Five minutes before her shift began Amber stuffed her purse into her locker. The new patient yesterday had been so optimistic and grateful that the day had flown. Maybe today'll be the same, she thought with hope.
Her hope, however, halted abruptly when she looked up and saw -- oh no....no! -- her standing at the nurse's desk. Amber's heart sank and a knot formed in her gut at the same time.
The mean nurse.
She was working with the mean nurse today.
Three days later, Amber sits across from me in her counseling session sorting through the day with the mean nurse. She fills me in on some history before processing the day.
"Her name is Tami. She's worked at Brookside fourteen years. I started there five years ago. Before that I was in ER, so changing to a nursing home nurse was really different for me. At first, I was her favorite."
When Amber says "favorite" she smiles a dramatic, fake-looking smile and blinks emphatically like female cartoon characters do when they're flirting. Her sarcasm leaves no question in my mind that she has zero fondness for having been Tami's favorite five years ago. I smiled and nodded. "From day one, Tami trash talked the other nurses. I didn't see it then, but everything she said about them wasn't true. She was so negative....suspicious actually: 'This one's slow.' 'That one took her vacation days.' Or 'The new hire's going out to lunch with staff from OT.'" Amber added, "Ya, how audacious. Making friends from another department."
She proceeded to describe her shift three days ago with the mean nurse. I wasn't sure what sounded worse: the critical eye riveted on Amber's every move, or when the mean nurse quietly talked to the director of nursing in a hushed volume just low enough that Amber couldn't hear what was discussed, but could see obvious furtive glances in her direction throughout the discussion.
"The thing that bothered me the most was she sat there -- half the time she doesn't even do her work, or she's trying to get out of it. She's sitting there, and throughout the shift, asks me to do her stuff for her! Like go give PT a report she forgot to give them for her own patient! It wouldn't have been so bad, but she was just sitting there labelling supplies at the desk while I was doing her stuff or running her errand! Labelling supplies is something we do when there's absolutely nothing to do. So basically, never."
Ug, how miserable, I thought. I felt for Amber and wondered how often she had to work with folks like she was describing.
"I hate my job. I really hate it. I can't tell you how depressing Sunday night is," she says, shaking her head.
We finish talking through some of the initial details of the mean nurse shift. Then we hunker down to examine the situation.
"Which of those things bugged you the most? Of everything she did that day?" I ask.
"Her sitting there pretending to look busy while asking me to do her work for her," Amber said without having to think about it much.
"Okay, so when she sat there at the desk 'looking busy' and told you to go check on her patient go take her report to PT, how did you respond?" I asked, curious about how Amber had experienced the situation in that moment.
Just before answering, Amber raised her eyebrows and tilted her head down just enough so that it appeared she was looking up at me. She looked like a four year-old looking up at an adult. Like she was asking for a cookie she just knew she didn't deserve.
"I said, 'Well, ummm, sure I guess I can.... but I've still got a lot of things to do on my own list.'"
I took in what she'd just said and asked, "And what were you hoping to convey to her?"
"I was trying to tell her that I had other things to do, my own things to do."
This helped me understand what Amber's intent was. "I notice you said it like this," and raised my eyebrows and tilted my head down like Iwas the four year-old looking up at her, the adult.
"Huhhh. Uh...." She looked at the painting to the left of me, thinking. Her eyebrows were no longer raised. Making eye contact again, she responded, "Well, I was trying to be nice...." When saying "nice" her eyebrows and vocal tone both raised slightly in a way that reminded me of a fourth grade student saying "Tallahassee?" as a tentative answer when called on to identify the capital of Florida.
"Sure," I said nodding, sensing how important being nice was to her.
I wanted to get Amber's take on how she might have come across. "Okay. So, you tell me....what does it say to you when I say" -- and I did my best to emulate the non-verbals she'd had a minute ago -- raised-eyebrows, tilted head, and the questioning vocal tone. Then I repeated what she'd said -- 'Well, ummm, sure I guess I can.... but I've still got a lot of things to do on my own list'"?
She paused again, then answered, "That I'm gonna do anything she asks."
She added, "and it's a little confusing, cuz when you-- or when I -- say 'I guess I can' -- it's like I'm reluctant.... But I'm definitely saying 'I'll do what you ask.' That's the message."
I pondered, "So you were trying to politely tell her that you had other things -- your own things -- to do, but the message you probably sent was, 'I'll do what you ask.'"
