Patients' perception of your demeanor.

Fiona59 · Oct 24, 2011

Here in Canada, hospital nurses are unionized so we can't be fired because a family hates us.

We have a lot of nurses start in LTC and usually leave within three years due to unrealistic family attitudes. Even then, if there is an issue the unions are involved and in most cases the nurse is validated.

I remember one nurse who had a family that wanted "a smiley, perky nurse who gave off good vibes" and made one nurse's life a living hell and tried to "fire" her. The nurse got to charge and told what was happening, she was backed up by the residents who had had the same treatment. The patient was an off service patient from a specialty on a general ward. Problem was the nurse who the family hated had the specialty experience the patient needed. Patient's mother shows up at the desk demanding a new nurse. Charge explains that Nurse Y is a fully experienced nurse with five years experience on that service, provides excellent care and there is nothing wrong with her personality, oh, and she's the only nurse on the floor with the specialized experience that your daughter needs. Mother backs down and say's "oh well, then we'll keep her". Charge looked at the Mum and said, "Nurse Y has accepted new patients, I'm sure our new grad nurse will manage your daughter's care and gives off great vibes" and walked away. The daughter wasn't seriously ill, just a drama queen that needed a minor surgery.

The daughter left the next day. The new grad learnt alot from Nurse Y and Nurse Y went home without a migraine.

Ruby Vee, BSN · Oct 24, 2011

can't one project both niceness and honesty at the same time in nursing? there seem to be so many either/or scenarios presented on this forum. it happens in the bsn vs. adn debate; it happens in the management vs. floor nurses debates; it happens in the lazy pcts vs. lazy nurses threads.
particular wording you chose strikes me: being honest, imo, doesn't automatically mean blunt and terse. terseness often borders on rudeness.
i guess the fact that we're having this conversation provides more evidence that, indeed, nurses are actors on a stage. we are almost required in the current environment to be what our patients and families want us to be. if we have five patients, we might have five characters to play.
as a new nurse, i'll accept it for what it is, but it is also very difficult to do.

the problem is that one person's definition of "nice" is different from another's. i can be honest without being terse, but never learned how to be indirect. i say what i mean and mean what i say. if what i have to say is completely positive, people are ok with that. but if i have negative feedback to give, it's different. i'll never forget a former manager telling me that you have to say five positive things for every negative. if i have three positive things to say about my orientee's performance, do i have to come with with two more before i can tell her not to defibrillate artifact? if i have four positive things to say about your husband's recovery, do i have to make up a fifth before i can tell you that he really ought to use his incentive spirometer more?

dudette10, MSN, RN · Oct 24, 2011

the problem is that one person's definition of "nice" is different from another's.

good point.

when i used the term "nice," i knew it wasn't the exact word i wanted to use because of the different ideas of niceness, especially in the healthcare setting. i guess i would describe it best using opposing terms: not terse, not sarcastic, not belittling. that might not be everyone's definition, though.

i remember a post where a nurse got called out when she said during patient teaching, "i just want you to understand..." apparently, the patient thought that phrase was condescending. i thought it was perfectly appropriate wording. it was probably clear to the nurse that the patient was missing an important point she wanted to get across, and she was using the phrase as emphasis.

as sistasoul pointed out, you are sometimes screwed where patients and families are concerned, regardless of doing your best.

Altra, BSN, RN · Oct 24, 2011

I completely agree with Ruby and The Commuter -- people just don't want to hear anything that is not their definition of positive or "nice".

I can think of several families of ICU patients (and some who we repeatedly see in the ER too) who desperately need someone to be terse with them ... to say, "look, your mom isn't going to get any better. If you think it would be acceptable to her to continue with the trach, the vent, the dialysis, the g-tube, etc. ... then have at it. But even if you allow all these things, she will inevitably expire from any one of the many sequelae of mechanical ventilation and/or prolonged immobility. Take whatever time you need to make your decision, but that is the situation we're in." But this is not *nice*.

Another example: when a patient arrives in the ER I need information quickly to make decisions about how to proceed with care, what kind of room the patient should be placed in, etc. Getting that information from the patient and/or family is often like pulling teeth. I will need to redirect the conversation, tersely, if you begin telling me at length about your illness 3 years ago. Also not *nice*.

When a patient is c/o chest pain & nausea and is turning a shade of gray appropriate for a Halloween costume, I must be *not nice* in quickly removing all 12 layers of clothing and getting monitor leads & defib pads on the patient in the hopes that I can get them to continue to live.

