Ask me about being a nurse

[PainRack]

I.... Badly need a spot to ventilate and yet reaffirm my choice in a career, that has led me to being so burnt out that I'm now on antidepressants, which cloud my mind and I'm blaming for my new incompetence at work.

So... Ask Me anything you like to know about being a nurse. I don't remember if farogthrax is here but if Knife will like to respond , great! I love to hear how life is on the Western world and in answering questions, I hope to find out why I still struggling in this career.
disclaimer: I'm legally and ethically bound not to reveal details which might identify patients under my care, all I post here is my own interpretation of care and has no official stance related to my hospital which I decline to identify since I'm probably breaking HR policies by even discussing what I do....
I'm not able to provide medical advice over the internet, please seek an accredited healthcare professional in your area instead. Everything I post is my personal view and knowledge and might not be valid....ok...boilerplate out of the way.


Let me start it off with, what does a nurse do? In Singapore, nurses are regulated by the Nurses and midwifery Act, with an addition for Advanced Nurses Practitioners and certification for nurse specialists. The later do advanced clinical work for nurses, from specializing in breast care for cancer patients, wound dressing, stoma care and you can find an APN in virtually all medical fields and specialised surgical settings like orthopedic.

Still, I'm just a humble registered nurse, leading or part of a nursing team comprised of enrolled nurses, healthcare assistants(well, I don't have any) and other staff/registered nurses.

Some roles don't translate well to the American context, but a RN is quite similar in scope.... But not practice. In Singapore, the act of nursing is legally defined as health education/promotion, serving ORAL medicines and acts of nursing such as toileting, bathing and feeding.


It always come as a shock to overseas trained doctors from a stint in Australia or the States when I try to explain to them no, i can't do that. Every act I do is closely proscribed by my hospital authority. I can't give a patient other mouthwashes thats might be required such as Oral7 and Biotene, because those are classified as medical products . If a patient, on my advice buys it and use it, I can help them use it, but I can't document and intergrate that into my care. Everything that's useful to a doctor, well, it's an authority given by my hospital. Taking blood specimens? I'm not a phelebotomist, so, its my hospital saying yes, I can take blood for this patient under my care. This is different compared to a doctor, who legally been allowed to practise his craft at the hospital, provided he show that he's competent. My competency is to allow the hospital to authorise, and be responsible for me taking a pregnancy test, a blood sugar test, giving IV drugs, taking bloodbspecimens and ordering tests to execute a doctor plan. My license only medical practice is that I can give oral meds, hence, my signature is to be submitted to the head of department so that I be one of the authorised list of people to administer meds.
Sometimes, when I make a mistake such as forgetting to top up the chest tube water valve, I feel like claiming in jest that I'm not competent to do that task. In truth, I do things I'm not authorised to do such as group and cross matches, because any doctor knows that An experienced nurse knows better than him how to do a difficult blood draw or has better sterility in handling central lines.we do a fiction where the doctor has verified and is there supervising me doing the GXM, although one doctor once has the..... Tactlessness to claim that he's the nurse there to assist me to do a difficult culture draw from a central line.

Of course, in reality, an experienced staff nurse like myself are the veteran NCO Corp of the army. Despite the inaccuracy of that term, I love to use it because the culture fits. Yes, I'm the nurse helping a doctor explain that his abnormal cells might be cancer but we can't tell yet. I'm the nurse who realises that the patient family, because of the doctor hemhawing has not realised the patient is dying, and helping them to realise it and pay their last respects.
I'm also the nurse who's standing calmly by and telling the dumbfounded, exhausted doctor I have a syringe of adrenaline , would you like to administer it(psssttt. If you don't know the strength of adrenaline in a resuscitation situation, ask the oldest nurse there. Don't be afraid to admit it.) And when you screw up , it's my job to bite the bullet and get the senior registrar in to handle the code, being scolded every single step of the way for every single mistake the doctor made in the code , because I knew where u fucked up and has to tell him to get it resolved and he shot the messenger.

