Trouble communicating with patients?

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Specializes in Cardiac, COVID-19, Telemetry.

So, I’m a new nurse. I’ve worked as a CNA all through nursing school, so patient care comes as a breeze. However, I am struggling with communication that patients “don’t want to hear”. Such as, “The doctor is not going to up your Norco 5 to IV pain meds” (while you sit there playing games in your phone, laughing, and chatting up your husband about what you’re going to order for lunch). Also denying patients things they want to do — like showering for the 5th time when I just have you phenergan — due to patient safety risks.

I encountered both of these situations yesterday, on top of trying to care for 8 patients. It makes me feel so awkward when the patient gets all pissy because they have been told no.

One of them was even going to fire me as her nurse because I “wouldn’t understand that the shower is relaxing and I didn’t care”. Even though I explained why she couldn’t and shouldn’t get in the shower, fall risks, and safety risks and education pertaining to medication.

Im sure this will come with time, but how do you handle your difficult patients/communication with them when it isn’t what they want?

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Specializes in ICU, trauma, neuro.

Try not to take it personally and phrase things as empathetically as possible. Example patient: "I want to take a shower".

My response: "Hospital policy requires that I get a written order from the MD for you to take a shower and because I just gave you a medicine that can make you dizzy the MD will likely be reticent to give me that order. However, if you can wait for about an hour I will ask for the order.

Patient "I'm still in pain and need more pain medicine".

My response: "Please describe the nature and quality of your pain."

Patient "It hurts like the dickens".

My response: "I will call the MD and ask for additional medication, but she/he may be reticent to order additional pain medication because (fill in the appropriate blank such as you are at max dose, your BP is low). Is there anything else that I can get you such as a cup of tea or a snack or to find something you might enjoy on TV that might also help make things better?" If the patient insists I will call the MD and express the patient's desires, but also give the information that they are "playing games" and do not appear in pain. I try not to care if anyone likes me, but at the same time maintain a sincere approach of "love in my heart" even when patients are mean. This can be a challenge.

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Specializes in Psych, Addictions, SOL (Student of Life).

Having been a chronic pain patient most of my adult life it does irritate me when nurses think I couldn't possibly be in "That much pain" because I am not lying white knuckled, silent and grimacing in the bed." What ever happened to pain is what the patient says it is." Myoglobin did give you some good advice though.

1. Don't take it personally.

Repositioning, hot/cold packs, massage and distraction such as music or television may work - but it is not a nurses job to "decide" a patient does not need more pain medication. When I am in severe pain in the hospital and I am on the phone, watching TV etc... I am trying to distract myself from the pain instead of sleeping and healing which I can't do with unmanaged pain. I am fortunate because my pain management doc will always order me a PCA when I am in the hospital after surgery.

2 .Try to do what you can to meet the patient's needs. In the case of the shower could the patient not have done this with a shower chair and an aid present?

3. Be empathetic in both your manner and words. Smile, laugh, be sad with a patient. Let them know that you understand what they are going through and that you will try to find a solution that is acceptable to the patient. Many times a nurse has told me that the doctor won't do something only to have the doctor come in and adjust/change orders so that proper relief can be achieved.

Hppy

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Specializes in Cardiac, COVID-19, Telemetry.
6 minutes ago, hppygr8ful said:

Having been a chronic pain patient most of my adult life it does irritate me when nurses think I couldn't possibly be in "That much pain" because I am not lying white knuckled, silent and grimacing in the bed." What ever happened to pain is what the patient says it is." Myoglobin did give you some good advice though.

1. Don't take it personally.

Repositioning, hot/cold packs, massage and distraction such as music or television may work - but it is not a nurses job to "decide" a patient does not need more pain medication. When I am in severe pain in the hospital and I am on the phone, watching TV etc... I am trying to distract myself from the pain instead of sleeping and healing which I can't do with unmanaged pain. I am fortunate because my pain management doc will always order me a PCA when I am in the hospital after surgery.

2 .Try to do what you can to meet the patient's needs. In the case of the shower could the patient not have done this with a shower chair and an aid present?

3. Be empathetic in both your manner and words. Smile, laugh, be sad with a patient. Let them know that you understand what they are going through and that you will try to find a solution that is acceptable to the patient. Many times a nurse has told me that the doctor won't do something only to have the doctor come in and adjust/change orders so that proper relief can be achieved.

Hppy

I do agree with pain is what the patient says it is. I actually did call the doctor about her pain medicine and he asked me to describe what she was doing, etc. Evidently, the nurse the day before had called him regarding the same exact thing and it had already been explained to her once why he wasn’t increasing the dose and they didn’t put in a note, so I didn’t know, and said MD was not very nice about being called regarding the same exact thing.

When I went to tell the pt what the MD said the situation was extremely awkward and then her husband starting yelling at me about how she’s laying there miserable and can’t do anything and all we are doing is working up a discharge to get her out. ??‍♀️

The shower scenario, I guess just would’ve been different if she had literally not had 4 showers leading up to this particular fit. My aid has 18 patients and can’t keep sitting in the bathroom every hour for a relaxing shower. I hate that staffing is what it is, but I can’t change that.

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Specializes in Psych, Addictions, SOL (Student of Life).
2 minutes ago, tropsnegRN said:

…….it had already been explained to her once why he wasn’t increasing the dose and they didn’t put in a note, so I didn’t know.....

The shower scenario, I guess just would’ve been different if she had literally not had 4 showers leading up to this particular fit.

Context is everything and had you said these things in your OP my answer would have been quite different. two things happened here - the previous nurse failed to make a progress note about the doctor's response so you were set up for failure. In this instance I find setting up a contract with the patient at the beginning of the shift. "This is what the doctor has ordered. I will check on you every time PRN medication is due to make sure you pain is managed to the best of my ability. " Chart your conversation and follow through on your end of the contract. Often if I or another patient in pain knows in advance that you care about my/their pain they will settle down. they may not be happy about it but at least they understand your rationale.

