View Full Version : Do we do too much?


geenaRN
11-09-2007, 03:14 PM
Thinking back on when Kaiser dumped a patient on skid row (http://www.signonsandiego.com/news/state/20051126-0727-ca-hospitals-skidrow.html), I started wondering if hospitals had too much responsibility to take on with patients. Is it really up to a healthcare establishment to fix everything wrong with a patient's life? If a patient comes in with a broken foot but is also homeless, is it up to the hospital to find a place for that person to go in addition to treating the broken foot?

When a patient is discharged and has a home but no one can come and pick them up, why is it our job to get them cab fare or a bus token?

I actually discharged a patient once in this situation. He said he had no one to pick him up, so if I could just take him out to the bus stop he'd take it from there. I felt really weird doing that. I've had other patients demand cab fare to get home.

Am I making sense? I don't mean to sound insensitive, but I don't see how we can fix everything.

If the patient has nowhere to live, and there's nowhere to take them - what are we supposed to do? I feel like the way things are going, we're going to have to start feeding patient's cats while they're in the hospital.

Of course it would be nice if we could fix everyone's problems, but our resources are already stretched thin.

What's your opinion?

Julie
11-09-2007, 04:25 PM
Ok, A persons lifestyle and home environment influence their health and may be detrimental to their recovery BUT we cannot fix everything, we must not assume even that people always want everything fixed. As a district nurse I was often shocked by the way in which people chose to live (lack of cleanliness, smoking even though they could barely breath etc) but it was not my job to either judge the way people lived or to set about completely changing everything for them.

BrianRN
11-09-2007, 06:59 PM
No need to try to change everything but an attempt to fix is better than nothing. As for taking them to the bus stop, I work at a hospital that the bus stop is between the emergency room parking lot and the visitor's parking lot. Nursing has a role in case management to try to fix the environmental factors but there's a limit to what you are able to do. Financial limitations as well as the behaviors of patients cannot be controlled by nurses sometimes. I think humanity in general is obligated to help out others and if nurses are in a position to do something to change a patient's environmental situation for the better then they should.

MyOwnWoman
11-09-2007, 08:23 PM
Geena........your question for the poll was way too hard! I can give you instances where I feel that each one of the responses are right; and I can give you instances when each one of the responses are wrong. My answer varies on the actual situation. For instance: 18 year old IDDM (just turned 18). Used to be on mom's insurance and now, since he turned 18 and was out of school, he did not have insurance. He was not on public assistance. He worked at McDonald's for minimum wage. His Mother told him that since he is 18, his diabetes is now "his" responsibility. Up until that time his diabetes had been well controlled. He came into the ER because he was running out of insulin (Lantus) and his blood sugar was elevating. He started taking half doses of insulin each day in attempts to make his insulin last longer and keep his blood sugar under control while still being able to give himself "some," insulin. He was at a loss and didn't know what to do. He said he was going to get paid from McDonald's the following week and was going to try to get his insulin then. (I sincerely doubt that he makes enough money at Mickey D's to buy insulin) He came into the ER, to quote him, "in the hopes we could help him not go into DKA."

I called every hospital coordinator, administrator, supervisor I could think of to ask for some assistance for him but in the end I was told there was nothing we could do; that "We can't dispense medication here and besides, insulin is NOT a life saving medication." (Yes, not life saving, but that's another story for another day.) I was freaking stunned; so in my "shy" manner I said, "You're right, it's not life saving, why don't we just wait until he goes into DKA then we can admit him to the ICU and give the hospital a huge bill instead of giving him a bottle of insulin now." Of course I had to add, "He's probably just going to go out and get high with the insulin anyway and share it with his friends."

I updated the doctor to the situation and he told me to just give him the bottle and he wrote the order for me to do so. Again, I was told by the powers that be that I was not permitted to give him the whole bottle.

How did the story end? I ended up giving him his normal dose of insulin for the day and....well....I don't know for sure, but I must have left the bottle of insulin on the bed and thrown it away accidentally when I changed the sheets. Opppsss.

His story, and his story alone is what made me choose the answer that "we don't do enough." Of course, I could give you examples of the other two answers to the poll that may want to make me answer differently. I guess in the end, all of us just want to help; and sometimes that means we do too much, too little, and not enough.

geenaRN
11-09-2007, 10:56 PM
MyOwnWoman, your answer was so awesome, but this part made me really laugh:


"He's probably just going to go out and get high with the insulin anyway and share it with his friends."

:laugh:

Julie
11-10-2007, 04:23 AM
And people don't think social medicine is a good thing?

I must say I find your story quite shocking myownwoman, because of course in the UK any young person (or indeed anyone) will get as much insulin as they can possibly use and what is more because of its life saving necessity they will get if for nothing, free el zippo.