Of course the view of me being a sargaent to a green officer is wrong, because I'm more than just an adjunct to a doctor. A doctor focus is to cure you. My focus is to take CARE of you. It's a difficult line to see but it's all too true. Yes, I'm the sarge who made the CT scan happen on time and recognised when it can't be done . But I'm also the guy responsible for planning your care needs at home.
Multiple myeloma patients admitted with T4 fracture? I make sure u get the brace, know how to wear it, get the doctor to recognise that I need stronger painkillers and a breakthrough dose so that we can walk you, and boy do u need that because you need to get to a dentist, then come back to clinic for your monthly infusion and weekly shots. I know how velcade affects your sensation and appetite, your strength and fatigue, so, I plan in advance so that you can get to the clinic so the doctor can do their magic and cure you.

It's not glamorous. It's dirty even. But some idiot has to do it so the doctor can focus on their magic, while we settle the down to earth details of you being able to withstand cancer treatment.
Orem theory of nursing states. we support, patients who can't do.We rehab,patients who lost function.we recover, patients lost potential.

There's no real magic though... You know you didn't cure him. But in your heart, you hold on to that myth that without you, his journey would had been harder, perhaps too hard to go on.

[Borgholio]

Nurses often get the shit work (literally) here in the States and get none of the recognition for it. They really are the unsung heroes of the medical profession, just like administrative assistants...without whom the rich and powerful corporate CEOs wouldn't be able to find their socks or order pizza.

[Simon_Jester]

PainRack, roughly what proportion of patients prove seriously problematic for you? In terms of behaving improperly, acting in ways prejudicial to their own care, et cetera?

[Soontir C'boath]

If I understand it correctly, doctors cannot tell you what must be done until the hospital gives the approval? It seems to be adding a level of bureaucracy I assume to control costs and litigation?

Is your being burnt due to the scope of work that you are limited to compared to nurses around the world?

[PainRack]

If I understand it correctly, doctors cannot tell you what must be done until the hospital gives the approval? It seems to be adding a level of bureaucracy I assume to control costs and litigation?

Is your being burnt due to the scope of work that you are limited to compared to nurses around the world?

It's more the scope of my license. It's actually a problem similar to many other countries, because from my limited understanding, training and technology has advanced faster than law.
malpractice insurance in the states for example regarding nurses.

The real burden is having to involve the doctor in details where overseas, it's not. A good example will be Australia, where Physical therapists have X-Ray rights .

It's an added burden on my overworked doctors(ahem, lowest doctor ratio to population in 1st world) and yes, it gets me pissed off and overworked because things I need done don't get done.
There was a period when nurses couldn't order tests electronically when my hospital upgraded to electronic records. It. Was. Hell.

Let me put it this way. I once ordered a patient test for 5 straight days on the basis that this was what the doctor needed,if I hadn't done so, the patient would had blood transfusions delayed and/or not received needed blood(I don't think that would had happened because I had a competent doctor rounding, it's just that there were so many details that he forgot to make the order for CBC daily.)

The system in Singapore is frustrating to everyone because despite the changes(2 decades ago, ALL tests had to be filled up by doctors. Hahahahabaha) , it's still heavily doctor centric. There's also the.... Different alarm system. To put it simply, I have to inform the doctor every time a person hypocount is 10 and above because that is out of normal range. It doesn't fucking matter if I know the reason why is because he had a big snack, I have to do so. And the doctors are just as irritated because even without the snack , as long as the person is on meds, it's not a medical emergency unless you talking about > 20 or other clinical signs such as sweating or altered mental state.

[PainRack]

PainRack, roughly what proportion of patients prove seriously problematic for you? In terms of behaving improperly, acting in ways prejudicial to their own care, et cetera?

that's....hard to say. It also depends on a person risk appetite.

Unlike my colleague, I have a larger risk appetite towards fall and I'm more willing to encourage ambulation with very limited supervision, some of my colleagues don't and require strict supervision at all times.

But on a weekly basis, since I'm routinely jinxed, around one patient every 3 weeks will be such. It's not so much inappropriate behaviour as they're not.... Able to. Dementia patients are always problematic, because we can't get them to engage in basic care needs. Pair up with one ill patient and I feel certain that we get a similar NHS Southampton complaint one of these days, despite the fact that my hospital introduced skilled staff( the NHS Southampton audit found that they introduced too much skill dilution. Mine is the opposite).


