1. Applying Ways of Knowing to a Clinical Case<br />Germaine Shannon<br />University of Central Florida<br />I was called to the emergency room by one of the nurses working that night. A patient was being discharged home by the emergency room physician, and the patient’s family had requested to speak to the nursing supervisor. When I arrived to the emergency room, the nurse that was taking care of the patient approached me. She pulled me aside, and voiced her concerns. The patient in bed three was sick with a respiratory infection. He had been given intravenous antibiotic and was now being discharged with a prescription of oral medication. According to the nurse, the patient was weak. The patient’s family was upset because the patient had missed two days of dialysis and they wanted him transferred to a hospital in Miami so he could have his dialysis done and also continue to be treated for his respiratory infection.<br />Before approaching the family, I decided to speak to the physician so I could understand this case better and try to solve the situation in the best way possible. This was the second night that this physician had been working in the emergency room, and my first time meeting her. I told the physician that the family of the patient in bed three had requested to speak to me. The physician review of the situation was as follows: The patient had been in the emergency room earlier in the week and he had been treated for an upper respiratory infection. On that first visit it was also noted that his blood urea nitrogen (BUN) and Creatinine blood levels were elevated. The patient had stated that he had missed his dialysis treatment because he had not been feeling well. On that day, the physician had discharged the patient with a prescription for antibiotic medication and discharge instructions to make sure he didn’t miss his dialysis appointment, scheduled for the following morning. <br />On this second visit to the ER, the patient presented with a higher BUN and Creatinine blood level. The patient’s family told the triage nurse, that the patient had again missed his dialysis treatment. It was also noted that the prescription from the first visit was never filled.<br /> The physician told me that she was going to discharge the patient because the patient had county transportation that picked him up and dropped him off to and from his dialysis. She continued to tell me that it was his “non-compliance” that had him now with a higher BUN and Creatinine blood level and with a worst respiratory infection. He was to be discharged with instructions to go to his dialysis treatment the next morning and fill-up his prescribed medication.<br />Next, I approached the patient’s family. I introduced myself and asked them how I could help. The son proceeded to explain what was happening. “The patient lived home alone, and for the past four or five days he had not been feeling well.” He had been to the emergency room earlier that week, treated and discharged. The patient had missed his dialysis treatments because he felt so weak that he could not get out of bed without help. The county provided transportation services in the form of a taxi. The taxi driver would stop to pick up the patient and beep his horn. However, if the patient was not out of his house in five minutes, the taxi would leave to go pick up the next patient. According to the patient’s son, besides the taxi driver, no other assistance was provided. Because the patient was feeling so weak and sick, he had not been able to get out of the bed, get dressed, and meet his transportation. For that same reason, he had not been able to fill his prescribed medication. The patient’s son told me that he lived in Miami, and had spoken to his dad on the phone and noticed his mental status changes. He had driven down to the Keys to see what was happening. When he arrived to his dad’s house, he noticed his weakness and lethargy and called 911. He had requested to speak to the house supervisor, because the doctor was not receptive to their requests. The patient was too sick to go home. If discharged to go home, he would not be able to care for himself without assistance. The son had requested the physician that his dad be transferred to a hospital in Miami where he could receive dialysis and antibiotic treatment. He would also be able to have family visit him at the hospital and bring him home when he was ready for discharge. The physician had been inflexible and unwilling to facilitate the family’s request. <br />After acknowledging the obvious stress the patient’s family was experiencing I apologized for not meeting their expectations and I proceeded to assess the patient. The patient was lethargic and disoriented. He was able to tell me what his name was but nothing else he mumbled was making much sense. His color was ashen. His lungs were diminished; his oxygen saturation was 92 percent. His temperature was 102 and other vital signs were stable. No urine output had been recorded. No arterial blood gases (ABGs) had been done. I then assessed the patient’s level of strength. The patient moved from side to side with some difficulty while lying in the stretcher. I then asked him if he could sit. He was too weak to do that without someone helping him, making it obvious to me that we could not discharge this patient. <br />I went to speak to the doctor. I voiced my concerns regarding the discharge of this patient and proceeded to explain the living situation of this patient. The physician turned around and told me in a rude tone of voice that she was not going to transfer this patient. She said the patient could go to his dialysis treatment the next day. I realized then that she could not have assessed this patient. Had she done so, she would have noticed the lethargy and disorientation that the patient was displaying. I went back to speak to the nurse, who confirmed to me that the physician had read the medical record from the last hospital visit but not done a thorough examination on the patient. Although the patient’s family spoke English, the patient did not. The physician had not evaluated the patient’s mental status. I went back to speak to the physician and told her this patient was in no condition to go home and I felt she met conditions for transfer. I called the administrator on call to discuss the situation and to ask for approval to transfer the patient. I then called a hospital in Miami and faxed the patient’s entire documentation. The emergency room physician finally agreed to sign the transfer. The patient left that night to a hospital in Miami. The family was thankful for having their concerns addressed.