oblivionenigma

Even if they have a POA or even a legal guardian, the legal guardian cannot say "Turn them every 2 hours no matter what" if the patient refuses. We cannot force them to do anything they don't agee to, period--even if they have been declared mentally unfit. I've been told that this is the law and that we would be arrested for battery and have our licenses brought before the board if we did provide care they refused, regardless of mental status. Regardless, it appears to be company policy. Similarly, there are of course people with advanced dementia without a guardian. We have had the ambulance refuse to take them to the hospital when violent (ie seen as a potential threat to self or others) and/or refusing important treatment because they refused to go...ambulance says "We can't transport without consent," and leaves us to deal with the the problem.

Thanks for your reply! I guess I've accepted that I can't "save" everyone, when that "everyone" is someone who can decide what choices to make. I'm still trying to accept that I can't "save" people when they don't understand that's what I'm trying to do. I just wish that thorough documentation and careplanning--even CPing that family does not wish the patient to be turned, fed, changed if refused, etc--would also eliminate the negative consequences. Regardless of the cause--including a thoroughly documented and accepted cause--we get severely penalized, have to go through months worth of repositioning audits (where we document every time an aide repositions someone, which aide it was, what side they are on), witness every episode of incontinence care and document thoroughly what product was used, did the aide perform care correctly, etc., go through sometimes hours of condescending training about the causes of pressure ulcers or incontinence associated dermatitis and how to prevent them. After approximately a year without a single pressure ulcer in our facility, we got one, and it was on a hospice patient who had stopped eating for weeks, was absolutely emaciated, was on an air mattress, and basically was the type of patient I described before...the family was totally on board with this, it was documented as such, and even when the patient got the sore their response was basically "Well yeah... we were expecting that. As long as they're comfortable we couldn't be happier with the care." That one pressure sore is when I learned that "there is never an acceptable reason for a pressure sore" and we had to undergo all of the above for several months, not to mention a lengthy investigation, state report of a sentinel event, etc. Maybe I could accept it better if it weren't thrown at me as a sentinel event when their refusal does result in injury. For the record, the DON is VERY supportive--this comes from above.

Hello! I have a bit of an issue. There are certain patients I often take care of who have profound dementia--to the point of requiring hand-over-hand assistance for eating, unable to consistently reposition self in bed, etc--in a SNF. They regularly refuse care, though clearly have no concept of what they are refusing (e.g. attempting to reposition in bed is met with "Go back to sleep before I spank you") Some will become physically violent if this avenue is pursued. Others will protest the action directly, but again only because they think the caregiver is someone they are not, they think they are somewhere they are not, or they don't understand their physical situation. So here's my dilemma... On the one hand, my staff and I need to care for these people. On the other hand patients have the right to refuse. On yet another hand, they have no idea what they're refusing--I had one patient refuse their medications once because they thought the water cup was the pill they had to swallow and began screaming that staff was attempting to assassinate them by trying to make them choke to death with huge pills. The company regularly reinforces the fact that we cannot force patients to do something they don't want to do. However, sometimes families get upset and say "They don't even know what they're doing. Why can't you just ignore it and roll them/change them/get a medication patch they can't refuse/whatever?" Staff gets frustrated with the situation when they truly want to care for people, yet these dementia patients sometimes lie in their own incontinence for hours on end. We try to medicate them, they refuse so it does nothing. Due to "right to refuse" we cannot give an injectable or topical/patch for the purpose of bypassing their right to refuse. Then they refuse to be repositioned, then develop a pressure sore, and we get blamed for it because "there is never an acceptable reason for a pressure sore." It's a helpless feeling, and then to get blamed, be told our "numbers" are bad, have to do audits, mandatory training, etc to atone for injuries sustained when the only solution is one the patient themselves refuses...it's a horrible feeling. I guess I'm just frustrated because if this is truly the way it is, perhaps the "right to refuse" pendulum has swung too far. Does anyone have any constructive advice? Perhaps there are better ways to go about this? Any ideas for increasing compliance? Anyone care to add to my rant? For the record, I try most standard approaches, and this is geared more for those that you can re-approach over and over in standard ways and will still refuse to be touched for hours. Please help me care for these patients who cannot care for themselves! ...or at least help me find some peace with myself in this situation--a new outlook or something! thanks

The first time I ever let the ball drop and was nearly beside myself, the director of nursing--who is absolutely amazing-- said "Oh my god, it's the end of the world! No one has ever made a mistake of this magnitude before!" I stood there stunned. Then she asked, "Did anyone die?" Uh.. no? "Okay, so who was horribly injured?" No one? "All right then. I could say something about this, but I honestly couldn't say anything you don't already know. Everyone makes mistakes. Learn from it and stop beating yourself up over it." Trust me, there are some times when I still feel like I'm the stupidest person in the world after a shift. You will have days like that too! But you know what, there will be many other time you'll feel like you really did something amazing that day. I like to think those experiences far outweigh the negative. Also, I hope that this eliminates the naivety of "I was sure this would never happen" as you said in your first line. We all make mistakes. Just keep them in perspective and learn from them.