There's.... Some spectular cases which I can't provide too much details, but a person insisted on following previous medical advice, taking charge of his own insulin injections and wound care, assuming that my wound nurse specialist can take care of his wound....

I could analyze it and say it's a matter of trust and him trying to assert control over his disease and Shit but seriously, deciding how much insulin you needed was crazy. I forcibly confisicated his insulin pen and had several discussions with him in an effort to get him over his denial but we couldn't get him to do what the docs needed and when he was dying, with a amazing doctor who would still go to him every few days to get him to agree to something that might reverse or make him more comfortable at least...... But he blamed us for abandoing him and not treating his needs.

[Fingolfin_Noldor]

The system in Singapore is frustrating to everyone because despite the changes(2 decades ago, ALL tests had to be filled up by doctors. Hahahahabaha) , it's still heavily doctor centric. There's also the.... Different alarm system. To put it simply, I have to inform the doctor every time a person hypocount is 10 and above because that is out of normal range. It doesn't fucking matter if I know the reason why is because he had a big snack, I have to do so. And the doctors are just as irritated because even without the snack , as long as the person is on meds, it's not a medical emergency unless you talking about > 20 or other clinical signs such as sweating or altered mental state.

Isn't this more to do with our tendency to worship titles and hierarchy and the commonly held belief that doctors earn more money (leading to the former problem)?

[salm]

Nurses I know in real life told me that euthanizing people who are in helpless conditions and in great pain is done by nurses. Legally it is considered murder but it is still widely practiced usually by incrasing the dose of whatever sedative is administered to a lethal one or poisoning the patiants by other means.
A couple of years ago several thousand French medical worker came out as having euthanized people in that way before in support of two nurses who were facing 30 years in prison.

Is killing people in this way common practice in Singapur as well and if so is the public aware of this?

[PainRack]

Nurses I know in real life told me that euthanizing people who are in helpless conditions and in great pain is done by nurses. Legally it is considered murder but it is still widely practiced usually by incrasing the dose of whatever sedative is administered to a lethal one or poisoning the patiants by other means.
A couple of years ago several thousand French medical worker came out as having euthanized people in that way before in support of two nurses who were facing 30 years in prison.

Is killing people in this way common practice in Singapur as well and if so is the public aware of this?

That's blatently illegal and not something I respect, if only for the problems this bring in bringing enough pain relief
to patients. There's a stigma towards opoids as it is and my colleagues once avoided me for a whole day after I lost my temper and said I shouldn't have to spend 4 hours running around to get pain relief for a patient. I bloody verified the protocol the next week and got pain team and pall med on my side to reinforce p

It's also easy to track if your insitutions want to.

Ultimately, this is a legal policy and it's wrong to take that decision into our hands. There are grey areas where we chose not to extend a person life(reversible vs irreversible) or where the sedative effect masks a reversible sign , causing a doctor to pronounce it as irreversible but otherwise....

That viewpoint is toxic towards pain management and one of my pet peeves with my colleagues, who refuse to initiate pain relief for fear of ending someone life. The difference between seeing someone crunched up in pain and being able to speak to relatives or even just to enjoy a peaceful rest is a huge one....
That's not to say mistakes aren't made, I lost count of how many times I had to do naloxone reversal by now. 8 perhaps? In my defence, only 3 were linked to my administration but my aggressive approach is probably linked to why I racked up such a high score

[PainRack]

The system in Singapore is frustrating to everyone because despite the changes(2 decades ago, ALL tests had to be filled up by doctors. Hahahahabaha) , it's still heavily doctor centric. There's also the.... Different alarm system. To put it simply, I have to inform the doctor every time a person hypocount is 10 and above because that is out of normal range. It doesn't fucking matter if I know the reason why is because he had a big snack, I have to do so. And the doctors are just as irritated because even without the snack , as long as the person is on meds, it's not a medical emergency unless you talking about > 20 or other clinical signs such as sweating or altered mental state.

