How do you deal with the name calling?

[pixierose, BSN, RN]

I have had a long string of bad evenings. I work in psych. Apparently I'm not the only one; those in my new grad residency have had similar experiences on telemetry, ED, med-surg, etc floors. No guidance was given by our residency superior; more a gripe session which is a pity.

Last night I wasn't fast enough apparently with meds for a particular patient; she told me several times that I was going to hell. Ok.

Another patient stated, "you're a terrible nurse! Just get me my damn meds!" when I got to her. Went downhill from there.

Granted, I work psych. One of my patients is detoxing so I just let her ramble the insults, didn't respond, and left.

However, the other one? She is borderline and paranoid, yes. But she just kept going off as I was starting to scan her meds from the WOW no matter what I said (or didn't). How I was a liar, how I was going to hell, and a whole slew of names. I finally had enough; after asking her to please lower her voice the 2nd time (she was beginnning to shout) I placed the meds back in the WOW and stated that she could have them after she stopped shouting rudely at me.

I then walked back to the nurses station. She was extremely angry ... but she did knock it off. Eventually.

After speaking to my classmates, it seems like this happens quite a bit ... psych patient or not (and there have been a lot of psych patients on floors who haven't been medically stable enough to come to us).

So what do you do when the nastiness rolls in as you're providing something like their scheduled 8p meds/prn pain/Ativan med which comes up a ton? I used every therapeutic communicative technique I could think of. Nothing. Ignoring? Nothing. Attempting to validate? Nothing. I wasn't even late with meds. It just seems like some patients are bent on venting their frustrations onto the staff ... and here I am, gritting my teeth and wanting to just walk away. Last night it worked for a certain patient; I just don't know if I did the right thing. It's distracting!

[Nurse Beth, MSN]

In working with behavioral health patients:

Remain calm and professional "I'm here to give your meds"

Set boundaries "That is not appropriate- please do not do that again"

Establish rapport "Sounds like you're having a rough evening. Want to talk about it?'

The response you've used so far are not working. Start practicing new responses and build from there. It's not easy but it's rewarding. Best wishes!

[pixierose, BSN, RN]

In working with behavioral health patients:

Remain calm and professional "I'm here to give your meds"

Set boundaries "That is not appropriate- please do not do that again"

Establish rapport "Sounds like you're having a rough evening. Want to talk about it?'

The response you've used so far are not working. Start practicing new responses and build from there. It's not easy but it's rewarding. Best wishes!

My apologies; I should have been more clear.

What do you do after the above that you stated do not work?

This week has been the first time that the above has truly just failed me. I typically have a good rapport with my patients, and I actually enjoy the hell out of my job. If I have an argumentative patient, I've set limits ("please lower your voice; it's disruptive to other patients") and use it to turn it back around to them (i.e. one patient was very angry, started yelling ... turned out she had a difficult probate hearing that morning that she was emotional about).

In the beginning of my shift, I make my rounds so that I check in with everyone ... not just during the heat in the moment interactions. Usually saves a lot of trouble.

But this week ... for example it's like ANYTHING I said made it worse for one patient in particular. She would start off the shift ok ... good rapport established ... and then as the evening went on would become more and more irritable, shouting my name across the nurses station and demanding a PRN that she says she has wanted for 30 minutes but hasn't asked for until just then. She's forgetful, so that doesn't help, but she doesn't want written reminders either. When I calmly explain that she has not asked but that I will get it for her, the (loud) insults begin. And they don't stop even after I give her the med. Or, one day I simply said, "of course, I will get that for you" (omitting the statement that she didn't ask as that didn't go well), same result.

Other nurses on the floor have done either two things in this scenario (so she's exhibiting this behavior to not just me): ignore the insults, or tell her to stop. Telling her to stop insulting them seems to up the ante ("please don't raise your voice at me; I treat you with respect and expect the same respect") doesn't sit well; she starts screaming in the milieu.

If I ask if she wants to talk about it, I get the ramblings of how I'm going to hell, I'm a liar, etc. it's not her, it's everyone else. That's why last evening I just walked away; I was getting way too distracted to safely administer her meds.

I've asked my nurse manager and my former preceptor and they said I'm handling it fine ... mainly because I'm doing the same things they are. It just doesn't feel right.

