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jeastridge BSN, RN

Faith Community Nurse (FCN)

BSN, RN, Faith Community Nurse

Posts by jeastridge

  1. 1 hour ago, KalipsoRed21 said:

    The idea that the examples given show “chummy” conversation instead of therapeutic is a moot point to me. 
     

    If a patient asks you something personal about your life and your answer avoids the question and tries to redirect it back to them, then there is a decent chance your patient will find you rude. Being completely “professional” often denotes you as being non caring for a lot of people. 
     

    I am currently stuck with this issue for MANY of my patients because I do home care. I come to their home and “visit” them 1-3 times a week. If I did not have “chummy” conversation they would feel that I am only there “for the money”. I have had several of my patients complain about other staff who provide visits in my absence of being “cold” because they didn’t “talk with me.” It is a conundrum to say “keep the conversation therapeutic and professional.” Sharing pieces of your life in “chummy” conversation with patients is mostly how people end up seeing you as a person they can trust....trust is what is most therapeutic. Yes, one can “over share” but there is a build to it as well. In a once or twice patient interaction it is easy to keep the “Polite” conversation about something innocuous such as the weather. 
     

    Over a 12 hour shift when you are seeing a patient 6 or more times a day this becomes more challenging. Patients start asking personal questions and if you are to vague with your answers then you seem “cold”, if you remind the patient that you are here to concentrate on them and try to redirect the conversation you are “cold”.....there is no winning this argument. If you spend 45 minutes at time with a person several times a week and actively avoid questions about yourself that doesn’t build trust with the patient....and makes them feel like you are uncaring. Yet even trying to share a minimal amount of information with your self with the patient to gain trust and have them feel cared for, one can end up in very inappropriate situations.

    I am currently pregnant. I have had 3 of my patients ask to be invited to my baby shower and 2 of them have also made it very clear that they expect me to bring the baby BY THEIR HOUSE after she is born. I have one patient who BOUGHT me a GIFT for my baby. So I have made up an excuse that my baby shower is very far out of town....but I couldn’t do anything about the whole gift giving issue and the idea that I am going to bring my kid to WORK except to kindly as I could disappoint these people. Now they are upset because they “thought I was their friend.”

    So tell me; what should I have said when my patients started asking me about my growing belly? “It looks like you got a little something going on dear?” “Oh Mrs. Sonso, yes I am pregnant, how are your blood sugars?” “They’re fine. I forgot to take them this morning. When are you due?” “Mrs. Sonso we discussed you were going to set an alarm so you would remember?” “Oh I forgot. Are you going to find out the sex?.” And on and on and on. And my pregnancy is just an obvious example of how INVASIVE patients are about our lives, about how emotionally needy people are. But there is some sort of consensus that there is a way to avoid these conflicts and it is SOLELY up to the nurse to do so? Not buying it. 

    Look, the patient can have a less trusting, less genuine, more professional connection with their medical clinicians and thus have little to no disappointing conversation OR the patient can have a relationship with their medical clinicians but that will mean communication issues will arise and that PATIENTS will have to bear SOME responsibility for an occasional miscommunication or “bad experience”. 
    The patients who wanted me to bring my baby to their house, who wanted to be invited to my baby shower, who bought me gifts, had a “bad” experience because THEY expected more out of our relationship than professional contact. That isn’t on me. I can only avoid sharing so much with repeated bombardment without seeming rude or cold. 
     

    Now if you watch politicians you can see demonstration after demonstration of how to communicate professionally and answer questions with an evasive non answer....but how many people do you know who trust a politician?
     

    Nursing is a damned if you do, damned if you don’t situation. 

     

     

     

    You make many good points. Nursing is not an easy job and home care poses even more challenges in terms of boundaries. Thank you for sharing your experiences and perspective. Joy

  2. 4 hours ago, scribblz said:

    I personally take my cues from the energy of the family/ patient on what "tone" they need from me. Some people are reassured by a formal, serious bullet list approach. IE good evening Mr Stevens I understand that you are here with XYZ. This is what has been done so far, and this is the plan for tonight and tomorrow. Assess and answer questions then leave them be. An elderly person might need a completely different approach where they don't want too many details, just to know the reason they feel like crap is they have PNA and that you are giving them medicine for it and will keep them comfortable. I rarely discuss my personal life with patients, but if it's a lonely elderly person I may mention my kids and a funny anecdote about them because it opens the door for them to share about their kids and grandkids which gives me insight into their needs and makes them feel connected/ safe with me. Which if they sundown later in the night I use those insights to remind them of who they are and what matters to them.

    Nursing is an art as well as a science. We're all just only human with unique skill sets. Some of us better listeners, some of us more comforting, some more clinical. There's no one way to be because nursing is too broad for that. 

    At the end of the day I say be practical and kind. If they are manipulative, be firm/ set limits. If they are anxious address their concerns/ if the concerns are unreasonable/ be kind but firm in trying to readjust expectations. If they talk forever... arrange for a co-worker rescue you. 

    If a communication goes badly learn from it, forgive yourself and move on. This expectation that nurses are expected to be all things is a harmful one. We should communicate in a way that takes into account the patient and their needs because that is therapeutic. We should not attempt to fill some void in their life... that's insane 🤷‍♀️

     

    You sound like an amazing nurse. I loved reading your comment. Thank you for sharing! Joy

  3. 48 minutes ago, Elaken said:

    I agree KalipsoRed. I am so tired of this “you need to make a connection” attitude. Why? Why is this my job? I am there to medicate a patient. Clean them up. Assess them and catch if things are going bad. Advocate for them. Encourage them to do what they need to get better. Why am I *also* required to do all this emotional labor on top of it? It is already hard enough to keep upbeat when you answer the patient’s 12th call light for a ridiculous request. 
     

    I am always polite and listen to patients but I shouldn’t have to try and connect with them. I know being in a hospital is rough and I give people tons of leeway on their behavior for that but I think it is crazy to expect us to also carry their emotional burdens. We don’t ask that of anyone else in the hospital.

