Published Jun 23, 2003
from Topics in Advanced Practice Nursing eJournal
Matthew Humphrey Loxton
A patient typically leaves the hospital or clinic with a patient education package that has been vetted by department heads, checked and sanitized by the legal department, trimmed and restricted by finance, and augmented by sponsors. The patient has perhaps also spoken to physicians, radiologists, nurses, and administrative staff. Much of the information given to the patient is intended to educate the patient in self-care following the period of dependence upon hospital staff. How does this information help the patient at home when there is no medical staff on hand? Does it tell the patient how to remove the dressing, what to clean the wound with, or what to do if the drainage tubes seem to be clogged? There are questions the patient will simply not think to ask while still at the hospital.
The Patient's World View
If all patients were physicians or nurses who belonged to the medical community and all ascribed to common conventions and practices, there would be no difference essentially as to who was on which side of the stethoscope; the patient could reasonably be expected to understand exactly what was going on, and why. Each issue the nurse highlighted would fit neatly into demarcated categories and every significance placed on them would be understood and accepted by the patient. After returning home, there would be nothing that was unfamiliar to them about what to do and when to do it.
However, in reality, patients are bricklayers, plumbers, bankers, welders, accountants, teachers, lawyers, and philosophers. They cannot be expected to understand what it is you are doing or saying in the same way as your fellow physicians and nurses are likely to. These real-life patients may demarcate issues and assign significance differently from how the medical professionals do. The resonance will have been lost, and the information will stand alone without the rich context of mutuality that was shared in the previous scenario.
Just as facts are "theory-laden," so also information does not "speak for itself," it is interpreted and acted on through the spectacles and gloves of our beliefs and view of the world. The nurse needs to impinge on patients' world views, conveying the information to them by resignifying and demarcating it in such a way as to make it actionable by the patient.
As an example, one patient had the experience of being given practical instruction that included taking her physically through many sequences and procedures that would prove to be important to her. Her nurses didn't just tell her how to change a dressing or clean the surgical wound, they showed her, and critiqued her techniques. It was not just this practical, actionable knowledge that was imparted, but also the knowledge of where more knowledge resided. The nurse as an information-source stands out.
As it happened, the patient's nurse was changed and the new nurse did not become familiar with the patient's history and could not answer questions about what to do next when a particular test was returned negative. The flow of information had changed and the patient's experience was altered entirely.
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Once I had a patient going home on tube feedings. The doctor brought in all the caretakers for me to teach. The doctor actually expected these lay people with no medical knowledge whatsoever to get one demostration and know how to do it. I did give the demonstration along with very careful written instructions that I had made up special for the occasion. However, I insisted that patient and care givers be supervised by homecare nurses for a while to make sure the knew what they were doing. Can you believe the doc was not going to order homecare! Can you believe he would actually ignore all the things that could go wrong!
NRSKarenRN, BSN, RN
In one of our Mgmt meetings today, we discussed a referral from Pittsburgh region:
1. Pt lived alone without caregiver support. Was on BID insulin and sliding scale insulin coverage. Pt stated she was unwilling to learn self injection or checking blood sugars. Homecare agency declined to accept referral as too high a risk for hyper/hypo glycemia, requested pt be sent to SNF to see if could be taught insulin injection if syringes prefilled.
2. What did the doctor do? Changed insulin to oral hypoglycemics, no sliding scale and discharged pt home WITHOUT ANY HOMECARE REFERRAL.
3. There is a clear difference in agency not accepting patient on insulin that refuses to learn vs one on oral meds that NEEDS diabetic teaching and followup. The agency wrote this situation upand sent it to hospital risk management.
Had staff members son have brain tumor removed on a friday, was discharged home Sunday evening WITHOUT HOMECARE. I offered to arrange for homecare, even gratis after CEO informed, family declined as they could "always get hold of a doctor".
I checked in with them 2 x a day. Severe HA, pain and nausea and vomiting Tuesday afternoon, unable keep fluids down since Mon night were concerns voiced at my 3:30 PM call. Told them to take him to ER. Spent the next 7+ hrs in er and discharged at 11:30PM.
Source of problem was inadequate pain control per Mom. A nurse could have intervened earlier if ordered I'm sure. Seeing many similar situations weekly re no homecare for tube feedings with panic phone calls to my intake staff as a result of "no home care order" being requested and son/daughter doesn't know how to stop the pump beeping.
One the chief causes of lack homecare orders IMO, is that discharge planners also trying to be case manager to insurance companies so not spending the time case finding or having daily/weekly rounds.
The case I talked about was related to the pressure to get people out of hospital quickly. This pressure was from the top of administration down to everyone, including nurses, dietary, physicians, medical records and social workers. All were constantly herded into meetings about decreasing lenght of stay. Large graphs were hung all over hospital showing weekly length of stay statistics. There was a particularly bad situation at my hospital that made the news. A patient that was very ill was hustled out of hospital to personal care facility that was totally unprepared for her. This person died and the owner of the facility and the staff were charged with wrongful death. The hospital was dragged into it and the hospital placed the blame on the social worker who refered patient to the personal care home. The relentless pressure to get people out was the real culprit. PS The case with the tube feeding involved intereaction between me and the homecare nurse. I am sure you are well aware of how critical those phone conversations with hospital staff are in preventing problems.
gwenith, BSN, RN
I hate to top your stories but I have the worst unprepared discharge story ever. Young kid about 15 was riding a bike on his property (ranch) when he ran into a barbed wire fence and avulsed his trachea. Initially he was very lucky - raced to the nearest rural hospital - only just maintianing his airway local doctor had to try and intubate stat. Just as he got the tube into position the kid breathed in - teh two sections of the trachea aligned and the doctor did the fasted intubation on record.
I was working staff development at the regional hospital he was referred to. I didn't get invovled in his case until near the end when I had to give soem education to the staff. Was told they were planning to sengd this 15 year old kid home with a permanent tracheostomy - no reconstruction possible. I remember pinning the surgical registra down and giving him a list of problems the kid was going to face from psychological problems ( they had not organised any counselling) to home care. The doctor just shrugged the lot off and refused to even consider that there might be ongoing problems. The young lad was discharged the next day. I got into trouble for "interfering" with a ward problem so I never did get to follow up and shortly after this I left that hosptial and that part of Australia but of all the inappropriate discharges I have dealt with in my time that one sticks in my memory - mostly because I felt so ineffective.
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