Dear Family Members

[TheCommuter]

Forewarning: this is an open letter that contains explicit material with which not everyone will find agreeable. However, these are my inner thoughts.

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Dear family members and visitors,

Let me start by saying that I know you care very deeply about the loved one who is laying in that bed. Each patient is a living, breathing, pulsating individual with memories, emotions, thoughts, perspectives and experiences that are far too unique to be exactly the same as any other person on the face of this planet. If you didn't care, in all likelihood you wouldn't be here to visit.

If you have been respectful in all interactions with nursing staff, I truly appreciate it from the bottom of my heart. On occasion you may observe something or hear statements that confuse you or cause some anxiety, so thank you for asking us questions to clarify instead of immediately taking a defensive stance. We are here to help people. We are not here to hurt people. Not only are we here for the patient, but we are also here to support you during this rough time.

I'm assured that I'm speaking for the vast majority of nurses when I say that we do not set out to abuse, neglect, ignore, or otherwise mistreat patients. Again, we are here to help the patient. I really detest when you camp out in the patient's room for 24 hours a day, snap pictures with your cell phone, and use profane language when communicating with staff. Not to be mean, but if you think you can provide a higher level of care, you are free to take the patient home. You would not be able to camp out at a library, curse out the librarian, get in her face, and take pictures for very long. You would be stopped in your tracks if you tried to waltz into a sandwich shop, swear and curse at the workers because you feel the service is crappy, and take cell phone pictures of the equipment and people. Why, then, do you feel it is okay to act like a fool at a healthcare facility?

My last question was silly because I already know the answer. You know that management at many hospitals, nursing homes, and other types of healthcare facilities adopt the 'customer is always right' mantra and will coddle to you, even if you misbehave. You know this, so you take advantage. Whatever happened to treating people in a way you would want to be treated?

I have been in your shoes because I have had gravely ill loved ones who once occupied that hospital bed. My mother was in a hepatic coma for nine days in 2002 while desperately awaiting a liver transplantation because a new liver was the only thing that would save her life. My father had a nasty bout of pneumonia in 2009 and required intravenous antibiotics. Not once did I become belligerent toward nursing staff. Some would say, "You're a nurse, so you weren't as scared as other family members." I was a factory worker back in 2002, not a nurse, and it was frightening to see my mother unresponsive. However, I always respected the healthcare team.

This plea is intended for the difficult, disrespectful family members out there. Keep in mind that you attract more flies with honey than with vinegar. Be aware that while the squeaky wheel gets the grease, it is not right to displace your anger. Nurses are working under increased pressure in this day and age and must do more with less, although administration forbids us from telling you this. Mutual respect and shared understanding go a long way during this trying time of illness. We know you love the person who lays in that bed and we'll be here for you. Just meet us halfway, please.

[itsnowornever, BSN, RN]

I'd like to add the poor mothers who are wailing in pain who have their own mothers berating them! "No, you don't need an epidural! I did it, your sisters did it, don't be a p**** just suck it up" or the ignorant baby-daddies who say "if you get that your cheating!" Or the one I wanted to haul off and punch....post-epidural the lady was having very nice contractions and finally moving along , after the delivery dad said "almost made it, but you had to wimp out." OMG can we add this to the "you are horrible" list?!?!?!?

[FurBabyMom, MSN, RN]

Lol... I don't have so much of this drama anymore. Cause I work in a procedure area. But yeah, there were some good stories of this variety from my time as a neuro med surg nurse.

[Piggles]

I had this weird experience during the break between my first and second semester of nursing school where I was the rude family member. It felt surreal, like I was out of control of myself. I felt terrible about it and promised myself that I would remember how I felt and the way it happened so that I can be more empathetic when I am in that nurses shoes in the future. My mom was in the process of dying from liver failure. It was the most gnarly thing I've seen before or since and I think I was just not capable of even simple social considerations.

