advice please

[Tarabara]

I am a nursing student, only in my first semester, and we are going to start our LTC rotation in about 2 weeks. I am writing here because I would like advice from people who have experience. For clinicals, I am most nervous about having a patient who is uncooperative, unwilling to help with anything, or just plain rude. How do you handle these people who dont really want the care you're trying to give?

Thanks!

PS. in class we watched a video on therapeutic communication, with a scenario of a patient who was rude and didn't want any care. In the video all they did was say they answered his call light right away, and gave him time to adjust to being in a hospital. All I could think during the video was how NOT helpful it was, i mean seriously? The patient just stopped being rude all the sudden on his own, didn't seem very realistic :/

[Virgo_RN, BSN, RN]

People can be hostile and uncooperative for a variety of reasons ranging from basic personality traits to disease process. For me, I have found the most effective way to gain trust and get around this barrier is to brush off the rudeness, do not take it personally, continue to treat the person kindly and respectfully, and try to connect with them in a human way. Try to meet them where they are at, rather than attempt to get them to conform to your expectations.

Always ask for their permission when providing care, and if they are incapable of giving consent, then be sure inform them of what you are doing so they are not surprised, and avoid manhandling or being rough. Even if the person is unresponsive, always assume they can hear and understand you, and speak to them as if they can.

Most people will realize when they're being a jerk, and will temper their behavior when they come to the understanding that you are on their side and are not a threat to them.

People with underlying dementia or other disease processes that affect cognition and behavior may be incapable of altering their behavior. For this patient population, gaining their trust and becoming a friendly familiar face to them is going to be the key. In advanced stages of disease, even this will not help.

Good luck! I learned invaluable skills interacting with my LTC patients when I was a CNA. I hope you do, too!

[twentytenRN]

I encountered this during clinicals. My advice is to be confident and competent in the care you are delivering. As VirgoRN stated, gain their trust. Anticipate their needs, answering their calls right away, getting their meds on-time, remembering they like a strawberry Ensure with their meals (cold, make sure they're stocked in the fridge during your shift), come back when you promise, explain things (meds, treatments, etc...) clearly and give a reason. A lot of times you will find that patients just don't understand why they need that certain medication. Instead they will bark "I've never taken that before in my life, and I'm NOT taking it now!" Another thing you need to remember is patients are scared to be in the hospital. Even normal everyday Joes. They relinquish a lot of control to you in their situation and this is displayed as defiance and sometimes anger. Put yourself in their shoes and just imagine how you would like to be treated when you're vulnerable. I'd hope that my nurse would come see me as much as possible, remember the little things like my Ensure and what flavor I like. And lastly, never rely on the report you get from other nurses at the start of your shift with regards to behavior. Cast aside all generalizations or opinions of that nurse. Go make your own observations and walk in the room with no prior judgments. I've had many a nurse tell me "Oh, Mr. So&So in 111 is a REAL pain, he screams, kicks, bites, etc..." I ignored what she said and did everything I just told you above and he never did any of those behaviors, and by the end of clinicals, I told him I was leaving and he asked if I was back the next day!

[canigraduate]

I am a CNA and work in an LTC with many rude and/or demented patients. I use a different approach for each.

For the rude A&O patients, I draw very firm boundaries about behavior I will and will not tolerate. I speak in a calm, assertive tone and use neutral language. If necessary, I will leave the resident's room until they calm down and can be civil.

For demented patients, I use a very calm, hypnotic way of talking and try to calm them down if they are agitated. Usually, with a demented patient, their moods only last a short time, so walking away and coming back later also works. One thing you should never do (EVER) is aggravate the situation using false cheerfulness or responding with anger. That just escalates things in my experience.

If someone is being uncooperative, calm them down first, then explain to them the consequences of not cooperating. Residents are allowed to refuse treatment, so don't force them into anything. If a resident emphatically says no, then forcing them is abuse. This is true whether the resident is demented or not. Demented residents are usually pretty good about cooperating, though, if you use the "leave and come back later" technique. Most of the time they forget why they refused in the first place.