    The examples were of people being upset that nurses didn’t cater to their emotional requirements. Maybe the first nurse didn’t even know you had kids. Or that you worked. Or anything else. 

    Attitude does have a lot to with how you handle pain. Maybe saying “good will come of this” wasn’t the best thought but nothing wrong with encouraging a patient to do their best to stay positive and try to reframe the issue. You said you need words of comfort and she thought that was what she was doing. 

    Maybe nurses wouldn’t misstep if patients weren’t trying to keep using us as their support blanket. There is a difference between needing some reassurance from a nurse that things are okay and taking advantage of someone who can’t easily extricate themselves from the conversation. 
     

    I don’t get complaints from patients and many give their sincere thanks. But I do my best to limit the non-care related conversations. And that is how it should be, IMO. 

    Thanks for your comment. As nurses, we certainly have our hands full. As you point out, neither of the examples cited was particularly egregious. We have all certainly seen worse! But I used those because they were little things but in both cases the patients brought those up with me much later. Yes, they are subtle but I thought they might effectively highlight how even small comments carry heavy weight coming from the nurse. Joy

    39 minutes ago, Emergent said:

    In the first scenario, That's exactly what the nurse was doing. She was having a chummy conversation with the patient. She was talking about more personal things, like her schedule and how it affected her children.

    I think we as nurses need to tread carefully when bringing personal stuff into conversations. It should be a rarity. I agree, we should focus on giving the patient details about their plan of care, informing them about their meds, and listening to their concerns.

     

    Well said. "It should be a rarity." It happens, but being on guard and being careful about what we say is a beginning. Thank you for your comment! Joy

  4. 19 minutes ago, KalipsoRed21 said:

    Sorry, but I am at a point with healthcare that we really need to quit trying to do self improvement. Healthcare motto of the USA...and maybe the world, “Do more, with less.” 
    We have reached a pinnacle of sorts. We are now so overwhelmed with just ridiculous patient and insurance expectations that it is taking me DAYS to get call backs on patients now...and that is me as the patient’s nurse it is taking DAYS for another nurse to call me back. How I, or anyone else, messes up in speech is so damn low on my totem pole of concerns for my patients, my license, and my future health should I actually need to access the healthcare system my self, that I just find it aggravating that it keeps getting brought up.

    It is like a ship in the ocean with a gigantic hole in the hull but someone decided the most pressing concern is what music is playing for the passengers. 
     

    In the past year I have had to take several CEUs about therapeutic conversation and one course was so FOS that it implicated that there is a way for me to make a deep and meaningful connection to my patients in 56 seconds. Such B.S. touted by companies/hospitals that need nurses/CNAs to take on more people in the name of the almighty dollar than one can do an actual good job at taking care of. I don’t want hospitals/companies to go out of business either, but medical persons are at the tipping point with administrative creep and unreasonable expectations for patient experiences. That is not where the corporations are going to maximize their profits...but it is the only thing they can do to maximize their profits because quality is regulated by the government and cost is regulated by the government and/or insurance providers. 
     

    There are just to many truths that aren’t spoken already in fear or out of concern for saying it “wrong” for me to see this as a top patient care issue right now. I’d rather people started saying what needs to be said even if it comes out harsh than to continue to pussyfoot around in order not to offend.

    I hear you. Thanks for sharing. We do live in a tough time, for sure. Joy

  5. 1 hour ago, JKL33 said:

    Of course.

    And nursing in general is a profession in which one will have the opportunity to experience both personal and professional growth related to our interpersonal interactions and relationships with others.

    It is good to think before we speak (in real time) and in general to think about the types of things we tend to say in order to learn better ways to respond therapeutically to patients.

    In my original nursing program therapeutic communication techniques were taught as part of the psychiatric nursing curriculum. Although the techniques are useful for helping patients requiring care for psychiatric and mental health concerns, I always wondered why the information was presented as if those situations were its sole (or main) use. The specific techniques are applicable to many different situations including most nursing situations and even some other professional, collegial, and personal situations. 

    Here's a scenario: A coworker had ongoing nausea and overall felt nasty during a pregnancy and didn't have much excitement for the situation (being what it was). When the pregnancy suddenly ended in a 2nd trimester fetal demise, another coworker tried to provide comfort by saying, "Well, you weren't really very happy about it anyway" as if to say the outcome was some kind of relief or blessing in disguise (maybe it was and maybe it wasn't, but that's for the person themselves to decide, not for someone else to suggest).

    That's the kind of thing we should be thinking about.

    We are wise to start with not assuming what others are feeling and go from there. Even if we start with that one little thing (acknowledging that people feel various ways about things and we can't assume how they feel), that will tend to lead us to make more careful choices with words.

    Well said. Joy

  6. 36 minutes ago, Emergent said:

    It's ironic to see someone come to this post and get defensive, and then complain that the patient took something the wrong way. 

    I think the takeaway from this article is just be professional. It's not a social interaction, it's about the patient. Avoid falling into the pitfall of letting your guard down and getting too familiar. That's what the nurse in scenario 1 did. Scenario 2 was just empty platitudes that are not helpful. Avoid them.

    Like the OP said, we all can improve.

     

     

     

    We can always learn more, do better, and grow professionally. Thank you for your comment. Joy

  7. 8 hours ago, CommunityRNBSN said:

    Some people are very thoughtless or even cruel with their words.  And all of us occasionally put our foot in our mouth. However, NEITHER of the cases here are examples of that. The nurses made innocuous comments.

    Especially in Case 1, the only thing the nurse was guilty of was not being able to mind-read.
     

    Case 2: She used an unhelpful platitude.
     

    But honestly, unless you want nurses to go about our business in total silence, it is totally unrealistic to expect us to never say anything that could be taken wrong. Particularly when a patient (as in case 1) is feeling highly-sensitized, vulnerable, and ready to find offense where none was given. 

