Help required on stubborn patients

Jo Anne -OLD · Oct 17, 2004

Hi my name is Lara and I'm a first year occupational therapy student from England - whilst I realise that the website is custom made for nurses I hope that you'll forgive me for joining even though I'm training to be a lowly OT. But my reasoning for joining is simple - one of our tutors told us that our most valuble and precious learning tools as an OT is the wealth of knowledge that nurses hold on the aspects of our jobs that coincide - I joined so that perhaps I might be able to tap into that some of that knowledge so that by the time I qualify I will be able to be a better OT.:)
As part of my training I have to attend multidisciplinery problem based learning groups - for the latest scenario that we've had to cover we have to research how nurses avoid becoming frustrated when patients won't follow medical advice - a basic outline of the scenario is:
A middle aged man with type 2 diabetes (I believe that's the non insulin required type - but I'm not exactly an expert) attends an appointment with his diabetes nurse. When the nurse learns that he has not stuck to his diet plan she becomes frustrated and yells at him in front of other patients. In response to this the man replies that if hes going to die he'd rather die having lived a good life i.e. drinking alcohol and overeating.
For this scenario I was asked to research how nurses would combat their frustration in these types of cases. I have looked elsewhere on the internet and in books but was having little success and with my presentation due shortly I hoped that if I came to the source it may help.
If anyone can help me out on this topic I'd much appreciate it
Thanks
Lara :)
PS I apologise if I've put this in the wrong forum - if I need to move it can someone please PM me and I'll be happy to do so - Thanks

Oh, my goodness no! You can post here all you want. We need your expertise as well.

Please stay tuned...you will find this site most helpful.

Welcome to ALLNURSES GLAD TO HAVE YOU HERE.:)

Ross1 · Oct 17, 2004

Welcome to the forums. I have the utmost respect for OTs and wish that the utilization of OT services in health care settings was higher. You are creative problem solvers with a strong grounding in both the physical and psychosocial aspects of health.

As to the nurse you mentioned in the above vignette. I'm sure you recognize that the behaviour of nurse in the above vignette was highly inappropriate. For some great ideas regarding how to respond to such situations, I highly recommend the book, "Health Behavior Change: A guide for Practitioners." The authors, Rollnick (Psychologist), Mason (Nurse), and Butler (Physician) discuss the concepts of motivation and motivational interviewing. They explain how the traditional educational methods for health behavior change provided to patients is quite ineffective. I've read this book myself, and as a clinical social worker (MSW) and student nurse, I agree with its concepts and techniques. I know many health care professionals and organizations, including the Case Management Society of America, are now advocating this method.

hypnotic_nurse · Oct 17, 2004

If a nurse is yelling at a patient, she needs a different job. :)

It's unlikely she'd yell, truly. More likely that she might try presenting food choices in a different way to show him that he can have some of the things he likes (just not as often or as much) and reiterate WHY.

If she's frustrated about the situation, she will probably vent to a coworker later, but might very well use that energy trying to find another resource for the patient.

Antikigirl, ASN, RN · Oct 17, 2004

Well, that sounds like every single client I do CBG's on! LOL! I work with the elderly, and they are very set in their ways and most have a pretty "I am near the end anyway" attitude towards life! Oh yeah...its fun trying to tell them to please change eating habits or exercise...goes in one ear...and hopefully doesn't end up as a two hour chew out about "in my day nurses just treated wounds and shut up!"...

But, I am rather easy going...I guage a client very quickly by simply starting casual chit chat when I come in their door. I look at their body language and word choices and get a feel before I enter into any medical conversation! I find you learn more from a "so where are you from?" than "so, how is your day today?" or "so I see by this chart your cbg's are really high".

As far as the scenereo, I wouldn't have yelled at the client plain and simple...but if I was the next nurse that had to deal with a very upset client from this...

