I need your advice/opinion desperately

[throwaway1]

I'm truly begging for advice. I am sick to my stomach. I can hardly sleep. I was tossing and turning into the early morning and had to call off work today. I had just gotten on shift yesterday and there was a patient I had taken care of before. She was on BiPap (which she usually ends up on) and was in the ER overnight on hold for the ICU since we didn't have beds. She was tearful from the moment I walked in the room. The doctor requested that we remove her BiPap for a few minutes for her to talk to family about where she would like to be transferred. Another senior nurse and I went in and removed her BiPap. Her O2 sat began dropping rapidly so we placed on on NC @ 5L and she came back up. She asked for a phone charger but we told her we didn't have one. I gave her a few minutes to talk on her phone. I relayed to the doctor which hospital she would like to go to. Then the requests started. She can be kind of demanding. She said that she has a headache and wants toradol since that normally works. I said no problem I'll let the doctor know. She said she wants to eat which I knew the doctor probably wouldn't allow but I said I'd ask. I told her the doctor says you can't eat but I got you another glass of water and let her have a few sips. He ordered magnesium on her so I drew the lab for that and hung her magnesium drip. I told her once the doctor ordered her pain med I would come back to give it to her and told her that it was time to put the bipap back on. I secured it and made sure that I asked her it wasn't too tight. She then states that she needs to use the restroom. I came back with her pain med. I told her that we should do a purewick since she is short of breath. She says I'm not short of breath. I want to get on a bedside commode. I said but your O2 sat dropped to 65% within 30 seconds when we took you off the BiPap. She did not need to be trying to transfer to a commode with the Bipap on. (We are also in the emergency room. It is ridiculous to think that staff should come transfer you with a bipap on to a bedside commode every time you have to go. I did not say this out loud. Just what I was thinking.) I ask if she's ever had a purewick before. She says well yeah. She says the ICU staff puts her on the bedside commode and I need to go desperately because you just gave me lasix. I say I will check with the doctor and walk out a bit frustrated and in a huff. She has had a purewick many times before. I ask the doctor and she says she will check with the ICU staff for consistency. (I normally try not to argue with the patient and just say it is up the doctor but I have been told to work on being more assertive per management. I don't want to keep immediately running to the doctor for answers I know so I tried to talk to her first.) They say, no we do not get patients up with Bipap on. I walk back in and she is hysterically crying yelling at me "I heard what you said" "You said "I'm not doing that." as you walked out the door" I don't deserve this. I want a new nurse. Get out." I tried to talk to her but she wouldn't let me. I don't even recall saying that but I guess it's possible. (Plus I don't really understand why even that phrase would be upsetting) In my four years as a nurse I've never been fired once. I am known as the overly soft and nice nurse. I know that I was more frustrated and less friendly than I normally would have been but I was still courteous. Nobody could believe that I was fired from a patient. I couldn't stop crying. I don't understand what happened. I am sick over this. I know I could have been more patient with her like I normally am, but it feels like if I am anything less than perfect, this is what I get? And when the doctor tried to explain she says the nurse was rude to me before that happened. I don't understand. I can't function like this. Please give me your opinion because I am baffled.

[throwaway1]

FolksBtrippin said:

I think you can improve on a few things.

1. Let a patient fire you without taking it personally. Sometimes patients do fire the nicest nurse. That's okay. You might even see it as a break from a difficult person. 

2. Understand that the patient was refusing a purewick, which is her right. Next time, get consent for the purewick before you give lasix so you don't have to find a solution for a person who has to pee really badly. If a patient doesn't want a purewick, offer a bedpan, and if a bedpan is also a no, then you have to let them use the toilet or commode. So think about this before it happens. 

3. You already know this, but I will second the idea that you should avoid passing the buck. Never pretend to ask the doctor and don't ask the doctor for things you know the answer to. Take responsibility. Both your patients and your coworkers will respect you more, even if they like you a little less. 

