3 Strike Rule: Non-Compliant Patients

Meriwhen, ASN, BSN, MSN, RN · Nov 16, 2016

Repeat customers are good for business.

As long as they wait 31 days between admissions, that is.

Im not being callous, and I mean it when I tell my patients I don't want to see them again

I tell my patients that all the time Unfortunately, medication compliance among psych patients ins't good.

NurseGirl525, ASN, RN · Nov 16, 2016

As long as they wait 31 days between admissions, that is.
I tell my patients that all the time Unfortunately, medication compliance among psych patients ins't good.

Do you understand why psych patiebts are some of the least to be compliant?

And to the OP, no you cannot be judgemental. It's your job not to be. You take care of everybody equally. You treat the perpetrator the same as the victim. Always. You do not know what is going on in that patient's life to make them noncompliant in their medications or lifestyle. More often than not, money is the barrier. Unless you are buying their scripts, and the healthy food, and buying that membership to the gym for each patient, you don't get to judge. You just don't.

Until you can buy fruits and vegetables for the same price as a Big Mac, I don't want to hear it. I just spect almost $50 for ingredients for salads and fruits today. Fortunately, I can afford it. Most cannot.

There's not enough time or space to point out what is all wrong in the world with health. And I'm a firm believer in you are responsible for yourself. But i also understand when the average person is trying to get by, especially when you are sick and can't work full time, things fall by the wayside.

Beaue · Nov 16, 2016

I partially agree with cocoa puff. If a person with no insurances goes to the hospital every week, someone has to pay the bill. People doing such things are probably the reason insurance is so expensive. People who refuse to use resources are in denial about their problem; or admits they have a problem and don't really want help. I lived with an alcoholic for twenty years and after he cheated on me, we got divorced. The effect of his mental abusive and running to rehab for treatments has an every lasting effect not only on my life but also on my kid. I agree alcohol addiction is a disease that is hard to recover from. Some people's behavior is destructive and changing that behavior can be hard. A person with destructive behavior causes pain for his/her family and hospitals trying to help them. Hearing about someone's recovery from alcohol or any other kind of addiction is always a great thing for both sides.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Nov 16, 2016

You need to leave your judgmental attitude in your car when you walk into the hospital. Then you can put it back on when you go home. Because judgment really has no place in nursing and it doesn't help you or the patient.
For that matter, if we wanted to examine you and your life under a microscope, we could find PLENTY to judge you on, because you are, as you acknowledged, human. You might not be an alcoholic frequent flyer, but you've done something, or do something, or are something very flawed, and if we exposed your flaws, we could sure go to town with the judgments. Try to remember that next time you feel the superiority complex overtaking you when you are assigned a patient who seems to be trying to kill himself.
And really, it's not like if you eliminated these particular people from your hospital that your job would be any easier. You'd have somebody else to take their place who would be just as much as a pain in the tush, in a different way, but just as flawed, just as annoying, maybe with a whole crew of annoying family members who are along for the ride.
This is hospital nursing.
These people are sick-just as sick as the guy with pancreatic cancer, or CHF, or diabetes. Like someone above stated, they didn't do this to themselves on purpose. There are genetic factors at play here, mental illness, lack of resilience in some cases, etc. It's addiction. Frustrating, NO DOUBT, but they are sick nevertheless. You don't have to approve of their actions, but there is no benefit to judging them. Just be glad you aren't one of them. Many of them wake up every day filled with self loathing at their "weakness." No need to pile on.

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Agreed^^^^. In addressing your very first paragraph, Cocoa-Puff has already stated that he or she rolls with the punches just like everybody else when on the clock, and saves the venting, frustrations, and judgments for after the shift is done.

NotMyProblem MSN, ASN, BSN, MSN, LPN, RN · Nov 16, 2016

I understand the OP's frustrations. As a float nurse, it seems that if the town drunk is on a unit that I've been floated to, I will be assigned to him. If the known drug seeker is there, I'm assigned to her, too. I think a lot (or a good deal) of the frustrations could be offset with a fair rotation in caring for our 'regulars'.