Isn't this more to do with our tendency to worship titles and hierarchy and the commonly held belief that doctors earn more money (leading to the former problem)?

Oddly enough, not really. It's a holdover from when that's how nursing was done, during colonial days and WW2.

I did enter the career when this mentality started dying away and by the time I was graduated, only diehards adhered to this. My CEO went forth and spoke to a enrolled nurse friend of mine during a gathering of some sort and ditto to my head or director of nursing.

However, the attitude still holds true in private hospitals, because the hospital needs to hold their star doctors for enrollment of patients.

Shrugs. One reason why I never head there. It's nice to hear a consultant complain to me and say :Eugene, if you know I made a mistake, just tell me and stop wishy washing your way can?

The VVIP attitude however still hold true. Shrugs, that's a Singaporean culture...

[PainRack]

Nurses often get the shit work (literally) here in the States and get none of the recognition for it. They really are the unsung heroes of the medical profession, just like administrative assistants...without whom the rich and powerful corporate CEOs wouldn't be able to find their socks or order pizza.

what... I sincerely dislike is how my efforts aren't tracked by my boss, be it nursing or medical. My immediate colleagues , be it doctors or nurses know I'm intelligent and contribute a lot. I'm flawed but so is everyone, the fact that I know a little more than my immediate peers however makes me..... Severely overworked.

Just three days ago, I stopped nuclear med from conducting a pointless PET CT, because I need to give glucose to correct my patient hypoglycemia. A PET scan for staging of cancer gives a high dose glucose injection tagged with radioactive agent, so areas with high metabolic activity, aka cancer can be detected. We starve the body of sugar so your cells will readily pick up the radioactive glucose..... Nuclear med didn't realise my patient was hypo in the first place and afterwards.... Suffice to say I needed to demand ttospeak to their radiologists before I could get them to delay the test to another date .

I saved the patient 900 dollars and prevented an errorneous staging of cancer...... This would not be reflected in my accomplishments . This would not even survive into my performance appraisal, because that column there? It's a hack job meant to say I prevented certain mistakes like med errors because .....

What I did was supposed to be routine. I never felt that way because if so, why is it that I'm always the only one to realise such a problem?
I stopped an errorneous test from being carried out months ago, bactracked and found that said mistake was done 3 times to 3 separate patients.
I saved a patient from being starved to death because nobody realised one meal a day for NGT feeding was inadequate. worse, I got condemned for it because I supposedly broke safety by feeding my patients.... Because idiots didn't realise that NGT can be inserted for supplemental feeds and didn't question what increase oral intake meant.

I'm constantly told that it's a team effort, so, why is it that I'm the one telling the doctor patients don't want chemo or you calculated the wrong dose(because u took earlier weight).... I told my nurse clinician after my review because of me being placed on antidepressants that for a certain patient, despite me going for my military reservist commitment, I did everything for said patient save giving the chemo(I did the teaching) and booking the ambulance and giving the family discharge paperwork. every other complex step, from caregiver training to silver fund application for wheelchair, review by PT, hell, even informing the doctors that patient family didn't want chemotherapy when the team was held in stasis because awaiting decision because no other nurse asked, or application held in limbo, or my personal fav. Someone actually followed my instructions and did something. when I followed up,doctor said nobody told me and application not done and after my review, wasn't needed.....

Said patient was under hospital care for 6-7 weeks. Even placing him on pressure ulcer monitoring wasbinitated by me....

I know I can make a difference because i just saw one of my first patient in clinic.... He was the First complex patient where I stepped out from the shadow of my seniors and took over his care(I'm still baffled at WHY I was targeted for his care ) ... I prevented a neurovascular patient with cancer, one sided weakness, infection, a hole in his throat from succumbing to pressure ulcer, severe loss of weight and trained him back to being able to walk, dress and feed himself. I can hear stories from doctors or others about prawns, or my clinician saying how she surprised gentleman only had one fall and no ulcers, how he steadily recovered.....
Seeing him alive was a morale booster, because it meant that even for palliation, when we can't cure, we can still give life...and a nurse could make said life enjoyable because I returned so much to him with the help of my friends.