Thank you for your reply and advice! You are right that I need to take it less personally. I'd like to clarify a few things. I actually did ask the doctor. I did not pretend to check. The doctor told me ICU does not allow it and she herself double checked because we wanted to make sure we were being fair. I had only given the lasix 5-10 minutes ago so I thought I would have a few minutes of time. Since she had done purewicks with me in the past, I did not anticipate it being an issue. I will not make that mistake again. As for letting her use the bedside commode while attached to BiPap, it is considered a safety issue similar to how we don't let people up to the restroom who are extremely weak or came in for a syncopal episode (which is why ICU doesn't allow it either) So if she wouldn't accept the purwick and bedpan and it is a safety issue to let them up, I don't really know what else to do.

FiremedicMike said:

Pt was offered a purewick, did you not even read the post?

To the OP, sounds like this patient sucked.  I've never personally been fired from a patient but I'm sure I had patients who didn't care for me.  At the end of the day, you're an ED nurse not a floor nurse and it's a whole different ball game.  We have a unique job in the hospital and unfortunately you can't please everyone.

Move on from this and (I say this emphatically and not condescendingly) toughen your skin a bit. 

Thank you for your reply. I read it yesterday, and it turned my whole day around. I completely understand that I do need to toughen up my skin a bit. I have a habit of letting things get to me.

[throwaway1]

Emergent said:

Goodbye and good riddance to a demanding patient. Count yourself fortunate.  You did your best, but this patient had unreasonable expectations. 

Thank you. I really appreciate it!

[throwaway1]

brandy1017 said:

I think bedside nursing has gotten more difficult ever since administration refused to allow foleys.  This was because Medicare refused to pay for adverse events like UTI's.  Never mind the added stress and workload on nurses who are more short-staffed than ever, combined with the increased obesity of majority of patients along with multiple chronic illnesses.  I'm sorry a purewick is a poor alternative for a foley as they tend to leak if the patient doesn't lay perfectly still or if it is a cheap brand which staff has no control over!  I really think the foley free movement is overkill as there are silver antimicrobial foley's available that could be used as well as maintaining good peri care.

As to the patient firing you well, I wouldn't take it personally, instead I would look at it as they did you a favor!  As others have suggested plan for bathroom needs before Lasix in the future so you aren't rushing to deal with trying to convince a disgruntled patient to use a purewick or trying to find a commode and adequate staff or lift equipment to move them.

Your symptoms sound like anxiety which is rife in nursing, especially ER and other high acuity fields.  I would consider if a job change to something less stressful would improve your quality of life!  You don't have to be a bedside nurse forever!  It is not a badge of honor, nor does it make you a better nurse.  I would consider finding a job that doesn't leave you feeling so stressed and anxious that you have to call out sick after a bad patient interaction because the truth is there will be plenty of difficult patients and situations in the future.

I say this as someone who spent her career as a bedside nurse for almost 30 years in a high stress environment dealing with anxiety and many times dreaded coming in to work.  I would take as many low censuses as possible to deal with the stress and take vacations even if staycations to try to have work life balance.  The only thing I have to show for it is a small church pension, but now most places don't even offer a pension.  I wish I had listened to my heart and quit and found a less stressful and more pleasant job years ago. 

I took early retirement rather than continue under the unsafe working conditions end of 2020.  If things had been decent, I would have stayed.  My back was wrecked so I can't stand without pain, so I didn't try to get a clinic job.  I've had PT several times since I retired, and a few facet injections and now I just had an ablation which might help with the back pain, but even if it does it is only temporary. 

Don't let this happen to you!  Don't stay where you are unhappy and where you will just end up injured and used up in the end.  Your health both physical and mental is precious and a healthy back is vital to work and enjoy life!  Don't make my mistake!   

You are right. As I mentioned to the other poster, I had given her the lasix 5-10 minutes ago and she had used a purewick previously with me, so I wrongly assumed I had a few minuted to get things worked out. I won't make that mistake again. I've been weighing things up heavily the last few weeks due to a myriad of issues and I actually did decide this morning to send my resignation in. Onwards and upwards!