[NightNerd, MSN, RN]

The reality of psych is that sometimes nothing you do is "good enough" for the patient. Sometimes we need to satisfy ourselves with the fact that we kept our assignment safe and free of harm. It sucks when the name calling and manipulation start, though. =/

It sounds like you did everything you could, from trying to address deeper problems to setting boundaries to ignoring bad behavior. I think it was perfectly reasonable to walk away for a moment until the patient regained control. Sometimes they just need to tire themselves out; just close the door, if appropriate for the patient and unit, and let them get it out of their system. It's no verdict on you and your nursing care; some people just have really bad days.

[Sour Lemon]

Who are these patients to you and why do you care so much about what they think? I work in psych and get insulted a lot. It absolutely never bothers me- at all. If the patient is able to follow instructions, I will attempt to encourage appropriate behavior. If they're not able, I just let them yell, document and hope they take their medication. The difficulty comes when they want to yell at, and fight with, each other.

[pixierose, BSN, RN]

Who are these patients to you and why do you care so much about what they think? I work in psych and get insulted a lot. It absolutely never bothers me- at all. If the patient is able to follow instructions, I will attempt to encourage appropriate behavior. If they're not able, I just let them yell, document and hope they take their medication. The difficulty comes when they want to yell at, and fight with, each other.

Good point.

This particular lady, she does interrupt the milieu. I've actually had other patients get upset when she's getting louder and louder.

One other patient in particular tends to "feed off" this ladies ramblings. So once my patient is set off, this other patient seems to gravitate toward her. This patient also likes to involve other patients (i.e. "Can you see what they're doing? What liars! Etc etc") and other patients can't read, watch TV, etc; they're actually, for the most part, trying to ignore her.

I would truly like her to go to her room when she gets like this; however, this would need to be in a care plan and has already been asked by the nurses and PCT's. Administration/her psychiatrist don't agree.

[JBMmom, MSN, NP]

I've worked in long-term care for years, and I have walked out the door with a clear conscience every night- even the night I had a patient tell me she hoped that on my way home I had a fiery crash and died. In any patient setting, we're dealing with people that are ill to some extent. Pain/ disease/ dementia/ environment change, all of these things affect the patients and their ability to process. Does it excuse bad behavior? No. And there are some people that are just jerks in life. I think you're acting in a professional manner and that's the best you can do. I know that in all of my communication I am confident that whether it occurred between just me and the patient, or someone else was watching/listening (because you never know when they are), I would speak in exactly the same manner. You can't get through to everyone, you can't fix everything, and sometimes you have to just let it go. Good luck.

[pixierose, BSN, RN]

I've worked in long-term care for years, and I have walked out the door with a clear conscience every night- even the night I had a patient tell me she hoped that on my way home I had a fiery crash and died. In any patient setting, we're dealing with people that are ill to some extent. Pain/ disease/ dementia/ environment change, all of these things affect the patients and their ability to process. Does it excuse bad behavior? No. And there are some people that are just jerks in life. I think you're acting in a professional manner and that's the best you can do. I know that in all of my communication I am confident that whether it occurred between just me and the patient, or someone else was watching/listening (because you never know when they are), I would speak in exactly the same manner. You can't get through to everyone, you can't fix everything, and sometimes you have to just let it go. Good luck.

Thank you; your post made me feel quite better, actually. I'm doing the best I can under the training (and even additional reading) I have received. People are people, and as long as I can walk out those doors with a clear conscience ...

Thank you. Good advice.

[JKL33]

I would truly like her to go to her room when she gets like this; however, this would need to be in a care plan and has already been asked by the nurses and PCT's. Administration/her psychiatrist don't agree.

Well that's unfortunate. I would've recommended addressing it through the care plan too.

Anyway, along the lines of the good advice above - remember, no matter what specialty you may be working in, you are the one who decides how you feel about these random comments thrown in your direction by patients. That is one of the things I wish I would've really internalized years ago as a new grad. It isn't easy. The fact is, these types of comments are not personal; surely they would be made to whomever was assigned to provide care. Even if it is a "personal" comment (such as something about your physical appearance), it is just not personal. These days I can hardly imagine what slew of nonsense a patient could say to me that would rile me. As Sour Lemon said, they just aren't important to me (in that way) - meaning, I don't derive my general sense of self worth or my sense of well-being from patients.