To the OP: be uniformly professional to everyone, and able to adapt to different conversational styles when there is time to do so. (I'm sure you do this already - adapting to differences in knowledge base and education level, etc.) But don't sweat the small stuff ... patient complaints often do not reflect poor performance. Learn to take them with a LARGE grain of salt, and hopefully your management does the same.

allnurses Guide · Oct 24, 2011

I am very direct and to the point. Co-workers in the past have used the word "Blunt" and "terse" to describe me at times. I worry about this a lot as I get on the floor. And I have no idea what to do about it because most of the time when it was used to describe me I thought I was being pretty sociable and nice. Scary.

allnurses Guide · Oct 24, 2011

Oh...and when my son was ill I was desperate to find someone who would be direct with me. So many spoke in some kind of code..it seemed purposeful to lull me into not really knowing what the plan of treatment was or the intended outcome. I really wanted that..and once I found it, I stayed friends with those nurses. But yeah...I was probably in the minority.

canesdukegirl, BSN, RN · Oct 25, 2011

Someone has a sig line on this forum that I think is pretty accurate. Something like "People don't care how much you know, until they know how much you care." or something.
I've found that to be true in my short nursing career. Especially in the NICU. If a nurse is tender with their baby, the parents love them (and don't question their ability).
I'm an old guy with a background in military, law enforcement and corrections (death row) that now works in a level 3 NICU. I am often the one that is called when a set of parents need an attitude adjustment. The parents take it from me better than they do from any of my peers (all women). One family that comes immediately to mind was out of control, and i sat them down and squared them away for about an hour one night. They now bring their baby back to the unit all the time to see me. I got an invitation to dad's bday party the other day.
On the other hand, I'm also the nurse that gets the gifts from parents, have parents hunt me down on the unit even when I dont have their baby assigned to me just to say hello and goodbye, get asked "I know you don't have her, but can you keep an eye on Angel for us? We wish you were her nurse every day".
So, I guess my point is: It depends. I think you can be both structured/professional/competent-appearing AND friendly/caring/sweet-appearing.
For every parent that has lauded my work, maybe there have been 3 that complained about me. But from what Ive experienced, both types of presentation have worked for me.

Yep, that's my signature line. It has proven to be the keystone in my delivery of nursing care.

I believe that first impressions are lasting ones. I greet my pts with a smile, and let them know that I empathize with their situation. I outline the plan of care and then go about my tasks. I find that the use of humor is the best way to make some patients feel more comfortable, but you have to read your pt correctly.

Dudette, I can relate to your post. When my mother passed, I couldn't understand how the world kept spinning. My world as I knew it just ended. Why was there still laughter? Smiles? It was a slap in the face that the world DARED to carry on after the loss of such a brilliant and giving woman. Irrational, eh?

Yeah, that was grief taking up residence in my mind. I try to remember that when I am around families that are dealing with either the loss or impending loss of a loved one. Sometimes we find ourselves in awkward situations like the one you found yourself in that day, but most people understand that the world DOES carry on, despite the heaviness they are carrying. A few days after my mother passed, I LONGED for normalcy, and was relieved when people stopped tip-toeing around me. My brothers are such clowns, and it was their skilled use of humor that made others around them focus the beauty of Mom's life, and not focus so much on the loss of her life.

All you can do is offer understanding, compassion and excellent nursing care. The rest is largely out of our control.

That Guy, BSN, RN, EMT-B · Oct 25, 2011

As a new nurse I struggled with what face I should play with families and with pts. By nature I am a huge people person. I can talk to anybody, joke around with them and make them feel comfortable. On the other hand I have that "**** is serious" side that comes out when it needs to. I dont mind playing the part of nice and talkative to people but if it comes to it, I can get it serious too.

elthia · Oct 25, 2011

I have found most of my patients think I am calmly efficient, I am not a touchy feely rainbows, butterflies, and unicorns nurse. I do laugh and joke with my patients, if I catch them up walking in the halls as I come in, I do tell them that they are too well to be in the hospital and I am going to "kick them out", or "go home, I don't need to see you here." However, I don't hug and pat arms or check on pt's when I am not at work.

I still have no clue why some patients dislike me and others love me.

The last time I had a pt "fire me" she said I was the worst nurse ever, put in a formal complaint to the charge nurse, the nurse manager, the MD. All because I made her stick to her NPO status when she had a bowel obstruction, I explained multiple times that the "green stuff" coming out of the NG tube was a good thing, had the ERT nurse come to her room to explain it also, told her she could NOT keep taking the NG tube apart and removing from LWS, bumped up her pain meds, got her on and off the toilet multiple times.