[throwaway1]

RatherBHiking said:

One day you're going to look back at this and think oh wow it really wasn't THAT big of a deal. You didn't harm her. Some people are difficult to work with and you can't please them no matter what you do. You sound like a very caring nurse trying to be patient and give the patient what they requested however, as you know, that's not always possible. You need to be firm and not waffle and say well maybe the Dr will allow it this time...people lie to get their way all the time. It doesn't matter if they allowed her in the ICU anyways because she is not there. You can be firm and nice at the same time. Say something like "oh wow I really wish we could let you get up but due your condition at this moment and our policy we aren't allowed and I agree it sucks…” If they argue back do not keep standing there and explaining or saying well let me check.... Say nope sorry and walk away to get what you need. You said you're known as the soft and nice nurse. That's the personality type patients think they can manipulate and get mad when they can't. It's not the best personality for the ER. If you love the ER you'll have to grow tougher and let this kind of stuff roll off your back. Think of the patients like your kids, you have to do what's best for them even if they don't understand or like it. If you just don't think you can deal with this all the time and/or find it too stressful look for a different job that fits your personality better. I know for me personally I would not enjoy the ER. 

Thank you very much for your reply. You are right. I didn't harm her. I just struggle to think that I upset her in an already difficult situation. I've come to realize more the last few weeks that I am not a good fit for the ER. As you said, if I really loved it, I would push through and do what I need to do, but I just don't think it's right for me nor worth all the stress to me. This incident is just one more sign to me. I put in my resignation to my manager this morning.

[RatherBHiking, BSN, RN]

There's nothing wrong with that. You are learning what your strengths and weaknesses are and you learn all kinds of things from every job you have no matter how short or long you've had it. I hope you can find a position better suited to your personality that causes less stress!

[FolksBtrippin, BSN, RN]

throwaway1 said:

Thank you for your reply and advice! You are right that I need to take it less personally. I'd like to clarify a few things. I actually did ask the doctor. I did not pretend to check. The doctor told me ICU does not allow it and she herself double checked because we wanted to make sure we were being fair. I had only given the lasix 5-10 minutes ago so I thought I would have a few minutes of time. Since she had done purewicks with me in the past, I did not anticipate it being an issue. I will not make that mistake again. As for letting her use the bedside commode while attached to BiPap, it is considered a safety issue similar to how we don't let people up to the restroom who are extremely weak or came in for a syncopal episode (which is why ICU doesn't allow it either) So if she wouldn't accept the purwick and bedpan and it is a safety issue to let them up, I don't really know what else to do.

Thank you for your reply. I read it yesterday, and it turned my whole day around. I completely understand that I do need to toughen up my skin a bit. I have a habit of letting things get to me.

I didn't mean to suggest that you pretended to ask the doctor. It's just something I've seen people do, and along the same lines of what I was talking about. I should have left it out of my comment to you. Especially since it seems like you needed to escalate this situation, given the fact that the patient was refusing to adhere to the policy of her not getting out of bed. 

I'm surprised to hear that you've decided to leave the ED, this must have been building up for some time.

Any idea where you would like to work next?

Along the lines of getting a tougher skin, I don't think that's possible, but I also don't think it's necessary. It isn't your emotions or sensitivity that cause the issue, it's the attachment of your self worth to the happiness of the patient. You need to feel like a good nurse, and when a patient fires you, you feel like a bad nurse. You don't need to get tougher, you just need to understand that patients fire good nurses sometimes. 
 

I sincerely wish you the best and hope you let us know how it's going.

 

[throwaway1]

RatherBHiking said:

There's nothing wrong with that. You are learning what your strengths and weaknesses are and you learn all kinds of things from every job you have no matter how short or long you've had it. I hope you can find a position better suited to your personality that causes less stress!

I learned a lot being there for sure! Thank you very much for your kind wishes!

[throwaway1]

FolksBtrippin said:

I didn't mean to suggest that you pretended to ask the doctor. It's just something I've seen people do, and along the same lines of what I was talking about. I should have left it out of my comment to you. Especially since it seems like you needed to escalate this situation, given the fact that the patient was refusing to adhere to the policy of her not getting out of bed. 

I'm surprised to hear that you've decided to leave the ED, this must have been building up for some time.

Any idea where you would like to work next?