    I hope these examples serve as simple reminders that even innocuous comments can be misconstrued. You are right, we would have to go around in complete silence if we were to never mess up, but we can all find an occasion, from time to time, to be more careful about our conversation. Thank you for your comment. Jo

  8. 9 hours ago, KalipsoRed21 said:

    I disagree with this. Being empathetic is always a nursing priority, but because someone is over thinking your kind words or polite conversation as their caregiver we need the be MORE thoughtful is just the wrong way to continue going. If we continue down this path where we censor EVERYTHING we say because THEY could take it the wrong way, no one will ever end up having the hard conversations about death, dying, end of life and quality of life that are ALREADY happening in such vague ways that patient’s don’t even realize what they are being told! 
     

    I just had a fragile patient who had bad COPD, orthostatic hypotension, end stage kidney disease, and a history of cancer 3 years in remission. She would end up in the ER with RDS and the X-rays there would say her cancer was back and metastatic. She would follow up with her oncology MD and he would tell her, her nodules were stable and the doctors at the other facility didn’t know how to read a radiated down lungs. She would come home and sit around for 3-4 days at a time. I was very stern, as she was adamant that she was not ready for hospice, that she had to get her but up every day. I wouldn’t let her tell me she was to tired to do therapy, I’d make her try. This had been going on for 6 months. Most recent ER visit with follow up with new oncologist (the old one had moved to a new job) proved sad because the MD confirmed that the little hospital where she goes for ER care was right, her cancer has been back x several months. She and her daughter were mad at me for pushing her all these months. I am devastated for her too, but I sure as *** don’t feel bad for pushing her based on the reports and repeated conversations I had with her MD offices. I don’t feel like I missed something or that I was doing anything more than trying to help her get to her goals...which are to live. Also I’m pregnant and they were also upset that I didn’t invite them to my baby shower. Actually I’ve had several patients offended because I haven’t invited them to my baby shower or promised them that I would bring my baby to their house after it is born. But you think that we need to be more compassionate with our conversations?!

    You are clearly a compassionate and involved nurse. This article is meant to encourage us all to do better where we can, not to be critical of the good things we are already doing. You will probably agree, that most of us have some room for improvement at some point. Joy

  9. Story #1

    “Oh, I work a couple of shifts per week. Just enough that I can get out of the house and feel like I’m contributing, but not so much that I’m letting someone else raise my children.” These words spoken to me in passing cut like a dagger to my worn-out-mama soul. Her innocent implication that I let someone else raise my children as a full-time working mother piled on to the thickly layered “mom-guilt” I already put on myself.

    The cruel irony of this moment was that the words came from the mouth of my hospital nurse, as I was recovering from surgery, unable to be with, much less care for, my children in my current state. I was already in physical pain, and rather than alleviate my pain as her job should have been, she added emotional pain to my heart and mind.

    I feel certain that the nurse did not intend to wound me with her words. She was just “making conversation.” But what she failed to remember was that just another day at work for her was a huge life-altering experience for me. A hospital is a workplace for many, but for those of us lying in the beds, it’s often a scary and intimidating time.

    I implore you, keep your words positive and uplifting, or don’t say anything at all beyond the standard phrases of patient care. What you say can be just as much of the healing process as what you do.”

    Story #2

    “I was in a rehab facility recovering from surgery to repair a shattered leg. I was in a lot of pain and had the feeling I was being judged unfairly as a ‘complainer.’ I just couldn’t get comfortable and desperately needed to talk with a doctor who had the authority to make some changes.

    During my discussion with the bedside nurse, she said, ‘You’ll see. Good will come out of this. Just think positive thoughts.’ Yikes. I know she meant well but that was NOT what I needed to hear. It may indeed be true eventually, but what I replied was also true, ‘I don’t need to hear that right now. I need words of comfort.’ Honestly, I don’t know if she even registered what I said.”

    Improving Communication

    Our words matter, don’t they? These simple comments, probably intended as attempts to connect, are received in a completely different way by the suffering patients. Sadly, the words linger long after the event and sometimes are repeated often as the patient struggles to make sense of a tough time.

    How do we improve our practice so that we don’t commit these types of gaffes? Researcher Brene Brown says, “Rarely can a response make something better. What makes something better is connection.” Making gentle connections without adding to our patient’s pain is our challenge, isn’t it? While this type of sensitivity may come more naturally to some than to others, all of us can learn and become better nurses in the process.

    Keep it Professional

    When we are in the patients’ room, our conversation and concern should be about them. We are not center stage. If they ask personal questions, it is courteous to answer, but generally, they are just being polite and they don’t really have the energy to know or care about our extended family or our troubles with our children or whatever our concern of the day might be. If the patient is argumentative or disgruntled or venting, we can begin to feel defensive and be tempted to offer them correction (or more!). Once a friend taught me the technique of saying, “Hmm. I had not looked at it quite that way…” and then let the sentence trail off without engaging. Another tool that can help us here is to answer their question as succinctly as possible and then turn it back to them with a question that helps us understand them better.

    Be Empathetic

    Our patients are sicker than ever before. Their family members are often super-stressed. As professional nurses, our job is to care for them to the best of our ability while recognizing the strain they are under and giving them extra grace in their time of need. Sometimes simply being present, prompt and professional is our best response—no particular words needed.

    Repeat What They Said

    Many of us nurses remember learning in nursing school about being good active listeners and reflecting back what the patient tells us by saying things like, “So you are saying…” In other words, finding ways to clarify what they say to make sure we are on the same page.

    Be Genuine

    When we are confident and comfortable in our own skin, we transmit that to others and help them feel comfortable as well. Being genuine does not mean that we tell people what we think, it simply means that we acknowledge their inherent dignity as persons and that we care for them with competence and professionalism, meeting their needs in the best way we can.

    No One is Perfect

    We are all going to be less than stellar nurses from time to time, but we must also keep trying to improve as we move forward in our careers.