[SleeepyRN]

Thank you for sharing this. My most challenging situations are with family members, and many times, internally, I became angry with them and have even become avoidant of patient's rooms when family is present. Your words rang so true when you said you weren't capable of simple social considerations. Thank you for that reminder.

[monkeybug]

Your article is well-written and I agree with the sentiment with one exception. I have to say that I disagree with the idea that the bulk of these visitors are visiting because they love the person in the bed. I know this is cynical but I honestly have come to feel that many of the visitors are really here for one of two reasons: a) they love a good drama and this one is no exception or b) they are curious about the ER world they saw on tv and want to stop by to check the scene out.

LIKE LIKE LIKE! I totally agree with this statement. So many times when I was at the hospital with a laboring patient, the room would turn into party central with everyone ignoring the poor laboring woman, who usually just wanted a rest. I really miss locked units!

[monkeybug]

I'd like to add the poor mothers who are wailing in pain who have their own mothers berating them! "No, you don't need an epidural! I did it, your sisters did it, don't be a p**** just suck it up" or the ignorant baby-daddies who say "if you get that your cheating!" Or the one I wanted to haul off and punch....post-epidural the lady was having very nice contractions and finally moving along , after the delivery dad said "almost made it, but you had to wimp out." OMG can we add this to the "you are horrible" list?!?!?!?

And don't forget the mothers that tell their daughters that they cannot have an epidural because mother wants her to endure the pain so she won't get pregnant again. In our state if you are 14 and pregnant you can consent for yourself, but not if mama is telling you that if you get an epidural you will find all your things on the lawn when you get home (true story).

[redhead_NURSE98!, ADN, BSN]

And don't forget the mothers that tell their daughters that they cannot have an epidural because mother wants her to endure the pain so she won't get pregnant again. In our state if you are 14 and pregnant you can consent for yourself, but not if mama is telling you that if you get an epidural you will find all your things on the lawn when you get home (true story).

Hey well, their awesome parenting didn't keep their kid from getting pregnant, I'm sure the pain of labor will do the trick!!

[redhead_NURSE98!, ADN, BSN]

Thank you for sharing this. My most challenging situations are with family members, and many times, internally, I became angry with them and have even become avoidant of patient's rooms when family is present. Your words rang so true when you said you weren't capable of simple social considerations. Thank you for that reminder.

I haven't been a nurse long enough to be jaded by family members but I still am. They are very taxing on your time. I can't think of a diplomatic way to tell them that if I didn't have to argue with them for 20 minutes at a time maybe I would have more time to care for their family member and my other patients.

Highlights of this week were arguing with a daughter in law (in law's are the WORST) of a pt in for stroke workup about 1) NPO pending swallow study:

"She's already HAD all those tests, she can swallow just fine."

"Ma'am unless that was in the last 24 hours we won't be feeding her until we have our speech therapist in to test her again."

"AM I GONNA HAVE TO CALL THE DOCTOR TO GET HER SOME FOOD? SHE NEEDS NOURISHMENT, SHE HASN'T EATEN FOR 4 DAYS!"

"She's been here for 6 hours, so I can only control the last 6 hours. But I can call the doc-"

[doctor steps into the room from hallway] "Ma'am I thought I explained all of this to you. Is there something I said or that the nurse said that you don't understand?" (this is the first time this doc has ever backed me up for anything!)

2) same daughter in law tells her mother "Don't you feel better with that oxygen on? Why is it so far down there, we need to turn it up so she can breathe even better."

"Doesn't she have a history of COPD? Not a good idea. (explain why)"

"Yeah well whatever."

I suspect Ms. Know It All probably turned it up at the nursing home and caused the low sats and confusion that we're blaming on a stroke. Oh, all of this while pt has documents of DNR-comfort care, and they refused stroke workup, which was the only reason she was transferred to us from small town crappy hospital. I tried to get out of them why she was even taken to the hospital in the first place but couldn't seem to get two sentences out of them without more kvetching about how none of us know how to do our jobs. (Woman is a teacher - we all know they know everything about everything.)

