Question for experienced nurses about caring for "marginal" clients.

[PHStudent]

Hello:

I am a student nurse in a western US state and have recently done rotations at both the psychiatric clinic and the Emergency Room. It is frustrating to me how little can be done for some of our "marginal" clients - and by that I mean those with few resources: (economic, intellectual, interpersonal and health reserve). I heard speak of "frequent flyers" and "repeat customers". While I understand that the role of the nurses in those circumstances was to handle the priority of the moment, I wonder what if anything we as nurses can do over the longer term in the way of activism, education or policy change that could help better serve those who have trouble serving themselves.

Any input?

Thanks so much.

[Pompom]

You know the old saying, you can lead a horse to water but you can't make him drink. Same with patients you can point them in the direction of care and counseling but it is ultimately up to them to take advantage of what is offered. Sometimes involving family and or significant others can help but often they have the same problems. It is a vicious cycle but when you are busy taking care of patients that want care that is what we end up focusing on, others are just processed through. It is frustrating for the nurse when the patient is admitted to the unit but refused all care, why take up the bed when someone who truely wants care needs it. Accountability needs to be levereged here too. We ultimately are all accountable for our actions or inactions.

[PHStudent]

I completely agree. I used to see the same sort of disproportionate call for resources in the classroom with "educationally handicapped" kids when that definition was extended to include those who had no interest in school other than staying out of juvenile hall.

I wonder though if many of these "marginalized" individuals are offered the same array of "choices" as most of us are. For example: a chronic alcoholic comes in for the umpteenth time. We assume because he is still drinking that he is non-compliant or doesn't want care. We assume without living his life experience or biochemistry that he chooses to be an alcoholic that he chooses to live on the streets or decides not to work.

How do we shift? How can we with an ER full of urgent needs, provide compassionate and meaningful care for this individual?

[kadokin, ASN, RN]

I completely agree. I used to see the same sort of disproportionate call for resources in the classroom with "educationally handicapped" kids when that definition was extended to include those who had no interest in school other than staying out of juvenile hall.

I wonder though if many of these "marginalized" individuals are offered the same array of "choices" as most of us are. For example: a chronic alcoholic comes in for the umpteenth time. We assume because he is still drinking that he is non-compliant or doesn't want care. We assume without living his life experience or biochemistry that he chooses to be an alcoholic that he chooses to live on the streets or decides not to work.

How do we shift? How can we with an ER full of urgent needs, provide compassionate and meaningful care for this individual?

I know. It is terribly frustrating, isn't it? The best I can tell you is to be as honest as you can be w/these clients and let them know that resources ARE available if they want them. (i.e.-AA, the local mental health ctr., etc.) and encourage them to put the onus on THEMSELVES as far as treatment goes. All you can do is make them aware of what's available, sometimes. They hurt too. They want a better life for themselves as we all do. Offer the information that you have and try to convey to them that they are in charge of their own destiny. (If only it were that easy). We can only do so much for others, and after that, it is up to them. Breaks your heart sometimes, doesn't it? (Not to mention breaking the healthcare bank, OY)

[jpetrunis]

Hello:

I wonder what if anything we as nurses can do over the longer term in the way of activism, education or policy change that could help better serve those who have trouble serving themselves.

Check out your state's policies regarding follow-up care services that people may be entitled to, and if there are none, work for change. If those services are available, make sure that the right contact/referral is made.

Example: in my "former life" (aka before nursing) I was a psych case manager. Our program was a state mandate; anyone with a state or county hospital commitment, or a certain number of local hospital commitments, was entitled to receive a minimum of 18 months follow up from us. We'd go meet folks when they were still in the hospital, then see them within 72 hours of discharge, get them set up with outpatient or partial care appointments, help with housing, social security, shopping, rehab, transportation, etc. etc. If they still weren't doing well with our help after a while, another team called PACT could take over; that team of social workers, psych doc and APN would do what we did plus more, like house calls for appointments. Not mandated, but funded by a new grant, is also a brand new program to do in-home med monitoring and therapy for people who chronically miss appointments due to stuff like no transportation, child care issues, can't deal with being in public for whatever reason, etc.

Obviously not all states/areas have these services, but you may want to talk to your local community MH center or NAMI branch to see what's out there, and find out what like-minded people are doing to address the service gap.

[traumaRUs, MSN, APRN]

Hi there - this is a topic dear to my heart. I live in central IL and worked for 10 years in a level one trauma center where all the homeless and indigent patients came. It is very sad that we are the richest country in the land and we can't provide decently. However, the caveat to this is that many of these patients have dug themselves so deep into a hole that they can't get out.