One person can make a change.... Just wish it didn't have to be me so many times or how I have to argue with people to get it done...

[salm]

That's blatently illegal and not something I respect, if only for the problems this bring in bringing enough pain relief
to patients. There's a stigma towards opoids as it is and my colleagues once avoided me for a whole day after I lost my temper and said I shouldn't have to spend 4 hours running around to get pain relief for a patient. I bloody verified the protocol the next week and got pain team and pall med on my side to reinforce p

It's also easy to track if your insitutions want to.

Ultimately, this is a legal policy and it's wrong to take that decision into our hands. There are grey areas where we chose not to extend a person life(reversible vs irreversible) or where the sedative effect masks a reversible sign , causing a doctor to pronounce it as irreversible but otherwise....

That viewpoint is toxic towards pain management and one of my pet peeves with my colleagues, who refuse to initiate pain relief for fear of ending someone life. The difference between seeing someone crunched up in pain and being able to speak to relatives or even just to enjoy a peaceful rest is a huge one....
That's not to say mistakes aren't made, I lost count of how many times I had to do naloxone reversal by now. 8 perhaps? In my defence, only 3 were linked to my administration but my aggressive approach is probably linked to why I racked up such a high score

Thank you for your insight.
Can you say if it is common in Singapur, though and if it is, is the public aware of it?

[PainRack]

That's blatently illegal and not something I respect, if only for the problems this bring in bringing enough pain relief
to patients. There's a stigma towards opoids as it is and my colleagues once avoided me for a whole day after I lost my temper and said I shouldn't have to spend 4 hours running around to get pain relief for a patient. I bloody verified the protocol the next week and got pain team and pall med on my side to reinforce p

It's also easy to track if your insitutions want to.

Ultimately, this is a legal policy and it's wrong to take that decision into our hands. There are grey areas where we chose not to extend a person life(reversible vs irreversible) or where the sedative effect masks a reversible sign , causing a doctor to pronounce it as irreversible but otherwise....

That viewpoint is toxic towards pain management and one of my pet peeves with my colleagues, who refuse to initiate pain relief for fear of ending someone life. The difference between seeing someone crunched up in pain and being able to speak to relatives or even just to enjoy a peaceful rest is a huge one....
That's not to say mistakes aren't made, I lost count of how many times I had to do naloxone reversal by now. 8 perhaps? In my defence, only 3 were linked to my administration but my aggressive approach is probably linked to why I racked up such a high score

Thank you for your insight.
Can you say if it is common in Singapur, though and if it is, is the public aware of it?

I don't think so.
most of the hospices here are religious run and Dover park Hospice nursing director is..... Too optimistic to endorse such a culture. For nursing homes, doubt they have the ability to do it given they don't have said drugs.

[madd0ct0r]

painrack, when did you last have a holiday?

I ask cos it seems like you are getting swallowed up in the day to day details when anyone looking at the situation from the outside can tell you're doing a hell of a good job. the world is a better place by your actions.

[PainRack]

painrack, when did you last have a holiday?

I ask cos it seems like you are getting swallowed up in the day to day details when anyone looking at the situation from the outside can tell you're doing a hell of a good job. the world is a better place by your actions.

Define a holiday:D

I got my own me time, but nothing spectular recently. Family burden so as to speak....... Next break coming up again in 2 weeks time, this time, screw it and just heading for a cruise resort if need be....

As for good job...... that's one of my peeves. My CV sucks and I'm honestly not that good. Its just that the areas where I'm good at happens to be areas where my immediate peers are weak in.

[biostem]

One thing I always wondered about is what can a nurse do to compel/force an uncooperative or dangerous patient to, well, behave? What if a patient has some degree of dementia or other issues where they may see hospital staff as a threat? What about less hostile situations, like if a person doesn't want to eat or makes inappropriate comments toward hospital staff, (not just sexual, but also possibly racial, etc)? What about situations where a person is very religious, and wants to partake in ritual that they may not be able to do, due to being hooked up to an IV, machines, etc?

