Rant: the first patient to make me truly disappointed in myself.

[renardeau, BSN, RN]

I'm a new grad going into my 4th month floor nursing at a busy trauma 1 cardiac IMC. Despite my expectations from this board, friends, and colleagues, the job is so far not that stressful. In fact, I quite enjoy it. The people I work with are great and I love going to work.

I've had a lot of angry patients, a lot of rude patients, a lot of patients who just seem to lack interpersonal skills, and they've never really bothered me. I've always just figured that they were very, very sick (many of them, clearly dying) and consequently unhappy with their situation, suffering through endless procedures and bad outcomes, etc, etc. And so, I have always put on a kind smile despite whatever dismissive or insulting behavior comes my way.

Yesterday, one particular patient bothered me. A former addict, he complained constantly about his care, and in his complaints, you could see that he was not very intelligent, and didn't understand much. It was strange, because I've had far ruder, far angrier patients... but this one in particular was difficult for me because literally, no explanation would work. I'm not sure if he just has an extremely low IQ or if it's a side effect from the years of illegal IV drugs or a combination of the two. His sister got some device put in her that fixed everything, why can't they do that to him? Why can't they do this faster? What are all these meds for anyway? (This, despite saying "just give them to me and quit talking so much" when I tried to educate him earlier.)

"Why are you interrupting me during my dinner?" (Because I just asked you two minutes ago if it was okay to give your medications while you were eating and you said yes.)

"I suppose I misunderstood you two minutes ago when you said it was okay to come give your medications now."

"Who raised you? Where you from? Japan? Korea? Well, where I was raised we don't interrupt people during dinner. You don't mess with a black man's dinner. Any black man will tell you that. Don't you got any sense of manners?" (No, sir. I don't think I share the same sense of manners as you, and I've had patients, some of whom were African-American, who prefer meds with dinner and have manners quite different from yours.)

"I can come back later?"

"You know what? I'm not even hungry anymore. You made me lose my appetite. Yup. You did that." (I know you're trying to make me feel bad. It's not working.)

"I apologize. I hope you change your mind before dietary comes to collect trays. Let me know if you need your food warmed up again."

Perhaps my disposition only makes it worse though. Some of our patients have made other nurses angry, made them cry, when they're being 'mean'. Sad patients can make me cry---very easily, in fact. Rude patients like him don't make me cry. In fact, I can hardly summon up any feeling except for a cold sort of amusement like "Wow. I can't believe people like you actually exist." For this reason, when other nurses, even the seasoned ones, decline assignments of difficult patients, they often get sent to me. Maybe it could be described as having tough skin, but to be honest, with some rude patients, my initial reaction is just to laugh at how ridiculous people are. I really can't help myself. It's like "Really. You, with little to no education and lacking basic literacy skills---you think you know better than me or the doctor? So why are you here again?" I find myself raising an eyebrow, trying to smile kindly, but really trying very hard not to laugh, and I think sometimes it shows. I know this comes off as really disrespectful, and this is probably what he was sensing. In my head, I can't help thinking, "You are literally so stupid. I can't believe people so stupid manage to live to your age. How?" And I try very hard to retain my politeness, but I think it comes off as passive-aggressive condescension. In the heat of the moment, I can't help myself.

"Man, you don't know anything, do you? And you're a doctor!"

"I told you this morning, I am your nurse. And despite 'not knowing anything', I just explained your plan of care to you, which you seem a little confused about still."

"I just don't understand why I need to be here so long. Explain that!"

"I just explained exactly how long it will take to titrate---to increase---your medications safely."

"But why do I need all these medications and tests anyway?"

"Do you want me to go over all your conditions and the specific medications and tests with you?"

"Nah, man! Nah! I don't got time for that."

"So... you just asked me a question. I just offered to answer it. You just said you don't have time to listen to the answer. What would you like me to do in this situation?" Silence. 1, 2, 3 seconds pass. "Sir?"

"I want to speak to the doctor."

"Then I'll go get him."

It's the best I can do. So maybe it's me. Maybe my lofty attitude toward people like him only perpetuates their frustration and rudeness, but it's not like I can yell at them back and it's not like I can just ignore them (I mean, I have to interact with them to care for them.) I just carry on either expressionless or with a little smile. You know, the one you give to a naive child when you're just appeasing him. Eventually he gets nice again, when his anger subsides and he sees that his abuse has no negative effect on the way I act toward him. But then he gets angry again. The cycle continues. Thankfully, my other patients were sweet and counterbalanced all the negativity, thanking me for giving them a good day, for being "a compassionate person".

