I’ve been a nurse for 2 years. I generally think I’m a pretty decent bedside nurse. I’m thorough, I work hard and I care tremendously about people and their health. Lately I’ve been burning out. Tonight I think may be an example of how burnt out I have really become.
Patient is a younger man in his late 20s. Came to our facility for pt/OT after an injury and surgery to both his legs. He’s been with us for a couple weeks. Came to us with massive amounts of pain meds to the point where our doctors were uncomfortable prescribing him that much and scaled him back a bit to OxyContin scheduled and oxycodon PRN.
9pm rolls around and he’s scheduled for his OxyContin. I give it to him at 925pm (I have 30+ patients, so I’m feeling pretty on track here). Facility policy we must wait +1hr before administering the oxycodon. Patient knows this and says he want his oxy at 1030. I tell him I will do my best but to put his call light on.
1000 rolls around and he’s calling for his pain med. It’s early and I am caught up helping other patients so I do not answer him but two CNA tell him I will be there as soon as I can.
By 1030, he is screaming and banging a stick against the wall. He’s calling me all sorts of names and screaming "pain meds, pain meds, pain meds" at the top of his lungs. I wait a little while hoping he will calm down and I can get in there and hand him his meds.
Well, it doesn’t happen.
He gets more verbally aggressive to the point where something tells me - don’t go in there. Just a weird gut feeling of not feeling safe around this man. So I start charting hoping he will tire and calm down. He eventually gets quiet so I pull his meds and walk to his room. As I’m almost there he starts screaming again and banging against the wall. I stand in his door way and tell him point blank: I do not feel safe walking into your room, so I’m not going to be helping you until you can behave in a way that shows me I can feel safe approaching you. Well this made him angry and I walk away. He proceeds to yell and scream for the next hour, calling me everything under the sun. Eventually he chills a bit and the charge nurse goes in and hands him his meds.
I feel like I did the right thing here? But now I’m not sure.
Specializes in Psych, Addictions, SOL (Student of Life).
On 8/29/2021 at 1:19 AM, Grande_latte04 said:
I’ve been a nurse for 2 years. I generally think I’m a pretty decent bedside nurse. I’m thorough, I work hard and I care tremendously about people and their health. Lately I’ve been burning out. Tonight I think may be an example of how burnt out I have really become.
Patient is a younger man in his late 20s. Came to our facility for pt/OT after an injury and surgery to both his legs. He’s been with us for a couple weeks. Came to us with massive amounts of pain meds to the point where our doctors were uncomfortable prescribing him that much and scaled him back a bit to OxyContin scheduled and oxycodon PRN.
9pm rolls around and he’s scheduled for his OxyContin. I give it to him at 925pm (I have 30+ patients, so I’m feeling pretty on track here). Facility policy we must wait +1hr before administering the oxycodon. Patient knows this and says he want his oxy at 1030. I tell him I will do my best but to put his call light on.
1000 rolls around and he’s calling for his pain med. It’s early and I am caught up helping other patients so I do not answer him but two CNA tell him I will be there as soon as I can.
By 1030, he is screaming and banging a stick against the wall. He’s calling me all sorts of names and screaming "pain meds, pain meds, pain meds" at the top of his lungs. I wait a little while hoping he will calm down and I can get in there and hand him his meds.
Well, it doesn’t happen.
He gets more verbally aggressive to the point where something tells me - don’t go in there. Just a weird gut feeling of not feeling safe around this man. So I start charting hoping he will tire and calm down. He eventually gets quiet so I pull his meds and walk to his room. As I’m almost there he starts screaming again and banging against the wall. I stand in his door way and tell him point blank: I do not feel safe walking into your room, so I’m not going to be helping you until you can behave in a way that shows me I can feel safe approaching you. Well this made him angry and I walk away. He proceeds to yell and scream for the next hour, calling me everything under the sun. Eventually he chills a bit and the charge nurse goes in and hands him his meds.
I feel like I did the right thing here? But now I’m not sure.
