Teaching Patients "A Lesson"

[purplegal]

Currently, I work at a rehab center where the patient population is 55 years and older, with the majority of them being in their 70s-90s. Most of our patients stay no longer than one to two weeks. However, we have one patient who is considered long-term care and will probably stay in our unit until she passes away. This patient is one that many of us don't always look forward to working with because she is so demanding and requires so much attention. She usually requires at least an hour or even an hour and a half to get ready for bed, which takes one of our two aides unable to help with anything else for that period of time. This patient is very particular as to who she will accept help from, and has been known to throw aides or nurses out of the room if they are not the exact person she wants to see.

The other night, one of our aides who had been working with this patient for five nights in a row, and was clearly exasperated, sighed and went, "I'm not putting this person to bed tonight! Someone else can have her." So, we sent our second aide into the room to help this patient. Five times that night, the patient sent that second aide out of the room. The patient told the aide, "You should accept that I have refused your help and not come into my room." She requested that the second aide get the first aide.

When the second aide told the first aide what the patient had said, the first aide's response was, "That's too bad! She can have you or she can have the night crew. I'm not going in there!" All night, the patient stood at the entrance of her door, glaring at the staff. The first aide then went on to say, "I'm teaching her a lesson. She needs to know that she can't have what she wants all the time, and when someone offers her help, she needs to accept it! She can't keep treating people this way and refusing them when they offer to help! She needs to learn to work with others" The first aide then "hid" from the patient, and would even duck underneath the nursing station desk whenever she saw the patient looking out.

While I completely understand the aide's frustration, I couldn't help but wonder if her response was really going to do anything. Furthermore, I also thought that we are there to help care for the patients, not "teach them a lesson." These people are elderly and are not likely to change their ways. Lastly, patients do have the right to refuse caregivers, and so I can't help but wonder if it's wrong on our part to make the patient work with caregivers she clearly doesn't want. At the same time, our staff is very limited, and we need everyone to be available to help the other 20 people we have to care for.

What are your thoughts, and how would you handle the situation?

[nutella, MSN, RN]

Sounds like a common nursing home drama ....

The big question is always why she is doing that.

I suggest you get familiar with the patient and background story including mental health.

Some residents in longterm care with mental health issues can be very difficult to deal with in the long run as they can have unrealistic demands and expectations, split the staff, and like to engage in power struggles with nurses and aids.

Perhaps review the care plan and the patient's needs first. Why does it take her so long and what are her reasons for refusing other people? Is she swearing at stuff? yelling?

After that go and discuss the case with the unit manager or if you are the unit manager with the supervisor or DON (whatever applies). Also, it is good to let the social worker know that there are problems.

A team meeting with the patient, social work, unit manager and DON / supervisor would be good to talk to her about her care plan, the expectation that the facility has, the expectation that she has, and to make sure that the normal boundaries are explained. Sometimes when all staff sticks with the care plan, those problems get better.

The CNA makes a good point in that the patient also needs to respect and accept some boundaries and can not expect to always have the same CNA - that is just unrealistic. Especially since it sounds that she is difficult to handle and probably throws everybody behind. She might have worded it unfortunate but what she expresses is actually her drawing boundaries. I guess a resident has the right to refuse a CNA but that does not mean that everybody else has to jump up and run to help her get ready for bed.

You have to have good boundaries in facilities and most likely the CNA has seen other situations similar to this. Being confrontational with the CNA will not help anything. Instead, see it in the spirit of her drawing boundaries, it does not sound that the patient was truly neglected or such. The resident made a choice. I would bring it forward to higher up and SW and discuss with them strategies to help the resident to accept help and boundaries.

[KatieMI, BSN, MSN, RN]

Sounds like a classic example of lack of teamwork, leadership and communication for me.

We have just such patients all the time. They are well-known, as well as their quirks, reasonable or not. There is a list of staff they accept, and assignments are rotated on as fair basis as possible. Nobody would be forced to care for "impossible" patient five shifts in a row, save for the lucky case when someone develops good working relationship with patient/family. If there is a demand disrupting the "rotation", the patient would be said directly that the staff member demanded is given other assignment and is not available. On the other hand, the "desired" staff member would be thanked if all "particulars" get documented and distributed among everyone so they are known. If necessary, charge and then manager will step in as soon as necessary, and the discharge will be very much expedited.

There is absolutely no reason to "teach patient a point", as well as confronting CNA. It just leads to nothing save for frustration and anger on both sides. The limits must be set early and followed by everyone involved in care, but it is never late. The key is to follow them, no exclusions. And, of course, leaders must do their jobs. If my patient would throw a CNA out of the room, he or she will have a not-so-nice talk with me first and then with everyone of every level of totem pole. If situation escalated to the point described, with patient hunting a particular CNA, I would offer patient a choice to accept my own care, and bring the situation to the Powers attention first thing after end of the shift. "Inability to provide necessary level of care" or "not needing that level of care we do here" are argumemts applicable to 99.99% of patients when used correctly. Meanwhile, polite asking for psych consult and talk with provider done right way can make things a bit easier as well.

[Cat365]

I agree with the suggestions of the two above posters, but I wanted to add that ducking behind the desk is very unprofessional. The CNA should have made it obvious that she was helping other patients by actually helping them.