A friend of mine from years ago had to drop out of a nursing program because she wasn't up to having to assert herself toward uncooperative patients, so this was always something I wanted to learn about.

[Alyeska]

I don't have any questions to ask. Instead I want to say that I have great respect for the profession. I have been hospitalized several times. The nursing and support staff was critical to my well being and they were always taking care of me. My last hospitalization there were nurses in training that were involved in my recovery.

When you are hospitalized or in for a procedure you are often at your most vulnerable. You don't always have friends and family to help you along. The nurse isn't just taking care of medicine, they are also taking care of the fundamental well being of the patient. I have had several doctors that were indifferent. But every nurse has been very concerned with how I was doing.

In 2013 my Crohn's disease took a significant turn for the worse. I was hospitalized for almost two weeks and had three surgeries. I was helpless and very sick. And the nurses were there taking care of me. I had to have an NG tube put up my nose and down my throat. It was the worst experience of my life. And the nurse having to do this to me was doing everything in her power to make me as comfortable as possible.

Or when I had a local incision in 2008 while still being awake. The nurse was simply holding my hand.

PainRack, your work is not unappreciated.

[PainRack]

One thing I always wondered about is what can a nurse do to compel/force an uncooperative or dangerous patient to, well, behave? What if a patient has some degree of dementia or other issues where they may see hospital staff as a threat? What about less hostile situations, like if a person doesn't want to eat or makes inappropriate comments toward hospital staff, (not just sexual, but also possibly racial, etc)? What about situations where a person is very religious, and wants to partake in ritual that they may not be able to do, due to being hooked up to an IV, machines, etc?

A friend of mine from years ago had to drop out of a nursing program because she wasn't up to having to assert herself toward uncooperative patients, so this was always something I wanted to learn about.

Ah.......... that's not pleasant.........

For dementia, what we're supposed to do involves orientating the person to time, place and situation per shift. You could get some additional help by
Eventually, you have to resort to some form of restraint or sedation for people who might hurt or endanger themselves/others. These range from the basic, such as hand mittens to prevent them from yanking out tubes to the full body/vest and hand restraints to bed thing...... Ironically, I once complained to a doctor that despite his assumptions, we badly need to alleviate the workload on the floor by some measure or another, because these things just make it safer, but you have to spend a shit load of time and paperwork to take care of the person needs from diapers to even simple stuff such as drinking and we weren't able to do anything like that and were finding it extremely difficult to even include the basic feeding of said person. Sadly, he still said we couldn't justify the transfer of said person to another department or his discharge and we both knew there was no way in hell we could reduce the medical demands of the other patients.

For the less, that's where a thick skin, a good sense of direction and situational awareness and black humour comes in. The guy who kept mumbling fucking vagina to me, I pointed out to him that I have a penis, not a vagina. Ditto to the guy who kept screaming fat bastard at me, you still got to look out for him and his needs. Threats is not a problem here and for violence, you can usually tell the cue.... although I once had no choice but to get close and get whacked anyway because............

For others, that's what hospital security is for.


Religion........ we actually do try to be very accommodating towards that. I'm helped by changing norms but in the past, even burning of joss paper was arranged for, usually by shifting the person to a special room but only for very special situations. The weird stuff comes when you have people asking for the joss paper to be mixed into the IVs but according to my lecturer, they just have to hold firm and say no to that and simply ignore any criticism. Essentially, you can do anything you want, no matter how disruptive and we try to accommodate it, as long as you don't severely risk the person life doing it.(such as requesting home leave to go to a temple when you're critically ill.)

Now. You wanna hear the hilarious. According to a nurse educator, early in her career, a lady once went hysterical when viewing her dead parent and proceeded to hijack the corpse, insisting that she was alive and tried to carry her away to another hospital. Cue benny hill music and a gaggle of people chasing her down through the entire hospital with her screaming things like she's not dead on the top of her voice.




I...... never had something like that happen before. What's really funky is when you get very eerie scenarios. I had this patient who asked me to get the Indian, long dark haired girl standing BEHIND me to stop staring at him while I give him an injection that requires me standing there for a few minutes.......... AT the start of the injection at midnight......... I never switched off the lights after that. Or how the bed call lights up after a patient passed away at night, or the next patient occupying that bed complaining about how the room felt cold and eerie.

