Behavioral Problems:Patients in Outpatient Clinics

Valerie Salva, BSN, RN · May 27, 2008

You pay $30,000. a month?

C'mon now.

bluefabian · May 27, 2008

The problem is, sometimes patient think that we as nurses are just there to do our job, according to our job scope and get pay at month's end. But in reality, we strive hard to do the best that we can to a patient in whatever means that we can. Even if it's like coming early and doing extra hours. Burnt out? Talk to all nurses of all discipline and they have a lot to tell. Last time I check, I still come to work on time and do what I am supposed to do - regardless of whatever emotions I am having. When people's life are in your hands, you see things differently and thus the extra stress on hand.

I am not trying to be rude. Some patient do have behaviour problems that clearly violates a centre's/hospital's protocol. They know it and still they act as if they don't care. If we are not gonna be tough, how will order be brought to light then?

As staff nurses, we have been tolerant more than we could even as far as know that the long term repercussions of not obeying to a certain protocol just because we..... CARE.

Extracting 3.8kg everytime you come, sure... bring it on. We don't like you having breathing difficulties and swelling all over. Over the weekends, we can tolerate that. Everytime? You make the call. If you think that we allow huge fluid extraction per session just because we want to (which clearly violates how much we can extract as per procedures and protocol), then think again. We just don't want to argue with you anymore. So that you know though: do that all the time and over time the excess fluid will have an impact on your ever enlarging heart. Soon enough... heart failure. Death. Why? Because nurses are too lenient? Because patients are too lax in control? You be the judge. I see this happening all the time and I wish I can do my best to help my patients. Unluckily some just don't.

We try to understand your financial woes - having to pay for each sessions, the EPO, meds for your HPT/DM or whatever sickness that you have. That travel spendings from home to hospital, food, dialyzer change. And time spent on treatments, missed time with family member, having to adjust to work because of this. Not able to go for vacations because you can't skip a dialysis. And even if you do, it's hard to get a hospital/centre that will accept you for immunological reasons... We see this on so many people. Patient having to sell a house to support treatment, outstanding bills for years (yes!) that we kept one eye shut even if the administration been pestering us for this.

Sometimes, all that we need is to take some time and see what other people are doing and why they are reacting as so. I try to understand yours, and I just hope you can at least try to know my reasons.

starbin, BSN, RN · May 27, 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.

I will tell you my experience, why we talk about dialysis patients' behavior. I have a gentleman in his mid fifties or early sixties who dialyses with us MWF. He refused to go for a fistula or graft, and we are dialysing him on catheter for more than 2 years now. He has a very controlling behavior, and has a very bad mouth. One day his catheter didn't work, and the machine gave arterial pressure alarm. the guy started shouting," Take your fu**ing machine away". I politely reminded him that his behavior was not appropriate, and I got another **** remark. He has signed behavior contracts but doesn't comply with it. Staffs are taking this behavior from him everyday.

This is just one example, we have many other patients who go to this extent or sometimes beyond it. I have also been punched by one of the patients while I tried to intervene the escalating fight between two patients.

Every nurse understands that he/she must advocate their patients, but we must learn to reject unacceptable behaviors but accept the patients. These patients' behavior don't amuse us, we understand going through dialysis is painful, but abusing the staff doesn't solve their problems. They will keep doing it, if we keep taking it from them. Just like our patients, we are humans and deserve respect.

bluefabian · May 27, 2008

starbin,

I was reading a newspaper report last time where a newly admitted renal failure patient into HD was making a police report against a staff - because his hands were brusing all over due to multiple cannulation attempts. The thing was, he has been on IJC for six months.

Six freaking months?! I guess the patient just doesn't like the pain associated with fistula cannulation and prefer the ease of catheter hook up. And we as staff nurses had to think about the real easy infection setting in, recirculation (and thus dialysis inadequacy), poor blood flow and access clotting.

I understand that the staff will have to try the cannulation sooner or later. It's not like long term catheter usage is all sunshine and party.

In the end, the hospital director dismisses the report and backed up the staff. Very good end indeed.

starbin, BSN, RN · 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.

Dialysis patients don't have to put up with the unacceptable behaviors from dialysis staff. They have a place to complain, give your complain in writing to the clinical manager first, explaining the details. You have the right to know if any corrective action was taken. If this doesn't solve the problem, file the complain with the company (or the owner), and if it still doesn't help- go to the department of public health and board of nursing (if nurses are involved). Your voice will be heard, and many other patient will benefit from your educated decision and assertive action.

Nurses must always document in detail any unacceptable behavior from the patient, and the actions taken. The investigators, and public health officers will review these documents in response to a patient's complain. If the patient was unfairly treated, corrective action will be taken against the involved people and/or facility.

Dialysis patients go through a lot due to the physical, emotional, social and financial changes they have to make due to their health condition. But neither the patients nor the staff are to be blamed for that. It is not appropriate for a patient to justify an inappropriate behavior by saying "I am abusing the staff because I have been through a lot due to dialysis."

The biggest challenge nurses and techs working in dialysis face is- they have no place to complain. We have a responsibility to provide a safe and professional care to our patients. We can't 'punish' patients for their 'insane' behavior. It is next to impossible to get the doctor or the facility owner kick the patient out of the program just because they abuse the staff. All they do is talking, which helps for a week and again the same.

errosmith · May 27, 2008

You pay $30,000. a month?
C'mon now.

