Difficult parents/patient

Specialties Pediatric

Published

Okay, so I am going to say it's mostly the parent that presents the problem. I'll set my issue up with a theoretical scenario.

Parent and 5-6 YO patient come back, I gather the history, gather vital signs, and then I decide that a strep test is in order. I gather my swab and tongue blade only to be met with resistance by the parent. Not that the parent doesn't want the test done, but they don't want to make their child hold still for the test. They also do not want their child to be held down by anyone else. As a result, I try to coax the child into allowing me to do the test by telling that that it's fast and I promise it won't hurt. I even demonstrate by letting another nurse do the test on me. Also, I'd bribe the patient with things like "if you let me do this test I'll get you a popsicle". All of these measures failed and the parent usually becomes upset themselves. Meanwhile, 5-10 minutes have passed, the doctor is growing impatient due to having to wait an extended period. I'm personally feeling fed-up with the situation. Eventually, the doctor and a couple of other nurses will come-in (we even had our guy nurse come-in to use as a threat in order to get the child to agree to the test though this did not help) and with all those odds mounted against the mother and child, the child finally agrees to sit on her mother's lap and then the doctor and nurses finally hold her still while one nurse finally finishes the test. The patient cries a little bit, but really is just fine, and one of the nurses give her a high-five, and the promised popsicle.

I along with other nurses encounter this type of situation from time-to-time. I was hoping for some advice on here. I only want the best for the patient, but sometimes obtaining the necessary materials for doing so is a difficult task, and I blame the parent for allowing their children to get out of hand. They are children, they need to be told what and how to do things.

Thanks

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#1. Hold off on the judgement about how people are parenting. And sick kids are not charming nor are parents who may be missing income or under pressure due to missing work.

#2. Go into the room with the provider. When s/he does the exam of oral cavity & it's suggestive of strep-do it right then. Sometimes kids have more respect for providers & will cooperate.

#3. Or try to have the child involved by providing a mirror & explaining what the test will do. And be quick about it.

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Okay, so I am going to say it's mostly the parent that presents the problem. I'll set my issue up with a theoretical scenario.

Parent and 5-6 YO patient come back, I gather the history, gather vital signs, and then I decide that a strep test is in order. I gather my swab and tongue blade only to be met with resistance by the parent. Not that the parent doesn't want the test done, but they don't want to make their child hold still for the test. They also do not want their child to be held down by anyone else. As a result, I try to coax the child into allowing me to do the test by telling that that it's fast and I promise it won't hurt. I even demonstrate by letting another nurse do the test on me. Also, I'd bribe the patient with things like "if you let me do this test I'll get you a popsicle". All of these measures failed and the parent usually becomes upset themselves. Meanwhile, 5-10 minutes have passed, the doctor is growing impatient due to having to wait an extended period. I'm personally feeling fed-up with the situation. Eventually, the doctor and a couple of other nurses will come-in (we even had our guy nurse come-in to use as a threat in order to get the child to agree to the test though this did not help) and with all those odds mounted against the mother and child, the child finally agrees to sit on her mother's lap and then the doctor and nurses finally hold her still while one nurse finally finishes the test. The patient cries a little bit, but really is just fine, and one of the nurses give her a high-five, and the promised popsicle.

I along with other nurses encounter this type of situation from time-to-time. I was hoping for some advice on here. I only want the best for the patient, but sometimes obtaining the necessary materials for doing so is a difficult task, and I blame the parent for allowing their children to get out of hand. They are children, they need to be told what and how to do things.

Thanks

whoa... thats a lot.

So I do have to agree with the poster above. Don't be quick to judge...any maybe there is more to the story and you just didn't type it all out.

-First pediatrics are not just little adults...everything takes more time with these patients because you are dealing with developmental age and parents. That may mean you need to sit down and speak with the parent to see what their concerns are...obviously not holding the child is not an option. Now depending on the situation it may be better if the child is held by the parent or another individual. For a strep test that is not necessarily painful but is "scary" I would have the parent give the child a "hug". Have the child sit on the parents lap facing them. Have another provider hold the head in place while you swab the back of the throat. For painful procedures never have the parent hold the child...this could create distrust between the parent and child as well as between the provider and the parent.

-Never tell a child that something is not going to hurt if there is even the smallest degree of unpleasantness. As someone who has done a number of strep tests and had strep test performed on me...it is far from comfortable.

-Never threaten a child with a male or by any other means. This is completely unacceptable and I would have reported this behavior. Making threats does not work with a child and even if it did subdue the child this is inappropriate.