Along the lines of getting a tougher skin, I don't think that's possible, but I also don't think it's necessary. It isn't your emotions or sensitivity that cause the issue, it's the attachment of your self worth to the happiness of the patient. You need to feel like a good nurse, and when a patient fires you, you feel like a bad nurse. You don't need to get tougher, you just need to understand that patients fire good nurses sometimes. 
 

I sincerely wish you the best and hope you let us know how it's going.

 

I've worked some in pediatrics in the past and enjoyed it greatly but decided against going completely into the field due to a bad experience I had in clinicals in nursing school. Silly, I know, but after working with some kids in the ER, I wonder if that might be a good avenue for me. It lights me up. And yes, there have been many other issues going on. The ER I'm working in has had 7 managers in 6 years. I've already had 2 managers in the 10 months I've been there. There is a lot of turnover and a lot of other problems which doesn't help in an already stressful department. I mean, they literally dissolved a bunch of nurses' positions while they were under contract and told them their only option to stay was to take over a 10 dollar pay cut. Needless to say, we lost many nurses that day so we got super short staffed. I had no orientation really to speak of. A nurse who was new to the ER and had only worked six months oriented me. There is even more, but I won't go into it.

Something really clicked when I read that I base my self-worth as a nurse on my patients' happiness. It's something that I've noticed of myself even in my personal life. I fall apart if I feel I've upset someone due to my mistake, unintentionally or not. I take it as a sign that I'm a horrible person/nurse and that I've failed.

Part of my struggle is that as I said, I wasn't my best self during that interaction. I think that if I had been my best self and she was still rude, it would be easier to let it go. However, I am usually very kind, patient, and understanding. (not tooting my own horn, I swear) I have always been the one that could take care of the overly emotional, dramatic, or difficult to please patient. I truthfully have in the past even been accused of being a doormat. I had talks with management about the need to be more assertive in the ER and due to a lot of work and personal stress, frustration with patients constantly arguing and refusing treatment, especially lately, I feel I was shorter with her than necessary. I could have reasoned with her more. As I said, I was not rude but the more I think on it, the more I know I should have been more understanding of her frustration and deescalated the situation instead of allowing my own frustration with her refusal to come through in speaking with her (which is why I think she felt I was rude.) Part of my feeling of failure in situations like this is that while I know that I did not deserve how she treated me, I feel solely responsible because I am the nurse. My job is to comfort my patients and not to let my own stress and frustration affect how I handle a situation. It makes me feel that I've let myself and my patient down but I also get so frustrated with having to be so perfect all the time. 

But the ER feels like a different ballgame. So many patients come in over and over crying over literally everything, anxious, and often extremely rude and/or demanding on top of that. When I first started here, I remember seeing patients come in crying and the other nurses rolling their eyes and being a bit cold and frustrated. I didn't understand it at first, but I find myself starting to feel that way too. It makes me literally hate myself and feel like a monster to say that sometimes you walk in the room and see that person who is always anxious/crying and demanding and you just want to walk back out (this patient was one of those people as well). You try to be kind, but recently it feels like my patience with fighting people just to do my job runs out. Just another reason I felt I needed to leave. I don't want to lose myself.

Thank you very much for taking the time to talk with me and give thoughtful advice. I appreciate it more than you know. It's given me some peace of mind. I will definitely update you all on what I decide to do. I'm spending some time soul searching and really figuring out where to go from here.

[brandy1017, ASN, RN]

I didn't mean for you to quit on the spot, although I found my best job when I did that myself.  It was not nursing, but it led me into it as I was doing secretarial work, word processing for an insurance company.  When I couldn't please them re speed no matter what I did, long story, I quit and gave my 2 weeks' notice and got a job as an ER admitting clerk.  The manager that hired me was really wonderful and kind, a true Christian who prayed for her people back when I was not close to God, but I guess she helped nudge me back.  It was my favorite job because it was enjoyable, low key and not stressful. 

