Disruptive families in acute care settings

[1Tulip]

I have been trying to search out information on a topic and am coming up dry. So, I'm turning to my on-line nursing community. Maybe I'm the only one that's had this experience. OR it's something that is negative in nature and not reported.

Here's the deal:

Adult med-surg patient. Nurse and patient getting along OK. But then... some family member/significant other comes into the room, and inserts themselves between the nurse and the patient. This is usually like a twisted sort of advocacy role.

Example: Older lady involved in MVA. Has a non-surgical back, burst fracture at T-12, being managed conservatively with a "turtle-shell" type brace, pain management, PT/OT. Has a daughter that lives about 50 miles away who has been calling the floor multiple times per shift telling us what mom wants and needs and demanding information. Finally, shows up. Sits down on mom's bed literally between patient and nurse, picks up my rounding log and states categorically that I was not in the room at any of the times noted, that the log is a complete fabrication and that her mother was ignored all day. The patient was passive. Didn't correct her daughter.

Another example: Mother of a 45 year old patient tells us we are not medicating her daughter with enough opiate. Then tells us we're giving the daughter too much ("she'll never get off that stuff if you keep giving it to her like that...") on and on. We are incompetent, we are ignoring her, we're giving her too much or not the right medication. Again, the daughter is passive, allows mom to drive all the action.

Another example: Chronically ill middle age woman, brought up from PACU with a lot of co-morbidities. From the jump her sister is taking the pulse ox off the patient because the alarm was disturbing the her (the patient). I explain purpose of pulse ox. Sister says I'm full of it and she doesn't see any reason for the alarm to go off until her sister is in the mid-70's range and if I can't make the alarm fit those parameters, she doesn't want it on at all. (No, the family member has no medical/physiological understanding, is clearly picking a number out of thin air.) Again, the patient is passive.

Common features:

1. There is nothing inherently defective in the nurse-patient relationship.

2. Objections of family member not rational, and are resistant to any explanation or education. (In fact, in my experience any attempt to educate or inform is taken by the disruptive family member as self-defensive excuses by the nurse and validates their complaints.)

3. This behavior places a barrier between nurse and patient that is poisonous, inhibits continuous assessment, treatment and evaluation. Basically short circuits the entire nursing process.

4. It is not directed at any particular nurse, since none of the nurses are competent in the family member's eyes.

5. Lots of threats and implied threats : "I'll contact my lawyer." "Who is the CEO of this place?" "Wait till I tell the newspaper how awful you all are."

Please help me NAME THAT BEHAVIOR? What mesh-heads can I use to search the literature? Is it just me? Do all nurses see this occur? If it's not in the literature, why not?

ANYTHING you can tell me would be appreciated!!!

[Tweety, BSN, RN]

Sounds like you're being "assertive" and that is an effective approach because you're setting boundaries as to what is acceptable and what isn't. Remember too that what works in Boston doesn't work here in the South. LOL

[leslie :-D]

Sounds like you're being "assertive" and that is an effective approach because you're setting boundaries as to what is acceptable and what isn't. Remember too that what works in Boston doesn't work here in the South. LOL

heh.

i'm sure that's very true.

i'd never last working in the south.

give me boston, nyc anyday.

leslie

[AngelfireRN, MSN, RN, APRN]

heh.

i'm sure that's very true.

i'd never last working in the south.

give me boston, nyc anyday.

leslie

Aww, darn!

Does that mean you're never gonna come visit us?

[leslie :-D]

Aww, darn!

Does that mean you're never gonna come visit us?

where do you live, ang???

of course i'd visit you.:redbeathe

you just can't bring me anywhere.

leslie

[1Tulip]

Well, in these days of "customer service" most of us in acute care don't have that option. Personally, I feel better about myself if I don't dope slap families, although God knows I feel like it sometimes.

I can't speak for Subee, but what I got out of that post was we must set boundaries. We must delineate what is acceptable behavior on the part of a family member and not let them cross that line. Also, we must delinate what is acceptable on our part, and usually it's not giving into our base nature which is to get defensive and agruementative, or as earle58 says above "dope slap" them.

The conundrum I've felt is that neither my base nature, nor my professional know-how has been adaptive in these types of situations. What I have always done (necessary but insufficient) was to kick the issue upstairs, first to the Charge, then to the NAM. They did what they could, but it remained touch and go with the nurses trying to reach over the family member to carry out their duties as best they could.

The closest I got to giving in to any primal urge was to say to the gal who claimed the rounding log was false ... "Did you realize we have to enter the room to sign the log?" (Of course she did... she took it from the wall where it hung.) But, because logic only inflames these situations, she just sputtered and said louder "I want to notify the administration that you nurses are falsifying medical records." Then I said... "You're pointing to my signature. Are you calling me a liar?" She said yes. I said, as I turned my back to her... "Then, madam, we have nothing further to discuss." And we didn't. There was nothing I could say. It was a set-up and a manipulative ploy from the start. The daughter was not after any information. She did not bring up ANY deficiency real or imagined in her mother's care. She just wanted a scene. She wanted to be the center of attention. She wanted to be in control and make everyone dance to her tune.