I don't often refuse assignments. (Once ever, because a patient was a sweet lady but required a lot of care and I was just horribly exhausted that day and just coming off orientation so I asked for a lighter assignment.) And as I said, I often get assigned people other people don't want. But something in me tells me that if I get assigned this man again, I'll want to refuse him.

It bothers me terribly, because I wish I had more empathy. I wish I found some redeeming quality that helps me to forgive how uncouth he is. I wish I had, somehow, found more love for this man. But I just couldn't. I don't feel bad for him like I do my other patients.

I know what you're thinking. Maybe I have some grudge against addicts, but I don't. I've treated other angry addicts before, no problem. I've even liked some of them, many who are more rough around the edges. I think the difference is they were slightly more intelligent, and I feel like even if we disagreed, they at least understood me---whereas this man was literally such a fool. To talk to him was to talk to a wall. It makes me feel like an awful person to admit it, but I honestly felt like he is a waste of time. A waste of tax dollars. A waste of space that could be used for someone else. Why are we trying so hard to treat him? What does he add to this world instead of just taking from it? I work hard because I take pride in my work and I'm not going to neglect someone just because I don't particularly like them. But as I work, these thoughts flow through me and it kills me that these are my opinions about someone, about another human being. I never thought I would have such harsh thoughts, such cruel judgments about an almost-stranger. I try to make excuses for him---it's not his fault. He probably had a tough upbringing. It's a little easier that way, to think of him as just a child who had bad parents. But even still. At a certain point, an adult is an adult and he is held to his own words and actions. After all, we don't excuse criminals for 'having it rough as a kid'. But he is a just a mean-spirited little man, not a full-fledged criminal, right? And he probably has someone who cares about him somewhere who wants him around? But I just heard him speaking on the phone with his wife and he's just as rude to her as he is to me. So the argument goes back and forth in my head. It's dizzying. And it disappoints me.

Anyway, if you had the patience to read through all this, thanks for listening.

[CrunchRN, ADN, RN]

Some people are just like that. Give them your best care and then do not lose any sleep for having a hard time feeling empathy. Not everyone deserves it sadly. Just like any large gathering there is bound to be someone who is just not a great person. All you need to be sure of is that you provide the best care you can considering the obstacles he is placing in your way.

[chrisrn24]

There are going to be patients with whom you don't click. I've had patients that get on my last nerve and then other patients with similar behaviors who don't bother me one iota. It doesn't make you a horrible person or bad nurse so please don't worry. We do a job a lot of people couldn't do...you're allowed to have feelings about it!

[Retired APRN, MSN, RN, APRN]

Sounds like that was really hard on you.

I have one practical suggestion. Being very honest with you, some of the answers you wrote do sound condescending (if that is really what you said). What I've found useful is this: Once I've discerned that the patient (or other annoying person) is either not capable of understanding my teaching and explanations or is just bound, set and determined not to, I revert to short answers that answer the specific question just asked without going over the whole subject or referring to previous conversations.

For example, here is an alternate version of the conversation you posted.

"Man, you don't know anything, do you? And you're a doctor!"

No, I'm your nurse. What would you like to know?

"I told you this morning, I am your nurse. And despite 'not knowing anything', I just explained your plan of care to you, which you seem a little confused about still."

"I just don't understand why I need to be here so long. Explain that!"

"I just explained exactly how long it will take to titrate---to increase---your medications safely.

Because these meds take a little time to get to an effective level.

"But why do I need all these medications and tests anyway?"

"Do you want me to go over all your conditions and the specific medications and tests with you?

Because you have _____ and we want to take the best care of you.

"Nah, man! Nah! I don't got time for that."

"So... you just asked me a question. I just offered to answer it. You just said you don't have time to listen to the answer. What would you like me to do in this situation?" Silence. 1, 2, 3 seconds pass. "Sir?"

I'm sorry; I know it's a pain, but time takes time.

"I want to speak to the doctor."

"Then I'll go get him."

Instead of asking him more questions, which only prolong the painful exchange, short and direct replies can be said with a smile (however fake) and make it easier to end the conversation.

