Define innapropriate?

maythen · Dec 16, 2004

At my small facility this type of behavior isn't uncommon and, unfortunatly, is tolerated. In this community our pts tend to be elderly, homeless, or have substance abuse issues (sometimes all three). Several months ago we had a homeless man that was absolutly impossible to place! He was non compliant, demanding, inappropriate, just about all that you hope NOT to see in your pt load.

He was especially bad at night. He would call for help to the BSC (he really did need help due to weakness and the WORST case of anasarca I've ever seen). But when he was done he would grab the nurse helping him back to bed (at night there's only one Aid for the entire facility), and begin fondling his testicles and stroking himself. All the while acting like there was nothing going on and calling us Darlin' and sweet heart.

It was HORRID. You couldn't get away from him. He really was quite strong in his upper body, but his legs were so weak and edematouse that he would hit the floor for sure if we didn't keep a good hold. He would also insist on us wiping him and would make inappropriate comments encouraging us to "dig in deep" around his orifice and testicles (his testicles were also severly edematous).

He was unpleasant most of the time, but only became overtly sexual on night shift. But this guy knew how to get away with it. Was always just fine when Admin was around, and never grabbed *us* sexually.

Eventually the small handfull of male nurses we have on nights started taking turns having him. At least he wasn't sexually inaapropriate with them, just demanding and unpleasant. But that really wasn't fair to them either, he was a real pain to care for.

We ALL complained, documented, wrote things up. Admin did NOTHING. We were informed that we needed to "take better care of him". And that they never saw any problems with his behavior.

Personally, I feel that a lot of this has to do with the fact that we don't have *patients* we have *customers or clients*. I'm now supposed to say "Here at (my hospitals name) we want you to be Very Satisfied with your experience. I have plenty of time right now. Is there anything I can get for you or do for you right now that would enhance your experience?" I'm supposed to say that exact thing before I leave any pts room. Every time. It's mad!

I'm not your waitress. I'm not your slave. I'm not your manicurist. I'm not your personal maid. I'm not your cook. I'm *certainly* not here for you to get a sexual thrill out of! I'm not here to kiss your butt either!

I'm your nurse. If I wanted to be any of those things I *would* be.

But the admin at my hospital is so bent on "customer sevice" that they turn a blind eye to the needs of their own staff.

When we're grabbed or hit or screamed at... we're basically told to shut up and take it by Admin. Most of our pts are mentally competent. The ones that aren't could have their symptoms managed if the MDs would quit leaving us with nothing but PO tylenol.

There are only two of the night charge nurses that will actually back us up, and that's only if they've got the time and the inclination. More and more I'm starting to see why so many nurses seek out other careers. I've only been working here a year, but the lack of support staff recieves (especially on night shift) is a recipe for burnout.

I've often wondered if the shift from pt to customer doesn't have an awful lot to do with why this behavior is allowed. Limit setting and all that doesn't work very well when the pt realizes that nearly anything is going to be tolerated. When there are no consequences to your actions... what's to stop you from continuing?

-Maythen

Thunderwolf, MSN, RN · Dec 16, 2004

He was unpleasant most of the time, but only became overtly sexual on night shift. But this guy knew how to get away with it. Was always just fine when Admin was around, and never grabbed *us* sexually.
Eventually the small handfull of male nurses we have on nights started taking turns having him. At least he wasn't sexually inaapropriate with them, just demanding and unpleasant. But that really wasn't fair to them either, he was a real pain to care for.
We ALL complained, documented, wrote things up. Admin did NOTHING. We were informed that we needed to "take better care of him". And that they never saw any problems with his behavior.
Personally, I feel that a lot of this has to do with the fact that we don't have *patients* we have *customers or clients*. I'm now supposed to say "Here at (my hospitals name) we want you to be Very Satisfied with your experience. I have plenty of time right now. Is there anything I can get for you or do for you right now that would enhance your experience?" I'm supposed to say that exact thing before I leave any pts room. Every time. It's mad!
I'm not your waitress. I'm not your slave. I'm not your manicurist. I'm not your personal maid. I'm not your cook. I'm *certainly* not here for you to get a sexual thrill out of! I'm not here to kiss your butt either!
I'm your nurse. If I wanted to be any of those things I *would* be.
But the admin at my hospital is so bent on "customer sevice" that they turn a blind eye to the needs of their own staff.
When we're grabbed or hit or screamed at... we're basically told to shut up and take it by Admin. Most of our pts are mentally competent. The ones that aren't could have their symptoms managed if the MDs would quit leaving us with nothing but PO tylenol.