I got a good lol because she stayed overnight with the pt and apparently none of our fabulous night shift told the woman that the chair was a hide a bed, she laid all curled up in it, I found out the next day. LMAO

Second was 30 minutes of the last hr of my shift last night with a son accusing us of "giving his mother something," saying she is confused and "she's never like this." Even when being admitted to the hospital. I busted out the chart: "EMS report: family says pt hallucinating, seeing things." "History of dementia." "Admitted for UTI-confusion." Also had the satisfaction (thank god) that not only had we not given her anything but her home meds which weren't anything horrible, but we didn't even have Ativan or anything AVAILABLE ON THE MAR to give her! "My brother said you just gave her something!" "Yeah, a Lasix, which I told them and explained when I was giving it. It's a "water pill" that she takes daily at home according to whoever filled out the home medication list. Not sedating. Not confusing." ARGHHHHHHHHHHHHHH

[Anna Flaxis, BSN, RN]

I agree with your sentiment, Commuter. It never ceases to amaze me how people can think that behaving rudely or aggressively toward health care staff is okay. I think it's a sign of a decaying civilization.

Poor behavior is not necessarily relegated to health care settings. Just last night, my spouse and I went to the movies. We were very pleased that when we arrived, the theater was practically empty. A large group chose the seats *directly* behind us, even though there was an entire theater to choose from. They whispered and giggled, opened soda cans that they had brought from home, crinkled food wrappers noisily, smacked their lips and chewed with mouths open, and the guy behind and to the left of me propped his feet up on the seat next to me (he also was sniffling and coughing, had obviously chosen to go to a potentially crowded space with an infectious condition*, one of my pet peeves), all through the entire movie. It was difficult to tune them out as they were directly behind us, plus I had a migraine coming on. It made me wonder, are these people just completely oblivious to how their behavior impacts others around them, or do they just not care?

Having said this, I think that when you're caring for a patient, you're also caring for their family members to a certain extent. It is one of the most difficult aspects of nursing care. The person in the bed is part of a family system, and you cannot completely separate them from that. Keeping family members informed and involving them in the plan of care is an important piece of nursing care for each patient. When the family behaves badly, it can be really difficult to do this. I have a couple of strategies for dealing with difficult families that have helped me many times.

One strategy is the "play dumb" strategy. When a patient or family member says something with "that" tone of voice (i.e. "How would you like it if someone was playing with YOUR heart???" or "You think it would be LESS traumatic for him to go to the ER for a blood transfusion?") just get a puzzled look on your face and say "I'm sorry???" as if you don't understand what they mean, and that you don't get that they're being a jerk. This gives them the opportunity to re-think their behavior and either back down, or rephrase their concern in a more respectful way. This allows them to A) realize they are being a jerk and choose to save face and stop being a jerk, or to B) continue to be a jerk. Reasonable people who are just under stress usually pick A. People who are jerks at baseline will usually choose B.

The second strategy is the "nip it in the bud" strategy. You just KNOW when certain families are going to be difficult. It's a sort of radar that nurses develop. Unless the patient is in distress and needs immediate intervention, introduce yourself to the group first. Look each of them in the eye, be pleasant, smile, etc. Address the issues you KNOW they're going to bring up before they have a chance to. For instance, you just KNOW that they're going to challenge you about pain control at some point in the shift. Establish the plan of care for pain control NOW, before it comes up on their radar. Beat them to the punch. Explain the plan of care, what interventions you will be able to do and when, and talk about the "whys" of it. At the end, ask "Does that sound reasonable?" (this is very important; you're involving them and getting their buy-in). Ask if anyone has any questions. Once the family has been addressed, then do your assessment. If pain control comes up during the shift, you can then say something like "Remember we talked about this earlier, and we agreed on x, y, and z?." If that doesn't satisfy them, you can then say "Okay, if we need to change the plan, let's talk about that. I'm in the middle of something right now, but I'll come in in a little while and talk about it with you." Delaying the discussion gives you the opportunity to mentally prepare yourself to deal with these people in a calm manner and to be in control of the room when you walk in, rather than walking into the room and getting caught off-balance so that you're not in control of the interaction.