I don't think we can win in these situations.

I will hasten to add that one of the incidents turned violent. The 45 y.o. BPD with the frantic mother, actually pushed me into a wall, (my knees buckled and I almost hit the floor as I was pushed into a walker that collapsed under me.) She also struck me in the chest and (when I was later trying to get a specimen from her catheter) beat me on the head. It was clear that her previous (non-violent) manipulation of her mother hadn't gotten what she wanted. But, after these physical outbursts, her mother responded by becoming more ramped up and lashing out at us saying our meds had made her daughter enter a fugue state in which she didn't know what she was doing. (That was when we had to get the shrink down to affirm that the patient was BPD, and not toxic on any meds.)

Ugh... It was Halloween. I will never forget that shift. I wasn't hurt. I just felt helpless to do my job, and there was no nurse there who could do anything different. I wanted to call security, but the NAM wouldn't hear of it. So, we muddled through.

Just another variation on the same theme, in my view.

[Pepperlady]

I am confused as to why your NM would not allow you to call security. The 45 y.o. was way out of line, no matter what she was in with or what allegations her mother was tossing around. Personally I would have had psych see her mother too.

We have a crisis intervention nurse in our ER and I have been known to call her and have her come talk to family saying "they are obviously in crisis, what else would drive such behaviour"...most back right down once the "psych nurse" comes in and does an "evaluation". Of course their role is to deal with patients in crisis, but hey, crisis is crisis.

[lindarn]

The conundrum I've felt is that neither my base nature, nor my professional know-how has been adaptive in these types of situations. What I have always done (necessary but insufficient) was to kick the issue upstairs, first to the Charge, then to the NAM. They did what they could, but it remained touch and go with the nurses trying to reach over the family member to carry out their duties as best they could.

The closest I got to giving in to any primal urge was to say to the gal who claimed the rounding log was false ... "Did you realize we have to enter the room to sign the log?" (Of course she did... she took it from the wall where it hung.) But, because logic only inflames these situations, she just sputtered and said louder "I want to notify the administration that you nurses are falsifying medical records." Then I said... "You're pointing to my signature. Are you calling me a liar?" She said yes. I said, as I turned my back to her... "Then, madam, we have nothing further to discuss." And we didn't. There was nothing I could say. It was a set-up and a manipulative ploy from the start. The daughter was not after any information. She did not bring up ANY deficiency real or imagined in her mother's care. She just wanted a scene. She wanted to be the center of attention. She wanted to be in control and make everyone dance to her tune.

I don't think we can win in these situations.

I will hasten to add that one of the incidents turned violent. The 45 y.o. BPD with the frantic mother, actually pushed me into a wall, (my knees buckled and I almost hit the floor as I was pushed into a walker that collapsed under me.) She also struck me in the chest and (when I was later trying to get a specimen from her catheter) beat me on the head. It was clear that her previous (non-violent) manipulation of her mother hadn't gotten what she wanted. But, after these physical outbursts, her mother responded by becoming more ramped up and lashing out at us saying our meds had made her daughter enter a fugue state in which she didn't know what she was doing. (That was when we had to get the shrink down to affirm that the patient was BPD, and not toxic on any meds.)

Ugh... It was Halloween. I will never forget that shift. I wasn't hurt. I just felt helpless to do my job, and there was no nurse there who could do anything different. I wanted to call security, but the NAM wouldn't hear of it. So, we muddled through.

Just another variation on the same theme, in my view.

Since when should administration interfere with a staff member filing a CRIMINAL COMPLAINT AGAINST A PERSON WHO COMMITTED ASSAULT? You have a legal right to call the police and press charges. There is no way I would allow any manager to bully me into not calling the police and pressing charges. JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Spokane, Washington

[Virgo_RN, BSN, RN]

Well, I haven't had anyone be physically violent with me, but I've dealt with some family members that made me want to pull my hair out.

Recently, older woman admitted with suspected PE, accompanied by a close friend. Close friend states she will leave once patient is settled in for the night. So, we get her tucked in, and friend comes out to the nursing station where I am charting my assessment. She proceeds to tell me all about the patient's breast cancer pain and how the patient will tell you she's not having pain and will not take any pain medications, how there are family dynamics going on and the children are not speaking to one another, and then asks me to call her after the CT with the results.

Okay. I guess you think I'm a complete idiot. I didn't notice the patient wincing with pain when moving from the stretcher to bed, or when she pulled her arm away from the other nurse who was trying to help her, and I did not notice the contradiction of the patient stating she was not painful while she clearly was. Nope. Didn't see it. I did not know the patient has breast cancer, as that information was not relayed to me in report from the ED nurse. Nope, we don't discuss patients' medical histories. Thank you for filling me in on all of this, so we can force your friend to take pain medications that she does not want, cause that's what we do. We have no experience with pain, so we need people like you to tell us how to be nurses (You should have seen the look on her face when I told her that we could not call her with the CT results. It was as if I had slapped her, even though I was very polite).

