Piggy back off "Irrational Patients"

[SleeepyRN]

I wanted to start a threat that piggy backs off the Irrational Patients thread. I think the situation OP described wasn't a good example because in that case, the patient's behavior could have had a medical cause that needed further assessment and intervention.

However, OP had a valid point. I'm interested in ways all of you, my colleagues, handle patients who act entitled and seem to think they are our only patient. Feel free to skip my anecdote and go right to responding as it is lengthy :-)

One of many examples: I work in post acute rehab. I had a patient in extreme pain where I had to change her supra public catheter out. Right when I started, a CNA told me room 210 (opposite side of our building) is asking for pain medication. I asked her to tell the patient I was in the middle of a procedure, and would be with him when I was done.

As soon as I was done, I began heading to get 210 his pain meds. On my way I see an aspiration precaution patient (who was soon to have a procedure for g-tube placement in a WEEK) choking. I run in. Literally saved her life. The food that was completely blocking her airway was out, but she was still hacking up a storm from small pieces. I called the MD, and as expected he told me to send her to the ED. (She needed that g-tube placement NOW, not in a week. She was malnourished and dehydrated and had CHF, so more fluids wasn't an option.)

By the time I get to room 210 to give him his pain meds, 30 minutes had passed since the CNA had told me he asked for me. He. Flipped

Out. Yelling that I was "out there d***ck***ing around.

There is nothing atypical about this encounter. It happens just about every shift. Even if we weren't understaffed, he still would have had to wait 30 minutes.

I understand and empathize with my patients AND the family members more than they can possibly know. Even the irate ones. I became a nurse because of my experiences as a patient. Particularly when I spent time in ICU and put my call light on only for no one to come for an hour. I didn't understand. I DID think the nurses didn't care. I WAS a little angry. I was 21, in the ICU, scared, my family 1200 miles away. And my boyfriend was kicking me out of our apartment. I did not act out. I was not rude. You can advocate for yourself without berating staff.

I used to not let this behavior get to me. My other wonderful encounters with patients throughout the day used to outshadow the bad. That's no longer the case. I'm jaded after only a year in this facility. I've been reconsidering applying to our local prison to get away from customer service "nursing."

So how do you all set boundaries with your patients? I recently had a firm tone after a patient was screaming at me, and then was taken off the schedule and investigated after she accused me of yelling at her. No, I used my firm, nurse voice.

[Lev, MSN, RN, NP]

I explain in clear simple terms that "unfortunately" I was occupied with other patients when they called and that I came as soon as I could.

[loriangel14, RN]

I just remind them that they are not the only patient on the floor and sometimes they have to wait. I don't let it bother me.

[ruralnurse84]

We have a patient like that now, has been "firing" all the nurses and even called the FBI on us...nursing supervisor came in and pretty much laid down the law that she couldn't fire anymore nurses and she would have to listen to her nurse. Oddly that calmed her down and being firm with her worked better than being sweet with her. Fortunately I work in a hospital that has good supervisors who tend to believe our word over that of an irrational patient.

[Libby1987]

Other than the outliers, I don't deal with agitated patients in the popular way often advised on this forum. I'm not burnt out and my/our patients end up less agitated, which is good for everyone including me.

With the patient in 210, who has a legitimate reason to be upset (in our first world society where if the general you were honest, at least once you've become irritated over much less at some point in your life), I would walk in briskly, acknowledge that he's had to wait too long and tell him I'm on it right now and then he'd see me hurry out to go get his pain med. In other words, he would see me (I'm moving briskly) and hear me ("you've been waiting on me and that pain med for over half an hour, I'm going straight for it right now") that he matters and that I'm physically making the effort to meet his needs. (Which as stated was not the perfect number of ice cubes*)

He likely won't completely satisfy him and he'll still be mad at the overall circumstances, but it'll take the intensity down a bit. And then he'll go home and tell his home health nurse that his pain meds were always late but there was this one nurse who was too busy but at least seemed to give a crap. (I get this kind of feedback all of the time).

It doesn't take any more time to deal with it my way (*our* way) than the popular "take a stern tone" and burden the patient with all of the *poor you have too many patients with much more serious problems* approach and the outcome is better.

