'what would you do?' from another nurse. Confronted with all of these things, you need to ask for help rather than crossing your fingers and hoping for the best. Why? Patient safety of course but ALSO look at how you feel right now . Nursing is hard enough, and then we think we have to have all the answers and know what to do all the time -- impossible. I've been a nurse for 23 years and asking for help, checking in with 'what do you think?' is about the most helpful thing I learned to do.

Do you feel comfortable asking for help from other nurses? Is the unit 'culture' team oriented, friendly, forgiving? I've worked in both. Were you afraid you'd be 'shamed' or thought of as stupid for asking 'what should I do?'

If you work in a place where there's a lot of negativity, asking for help which every nurse NEEDS to do no matter experience, can get you a nasty comment. Those hurt. Sometimes though it is our own self that is so critical and perfectionistic we don't ask for help lest other nurses thing we are an idiot.

Just some things to think about . . . this is all common stuff we go through :)

[RainMom]

What Gooselady said^^^

One of the best pieces of advice I had in school from an instructor is that you often will not have the answer or know what to do in every situation. I find myself saying to a pt "I'm not sure about that, but I'll find out" & then do. Ask other nurses on the floor/supervisor/other depts.

[been there,done it]

Absolutely nothing wrong with clicking your heels when a PIA is discharged.

"Earlier in the day I had let her take some of her home meds that were discontinued "..

is going to cost you your profession.

That is called prescribing. Always get a physician order.

[toomuchbaloney]

Patients are allowed to self determine and they own their medications.

When patients want to take home medications which are in their possession but are discontinued by the MD we are required to inform them of the DC order, educate them on why and document their response (pt self administered oral diuretic from her purse). You should notify the prescribing and managing provider that the POC was not followed.

Control of the medication POC is one of the reasons that many hospitals do not allow the majority of patients to have possession or control of home medications while hospitalized.

When you say that you "let her take some of her home meds" does that imply that you actually handed them to her?

[dream'n, BSN, RN]

I'm reading this differently than some of the other posters. The OP KNEW she was doing wrong, but made the decision to not follow the policies and made unsafe decisions. These weren't mistakes, she purposefully and willfully broke rules. Of course everyone gets frustrated sometimes, but that does not excuse willfully providing unsafe care.

I like to sleep at night and I know if I purposely provided substandard care, my stress level would skyrocket. Any screw-up of mine is at least an honest mistake. OP, I learned long ago that if I'm ever called to the carpet for something, I will always be able to defend myself because I gave my best and if that isn't good enough for TPTB, well then ***** them because I tried my hardest.

[jadelpn, LPN, EMT-B]

If a patient has a medication in their possession that is their own, we certainly can educate, but can't observe 100% of the time. Additionally, if there were to be alternate plans for this patient's discharge, then social work needs to deal on the discharge plan side of things.

Sounds to me as if this was a manipulative patient who was upping the ante in order to set you up to fail.

When patient states "I took my diuretic" it is something that I would bring to charge as to how to handle that. If the patient doesn't have a ride, again, I would bring it to charge "The patient is driving herself. What is the policy on that?" You need to inform yourself, so that you can inform the patient.

The patient, however, can not be held against their wishes, so if she was going to walk home, that would be her choice. But it sounds more to me like the patient had no desire to go home, therefore, was creating ways for her to stay.

Integrity and character in practice is something we all learn. That you are frustrated with the process, frustrated with difficult patients is understandable, but don't incorporate this type of practicing into your character. You need to figure out a way to deal and move on. Because 9 times out of 10, there's a couple more just like this patient waiting for you to round.

I can't stress enough how important it is to use your resources. You don't need to do this by yourself if you are unaware of the policies that are in place. You can only learn and go forward from here.

[Iwander]

Thank you so much everyone. I did not hand her the medications; she took them herself. I still agree with the poster who commented on purposefully doing something substandard and that this needs to not happen again in my practice. Thank you everyone and I will use my resources more. I must not let hurried situations or any situation be an excuse for substandard care or an excuse for not stopping and contacting the charge nurse (who had printed the patient's discharge papers and was so ready for the patient to leave also). Thanks everyone you helped a lot.

[Ruby Vee, BSN]

You keep your integrity by not knowingly doing the wrong thing. It's easy enough to make a mistake without realizing, why would you deliberately choose to circumvent the rules?