We had a patient that had been in the hospital for months. Her demanding behavior, coupled with q2h narcotics (and Benadryl, wound care, and other routine meds), and contact precautions to boot, meant we were ALWAYS in that room. It was so bad, that a roster was created to track the shifts each of us were assigned to this patient. So, if I was assigned and we maintained 8 nurses on the floor, then I would not be assigned again for another 7 shifts.

The BS gets old! I applaud you guys and dolls who manage to do this on a full time basis. My PRN status is a handful for me sometimes...especially when I add an extra shift to total TWO WHOLE SHIFTS in the same week. My Black Beauty stallion days are over. All that's left now is Festus Hagins' mule, Ruth.

WinterLilac · Nov 16, 2016

When I am frustrated by patients like this (because let's face it, these same patients are often less than nice people to boot) -- I remind myself that there are few inherently bad people and that most likely, the patient in question didn't set out to be this way. Few children think "gee when I grow up I want to live in and out of hospitals/be homeless-quasi-homeless/suffer through a myriad of painful and debilitating medical complications." There are confounding factors like mental illness (which often by its very nature can lead to a profound lack of insight), lack of social support, environmental factors, socioeconomic factors, etc.

Amen.

Tenebrae, BSN, RN · Nov 16, 2016

I have a patient with advanced dementia, who if you didnt know her would appear quite nice and reasonable. Who if you asked her if she would agree to treatment would say "no thank you dear" who when needing life saving treatment told doctors to F*** off.

Problem with black and white rules is that they ignore the fact that the world is full of alot more than 50 shades of grey

ManicRN911 · Nov 16, 2016

When I am frustrated by patients like this (because let's face it, these same patients are often less than nice people to boot) -- I remind myself that there are few inherently bad people and that most likely, the patient in question didn't set out to be this way. Few children think "gee when I grow up I want to live in and out of hospitals/be homeless-quasi-homeless/suffer through a myriad of painful and debilitating medical complications." There are confounding factors like mental illness (which often by its very nature can lead to a profound lack of insight), lack of social support, environmental factors, socioeconomic factors, etc.

I emphasize with the frustrations OP expresses. Working in an inner city ED, we have many frequent flyers that every staff member is quite familiar with. Having to spend time on someone who comes in every night with the same complaints and demands can make you feel abused and manipulated. I agree with dirtiehippiegirl, they are often less than nice. In fact, my experience has been that they make up a large percentage of the most demanding and abusive patients I have had, demonstrating "learned helplessness", will not be cooperative until they get what they want (such as food or pain med), and just plain old nasty treatment towards staff. They continue to behave like this despite countless hours of staff trying to communicate therapeutically and all the other buzz words you'd like to use.

The reasons behind their behaviors do NOT make it easier to care for them for most of us. If it makes it easy and frustration free for you to know all the reasons that led the patient here and acting like a meany then that's great for you. When you have a heavy assignment, have a critical patient(s), are short staffed, been putting off that bathroom stop for the past 4 hours, and have a ton of charting to catch up on, to be verbally (or physically) abused and threatened and manipulated, by the same patient who made your shift harder last week, does not inspire empathy in many people. Most of us do suck it up, and do not let it interfere with the care we need to provide these patients. And no, not all of the non-compliant or frequent flyers are nasty to us, some are as sweet as can be and just trying to get by. I highly doubt those patients are the ones that led to OP's frustration even thought they do use up as much resources as someone who isn't nice.

OP did not send this post as an email to the hospital administrators, she posted on AN forum as an outlet for her frustrations hoping to connect with others who have lived this frustration.

I find it hard to believe that anyone can honestly say they don't form opinions about their patients. I think the use of the word "judgement" has skewed the concept. It leads us to relate it to their being a negative outcome due to judging someone just like in a court. What everyone is calling "judgement" is actually just our personal opinion we have developed about someone or something. We keep those opinions to ourselves most of the time and do what we need to do.

I do find it makes me feel less abused to remind myself that this life the patient lives, is not one that anyone "chooses". I do not think of them as victims either (unless they are actually a victim). I treat all patients as real life human beings, and I'm sure OP does too. I also remind myself when I need to, that this is a problem I CAN'T fix and should not look at it as one. Nurses want to make things better. It is discouraging when you are not able to, it can make you feel helpless and overwhelmed.

