What if a Patient Won't Follow My Advice?

Question
What is a nurse's responsibility when a patient wants to do something that is unsafe?

Response from Carolyn Buppert, MSN, JD Healthcare attorney, Boulder, Colorado

The nurse who asked this question provided the following example: A patient who was admitted to the hospital because of increased seizure activity leaves the unit to go outside to smoke, against the nurse's advice.

The nurse's responsibility is to give the patient evidence-based advice, to explain the rationale for the advice, to advise the patient of the consequences of not following the advice, and to give the patient a time frame -- when the patient should do whatever is advised. The nurse should then document the advice given and the patient's response. What happens next depends on the nature of the advice and the risk. For example, if the patient with increased seizure activity goes outside to smoke, against advice, the nurse has no responsibility or authority to detain the patient. However, if the patient is threatening to jump out the window or otherwise hurt him- or herself, clearly the nurse's responsibility moves to a higher level: Call for help and make every effort to dissuade the patient from jumping.

Usually, the situation is somewhere between the extremes of these 2 situations. For example, a patient needs some sort of follow-up (diagnostic test, consultation from a specialist, medication, or lifestyle change) but doesn't comply. Then, the nurse's responsibility is to persist; that is, attempt to find out why the patient isn't complying, urge the patient to comply, repeat the explanation of the necessity for compliance, continue to teach the patient, and enlist other healthcare providers to reinforce the advice. The level of assertiveness of the nurse must be titrated to the severity of the consequences if the patient doesn't take the nurse's advice.

One class down.....

 All the grades aren't in yet but I am glad with all the work I've done in my first class of  my  Master's Program. 
The class, which was Theoretical Foundations for Nursing Roles And Practice, was very interesting.  I learned a great deal about nursing theories and the different schools of thought on the how, what and why of what we do as nurses.  There were days were I felt like I was not given all I needed to be the best nurse.  I most days than not asked "Why weren't we taught this sooner?"  There is so much ADN and BSN should be exposed to before they hit the unit and I hope as a future educator to impress upon my students and colleagues the value of being committed to live long learning.  Right now I have the skills, the critical thinking, the passion to be a nurse, but there is so much more and I want it!
My new class starts today...Nursing Research & Evidence Based Practice!  If its similar to my research class while getting my BSN I hope to do well.  I liked learning about research and it was interesting to see all the different types of questions researchers ask and investigate.  I don't see myself, at this point, being an active researcher, but I could see myself collaborating with others on certain projects.  That brings up my other topic, team work.  I realize as a nurse, I must work with others and I want to work with others,especially when dealing with patients and their health.  Now when it comes to my grades/points I want to be the responsible party.  Having to work with others who may not be as zealous as I am, concerns me because I want to give my very best each and every time....no half stepping.  I learning that isn't always the case, even in this setting,which is sad to me but you see it work, in organizations, everywhere.  No one puts care into anything unless they can get something out of it.  Why waste the time?  Well I see this as a learning ground for me to have to deal with this people, maybe be a good example/role model and store this information for when I am practicing, which I hope will be soon!
Well got some more reading to do for this first week.  Here's to another great 8 weeks & prayerfully an "A" not an A- (missed by .07 last class)!  

Times flies and I'm still having fun!

It has been 8 weeks since I went back to school and despite the hard work and dedication I must have I am loving it.  In many ways this class is preparing me for the next step....working.

There have been so many things that I have learned that I wish we were learning at the baccalaureate level.   Because we are with patients when they are at their most vulnerable we should want to be at our personal best.  Life and death should not be watered down to a collection of skills.
All in all it has been an awesome 8 weeks and I am confident the next 8 will be just as great, especially since I'll be adding working to the mix!

