Behavioral Problems:Patients in Outpatient Clinics

Trauma Columnist · Mar 8, 2008

They get taken off of HD and booted to the curb!

I unfortunately am the APN in two chronic HDUs where we have the demented and stupid. I say that only partially in jest too.

However, there is a behavior policy which is enforced too. For some of our demented pts who pull their own needles we require that someone come and sit with them for the entire tx. For those pts that swear and are aggressive, we take them off and out the door they go.

jnette, ASN, EMT-I · Mar 11, 2008

Ditto to the above reply.

Our facility had a contract for patients like these if it were needed. Thankfully we never had any patients we had to contract with, however.

Remember patients have both rights AND "responsibilities". :)

GeauxNursing · Mar 15, 2008

we have some pts on "behavior contracts", they got in a yelling match one day, right across the bay from eachother. they would've thrown down if it hadn't been for those handy needles in their arms : )

basically, you are to have no more outbursts, fights, problems, etc or you will have your shift changed.

lady X decided to test it by smack talking about some ppl at the other end of the clinic. very loud, just talking about stuff that was none of her business. really upset some pts. she was told that her shift was going to be changed by the FA; she cried and carried on and cried and carried on.

her shift didn't get changed.

our doctors don't believe in "kicking them to the curb" although we all wish we could sometimes. like the 1.5 hours late EVERY day guy. or the tuna fish sandwich, salt and pepper packets, fruit punch spilled all over the floor lady.

i love dialysis : )

errosmith · May 21, 2008

One has to wonder why a dialysis pt acts aggressive in the first place. It could be that they are aware that whatever tx they receive, good or bad, they must put up with poor attitudes from aggressive staff. More than likely they know that without dialysis they will die. How would anyone expect a person to react to this type of life changing situations? Jorlus stated: our doctors don't believe in "kicking them to the curb" although we all wish we could sometimesDoes this attitude give one power over life and death to determine who lives and dies? Seems more time could be spent determining why these pts are aggressive instead of pulling the plug because you don't care enough to care. Jorlus stated: they would've thrown down if it hadn't been for those handy needles in their arms : )Tell me what you find so amusing about this? Dialysis is so very hard to go through. Pts are not there for your amusement and welfare but are there to try and live another day. Put yourself in the pts chair for just one day and then tell me how you would feel to be constantly on edge wondering if you will make it through tx especially having to put up with all the stuff throw at you by staff who control your destiny and treat you like a child....knowing you have to put up with all the turmoil to live. Tell me how angry this would make you feel to know you are basicly a commodity, no longer a person who deserves respect and dignity. Step back and take note. Your behavior is not professional in the least.

GeauxNursing · May 21, 2008

not my intentions at all. do you work in dialysis? i am not on a power trip. i do not try to "control a patient's destiny". i go in, do my job, try to make everyone more comfortable, help them understand why they have high phosphorus, how can we work on controlling their fluids? how is their day going? I am not talking about the new patient on dialysis who is scared and trying to get through the day. I am talking about the person who has been on dialysis for 8 years, who thinks our rules do not apply to them, who thinks that they know everything.

do not misconstrue my words. I was simply responding to the OP's question of about behavioral problems in dialysis. If you think chronic dialysis is all sunshine and flowers, you are mistaken. sorry

GeauxNursing · May 21, 2008

it could be that they are aware that whatever tx they receive, good or bad, they must put up with poor attitudes from aggressive staff. if they do not like the treatment they receive, they have the right to go elsewhere.
jorlus stated: they would've thrown down if it hadn't been for those handy needles in their arms : )tell me what you find so amusing about this? dialysis is so very hard to go through. if we cannot use a llittle humor to keep our sanity, what else do we have? please lighten up. i was simply painting a picture of what it is like from day to day in the unit. as a professional, you have to learn to deal with the childish behavior, the outbursts, and try to not let people kill eachother.
pts are not there for your amusement and welfare but are there to try and live another day. put yourself in the pts chair for just one day and then tell me how you would feel to be constantly on edge wondering if you will make it through tx especially having to put up with all the stuff throw at you by staff who control your destiny and treat you like a child....
treating them like children? no. explaining to them, day in and day out, how their actions at home are detrimental to their heatlth, yes.
knowing you have to put up with all the turmoil to live. tell me how angry this would make you feel to know you are basicly a commodity, no longer a person who deserves respect and dignity. step back and take note. your behavior is not professional in the least.

you have taken my words way too literally. a commodity? to the big ceo of the dialysis companies, they are most likely just moneymakers. if anything, i am the one who cares for them the most. my patients are everything to me, they make me cry, they make me laugh. no one can tell me how i feel about my patients.

errosmith · May 21, 2008

Jorlus: I am a dialysis pt and I also am an apheresis technicain with transfusion medicine. I am well aware of the fact that "chronic dialysis is not all sunshine and flowers". I have seen first hand both sides of the coin and it is not pretty. I am well aware what the day in and day out is like in the dialysis setting. Pts are seldom treated with the same respect that one would give an animal. Let me inlighten you on how this is preceived by the dialysis pt...we are told what to do, when to do it, how to act, how not to act, threats of transfer, lied to, intimidated into submission and basicly kept in compliance (that changes to fit the staffs needs daily) to control the situation. It is very rare not to be treated as a child. We are told, "sit down and shut up", "Don't be such a baby"...We are scolded when we speak our minds or question prescription changes or lack of. And through all this, the proactive pt is looked upon as a trouble maker because we question the numerous mistakes and lack of direction of unit protocols. We question the lack of consistent prevention of a cross contamination, lack of universal precautions, false documentation and non compliance of pre or post assessements by staff. Those of us who are aware know that mistakes are made in our care but no corrective action is ever taken.