  10. The Dreaded Diagnosis: Lice

    As Chris, RN, took report for the day shift in the Pediatrics ICU, she overheard the dreaded words: lice. Tuning in, she paid attention as the staff discussed a 3 year old being treated for RSV who was improving but began vigorously scratching her head, to the point of leaving marks along her hairline and around the base of her neck. When the night nurse leaned in to examine her head, she noticed the lice moving. Drawing back, she motioned for the doctor who was nearby to step over. Together, they confirmed the unpleasant diagnosis: lice infestation.

    Pediculous humanous capitis or head lice, are “ 2.1–3.3 mm in length. Head lice infest the head and neck and attach their eggs to the base of the hair shaft. Lice move by crawling; they cannot hop or fly.” - Parasites - Lice - CDC They feed on human blood and lay their eggs, called nits.

    Who Gets Lice?

    Almost on cue, all the staff felt their scalps crawling and began to have the urge to scratch. While lice are not a health hazard, per se, there is a strong stigma attached to having lice. The truth is, however, that the infestation affects all socioeconomic levels and all ages but primarily children in crowded conditions, especially Caucasians. “Head lice are more common in girls than in boys and are more common in Caucasians than in African-Americans. Anyone can get head lice. It is not a sign that a person is unclean.” - Head Lice - Cleveland Clinic  head lice

    Chris said, “It is unfair to equate lice with poor hygiene. At times, they do go together as families who live in conditions where there is no running water or access to lice treatment, can have significant problems. These issues will often become apparent at admission during the history-taking process. Sometimes we see red flags that alert us to check. But sometimes, we miss the infestation as we are busy prioritizing other needs that are more life-critical and it is only after they are stabilized and doing better that we detect lice. Lice is an equal opportunity infestation.”

    Chris elaborated that the detection of lice almost always fills everyone with dread because lice can be so hard to eradicate. It takes a concerted effort, treatment of the whole family, cleaning of all linens, car seats, upholstery—it’s a job!

    How do you diagnose lice? lice infestation

    Scratching

    When people have lice, they usually scratch vigorously, so hard, in fact, that they sometimes have scratches along the hairline and around the ears and at the base of their necks, where the lice are most likely to take up residence. Children will employ a “two-handed scratch” where they get both hands up to their heads. Their hair will often be tangled and messy because of the scratching.

    Visualize

    In the hospital, to diagnose it, you have to see a louse and have it confirmed by a second person, usually the doctor. Also, sometimes the nits, little white eggs that cling tightly to the hair shaft, are the first sign.

    So what do nurses need to know?

    And how do we best help ourselves and our patients?

    Getting Rid of Lice

    Getting rid of lice is not always easy. It requires dedication and persistence but it can be done. By encouraging our patients and their families in a straightforward, professional manner, we can maximize their confidence and their potential success.

    Reading about it on the internet can sometimes raise unreasonable fears of “super lice” and persistent infestations. It might be helpful for us to give our patients guidelines from trusted sources such as the CDC and Cleveland Clinic. The CDC.gov site has thorough and practical recommendations.

    lice treatment Treatment with lice/egg killing pyrethrins is the beginning of the process. Some pediculocides are ovicidal and some are not. Sold over the counter in kits, the shampoos are generally effective in eliminating the lice. Following up with dedicated hair combing for nits is critical. Otherwise, the eggs will hatch and the infestation will return. Some sources advise treatment of the head, treatment of the environment, daily nit removal and then a repeat treatment in 7-10 days with continued combing after that if nits are found.

    If treatment with over the counter kits is not effective, patients can follow up by contacting their primary care provider for perscriptions which go by brand names such as Sklice, Ulesfia, Ovide and Natroba.

    Practical tips on combing it out:

    • Wearing gloves, brush the hair first to get the snarls out (then clean the brush).
    • Treat the hair as per directions on the box.
    • Divide the hair into very small segments.
    • Using a nit comb from kit, comb through thoroughly, using detangle spray.   (Sometimes provided in kit)
    • After each pass of the comb, wipe it off on a paper towel or toilet paper and discard into a prepared trash bag.
    • Wash all combs, brushes, towels, hats, etc. after each treatment.
    • After initial linen and pillow wash, consider changing pillowcases and washing favorite blankets or stuffed animals daily throughout duration of the process.

    Internet solutions are plentiful. Some of them have merit such as the “goop” that helps make the hair slick and easier to comb through after the initial treatment. Additionally, parents can find community and support online, when sometimes talking with family or other parents is hard.

    Prevention?

    head lice The usual recommendations involve keeping hair pulled up and back off the face, not sharing brushes, combs or hats and prompt treatment when problems are discovered.

    Lice treatments can be expensive for parents on a limited budget. It is important that we be sensitive to this and try to help parents find funding for treatment kits as well as for the laundry a lice infestation generates. Working together in hospitals, schools and daycares, we can help promote prompt treatment and fewer cases of head lice.

    Are you itching yet????

  11. 8 hours ago, RNat55 said:

    I found this part interesting. Hmmm? Hope is a way of thinking...interesting. I need to constantly change my thought process to maintain hope. I am intrigued by this. Thank you for sharing.

    Brene Brown always gives me a lot to think about! Thanks for your comment. Joy

  12. Gathering my thoughts and hospice computer, I climbed the outdoor steps to the second-floor apartment. The gloom in the small room was palpable as I entered. Crowded together on the couch sat a group of relatives and sitting close by in a worn recliner was the patient, a man in his late 60’s, jaundiced skin betraying his terminal diagnosis of advanced pancreatic cancer. On the arm of his chair, arm circled protectively around the top sat what appeared to be a daughter.

    After the introductions and greetings, we began to talk about what hospice is and does and how our services might be of help during this time. The patient waved his hand weakly to indicate his desire to speak, “This is it, isn’t it? I don’t have any more hope.”

    It seemed almost as if everyone took a collective breath, held it and turned to me, waiting for some word that would help them through this impossibly difficult moment.

    What would you say at this point?