8 things you can do to help your patients’ families

by Scrubs Contributor • May 14, 2013 Career, Career Advice for Nurses

Tell me if this sounds familiar.
I’m sitting outside our children’s hospital waiting for a relative. The woman next to me is smoking her cigarette with an intensity that screams “patient’s mother,” and her orange wristband is a clear giveaway.
I’m open about my son’s heart defects and surgeries, but I don’t assume others share my openness. So, I gently opened a door for the woman to talk if she wanted to. We were in the same club, after all, and had the bracelets to prove it.
She proceeded to bear her soul to me.
Her teen daughter was airlifted after a car accident and suffered severe brain trauma. The mother rode in the helicopter and had no change of underwear, had little cash and was down to her last few cigarettes. She wanted to go to a Walmart, but feared she couldn’t afford a cab.
I asked her if she’d spoken with a social worker yet. She said no.
She was at her child’s side for 48 hours. She hardly used the toilet, hadn’t slept outside of the bedside chair and this cigarette was her one reprieve. I told her to ask her nurse to page a social worker, that there were vouchers for cab fare, cafeteria meals and things like that. I told her to use the specific term “social worker.”
Television hasn’t engendered trust in “social workers.” The average person has no idea that hospitals staff them to help in crises. Then again, the average person doesn’t know the protocols of being airlifted with a critically ill child. Under extreme circumstances, families are not filtered through the standard admissions process. If no one asks if they want emotional or financial support services, they cannot say yes—they don’t know to ask.
Is there more that nurses can do?
As a nurse, you can help guide a struggling family through the hospital ropes…but it’s hard to know what you can and should offer if you’ve never been on the other side of the critical care bed before. If you’re a new nurse, or recently have moved from a less intense setting to the ICU, these tips can help you better help your patients’ families.
8 things you can do to help your patient’s family:

• Put yourself in their chairs. What would you need and would you know where to find it?
• Show and tell them where to get free coffee or water, if available.
• Explain shift change before shift change. Getting kicked out without warning is stressful for parents or spouses.
• Learn the resources available to families in your hospital so you offer them in an appropriate context.
• Ask if they want a social worker to talk to them about vouchers or services. Many, especially first-timers, won’t ask you or are reluctant to take “charity.” Keep asking.
• Offer to contact child life, family counseling, a chaplain or social worker (and make sure the resource actually shows up). The family’s stress isn’t helping your patient.
• Encourage them to take a walk and use a volunteer or friend to fill their seat. If sitting for long periods is bad for airline travelers and office workers, it is no less bad for families sitting bedside.
• Visit a parent/family room or the Ronald McDonald House (or similar) at least once in your career. Knowing you’ve bothered to see things from their side of the bed will increase a family’s trust in you.

Amanda Rose Adams is a child health advocate. Her first book, Heart Warriors: A Family Faces Congenital Heart Disease (Behler Publications, 2012), recounts the journey the Adamses took from expecting parents to Heart Warriors. Adams founded two nonprofit organizations to both educate parents about rare congenital heart defects and raise critical research dollars. She is currently a member of Baby’s First Test 2013 Consumer Advocacy Task Force. Adams has written for scrubsmag.com and the American Academy of Pediatrics Section on Bioethics. She holds a master’s degree in technical journalism from Colorado State University.

Safe Patient Handling and Mobility: Interprofessional National Standards

Safe Patient Handling and Mobility: Interprofessional National Standards
No health care worker should face the constant risk of instantaneous or cumulative musculoskeletal injury from lifting, moving, and re-positioning health care recipients, when assistive technology that has been proven effective is available. Likewise, health care recipients should no longer be exposed to an injury risk – or an affront to their dignity – from manual patient handling. The Standards set the path to a stronger culture of safety and higher quality of care.

• The Movement Toward a Vigorous Culture of Safety (Press Release)
• Teleconference – Launch of ANA’s Safe Patient Handling and Mobility: Interprofessional National Standards (Audio - 29:26)
  Experts present the background and goals of the initiative to implement comprehensive SPHM program across the care continuum with guidance of the new national standards:
  • Suzy Harrington, DNP, RN, MCHES, director, ANA’s Department for Health, Safety, and Wellness
  • Karen Daley, PhD, RN, FAAN, ANA president
  • Mary Matz, MSPH, CPE, CSPHP, national program manager for patient care ergonomics, Veterans Health Administration
  • Ronda Fritz, MA, BSN, RN, Safe Patient Handling Facility Champion, VA-Nebraska-Western Iowa Health Care System
  • Robert Williamson, MS, BSN, RN, CWCP, director of associate safety, Ascension Health

• The Safe Patient Handling and Mobility book: A Sampler
• Safe Patient Handling and Mobility: Creating the Framework (video)
• Frequently Asked Questions
• SPHM Overview
• Myth vs. Reality
• Navigating the Safe Patient Handling and Mobility Interprofessional National Standards Webinar
• Infographic: Survey Results, Injury Stats, Lift Estimate
• SPHM Work Group: A Diverse Array of Professionals

Back To School!