I'm always looking to develop a rapport and to speak carefully using good therapeutic communications with patients, but if I know it's a situation that is not amenable to those techniques at that time, I concentrate on the task at hand, and on remaining professional/pleasant and not showing any particular reaction. It will become natural with practice.

Good luck!

[guest52816]

I worked at a psychiatric facility for eight months. Just recently left the position.

I empathize with you. Several months ago, I was in your exact position. The patient was BPD and Bipolar. She accused me of personally messing up all of her medications (despite the fact that I was the ONLY nurse who took the time to sit with her and try to get medication pass more suitable to her actual schedule). This goes to the point that with psych patients, there is often nothing you can that is RIGHT.

They are in a locked-ward for a reason. Just keep that in mind. This particular patient caused a two-hour code and hurled insults at me, another nurse and her own mother. I won't lie to you, it was mentally exhausting.

Again, keep in mind these patients are in a locked-ward for a reason. Don't take anything they say personally (good or bad). They will try and manipulate with flattery as well.

It seems to me that you did everything right, but didn't get a textbook outcome. That will happen a lot. Get a good support system (which includes coworkers) and let it roll, baby roll. That's all you can do. In no way is this a failure on your part. It is part of the patient's illness.

[hppygr8ful, ASN, RN, EMT-I]

My apologies; I should have been more clear.

What do you do after the above that you stated do not work?

This week has been the first time that the above has truly just failed me. I typically have a good rapport with my patients, and I actually enjoy the hell out of my job. If I have an argumentative patient, I've set limits ("please lower your voice; it's disruptive to other patients") and use it to turn it back around to them (i.e. one patient was very angry, started yelling ... turned out she had a difficult probate hearing that morning that she was emotional about).

In the beginning of my shift, I make my rounds so that I check in with everyone ... not just during the heat in the moment interactions. Usually saves a lot of trouble.

But this week ... for example it's like ANYTHING I said made it worse for one patient in particular. She would start off the shift ok ... good rapport established ... and then as the evening went on would become more and more irritable, shouting my name across the nurses station and demanding a PRN that she says she has wanted for 30 minutes but hasn't asked for until just then. She's forgetful, so that doesn't help, but she doesn't want written reminders either. When I calmly explain that she has not asked but that I will get it for her, the (loud) insults begin. And they don't stop even after I give her the med. Or, one day I simply said, "of course, I will get that for you" (omitting the statement that she didn't ask as that didn't go well), same result.

Other nurses on the floor have done either two things in this scenario (so she's exhibiting this behavior to not just me): ignore the insults, or tell her to stop. Telling her to stop insulting them seems to up the ante ("please don't raise your voice at me; I treat you with respect and expect the same respect") doesn't sit well; she starts screaming in the milieu.

If I ask if she wants to talk about it, I get the ramblings of how I'm going to hell, I'm a liar, etc. it's not her, it's everyone else. That's why last evening I just walked away; I was getting way too distracted to safely administer her meds.

I've asked my nurse manager and my former preceptor and they said I'm handling it fine ... mainly because I'm doing the same things they are. It just doesn't feel right.

Sounds like you are dealing with a borderline personality or perhaps one that has crossed the border entirely. The fact that you are not the only nurse she is targeting should give some idea that her behavior has nothing to do with you or your coworkers and everything to do with her psych diagnosis.

This is a person who seeks attention in the only way she knows how. In such cases I remind myself the she is the one with the mental illness and I am not. I am not going to change her - but I am going to medicate her, on time without being asked with everything in the orificenal that the doctor has ordered - unless there is a strong clinical reason not to.

Some people (especially in psych) you are not going to fix just stabilize.

Peace and Namaste

Hppy

[Nurse Beth, MSN]

My apologies; I should have been more clear.

What do you do after the above that you stated do not work?

You just keep doing the best you can do, which is really all any of us can do. You can't control her behavior, but you can take pride in your own professionalism.

Also identify your own triggers, meaning what remarks really upset you.

And thank you for being one of my heroes- a psych/behavioral nurse. Seriously :) Best wishes