Nurse Stella
11-10-2007, 08:10 AM
It's a tough call sometimes. As for MyOwnWoman's post, yes there are some cases when "we", (management, too), don't do enough. But we had a case a few years ago when a young paraplegic from a BIG city took a bus up here to the very rural north country. He was paralized from a gunshot wound during a gang fight, and had a colostomy, but no pouches for it. He went to one of the few homeless shelters here, but they wouldn't take him because of his "medical issues". They sent him to our ER. Although very stable, medically, the ER doc admitted him for social reasons. He thought he was in a hotel, and that the call bell was room service. "I want a chocolate bar, change my ostomy pouch, bath me." He was able to do all this himself, he did have a w/c, but because he was a "patient", we did for him. Sure, we tried the teaching route for his ostomy, but he already could do it, just chose not to. For 4 months, this man lived at hour hospital, because case management had no where to send him. Finally, he mentioned he wanted to go to Colorado. So case management gave this man a bus ticket, (from Northern New England!) took him to the bus station, 40 miles from here, and helped him onto the bus. He also left with several hundred dollars of ostomy supplies, $100 in cash, and some new clothes. He got all this, plus 4 months of free room and board, as he wouldn't supply the information to apply for medicaid. In my opinion, this was too much. (BTW, nursing had a party after he left!!

B.

MyOwnWoman
11-10-2007, 08:04 PM
Stella....that is going above and beyond the call of duty and it is just that type of scenario that would make me want to say "you need to learn how to help yourself. and that we already do too much." What is really worse is that the cost of the ticket to Colorado, the ostomy supplies, the hotel room, etc was probably well worth it to get the "monkey" off of the back of the hospital; but unfortunately, that "monkey" will be back one day only because he knows "if you did it once, you'll do it again."

I'm almost sure that is not what is meant by "The Circle of Life."

jojodow
11-16-2007, 11:16 AM
I worked with a lot of Homeless patients at the hospital. We were actually surprised to be assigned to a patient with insurance.
Some would take advantage of the system, some just wanted to get better to go back to their freedom of the streets.
I've always taken the "leading the horse to water" philosphy. Do what you can, if they won't help themselves, then there's nothing left to do.
Yes I do think we do too much, I think we wouldn't have to if there was a govt. program in place. I think everyone needs to take responsibility for themselves if they can. There's only a problem when too many people don't. :(

Petro Heller
11-21-2007, 08:13 AM
I don't really understand what is meant by that question. I am a RN specialising in the OR and as Theatre sisters we are often expected to assist in operations in cases of emergency e.g. Cesarean sections. I honestly think I do as much as I must,and sometimes I go the extra mile if needed. When is it too much? When is it not enough? Surely we must all judge matters for ourselves against our own conscience

Mr Ian
11-28-2007, 03:55 AM
My answer to the question is -
It's not my problem.

But I'm not talking to the patient when I say that. I'm talking to the policy makers, the insurance companies, the bureaucrats, the administrator.. etc..etc...

I took on the role of nurse to help people. Not just treat an illness. If I wanted to do that I'd have studied medicine.
If the hospital/service doesn't have a protocol to manage the stuff I deem clinically necessary then they can go deal with it in a forum somewhere after I've done it. If I'm getting too much 'social health' (or other) issues that I can't even deal with the essential clinical stuff, then I bang on someone's desk until they give me someone or some way to get it done.

The hospital is not there for the insurance company; not the nursing board or council; not the politicians and it's not there to give some administrator a cushy life.
I'm not about to help them avoid making decisions or providing service because we decide for them based on their non-clinical needs. Not until they start coming to the floor and helping me deal with my patients.

If I deem it necessary in the interests of the person then I do it to the extent of my ability and resources (and I can be pretty resourceful!).
My responsibility is to the people who need my services and to them alone.

Mr Ian
11-28-2007, 04:00 AM
PS.
If I was posting on an administrators forum as an administrator or if I was a politician, my answer would have been completely different.

But I'm not.

So it isn't.

Julie
11-28-2007, 04:54 AM
Well interestingly Ian I am now one of the 'administrators' or managers that you speak. I work in the area of the health system that holds the money and whose job it is to make sure that money is spent in the most effective way. Effective does relate to cost, but it also means best, appropriate and evidence based. Having said that, I am also a nurse. Ok so any contact I have with patients is coincidental these days but it is my job as a clinician employed as a manager to keep the focus on patients.

while technically it is the problem of the manager or administrator if the health care system is providing social as well as health care, but it is down to us as nurses to make sure that we know the difference. As a district nurse I worked with someone who took her patient's clothes home to wash. The lady had no relatives and in her view no one to do the washing, therefore in her eyes she was providing a necessary service. However, not withstanding the infection control issues, this was not appropriate behaviour. There were people in social services whose job it was to assess and ensure that social needs could be met (all be it at a financial cost to the patient) and what is more doing patient's washing is not the job of a nurse. No manager told her to do what she did, but sometimes people need to be needed and for that reason it is difficult to legislate that people won't do things they are not supposed to do.