<br />Application of Ways of Knowing in the Solution<br />Empirical knowledge results from experimental, historical, or phenomenological research and is used to justify actions and procedures in practice (Schultz & Meleis, as cited in McEwen & Willis, 2007, p. 15).<br />The application of this knowledge can be observed by my nursing interventions used to evaluate the patient. This was observed when recognizing the signs and symptoms of uremia such as decrease attention span, lethargy, and fatigue. It was also evident when identifying the febrile state of the patient and the current respiratory infection as a high risk for further deterioration. <br />Infections are the major cause of death in patients with acute renal failure and can seriously compromise the patient with chronic renal failure (Alspach, 1991, p. 514). <br />The auscultation and physical assessment of the patient, the observation of oliguria, the absence of ABGs, and the understanding of the guidelines for ER to ER EMTALA transfers were all inclusive in the empirical knowledge of nursing.<br />Esthetic knowledge was demonstrated throughout the nursing-patient/family interaction. The social needs of the patient were identified early on, when the family informed me that the patient lived alone. Recognizing the valid reasons for concerns from the family and offering a sincere apology for what was perceived by the family as rude behavior from the physician, demonstrated empathy from my part, and an awareness of this patient’s unique needs. <br />Personal knowledge could be observed from the initial encounter with the patient and the patient’s family. I approached the situation without preconceptions and conclusions. I have learned from my own experience that things are not always what they appear to be. I have learned that it is important to first listen to all parties, gather data, do any additional investigation, seek advice if needed and chose the best option for the situation. I was able to gain the trust of the patient and the patient’s family possibly due to my sincerity and desire to help. My ethnic and cultural background, along with the knowledge of the Spanish language added to the sense of trust and commitment to nurse-patient/family relationship. <br />The ethical knowledge was applied the moment I became the patient’s advocate. I reviewed the situation and weighed in all the pros and cons of the situation. Following my own values, and the norms and values in our society, I decided to rule in favor of protecting the patient. Discharging a very sick elderly without the ability to care for himself was not acceptable in my mind. Our society entrust us to protect women, elder and children. Advocating for his transfer to a higher level of care was the right thing to do. I also believe the physician was unethical by not doing a thorough assessment of the patient and drawing conclusions based on a note written by a previous physician in another chart, totally contradicting the Hippocratic Oath she promised to keep.<br />As noted in White (1995), sociopolitical knowing:<br />…causes the nurse to question the taken-for-granted assumptions about practice, the profession, and health policies (p. 84).<br /> In addition, White (1995) states that:<br />The sociopolitical context of the persons of the nurse-patient relationship fundamentally concerns cultural identity, for it is in culture that “self” is intrinsically located. This cultural location influences each person’s understanding of health and disease causation, language, identity and connection to the land (p. 84).<br />My awareness on the disparity that exists in healthcare as a result of culture and language, and the impediments that create this inequality in the care that we provide, helped me intervene and advocate for the standard of care that a patient presenting to the emergency room with this conditions should receive. Every patient in the emergency room needs to be assessed by a physician. Inconsistencies in treatment because of a language difference can be overcome by using the appropriate services available in the hospital setting such as a phone translation service available to all 24 hours a day, 365 days a year. Nursing participation in professional organizations continue to advocate for a safe and effective practice.<br />Summary and Conclusions<br />A clinical case scenario was introduced which involved a complexity of issues. My nursing interventions, and the approach used to solving the situation resulted in a positive outcome for the patient involved in this case. Some of the issues that could be easily observed included laboratory results, vital signs, and physical appearance of the patient. What was not obvious and required a deeper analysis had to do with the understanding of the patient’s unique situation regarding his social network, family dynamics, economic and physical limitations, chronic illness, and disabilities. The assessment of the case was also influenced by my personal beliefs, experiences as a nurse, and as a follower of the norms that guide our society. After analyzing the case and the steps taken in the process, I was able to identify the application of the different ways of knowing proposed by Carper and appreciate how nursing epistemology can continue to evolve and improve nursing practice. <br /> <br /> References<br />Alspach, J.G. (1991).American association of critical-care nurses: Core curriculum for critical care nursing (4th ed.).Philadelphia: W.B. Saunders Company.<br />McEwen, M., & Wills, E.M. (2007). Theoretical basis for nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins.<br />White, J. (1995). Patterns of knowing: Review, critique, and update. Advances in Nursing Science, 17, 73-86. Retrieved January 24, 2010, from http://illiad.lib.ucf.ezproxy.lib.ucf.edu. <br />