I think to myself, I'll call the doctor and make sense of this situation. I call the doctor, who tells me it is 100% his intention to send this confused patient home- in the dark, with no family support, via taxicab. Using my nursing judgement I know this is unsafe, what if he doesn't have his house keys, how will he pick up his prescription medications tomorrow... the questions start lining up.
The nurse and I get very proactive: we call the listed family contact who say they live out of town and are unable to visit him for a few days. Strike one. We call the social worker in the ED who is still here this time of day, she comes to the floor and agrees we should just wait until the morning to facilitate the discharge. The stories continue to mount... more documents are discovered and ultimately the patient has to be held overnight for an involuntary hold. I felt frustrated as the charge nurse and so did the gentleman's nurse because we spent hours discussing with the MD how we can't just send this elderly man who has no idea who he is or where he is back to his home yet- all while meeting aggressive resistance from the MD.
I like the how straightforward the Stephenson Model (2000) is, so that's the one I'm going to use...
My role in this situation was to oversee the safety of all the patient's on our floor and be a resource for the floor nurses (aka, charge nurse). I felt comfortable arguing our point and getting all the ducks in a row to prove our cause, however I felt very uncomfortable that the doctor was being so resistant. I usually try to see the middle ground and not be a stickler, however our job as nurses is to see the bigger picture and look out for our patient's overall safety- especially if they are not ready to transition back to their home setting yet.
The actions I felt were best to take at this point, was rally as much support for our case to keep him one more night. I contacted the family, contacted the social worker, who ultimately contacted the head Mental Health doctor's at Virginia Mason. Because they were all in agreement with myself and Jennie, the patient's nurse I felt our case was much stronger. I also like that approach because it takes off the head to head tension in which I as the nurse would ultimately loose. As it is the doctor who enters the discharge orders, if I as the nurse don't let the patient go I am detaining a free man against his will. I felt my actions were appropriate without loosing my cool.
I could have improved the situation for myself and my patient by getting the social worker involved immediately. I did not know there was a 24hr social worker in the ED at the beginning of this experience. Now I know that, the next time something fishy comes up that is similar I will call them and ask their input from the beginning. I say this because the social worker has a wealth of other resources and knowledge that they can bring on board. I learned that I feel very protective of my patients. It almost reminded me of a parent looking out for their child. I knew there was no way this man could fill his medication prescriptions, let alone take them as ordered. The thought of sending him home to a life full of unknowns was something I was not ready to let happen on my watch.
Going into this situation I expected a totally different outcome, I expected the doctor to at least listen to my concerns and then be amenable to a morning discharge. This changed my way of thinking as a nurse to being able to put together a case for your cause. I felt like I had to channel and inner lawyer and think what is the best way to win my point. I have never thought of nursing in that way before, but it can be helpful in many situations I'm sure.
I applied my knowledge and theory that our duty as a nurses is to oversee the safety of those we care for. We as nurses spend our 12.5 hour shifts interacting directly with the patient. We know their mentation, their ability for self care, we see the questions they ask, and this is not something to be overlooked. Doctor's have their large role in patient care as well, but they only spend about 20 minutes at each patient's bedside everyday. A broader issue it to continue nurses being empowered to speak up for their patients and to realize the power and knowledge from being at the bedside all day long. I think that is important to emphasize in nursing school, in nursing literature, and throughout the practice. I think the continuous bedside care and relationship is what gives nurses great trust in public opinion and power in the patient care relationship.
SSU,
ReplyDeleteI was really surprised when you wrote that you were met with resistance from the doctor. Some situations just seem like common sense. Great work to put together your “case” but how frustrating that so much time and effort (from all of you!) had to go into it in order to persuade the MD.
My dad was at the Cleveland Clinic once, which is an 8-hour drive from where my parents live in Upstate NY. After 6-weeks in the hospital (and my mom stayed in Cleveland too that whole time), he one day in snowy December got a random discharge late afternoon/early evening. No warning to my mother (the driver) and very little in the way of discharge instructions. One minute they were there for 6 weeks, the next they were to just get in their car and hit the road. But first they had to go to the pharmacy and get all his meds. By then it was late, dark, snow on the roads, no hotel room booked because they didn’t know how far they’d be able to drive that night. My mom could barely get my dad out of the car and into the motel …and again the next morning when they had to leave and finish the last 5 hours of the drive. My mom was a basket case by the time they arrived home and two neighbors had to come help my dad inside. The whole thing was so egregious. The next time when he went a year later, my mom commented on how the whole process was handled correctly and what a completely different experience it was for both of them. They had 48 hours for my mom to prepare to leave, and the discharge was in the morning, when they had daylight to take care of everything and drive, including call friends to do a little food shopping, etc to prepare the house ahead for them. Anyway, my point is that the second time was so much more humane and also factored in all of their logistics and needs. The first one was totally thoughtless of the scope of their situation.
So good to hear that there is staff like all of you who thought the whole thing through and took steps to correct it. It sounds like you learned a lot from this, including the social worker aspect. I liked your team approach to avoid the one-on-one tension and your mention of the power and knowledge of spending so much time with your patients. It was nice to read that despite the MD, how supported you were in all of your efforts, critical thinking, and actions. I like the cyclic nature of the Gibbs cycle and they way it ties your writing back to where you started but with new knowledge how you might tweak things next time. You are a really great writer, by the way!
I’m so glad you were able to act as such a strong advocate for this patient. I don’t want to even think how badly this situation could have turned out if the man had been released then. It sounds like you really had to fight hard with the doctor….it seems a little sad that he was unable to see what you and the other nurse found to be completely obvious. I guess this is just another example of how doctors learn to treat diseases and nurses learn to treat the whole patient and look at the bigger picture. Well done my friend.
ReplyDeletethis brings up a question for me, which is, whose responsibility is it to initiate change in the system? I think that there is follow up to be done with this incident, that if you're up for it you need to also inform your managers, etc. that you spent so much extra time saving the hospital from liability while saving a patient from a potentially bad discharge experience or worse. It seems like you should expect the MD to listen to your concerns, to allow you to do what is appropriate without requiring of you all that extra effort.
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