    As professional nurses, we are present to help people wherever they are on their journey. From pediatrics to geriatrics and everywhere in between, we work to help people recover, rehabilitate, or compensate. Sometimes, we find ourselves in situations such as the one describe above which fits the traditional definition of “hopeless,” and yet, we are there to help inspire some degree of hope, however small.

    What is Hope?

    The stuff of life... 

    As long as we have some hope, we can keep pushing forward.

    A thought process...

    Researcher Brene Brown says, “I was shocked to discover that hope is not an emotion; it's a way of thinking or a cognitive process. Emotions play a supporting role, but hope is really a thought process…” (http://www.bhevolution.org/public/cultivating_hope.page)

    A tool to face the day...

    Sometimes we hear ourselves or our colleagues referring to a reluctance to encourage “false hope,” or the possibility of inspiring unrealistic expectations in our patients. Given the definition above, maybe false hope is not such a concern since hope might be more about giving those in our care the tools they need to face the day, so they can manage to wring out a bit of joy even in the midst of terrible trials.

    Hope fills the balloon of life...

    We talk about hope all the time: I hope it doesn’t rain; I hope I don’t spill spaghetti on my white blouse; I hope he passes his test; I hope he gets better; I hope I will be forgiven. It is the same word, but holds vastly different meanings! Hope is hard to pin down—it fills the balloon of life and floats, held by a string of desire, tightly wound around our fist of determination and strong will. We won’t let go, for as long as there is hope, there is life.

    So what is our role as nurses in inspiring hope?

    Set goals.

    While it is impossible to foresee the future, with our knowledge base, we can help our patients set goals they have the ability to meet. We can help them set goals for today, e.g. “Let’s focus on getting bathed and dressed and sit in the bedside chair for 20 minutes. Does that sound good to you?” Meeting goals, even small ones, helps us to feel a sense of achievement and success which gives us hope for reaching other, more long-term goals.

    Focus.

    When life feels out of control, our patients may need help in focusing their goals and hopes on a more short term accomplishment. After a major stroke, or some other serious health set back, people have a hard time with looking too far ahead. We can help them reframe their thinking and thus give them true hope. By listening carefully and asking questions, we can help guide them to their own goals, zeroing in on what matters most.

    Reframe.

    When we get down to the nuts and bolts of life, time on earth is always rather limited. But when our patients and their families face a hospice nurse at the door, the limitations seem rather glaring and hope appears to take its bright light over into a corner where it is hard to reach. By helping our patients reframe their thinking to goals that are achievable in this new setting, we can help them have hope. For example, finding out what really matters to them in terms of pain management, family time, and closure can help leave them with a measure of hope.

    What to say?

    As I faced the family, I breathed in too, silently praying for inspiration and desperately asking for wisdom. “This is pretty hard, isn’t it? What is the hardest part for you?” I asked. He went on to talk about his fears of being a burden and of having pain that would be out of control. Once I understood his greatest concerns, I was able to help him and the family make plans for caring for him and was also able to describe some of our pain control plans. As we spoke, I could feel the gentle presence of hope re-enter the room. While the hope of eradicating his pancreatic cancer through treatment appeared to no longer be an option, there were other parts of his story that opened themselves up to hope and plans.

    Make each day as good as it can be...

    As I gathered my things two hours later, I touched the patient’s hand and spoke to him and his family, “None of us knows what tomorrow holds. But we will do our very best to care for you and to help make each day as good a day as it can be.”

    https://youtu.be/U92nQRS2vok/

  13. Bah humbug! 

    Driving to the hospital, I reached over and clicked off the Christmas music that proclaimed a commercialized version of the holiday was fast approaching. I just wasn’t in the mood for “jolly” when all around me, I witnessed sadness, loss and broken hearts. Besides the heaviness for my patients, I also felt burdened by the expectations of others’: gifts, meals, cards, cookies all seemed to sweep through my busy mind, riding on the wings of a tornado-like wind that whipped the whole mess into a funnel cloud and plopped it all in my lap, there to sit with the other normal chores which required attention—just the usual laundry, grocery shopping, car maintenance (yes, mine was in the shop again…) routine.

    The "Right Way"

    I know. I know. It’s supposed to be fun and meaningful. The expectation is that this time of the year, focus solely on the reason for the season (for Christians, that is the birth of Jesus and for others maybe it is family gatherings and gift-giving with love). Whether you have a spiritual bent or not, we all know what it is to feel the pressure to do things the “right” way and the subtle competition to manage it all with great aplomb.

    As a Faith Community Nurse, one of the things I do is visit people when they are in the hospital with a focus on helping them transition to an appropriate post-hospital stay location. For some, that is as simple as suggesting rehab facilities to the family, and for others, it is helping them prepare to take a loved one home to a greater level of care than previously. At Christmas, illness, falls, disease, cancer do not go away. In fact, their prevalence and effect seem more pronounced as others hang garland and put on old Christmas sweaters and indulge in homemade Christmas candy.

    Charlie's Story

    I pulled into a parking space and headed up to visit Charlie, a parishioner who had been in the hospital for an extended stay with complications from a routine surgical procedure. Already elderly, Charlie’s small family was mostly gone, and he had very few resources. I sat down and caught up on the last two days’ news when the Case Manager stopped in to discuss possible placement in a local nursing home. Charlie was sad but resigned, realizing that he couldn’t go home and that he needed the rehabilitation this facility offered. But it was almost Christmas. And it was sad. I saw his eyes sparkle with unshed tears and squeezed his hand, offering the gift of presence and silence. He returned my gaze with a small smile and said, “I’m not worried. I will be ok. I have faith.”

    Charlie’s words both encouraged me and challenged me. His ability to maintain perspective in the midst of great obstacles inspired me to shed some of my feelings of resentment and heaviness and to replace those negative feelings with something that comes from light and life and love. In those few moments, I tried to reframe my own thoughts and ask myself a few questions about how I can face excessive expectations and maintain my morale?

    How to Encourage Others  

    As nurses, how can we keep working to encourage others even when we feel discouraged ourselves?

