Nursing today is not what it was many years ago. Over the years the practice of nursing has adapted to the changes in medicine, changes to the health care system and the changes in maintaining infection control. With these changes, the care that the nurses provide to their patients require an advanced education to practice nursing to provide nursing care such as administering medication, assessing and carrying out doctors orders. The purpose of this paper is to apply the patterns of knowing to a personal experience to help improve my nursing practice.
A 62 year old caucasian female was admitted to my unit with a malfunctioned Arteriovenous (AV) Fistula. To protect her identity we will call her Jane. Jane has End Stage Renal Disease (ERSD) and was admitted to my floor from PACU after a fistulogram. Jane came to the hospital to open up her fistula so it could be properly be used in dialysis, through a procedure called fistulogram. For a patient with ESRD this is very important because it is through dialysis where all the the toxins of the body are removed since their kidneys are not functioning as they’re suppose too. She had a Jackson-Pratt (JP) drain to the site to collect the serosanguinous drainage. Patient who under go a fistulogram stay in the hospital for about 24-48 hours for observation. Jane was post op day one, she was medically cleared and her vital signs were stable. The doctor placed an order for the patient to be discharged home. I printed out the papers, explained the discharge instructions and asked her to sign. When speaking to her I noticed she looked worried. I asked her who would be taking her home. She said she would take the bus, and couldn’t afford 20 dollars to take the Ambulette home. She also begins to tell me that she has a stack of medical bills at home that have not been paid yet from her previous admission to the hospital. This inquired me to ask if she was comfortable taking care of her own JP drain, she states “my home is dirty”. I knew this would equate to her to getting an infection and having to return back to the hospital. She looked up at me and started to cry. I knew this was an unsafe discharge and that we needed social work to discuss options so she may receive help and care when she returned home. The discharge orders were discontinued until social work could set up visiting home nurse services. To my knowledge she was discharged home the next day after social work had set up services for her. Jane has not retuned to the hospital since then so I can only hope that all went well.
Carper’s Ways of Knowing encompasses four patterns of knowing in nursing: empirical knowledge, esthetic knowledge, personal knowledge, and ethical knowledge. Chinn and Kramer developed a fifth pattern of knowing termed emancipatory knowledge. Empirical Knowing is the knowledge learned through theory and application of scientific evidence which is learned through textbooks and classroom settings. In nursing school we learned how to care for a surgical site and prevent infection from occurring. So when I explained the discharge instruction I explained how to empty the Jackson Pratt bulb, what to look out for when caring for a JP insertion site and when to return to the ED if she had any signs and symptoms of an infection.
Ethical knowledge consist of the moral code of nursing; a nurses obligation to their patients and their community. Ethically I couldn’t allow the patient to leave the hospital even though she was medically cleared. Since Jane was medically cleared I could have easily had my Director of Nursing supervisor pay for her cab ride home, gave her some medical supplies, teach her how to take care of the JP drain and send her home. But (2) ‘The Code of Ethics for Nurses with Interpretive Statements is the social contract that nurses have with the U.S. public. It exemplifies our profession’s promise to provide and advocate for safe, quality care for all patients and communities” As Registered Nurses we took a vow to advocate for “safe, quality care” for all patients. So I ethically could not discharge Jane home until social work saw her and helped set up visiting home nurse services.
Personal knowing is acknowledging oneself and self in relation to others. When Jane stated her house was dirty. In my head I immediately wanted to judge her and blame her for having an unkept home. I immediately stopped myself and put myself in her shoes. Jane goes to dialysis 3 times a week, she does not have help at home to help her keep her home clean. Her main mode of transportation to places is mass transportation. By the end of the day Jane may be too tired to spend an extra hour to two and the end of her day to clean up the house.
Aesthetic Knowledge is the ability to “sense the meaning of the moment” . Once Jane had explained her financial issue and her home life things made sense to as why she was so reserved, quiet, closed off. I pulled up a chair and sat with her and I listened to her vent to me about her inability to keep up with the bills at home. It was a silent cry for help. It didn’t go unnoticed because I did my best to get all the services she needed prior to being discharged home.
Emancipatory knowledge is the ability to recognize and reflect on the social, cultural and political aspects of a situation and identify what we could have done to prevent it. Jane’s unsafe discharge could have been prevented if at admission a social work consult was put in. Social work could have provided Jane with the services that she’s needed prior to patient being discharged home. As nurse we are patients advocate, so if we feel it is unethical to carry out doctors orders that we feel would not benefit the patient. We should advocate for them. We are the last line of defense for our patients. So as nurses it is our role to ensure patient safety. Its hospitals nature to admit and discharge patient sooner than they should.
A social justice that is evident in this situation is health care and its accessibility. Jane was admitted and was taken care of immediately after her AV fistula failed to function properly. However the medical services that was provided for her so that she may continue living her best life and costing her thousands and she cant afford to keep up with the medical bills that are piling up at home. By her social status, age, and medical condition why isn’t the help of medicare covering the cost of these bills that are pilling up at home. If the patient doesn’t work or is unable to work how is it expected for a patient to cover the cost of the copayments of these visit to the doctors, ER, in Jane’s case dialysis three times a week. Jane had stated her home was dirty, so one can only assume she lives in poor housing, and most likely using the government funds to help pay for rent and buy the bare necessity items for groceries. So whats left of her income may go to transportation to and from dialysis and buying the important prescriptions to help her remain alive. To my knowledge I’m not even sure if Jane had insurance. If she did ambulette services would have already been set up for her return home. A possible solution this nationwide inability to have access to health care is a universal healthcare.