Try reading "Leadership and Self Deception". It changed my attitude, perception, practice and the culture of our company from the top down.

*all of these patient satisfaction practices stemmed from legitimate care issues, the fact that corporations are trying to improve satisfaction and reimbursement by focusing on pillows and sodas while not improving ratios doesn't negate that.

[SleeepyRN]

I would walk in briskly, acknowledge that he's had to wait too long and tell him I'm on it right now and then he'd see me hurry out to go get his pain med. In other words, he would see me (I'm moving briskly) and hear me ("you've been waiting on me and that pain med for over half an hour, I'm going straight for it right now") that he matters and that I'm physically making the effort to meet his needs. (Which as stated was not the perfect number of ice cubes*)

He likely won't completely satisfy him and he'll still be mad at the overall circumstances, but it'll take the intensity down a bit. And then he'll go home and tell his home health nurse that his pain meds were always late but there was this one nurse who was too busy but at least seemed to give a crap.

That is actually EXACTLY what I did. To a T. Then proceeded to be yelled at still for "d...ck...ing around out there."

I ignored it and hurried out, got his medicine, asked if there was anything else I could do for him and left to the next patient waiting for me.

I used to be able to brush off this behavior for years. I'm just in a place where I'm so done with it, but in no position to switch jobs right now.

Thank you for your response. I'm really interested in how everyone deals with certain behaviors. Me, sometimes I'm firm, sometimes I'm sweet and apologetic...it depends on the situation and individual.

[Libby1987]

That is actually EXACTLY what I did. To a T. Then proceeded to be yelled at still for "d...ck...ing around out there."

I ignored it and hurried out, got his medicine, asked if there was anything else I could do for him and left to the next patient waiting for me.

I used to be able to brush off this behavior for years. I'm just in a place where I'm so done with it, but in no position to switch jobs right now.

Thank you for your response. I'm really interested in how everyone deals with certain behaviors. Me, sometimes I'm firm, sometimes I'm sweet and apologetic...it depends on the situation and individual.

I'm rarely sweet and apologetic and I don't ignore the yelling but I do validate their pain and delay in rx etc. Nor am I play acting, I validate from a place of sincerity.

You're understaffed, yes? And the patients are truly affected by it? And probably act out not because they're just jackasses all around but because they have no control and some just can't maintain their composure under the conditions. It's not you persoanlly but the overall situation.

And if what you're doing is not working for you, consider trying something different, even if it goes against your natural or conditioned inclination.

[SleeepyRN]

I'm rarely sweet and apologetic and I don't ignore the yelling but I do validate their pain and delay in rx etc. Nor am I play acting, I validate from a place of sincerity.

You're understaffed, yes? And the patients are truly affected by it? And probably act out not because they're just jackasses all around but because they have no control and some just can't maintain their composure under the conditions. It's not you persoanlly but the overall situation.

And if what you're doing is not working for you, consider trying something different, even if it goes against your natural or conditioned inclination.

Much of the time their anger is absolutely justified....and I'm angry FOR them. I stand up for them to management and when I'm not at work I'm educating the public of the state of healthcare today and what we all can do about it.

The times I take it personally are when they are the very patient my heart is going out to the most, and I'm advocating for their behalf on the phone with doctors, but they don't know that. They don't know I go home in tears knowing the needless suffering they are going through.

They are taking it out on the wrong person (me) who works 12 hours during an 8 hour shift, no break, no food....

Their justified anger does not justify repeated verbal abuse toward me. That day we actually weren't short staffed.

[margin261]

Sleepy- what you're describing is why I left bedside nursing.

When I started my career in nursing 16 yrs ago in the hospital, those types of pts were few & far between. I had larger pt loads, but the paperwork (yes, on actual paper) was nothing like it is now & I actually got to spend time with pts. They seemed more calm & happier with their hospital stay & I know I felt like I made a difference & felt more satisfied.

Fastforward to 2014-15, working on the floor again after being out for years & it was so different. Pts acted differently & I had barely time to do the required things for the pt much less be able just to listen for a bit which often helps the most! I couldn't be the nurse I wanted to be & finish paperwork on time. I felt awful & stressed after every shift.