We are certainly entitled to our own feelings and we all develop our own ways of coping with work stress. The trick, the hard part, is not to let our coping mechanisms interfere with patient interactions.

I hope I am not coming off as critical. I only want to respond to what I understood as the question in your post.

[chrisrn24]

Sounds like that was really hard on you. I have one practical suggestion. Being very honest with you some of the answers you wrote do sound condescending (if that is really what you said). What I've found useful is this: Once I've discerned that the patient (or other annoying person) is either not capable of understanding my teaching and explanations or is just bound, set and determined not to, I revert to short answers that answer the specific question just asked without going over the whole subject or referring to previous conversations. For example, here is an alternate version of the conversation you posted."Man, you don't know anything, do you? And you're a doctor!" No, I'm your nurse. What would you like to know? "I told you this morning, I am your nurse. And despite 'not knowing anything', I just explained your plan of care to you, which you seem a little confused about still." "I just don't understand why I need to be here so long. Explain that!" "I just explained exactly how long it will take to titrate---to increase---your medications safely. Because these meds take a little time to get to an effective level. "But why do I need all these medications and tests anyway?" "Do you want me to go over all your conditions and the specific medications and tests with you? Because you have _____ and we want to take the best care of you. "Nah, man! Nah! I don't got time for that." "So... you just asked me a question. I just offered to answer it. You just said you don't have time to listen to the answer. What would you like me to do in this situation?" Silence. 1, 2, 3 seconds pass. "Sir?" I'm sorry; I know it's a pain, but time takes time. "I want to speak to the doctor." "Then I'll go get him." Instead of asking him more questions, which only prolong the painful exchange, short and direct replies can be said with a smile (however fake) and make it easier to end the conversation. We are certainly entitled to our own feelings and we all develop our own ways of coping with work stress. The trick, the hard part, is not to let our coping mechanisms interfere with patient interactions. I hope I am not coming off as critical. I only want to respond to what I understood as the question in your post.[/quote'] I agree. There are better ways to response to someone. You can't expect every patient to remember every nurse's face.

Using short simple language is the key. "I have your blood pressure pill" is more effective for most people than "I have your metoprolol," for example.

Also I wouldn't use terms like "plan of care" with people, instead I would just say what it is! "You're here to get your meds adjusted /pain under control" etc.

[jennycRN]

To the PPs, I think the OP's dialogue was a mixture of what she was thinking and what she actually said... But maybe I am wrong.

No matter how thick your skin is, there is always that one patient or family member who really pushes your buttons.

But I agree with PPs... Avoid arguing with difficult pts at all costs.

[renardeau, BSN, RN]

Thank you for all your replies. Again, I know it's a personal habit that my speech, especially when I'm annoyed, gets very formal, which comes off as condescending, especially when I can't help myself and unnecessary explanations and comments slip in . Those were pretty much the exact words I said to him, and some things, I admit, came with an edge (but hey, I'm not perfect and I have emotions too).

As an aside, when I said "titrate" at first, it was just the first term that slipped out and I quickly realized he probably wouldn't understand that word and thus added "to increase" meds safely; thus, if you took the initial sentence "it takes time to increase your medications safely" it doesn't really get much simpler than that in terms of explanation... The suggested comments offered above probably would've been received better by him, but again, if I wrote down all our conversations and looked at them in retrospect, it's pretty easy to see what I should have said. In the moment, it's harder, and I know it will come with practice. Unfortunately, as short of a comment as you make, he's also the type that will continue talking, take what you said the wrong way, or take the opposite of what you said because he misheard or gets it mixed up later, even if you write it down for him (e.g. "our goal is to get this medication to 20 nanograms and it is going at 7.5 now" gets turned into "you just said I had to be here until we got this 40 grams" later). The "you don't know anything" conversation happened at the very end of the shift, at which point, I called the doctor to speak with him and called it a day. But the dinner conversation, for instance, was a good example of how every conversation would go throughout the day. Can I come do assessments at 10 if you don't want one done now? "Yeah." So I come back at ten. "Why are you bothering me, can't you see I'm laying down and relaxing?" "You said to come back at 10. I thought we decided that was okay." "Yeah, but you see I'm relaxing right now, don't you? Why would you come bother me now?" Etc., etc... For the most part, it's comical and mildly amusing. At the end of the day, I was just not having it, and the attitude slipped out...

