Author: Pamela M. Ironside, PhD, RN, FAAN
Title: Associate Professor
Institution: Indiana University School of Nursing
Online or Web-based Modules
Integrate understanding of multiple dimensions of patient centered care:
- Patient/family preferences, values
- Coordination and integration of care
- Involvement of family and friends
Provide patient-centered care with sensitivity and respect for the diversity of human experience
Acknowledge the tension that may exist between patient rights and the
organizational responsibility for professional, ethical care
Act with integrity, consistency and respect for differing views
Initiate requests for help when appropriate to situation
Explore ethical and legal implications of patient-centered care
Describe basic principles of consensus building and conflict resolution
Value vigilance and monitoring (even of own performance of care activities) by patients and families
I have been a diabetic for 33 years of my life. I am 43-years-old, a divorced father of two, a grandfather of one, and a brother to three. I sell cars for a living and most months barely make ends meet. I don’t have the best health insurance so I have to pay for most of my diabetic supplies and office visits out of pocket. I had seen my doctor 3 times in the last six months for chest pain and he said I was having panic attacks. Then one night I had my fiancé take me to the emergency department at our local hospital because I was more short of breath than “usual” with these panicky feelings I was having. Well, come to find out I was having a heart attack. I am not ready to die and don’t want to be a cardiac cripple like my dad. I am too young! I am finally in love again and things are getting good in my life. Well, I ended up being transferred to a large hospital about an hour away from my home because I needed bypassing of four of my major arteries that supply blood to my heart.
Because I am a diabetic I live with my insulin pump and have very strong feelings about managing my blood sugar. Despite what they tell me “normal range” is, I know exactly where my sugar needs to be at exactly what time of the day in order for me to feel good and stay healthy. So, of course my chief concern in facing this heart surgery was how I was going to run my pump (bolusing myself or changing the basal rate) if I was “out of it” after surgery. The nurses were insistent about stopping the pump and putting me on an insulin drip because that is their routine for caring for diabetic patients post-op. But I know myself and that really messes my blood sugars up! Wasn’t my body going through enough stress the way it is? I was really steamed and I was worried that I would not recover like I should if they messed with my sugar so I pressed the issue. Besides, my mother is a nurse and would be at my beside and more than capable of monitoring my pump while I was zoned out. Well, the nurse manager finally came in and told me that the nurses weren’t comfortable with my pump because it is different than what they usually see. She suggested I purchase a new pump so they could manage it better—it was the only way she could keep me safe.
If you were the nurse assigned to care for this patient, what would you do at this point and why?
As you formulate your answer to the above question, also reflect Topics to discuss with a Cougar on the following:
- Whose interests are being served by “standard post-op orders?”
- What is the relationship between nurses having control of patient care and patients being safe? How is “safety” determined?
- How do nurses account for patients’ experience and embodied knowing?
- What is the meaning and significance of a patient’s experience of illness?
- How exactly would you include the patient as a co-collaborator in his care? When patient safety and patient wishes conflict, how do nurses decide what approach to take in each particular case?
- If this patient was your brother or father, how would you intercede to influence the staff in respecting his requests? What does it mean to patients’ and their care to have an advocate?
This exercise is intended for discussion, creating the opportunity for students to explore the complexities of advocacy in light of commitments to both patient-centered care and safety. In my experience, students initially tend to “side” with either the patient or the nurses and argue for the ascendancy of their perspective rather than exploring issues such as: a) the common concerns patients/families and nurses share, b) how common routines and practices inadvertently curtail communication and the consideration of workable alternatives, and c) how nurses, “with their hearts in the right place,” may use power over patients when conflicts arise. Alternatively, you can ask students to share experiences wherein they experienced being “discounted” or ignored or when their own actions or decisions were deemed unsafe by others who disagreed with them. Again, the point of these discussions is to engage students to exploring advocacy and the difficulty of being a patient advocate in situations that are new, unfamiliar, contentious or potentially dangerous.
In most cases, this is an ungraded exercise or, alternatively, students may be marked with a pass/fail (passing for participating in the discussion). If you are asking students to journal in your course, this may also be something students reflect on further and create a journal entry describing their thinking related to this case. This will allow you to evaluate the extent to which students are becoming more adept at thinking through difficult clinical quandaries.