Compassion is a Commodity

marshmallownurse, ASN, RN

After five days off, I drive to work singing. I'm a little off-key, but the windows are up, and my favorite songs are all queued up in preparation for the forty or so minutes my car will take to weave through 1740 traffic on my way to a place that I used to call my sanctuary. I grew up in hospitals, I used to tell anyone who asked why I would ever want to be in this profession. This is my natural habitat. But I digress..

The point is that I've been away for five days, and I was, for once, happy to be going to work. Or, more appropriately, I was very, very hopeful that I will not feel the oppressive depression that work has been inducing lately. I want to love my profession. I employ so much conscious effort in staving off the negativity that overwhelms me when I remember that I don't know how to be anything else other than a nurse. When positive thinking, meditation, deep relaxation, venting, and all the other internet suggestions didn't work, I even sought out a therapist who might be able help me come up with other ways to start loving patient care again. That's how much I want to embrace this profession. But, again, I digress.

I am always cheerful when I walk through those double doors. I smile, I greet everyone appropriately, I take report, I assess my patients. It's the usual routine, bolstered by all the repetitive positive self-talk ringing inside my head. This will be a good day. I love my job. I love the people I work with. I make a difference.

Then one patient's CIWA rises to 28 while he's cussing at me. He swings at the staff and hurls misogynistic derogatory remarks while we empty his urinal and try to keep his trembling legs from sending him face down to the unforgiving floor. He doesn't show an ounce of decency until first the security guard then the doctor walks in. They barely say anything to him but he's suddenly reasonable. He gets back to bed. Even in his poor mental state, he respects them, these gentlemen who were kind enough to grace his presence for exactly two minutes.

But the nurses who struggle to keep him safe, who rearrange the entire unit so that we can put him in a room closer to the station because he's at such high risk of falling, who get yelled at by the doctor for calling for the nth time because he had no withdrawal medications onboard, who change his linens because, once again, this grown man has soiled himself, the bed, and the floor-we're just female dogs and prostitutes who need to shut the hell up or we'll get what's coming to us.

This is Day 1. It ended with a CNA sitting beside me at the station waiting to give report to the oncoming shift. She was pulled from the floor and had to stay at the patient's bedside for the latter end of our shift. For the sake of my patient's safety, nurses with full patient loads willingly surrendered their aide.

"You must not have been doing this for very long," she says, exhaustion apparent in her voice. She spoke with no hint of mocking or irony. "You still have a lot of compassion. Patient's like that-- they make it so hard to care."

pinkiepieRN · Nov 29, 2013

This is really good writing. I often feel the same way after coming in from a long weekend or even just a particularly good "day" (I work nights). Sometimes I try even harder to be positive and compassionate when I'm having a difficult shift, almost as a compensatory mechanism. :) Keep up the compassion!

Kooky Korky, BSN, RN · Nov 30, 2013

I'm not sure I'd force him to get cleaned up. If he's "with it" enough to notice and show respect to males, he's able to control his mouth and his behavior toward females. You are not required to endanger yourself by forcing him to receive care that he seems to not want and definitely does not appreciate.

Stop being a doormat so that he and others like him will stop walking on you.

There need be no arguing, no loud, angry discussions. Just do "no".

As for the doctor not ordering withdrawal meds, what is up with that? Your Manager/director needs to address that with the doctor who is neglecting to order appropriate meds. And if the doctor is not open to cleaning up his act, it's time to go to the Chief of the service.

Kooky Korky, BSN, RN · Nov 30, 2013

And you and your colleagues and your bosses need to set that doctor straight about yelling at you, especially when he is the one who failed to write proper orders (apparently, based on what you wrote here).

As for the security guard - the pt probably has been arrested in the past and fears/respects the uniform and badge and the authority behind them.

**canoehead, BSN, RN** · Nov 30, 2013

OP, I've been there. Even if you handle it perfectly (and I've never been perfect) that kind of patient is a trial for everyone involved.

marshmallownurse, ASN, RN · Nov 30, 2013

Oh wow, I do this too! Or at least try very hard to. I'm glad to hear I'm not so strange after all.

marshmallownurse, ASN, RN · Dec 1, 2013

I do appreciate the advice and agree completely that nurses are not doormats.

