Staff driving while symptomatic...advise

[loving2]

I have a staff member that frequents the nurses office. Today she came to me, feeling dizzy. Her vitals were WNL, except BP was 145/90. As I was talked with her more, she started complaining of other symptoms. Nothing really lined up. She is young, lives alone, no family close by, visits several doctors. Has been out of work (sick) a lot. Something is always wrong.

My concern is allowing her to drive herself from school property to the doctor's office or hospital. If she is symptomatic, and I know that, I feel uncomfortable allowing her to drive. She is a threat to herself and others on the road. I'm afraid this will come back to haunt me and my license. I offered to call an ambulance transport. She declined. We made arrangements for another staff member to transport her to the doctor. She declined. She was very indecisive and spent 1.5 hrs in my office with myself and the Principal trying to devise a plan. We scheduled a doctor's appt. She decided to drive herself, even though I voiced my concerns and made arrangements for her otherwise. What is my legal responsibilty?

[schooldistrictnurse]

I don't understand why/how you would be responsible for this adult person. You give your advice and she does what she chooses with it. I don't mean to be harsh, but I feel like you and your principal spent way too much time on this. Why on earth would you make a doctor's appointment for her? Make your recommendations and move on. If the principal thinks she's too ill to be at school, he or she sends the person home. I know you have to be in the situation to understand the dynamics, but re-read your post and see if it sounds reasonable to you.

good luck!

[rn/writer, RN]

She is an adult, who is presenting with a list of complaints and slightly high blood pressure. Unless you see signs that directly point to her being unsafe in the short term (slurred speech, unsteady gait, inappropriate responses to your questions), she is allowed to make her own decisions, right or wrong though they may be.

Unless she shows signs of an imminent problem (possible CVA or other worrisome dx), your job is to give her the information, offer whatever help and encouragement you can, and back off. Then document the heck out of your encounter.

I used to be an EMT. The only time we were allowed to transport someone against their will was when they were taken into the custody of law enforcement (suspicion of drugs or ETOH), and/or their behavior combined with the mechanism of injury suggested a possible traumatic brain injury that would render them incapable of making an informed decision.

Even if you called EMS, she could still sign off, and they would have no recourse but to let her go on her way.

Sorry. That's a tough situation. But you can't force her to do anything against her will. What you can do is encourage her to take care of herself. But do this because of genuine concern for her, not worry over your liability issues. She's more likely to come around with someone who cares about her and wishes her well.

[loving2]

Let me be clear that I didn't call her doctor. She did so herself while sitting in my health room. The arrangements I made were to have another staff member drop her off at her doctor, and I would pick her up since my daycare is next to her doctor's office. I made several attempts at nudging her to make a decision and move on. There were students coming into the HR for treatment and she's sitting on my cot being indecisive, crying, calling her mom that lives in another state, etc. She's had a history of visits to the nurse's office with various complaints. She was transported via ambulance from a different school a few years ago.

I hope, as school nurses, we don't treat ONLY students. Yes, she is an adult, but while she is on the clock and on school property, I feel a responsibility as a health professional to look out for her best interest and the protection of the school board.

[LACA, BSN, LPN, RN]

The staff at my school know I am here to offer them my opinion and thoughts on whatever situation they may have. I don't make any mention of diagnosis or anything like that, but I do often talk to them about whatever problem it is they are having. They are adults and are more than capable of knowing what they should do.

Honestly, from what you have mentioned about this person, they sound pretty unstable. I probably would have drawn the line when she refused the arrangements I made and just told her then and there that I couldn't help her unless she was willing and if she wasn't willing, then I need my office back.

[bergren]

Some school nurses job descriptions include responsibility for the entire staff, others are responsble just for the students (except in a emergencies). This adult employee took up 90 minutes of nurse time and 90 minutes of administrator time while refusing to take responsible steps for her own health. That is a work behavior issue, and some decisions need to be made about how to handle the next time she presents with similar symptoms.

Her mental well-being needs to be addresses in a proactive, not a crisis manner. But asking her to get some counseling is a issue that her supervisor should address, and you can reinforce. You and or human resources could support that plan by locating potential referrals.

This article on somaticization in school is about students, but many of the same principles apply to an adult:

R. A. Shannon, M. D. Bergren, and A. Matthews

Frequent Visitors: Somatization in School-Age Children and Implications for School Nurses

The Journal of School Nursing, June 1, 2010; 26(3): 169 - 182.

Sign In â€" The Journal of School Nursing

[loving2]

She told me her doctor referred her to a psychiatrist.

[schooldistrictnurse]

Here's hoping she will follow up for her own well being and that of her students!

[rn/writer, RN]

I hope, as school nurses, we don't treat ONLY students. Yes, she is an adult, but while she is on the clock and on school property, I feel a responsibility as a health professional to look out for her best interest and the protection of the school board.

Because she is a competent adult, she is the one who must look out for her own best interests. You can give her information and encouragement and whatever assistance you have to offer, but you cannot save her from herself if she is not willing to cooperate.

As far as protecting the school board, they shouldn't be in jeopardy after you properly documentat the encounters you have with this person, the suggestions you made, the help you tried to give, and her refusal to avail herself of these things.

At this point, with her history and her obvious distress, I would refer this to the principal who may have a little more leverage. You don't have to divulge her medical details, but I do think her repeated visits and anxiety stand to affect her students.

Maybe the school or the teacher's union has some kind of employee assistance program that could give her low- or no-cost counseling so she can figure out what to do next.

You can care about her situation, but you are not responsible to anywhere near the degree you would be with one of your students. She has the right to refuse care, and as long as you document this, you have fulfilled your obligation to her.

If you continue to feel personally responsible, you leave yourself open to manipulation. Even if this is something she would not do consciously, people faced with anxiety-producing circumstances sometimes try to engage others in an external battle that replicates the internal one.

Be there for her, certainly, but be clear that she is an adult and needs to take care of herself in a way that doesn't put others at risk.

I'm glad you are a caring person. But boundaries are there for a reason. You have to respect her autonomy, even if it makes you feel bad.

[loving2]

Thanks for your comments. Where do you document staff visits? We only document student visits. My principal is aware of this situation and will keep an eye on things. Thanks again.

[rn/writer, RN]

I suppose every school has its own system.

I don't mean to sound harsh (and hope I didn't), but I was a psych nurse for years, and this is a common (and often unconscious) pattern of behavior for some folks who are struggling with a dilemma. They take their inner turmoil and, through circumstance like the ones you mentioned, they recreate their distress in other people. They just don't know what else to do with it. This isn't a conscious choice. It's more of a spilling over of their angst, a bleeding off of the pressure, so to speak.

Picking up the tug-of-war rope is a de facto acceptance of this angst.

Not picking it up is difficult, but necessary, if she is ever going to come to grips with what is bothering her. Not letting her bleed of the pressure will allow it to build to a point that she has to do something. Again, this is not pleasant, but the only way to win (find a positive outcome for all concerned) is not to play.

What do you do? You say, "Gee Mary, I really hope you see your doctor. You're too nice a person to be feeling so miserable. I won't pressure you about it, though. I trust your judgment on the subject."

I have used this on our young adult kids when we have locked horns over similar subjects, and it changes the equation. When I stepped out of the "dance," there was no one left to argue with but themselves. And darned if they didn't usually end up doing exactly what needed to be done.

I wish you well with this tough situation.