You did great! This kind of patient needs firm boundries! The only thing I would have done would be to tell him ti behave sooner!?
I will agree with those saying there was a delay that could be argued should not have happened.
I have had similar situations many times. I do everything in my power to show up with the med when it is due. I do not think it is appropriate to do anything at all that could be viewed as punitive with the orders as they stand.
Honestly didn't feel like writing this the first go-round because I also think there is way too much criticizing of nurses when they are trying to navigate stressful situations. Please admit that a newer nurse might be something between slightly frazzled and terrified at the situation as described.
This patient has a problem that is beyond simple pain relief. We all know that. He started disturbing the nurse's work and the care of other patients long before his dose was due.
So sometimes....just every once in awhile we need to understand that the nurse got through it and call it good.
@JKL33 I think when I saw burnt out I mean fed up with my current position. Not to complain about my job…. But because you asked… I feel fed up with the constant understaffing, feeling like I can not help people like they need to be helped, like they should be helped. I just can’t do it with 33 patients. I feel myself physically and emotionally dragging under the weight of so many peoples needs. We have some easy patients and we have some exhausting ones- the ones who need round the clock pain meds, the psych patients who have complex medical needs as well who want to go AMA. I just feel tired. I feel bad for the people I can not help like they need. I feel tired with covid, I feel tired with my boss who calls me at all hours of the day and night asking me to cover shifts on my day off.
Sounds like time for a new specialty. Are you interested in pursuing a job where you don't have 33pts?? Inpatient nursing, pacu, pre-op,clinics, public health, etc... Almost everything but long term care/rehab is going to be an improvement
I remember a clock-watcher patient who would get in power struggles with nurses and demand pain meds.
For one of these guys, I started bring his pain medication 10-15 minutes early. It worked so well, less negative energy overall.
I remember an occasion where I was assigned a particularly bad situation with an abusive patient.
My tack was to go in and introduce myself in a generally-kind and professional manner. I said I knew there had been problems and that I thought we should make a plan. My plan was "I WILL be here on time and do NOT call me before the time." We actually both had a couple of laughs as this plan was laid out.
That sounds kind of bad. But...there was not a single problem. I said good-bye at the end of the shift and the patient told me I was "alright."
So telling the patient not to call me sounds horrible but...??♀️
I will admit I handled a similar situation about the same. When multiple redirects, re-approach and interventions from other nursing staff including the unit manger did nothing to alleviate this gentleman's outrageous behavior when asking for his pain meds early I ended up holding that pain med with the blessing of the MD.
When I called the provider to report the resident's behavior and asked if there were any med changes or scheduled administration time changes the provider told me give him his damn pain meds when he could act like the adult he supposedly was. I'm guessing from that response this provider had a history dealing with that resident's behaviors. That approach actually worked with this resident. Knowing he could face not receiving his pain med at all based on his abusive behavior he never acted out like that again while he was in our facility.
I remember an occasion where I was assigned a particularly bad situation with an abusive patient.
My tack was to go in and introduce myself in a generally-kind and professional manner. I said I knew there had been problems and that I thought we should make a plan. My plan was "I WILL be here on time and do NOT call me before the time." We actually both had a couple of laughs as this plan was laid out.
That sounds kind of bad. But...there was not a single problem. I said good-bye at the end of the shift and the patient told me I was "alright."
So telling the patient not to call me sounds horrible but...??♀️
Not at all horrible! I love it ? You showed them respect.
I learned to have more empathy with drug seeking patients bc I reminded myself I did not know their childhood, experiences..and I didn't walk in their shoes.
They can be so annoying (just being real) but I said to myself "Beth, why would you expect an addict NOT to manipulate, lie, act out?"
Not at all horrible! I love it ? You showed them respect.
Thank you. It was a pretty interesting experience and I learned a lot, actually.
I ended up taking care of that patient quite a bit over time. Once you can establish some kind of genuine trust everything is so much easier.