I would enter with a smile and casual conversation and guage the situation..if he is very angry, I would polietly ask if I may make an appointment with him at another time that is convienent with both schedules. Sometimes if you give something respectful, they will open up to you! I would be empathetic to his anger and upset, and direct the conversation more towards his aspects towards his attitude that he is going to die anyway, which should make anyone concerned! Most patients don't realise that there are so many painful complications with their disease processes...and sometimes when you simply have a few minutes to converse..it becomes plain what those are to them, and they sometimes re-think that whole death thing! That death thing is an unknown really, but pain...now that anyone understands and avoids!

One of the best tools, in addition to being real in coversation and being a good listener, is SITTING DOWN! Be at eye level of a client and make eye contact (if that seems comfortable to them...only make occasional eye glances and look towards them, some cultures do not like eye contact and it makes them nervous or uncomforable) and really look like you are listening! When you stand you don't look like you are taking the time to listen, and that is what they and you need! It also is a sign of superiority...and that closes doors more often than opens them :).

I have walked into rooms with a spitting mad client throwing things..and with a calm voice and sitting down I have been able to turn the situation around :) (learned it from my hubby who is a paramedic...he is so cool under pressure and always knows just what to say to get patients to trust him! Very good reference there! He deals with more frustrating cases/clients than I do! LOL!)...or sat down saying "whew..what a gorgeous day outside, makes me feel like taking a long slow walk and breathing in that crisp air!" and that normally gets people talking about their plans for the day..which generally includes meal times ...and for a diabetic..that is my in! :)

Hope that helps you..and btw, welcome! I really like talking to diffent types of medics...I learn more and become a better team player with all the displines..and you really need that! :)

talaxandra · Oct 17, 2004

Hi Lara, welcome - alternate perspectives are always beneficial :)

I'm very glad to hear that that's what your tutor has said about nurses - I think cooperation between us all is vital, and part of that is realising that we all have complementary skills, knowledge and experience.

For me the key to reducing frustration in situation like this is to realise (in the immortal words of Samuel Shem) that the patient is the one with the illness. This means two things - first is to remember that we're not sick, and what happens doesn't impact on us unless we chose to (ie don't agonise over trying to change what you have no control over); second is that the patient is the one who actually has to live with the condition and its' consequences.

I remember a guest lecture I did for a group of fourth year medical students a while ago - the class was on medical ethics, and I was presenting a case study, about a patient with complex medical issues who had refused treatment.

The medical paradigm tends, from necessity, to focus primarily (or even solely) on the medical aspect, with compliance a default position. As I said to the students, it's one thing for us to say what people should do, it's another thing to have to live with. Provided it's a fully informed decision, chosing to have a shorter but more glorious life is a valid option. The trick here is to determine whether that's what's going on, or if the patient is A) in denial, B) uninformed, C) bloody-minded, D) scared, E) all of the above... Our priorities are not necessarily going to be the priorities of the patient, and sometimes we just have to accept that.

My supervisor (whose class it was) told me that, weeks later, her students would be talking about something entirely different, then stop and say "But what would it be like to live with that?"

Katnip, RN · Oct 17, 2004

Hello, Rain. Welcome.

As far as the nurse who yelled, obviously that's not a great approach, and most of us wouldn't do it. Our responses are supposed to be therapeutic.

I suppose, exploring with the patient the consequences of his actions more deeply might help. After all, death is not always the worst thing that can happen. Long before that he could end up blind, amputated, and in a wheelchair. He may not realize that those things can sneak up on him fairly quickly and THAT would not be much fun for him.

In the end, it is his decision.

But, there will always be people who just refuse to comply then expect us to pick up the pieces when serious problems develop. You cannot force a person to comply.

Nurses are often frustrated by patients, trust me. Working in the emergency room, we see some of the most astounding cases of non-compliance. But we learn to take a deep breath, do what we can, and not take it personally.

SmilingBluEyes · Oct 17, 2004

You received some excellent responses here. I just want to welcome you to allnurses, Lara!

Rainclouds · Oct 20, 2004

Thankyou all so much. My prestsntation was earlier today and it went brilliantly. The tutor actually commended me on using the website as a source of information and had me give the address to my classmates so you may see a few more of us floating around. Once again thankyou all for your help and cooperation.

Lara