    1. Keep first things first- Even in the middle of a busy season, let us not forget to maintain our centeredness—whether it is reading a spiritually encouraging book, doing Yoga, going for a brisk walk outside, corporate worship—whatever feeds our spirits needs to take precedence over the other chores that might try to crowd it out. Busyness has a way of wanting to be more important than it really is, doesn’t it?
    2. Get rest and eat right. We can provide well for our patients, our co-workers or our families if we are running on empty. It may mean turning off that TV or letting our Facebook feed rest for a few days, but it is critical care for our bodies to get balanced rest and food, especially during the busy and challenging holidays.
    3. Maybe find someone to talk to. Holidays can bring out our own pasts and our sadness over previous losses. Unfortunately, this has a way of spilling out all over our lives in strange ways. We find ourselves angry and frustrated “for no reason” and over-reacting when someone asks us to bring a side dish to a gathering or participate in a secret Santa exchange…Over the top responses can signal that there is more going on than we are consciously aware of. When we feel like a pressure cooker waiting to explode, it may be time to pro-actively seek out some help in the form of a spiritual adviser or a trained counselor. Working hard in a therapeutic counseling relationship can be some of the best investments we make in time and energy. Working through past trauma and grief pays off big dividends in the present as we try to be the best nurses possible for our patients and the best family members we can be to our families.
    4. Cut yourself some slack. When the external pressures are high, sometimes it helps to acknowledge it and to also accept our own limitations. Perfection can be the enemy of well-being.

    As I wrapped up my visit with Charlie, he said, “Thanks for coming. It will be a good Christmas no matter where I am.” After a quick prayer, I left and walked back toward my car, feeling lighter than when I came, daring the “Bah-humbug” spirit to try to bother me again!

     

  14. A few weeks ago, several of us nurses got together for a cup of coffee outside of work, a rare event but an occasional holiday celebration. We sat around a table, holding our hot drinks and warming our fingers from the bitter cold outside. After some light banter, one of our colleagues shared a recent difficult encounter with a patient, one that left her feeling defeated and out of sorts as a professional. We all listened intently, and it was interesting to observe the various responses from her friends and co-workers. Because our responses were so reflexive, it made me think that we might also respond this way in other situations. Is good listening a skill we can learn and get better at? Consider the responses from around that table and think about how you respond to patients, co-workers, family members that share vulnerably with you.

    3 Responses

    1.  Almost before she could finish her story, one of the group asserted loudly (even pointing a finger in her direction), “I would not take that. I think you should respond by saying…” She went out to detail how the conversation might have gone had she been a participant, laying out clearly what she saw as the answer to her friend’s problem. Her body language, her forcefulness, her certainty all seemed to push the storyteller back in her chair, away from her cup of coffee, as she raised her eyebrows questioningly. “Do you really think so?” She queried, her hurt and confusion visible and audible.

    2.  A second person listened a little longer then said, “Well, I don’t think you should feel that way at all.” She continued to “should” all over the teller, minimizing her struggle and essentially asking her to harness her feelings into something less hurtful than they really were. “Shoulding” is so common, isn’t it?

    3.  The third person, the speaker’s close friend, remained quiet through the various exchanges, allowing the story to have plenty of time and space. She leaned forward a little before quietly offering her empathetic response: “What happened to you really stinks. I am so sorry that you had to go through that.” To me, it felt like she came alongside her friend and figuratively put her arm around her shoulders, sharing the difficult space and sitting with her as she felt the feelings she was feeling.

    Same story, three very different responses. Where do you see yourself? Ideally, we would like to say that we are consistently in #3, but most likely, we vacillate in our responses, employing all 3 from time to time and moving back and forth.

    Adviser

    The advice-giver meant well, but she effectively shut down communication, didn’t she? By delivering her pronouncement, she declared that she knew what was best and how that situation could be resolved. As unrealistic and presumptuous as her response is, we see it and experience it often, don’t we? People want to “set things right” by their standards and don’t want to leave a lot of uncertainty hanging around. While it is possible to offer advice, people rarely really want it, even if they ask. Generally, people need to work out their own individual approaches, their own answers, in their own time. Occasionally, if we have been in the exact same situation (unlikely) we can share what we did, but most of the time, those who share with us are looking for validation, a careful listener, and help in the form of a well-placed question such as, “So how do you feel about things now?”

    The advice-giver’s body language also closed more doors. Finger-pointing rarely feels good to the recipient of the gesture. It can be a strong, power-loaded motion, one that requires careful thought before deployment.

    “Should-er”

    The “shoulding” friend also delivered a put-down, didn’t she? We have the right to our feelings even if our feelings are not right. Feelings are proprietary. We acknowledge them, deal with them in our own way and hopefully find a path to mastery over time but “shoulding” brings some shame into the picture and makes us ask ourselves, “What is wrong with me to feel this way?” Of course the “should-er” doesn’t mean to elicit these feelings at all; she simply wants to make everything “all better” and smooth over discomfort. She longs to fix it, doesn’t she? As nurses, we can be attracted to the profession because we long to help our patients. This charitable desire has a dark side which is the “fixer” of the profession—always knowing what is best for others and letting them know what we think instead of allowing them to feel their own feelings and find their own way. If not carefully monitored, our desire to help can morph into control and manipulation and codependency.

    Empathetic

    The third friend’s empathetic response felt the most compassionate to me as I observed these interactions among friends. While the first two seemed to close doors of communication, the third response pushed the door ajar, allowing for future conversation and more opportunity to discuss the hurtful occurrence and to process it.

    The conversation at the table moved on to less heavy topics and we continued to share and laugh as our coffee cooled, offering healing and support to one another. Long after we went our separate ways, I thought about what I had witnessed and how many times we miss the mark in our responses to others.

    Were #1 and #2 “wrong” and #3 “right?”