Some people who are just jerks or who have zero coping skills aren't going to respond to these strategies, but they are worth a try!

*These are the idiots who are going to spread the pandemic plague that wipes out the entire human population.

[CountryMomma, ASN, RN]

I'm on both sides of the line.

I have been that family member. I have berated a nurse, and a NAP, because they, in my eyes, were quite derelict in their duties to the point that I was caring for my father while he was still in the hospital. There is no reason I should have to empty my father's urinals, TWO FULL URINALS, that are sitting in plain view on his nightstand. There is no reason he should still be covered in coal dust three days after admission to the cardiac floor. There is no reason he should still have coal-dust covered sheets on his bed. These things are not just slight mishaps. When I have been asking to have him sponge-bathed, to have his sheets changed, for two days after admission, the time for diplomacy has passed and I will break out the bad language and threats if it means he is treated like a human being. It is not always the family's fault alone. Stress, fear, anxiety, all lower our reasoning and inhibitions.

I've cursed at a nurse while in labor. I've done controlled screaming to deal with pain. I asked nicely to begin with, that they cease doing a non-required task that was distracting me. I've asked nicely if they could please stop forcing me back to the bed for no reason other than their own comfort. Once a nurse, or any HCP, places their convenience or preference over the client's, all bets are off. I suspect many people lash out because they are terrified, in pain, and feel reduced to another sheet of paper, another annoyance. When I can come to them as a nurse with care and compassion, open and understanding about their unique being, ears listen and mouths still.

And, as a CNA, I have had family accuse me of stealing, berate me for not having knick-knacks just so, lambast me for not going against facility policy, and degrade my coworkers while expecting me to agree. I worked very hard to cultivate a feeling of understanding, that there are many reasons a person may do what they do, and most of them do not involve me directly.

Water off a duck's bottom and all that.

My goal is to not see family as hindrance or annoyance, as an obstacle. I truly hope that my outreach to them will engender like behavior, or at least deflect their negativity. I wish to be the change I wish to see in the world.

[Anna Flaxis, BSN, RN]

I'm on both sides of the line.

I have been that family member. I have berated a nurse, and a NAP, because they, in my eyes, were quite derelict in their duties to the point that I was caring for my father while he was still in the hospital. There is no reason I should have to empty my father's urinals, TWO FULL URINALS, that are sitting in plain view on his nightstand. There is no reason he should still be covered in coal dust three days after admission to the cardiac floor. There is no reason he should still have coal-dust covered sheets on his bed. These things are not just slight mishaps. When I have been asking to have him sponge-bathed, to have his sheets changed, for two days after admission, the time for diplomacy has passed and I will break out the bad language and threats if it means he is treated like a human being. It is not always the family's fault alone. Stress, fear, anxiety, all lower our reasoning and inhibitions.

While I'm in no way excusing your father's care, I just want to play Devil's Advocate a bit here. The things you describe are symptomatic of staffing practices that directly impact the quality of patient care. When the nurses and aides are stretched too thin, some things fall by the wayside. When documentation requirements are so cumbersome that you spend more time charting than at the bedside, when you're asked to take on more patients and sicker patients with less resources, some things fall by the wayside.

As the RN responsible for a group of patients on the floor, there are many things that supersede emptying a urinal or doing a bedbath and linen change. I'm sure you understand this. This is why we have aides to delegate these things to. However, the aides can also be stretched too thin, to the point where patient care falls through the cracks and basic things like oral care aren't even being done.

I know, your father's situation was different. You know for a fact that that nurse and NAP (I am not familiar with this term, so I'm assuming it's an aide) weren't busy, they were just being lazy. You saw them sitting around texting/Facebooking/talking on the phone with their friends while call lights were going off. That's not what I'm talking about.