-Bribing doesn't work with children usually. If they are scared...they are scared. What you can do is let them know there is a reward at the end...it may or may not help but at least it establishes some trust if there truly is some sort of reward at the end...regardless of how they behaved during the procedure. Don't hold back a reward because they screamed or kicked...this is normal behavior for a child of this age.

-as far as the provider getting impatient...tough. Its pediatrics. Its going to take longer regardless of how smoothly it goes.

In general do not do anything to a child until the parent is comfortable. Usually explaining why the procedure is necessary helps...if that doesn't work get the physician in the room to speak with them. If there is a child life specialist in the area get them involved. Is getting a strep test or not getting a strep test really critical...probably not. If there is something that is necessary we are all mandated reporters to child services.

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additional note... pediatrics is not for everyone.

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"-Never tell a child that something is not going to hurt if there is even the smallest degree of unpleasantness. As someone who has done a number of strep tests and had strep test performed on me...it is far from comfortable."

I tell them it's uncomfortable, but it will not hurt. That is the truth.

"-Never threaten a child with a male or by any other means. This is completely unacceptable and I would have reported this behavior. Making threats does not work with a child and even if it did subdue the child this is inappropriate."

This whole thing is actually a trick question. I am actually the male nurse mentioned in this scenario. I am constantly used as a threat to get children to mind. Something I am not entirely comfortable with, but that's just how things are where I work.

"-Bribing doesn't work with children usually. If they are scared...they are scared. What you can do is let them know there is a reward at the end...it may or may not help but at least it establishes some trust if there truly is some sort of reward at the end...regardless of how they behaved during the procedure. Don't hold back a reward because they screamed or kicked...this is normal behavior for a child of this age."

If they are difficult then I always offer and follow up with a popsicle. Sometimes I let them get an extra sticker.

"-as far as the provider getting impatient...tough. Its pediatrics. Its going to take longer regardless of how smoothly it goes."

I was actually told by the NP to go in and help the nurse currently in there (who had been in there 15 minutes already). I didn't really want to do it, but I begrudgingly did. At first, the other nurse I work with said "if you don't let me get this swab then I will have "my name" hold you down." Once again I don't like being used like this.

"In general do not do anything to a child until the parent is comfortable. Usually explaining why the procedure is necessary helps...if that doesn't work get the physician in the room to speak with them. If there is a child life specialist in the area get them involved. Is getting a strep test or not getting a strep test really critical...probably not. If there is something that is necessary we are all mandated reporters to child services."

I left the room when the mom started to act upset. I figured it would be better to just leave as my presence was just making her feel upset. Although I'm not entirely sure why. I suppose it's because I was being used as a threat. Eventually, the nurse practitioner came in the room, looked at the patient's throat, and said yes we have to do the strep test. Finally, the mom caved-in and the patient finally got on her mom's lap (after I was used as a threat of course.) Following that, I held her arms down, the NP got the head, the mom hugged around her body, and another nurse got the swab. Given the state of antibiotics being over prescribed I think it is critical to have enough evidence to support prescribing them.

This case was actually very special in terms that I've only encountered 2 or 3 other patients this bad with 1.5 years of experience. I'm not a doctor, but I think they may have had undiagnosed ODD (oppositional defiant disorder), but of course that's just speculation. Thanks for the advice.

I'm also trying to figure out how to not be used as a threat. They do it all the time behind my back while it's just them in the patient's room, so it's impossible to truly stop them. I've told them that I dislike holding patient's down.

"For painful procedures never have the parent hold the child...this could create distrust between the parent and child as well as between the provider and the parent."

Is there any scientific evidence to support this claim? I genuinely want to know because we have the parents help hold all the time when the lab does blood draws.

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-As a male myself I have also been put in this situation. Oftentimes people do not realize what they are doing when they do it. People think of males as the muscle”…this is just a societal norm. What I have done to get past this is pull the person aside after the interaction and just say hey I know you didn't mean anything by it but please do not put me in that situation again…it makes me feel like I am being used as a threat” and that doesn't feel as though I am being treated as a professional” or something along those lines. It is truly unintended and people think its harmless but its not.

-It sounds like you are up against some work cultural issues when it comes to speaking appropriately with patients and families. Some patient families are difficult to deal with but its important we remember that they are stressed. Its not ok to take verbal abuse but it is ok to cut them a little slack. I would advise the nurse practitioner to take a minute to sit down and explain. If that doesn't work, do it again. Threatening with a male or anyone else is not a good solution for anyone especially YOU.