Again, thank you for your constructive criticism on communication faults, but all that aside, what bothered me a lot was how I felt about the patient. Most days, I consider myself someone who tries to value humanity, as ugly as it can be at times... without dark, there isn't light, right? There's no such thing as good without bad, otherwise everything would just be "neutral", thus everything is relative, and so you have to accept the bad to have good, right? I mean, I think myself into circles sometimes haha. In the end, he may not be that smart, and not a very productive member of society, and kind of a mean person, but still, I never thought I would catch myself thinking another person was a wasted effort and all these other terrible things like "Seriously, why is he even on this planet?" I suppose some form of faith would come in handy in instances like this, but having not been raised on any, it's hard to find something to just force yourself to believe in and find some value in something that outwardly seems so... ugh see, I was about to say "worthless", but I hate that I was just about to describe another human being as worthless! And when it's probably not his fault he grew to be the way he is in the first place... Well. I could continue this conversation with myself forever probably.

[renardeau, BSN, RN]

I guess, in short, I'm having a small existential crisis where I realize my thoughts about someone are really mean-spirited (really, much meaner than some of the things he said me) and I'm consequently kind of ashamed

It brings me back to nursing school (WARNING: tangential digression) when our clinical instructor sat our group down for a hypothetical ethical situation and said, "Many prisoners purposely hurt themselves, e.g. gave themselves deep cuts, in order to be put in the hospital and receive a period where they are treated well. One physician said, 'Okay, I will still give them medical care. I will still sew this man up, but without anesthesia. Why should our extra money, our healthcare efforts and time be spent on things like this?' What do you think of this doctor's actions?"

Most of the students in my group were aghast that anyone would do such a thing. But me, I thought "Well. It's wrong, because that's cruel and that's another human being. But... I kind of see the doctor's point too in that he might be trying to discourage such actions." (And then the conversation went further to well, maybe all these people need psych consults, maybe they were wrongfully imprisoned in the first place, etc. And I spent many late night thoughts and showers and walks pondering this situation and what my stance on it was and what that speaks about me as a person and if it meant I was kind-hearted and forgiving enough to be a nurse...)

I guess it's not a big of a deal if I don't let these thoughts affect my care, but still. It just makes me feel kind of awful. Anyway. rant>

[LadyFree28, BSN, LPN, RN]

In think you have the right coping attitude for your pts; you've done exactly the "right" thing.

Keep doing what your are doing, more pts appreciate your disposition than the one who is struggling and needed that disposition-trust me, it gets it to the quick when you keep your emotions like that; I find more pts sift through their own feeling and give that up, making it easier for themselves and allow me and fellow nurses to truly help them.

I've had a similar disposition since 2000; I learned pretty quick how to handle pts who are struggling and will use ANY emotion or maladaptive coping to lash out. It gets old then they get over it...I've finessed it after all these years, but it's still there, and it works.

[CrunchRN, ADN, RN]

I think only Jesus could love everyone know matter how awful they were. At least that is what i read a long time ago...... :)

You need to accept that you may occasionally feel this way and it is not unreasonable.

[Nurse SMS, MSN, RN]

Not every nurse/patient combination will be a good "match". This patient challenged your patience. It happens. It won't be the last time. When I get one like that, I just let the charge nurse know he/she needs to be assigned to another nurse tomorrow, that I had my turn. Sometimes it was just the combination of me to them, sometimes the patient has trouble with all the nurses and gets turned over to a different nurse every day. I do not ever feel guilty for refusing a patient. If it is a bad match, the patient will get better care from someone else. If the patient is a difficult personality, then I feel well within my right to refuse to be in a bad working environment two days in a row.

Self evaluation is crucial, as is learning to control your emotions and remain professional. As mentioned above, many of your responses were unprofessional/inappropriate, particularly if delivered with irritation or an "edge". Yes, we are all human, but you are in a service industry. In the current healthcare environment, allowing an "edge" in your voice will get you fired quickly. It is all about patient satisfaction. You will want to work on this. It is good you recognize it. Next step is to recognize that saying "I am human" isn't going to fly. It implies you have no control over it. You do have control over it and you must exert that control.

[ceebeejay]

Working out that you have those feelings is a good thing. Burying them would not be. I have trouble with illogical people. I am the Spock of nursing. LOL!