My other 5 patients loved me. 2 even put in my name on the press-gainey surveys as one of the best nurses they had had. And one of those pt was a fresh post op thoracotomy with an epidural and 2 chest tubes.

I don't get it. I never had, and I don't know if I ever will. I asked her what happened, what I could do to make it better, all I got was an ominous "you know what you did". Per the charge nurse and the NM, I was not therapeutic and blew off her concerns.

sistasoul · Oct 25, 2011

I have found most of my patients think I am calmly efficient, I am not a touchy feely rainbows, butterflies, and unicorns nurse. I do laugh and joke with my patients, if I catch them up walking in the halls as I come in, I do tell them that they are too well to be in the hospital and I am going to "kick them out", or "go home, I don't need to see you here." However, I don't hug and pat arms or check on pt's when I am not at work.
I still have no clue why some patients dislike me and others love me.
The last time I had a pt "fire me" she said I was the worst nurse ever, put in a formal complaint to the charge nurse, the nurse manager, the MD. All because I made her stick to her NPO status when she had a bowel obstruction, I explained multiple times that the "green stuff" coming out of the NG tube was a good thing, had the ERT nurse come to her room to explain it also, told her she could NOT keep taking the NG tube apart and removing from LWS, bumped up her pain meds, got her on and off the toilet multiple times.
My other 5 patients loved me. 2 even put in my name on the press-gainey surveys as one of the best nurses they had had. And one of those pt was a fresh post op thoracotomy with an epidural and 2 chest tubes.
I don't get it. I never had, and I don't know if I ever will. I asked her what happened, what I could do to make it better, all I got was an ominous "you know what you did". Per the charge nurse and the NM, I was not therapeutic and blew off her concerns.

Your last paragraph just made me mad. I don't know how to just show the part of the post I want to reply to. I am out on medical leave for a few weeks and just reading these posts and I start to get stressed. I live in fear of what a patient or family might say. It makes me crazy. I am very attentive and do all that I can for my patients but you can never tell who is going to take something the wromg way.

**canoehead, BSN, RN** · Oct 25, 2011

Look, I'm going to be blunt.

"Patients don't care that you know until they know that you care."

Guess what...I DON'T care. Not about each individual the way their families do. I don't have time to talk the way I need to to get there, and still do the tasks. I don't have the emotional reserve to get attached to each individual patient and then probably never see them again. Even worse for me is the patients that die, or go home to less than ideal conditions. I do what I can, and I move on to the next shift. Even then, I've spent days with a headache because we had a string of horrible deaths. I don't care like family, but it still hurts. Are they asking me to invest more, feel more, worry more, until I lose my own identity? No way.

I DO care deeply about doing a good job. So you will get all the tasks done, and done correctly and on time. I'll be watching your vitals, and dogging the lab if we need the results ASAP. You will get the little things that should be done, but are often neglected in the ER (bath, toothbrush and toothpaste anyone?). I will also spend my down time updating your family about the never ending wait. I'll look for a way to make them more comfortable, if I have a second I'll make a tea/coffee run to the kitchen. If someone dies, if someone makes a stupid mistake, they are treated with respect. If I can "teach" some you of the coping skills I've learned in horrible situations I'll pass them on. If the family can't even think I will call in backup for them, or care for them too until they are able to manage.

I can tell you that all those extras look easy (it was just a cup of coffee) but to do it day after day, and keep up quality technical care takes practice and determination. I don't think our employers "get" this, and their emphasis on care over quality is only going to worsen survival rates. It's much easier to give the warm fuzzies if you let all the extra vital signs/lab checks slide. Warm blankets are nicer for me to give than forcing an extra IV line or 12 lead. If patients wanted warm fuzzies they could get them at home. I am working as an RN in a hospital...I provide lifesaving. If that's not what you signed in for, then move on.

canesdukegirl, BSN, RN · Oct 25, 2011

"patients don't care that you know until they know that you care."

guess what...i don't care. not about each individual the way their families do. i don't have time to talk the way i need to to get there, and still do the tasks. i don't have the emotional reserve to get attached to each individual patient and then probably never see them again. even worse for me is the patients that die, or go home to less than ideal conditions. i do what i can, and i move on to the next shift. even then, i've spent days with a headache because we had a string of horrible deaths. i don't care like family, but it still hurts. are they asking me to invest more, feel more, worry more, until i lose my own identity? no way.