I learned how much nurses did and gained a lot of respect for them though I didn't think I could be a nurse back then.  After working 5 years there I went back to school to my dream university and that is where I had the aha moment that I should go back to school for nursing.  But while school came easy, clinicals not as much due to my anxiety although I had very nice instructors and friends.  Then got the nursing job I stayed with over my career, but it wasn't easy at all.  Dealt with a bully out of the gate, an insane LPN who was jealous of new grads RN's just because she wasn't!  I persevered thru that and other issues till I finally took early retirement end of 2020.  

They used to send me job offers in the mail from hospitals, nursing homes and home care etc.  I considered them but most didn't come with a pension so that is one of the main reasons I stayed as well as free parking and I was close to work.

But the important thing for you is that with this nursing shortage you should have no problem getting another job.  Just take your time and find one that you will enjoy.   You can always do agency nursing to fill in the gap in the meantime.

[Lipoma, BSN, RN]

No way I'd be getting a patient who is on BiPap to the commode. One quick pull and the mask gets yanked off, O2 sats drop, and down they go to the floor. If they're able to tolerate being off for some time with some minimal exertion sure, I'll be in arms reach, if they become hypoxic just sitting there talking, they get a purewick. The fact she said "they do it in the ICU all the time" would warrant a stern response from me "well, we're in the ED, and the ED does things differently."

Otherwise, now you're being written up for being unsafe, the patient gets tubed on the floor, or worse, they arrest. This is where I do "paternalistic nursing" because safety > comfort. It took me years in the ED to set appropriate and SAFE boundaries for patients. 

You did the right thing putting the patient's safety above all. I've been fired 3 times in my 5 years as a nurse, and each time it was a blessing in disguise because I refused to be a pushover. Twice from a patient and once from a patient's family member. As for the being overly dramatic, I've seen patient's WALK from their car, through triage, and miraculously need a wheelchair to go from the triage room to the treatment area.

[Ruby Vee, BSN]

I've never been regarded as the nicest nurse on staff, but as a Crusty Old Bat with over 40 years of critical care experience, my advice is this:

People who fire you generally are just angry and trying to flex.  I've been fired many times, and it is nearly always something for which to be grateful.  Angry people more concerned about their "rights" than their health are not pleasant to take care of -- you dodged that bullet.  Frequently fliers are not generally pleasant to take care of (although I've had some frequent fliers I enjoy taking care of and believe it or not, some of them ask for me on admission).  You dodged that bullet, too.  It may have/probably has nothing to do with you.  I've been fired for being fat, for being white, for being blonde, for being young, for being old, for being the float nurse, and because I wouldn't give out my phone number.  (That was in 1980-something.  I don't get asked for my phone number any more.)  The nurse who *doesn't* get fired is probably not doing their job safely.  People will fire you just because they don't like the word "no."  

"No" is a valid response to a patient request/demand -- but make sure you explain the rationale.

As suggested before, plan how you're going to toilet the patient before you give the furosemide.  Get them to agree.  If they won't agree, a conversation with a male usually helps -- male nurse, male doctor, male respiratory therapist.  One time a male secretary got the patient to agree to stop asking for water while she was NPO.  I dunno why that works -- probably patriarchy.

If you're going to get the patient up to the commode against policy, having a doctor's order for it will probably save your butt.  It's usually worked for me, but your milage may vary.  Talk to you manager about it at your first opportunity.  Heck, text her and let her know.  Either way, get the doctor to talk to the patient.  (Or the male medical student.)  Don't ever tell the patient. you've talked to the doctor when you haven't.  All you need is for that doctor to drop in unexpectedly and look puzzled when she demands to know why he won't let her get up.  

And again, so you hear this.  Getting fired is a milestone, a badge of honor and usually a boon.  Patients who fire staff aren't easy or pleasant to take care of.  

[Jael]

Hello, I just read your post. I could empathize with you because the way you describe yourself at work and in life in general, resonated with me. Like you, I also beat myself up if/when I thought I could do/be better. What helped me with that was a fellow nurse I was lamenting to that I did not give it my best as I should have replied with: oh great, so now you realize you are not perfect, good, join the club. Now when something happens, I remember her wise words. Instead of commiserating with me and trying to make me feel better she told me the truth. I am not perfect, nobody is. Good luck with your journey, your patients are lucky to have you!