I have two insurance policies and also medicare. I am billed $34,000 a month for 12 tx and the insurance pays $30,000 as payment in full. I did not mean to say that I personally pay this but this is what is billed. Dialysis is a big business with the billing of medication often totals 40% of the units profits. Pts with Medicare only are billed as bunch payment (set amounts). This no where near what the private insurance sector is charged.

Your tone of "C'mon" tells me that you think my figures were made up? It is what it is.

Trauma Columnist · May 28, 2008

errosmith - I feel bad for you. You seem like a totally compliant patient who wants to feel well. I'm sorry that you need dialysis. We are not discussing pts like you at all and you are like the majority of my patients.

However, as in society in general, there is a subset of folks or pts that feel life owes them. In life they can't live by the rules of society and in dialysis that feeling carries over.

I'm an advanced practice nurse in two dialysis units with a total of 200 patients. I also work weekends and see all our inpatients on my scheduled weekend. As you well know, most dialysis pts are there due to hypertension and/or diabetes. Many are noncompliant with their care BEFORE renal failure sets in.

The patients we are discussing are those that spit on us, atttempt to hit us, threaten us verbally or are physically aggressive. Sorry, but this is not to ever be tolerated for both the staff's and other patients' safety. These pts belong in jail - where folks that can't live within society's rules.

As to payment. You are right that Medicare bundles payments. However, after several months on dialysis, you qualify for Medicare which picks up 80% of the billable amount and then your secondary private insurance should pick up the 20%. I can't imagine living on dialysis and I'm sorry that you have experienced poor care. That should always be addressed too with the unit manager, area manager and on up the food chain.

Care goes both ways.

errosmith · May 28, 2008

quote: However, as in society in general, there is a subset of folks or pts that feel life owes them. In life they can't live by the rules of society and in dialysis that feeling carries over

You are so right! People by nature are egotistic. Me first attitude. Being in the health care field (transfusion medicine) I do see a lot of this from donors who donate. Some do it out of the pure goodness of heart and expect nothing in return, others donate to make themselfs feel better and expect to be honored and patronized every minute they are at the blood bank. Some donate to have control over you with threats, ie, if you don't take me first I will not donate. Some donors are just unhappy and mean people regardless of the gift they are giving.

Dialysis is like this is many ways with both staff and pts. Unhappy people, before renal failure, are going to be unhappy dialysis pts regardless. Staff who normally are/have an in charge attitude will carry this trait over to dialysis. You will constantly have conflict. Pts who once were in charge of their lives are now adapting to words like, compliance, protocols, restrictions etc. Its a big life changing situation and many pts have fear and anger that tranposes to others. But under no circumstances should anyone tolerate abuse. Its not right and can be considered criminal.

Quote: As you well know, most dialysis pts are there due to hypertension and/or diabetes. Many are noncompliant with their care BEFORE renal failure sets in.

I do see a lot of pts who are diabetic at dialysis , hypertentive and with heart disease. I have none of these, and for that I am very lucky. Still I would not judge them for past mistakes for their lack of care to not be sick. We all have done things that are not good for us, eating too much, drinking, smoking...but not everyone is on dialysis. I do see these pts passively punished by staff for not taking better care of themselfs. Its as if they deserve to be punished by spending their lives at dialysis. Its a conflict...you screwed up, you should be punished. And I believe thats where the anger comes in, on both sides.

Quote: As to payment. You are right that Medicare bundles payments. However, after several months on dialysis, you qualify for Medicare which picks up 80% of the billable amount and then your secondary private insurance should pick up the 20%.

I have been on Medicare for about 6 months now. If all I had was Medicare, the unit would accept that as payment in full. Since I have other insurance, those are also billed to get the most out of my insurance to a higher rate than by just having Medicare.

As far as poor care that I have received in the past, I have always gone to the unit manager first followed by the network, risk management and CMS and the State Health department. Mental abuse is subjective. And with that being said, nothing is ever done to fix a problem. No corrective action is ever taken. The only results of this was that staff treated me with abuse to the point of me in tears most of the day, being put on paxil, unable to sleep nights and transferring to another unit. Transferring to another unit did not stop the problems at the other unit, those things still continue and I am not there to help the less than cognitive patients deal with it. For that I feel really bad.

Trauma Columnist · May 29, 2008

errosmith - have you considered PD or home hemo? What about the possibility of living donor transplant? I am sorry that you have had such poor care.

errosmith · May 29, 2008

I researched PD and is just is not a good idea. It takes so much room for supplies plus I have animals at home. Also it has such a high Insident for infection. Home HD would not work for the same reasons above. Plus my family all work and I just would not feel comfortable, house not in order for company, phone ringing, dogs barking etc.

I have a living donor available but do not fit the weight requirements for a transplant at this time. My job right now seems to be to advocate for better treatment of dialysis pts and to call attention to changes that need to be made in dialysis care.

Trauma Columnist · May 30, 2008

Good luck errosmith - I'm sorry things aren't working out. The other option - are you eligible for weight-loss surgery? One of my pts did this, got a transplant and has done very well.

errosmith · May 30, 2008

Good luck errosmith - I'm sorry things aren't working out. The other option - are you eligible for weight-loss surgery? One of my pts did this, got a transplant and has done very well.

Yes, I am. I have done most of the required meetings and doctor visits but am now trying to get my thyroid in order. They will not accept you with a thyroid problem. I just started synthroid , lab work done again and have an appointment next week for follow-up. One hurdle at a time...but there sure are a lot of them.