It is so sad to read this. When events like this are not dealt with swiftly and effectively, ALL SUFFER. I agree. No nurse or caregiver should ever be expected to condone or excuse offensive behavior, especially directed at them. Do not think that his behavior may not be unnoticed by other residents. If you see it, other patients do to. It becomes a safety and security issue regarding the other residents. Regarding nurses, you are not the "sexy kitten" for Mr So and So. Giving platitudes to you by others to accept this type of behavior is a cop out and unacceptable. It makes sexually acting out OK, which it is not. You nurses need to ban together if you can, develop an behavioral mod action plan regarding his care and who is to provide it (male preferrably), and document, document, document. If the care person is female, it may be more appropriate to have TWO caremembers present during care. I would even suggest that each time care is rendered to said patient that I would start off with:

1) "I am nurse so and so"

2) "I am going to provide (state the specific care to be performed)"

3) "This other nurse is nurse So and So" with clipboard HIGHLY visible

4) "This other nurse will document what happens during the care"

--------The key is be Objective, objective, objective

If patient presents with a sexual behavior

5) "Mr So and So, (name the behavior observed) is inappropriate and the Other Nurse So and So has just documented that it has occurred"

6) If behavior stops, say "I can continue with your care if you agree to stop.

Otherwise (consequence), I will have another nurse assist you. Do you understand?"

7) If behavior occurs again, repeat steps 5 + 6.

8) If not effective, say "Since you continue to (name the behavior), I will have another nurse assist you."

9) Get a different nurse

10) If continues, a male nurse is most appropriate to perform care.

(In fact, I would inform the patient that he has 3 strikes your out...with regard to female nurses...3 times, you get a male caregiver... another consequence)

11) Document, document, document and forward interventions rendered and results to admin for admin to bare the burden of decision. If admin is worth their salt, they would ensure that a male care giver is available on each shift or have an agency nurse come in to relieve you or give you respite if all else fails.

Another key thing with sexually acting out patient is that when it occurs, be objective...give no, and I mean, NO EMOTIONAL RESPONSE to it which just gives a secondary gain to this type of person...he wants to see you emotionally respond...DON'T DO IT.

Other folks may say, just provide benign neglect to the behavior. However, if it has already been tried and found unsuccessful, I would not hesitate to implement the above...especially if benign neglect cannot be implemented without fail by "all" caregivers successfully around the clock. The Key is practical, consistant, and immediate nursing action. If not, the behavior repeats.

What I describe above is not harsh, but rational. It sounds, by the way you describe this patient, that he has descrimination abilities of correct and incorrect behavior as evidenced by his ability to refrain from it when certain persons are around to observe. Just because his wife is codependent on his behaviors doesn't mean that you are to be codependent too. Boundaries, behavioral expectations, consequences for behavior, and documentation are your tools. This behavior is not cute, not funny, or OK. By not intervening, it also places the patient at risk for physical harm if he should try this behavior on another resident, visitor or care giver who may not be able to restrain their own behavior in retaliation. It also makes your facility look bad.

A psych eval is definately called for as well, which may support your own findings.

Oh, and I agree, the worst thing that has happened to the history of healthcare was to make it a "business" with "service" excellence as the criteria of care to "clients/customers"...it sets up nursing big time, making us little more than waitresses/waiters. Healthcare has been equated with the Walmart or Hilton mentality now adays...thanks to the big boys and girls in suits. No wonder nurses leave in droves and the ones who stay burn out. Healthcare won't change until the mentality does first.

maythen · Dec 16, 2004

Thunderwolf,

Those are really great suggestions. But the problem is... most would need staff to implement it. My hospital is VERY small. It's not uncommon for a single nurse to have the whole hall. There's only one aid for the entire facility. Most nights I could probably scream my head off and no one could hear me. Last night was actually a really unusual night in that we had 6 nurses. Most nights there's only two or three of us. (that's if you don't count ER, CCU, or OB which are more heavily staffed but also seperated by locked doors and long hallways).

When I enter a room I'm doing it all by myself. Not neccesarily because it's safe or because I want to, but because if I dont then no one else is going to either. It's a small hospital, but it's spread out. We can't even go get help, because then that other nurses patients don't have anyone that can hear them. We also are not allowed to "leave our hall". So if there's only one person per hall, and no help... you're on your own.

