The new patient controlled analgesia (PCA) pump was to be the answer for all units of the hospital and in fact the entire health network. There was a plan to provide in-service training to all staff, and this promised to aid in the seamless transitions of patients between units. PCA pumps have been noted as having benefits such as a reduction in opioid use, pain reduction and increased patient satisfaction (Dobbins, 2015). In the oncology/palliative care unit the plan was implemented, the training was received, and the staff was ready to use PCA pumps, but a particular frustration began to build with regard to the terminal weans and end-of-life transfers of patients from the ICU unit. These patients continued to have continuous morphine infusions running using a narcotic lock box instead of the use of the PCA pump. This has an impact on patient care, but also on the work environment, creating an atmosphere of distrust and animosity between the units. This perception has interfered with unity in the health care network. Staff typically comments after ICU staff leave regarding their “special treatment”. In particular, it increases the workload of the staff in oncology/palliative care. There are further concerns by staff here that the need to switch from the lock box to the PCA pump can increase risks, as each setting must be reset, increasing opportunities for problems or errors. When making such a transfer, the ICU staff tends to leave quickly, after explaining that they have not been trained in the use of the PCA pump.
This is a conflict which has two levels of impact, that being the quality of patient care and the other being the work environment. These are both critical issues which must be addressed, and consulting with the Human Resources (HR) department is a step towards resolving it. Ideally the senior authority responsible for the oncology/palliative care unit would reach out to their equal in the ICU unit for an informal discussion that aids in understanding why the ICU persists in their practice of using methods other than the PCA pump. Once both parties have a better understanding of the situation of the other, it is likely that consultation with HR can facilitate a response by making that department aware of the situation, the risks and any proposed resolutions. One clear method of resolving the situation is to ensure in-service training for the ICU staff. Ensuring that HR understands this and appropriately prioritizes this may help reduce tensions and increase patient care quality. Another might be for the two units to co-manage a research project or exploration of the situation as a case study, although this would further increase and impact workload.
The use of scripting can assist in directing a difficult conversation in a positive direction, as scripting helps to ensure that key points are made with succinct messaging (Bylund, 2016). The script which was drafted for this situation is intended for use during a specific time, that being during the transfer of patients who require switching from the narcotic lock box to the PCA pump. An example of the script for use by the lead nurses in our department, in discussions with lead nurses in the ICU, might go something like this:
There are some concerns about the transfer of pumps for pain medication for your patients.
It is a difficult situation that the ICU staff has not received in-service training on the use of the pumps.
Our unit would like to better understand the challenges that are faced in the ICU with regard to the administration of pain medication, and we
We are currently discussing different ways to ensure quality of care, and your input would be valuable.
- Bylund, C. L. (2016). Communication Skills Training for Healthcare Providers. The International Encyclopedia of Interpersonal Communication.
- Dobbins, E. H. (2015). Sidestep the perils of PCA in post-op patients. Nursing2015, 45(4), 64-69.
- Westphal, J., Lancaster, R., & Park, D. (2013). Work-arounds observed by fourth-year nursing students. Western journal of nursing research, 0193945913511707.
