Advanced Nursing Practice Situation
Today is a busy day at the community health center since yesterday was a holiday. I am seeing walk-ins, and my three examination rooms are full. I hope I will be able to see more than 20 patients today—the expectation of ‘management’—and will be rewarded with a productivity bonus. My next patient is John, a 42-y.o. man I have known for several years. He is accompanied as usual by his wife Mary. Today, John is complaining of lower extremity swelling and pain in most of his joints. He is worried about losing his job as a truck driver, because he is having difficulty climbing in and out of his truck. He is afraid that he may have lupus, because all of his siblings and his mom have this disorder. He also requests a refill on his antidepressant, which doesn’t seem to be working as well as it did a month ago. While reviewing his chart, I notice that John has gained weight—he now weighs over 300 lbs. In reviewing his medications, I see that the antidepressant he is taking may be contributing to his weight gain. John’s physical examination is unremarkable. His heart rate is regular without murmur or irregularity, and his lung sounds are without wheezes or crackle. Since John is a large man, all of his joints areas are large, but they are all symmetrical, with good range of motion and only mild palpation tenderness in his wrists. His ankles are large but without erythema or other skin discoloration or disruption, and his pedal pulses are strong and equal bilaterally.
I ponder how to manage this visit. Do I take the time to investigate John’s depression more thoroughly, wondering about his 11 y.o. daughter, who at his last visit was on chemotherapy for a neuroblastoma? Should we discuss the pros and cons of different antidepressants? Should we discuss the possibility of a gastric bypass again, even though I know the thought of anesthesia terrifies him? Do we again discuss the importance of a healthy diet and increased exercise, giving consideration to his joint pain? I am torn between what I feel this patient deserves and the call of the clock. Would it be unreasonable to order the necessary lab tests to investigate the possibility of lupus, hypothyroidism, or some other disorder and postpone these time-consuming discussions until his next visit?If I am expedient with this visit, the other patients waiting also will be grateful. Maintaining a caring practice in an economically driven discipline requires skill and grounding in those values that are essential for quality patient care. In the context of the caring theory and analysis of the Advanced Practice Nursing Situation above, let’s discuss this situation using “multiple ways of knowing.”
Questions for this week’s Postings:
- In your posting this week please provide a word metaphor that might express the meaning of this situation as described above?
- Remember this is your opportunity to tap into the aesthetics of knowing that is seeing the beauty and uniqueness in this situation so think about it a bit before responding.
- Make it your own word and not just what someone else said.
- Please explain why you chose this word and if you have experienced this type of situation before and what did feel about that situation?
- Write substantive response of 200-250 words to the question below and include in-text citation. APA format.
- References and citations should conform to the APA 6th edition.
- .Make sure to respond to your fellow classmates postings The postings should be at least one paragraph (approximately 100 words) and include references.
Classmates Posting below:
Timothy’s Post
The best word that I can think of would be a beacon. According to Houston (2018), a beacon is installed at an airport from one to ten degrees above the horizon to help guide pilots at night back to the airport. Nurse practitioners are the beacon patients need to help guide them with their health care and well-being. The patient in this scenario needs a beacon to help with all the different type of problems that he is facing and going through. The nurse practitioner must learn how to balance patient load and time management to compensate for the number of patients seen during the day. Patient care is what we as healthcare providers are supposed to provide for our patients to achieve better outcomes for them. Healthcare is not a production line where a quota must be reached the same way every day. As nurse practitioners, we must remember that we are taking care of our fellow humans and they are trusting us with their care. In this scenario, it might take some extra time to change the patient to a stronger antidepressant and order test to rule out other problems the patient might be encountering, but that is what is needed to help with the care of this individual. Taking time to make sure this patient gets the attention and care needed to help guide them to achieve better outcomes for their healthcare and well-being would be the same as how the beacon helps guide the pilots safely back to the airport to achieve the best flight possible for better outcomes. One can only hope to be a beacon for my patients so they can receive the best evidence-based practices to achieve the best patient outcomes.
References
Houston, S. (2018, August 20). Airport and Runway Lights Explained. The Balance Careers. Retrieved from https://www.thebalancecareers.com/airport-runway-l…
Stephen’s Post
This patient care scenario brings to my mind a classic logic problem about a train. In the logic problem, you are driving a train and if it continues to go straight it will hit and kill four people, but you have the opportunity to switch tracks. On the other track, the train will hit and kill only one person. In the first case, four people die but not because of your actions, in the second, one person dies directly related to your actions. This case is a more positive version of the logic problem. If you stay with John and address each of his needs, he will greatly benefit and your other patients will wait longer and have less time, however, if you rush through John’s complex issues, his care will suffer and your other patients will receive timelier in-depth care. Neither scenario produces the best outcomes for everyone. Neither case is optimal for the patients or the provider.
One study looked at common ethical issues in nursing. Among others, it identified workload, usually related to staffing, as a significant barrier to providing ethical care and a significant cause of frustration (Ulrich et al., 2010). This finding is recreated in the given scenario. In this case, the provider is unable to administer ethically appropriate care, addressing the complex and multifaceted needs of John, because of the workload, the needs of the other patients.
Carper identifies four patterns of knowing through which the provider acquires clinical knowledge and comes to know the patient as a person. These patterns are empirics, aesthetics, ethics, and personal knowing (Mantzorou & Mastrogiannis, 2011). Simply ordering the tests as proposed represents knowing through empirics while knowing John’s concerns for his daughter and his fear of anesthesia are aesthetic in nature. Lastly, when the provider acknowledges their time constraints, workload, and ultimately their own limitations, that is personal knowing.
Working in a busy emergency room with a heavy patient load, I frequently felt that I could not deliver optimal care to a single patient because it would negatively impact the other patients. It is very frustrating. Sometimes I would employ prioritization strategies. Other times I would say to myself, “I can only treat one patient at a time and right now I am in the room with this patient”. In that way I gave optimal care in the moment to a single patient. The shortcommings of these strategies is that ultimately they place one patient above the many or many patients above the one. There is no easy answer. The nurse or NP must acknowledge the limitations of both themselves and the situation first before they can begin to administer care.
References
Mantzorou, M. & Mastrogiannis, D. (2011). Professional practice, according to Carper’s patterns of knowing. Health Science Journal, 5(4): 251-261. Retrieved from http://www.hsj.gr/medicine/the-value-and-significance-of-knowing-the-patient-for-professional-practice-according-to-the-carpers-patterns-of-knowing.pdf.
Ulrich, C., Taylor, C., Soeken, K., O’Donnell,P., Farrar, A., Danis, M., & Grady, C. (2010). Everyday ethics: ethical issues and stress in nursing practice. Journal of Advanced Nursing, 66(11). Doi: 10.1111/j.1365-2648.2010.05425.x.
