How to recover after inserting foot into mouth?

[eggyweggy, MSN, RN]

I made what I thought was a light-hearted remark to a patient a few days ago and the patient was completely offended by it. It's a big no-no to leave pills unattended with patients, but I have coworkers that do if all the time. Which means that I'm often in a position where the patient will say, "you can just leave the pills on the table. So-and-so does it all the time. I promise I'll take them when I'm done with x-y-z." My standard response is usually something along the lines of "that's ok, I'll bring them back in 15 minutes/after you've finished breakfast/whatever." Most patients are ok with that, but a few get all bent out of shape when I offer to bring pills later, telling me that I must not trust them. That's when I typically make a lighthearted remark like "I wish I could, but technically these are mine until you're ready to swallow them." Or "sorry, but I have to make sure that your table-mate doesn't try to swipe your lasix." Or even "you've got some pretty big pills - I want to make sure they go down ok!"

My tone is very light, and I'll smile or wink to make it clear that it's not an issue of me not trusting them to take their meds. So the other day, one if my patients kept asking me why I wouldn't leave the pills and without thinking, I said "there are a few controlled substances in the cup, wouldn't want them sold on the street!" I realize in hindsight that the remark was just a little too glib and I did try to backpedal a bit and explain that they make us count narcs and account for every little pill, so I'm reluctant to let them out of my sight.

But the damage was done. The patient feels totally insulted and has brought up my comment repeatedly. I have apologized profusely and reassured the patient that I absolutely do not think they would ever do such a thing, but the patient is still fixated on the exchange. I feel like a heel for unintentionally offending them, but bit sure what else I can do to smooth things over.

The majority of my patients laugh and appreciate my humor so I feel extra bad that it wasn't perceived as such. I feel terrible that I offended her to this degree. Any suggestions for stopping my monkey mind from dwelling on it? I feel like I've already learned that I need to know my audience a little better before using dry humor like that.

[CarryThatWeight, BSN]

No advice, but I completely sympathize with you because I could see myself saying that. I often joke with my patients too and it typically goes over well. I actually don't think what you said is bad at all!

[RN403, BSN, RN]

I agree with the PP. Don't beat yourself up we have all said something at one time or another that we wish we wouldn't have! I also use humour when communicating with my patients at times...just be sure it is appropriate and recognize when your audience might not enjoy your sense of humor the way you do.

[Gooselady, BSN, RN]

You must have hit a nerve

We can be as careful as possible, go to extraordinary lengths to be 'sensitive' and alert to people who tend to take things negatively. But you don't have that kind of TIME it takes with a patient. And sometimes, it's just gonna happen, to the best of us.

You are beating yourself up as if you KNEW what you said was going to upset the person, and you said it anyway.

Give yourself some credit for honestly having no idea, and the fact you are genuinely sorry.\

Now here's a hint about other people -- even PATIENTS, the nurse's very mission in life -- can be a-holes. Even mean people get sick. And if you've apologized profusely, and the patient continues to bring it up even after profuse apologies -- that patient is deliberately jerking your chain. They are being a bit sadistic.

Not that I am hinting you should be nasty right back (which I doubt is possible for you). I'm saying don't take it personally. It literally would have been anybody, that triggered this person's nastiness. You were in the wrong place at the wrong time, that's all.

One thing I might do is CONTINUE to joke with the patient, like really over do it until even they can't miss the darn JOKE.

But stop apologizing. This person is enjoying making you uncomfortable. Don't give them the means. You apologized and did your 'part', and that's all you need to do. But just cuz what you said was taken so poorly doesn't mean it's your fault that it WAS taken so poorly -- that is on the patient. You'll find people like this both inside and outside the hospital.

[jadelpn, LPN, EMT-B]

Nerve hit. And one wonders what in the patient's history is hitting that nerve. Could be family giving patient "hard time" for taking narcs. Could be the patient feeling "badly" they have to rely on narcotics. Could be a political/social thing that the patient knows that people get them off the street, selling them brings big bucks, whatever--and this patient has to/has had to deal with a lot to get pain relief in the past. And just as a thing in the back of my head, perhaps the patient is hoarding some or a lot of them.

In my experience, I had a patient who was very into "leave the pills", which included narcotics. Was able to manipulate many nurses to "leave them". I would say things along the same lines as you "eh, we get in trouble for leaving pills..." some lighthearted thing. CNA goes in a few days into this admission, and lo and behold, is asked to grab patient's bag. CNA accidently dropped bag, and out rolled what must have been 30 pills. CNA panics, patient is really angry. Come to find out, the patient was concerned they were not getting adequate pain control, so kept extras "just in case" as well as the cost of the medication upon discharge.

So, OP, if this is brought up again, I would say "You know, I was really attempting to lighten the mood in that I KNOW you like your privacy and independence when taking your meds, and our policy is that I need to dispense and observe. And I have apologized for taking that concern lightly. So now I really want to get to the heart of this issue. Are you feeling as if your pain is getting out of control? Are you feeling like your meds are not holding you? Are you concerned about how you are going to pay for these medications when you leave? These are all things I can get you help for, but we need to talk about your concerns. My goal is for you to function when you leave here. So lets talk about that."

People get really weird about meds. Some long term chronic painers are in a constant regulatory process for obtaining prescriptions, that they get alllll sensitive about buying/selling on the street when they have to sign and "plead" and go through hoops to get adequate pain control. And some still don't get relief to the point of function.

Others can't afford all of their meds, so they play the "I will give you 2 Percocet for you to give me 2 ativan cause you have better insurance than me......" or even the "I only take one puff of my inhaler every other day because it is too expensive....then I have to take a Xanax because I get nervous I can't breathe...." You know the drill.

Explore what is behind the reaction.

Best wishes!

[eggyweggy, MSN, RN]

Thanks for the support and the insight. Yep, I definitely hit a nerve. This patient is dealing with a lot of issues related to being sick, including a general dislike for taking pills and some personal issues with needing narcotics to manage her pain. My comment was, unfortunately, not the right one to lighten the mood in this situation. Jadelpn, thanks for your suggestion for how to address if she brings it up again. I like that approach because she's dwelling on my comment for a reason that is likely more related to her terminal diagnosis and the loss of autonomy that comes with being in a facility because you're too sick to go home. She is an absolute sweetheart and our nurse-patient relationship is fine aside from this one issue. I think a lot of it has to do with her not wanting to inconvenience the nurse by having us return with the pills at a later time and then feeling like she's being high-maintenance and needy, when I'd happily take care of a dozen patients like her any day. Case in point, she was apologizing to me last week for being so ill that we had to transport her to an acute care hospital for treatment. Meanwhile, I'm thinking gosh, I just want you to feel better and get the level of care you need and I really don't care if it means that I have to spend more time with you than some of my other, less acutely ill, patients. So it's probably one of those issues where she just isn't very good at letting people take care of her.