"Totally," she said, punctuating her agreement with a slow, deliberate nod.
We then talk about rethinking "being nice." How when "being nice" is your highest priority, you wind up doing things you don't want to do -- things that often don't align with your values (like doing work on your own list that you're not especially proud of because you were completing someone else's list while they labelled).
How it especially doesn't gain you respect from mean nurses or people who generally are comfortable in the taker-role.
And how it ultimately can lead to low self-esteem and a lot of resentment.
We talk about how sometimes different communication styles are needed for different personalities, especially difficult personalities. Like with her friends, she could continue using less direct communication. With them, it worked. They spoke the same language and her friends generally didn't seek to take, take, take. With someone more prone to pushing boundaries? She would need to use more direct communication. Firm but kind.
"So let's pretend you weren't worried about what the mean nurse thought of you, and you weren't worried about being nice, what's your answer, stated as simply as possible?" In a neutral voice I repeat the question, "'Would you take my report down to PT?'"
Amber looked settled and "in her skin" as she thought about this -- totally different than when she had the four year-old look on her face earlier. This was in her real self now.
"'I've got my own things to do.' That's the real answer," she replied.
"When you just said that right now, how did that set with you?" I asked.
"Good. Like, normal." She thought some more looking at my painting again. "Like I was thirty-four -- my normal age -- instead of feeling like a little kid." She paused again, then said, "Ya....it felt good," like she was still discovering a new mystery.
I cocked my head a little, "You sound a little.... surprised."
"Well, ya. I guess I am. I just thought it'd be so mean to say something like that, but when I just said it now, it was.....like.... Normal. I was just saying what was true."
"It didn't feel rude to say what was true: 'I've got my own things to do,'" I said, wanting to make sure I was understanding her.
"Right."
"And how would that be if you imagined saying that to the mean nurse?"
Amber's face became less relaxed. "Thaaaat might be a little harder," she said with a slight grimace.
We kicked around some options to figure out what Amber would be most comfortable with. What would be direct, as kind as possible, and fit her personal style. After going through a number of options, she landed on one.
"'I've got my own list I'm still working on. I'll let you know if I get it done and have extra time though,'" she practiced out loud, thoughtfully. Almost like she was reading the words in her mind.
She continued, "Ya, I think I could do that one. Cuz I don't actually mind helping people with their stuff. Even if mine's not done and the task is something urgent, I'm happy to help out another nurse. I just don't want to do someone's stuff so she can sit and label things. Something that's, like, number 500 on our priority list."
Amber and I roleplay, her being herself, me being the mean nurse. She practices her new response, and I look scowlingly at her, imitating how I imagine the mean nurse will look when this happens in real life. We go back and forth with me asking her to do my work, and her giving her new response.
Each round, after she gives me her new response, we highlight what she did well, and figure out what doesn't yet match. Sometimes I demonstrate her non-verbals back to her so she can see how she's coming across. After about eight rounds, she gets it down to where she no longer has a vocal uptick question mark inflection at the end of the sentence, and to where she looks straight at me without insecurely raised eyebrows and a downward tilted head.
Over the next couple of weeks, we continued talking about ways Amber can make her message and non-verbals "firm but kind" with the mean nurse and other boundary-pushing co-workers. We do more roleplays to help her develop non-verbals that have the same message as her spoken words, rather than a different message. Amber practices the skills wherever she can -- friends, family, co-workers, and clothing retail cashiers (who ask for her phone and email address that she doesn't want to give!) while checking out.
A few sessions later, Amber reports that she had to work with the mean nurse again. She says she used the "firm but kind" communication skills, and was only "about a third as depressed and exhausted" afterwards. A few months later, after having worked with the mean nurse and, she "didn't feel depressed at all," and was only "a little uncomfortable" when using the new communication skills.
We agreed that she might always feel a little uncomfortable using the "firm but kind" direct style of establishing boundaries. Realistically, advocating for herself with boundary-pushing personality types was probably never going to be Amber's preferred style of communication.
"I use the skills anytime I need to now," Amber said on her last session. "And I don't hate my job and get depressed Sunday nights anymore." She looked at my painting, reflecting one last time, "If someone had told me that the way out of this whole mess, was going to be by my experimenting with new communication skills, I wouldn't have believed them."
"But hey, whatever works," she said with a smile.
Author's note: While this article highlights topics discussed with nurses in my therapy practice, identifying characteristics and details have been altered to protect patient confidentiality, and to uphold HIPAA standards.