i see what you are saying. you don't have to care like family, because to do so would be overwhelming. you seem like you have appropriate boundaries, as you should. having boundaries and having a sense of self-preservation doesn't mean that you don't care, canoe. obviously, you care. we can still show that we care without owning the strong emotions and horrible conditions that comes with seeing our patients and families in despair.

take for example when you are flying somewhere, and the flight attendants go through the instructions pre-flight. they instruct parents who are flying with children to take down their own o2 masks first and then place one on their child. our practice is much the same: we can't constantly bankrupt our own emotional reserves for our patients. we learn how to set emotional boundaries, but also know how to show that we care. we are at once offering empathy, but we never take on the emotional complexities of our patients and families. it is impossible to do so without being escorted to a padded room.

i do care deeply about doing a good job. so you will get all the tasks done, and done correctly and on time. i'll be watching your vitals, and dogging the lab if we need the results asap.

i would want you to take care of me or mine any day of the week, honey. you are spot on.

you will get the little things that should be done, but are often neglected in the er (bath, toothbrush and toothpaste anyone?). i will also spend my down time updating your family about the never ending wait. i'll look for a way to make them more comfortable, if i have a second i'll make a tea/coffee run to the kitchen.

updating families is so important. i thank you for doing this. when my mother was dx with renal small cell ca, she had mets to her brain that was causing seizures. she had palliative surgery to remove the tumors that were causing these seizures. it was instrumental to the retention of my sanity when the or nurse called to give me updates when mom was in surgery. because of my experience, i am also vigilant regarding family updates.

bless you for doing this.

i don't give a hairy rat's a$$ about tea. furthermore, i don't care if she has sweaters on her teeth. i just want you to tell me that my mom is still breathing.

if someone dies, if someone makes a stupid mistake, they are treated with respect. if i can "teach" some you of the coping skills i've learned in horrible situations i'll pass them on. if the family can't even think i will call in backup for them, or care for them too until they are able to manage.

ok, again, you can take care of me or mine anytime!

i can tell you that all those extras look easy (it was just a cup of coffee) but to do it day after day, and keep up quality technical care takes practice and determination.

the extras aren't easy, and most of us know that. the critical things are necessary, the extras are just that...extras.

i don't think our employers "get" this, and their emphasis on care over quality is only going to worsen survival rates. it's much easier to give the warm fuzzies if you let all the extra vital signs/lab checks slide. warm blankets are nicer for me to give than forcing an extra iv line or 12 lead. if patients wanted warm fuzzies they could get them at home. i am working as an rn in a hospital...i provide lifesaving. if that's not what you signed in for, then move on.

you are so right. we have to prioritize tasks and triage patients. warm fuzzies are appropriate when life saving measures have been accomplished. sometimes the families understand this, sometimes not. management seems to focus more and more on the 'concierge' mindset of our jobs, and not so much on the hours that we have spend dogging the lab for results, paging the attendings again and again, hounding pharmacy for meds that were stat ordered 2 hours ago, calling x-ray again to shoot a film for the central line that was just placed, the time it takes to review orders and double check them, or the hours of charting that it takes to complete in the wake of a code.

at this juncture in our practice, it does seem as if our technical skills, critical thinking skills, the implementation of plans using evidence based practice along with nursing judgment is not as valuable in the church of press ganey as providing a fluffy warm blanket to the patient that we just coded for 2 hours. oh, and don't forget the chairs that you must gather for the 14 family members of the patient that you soaked your scrubs for. just ignore that jittering in your arms. the muscle fatigue from chest compressions should go away soon...but remember that you must always smile so that you do your part in providing the highest press ganey scores! your manager will love you! (insert sarcastic/exhausted smile/grimace/projectile vomiting here.)

but honey, everything in your post resonates with caring. to implement tasks, prioritize tasks and treat the pt clinically is not uncaring. it is our job to do so, and to accomplish each task flawlessly and in a timely fashion. in effect, nurses are tasked with an overwhelming set of standards that must be carried out without error, and with diligence. nevermind the fact that our licenses and contingent livelihoods depend on our neverending vigilance.

yep. we signed on for this.

i am not suggesting that each and every nurse provide a stuffed animal and a song/smile to each patient. i am suggesting, however, that nurses show caring by updating family members, using anticipatory guidance with patients, and by providing the best nursing care that they can...no rainbows and unicorns necessary.