Yes, maybe your pt had a legitimate reason to be upset but not to speak to you that way. And I've been spoken to in the same way by pts that were angry that I was 'late' with their prn pain meds even though I brought them when they called for them. Angry because I didn't wake them up for their pain meds. You know, now that I think about it- I can't remember one time I was yelled at that it didn't involve narcotics...funny, huh?!

It got to the point I dreaded going to work every shift so I got out. I'm doing home health now. There's a s***load of paperwork there too- but at least I get to talk to the pts & feel like I make a difference.

[Libby1987]

Much of the time their anger is absolutely justified....and I'm angry FOR them. I stand up for them to management and when I'm not at work I'm educating the public of the state of healthcare today and what we all can do about it.

The times I take it personally are when they are the very patient my heart is going out to the most, and I'm advocating for their behalf on the phone with doctors, but they don't know that. They don't know I go home in tears knowing the needless suffering they are going through.

They are taking it out on the wrong person (me) who works 12 hours during an 8 hour shift, no break, no food....

Their justified anger does not justify repeated verbal abuse toward me. That day we actually weren't short staffed.

I'm not justifying how they speak to you, I'm offering a different way of handling and diffusing it a bit by reducing some of their anger, which is better for you and them.

You can keep doing the same thing and maybe venting about it is all you need. I can tell you though, as long as you are in nursing you will experience people on their last nerve and worst behavior.

[CanadianRN16]

There's a resident at the LTC facility I work at, where the resident calls their POA if they do not recieve their medication exactly at a certain time, or they do not like you and will tell lies about you. So for this resident, we have a policy of having at least another staffer present when entering the room at act as a witness.

I would advise you to do the same of you experience similar patients, and proceed to chart thorpughly whenever there is an alleged complaint towards you or another staffer. You never know what perception of an incident could get you fired or on probation...

[Lad345]

I use a few different things, depending on the severity of the belligerence. If I'm delayed by something serious and the floor is too busy for a coworker to help me out, I'll go in quickly, apologize for the delay using an even and uninflected tone, then launch into my pain assessment and scanning the band/med. If they snark off, I'll again apologize and ask if there's anything in addition to the med that I can do for them.

If they STILL continue to grumble, I'll tell them that while I'm sorry that circumstances beyond my control prevented a swifter response, I understand and acknowledge that they are frustrated. I then tell them that in order to improve our night, let's talk about how I can provide them with better care moving forward. Then I'll just keep changing the subject: Do they want the next dose as soon as it's available? Need ice/heat pack? Thirsty? Comfortable position? Need to go to the bathroom? Until they give up trying to get a rise out of me, and let it go.

I get that sometimes they just need to vent and smart off initially, but let's move on after. I don't operate in the past, and you're not roping me into an argument so you can report me. It happened, I've apologized, I've made amends, and I've encouraged their input on how they'd like the rest of the shift to go. I'm not going to use a soft, shamed voice and fall all over myself showering patients with apologies and play into their anger. I try to stay even-keeled and objective.

If they're cursing and yelling at me, I'll calmly and quietly scan them and the medicine and attempt to do a pain assessment. If they won't answer, I'll chart they endorse pain but refuse focused assessment at the time. After I've medicated them I'll tell them that their language is inappropriate, apologize again for the delay, and inform that I will be bringing another staff member along each time I return until we can speak to one another calmly and with mutual respect.

Last of all-- if they're yelling, carrying on, AND threatening me or using aggressive body language, I tell them from the doorway that I will not be entering the room until we can talk calmly. If they keep on threatening and yelling, despite my warning that escalating and violent behavior won't be tolerated, then I'm calling security. Then, they're not getting a thing from me nor are they getting within arm's length of me until someone formidable from security has arrived to support me. I'll take my charge in too if they're available.

To me, the prioritization of the nurse-patient duty takes a backseat the second a pt starts hurling threats towards me. My safety will always trump everything else to me. Once i have support and three people are looking them in the face, they'll usually start feeling foolish and downplay it as though I'm overreacting. They may even make up some elaborate lie about me and "report" me. But, remaining in the doorway has more than one advantage: everyone at the nursing station will be witnesses to hearing them call me a stupid b**** and say they want to "show me what pain is". Cute, but no cigar, bud. .