Fortunatly, that particular patient finally did get placement. I doubt he's reformed, but at least maybe he's somewhere that has enough staff to deal with him, or administration to back the staff up. Please don't burst my bubble, I'm hoping really hard. :-)

We keep getting these notes from admin about how we're not supposed to move pts without assistance. Which is great for day shift, who have staff. But at night we're pretty much forced to either break the rules or else get another nurse to temporarily abandon her pts. We're also supposed to be using special lift boards and stuff. Which our head admin locks up in her office at night, and which requires at least three people to operate properly.

Maybe if the *entire* staff could pull it together... but I don't see that happening. The day shift thinks nights are sitting around on our butts eating bon bons while all the pts sleep. Night shift is angry because day shift has all the extra staff (and quite a few of the day shift are openly disparaging of night crew). Admin are all wearing magic customer sevice glasses.

It's just really not supportive in any capacity. Patients pick up on this stuff... and, unfortunatly, it often leads to them acting inappropriate.

In fact, I was discussing it with one of my co workers this morning over breakfast. Untill we can stop abusing each other, there's not much chance of getting anyone else to stop abusing us either. :-(

CrunchRN, ADN, RN · Dec 16, 2004

Maythen - this is so wrong it is just disgusting. I am totally against frivilous lawsuits, but these kinds of abuses are why they are warranted. Obviously it will take some tragedy for the administration to get a clue. I really wish I could do some thing to help, it is just outrageous. I hope you do not say that stupid statement about having plenty of time, blah, blah, blah - no one could choke that out with sincerity. I hope things do get better, somehow. You must be a really wonderful and dedicated person to continue working in these circumstances.

smk1, LPN · Dec 16, 2004

when i was an NA in assisted living i had this resident that one day walked down the hall with no pants or underwear on and as i tried to get hime back to his room he grabbed my buns and in the process rubbed himself on me... EWWW! but this resident had never done anything like this before, he had just had a 3 day bout with diarrhea and i think he was just not himself. I reported the incident to the nurse and other NAs and we all watched for further incidents. He returned to normal pretty quick and everything was fine for a few months and then another incident of flashing occurred. This time to a frail female resident. This made me nervous because he could sexually assault one of our residents. He was deteriorating mentally and in assisted living he was starting to need more care than we were staffed to give. This is when the RN came in and had a meeting with the director and he was moved shortly thereafter. I would never put up with being grabbed and touched inappropiately.

JHUBRAIN · Dec 16, 2004

I think the Psych eval is a good start. But, it seems this guy can do a lot of things and is not as "helpless' as it seems. i would always go in the patient's room in pairs and document. i do feel bad for his wife

when i was an NA in assisted living i had this resident that one day walked down the hall with no pants or underwear on and as i tried to get hime back to his room he grabbed my buns and in the process rubbed himself on me... EWWW! but this resident had never done anything like this before, he had just had a 3 day bout with diarrhea and i think he was just not himself. I reported the incident to the nurse and other NAs and we all watched for further incidents. He returned to normal pretty quick and everything was fine for a few months and then another incident of flashing occurred. This time to a frail female resident. This made me nervous because he could sexually assault one of our residents. He was deteriorating mentally and in assisted living he was starting to need more care than we were staffed to give. This is when the RN came in and had a meeting with the director and he was moved shortly thereafter. I would never put up with being grabbed and touched inappropiately.

Thunderwolf, MSN, RN · Dec 16, 2004

Maythen, I am glad that that patient is no longer an issue for you...but, patients like that will swing through your doors again down the road. It would be good if there was a protocol for your hospital to follow when a patient like this presents himself. It would be good now to develop one...an action plan. It will happen again. Do you want to be in that same situation again? Now is the time to plan. I hear you regarding the backbiting and disrespect nurses can have from one shift to the next. It is a shame. However, it IS a different world altogether during night shift. Lack of staff availability, as compared to days, will always be an issue. That is why a protocol for acting out patients is necessary. No different than a protocol if someone codes on your shift. I hope things get better for you. No, night shift does not hang around the desk eating bon bons. I've worked my share of nights. You can work your butt off. People have this wild notion that accuity suddenly drops at night, that all patients sleep soundly, and all is well during nights. Of course, this is a fantasy, but rarely occurs on any regular basis. Night staff personnel work just as hard, but in a different way. Just because docs, suits, tests, labs, activities, surgeries are much less to occur on nights doesn't mean you work less...a fantasy some have during days. No, we oftentimes need to work in each others' shoes to get the message. As a male nurse, if I had a female patient groping me inappropriately, I won't hesitate to implement change or some reassignment. If it falls on deaf ears and nothing is done and places me at risk as a person and as a nurse with a license, I wouldn't hesitate to look elsewhere for employment. I deserve better. So do you. I wish you well, Maythen.