    Well, yes and no and maybe. We are not perfect humans. We must offer each other grace and forgiveness every day if we hope to find any joy at all in this life. Friends sometimes say the best thing and sometimes not. We don’t discount their input either way, and we usually try to overcome differences. But such conversations shine a light on how we communicate and can help us to pause and think as we listen to someone’s story, careful as we try to respond with empathy and concern.

     

  15. 9 hours ago, Kooky Korky said:

    I can relate to the bitter, mean girl part.  I have worked with some really unhappy people.  Their personal lives were a mess, they brought their misery to work, they took it out on newbies like me.  40 years later, I recall their ugliness, their meanness, their selfishness.  I should have a fake funeral for them, where I bury them once and for all.  Maybe that would help me forget them.  Of course, they were great examples of how not to be.  Many times, I've been told how helpful, friendly, otherwise wonderful I was by students and by coworkers.  Mainly, I don't talk about personal stuff, I get to work on time and actually do my work, I help others when possible, and try very hard to be friendly and courteous.  

    Yes, I wish I'd known way back when that personal misery came out as ***ery at work.  I took it personally, like I was the one doing wrong.  Later, I figured out it could't have all been me.  From these horse's asses, I learned and have always practiced being a pleasant fellow to all.

    Stand up for yourselves, guys.  No one else will or should have to.

    Thank you for your response and glad you stayed with it! Joy

  16. 4 hours ago, Here.I.Stand said:

    If past trauma isn’t an excuse to be violent on the outside, it isn’t an excuse to be violent with healthcare staff.  

    And frankly as one with PTSD herself..... what the what??  If I am getting violent, staff SHOULD call a Code Green.  However, I won’t be getting violent.  While I may not have complete control over my feelings or internal physiological responses, I am adult and can certainly conduct myself as such.  

    Honestly I am a bit offended by this.  

    Thank you for your honesty. You make excellent point. The staff should always call a code green whenever there is a threat. I'm sorry it feels like the article implies otherwise. That was not my intent. Joy

     

  17. 28 minutes ago, HarleyvQuinn said:

    As someone trained and working in the inpatient psychiatric realm, I want to caution that there is a stark contrast in how you respond to a person who is agitated and acting out and a person who has escalated to violence. This is particularly true if the person is armed with a weapon. De-escalation techniques require training and experience to work at their best. Our facility utilizes a response team for anyone presenting in a behavioral crisis where psychiatric or other trained staff respond similarly to other code situations. Our security staff also receive the same training our psychiatric staff receives on de-escalation and hand-on interventions. Unfortunately, we only offer basic level CPI at this time in our facility. 

    Thank you for your helpful comment. You highlight the importance of preparedness, knowledge and rapid response. Joy

  18. 1 hour ago, V888 said:

    Please just remember this can be a very dangerous way to think. Don't let your sympathy or empathy let you put your safety at risk  

    Someone in psychological crisis can, especially if armed with a weapon, kill you just as easily as a hardened criminal. I believe there was a story on here about a nurse who died after getting caught between a psych crisis patient and a clamshell shield. 

    Defusing and de-escalating are things that are great...until they aren't. 

    I would also push back on the idea that all outbursts or misbehavior is caused solely and directly  by trauma as that idea can be dangerous for society...(minimizing agency and free will, not accounting for rights of victims, etc)

    So well said. Thank you for your thoughtful comment and for sharing your perspective. You make some important points. Joy

  19. “Code Green 5th floor. Code Green 5th floor.”

    The hospital operator’s voice made my pulse skip a beat even though I was far from the announced location. Code Greens [in this case meaning a combative person who may be armed] have become more common as we face more crowds, more recreational drug users, and more angry, frustrated people in our facilities. As nurses, we are sometimes part of situations that lead to the dreaded “Code Green” announcement as we call out for the necessary help. We undergo training in how to respond and follow the required steps, but we do begin to wonder if the number of these types of crises is increasing, and if so, why?

    The Team Approach

    Some hospitals have successfully formed specialized teams to address Code Green situations and to help de-escalate highly charged encounters. At Pinnacle Health System in Harrisburg, Pennsylvania, their Code Green Response Team, started in 2013, has saved personnel and patient injury, money and time away from work. Their example may be trendsetting as other systems look to find ways to decrease violence inside our hospitals. Code green prevents workplace violence

    Trauma-Informed Care

    Another opportunity for learning and forward-thinking is the Trauma Informed Care Project .The training invites participants to acknowledge that past trauma affects daily behaviors. Children are especially vulnerable to the effects of trauma and many childhood experiences accumulate to produce adverse effects leading to the term ACES (Adverse Childhood Experiences). The website goes on to explain that the goal of this foundation and this project is “organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma. It emphasizes physical, psychological and emotional safety for both consumers and providers, and helps survivors rebuild a sense of control and empowerment.”

    During the training, participants are invited to re-think “acting out” and instead of asking “What’s wrong with that child?” Ask instead, “What happened to that child?” These subtle but significant shifts in thinking can help us move from finger-pointing and judging to more constructive patterns of interaction where healing can actually take place.

    Emotional trauma carries over, of course, into our adult years. If unacknowledged, untreated, unresolved, it can surface unexpectedly and often explosively, leading to our current question regarding Code Green. Victims of traumatic incidents can sometimes repress or “forget” the memories of what happened to them only to have those come back during challenging or stressful times —such as times in the hospital with a loved one or being sick and in pain themselves. The post-traumatic stress of past troubles can lead to excessive anxiety, anger, and unstable emotions.

    The Body Keeps the Score

    In his book, The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma, Bessel Van Der Kolk, MD, asserts that past trauma manifests itself in actual physical disease. If unresolved, trauma will eventually lead to physical illness in a variety of diagnoses.

    “Even though the mind may learn to ignore the messages from the emotional brain, the alarm signals don’t stop. The emotional brain keeps working, and stress hormones keep sending signals to the muscles to tense for action or immobilize in collapse. The physical effects on the organs go on unabated until they demand notice when they are expressed as illness. Medications, drugs, and alcohol can also temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score.”(p46)

    Responding Appropriately

    As nurses, we are occasionally faced with responding appropriately to challenging situations: talking an agitated patient down, listening well, knowing when to get help. How can we prepare ourselves to be even better equipped to face difficult encounters?