Or just the freaky, when you have a person bleeding blood from the eyes and gums proclaiming to you that he's god and that we're trying to imprison him for his godly powers. I had no fucking idea how to tackle him to the bed and frankly, its fucking freaky when you're talking to a person like that.

[Knife]

Nurses I know in real life told me that euthanizing people who are in helpless conditions and in great pain is done by nurses. Legally it is considered murder but it is still widely practiced usually by incrasing the dose of whatever sedative is administered to a lethal one or poisoning the patiants by other means.
A couple of years ago several thousand French medical worker came out as having euthanized people in that way before in support of two nurses who were facing 30 years in prison.

Is killing people in this way common practice in Singapur as well and if so is the public aware of this?

I worked hospice for two and a half years. Nurses don't kill people. Some people are dieing and sometimes, in that state, have end of life anxiety and restlessness (along with pain) and they physically and mentally hunker down into a tight ball prolonging their suffering. A good hospice nurse will medicate the anxiety and restlessness, as well as the pain, and allow the patient to relax and let nature take it's course.

Painrack, I guess my response is it depends on what area of nursing you are in. I recently swapped to a more acute setting, acute rehab, and while it is way different, I find it fun. It's more a med floor vibe than hospice. Anyway, burn out is always an issue. It's the nurses trap. You are there because you care, and patients and facilities take advantage of that and you work more with less because you care.

In the US, my license gives me the authority to provide various procedures but most of which only with a doctor's order. So, I have more leeway, it seems, in what I can do, as long as the MD writes it on something. However, like you, some of the time and when the RN is experienced or the MD just might not be aware or care, it's a simple matter to 'recommend' xyz gets done if you would be kind enough to write me that order doctor. That said, sometimes with a tricky situation, I really want that MD there too.

[Knife]

One thing I always wondered about is what can a nurse do to compel/force an uncooperative or dangerous patient to, well, behave?

One of the biggest jobs RN's have is education. We have to break down what the doc says into easy to relate bits of info. When patients are listening to doc's they tend to glaze over but don't really push the doc's to slow down or make sense 'layman wise'. So it's up to the RN to interpret. It is also our job to reinforce that info when the patient wavers. That said, a patient has the RIGHT to refuse medical services or procedures, so there does come a point where you say "OK, if you don't want it, you don't want it." It's called Against Medical Advise (AMA) and usually at that point the person is discharged from the facility or service.

What if a patient has some degree of dementia or other issues where they may see hospital staff as a threat? What about less hostile situations, like if a person doesn't want to eat or makes inappropriate comments toward hospital staff, (not just sexual, but also possibly racial, etc)? What about situations where a person is very religious, and wants to partake in ritual that they may not be able to do, due to being hooked up to an IV, machines, etc?

This one is a matter or training and experience. When you work with dementia patients you get the feel for when they are being combative, lost inside themselves, or just confused. Usually you divert them onto something else and/or wait for them to forget the current issue at hand and continue with cares. Again, being careful not to cross the line into making them do something they don't want to do. Not wanting a bite of oatmeal for 5 seconds while they stare at the wall until they forget the wall and eat their oatmeal is different than forcing oatmeal down them when they hate oatmeal.

A friend of mine from years ago had to drop out of a nursing program because she wasn't up to having to assert herself toward uncooperative patients, so this was always something I wanted to learn about.

What can I say, it happens. You can give them all the help, support, and education but at the end of the day you can't make them do the RIGHT thing. Granted, that is sometimes a matter of opinion, what is right versus not right, but often there really is a right and wrong in a lot of care. You can't make the 400lbs diabetic with various stage IV pressure ulcers and neuropathies stop eating MacDonald every day. It's frustrating but sometimes, at least I do, you have to sit back and say 'Fuck em' and let them do as they wish and while you don't wash your hands of them while they are under your care, you certainly don't push as hard or invest yourself into it as hard as someone who genuinely wants to get better or genuinely wants your help.

It's human nature.