Antikigirl, ASN, RN · Dec 16, 2004

I am very shocked that protocols are not in place commonly for this, or in other cases of physical abuse/emotional abuse/verbal abuse for residents in facilities. All facilities seem to have a "tell your administrator" in play (not in writing) but nothing about what will be done so that you know that your complaints are being followed up and implementations are to be done to try to quell the situation. There are sure as heck protocols for if staff does these to a resident, but rarely the other way around or resident to resident!

I was really thinking of getting some facts together and volunteering for an inservice on innappropriate behavior, but with little or no protocol at my facility to turn to...it would be more like a lecture about "okay this is innappropritate...why...and tell your administrator"..and pretty much that's it! I will still seek around and see what other info I can get about it and maybe get this set up, this and I wanted to do an inservice for spousal abuse in the elderly (we had an issue with this months back, two couples living in small apts...one very verbal abuse, one physical to the point of almost breaking a womans arm!).

IN those cases admin came in to talk to the residents and that was IT! Family involvement was little to none because their children grew up with this abuse in the family and it was sadly commonplace for them, and now that they are grown they want no part of that...I don't blame them, but not very helpful for us huh? But I find recognizing these types of abuses was poor, full of stigma's about 'being old and cranky", or again "oh that is the dementia" or even "well they are husband and wife, this has always been a part of their lives...he/she will cope with it". OH MAN those attitudes..I thought they were out with the dino's..but no..still so very much alive, and in geriatrics it takes such a horrible spin towards interesting (and incorrect) excuses!

And ayndim...oh you nailed it when you said NOT to have just men go in....We just hired two (oh boy that is another post all together, these poor guys!) and that was the FIRST suggestion I heard!!!!!! I said NO, that that was pretty rude of them to do to them, and sexist to a point to boot. I put that in the same catagory of "oh that is heavy, have the male CNA do it" or "that residents TV isn't working...let one of the male CNA's work on it..he is a guy!". UHGGGGGGG!!!!!!

Why does it seem that nursing in general still is stuck in the dark ages when it comes to inappropriatness with the sexes??? Female nurses are still seen as the "sex kitten" or "old fat one"...while male nurses just get the old "he must be gay"...makes me so sick...you would think we were done with that!!!!! And these attitudes certainly lay a foundation for inappropriate behaviors for residents.

Thanks all of you for posting...if we add new ideas, new implementations, thoughts, stories..maybe us reading these will come up with some tactics to help quell these behaviors, stereotypes, situations! Like others have said...we have to work together, and I am sure that together we can make a difference...even if the changes may take time...heck...LOL, welcome to healthcare..hurry up and wait..LOL!

aileenve, ASN, RN · Dec 16, 2004

The first thing is to document all behavior and comments, then order a psych eval. also the staff should whenever around this patient, tell him in no uncertain terms "That behavior is innappropriate"!, Do Not act "shocked", or upset, this is generally what reaction they want, only talk with him when necessary and eventually will get the message, Never reward bad behavior! :rolleyes:

maythen · Dec 22, 2004

The protocol for handling these issues is to write a "Quality Controll report" that gets sent to admin. Unfortunatly the result of these is always a note back on what *you* did wrong, with occasional "helpful suggestions" which are usually impossible to implement due to staffing or else outrageously unsuitable for the situation. In the case of this gentelman I was informed that I must have transferred him wrong, that I should be doing it with two staff members to assist me, and that if I had just been taking better care of his needs then he wouldn't feel the need to act out. It was reccomended that I spend more time in his room talking to him about what he feels would make his stay more "satisfying". I nearly vomited over that one!

There's an "ethics council" meeting at the end of this month. and the nurse I usually work with is part of the committe. He's one of the few BSNs we have and the hospital really listens to him. So he's taking some of my concerns to them for review. Maybe that will help.

But, then again, maybe it wont.

However, my BSN friend is leaving for hospice soon. He wants me to come with him. I've always wanted to do hospice at some point, but thought I would need at least 3 or more years of acute care. I'll only have about a year and a half of experience when he leaves. But more and more it's looking like the avenue I'll be walking.

That's a whole new set of problems :-) LOL