    Be in the Know

    Take mental health classes that are offered for CME; the Mental Health First Aid class is valuable as are the Trauma-Informed Healing sessions. Learning about mental illness, PTSD, and other psychiatric illnesses gives us a good preparatory knowledge base.

    Responding Empathetically When Possible

    This can help resolve some low-risk situations. Many people long to be heard, really heard. They may even realize that we cannot resolve their situation, but they don’t want to be brushed off. They want to know someone cares. For some, that may be the beginning of healing and just what is needed to get them through a rough patch.

    Call for Help as Needed

    There is simply no substitute for getting help when a crisis arises. Maybe your facility, like Pinnacle Health, can consider starting a Code Green Team which specializes in defusing and de-escalating crisis situations.

    Sadly, Code Greens are more common than we would like for them to be. There are a lot of hurting people out there: both our patients and those that are surrounding them in their time of illness. We have no way of knowing what trauma might have happened to our patients or their families and loved ones previously. But we do know that they carry those hurts with them when they come in for treatment. As nurses, we are often presented with really messy scenarios. Being professionals, we do our best to make the best of even the worst of times.

    What helps you to respond appropriately to tense situations?

  20. 3 minutes ago, TitaniumPlates said:

    Wrong. The person in the example is an experienced, second careerist and a highly educated Chemist.  Which is precisely what some nurses find soOsoOOooooOOOO  intimidating and threatening.

    I've seen this before many times. An older, more mature and life experienced nurse comes in---maybe she's a new grad--but she's certainly not stupid. She ran a household of 5 kids or a department of 27 sales people or a unit of soldiers.

    But nurses do this just like any other profession. Don't give me that crap about "she's just harried and rushed"---sorry---I don't act like an arsehole to people because I am "rushed". I don't say s#itty things or threaten people because I'm "harried".

    If you have to act this way---when your rushed or overworked?  This profession is not for you and this says so much more about YOU than about the new grad.

    It's about time good nurses start walking and finding other places to be. Misery loves company---leave the nasties to each other--maybe they'll drive the unit into being shut down or the patients will complain enough because there isn't a one that can hold their tongue.

    I love how nurses seem to think they're some sort of special sauce that they get to act all crappy and get away with it because...stress. Like nobody else has a stressful job. Just them.

    Best advice is in the article.   document and burn them. Don't sit back and be afraid and don't ever run if you can fight.  I document, document, document. And when they least expect it---they're sitting in HR cooling their heels---and a few times?  Losing their jobs.

    Yeah. I think they deserve it....because now I'll get the "but you cost a nurse her job!"

    No. The nasty  nurse cost herself her job.

     

    You bring up some good points. Thank you for sharing your perspective. Joy

  21. On 11/29/2019 at 3:44 PM, FullGlass said:

    Thank you for a thoughtful article.  Bullying is all too common, and occurs in many different professions.

    Like the example in the article, I switched became an RN then NP in mid-life, after being a business executive.  Looking back on my career, standing up to bullies in the right way generally worked for me.  There were times that I did not, due to fear, and in retrospect, wished I had stood up for myself.

    In my experience, people in the helping professions, or people who are great for advocating for other people, often have trouble standing up for themselves.

    There have been some excellent suggestions given.  I'll add a couple more thoughts:

    - try to find an ally and/or coach.  An experienced RN that you trust and can provide some insight and guidance.

    - it's important to have "f*ck you" money.  A minimum 3 month emergency fund, ideally 6 months, so you can quit a job that is making your life miserable.  Bullies sense weakness and fear.  When you know inside yourself that you can walk away from the job, it will subconsciously give you a more confident air that can deter bullies.  

    - read up on developing assertiveness.  There are many books and videos out there.  There are also books and videos for learning to deal with workplace bullies.

    Best wishes.

    What great suggestions! I especially like the idea of having cash on hand. Money can't do a lot of things but it CAN buy options. It can make life more bearable by providing that escape valve--just in case it is needed. Thank you for sharing your constructive ideas. Joy

  22. On 11/30/2019 at 9:37 AM, Nurse Beth said:

    Great article, thank you.

    I was a new nurse manager when a doctor who was a well-known bully began to berate me at the nurses station bc a lab was not resulted. It was so humiliating. He was tall, imposing, and absolutely withering in his manner.

    I asked him if we could speak in private and amazingly, he agreed. He followed me to my office. I said "Dr. Baker, we both want the same thing. The best for your patients. I will do everything I can to provide the best patient care on this floor, but you cannot undermine me in front of my staff. If you ever have a problem, let me know. In private".

    To this day I have no idea where those words came from!  But it worked and he gave me nothing but respect from then on.

    I learned a lesson that day that I had to use later on with a nurse colleague who bullied me. Another story :).

     

    Great story. Thank you for sharing. I was reading Richard Rohr's book, THE NAKED NOW, this morning and he says, "What you see is what you get. What you seek is also what you get. We mend and renew the world by strengthening inside ourselves what we seek outside ourselves, and not by demanding it of others or trying to force it on others." (p.160). You showed respect and behaved with decorum and integrity. 

  23. 8 hours ago, Leader25 said:

    First they need to stop covering up for abusive nurse managers some can be as bad  or worse than co workers.Stop giving exit interviews while you are still working there.

    They need to stop covering up for the real bullies,just because someone has drinking/money/family  problem is no reason the rest of us have to tolerate the abuse.

    You bring up an important point: our personal lives can "bleed over" into our professional lives so easily. We also can have a tendency to promote co-dependency and tolerance of bad behavior based on excuses. While we all want to be sympathetic to the troubles our managers and co-workers are experiencing, we also want to keep our patients front and center--while at work, they are our #1 concern and responsibility. Thank you for your comment. Joy

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