Mr Ian
11-30-2007, 06:26 AM
Absolutely Julie, and I have moved to a more considered understanding over the years that each role has its responsibilities.
Health care is a business, I make no mistake. It is also one of the top three or four issues of politicians (more often in UK and Aus than US); not because politicians care about our health as much as they care about what gets them votes.
But perhaps necessarily so, as votes reflect the peoples choice.

The whole structure is a game of balance; the wants of the mass of the people; the needs of the individual.
Unfortunately, boards and committees and administrating staff, as you identify, only meet with patients coincidentally from their positions.
Nurses, however, ought be seeing them 90% of the time they are at work. (Tho this 90% is in much contention with the anti-litigious paperwork required nowadays).
It is not easy for a nurse to see a patient with a need and simply walk away from their ordeal muttering to themselves about maintaining budgets and keeping the professional boundaries. Nurses simply do what the job requires them to do. In mental health the boundaries of 'nursing care' are much more smudged such as when a CPN (community psychiatric nurse) sees old Jo who hasn't got enough food for the week in his cupboard. I know many a CPN who will tend such needs under the consideration that addressing a minor issue now can prevent a major issue in a week. And trying to get it done thru submitting paperwork to another agency just doesn't happen in timely or purposeful fashion. Such diligence is oft found at the shop floor; sometimes just because it saves the nurse who knows in 3 days they'll be getting an urgent call to attend if they don't do a simple task now. But always it is done because the social issue is linked to the mental health issue. Nursing is part preventative and to not address it would be like the surgical registrar not treating the infection and waiting for the gangrene to set in because amputation is his job. Even when the CPN later raises their issues, it becomes subsumed by other issues that seem to take priority. Meanwhile, CPN is just happy to know that Jo is well and will eat tonight - and doesn't really give a stuff about someone else's policy need 3 floors up.
The failings I believe are not that nurses cross from health to social (or other) boundaries. Neither do I believe they are from ministerially led decision-makers. The problem comes when you try to marry the two together - two different needs bases; two different roles and most definitely two different daily experiences at work.
The service(s) are not flexible enough to meet the unique and emergent needs of the individual; the management is too defined in terms of it's administrative role and restricted in it's latitude to move away from the generalised and profession/task-specific policies even where a need is identified. This is no different to the issues facing nursing when, eg, 'health & safety' teams define 'how' the job is to be done.

Open and transparent practice management that welcomes the issues from, and considers them at, service delivery levels can support health care staff to resolve them in terms of their needs, and the balance of issues of service structure and service cost can be passed up the line to be raised as a point of concern that may or may not need further address. A management that simply tells you "You shouldn't do that" or one that says "I'll get back to you on that" and takes the issue further up the administration ladder; until 6 or so other nursing service issues emerge, or the medical or governmental team issues take priority, will lose the responsiveness to the issues that the service delivery staff require. For those issues that make it through the administrative barriers you can only hope the actual reality of the problem isn't already lost amidst the bureaucracy.
If I had that kind of service administration response, then I wouldn't need to be banging on your desk :)

DisappearingJohn
12-10-2007, 02:39 PM
In the ED we see every end of this spectrum. Sometimes it feels like we have become too hardened, because I can discharge some to the street, and have it not bother me; other patients, it really bugs me...

I think we do as much as we can, for as many as we can, but with the healthcare industry in the shape it is, and the political climate what it is, we can't fix everybody or everything.

NurseSean
12-13-2007, 07:44 AM
I don't think it's so much about whether we do enough or not, but rather shifting our focus to a health promotion/illness prevention model. I feel the training of RNs has grown much bigger than bedside nursing to include holistic care of individuals and populations. We underestimate our ability to, as the pole states, do more.

P/J
12-13-2007, 08:29 AM
I agree NurseSean. The focus of the RN has changed since the start of nursing. As more is discovered about health it is becoming the role of the nurse to be health promoter not just hand madden. So we are doing too much for our patients by taking the recovery off them (by doing everything for them), and I have heard a patient being told that this was a hospital not a hotel.

I have had a few pts who could be considered a handful, many were capable of their own care but were not willing to do it themselves. These people generaly got left to the bottom of our list as we cared for the patients who needed assistance. I have also had patents who were aware of their limitations and would ask for specific things, like 'I'm going for my shower now, can you help we with my iliostomy when I come out, I'll buzz when I'm ready' This meant that I had time to check on my other patients and to just keep an eye out for the bell. When I did go back in, she had all she suppliers layed out, with the tape already cut. It was just a matter of lining everything up for her and help her with the taping. I was done in 2min.

So are we doing too much. It all depend on the circumstances, we are there to promote recovery and health, not to wait on a pt hand and foot. I have seen nurses after 2 days of waiting on the same patent and being there when the doctor has told the patient that they can transfer by themselves; have to tell the patient that they were not going to get another bed bath and if they required assistance in the shower one of the student nurses (male) would be willing to help, the patent suddenly was able to do everything themselves.

amygarside
01-20-2014, 12:21 PM
i think we are just doing enough. Not much though.