DISCLAIMER: This is just from my limited experience as a CNA working with LPNs at a LTC/Rehab facility. However, these techniques have worked very well for me and my fellow coworkers often ask me for help to get residents to cooperate.

[fuzzywuzzy, CNA]

Sometimes people DO stop being rude on their own. I've seen it with rehab people a lot. I just ignore their tone and give them a lot of space. If they complain about something I give a very quick explanation of why things are done that way- no making excuses or whining- just a simple "We do _____ because of__________." Usually they just didn't know. Once you explain it to them and they get used to the routine they stop being so rude.

Sometimes you have to get creative with people who have dementia that are resistant to care, combative, etc. Sometimes walking away and coming back in 10 minutes is enough for them to forget what just happened and be in a different mindset. And usually one-on-one interaction will get better results. It's tempting to go in there with "backup" but even having your helper standing in the doorway confuses them and/or makes them feel outnumbered, so they start fighting you. I also save these people for last, if I can. They do not like to be rushed. I can act as calm and quiet and slow as possible and they can still sense that I'm anxious. If I really do have very little left to do when I get to them and I'm not so stressed out about having to deal with their potentially difficult behavior, it tends to go more smoothly.

[Zeta_Xi_208, RN, BSN]

I am only there to help. If they are rude, I can take it. I have very big shoulders. If they refuse help, that is their right. I let them refuse and move on to the next patient.

[fuzzywuzzy, CNA]

I actually think the hardest people to deal with are the alert ones who want you to wait on them hand and foot when you don't have time, because "their money goes towards your paycheck" or they're just so much more special than everyone else, or whatever. Everything is a mind game and a power struggle with them. The path of least resistance is to cater to their every whim and suck up, but oooohh, it's so aggravating! Especially when not all the caregivers respond the same way. Some of them suck up, some push back and try to make the person more independent, and in turn the resident/patient goes into overdrive with their manipulation tactics.

[canigraduate]

I actually think the hardest people to deal with are the alert ones who want you to wait on them hand and foot when you don't have time, because "their money goes towards your paycheck" or they're just so much more special than everyone else, or whatever. Everything is a mind game and a power struggle with them. The path of least resistance is to cater to their every whim and suck up, but oooohh, it's so aggravating! Especially when not all the caregivers respond the same way. Some of them suck up, some push back and try to make the person more independent, and in turn the resident/patient goes into overdrive with their manipulation tactics.

I hear you on this one!

We have a lot of these manipulators at my facility. Usually we nip it in the bud, although some of the younger or more passive employees fall for their tricks. It's funny how the manipulators can tell who will put up with them. Most of them don't even try with me, so I'm amazed when I hear the stories that go around the facility about what goes on.

I did have one resident who wanted me to fluff up her pillows every time I went in her room (she had full use and range of motion in both arms). I would tell her that having me doing it for her didn't help her recover any. She kept asking, though, until one day I just said "No" and walked out. Her mouth dropped open. Never had another ridiculous request from her, though.

[leslie :-D]

with the resistant, demented folks, i don't know how realistic gaining their trust will be, since you will seemingly be in there 1 time.

if you were to see them on a regular basis, then yes, earning/gaining trust is imperative.

i try to get a sense of their resistance, by continuing to set up and gently explaining to them what i'm doing...

while distracting them by asking them to talk about spouse, children, job, etc.

throughout, i ensure i am gentle and compassionate.

for me, this usually works.

leslie

[fuzzywuzzy, CNA]

I hear you on this one!

We have a lot of these manipulators at my facility. Usually we nip it in the bud, although some of the younger or more passive employees fall for their tricks. It's funny how the manipulators can tell who will put up with them. Most of them don't even try with me, so I'm amazed when I hear the stories that go around the facility about what goes on.

I did have one resident who wanted me to fluff up her pillows every time I went in her room (she had full use and range of motion in both arms). I would tell her that having me doing it for her didn't help her recover any. She kept asking, though, until one day I just said "No" and walked out. Her mouth dropped open. Never had another ridiculous request from her, though.

