New Grad learning how to deal with manipulative parents/families

[atxgirly]

Hey guys! I'm a new grad RN at a pediatric hospital and I recently had a situation arise with a patient and their family and looking back I'm trying to think about what I could've handled the situation better. I just received report on all of my patients, organized my brain, planned out my shift, etc. The night shift nurse told me there was a big ordeal about her son not getting the pain medicine mom was requesting overnight because they switched him off Toradol since it's damaging to the kidneys, and instead had tons of other options for narcotics or regular meds PRN. The attending was called into the pt's room at 3:00 am because mom was furious that we couldn't give a certain medication. So, during BSSR at 7am mom was complaining about how terrible the docs were, the nurse wouldn't give her son any pain medicine, etc. I rolled in the COW into their room and went over allll morning meds (she refuses half of them, but requests almost every PRN pain med on board). She kept throwing every nurse and doctor under the bus and said she wanted to speak with a patient rep to complain. Sure, no prob. We get them involved. Our charge nurses were made aware of the situation and tried to remedy it. Anyways, she was requesting Dilaudid at 7:30 am while I had the MAR pulled up, and I said, "mom I can try to see if he will take Norco first because the order says to only take Dilaudid if not able to take PO, etc. It will pretty much knock him out. Can we try Valium or something else?" Mom snapped at me and said, "this is the exact problem we had last night. I would like to speak with the doctors. Bring them in now!" I said, sure I will text them and let them know so they will speak with you about this during rounds this am." I let them know via text and they said to go ahead and just give it because she was demanding it allll night and wouldn't take no for an answer. So, I go draw it up in the med room and I hear mom come out in the hallway and started complaining about me to another nurse saying, "my nurse is taking forever to get his meds and my son is in excruciating pain. I'm tired of waiting for her. What's taking so long?" I poke my head out and said "ma'am, I'm drawing up his meds right now I will be in there in just a sec". I go in the room and ask the son, "how's your pain doing? Is it better or worse?" He said he feels fine. But mom was freaking out and over exaggerating. Then mom asked if we could change the orders from PRN Zofran 4 mg q4 to 8mg q4. I let the docs know and they said they couldn't even order it if they wanted to because pharmacy wouldn't let them overdose. They talked to her about it and she said she never asked for that much zofran, so the docs snapped at me and I told them she did the same thing to night shift. Sure enough, I checked the clinician notification and the night nurse contacted the docs about the exact same requests she had with me that day. Zofran 8mg q4 and Dilaudid instead of PRN Norco. This mom lied to get me in trouble and could possibly have jeopardized my license by overriding orders and demanding I give her son the strongest pain medicine we have when it isn't scheduled and it's used as a last resort med. I've had this family for 2 days in a row and she does not respect my time or understand that I have other patients that I care for. I spend a minimum of 1.5 hr at a time in his room doing total care. This lady is crazy and I'm having nightmares about the whole ordeal. Any thoughts or suggestions?

[caffeinatednurse, BSN, RN]

I don't work pediatrics, but I do work med-surg, and regularly work as a charge nurse on med-surg. I put out fires like this non-stop. What I've learned is to maintain defined boundaries and rules with patients/families like this. Use only facts when you're speaking to them. Like, "I understand you want this Zofran order changed, but I can see where the night shift nurse already addressed this with the doctor. It looks like they declined to change this last night because that would be overdosing your son with this med." Sometimes you have to be blunt before manipulative family members *get* what you're saying. If it continues after that, you can respectfully say something like, "I'm sorry ma'am but it's against hospital policy for me to give your son too much of a med against doctors orders." Which is truthful - I'm guessing your hospital does not want you overdosing your patients. I've pulled pharmacists and doctors in the room for back-up, too, when a family or patient gets really unreasonable with their med requests. Not all hospitals are able to do this, but I work in a small one where it's possible.

It's hard as a new grad because you instinctually thing you're being rude, but you're not. You're setting the tone for this relationship. She can't yell at you or chew you out, and while you will do everything in your power to take great care of her son, you also can't be pushed around and manipulated. Hopefully you have a good charge nurse on your unit that can provide back-up as well.

[Cowboyardee]

A degree of not particularly combative world-weariness often helps with these kinds of situations. Once you determine that a patient or visitor is being manipulative, it helps if your demeanor non-verbally communicates something to the effect of "ok lady, you're not my first fussy patient/parent and we both know how this game plays out; I'll call the doctor and ask because that's my job and I want to do right by your son, but still I can only do what the doc's willing to order and yelling won't change that or make the doc magically appear this instant." This works because panicky or manipulative people feed off your emotions and creating an alarmed response in you; it also works because it communicates that getting even more worked up probably won't have much of an effect.

Verbally, you should listen more than talk, express willingness to cooperate, but don't over-promise or get flustered or otherwise worked up. Document like crazy, in as close to real-time as you can manage.

[JKL33]

I agree this situation is immediately made worse by any degree of fear/panic on the part of the nurse. It is imperative that one way or another (whether new or experienced) we refuse to become flustered.

Remain strictly professional. Not nitpicking, but, for example, I would not refer to her as "mom" [I really dislike that even on a good day]. Or, ma'am. These little things are details that inflame people.

15 hours ago, atxgirly said:

He said he feels fine. But mom was freaking out and over exaggerating. Then mom asked if we could change the orders from PRN Zofran 4 mg q4 to 8mg q4 [...]

With the scenario you describe, I don't think this is any run-of-the-mill fire; it isn't going to be easily put out. It is interfering with care of this patient and other patients.

The more of a crowd (or variety of individuals) that becomes involved the worse it gets, because these people thrive on having everyone bending over backwards; the more the better. And as soon as people start compromising on common sense, safety, and ethics, the better position this woman is in to criticize you! This is unwinnable without someone putting their foot down.

Consequently...I typically use some accrued brownie points to insist that management take control of the situation. These situations call for real authority, and for authority figures to have skin in the game. In addition to that, all care must be provided in tandem with another RN.

Just the right-tempered, usually-experienced nurse could probably finesse this, but not necessarily unscathed, and the people who can handle this are not that common, even amongst excellent nurses. For that reason, I think as far as basic advice I recommend only doing what you know is right (not compromising where compromises shouldn't be made), and increasing your support though involvement by management.

[brownbook]

JKL33 is correct as usual. I was an 11 p.m. to 7 a.m. supervisor. Patients or family escalating is what supervisors get the big bucks for ?.

Tell them your supervisor is coming to see if she can resolve this issue, or something along those words.

[Nurse SMS, MSN, RN]

My tactic in these situations was to always do what was right for the patient and escalate anything else to people with more authority than me. Wanting more/different pain meds? Doc involved. Family shrieking in the hallway or being otherwise obstructive? Management involved, security too if its bad enough.

All meds given on time, regular hourly rounding, impeccable documentation and then notifying the charge nurse at the end of shift that I had my turn with this hot mess and someone else needs to be assigned to that patient tomorrow.

[JadedCPN, BSN, RN]

Yes to what everyone above me said.

Welcome to pediatric nursing , where having the parents at the bedside is either the biggest blessing or the biggest headache.