The patient requested I do other stuff I didn't think I should, for example slam the meds through the port nearest the huber needle, and applied more pressure by saying that everyone else did it. I just said, "Now you know I can't do that. Don't ask me to do things that you do know would not be what a nurse is supposed to do."
Another helpful resource (if available) might be hospital security. Have them walk in with you so that if things continue to escalate, you have your security folks right there. I understood why you held off from giving the meds, OP, but the further delay did seem a bit punitive. I would have called my charge immediately at 1030 when the med was due to try to de-escalate the situation, which wasn't going to improve, the patient wasn't likely to become calmer, there is no "tincture of time" when it comes to patients and their needs for narcotics. (I also don't like the whole "de-escalation" thing, it somehow takes the responsibility from those who are behaving badly and puts it on us to somehow talk them down, I think that's misplaced, but that's neither here nor there.) I would have notified the physician as well. I also hope that the physicians have had a chat with the patient about scaling back the narcotics, vs. just changing the orders and letting the nurses take the abuse from the patient.
Also, OP - you are under NO obligation to answer your phone on your off time. Put that thing on SILENT! They will always call, there will always be shifts open, but you don't have to answer. Take care and be well.
Take someone with. You do not ignore someone like that. It will only cause them more agitation. And is totally unprofessional.
This would be a Plan B approach. Everybody needs a Plan B. (my bolding)
Lunah - I didn't even think about Security! Altho I have seen that not always the best idea. But if OP had a fire or a code blue, people would have come a-running right away! So SOMEONE ELSE could have given the med rather than delay it. That's Plan B.
I guess I also have issue with why the med couldn't be given a wee bit early.
Like 10:10 or 10:15. Used to be that there was an ACCEPTABLE window when a med could be given up to an hour late or early. And there was no error brouhaha. I didn't see where fifteen minutes would stop the world's spinning on it axis!
Another helpful resource (if available) might be hospital security. Have them walk in with you so that if things continue to escalate, you have your security folks right there. I understood why you held off from giving the meds, OP, but the further delay did seem a bit punitive. I would have called my charge immediately at 1030 when the med was due to try to de-escalate the situation, which wasn't going to improve, the patient wasn't likely to become calmer, there is no "tincture of time" when it comes to patients and their needs for narcotics. (I also don't like the whole "de-escalation" thing, it somehow takes the responsibility from those who are behaving badly and puts it on us to somehow talk them down, I think that's misplaced, but that's neither here nor there.) I would have notified the physician as well. I also hope that the physicians have had a chat with the patient about scaling back the narcotics, vs. just changing the orders and letting the nurses take the abuse from the patient.
Also, OP - you are under NO obligation to answer your phone on your off time. Put that thing on SILENT! They will always call, there will always be shifts open, but you don't have to answer. Take care and be well.
I wish there had been security or an available charge nurse but unfortunately neither were available-1) we do not have security 2) charge nurse was busy with other patients.
By 1030, he is screaming and banging a stick against the wall. He’s calling me all sorts of names and screaming "pain meds, pain meds, pain meds" at the top of his lungs. I wait a little while hoping he will calm down and I can get in there and hand him his meds
I think it was passive aggressive to chart first only increasing his acting out. I agree that I would not have responded at 10, but right at 1030 I would have taken his meds and from the door stated that this behavior is not acceptable leading me to feel unsafe, that I will come in with meds as soon as behavior is acceptable. Tell him You will speak with MD about meds and request pain specialist. Also that such behavior will not be tolerated.
if you were feeling unsafe, I am sure that the cnas felt unsafe as well and delaying beyond the agreed (think contract) time could create a mistrust increasing the risk of escalation now and future which increases the risk of violence toward you AND the cnas. By delaying you may have endangered other staff who had to answer and try to calm him.
I am sure that many disagree, but the chart first choice really didn’t sit well with me
hppygr8ful, ASN, RN, EMT-I
4 Articles; 5,212 Posts
You did great! This kind of patient needs firm boundries! The only thing I would have done would be to tell him ti behave sooner!?