It seems I may have failed to state what I thought was implied, so here goes:

I will never share a play-by-play of any specific nurse-patient or nurse-doctor interaction on this board or any other like it. I am far too nervous to do that, thanks to all the horror stories about innocent sharing that turned into nightmares for the nurses involved. I may very well draw inspiration from my reality and experiences, but the narratives, though written in first person, are fictional. They are likely amalgamations of different aspects of events that I deem relevant to the emotions or issues I want to address - the "demons" I need to exorcise for the sake of my sanity.

That being said, I disagree that it would have been okay to allow a patient like this to be without care because he was "with it enough". I don't know how familiar you are with DTs, but patients in this dangerous phase of withdrawal are not in control of anything. All they have are basic instincts and they often hallucinate intensely. Knowledge of the pathology behind the withdrawing patient's mental state may assist healthcare professionals in simply brushing off the horror that may leave a patient's mouth at this stage. Unfortunately, our humanity can sometimes betray our logical understanding of altered brain chemistry. We can be worn down. Feelings, personal and deep, can seep through the cracks in our carefully-woven armor.

Offense, hurt, frustration--I sought to capture these forbidden emotions in this narrative, coupled with the common circumstances we often face: the inappropriate doctor, the difficult patient, the filth, the verbal abuse.. These are the bedside nurse's constant burdens, and they are the greatest challenges to compassion. In the end, that is the purpose of this article. I wanted to underscore the fact that sometimes, compassion - the core value of our profession - can be incredibly difficult to manufacture in the face of all the negative chaos so rampant in our chosen world.

jadelpn, LPN, EMT-B · Dec 1, 2013

Interesting read. I do take pause with an actively withdrawing ETOH patient not being medicated. That is wrong on a number of levels. ETOH withdrawal is multi-faceted, should not be personalized, (ie: female dogs, prostitutes) and perhaps the reason that any sort of behavior change is evident is due to a "male" is ususally a "doctor" and can get this man medicated--or at least in a patient's eyes.

Compassion for a patient--and yes, there are those who are in active withdrawal who soil a bed--is far different than internalizing and personalizing interactions with same.

It is of interest that when women are in the same situation, there's a tremendous amount of compassion shown. It is further interesting that if it is a demented or brain injured patient, more compassion applies.

Personal and deep feelings are for one's own life. In nursing, neither one should apply.

xoemmylouox, ASN, RN · Dec 1, 2013

You still care enough to try. That says a lot considering how frustrating caring for this type of patient can be. It's so tough to keep things like the pt being in withdrawal, in mind when they are talking down to you. Keep fighting the good fight and know you're making a difference.

marshmallownurse, ASN, RN · Dec 1, 2013

Interesting read. I do take pause with an actively withdrawing ETOH patient not being medicated. That is wrong on a number of levels. ETOH withdrawal is multi-faceted, should not be personalized, (ie: female dogs, prostitutes) and perhaps the reason that any sort of behavior change is evident is due to a "male" is ususally a "doctor" and can get this man medicated--or at least in a patient's eyes.
Compassion for a patient--and yes, there are those who are in active withdrawal who soil a bed--is far different than internalizing and personalizing interactions with same.
It is of interest that when women are in the same situation, there's a tremendous amount of compassion shown. It is further interesting that if it is a demented or brain injured patient, more compassion applies.
Personal and deep feelings are for one's own life. In nursing, neither one should apply.

I find that the bolded part does not apply to my experiences. My compassion and feelings towards the mentioned demographics undergoing significantly similar alteration in mental states/behavior don't really vary in terms of intensity. It would be interesting to hear other nurses' takes on this.

While I agree that personal and deep feelings should be minimized in nursing, I would love to see the actual percentage of bedside nurses who can completely shut these feelings down. While I strive to never cross the line of therapeutic relationships, my feelings continue to exist. I just refused to let them show or drive my actions as a nurse.

marshmallownurse, ASN, RN · Dec 1, 2013

You still care enough to try. That says a lot considering how frustrating caring for this type of patient can be. It's so tough to keep things like the pt being in withdrawal, in mind when they are talking down to you. Keep fighting the good fight and know you're making a difference.

Thank you. Every nurse needs to hear this once in a while. :)

tarotale · Dec 3, 2013

interesting, yet very sad because I deeply empathize.... i think what you described is the in the core of nursing burn out... the core i tell you. Yes, THEY make it hard to care.

Compassion is a Commodity

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