Of course, I didn't express these thoughts, but instead, used active listening techniques, with lots of nodding and "Uh huh"s, as if I were hanging on her every word, then when she was done, directed her to the elevator with a statement of concern for her well being, which was "Drive safely, and get some rest.".

That's generally how I handle these folks. I let them vent their little vents, appear to be listening, then go about caring for my patient the same way I would despite these people. While they think they've made an impact on the care their loved one is receiving, what they don't know is that their loved one would be getting the same level of care without their meddling. I figure I'm not going to change behaviors that they've had a lifetime to practice, so I just let them think I'm listening, while I do what I do.

[1Tulip]

I am confused as to why your NM would not allow you to call security. The 45 y.o. was way out of line, no matter what she was in with or what allegations her mother was tossing around. Personally I would have had psych see her mother too.

We have a crisis intervention nurse in our ER and I have been known to call her and have her come talk to family saying "they are obviously in crisis, what else would drive such behaviour"...most back right down once the "psych nurse" comes in and does an "evaluation". Of course their role is to deal with patients in crisis, but hey, crisis is crisis.

That is a superb idea. Does the "crisis nurse" only see pts. in the ER? Does he/she go to the units? Work just 9-5 M-F? How available are they?

Here is a caveat. A family member is not under our care. He/she can refuse to talk to the "psych nurse" and refuse to follow advice. But, it would seem to me, that an clinical expert in psych (Social Worker, psychologist, RN) can assess the situation and determine if the family member is manifestly irrational, or if there is a rational way to resolve their problem. It would further seem to me, that if the expert informed the NAM that the nurses have been placed in a bind, not of their making... that the family member is interfering with patient care (for whatever reason) and that the patient could be placed in danger...

THEN...

the administration would have to grow a pair, so to speak, and back the primary nurse and nursing staff. If the disruptive family member persists, then I would think we should be allowed to have security escort them out.

I like it. Don't know if I'd ever live long enough to see it, but I like it.

[1Tulip]

Well, I haven't had anyone be physically violent with me, but I've dealt with some family members that made me want to pull my hair out.

Recently, older woman admitted with suspected PE, accompanied by a close friend. Close friend states she will leave once patient is settled in for the night. So, we get her tucked in, and friend comes out to the nursing station where I am charting my assessment. She proceeds to tell me all about the patient's breast cancer pain and how the patient will tell you she's not having pain and will not take any pain medications, how there are family dynamics going on and the children are not speaking to one another, and then asks me to call her after the CT with the results.

Okay. I guess you think I'm a complete idiot. I didn't notice the patient wincing with pain when moving from the stretcher to bed, or when she pulled her arm away from the other nurse who was trying to help her, and I did not notice the contradiction of the patient stating she was not painful while she clearly was. Nope. Didn't see it. I did not know the patient has breast cancer, as that information was not relayed to me in report from the ED nurse. Nope, we don't discuss patients' medical histories. Thank you for filling me in on all of this, so we can force your friend to take pain medications that she does not want, cause that's what we do. We have no experience with pain, so we need people like you to tell us how to be nurses (You should have seen the look on her face when I told her that we could not call her with the CT results. It was as if I had slapped her, even though I was very polite).

Of course, I didn't express these thoughts, but instead, used active listening techniques, with lots of nodding and "Uh huh"s, as if I were hanging on her every word, then when she was done, directed her to the elevator with a statement of concern for her well being, which was "Drive safely, and get some rest.".

That's generally how I handle these folks. I let them vent their little vents, appear to be listening, then go about caring for my patient the same way I would despite these people. While they think they've made an impact on the care their loved one is receiving, what they don't know is that their loved one would be getting the same level of care without their meddling. I figure I'm not going to change behaviors that they've had a lifetime to practice, so I just let them think I'm listening, while I do what I do.

Yes, I think this is a case similar in many respects to what I am talking about. The "advocate" is placing herself as the one-in-charge. I-care-more-and-I-know-what-is-best. But she did respond to your efforts. Apparently she didn't like being cut out of the information loop, but she left and appeared to understand you meant what you said. (And I like the re-direction you used... "drive safe, take care of yourself." Nice touch. Appropriate. You didn't denigrate her, or blow her off.)

But take that "I'm the only one who understands and cares for her" thing an order of magnitude farther along the crazy scale, and I think you have a picture of what I'm talking about.

[4theBetterGetter, RN]

guilt....................

[Ms.RN]

i'm glad you brought this subject because i had problem with family members before. i calmly explained to the family and its like they are deaf and they didnt hear what i told them and they repeated what they complained about like 3 more times. i'm thinking this is not a control issue. i think these people have no sense of rationalization and i wonder how this people can live daily with no sense of rationalization. if they do have it then if someone explains something, wouldnt they listen to you?