Encouragement from OP's peers is what this nurse needed. Helpful advice like dirtyhippiegirl's post and empathy for or acknowledgement of OP's frustrations would demonstrate more support for nurses and nursing.

This is just my opinions based on my own personal experiences.

Chisca, RN · Nov 16, 2016

I think there should be a three strike rule for patients who are consistently non-compliant with medical advice and medications following discharge. After 3 strikes, we don't take them back.

Why do you hate Mississippi?

Horseshoe, BSN, RN · Nov 16, 2016

I think it's perfectly possible to find certain patients and their behaviors EXTREMELY FRUSTRATING, all the while not being "judgmental" about them as human beings. The most difficult patients I've ever worked with were addicts, those with personality disorders, and those with eating disorders. They can make you dread going to work, and at times, you have to ask for a break. But the OP is talking about another thing altogether, imo, and admits to being judgmental. I personally don't think frustration and non judgmental attitudes are mutually exclusive.

NONE of are perfect, and I guarantee you SOMEONE in your life finds you to be a complete pain at times. Just have some empathy and think of it terms of behavior rather than character or worth. And finally, it's really rare that being punitive is ever a good thing in health care. That's what the legal system is for.

FolksBtrippin, BSN, RN · Nov 16, 2016

I think there should be a three strike rule for patients who are consistently non-compliant with medical advice and medications following discharge. After 3 strikes, we don't take them back.
For example, a frequent flier, non-complaint patient with alcoholism, tobacco use, COPD, and HTN, comes in at least every week for alcohol withdrawal, gets put on CIWA, gets valium, but then either leaves AMA or does not comply with medical advice or use any of the resources provided (ETOH rehab, housing, getting a PCP, medications provided thru medicaid, respiratory meds/equipment), or take any of his/her medications, or be willing to stop smoking (even with nicotine patches provided), follow up on appts, or get any help for ETOH addiction.
I think after 3 strikes of being non-compliant and showing no effort to change or take advantage of what is provided, we shouldn't take them back for the same issue.
Of course, if the patient has another unrelated, serious problem, such as broken leg, gun shot wound, stroke, PNA, etc...we should treat them.
I feel like if we keep taking these types of patients back, we are enabling their destructive behavior. They can drink and drink, run out of money, come in with withdrawal, and we basically bail them out until they recover, then they go back out and do it all over again. The same thing for dialysis patients who consistently miss appointments, eat and drink whatever they want, and then frequently come in to the hospital in crisis with a weight gain of 12lb, K of 8.5, creatinine of 5.7, and a BUN of 85.
And yes, I know this would never be a realistic idea. I know we can't refuse care to patients (and I don't treat these patients differently, just internally I'm very frustrated at their waste of resources). And yes, I know ETOH withdrawal can be deadly, I'm just very frustrated at the moment

Research on addiction and other habits shows that it takes the average addict 7 tries to finally quit. And that's just an average.

I am curious as to why you feel like these people are wasting resources? How is it a waste to treat an exacerbation of a chronic condition? I understand that the exacerbation might not have happened had the patient had the wherewithal to act preventively, but that does not mean that treatment is a waste of resources. Non-compliants deserve care also.

Maybe you need a vacation.

SmilingBluEyes · Nov 16, 2016

You know, I have had some excellent conversations with patients whose very lives depend on "compliance". But they really bristle at the use of that word because to them, it conveys us having "power" over them or an adult-child relationship that puts them in a minor role in managing their health/wellness...... I agree and understand where they are coming from.

I have used "adherence" instead and I think it applies. Patients seem not to have a problem with that term, either. I don't know about a "3 strikes" rule being all that fair. MANY factors affect so-called "compliance" and this is far from black and white.

It behooves us all to try and understand why our patients choose non-adherence to recommendations made by us and their doctors. Because sometimes, money/finances, family hardships, mental illness, varying abilities to understand/comprehend and cultural factors are things to consider. For our patients, tough things to overcome are at play here in so many cases.

Like another member, Spideysmom, has said, words are powerful. If we want the patients to "comply" and be on "our side" it may help to change the language and tone we use when teaching and encouraging them to adhere to care planning recommendations and improve behaviors and outcomes. This, in turn, may help them make better decisions.