Yeah. I am actually pretty passive so a lot of those types give me a hard time, thinking they can get away with it. We have the same person in our facility who wants her pillows fluffed. Or her cup of water held up to her lips or whatever. You tell her, "You are supposed to do that yourself" and you get "you're supposed to help me, that's your job!" No, it's my job to walk you to the bathroom, wash your back, fasten the tiny buttons on your shirt, and tie your shoes because you can't bend down. You are capable of fluffing your own pillows, so that's not my job, it's YOUR job! You repeat that if she wants her pillows fluffed she is free to go ahead and fluff them and that you're leaving. As soon as you walk out the call light goes right back on. And then you have people that cater to them and there's no consistency.

Our DON actually wants us to baby everyone. You learn in CNA classes that you're supposed to promote independence and then you get yelled at for doing so. One time I got in trouble with her for letting a fiercely independent resident go about her business while I was down the hall. This woman is allowed to walk around by herself and doesn't like to feel helpless. She wants to do her own thing. I set up her nightclothes, toothbrush, etc. and left. The resident was totally fine with that. The DON however reamed me out for not wasting time that I didn't have to stay in there and baby someone who hates being babied.

[canigraduate]

Our DON actually wants us to baby everyone. You learn in CNA classes that you're supposed to promote independence and then you get yelled at for doing so. One time I got in trouble with her for letting a fiercely independent resident go about her business while I was down the hall. This woman is allowed to walk around by herself and doesn't like to feel helpless. She wants to do her own thing. I set up her nightclothes, toothbrush, etc. and left. The resident was totally fine with that. The DON however reamed me out for not wasting time that I didn't have to stay in there and baby someone who hates being babied.

That sucks. I know exactly what it's like to be stabbed in the back by your higher-ups. I used to be a very passive person.

I don't put up with that stuff anymore, though. My ADON was a queen bee to me the other day and I sent a formal (very polite) letter to the DON, with the threat of a copy forwarded to the corporate compliance department of our parent company. Everyone's been reeeeaaallllly nice to me lately.

Sorry, I just realized I am completely hijacking this thread. However, the underlying principles of assertiveness, politeness, and following policy will also help in dealing with difficult residents.

[dudette10, MSN, RN]

I just finished my LTC rotation, and there were so many different personalities and ranges of A/O.

With the ones who were A/O x 2 or 3, I would let them guide me for assistance. They knew what they could do and what they couldn't. I made it as efficient as possible by asking for the next set of "directions" while I was finishing up my first set. I also did it because they have so little control as it is, I wanted to give them a sense of control over what they could do. They seemed to appreciate it.

For the demanding ones who were A/Ox 2 or 3, I would just do what they asked, with a smile on my face. I was a student, not an employee, so it took very little for me to be their handmaiden for a day. If I were working there, with a larger, more difficult work load, I might not be as pliable.

For the demented patients, I would answer their repetitive questions while doing other tasks for them. Occasionally, the demented patients would become scared, and touch can make a huge difference. For example, there was one who was obviously frightened by the security system being tested...all the fire doors were shut, leaving the nurses station (where she was) completely encased in closed doors. I held her hand and explained the situation to her. Even if she forgot what I said in the next moment, the look on my face told her everything was all right and she calmed down.

Get as much out of this learning experience as possible by looking to the CNAs for guidance. The CNAs I worked with were WONDERFUL. I hunted them down and told them to call me if they were going to do something that I had never done. They did! They seemed to really enjoy teaching us students, and I'm grateful for that. I'm sure the extra set of hands they had helped them also. Near the end of my rotation, they would hunt me down if they were going to do something that they knew I hadn't seen before.

Let the CNAs know you are willing to help them. Ask them, "Is there anything I can do?" If you've earned their trust--remember, they are responsible for their patients and it makes sense that they need to trust you--they will ask you to help get patient X ready for breakfast or lunch on your own. If you get "stuck," they will come to your rescue, too!

During clinical evaluation, let your instructor know what you want to experience. If you haven't seen/done X, let her know! It's her job to provide you the opportunities to use your skills, if at all possible; it's your job to let her know what you have and haven't done.

Never be twiddling your thumbs. There is always something to do; one just needs to recognize it!

Have fun, and good luck!