Morton's Multiple Transitions:
Organizational Systems Competency
At the age of 92, Mrs. Morton (not her real name) lived happily in the assisted living wing of a continuing care retirement community. She was nearly blind from macular degeneration and had a medical history that included hypertension, two previous MIs, and two hip replacements due to osteoarthritis. She used a rolling walker for walking.
Mrs. Morton considered her room in assisted living as her home. She had many friends in the retirement community and enjoyed eating in the dining room with different people each evening. She played the piano for monthly sing-alongs and musical programs in the facility. Mrs. Morton was alert and cognitively intact, with occasional difficulty remembering names. She and I talked weekly by telephone.
One Sunday morning, the aide who picked up Mrs. Morton's breakfast tray noticed that she hadn't eaten anything. When she talked with her, the aide discovered that Mrs. Morton was very confused. She thought she was 23 years old. Concerned about this sudden confusion, the aide notified the nurse.
Soon, Mrs. Morton was on her way to the emergency department of a local hospital. That was the first transition between health care settings.
Apparently, little information about Mrs. Morton's previous level of functioning was communicated to the emergency department personnel. No family members lived near her; I lived several thousand miles away. When I reached Mrs. Morton by telephone in the emergency department, she knew who I was and that she was in a "place for emergencies." She insisted that she was not in a hospital.
|A nearby television was broadcasting news of war in Iraq. Mrs. Morton thought that she was in the middle of a war, in an emergency shelter. She was very frightened and seemed to cling to my voice as a source of comfort. Her voice was dusky and her speech was slurred. She drifted in and out of reality multiple times as we talked.|
After she had been in the emergency department for more than 6 hours, the cause of Mrs. Morton's delirium was discovered: severe digitalis toxicity. Mrs. Morton was transferred to the ICU. This was the second transition between health care settings.
The ICU nurses admitted a confused 92-year-old woman with slurred speech who was having cardiac dysrhythmias. They apparently received no information on her level of function prior to hospitalization.
|I telephoned every shift and asked to speak with Mrs. Morton's nurse.||
"Mrs. Morton was mentally alert on Saturday," I said every time. "She is cognitively intact. She is nearly blind but she can see faces if they are within a foot or so of her face. Please turn off the television before the news programs. The war news is frightening her."
In order to facilitate Mrs. Morton's care, I asked her nurses to write these items in her cardex or care plan. I don't know whether or not they did. Only one of the nurses I contacted already knew that Mrs. Morton was nearly blind.
After a day or so, Mrs. Morton was transferred to the telemetry unit: Care setting transition number three. Her confusion was clearing slowly. Her speech was less slurred. She now knew that she was confused and kept asking me questions to clarify what had happened and to explain the stimuli in the room.
|I continued to telephone the nurses.||"She likes classical music," I said. "She is nearly blind. She doesn't watch TV at home. Please ask her if she wants to listen to music instead of just turning on the television."|
I contacted the nurse manager in an attempt to gain some continuity of care that was directed toward returning Mrs. Morton to her prehospitalization level of functioning. However, health care setting transition number four happened the next day. Mrs. Morton was transferred from telemetry to a medical floor.
In spite of my best efforts, the information I kept providing did not seem to travel with Mrs. Morton from unit to unit.
|When I telephoned her new room, the telephone rang and rang and rang.||I telephoned the nurses' station and explained that Mrs. Morton couldn't see, so she probably couldn't find the telephone that was ringing.|
When I called again and her nurse handed Mrs. Morton the telephone, I learned that Mrs. Morton did not understand why she was in this new place in the hospital. "They're not taking good care of me," she said. "They don't check on me as often. I'm just lying here all alone." Although she was still mildly confused and occasionally still misinterpreting environmental stimuli, Mrs. Morton seemed to understand when I explained that she was moved to this new room because she was getting better and didn't need such close monitoring.
I kept telephoning and explaining to the nurses that Mrs. Morton had been cognitively intact and walking independently with her walker before her hospitalization. I reinforced that she could not see them enter the room and asked them to post a sign in her room about her impaired vision. At my urging, the nurses began to speak to Mrs. Morton when they entered the room. One of the nurses was surprised to discover that she could actually carry on a real conversation with Mrs. Morton.
My relentless telephone campaign continued. I urged Mrs. Morton to tell the nurses that she wanted to get up to the commode and to start walking again so her muscles wouldn't get too weak from lack of use. When I reminded her that she needed to be able to walk down two long hallways to reach the dining room back at the retirement community, that did the trick. She asked to get up and walk.
Meanwhile, I kept telling the nurses (always different ones when I telephoned) that Mrs. Morton had been independent with her walker until the day of her hospital admission. The ambulation order was obtained. The nurses brought in a wheeled walker. They were astounded at how quickly Mrs. Morton progressed from the first few assisted steps to walking to the bathroom by herself with the walker. "They keep wanting to help me," said Mrs. Morton. "I keep telling them I'm slow but I do this at home all the time." Mrs. Morton basked in the praise of the nurses, who were finally realizing how physically and cognitively functional this 92-year-old woman could be.
|With her heart finally stabilized, her digitalis level normalized, and her confusion nearly resolved, it was time for care setting transition number five. Mrs. Morton was discharged from the hospital and transferred to the nursing home unit of her retirement community.|
My telephone calls to Mrs. Morton revealed that she was very cold in her room, that she wasn't eating the food because it wasn't the kind of food she liked, and that she was afraid to go out of her room into the hallway because she couldn't see well. She just laid in bed unless she needed the bathroom. Mrs. Morton was becoming depressed.
Mrs. Morton's clothes, except for the nightgown and robe she was wearing when she was taken to the emergency department, were in her closet in assisted living. The assisted living unit was physically located in the same building as the nursing home unit, just one floor above. However, on a systems level, they seemed totally separate. Per policy, Mrs. Morton's room had been locked when she was transferred to the hospital. The nursing home staff did not have authority to access Mrs. Morton's room, even when she asked them to get her a sweater. It was a weekend. The usual assisted living staff were not on duty. None of Mrs. Morton's friends could access her room either. My telephone call to the nursing home unit nurses' station was not effective. It was an impasse.
Since Mrs. Morton was now back in her own retirement community system, I urged her to use her knowledge of that system to meet her needs.
|After we strategized at length over the telephone, Mrs. Morton telephoned the assisted living nurses' station and left a message for a trusted employee who brought her a sweater the next day.|
At my urging, Mrs. Morton requested a dietician consult and soon began receiving the foods that she liked and would eat. I coached her to request a physical therapy consult and soon daily P.T. was helping her regain her previous strength and endurance with walking.
The last, and most smooth, care setting transition in this story was the triumphant return of Mrs. Morton to her own room in assisted living. Mrs. Morton was once again in a familiar environment with care providers who knew her needs. She was greeted with delight by staff and friends. After her recovery, Mrs. Morton made an appointment with the administrator of the retirement community to express her concerns about the problems she had encountered during her stay in the nursing home unit.
This story ends happily.
|Today, at the age of 93, Mrs. Morton continues to play the piano at musical programs and to walk slowly with her walker down the long hallway to enjoy mealtime conversations with her many friends.|
To hear this story narrated by the author, use this audio link.Narrated by L. Felver, Ph.D., R.N.
|Organizational Systems Competency Learning Activities|
|Home page||How to use this website||Subject index||Tools index||Authors and contributors|
|email@example.com||Copyright Linda Felver and Catherine Van Son, 2006, 2011|