Imagine instead that the nurse and NAP are running their tails off just to keep everyone safe and alive, and simply did not have the time to empty a urinal or do a bath and linen change. Neither of them took a break or used the bathroom all shift. Then the next shift comes on and it's the same thing. Pretty soon, several shifts have gone by and these things still have not been done because nobody has the time. Berating the poor nurse who happens to be present when you finally lose your temper just seems a bit unfair, don't you think?

Generally, I find that when people are angry, they are angry at the system or the institution itself, but the nurse is the face of that system or institution, and so people take out their anger on the nurse.

A solution to the kind of situation your father was in would be for the hospital to have bath aides on day shift, whose sole function is to bathe and do linen changes, freeing the other aides up to do everything else. But in this day and age, hospitals are cutting aide positions, not adding them, so I think it's probably going to get worse before it gets better.

Want to improve patient satisfaction scores? Hire more staff!!!!!

[mc3, ASN, RN]

Forewarning: this is an open letter that contains explicit material with which not everyone will find agreeable. However, these are my inner thoughts.

Dear family members and visitors,

Let me start by saying that I know you care very deeply about the loved one who is laying in that bed. Each patient is a living, breathing, pulsating individual with memories, emotions, thoughts, perspectives and experiences that are far too unique to be exactly the same as any other person on the face of this planet. If you didn't care, in all likelihood you wouldn't be here to visit.

If you have been respectful in all interactions with nursing staff, I truly appreciate it from the bottom of my heart. On occasion you may observe something or hear statements that confuse you or cause some anxiety, so thank you for asking us questions to clarify instead of immediately taking a defensive stance. We are here to help people. We are not here to hurt people. Not only are we here for the patient, but we are also here to support you during this rough time.

I'm assured that I'm speaking for the vast majority of nurses when I say that we do not set out to abuse, neglect, ignore, or otherwise mistreat patients. Again, we are here to help the patient. I really detest when you camp out in the patient's room for 24 hours a day, snap pictures with your cell phone, and use profane language when communicating with staff. Not to be mean, but if you think you can provide a higher level of care, you are free to take the patient home. You would not be able to camp out at a library, curse out the librarian, get in her face, and take pictures for very long. You would be stopped in your tracks if you tried to waltz into a sandwich shop, swear and curse at the workers because you feel the service is crappy, and take cell phone pictures of the equipment and people. Why, then, do you feel it is okay to act like a fool at a healthcare facility?

My last question was silly because I already know the answer. You know that management at many hospitals, nursing homes, and other types of healthcare facilities adopt the 'customer is always right' mantra and will coddle to you, even if you misbehave. You know this, so you take advantage. Whatever happened to treating people in a way you would want to be treated?

I have been in your shoes because I have had gravely ill loved ones who once occupied that hospital bed. My mother was in a hepatic coma for nine days in 2002 while desperately awaiting a liver transplantation because a new liver was the only thing that would save her life. My father had a nasty bout of pneumonia in 2009 and required intravenous antibiotics. Not once did I become belligerent toward nursing staff. Some would say, "You're a nurse, so you weren't as scared as other family members." I was a factory worker back in 2002, not a nurse, and it was frightening to see my mother unresponsive. However, I always respected the healthcare team.

This plea is intended for the difficult, disrespectful family members out there. Keep in mind that you attract more flies with honey than with vinegar. Be aware that while the squeaky wheel gets the grease, it is not right to displace your anger. Nurses are working under increased pressure in this day and age and must do more with less, although administration forbids us from telling you this. Mutual respect and shared understanding go a long way during this trying time of illness. We know you love the person who lays in that bed and we'll be here for you. Just meet us halfway, please.

Commuter - As usual you hit the nail right on the head! I wish I could print th'is out and hang it in my clinic. (I'd change hospital to school, though).

Thanks!!

mc3:yes: