Difficult patients?

[nursingpower]

I've come to the conclusion that I may not know how to adequately deal with what I call difficult patients. Setting: ICU with 2 patient load.

I had a 71 y/o woman who was A+Ox3 that complained she could not lie on her back due to arthritis. So the plan was to have rotate side to side. She had a PCA and was encouraged to use it. It seems as this was working in the beginning. The first complaint was that the lift team was taking too long to get her out of bed. Then the lift team was taking too long to get her back into bed. She was still NPO (post op). She insisted on prune juice. Got the doc to change her diet and got prune juice. Then she calls me back and insists on an enema. I tried to tell her she hasn't eaten since surgery, sometimes it take a while for the stomach to wake up (postanesthesia). In the meanwhile she gets nauseous and I hate to run to treat her for that.

Once back in bed, she wanted the bed flat. Even with the bed flat at 0 degrees she kept calling me to come back to lower the bed more. I told her the bed is flat. I can't lower it anymore. She kept saying, "I want my head down more" or "I want my feet down more". I did dismiss this because I thought it was nonsense. The bed is flat,what more do you want me to do??? I need to tend to my other patient. If you are having pain use your PCA and it may make you more comfortable. It wasn't long before she called me back. Forget that I have anything else to do but tend to her. I spend literally 5-10 minutes raising the bed, lowing the bed, putting a pillow behind her, removing the pillow, raising the feet, lowing the feet. I felt I tried everything I could to help her.

Per management/protocols the HOB should be >30 degrees and for a while I allowed the patient to lie flat. For the second time the patient desaturated. Respiratory came to the bedside and sat the patient up to 30 degrees and explained to her she needs to sit up for a while, told her about pneumonia prevention, lung expansion, etc. The patient begin complaining she wasn't comfortable. Her daughter tried to comfort her and get her to tolerate being up. She still insists on getting an enema. I speak to the doctor who told me he wasn't going to order that. I go back and tell her that the doctor feels she doesn't need one at this time.

I felt this was the most demanding patient, I've had. Every time I leave her bedspace after each episode, I ask her if there is anything else I can do for her. When she said yes, she tells me the same thing: enema, lie flat. Whenever she did say no she would call me back within minutes to adjust the bed. Two times she called me back to say she had gas. The firs time, I asked was she having belly pain, she said no. Told her I needed to tend to my other pt who was in a-fib (I need to call the doc, mix meds etc). She continued to ask for an enema. I begged the doctor to please see the patients about her bowel concerns and he agrees to see the patients. I return to the bedside and she continues to complain. I say nothing else because all the time I spent explaining everything, she wasn't hearing me. The doc finally came, said that Milk of Mag and PRN enema won't hurt her. Told the patient he was ordering these things. She seemed to more satisfied. I did keep the HOB at 30 degrees as respiratory left it and the patient did not voice anymore complaints. Again I asked if there was anything else I could do for her and she stated no for the remainder of my shift.

It was so bad that my other patient told me, "I hate to bother you because she seems like a handful over there".

The next day, my managers call me in to tell me that this patient requested that I not be her nurse. Reason: that nurse doesn't care about my comfort at all. I feel that all of the things I did didn't matter. I might as well just left her lying in bed for 12 hours and this complaint I feel would have been justified.

My managers want to send me to classes, feel that I need counseling etc. I feel that this isn't fair. I'm left to wonder if this patient just didn't like me. Was she messing with me (head up, head down, wanting the bed lower even though it was flat)??

Only thing I could think of in retrospect was to have called management in to deal with her in the beginning when she was making all of these demands. I was getting overwhelmed, felt I was neglecting my other patient and fell behind in other tasks (giving meds, charting etc). I have no idea of what else I could have done. Management is concerned because this is the 2nd time in one month I was requested to not be the nurse. 4 times in 2.5 years that a patient has complained not being rude, disrespectful, unsafe, dirty etc but of me being "non caring" or "cold". I feel that it does come to a certain point that I feel a patient is being unreasonable and I stop responding to him/her WHILE I WORK ON THE ISSUE WITH ANOTHER TEAM MEMBER (respiratory, physicians, anethesia etc). I have called everyone but management because i feel don't want to bother them.

Your thoughts?? I'm open to any advice at this point to take into consideration. Sorry so long but I tried to sum it all up. Thanks for reading.

[riahroo]

I don't have much good advice for you because I'm in the same boat. I work in a nursing home and deal with this sort of stuff all day long. In my experience it doesn't do much to complain or ask for help from the higher ups. They don't understand what it's like to be in the trenches. They go by the old adage the customer is always right. I know you feel it is unfair to have to take classes but they may have some beneficial advice for this type of situation.

[xtxrn, ASN, RN]

There will always be patients who are not satisfied with anything, and are often scared to be alone. As for the enema and prune juice thing- at some age, it seems that LOLs (little old ladies, if I'm dating myself- not laugh out loud :)) join the Cult of Supreme Colon Consciousness.... there is no cure.

These patients are not going to be satisfied- all you can do is know in your heart that you did the best you could, and be glad you don't live with them :)

[Esme12, ASN, BSN, RN]

There will always be difficult patients and patients you can't please. It's not the 4 patients in 2.5 years but 2 in a month. Is there something going on personally that you are dealing with or unhappy with that may be affecting you demeanor? Are you do for some time off? Unfortunately in our profession we have to amintain unpopular rules (unpopular to our patients) but in this culture of reimbursement depending on patient satisfaction, management is going to be pressured to forget how difficult our jobs are in favor of patients whether or not they are right......which makes me worried for us all.

With management....stay calm. Listen to their......uhmmmm....how do I say politely....crap. Tell them what they want to hear.....you tried everything you could, you called for interventions, enlisted the daughter's help, recieved orders.....ask for suggestions on how they would have wanted you to deal with this patient. Play the game....to a degree.....but don't be a doormat either. Remember telling your Mom what she wanted to her so you could go out? Kind of the same principle. Try to hide your exasperation and if they start getting to you enlist the charge nurse or the nursing supervisors help. Ask you management what steps they felt you missed so you can improve the perception that you care to match how much you care on the inside. Yes it's a lot of lip service but it will help to get you back under the radar.

When patients start getting on your nerves....sit down for a second act like you have all the time in the world (which I know you don't) and ask......what can I do for you.......I am feeling frustrated because you are not comfortable and I want to make that better and everything I have done (sometimes it is helpful to insert the list of interventions here) hasn't helped and that bothers me. "What can I do for YOU" Act like you have the time for her......that sometimes helps. There will always be THOSE patients that just act out because of a personality flaw or just because they don't deal with illness well and some are just pre-madonnas.

:hug:Never let them see you sweat!!!!! :heartbeat

[xtxrn, ASN, RN]

There will always be difficult patients and patients you can't please. It's not the 4 patients in 2.5 years but 2 in a month. Is there something going on personally that you are dealing with or unhappy with that may be affecting you demeanor? Are you do for some time off? Unfortunately in our profession we have to amintain unpopular rules (unpopular to our patients) but in this culture of reimbursement deoending on pagient satisfaction, management is going to be pressured to forget how difficult our jobs are in favor of patietns whether or not they are right......which makes me worried for us all.

:hug:Never let them see you sweat!!!!! :heartbeat

Those horrible patient surveys- Arghhhhh :) It really ticks me off that medicine has become a popularity contest vs competition for good patient outcomes/care. :) Doctors, nurses, and everybody in the hospital are at the mercy of the opinions of those who have no idea what makes care good.... I had one patient who actually whined about the BRAND of bullion we had.... like we didn't make the Zagat restaurant survey, so we must be horrible.....

Patient care suffers because of those satisfaction surveys, not improves. Something has to be sacrificed to kiss _ _ _... JMHO

[nursingpower]

Is there something going on personally that you are dealing with or unhappy with that may be affecting you demeanor? Are you do for some time off?

Nothing that I am dealing with personally. I was off work for 2 months due to surgery. I was eager and could not wait to return to work. Live in a nice quiet neighborhood by myself. No kids, no pets. I find more peace at home that anybody I know. I even LOVE my job. I love what I do. No regrets in my choosing my profession/field. The only stress positive/negative happens at work.

The only thing that upsets me is that I pride myself in saying, "My patients appreciate what I do" It's the whole reason I went into nursing was because I had a bad hospital experience with a nurse. So when I have patients that feel I don't care IT BOTHERS ME.

One thing I can honestly say is that I used to be in the military and had a very tough upbringing. I am tall and appear "mean", "tough", "unapproachable" to some people from what I am told . I can be honestly happy on the inside but may be focused on a task and people will think I'm mad or upset about something. I am even misread by family and even my boyfriend at times. This is nothing new to me. One of the 2 patients this month said that he was "intimidated" by me. I was thoroughly shocked by that!

I have made significant changes in the past. I hold conversations to connect with my patients when I have time. I listen to their stories, laugh at unfunny jokes, and when they ask questions about my personal life I even talk about that. (i.e. Do you have kids, are you married, do you live in the area). Nothing inappropriate but I do the small talk with them even though I don't want to. I make sure I ask every time if they are comfortable before I leave (pain, comfort, need anything else??) I come back when I say and I try not to make promises I can't keep.

I am more than willing to take classes as suggested by management. I look forward to the input, class room discussions and overtime . I feel that I am a professional, I knew going in that I had to deal with insane, combative, delirious, demanding patients. I want to know the best way I can deal with this patient population. I've only been a nurse for 2.5 yrs. I do very well in all that I do except this communication issue. I want to improve on that so that even I can get along with or calm the most craziest patients and without them asking me to NOT be their nurse.

[rn/writer, RN]

The only thing that upsets me is that I pride myself in saying, "My patients appreciate what I do" It's the whole reason I went into nursing was because I had a bad hospital experience with a nurse. So when I have patients that feel I don't care IT BOTHERS ME.

There might be a clue or two in this paragraph. If you pride yourself on having your patients appreciate what you do, you are setting yourself up to be at their mercy. All they have to do to upset you is withhold appreciation. As you can see with this patient, some people are, for a variety of reasons, unpleaseable.

You said, "When I have patients that feel I don't care, IT BOTHERS ME." In a similar vein, you are saying that your goal is to have them acknowledge that you care. That's another bump in the road because, in a way, you are asking them to validate you as a nurse. That's not the job of the patient. Looking to sick/injured people to give you your strokes puts you and them in harm's way. It actually endangers you to put your self-worth as a nurse into the hands of people who are hurting and drugged and might not like some of the things they have to do to recover. They have many more things on their minds than, "Did I take care of my nurse's emotional needs?"

I'm not saying this to be harsh. Not at all. I'm suggesting that you revamp your thinking and decide whether you're a good nurse or not based on the care you give, not the patient's willingness or ability to say thank you. Does it feel good to have a patient say that you made a wonderful difference for them? Of course it does. But we nurses need to fill our emotional wells in other parts of our lives. We need to be able to believe that we did our best, even when the patient is a crabby complainer who can't be satisfied.

Your need for appreciation or at least some acknowledgment that you did your best for this woman made it personal for you. Here you are trying your guts out, and she has the gall to go and complain about you.

My guess is that she read this frustration in you and saw that as not caring about her. There is a grain of truth to her claim if you were jumping through her ridiculous hoops trying to get some kind of validation from her. At that point, even though you kept trying to fulfill her wishes, it appears you were also becoming annoyed with the situation. In part because you really wanted to help her. But also because you wanted her to help you feel good about what you do. You'd have to be a saint not to let any of that show in the hours-long confrontation.

So, what do you do about this? You rethink your goal of working for patient appreciation and their recognition of your caring. You refuse to take the lack of these things personally and chalk their silence or their guff up to the fact that they don't feel good and they are experiencing a frightening loss of control After all, you're seeing them at their worst.

Now, you work on building a new compass. You judge yourself firmly, but with kindness. You do not expect yourself to be Superwoman who never makes a mistake, but rather a nurse who really does care about her patients whether they can reciprocate or not. You let them off the hook and do what you can. When you've done everything you can, you take five minutes, pull up a chair, and tell the truth. "I've done everything I can think of. I have to be with another patient for the next half hour, but I'll come back and see if we can think of anything more to try." You can afford this kind of honesty if you aren't worried about losing your tip (appreciation).

If you can axe the old agenda ("I need to know that you know how much I care.), you will be freed from the hidden power struggle this patient may have felt. With that unspoken mandate off the table, patients will actually be more likely to sense that you care because you'll believe that about yourself and they'll take their cue from you.

You seem to have a teachable spirit, so learn from this. You're there to take care of your patients, not to have them take care of you. Get your emotional needs met away from work. Liberate yourself from expecting personal perfection. If you're wrong, own it, fix it and move on.

If you can learn this lesson, you will be a better nurse and a better human being. You'll be strong in your own heart and you'll be able to deal with difficult patients without taking things personally.

Take the classes, dust yourself off, and get back in the game.

[Esme12, ASN, BSN, RN]

There might be a clue or two in this paragraph. If you pride yourself on having your patients appreciate what you do, you are setting yourself up to be at their mercy. All they have to do to upset you is withhold appreciation. As you can see with this patient, some people are, for a variety of reasons, unpleaseable.

You said, "When I have patients that feel I don't care, IT BOTHERS ME." In a similar vein, you are saying that your goal is to have them acknowledge that you care. That's another bump in the road because, in a way, you are asking them to validate you as a nurse. That's not the job of the patient. Looking to sick/injured people to give you your strokes puts you and them in harm's way. It actually endangers you to put your self-worth as a nurse into the hands of people who are hurting and drugged and might not like some of the things they have to do to recover. They have many more things on their minds than, "Did I take care of my nurse's emotional needs?"

I'm not saying this to be harsh. Not at all. I'm suggesting that you revamp your thinking and decide whether you're a good nurse or not based on the care you give, not the patient's willingness or ability to say thank you. Does it feel good to have a patient say that you made a wonderful difference for them? Of course it does. But we nurses need to fill our emotional wells in other parts of our lives. We need to be able to believe that we did our best, even when the patient is a crabby complainer who can't be satisfied.

Your need for appreciation or at least some acknowledgment that you did your best for this woman made it personal for you. Here you are trying your guts out, and she has the gall to go and complain about you.

My guess is that she read this frustration in you and saw that as not caring about her. There is a grain of truth to her claim if you were jumping through her ridiculous hoops trying to get some kind of validation from her. At that point, even though you kept trying to fulfill her wishes, it appears you were also becoming annoyed with the situation. In part because you really wanted to help her. But also because you wanted her to help you feel good about what you do. You'd have to be a saint not to let any of that show in the hours-long confrontation.

So, what do you do about this? You rethink your goal of working for patient appreciation and their recognition of your caring. You refuse to take the lack of these things personally and chalk their silence or their guff up to the fact that they don't feel good and they are experiencing a frightening loss of control After all, you're seeing them at their worst.

Now, you work on building a new compass. You judge yourself firmly, but with kindness. You do not expect yourself to be Superwoman who never makes a mistake, but rather a nurse who really does care about her patients whether they can reciprocate or not. You let them off the hook and do what you can. When you've done everything you can, you take five minutes, pull up a chair, and tell the truth. "I've done everything I can think of. I have to be with another patient for the next half hour, but I'll come back and see if we can think of anything more to try." You can afford this kind of honesty if you aren't worried about losing your tip (appreciation).

If you can axe the old agenda ("I need to know that you know how much I care.), you will be freed from the hidden power struggle this patient may have felt. With that unspoken mandate off the table, patients will actually be more likely to sense that you care because you'll believe that about yourself and they'll take their cue from you.

You seem to have a teachable spirit, so learn from this. You're there to take care of your patients, not to have them take care of you. Get your emotional needs met away from work. Liberate yourself from expecting personal perfection. If you're wrong, own it, fix it and move on.

If you can learn this lesson, you will be a better nurse and a better human being. You'll be strong in your own heart and you'll be able to deal with difficult patients without taking things personally.

Take the classes, dust yourself off, and get back in the game.

Well said.......:heartbeat

QUOTE] The only thing that upsets me is that I pride myself in saying, "My patients appreciate what I do" It's the whole reason I went into nursing was because I had a bad hospital experience with a nurse. So when I have patients that feel I don't care IT BOTHERS ME.

One thing I can honestly say is that I used to be in the military and had a very tough upbringing. I am tall and appear "mean", "tough", "unapproachable" to some people from what I am told . I can be honestly happy on the inside but may be focused on a task and people will think I'm mad or upset about something. I am even misread by family and even my boyfriend at times. This is nothing new to me. One of the 2 patients this month said that he was "intimidated" by me. I was thoroughly shocked by that!end QUOTE]

I am glad everything is good in your personal life ...sometimes we are unaware how things from home affect our demeanor. You already know how you are percieved now moderate or soften your approach. Facilities have EAP or employee assistance that is confidential. Hve you tough about maybe talking to a counsiler on ways to help how people percieve you? It's free.........Embrace what class they ahve....take a deep breath. Truly.....it's just growing pains ((HUGS))

[nursingpower]

There might be a clue or two in this paragraph. If you pride yourself on having your patients appreciate what you do, you are setting yourself up to be at their mercy. All they have to do to upset you is withhold appreciation. As you can see with this patient, some people are, for a variety of reasons, unpleaseable.

You said, "When I have patients that feel I don't care, IT BOTHERS ME." In a similar vein, you are saying that your goal is to have them acknowledge that you care. That's another bump in the road because, in a way, you are asking them to validate you as a nurse. That's not the job of the patient. Looking to sick/injured people to give you your strokes puts you and them in harm's way. It actually endangers you to put your self-worth as a nurse into the hands of people who are hurting and drugged and might not like some of the things they have to do to recover. They have many more things on their minds than, "Did I take care of my nurse's emotional needs?"

Your need for appreciation or at least some acknowledgment that you did your best for this woman made it personal for you. Here you are trying your guts out, and she has the gall to go and complain about you.

I don't feel that I come to work to get "strokes" from my patients. I can careless if they compliment me, praise me or not. When I say I take pride, I meant that I enjoy that I can come to work to make a difference. If I was working for brownie points I wouldn't be a nurse. My thing is this: how can a patient say that I didn't care about her when I did all of the things I did to help. My charting reflected that. When management reviewed my charting, the orders that were placed during my shift, they did tell me, "Well it seems like you did try to help her". But you came off this way to her....

Actually I feel like maybe she felt I wasn't satisfying her emotional needs. Now I do feel like part of my job is to do that so I am trying to get better at that. I have patients that think I'm cold or uncaring because I don't want to tell them if I'm single or married, kids or no kids or what I do when I'm not at work. To me, I don't want to talk about those things because it's not work related...Does that make me an awful nurse?

[DookieMeisterRN]

These patients have to be scared to death being in a critical care unit. I know I would be if I were the patient. This lady was being a PITA but she obviously needed something you weren't providing. Whether that be empathy, some TLC, or just flat out asking what's wrong can help with some of these difficult pts.

I can't be sure that's the case really because I can't see how you interact with your pts. Body language speaks volumes and so does listening with your undivided attention. Now possibly there was nothing you could have said or done for this woman to make her happy. It might have been a good idea to ask the daughter in private if her mother typically acted in that manner. If no, was it anxiety, a med reaction, neuro changes, undiagnosed dementia?

I typically will chat with my pts and answer most questions and ask them in return. You'd be surprised how much you can learn about a pt just from casual conversation. When a pt is in the hospital, you, the nurse, are this pts lifeline literally. Try and see things from their perspective. They want to connect, to trust, to feel cared about and cared for. And there are just some downright mean and/ or crazy pts too

[anotherone, BSN, RN]

These patients have to be scared to death being in a critical care unit. I know I would be if I were the patient. This lady was being a PITA but she obviously needed something you weren't providing. Whether that be empathy, some TLC, or just flat out asking what's wrong can help with some of these difficult pts.

I can't be sure that's the case really because I can't see how you interact with your pts. Body language speaks volumes and so does listening with your undivided attention. Now possibly there was nothing you could have said or done for this woman to make her happy. It might have been a good idea to ask the daughter in private if her mother typically acted in that manner. If no, was it anxiety, a med reaction, neuro changes, undiagnosed dementia?

I typically will chat with my pts and answer most questions and ask them in return. You'd be surprised how much you can learn about a pt just from casual conversation. When a pt is in the hospital, you, the nurse, are this pts lifeline literally. Try and see things from their perspective. They want to connect, to trust, to feel cared about and cared for. And there are just some downright mean and/ or crazy pts too

Exactly some people might bennefit from a stat psych consult......

[anotherone, BSN, RN]

when these types of patients "fire" nurses i usually laugh since most of the nurses COMPLAIN A LOT when they are assigned these patients and they have to be rotated throughout the whole staff, where for the most part charge will try to assign the same pts to same nurse.