I have had good care and horrid care. I have been called a "witch" and "adorable". The point is, horrible care should never go hand in hand with dialysis regardless of the situation or the pt. We should be treated with professional care and dignity without making fun of how much control you have over the dialysis pt who is hooked up to a machine. It might make you feel big but it makes up feel nonessential. We deserve more out of life than to constantly have to fight to live.

Trauma Columnist · May 22, 2008

Totally agree that one should never ever tolerate less than professional care from the dialysis staff.

This thread is dealing with behavior issues in a chronic HDU.

GeauxNursing · May 22, 2008

Well I am truly sorry that you have had bad experiences in your treatment units. I did not not mean to offend anyone.

bluefabian · May 25, 2008

May I cut in?

Yes, I deal with lots of behavioral problems in chronic HDU and it drives me nuts most of the time. As much as I believe I am trying to comprehend the needs of the patients, who are dealing with very tough times... most of the time, I come across a few patients who are just that. Coming in late, always wanting to be on the rush where the are just two staffs tending to seven patients, complaining to us about our inability to understand their grievances and timing needs. I was once placed in a centre where we had to stay back 30 minutes late just to finish all things up. Sometimes more, all because of patient who come is as they please. And as the good nurses that we are, we dare not cut down the time. Not with the 3.5 kg weight gain you have, almost all the time (everytime?). And may I add in that the management don't pay for that overtime? I have other life beyond work, thank you!

The thing is: sometimes most patients don't realize the sacrifices that we made. When we come say 6.45am, they say that we are late. Just because I used to come around 6.15 am, that doesn't mean that should be a yard stick to measure how other people should arrive. All that was done in favour of getting things done fast and not staying back more than we wanted. I can say, I've been doing extra hours of work just by coming early and still get remarks of "Oh, you are late' when it is like 6.30? When I am supposed to be there by 7? And the constant harassment of 'Me first!" all over the place just as I was diluting the first syringe of heparin. And the table thumping and grunting as I was late to get them off while the machines sing away. Where was I? Oh... stopping a bleed. Taking off one patient who is on the verse of collapse. The last thing I need to do is some patient treating this as Hilton and I am valet parking his ride. No thank you!!!

How about those who fails to heed our advice of fluid control? Come bloated with 4kg excess, got away with it and came back with a stroke, exacerbated by a smoking behaviour? Cool. Or that trip to ER for breathlessness, spent the Sunday doing extra dialysis in a costly dialysis centre?

Or those who skipped dialysis as they please? We having to call them after being absent for treatment just before the weekend. And then telling me they want to come tomorrow when it's not even their shift, their day. Can I? When the place is already so crowded? How about not willing to switch places and making a scene of not budging to the next floor until I shouted out loud and rightly refusing to prime her line. That man with the weak knee will thank you so very much. And that uncle with a post diabetic amputation will gladly feel your pain.

Dialysis nurses are tough. I've seen the best one, the in-charge... having this trait. Not that we want to, circumstances made us.

That from the view and experiences of mine.

errosmith · May 27, 2008

Blue, it is unforunate that you are not paid overtime for your work. In the US it is the law to pay for overtime. It is also unforunate that there is no control over start times for pts at your unit. It would make your job easier if pts came when scheduled.

That being said, No one is going to deny that a job as a dialysis nurse is less than a bed of roses. The hours are harsh, staffing is short and you are expected to multi task without error. You say that (quote) sometimes most patients don't realize the sacrifices that we made.

As a dialysis pt, I understand how challenging your job is BUT I did not pick your career. Dialysis pts are consumers of care. It is not our job to praise you for the "sacrifices" you have made to do your job. After all, that IS your job. I personally appreciate the care I receive and let the nurses and or techs know this. Your sacrifices are compensated with pay. My sacrifices as a dialysis pt is compensated with living and I pay for this to the tune of 30,000 dollars a month.

My life is totally changed as a dialysis pt. My family and I have sacrificed time, money, emotions, holidays, vacations, activities, and pt care etc everyday and they do this without monitary compensation. I can not work full time anymore and sacrifice not being able to do my job. We all lose something to gain something else. You can get another job if the one you have lacks the excitement it once had. I must go to dialysis wether I like it or not.

As far a behavior problems of pts at dialysis??? I see more behavior problems with staff who are burnt out than pts. Some staff are just angry that they have to work the long hours and take it out on the pts. We are easy targets and are expected to put up with mean, nasty staff in order to feel better. Its a helpless feeling to be hooked up to a machine, unable to help yourself, at the mercy of an angry nurse or tech. That is the biggest problem with behaviors in dialysis.