Hey, I was you once! I know exactly how you must feel! The med carts are always a disaster. The clean utility room is a mess. Even the linen closet is out of whack! You're just having a hard enough time knowing what the names are for the meds and what you need to know about them, let alone trying to FIND the suckers in there. The fact that you finished at 11pm is not as bad as you think for a new nurse. As far as some of these things, it is important to assert yourself. Make sure you make it clear to the CNAs that you expect vitals done by a certain time. If it's not done and there is not a legitimate reason for it, there need to be consequences. Hold people accountable. As for the organization disaster, as you get more comfortable, maybe you can take a little bit of time each day organizing a little bit. Try to get 11-7 to assist. Don't expect things to better overnight. But they can get better slowly. I've no doubt you're an awesome new nurse and that you're going to get better and better. The fact that you're so upset about finishing at 11 lets me know that you'll not settle for anything less than your best. Oh, and relax as far as the testing from patients is concerned. That should die down once you get some confidence and experience or at least make THEM feel more confident in you. :)

I'm sorry to hear about your difficulty and your feelings of incompetence. However, you're just inexperienced and this is totally expected. It's hard to think to look at the "big picture," to know when to ask why, etc. Heck, "what IS the big picture" is a hard enough question to answer sometimes. You made a mistake that tons of experienced nurses make--focusing on someone you felt needed your attention to the detriment of those who are lower priority. Give yourself some slack. :)

I had one 80-something patient use the call bell. When I came in, she started screaming "Where's the **** call bell you ****er?" (use your imagination in the *'s; she had quite the diverse vocabulary of insults) I showed her where it was. She responded by saying "That's not my ****ing call bell you ****" and then proceeded to try to choke me out with the lapel of my scrubs while screaming "I'll ****ing kill you, you little ****". Wound up with a nice abrasion on my neck. Best part about this story? While she may have had dementia, I learned later that this is apparently pretty much how this patient was her entire life. No one bothered to tell our facility this while admitting her for "strengthening"

From what I've read, recent evidence seems to suggest that there is little benefit. You can have it in a blood vessel and it won't aspirate blood, and you might not have it in and get blood. As a previous poster reported, it seems it could only be good for dorsoglut

Agreed. Though if one is forthcoming with praise, other people are sometimes motivated to be forthcoming with it was well.

Thank you for hitting a nail beautifully on the head! Some nurses refuse to do "CNA work;" everyone knows who they are very quickly, and everyone hates to work with them. I've found that if I go the extra mile for my staff, my staff takes extra good care of me. I don't know how many times staff has bailed me out of overwhelming situations. Also, if you are open, pro-active with communication (as defyinggravity says), and make your needs known to them, you'll usually find that your need to delegate decreases. They learn your expectations and fill gaps as needed. I've found I usually have to "delegate" by exception; that is, when something goes wrong or we need to prioritize. Also, if it makes you feel better, delegating does not mean micromanaging. Your staff is trained. Trust them. :)

I guess it's not. I had been under the impression that, for my aunt at least, her children were taking care of that. I guess I'm just frustrated as I saw the whole "sitting at the station saying 'That's not my patient'" at two separate hospitals; and I continually see it. Sorry for the confusion, as there were two hospitals in that story. The IV, ignoring signs of abdominal complications, and no signs of a leadership role anywhere (not saying there wasn't; it's just not clear) is a non-magnet hospital with a generally negative reputation, periodically in the news for fatal complications of med errors, massive layoffs, strikes, etc. The magnet hospital is known for being competent but rather cold/uncaring. They simply ignored pain, made assumptions about pain, etc. As I said in my original post, a CNA actually stepped up and advocated beautifully. To be fair to the magnet hospital, it is 2 hours away, and I saw it at specific times. Maybe I was seeing the exception. I cannot find any such excuse for the other place.

Yes, you will earn some delegation in nursing school as part of clinicals. If you're doing a baccalaureate degree, you'll probably have a class somewhere in there about leadership and management as well. The rest you just learn from experience. If you feel that this is a serious issue, you may wish to talk to your instructors. They may have some suggestions and/or resources for you :)

Our director of nursing is absolutely amazing. She will work on the unit almost daily if needed. If there is a call out she can't fill, she'll fill it herself, day or night, even if it's a CNA position. Actually, even our head administrator will work the floor providing food/drink, answering call bells, rolling silverware into placemats for meals, what have you. The management at our facility blows me away with their presence on the floor

Your mother is creating a self-fulfilling prophecy. No, you may not be a natural leader, but that doesn't mean you can't be a good leader. On the bright side, a good staff kind of knows where they fit in in the general scheme of things. However, it is the nurse that guides the staff, delegates, etc., particularly when things don't go well. That said, this is a skill you can learn! Become very familiar with scope of practice for those under you, as well as familiar with strengths and weaknesses of individual staff members. Then you'll know what the staff can and can't do, and who would be best for what. Try to relax; this is not something everyone is expecting you to magically be a master of.

First, rest assured that, as a nurse, you WILL ask yourself "Why am I doing this? I'm too stupid/not brave enough/too sensitive/not sensitive enough/whatever for this." I have had that crisis several times now. It seems to be pretty normal and, after the dust clears, I think this self-reflection can be beneficial. Just don't give up because some people are backstabbing jerks. Second, as others say, this is not your fault. I don't know if you're new to nursing or not. As you get more confident, you may feel braver and be willing to politely ask that they be more considerate. I quickly realized, as you did, that some staff love to backbite, use others as patsies, etc. After I discovered I actually knew what I was doing, I " got a spine" and spoke up. As I'm sure you know, though, that's a lifelong learning process in itself. HR, administration, etc may be a good route to go. Worst case scenario, as other have said, try a new place of employment. What you're seeing are signs of general stress, discontent, and burnout. If a place has employees that feel empowered and meaningful, you'll see less of this behavior.