So on June 13th I began the Master of Science in Nursing with an Emphasis in Nursing Education curriculum at Grand Canyon University. I am extremely excited to be actively working toward one of my goals as a nurse. 

We have reading assignments, discussion questions and a paper already! Groups have been assigned and it will be interesting getting to know my fellow classmates.  Trying to curve my enthusiasm and post once daily so I stay on track with the requirements. 

The chapters we have to read have been engaging and inspiring.  I've always liked school and I am glad to be back to working toward not only being a staff nurse and a future nurse educator.

New Blood

No, I’m not trying to create a title for a new paranormal romance novel but I thought the title was appropriate for my comments.  Blood is the river of life that surges within us, transporting nearly everything that must be carried from one place to another in the body (Marieb, 504). 

The blood is composed of various elements, leukocytes, platelets and erythrocytes that are suspended in a fluid called plasma.  Erythrocytes or red blood cells (RBCs) develop in 5-7 days and live for 100-120 days.  Leukocytes or white blood cells (WBCs) that make up our body’s defense against disease has five types: the granulocytes family has neutrophils, eosinophils and basophils.  The agranulocytes have the lymphocytes and monocytes.   Neutrophils develop in 6-9 days and live 6 hours to a few days.  Eosinophils also develop 6-9 days and live 8-12 days.  Basophils develop 3-7 days and the life span can range from a few hours to a few days.  Lymphocytes develop over days to weeks and have a life span of hours to years (boy is immunity important!).  monocytes develop in 2-3 days and have a lifespan of months.  Platelets develop in 4-5 days and have a lifespan of 5-10 days (Marieb, 511).

Each cell type has a specific function and satisfies a specific need.  So now that I have completely lost your interest and bored you with the exciting world of blood you want me to ask me why am I talking about blood.  No new romance story between the eosinophils and the monocytes.

As you can see from the days there is a time for replenishing.  As blood cells age, new ones develop and take their place to keep the body functioning and healthy.  We monitor WBC, RBC and platelet levels, among other important lab results, to assess our patients’ health.

As a new nurse I know I am a new blood.  I am developing and preparing to be launched out into the plasma and work where I am needed.  A new grad can hope to work with matured blood, experienced nurses that have been on the front lines of patient care.

We have all read or heard about the nurses shortage and how there is an extreme need.  As a new graduate registered nurse yet to receive her first position, I am ready to help alleviate the need but getting in the door is proving challenging.

I posted on Twitter how my wish: A place where new nurses can keep their skills current while waiting for their first nursing positions.  I think hospitals and medical centers are hurting themselves but reducing the availability of new grad positions and nurse residency opportunities.

If the body does not have a replenishing of blood, it is put at risk.  Our hospitals are at risk for having a large influx of well-trained but inexperienced nurses.  This of course could affect patient centered care efficiency.

A smart solution would be to make sure all new graduate nurses were under the proctorship of an experienced nurse.  One this would make sure that the new nurse learns the healthcare system’s culture and two, this provides an appropriate avenue for the transfer of vital information.

The economy and just the way the capitalistic culture of our country doesn’t always allow for what would be “smart.”  For example I would love to be on a unit right now working with a nurse who is planning on retiring in the next year or so.  To be able to glean his/her vital knowledge would not only be a benefit to me but it would be an asset to the healthcare institution.

I am thankful for my mentors.  I utilize every opportunity to ask them questions and have them share their experiences.  I volunteer on a regular basis to help keep my skills sharp and I try to read about a  new patient centered care implement every week.

I do hope that my fellow new graduates will continue to remain hopeful and ready for the new opportunities coming our way.  As we move along in our careers as nurses I hope we will make sure to implement passing the touch and keeping the infusion of new blood into our organization so we can stay on the cutting edge of evidence based practice protocols and patient centered care changes.  May we impress upon our future employers and the people who spend a great deal of time thinking about “the money” will recognize experience is important but also new graduates will bring important assets to the table as well.  May the next generation remember that a mixture of new and matured is vital to providing the best health environment for our patients and anything less means we’re failing not just ourselves, our profession and industry but also our patients.

Reference:

Marieb, E., & Mallatt, J. (2003). Human anatomy. (3rd ed.). San Francisco: Benjamin Cummings.