-While I do agree antibiotics are overused…there are times when I grudgingly would support using antibiotics for something like this without obtaining the test. Absolutely it would be best practice to rule out a viral infection prior to prescribing antibiotics. Its important to educate families on why we do not prescribe antibiotics for viral infections or even some bacterial infections that will run their course.

-While I do not have any great quotes or references for the statement I made about not having a parent hold down a child, I do know this is best practice. I am not saying it is never going to be effective but it is an absolute last resort and should make you feel a little unsettled if you have to do it. There are many supportive, therapeutic holds that a parent can participate in without holding them down”.

Here is an excellent resource from the child life council http://www.childlife.org/files/ComfortMeasuresandTips.pdf

I implore you to take a look and maybe just take a breath and reconsider some of your opinions. This is not a judgement, just a request from a pediatric provider to someone who has shown an interest in providing better care to his patients. The child life council offers many great resources. If you have a child life therapist in your organization I would advise you to have them come do some inservices! It can be a great experience for you and your team. I also realize that much of what I have proposed takes a lot of time so you do have to be in a supportive environment to make that happen.

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As a parent and a nurse on an adult unit, I find it odd that the parent would be against getting the test done. At 5-6 years of age my kids were pretty compliant given I was in the room and they were comfortable. Nurses and doctors have never threatened my kids with male nurses or being held down. I think that is wrong.

Don't allow your co-workers to use you to threaten patients. Think about the pediatric patients that are frequent fliers and will encounter you as their nurse. They will remember the time you were referred to as "the male nurse that will hold you down".

Consistency is key with kids, whether they are sick or well. Some parents just don't know how to communicate with their kids when it comes to hospitalization. They may rely heavily on the doctors and nurses to explain everything.

Coming from a mother of three, your best bet is getting down to their eye level and being as honest as possible about what is about to be done. I agree with role playing with another nurse just to show them and have them return the demonstration on a doll or something like that.

I wish you the best of luck ☺

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Specializes in PICU, Sedation/Radiology, PACU.

I'm trying to quote your post but this browser isn't cooperating, so please bear with me:

and then I decide that a strep test is in order. I gather my swab and tongue blade only to be met with resistance by the parent. Not that the parent doesn't want the test done, but they don't want to make their child hold still for the test.

Parents are going to be resistant to putting their already sick child through something uncomfortable if they aren't certain it's necessary. Deciding yourself, as a nurse, to perform (essentially ordering) a strep test is outside of your scope of practice unless you have standing orders. Even if it's done routinely- even if you know it's what is going to be ordered. After consulting with a provider, you can then tell the parents what uncomfortable or painful procedure needs to be done. They will be more willing to comply if they know the doctor wants it done.

As a result, I try to coax the child into allowing me to do the test by telling that that it's fast and I promise it won't hurt. I even demonstrate by letting another nurse do the test on me. Also, I'd bribe the patient with things like "if you let me do this test I'll get you a popsicle"

These are all valid attempts at educating the patient and family about the test. Demonstrating is good, when possible. Avoid "bribing", but you can offer rewards. Just try not to phrase it like the child has a choice. You can say, "If you let me do this, I'll get you popsicle." But that gives the child the choice to say "no." Say something along the lines of, "Once we swab your mouth I'll get you a popsicle to help your throat feel better. The child doesn't have a choice about getting the test done, but you can give them options when they have them. "Would you like to sit on mom's lap while we swab your mouth or on the bed?".

(we even had our guy nurse come-in to use as a threat in order to get the child to agree to the test though this did not help)

You addressed this already, but please do not threaten or allow yourself to be used as a threat to a child. When it happens in front of a family, correct it immediately. Say, "No, I am not going to hold your child down, but I can help you work with her to get this test done in a way that is easiest for all of us and gets her the care she needs to get better." To the nurse who does it, say, "I am not going to be used to threaten children to cooperate. I am a professional and children shouldn't be made afraid of me anymore than you would want them afraid of you."

I blame the parent for allowing their children to get out of hand. They are children, they need to be told what and how to do things.

Do you have children? Let me let you in on a not-so-secret emotion that we parents have called "helplessness". Those tiny little humans are the most important thing in the world to us. It's our job to take care of them. When we can't- when they are sick or hurt or they have to experience pain and discomfort in order to get better- we are overwhelmed by helplessness. It terrifies us. It frustrates us. It makes us angry, and emotional, and feel inadequate. And in that hospital room, when we need to ask- make- our child to do something we know will cause discomfort or pain- we are lost. They may be our child, but we have much less experience in that area than you do. Sometimes parents need some direction. Please do not blame parents for not knowing how to respond in a situation that they are entirely unfamiliar with. (Unless they are actually being belligerent in which case you escalate and get the provider in the room to talk to them.) They need you to tell them what to do, and how to help you AND their child. Asking the parent and child to do something is very different than telling them what needs to be done. This can be done professionally, and gently. Saying something to the mother like, "The easiest way to do this is usually with Sally sitting on your lap. I'm going to have another nurse come in to help remind her to keep her arms still, since it's normal for her to want to reach for her mouth." To Sally, "Sally, Mom is going to give you a hug. My friend Jane is going to come into help you hold your arms still. Then you're going to open your mouth for me and say "AHHH" while I count to five. Then I'm going to swab your mouth and you'll be all done and can have some juice or a popsicle."

I'm going to disagree with jrt4's statement that parents should not hold children. However I think he/she was unclear. Parents shouldn't be asked to restrain a child (hold them down), however there are wonderful things called "comfort holds" that can be used to facilitate many various tests and procedures. These involve the caregiver holding the child in various ways that provide both safety and comfort. I suggest looking them up, as they can be very helpful tools.

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Specializes in pediatric special needs, trach/vent.

I definitely disagree with using male or any other nurses as a threat tactic. This will only increase anxiety and decrease trust. If this is a common occurrence where you work I would discuss it with your supervisor. Don't bring it up as strictly a complaining session, but go armed with some research. I'm sure there are some good articles out there that address dealing with anxious pediatric patients when doing procedures. If you approach management by expressing a desire to improve patient care they will be more open minded. Sounds a little like some of your coworkers may benefit from some education on this topic.

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Specializes in Pedi.
"-Never tell a child that something is not going to hurt if there is even the smallest degree of unpleasantness. As someone who has done a number of strep tests and had strep test performed on me...it is far from comfortable."

I tell them it's uncomfortable, but it will not hurt. That is the truth.

Pain/hurt is subjective. Just because you don't think a throat culture hurts doesn't mean a child won't think it does. When I was a child, I thought they hurt. I got strep all the time and I used to gag and cry with throat cultures. When I had brain surgery at 19 and had to get my hemovac drain removed, I asked if it would hurt. The PA told me no. It was the worst pain of the whole experience. I never definitively tell a child something "won't hurt." I will remind them that they have Emla on their port or that they've done a dressing change many times before and have always been ok, but I am not risking their trust by lying to them and saying something "won't hurt" when it very well may from their perspective.

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Specializes in NICU.

I've never worked with peds pts but I would offer my parent insight...

My daughter is autistic. She was not diagnosed until age 6 yr (long story). Before that, I didn't know about the autism but I knew my daughter well and knew what would set her off. She was speech delayed and couldn't have things explained or be reasoned with. Being held down for something unpleasant would be traumatic.

Something traumatic could literally mean my daughter would refuse to ever go back. I would be screwed if something negatively reinforced the doctor's office. 65lbs of "I'm never going back" is hard to deal with. That mom might have been in a self preservation mode of "Do I risk this or not?" I don't know, just offering my thoughts.

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Specializes in Family practice, emergency.

I like KRVRNs perspective as a parent with autism because I was thinking along similar lines when I saw OP's post... If parent stated "You can do the test but can't hold my child down" I would ask why first... Maybe child has autism, abuse hx. If no factors existed that made a hold out of bounds, I would explain to the parents that your child will not like this, it is not painful but most cry from restricted movement, it will take 3 seconds, when they cry, I get the test and they are immediately released.

At 5-6 years old they can understand a bit of what's going on. Be aware of methods to help by age groups... this group might respond by knowing that you are going to "see if there's a germ and catch it with this swab." I wouldn't go overboard by saying 'this doesn't hurt' but I might give them a swab so they can figure it out by themself. I avoid bribery at all costs, even if parents do it. And I don't give the choice, I say "We are going to do XYZ." If a 'prize' was offered, I would say "We are going to do XYZ. Then you will get the sticker." Works for adults, too.

In OP's defense, sometimes parents can take it waaaaay out of bounds. I once had to do a conscious sedation for a very simple procedure in a 10 year old (no needles, no autism, perfectly healthy kid), 100% related to the permissive nature of the parents. No judgement... well, maybe a little...

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