The shower scenario also takes a different note as described in your clarification - If the vomiting patient has any PRN for anxiety from Vistaril to Ativan give it as long as criteria for meds is present.

The saying goes you can make some of the people happy some of the time but you can't make people happy all of the time.

Hppy

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The patient wanted a shower for the 5th time that day? And needing supervision/assistance for each one?

That is unreasonable. I would have no problem explaining that the tech can assist her with a shower each day, but there is not enough staff for that many showers. It wouldn't even be an awkward conversation - just stating the facts.

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I think your post raises a crucial ethical concern. As other posters have pointed out, it is also difficult to address patients who are in deep pain but are relatively calm. I understand you're interested in dealing with demanding and/or rude patients. Nurses and caregivers are barred from calling patients "needy," "desperate," or other such things. It is even taboo to say this to another caregiver in a personal, non-professional context. In many ways, this is a thankless job. Nurses are held to high professional and ethical standards. So, whether a patient describes her pain stoically, or whether a patient is being rude and excessively demanding, it is a difficult situation. Medical humanities courses and modules are becoming more popular today. Doctors, caregivers, nurses, and even patients are actively invited to partake in these. Most discussions here are foregrounded in ethics. It would be beneficial, I think, if more people are introduced to these perspectives. It helps people understand that caregiving is not easy, to say the least. Sociologists have also argued that it is deeply difficult to describe the nature of pain--mental or physical--via language. That is, we can say a pain is severe or moderate, but nothing more. Even if we can, it is hard for other people to relate to these descriptions. Interesting argument (See: Sociology: The Essentials)

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Specializes in Geriatrics.

Great topic. I try to offer to do something toward meeting their request, even if it is not what they ask/demand. A little try often goes farther than we think. I try to hear what the residents are saying beyond what their words are saying. We all want to be heard and know that someone is concerned for our wellbeing. Lots of good perspective here on this board. I look forward to hearing more about your journey as a LTC nurse.

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Specializes in Mental Health.
55 minutes ago, peacepilgrim66 said:

Great topic. I try to offer to do something toward meeting their request, even if it is not what they ask/demand. A little try often goes farther than we think. I try to hear what the residents are saying beyond what their words are saying. We all want to be heard and know that someone is concerned for our wellbeing. Lots of good perspective here on this board. I look forward to hearing more about your journey as a LTC nurse.

^^ This. You can't always give people what they want, but you can usually give them a couple of other choices. They still get to feel in control by having a choice, and they don't feel like you are totally blowing them off either. People have different ways of coping with being laid up in the hospital, they aren't just trying to be difficult (usually lol).

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On 7/11/2019 at 11:59 AM, hppygr8ful said:

" What ever happened to pain is what the patient says it is."

What happened is that it was never correct to take that statement the one exceedingly common step further: "If the patient says they have any pain then we must do whatever they want us to do about it or else we are judgmental and uncaring." It also never meant that objective assessments of the situation are always judgments any more than saying that a patient "ambulates independently with steady gait" is a judgment (there are some elements of "judgment," for example does the patient feel secure while ambulating, or just appear steady, but the information is still valuable and helps figure out the situation). Various appropriate assessments (objective and subjective) do aid in understanding the individual picture and in helping to decide the appropriate intervention.

Believing patients when they say they have pain means assessing the patient and their situation carefully (objective) and hearing their descriptions of their pain and their perceptions of it and the effect they perceive it is having on their lives (subjective). That is our duty. Communicating these to the provider is our duty. Empathizing is our duty. Being a therapeutic support who seeks to offer prudent interventions is our duty. So that is how we can advise our peer.

On 7/11/2019 at 12:25 PM, hppygr8ful said:

Context is everything and had you said these things in your OP my answer would have been quite different.

The poster did mention 5 showers and phenergan in the same sentence in the OP. When these topics arise we should move on to discussing the real ways that nurses can maintain professionalism, remain caring, remain therapeutic and deliver appropriate interventions without constantly being accused of having made an unfair/snap judgment.

Newer nurses and all nurses do have to learn how to deal with this subject matter. I think that newer nurses almost always deserve a patient approach involving the extension of a little bit of grace and guidance. These are great opportunities for learning both practical stuff and also help shape someone into the kind of nurse they want to be. We are all on a lifelong endeavor of personal growth.

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On 7/11/2019 at 11:59 AM, hppygr8ful said:

What ever happened to pain is what the patient says it is.

Well for one thing it (and Press Gainey) got us into the opiod abuse pickle we are in today and the extremely sad result is that chronic pain patients, such as yourself, are the collateral damage now that we are trying to turn the ship around.

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5 hours ago, James L said:

I think your post raises a crucial ethical concern. As other posters have pointed out, it is also difficult to address patients who are in deep pain but are relatively calm. I understand you're interested in dealing with demanding and/or rude patients. Nurses and caregivers are barred from calling patients "needy," "desperate," or other such things. It is even taboo to say this to another caregiver in a personal, non-professional context. In many ways, this is a thankless job. Nurses are held to high professional and ethical standards. So, whether a patient describes her pain stoically, or whether a patient is being rude and excessively demanding, it is a difficult situation. Medical humanities courses and modules are becoming more popular today. Doctors, caregivers, nurses, and even patients are actively invited to partake in these. Most discussions here are foregrounded in ethics. It would be beneficial, I think, if more people are introduced to these perspectives. It helps people understand that caregiving is not easy, to say the least. Sociologists have also argued that it is deeply difficult to describe the nature of pain--mental or physical--via language. That is, we can say a pain is severe or moderate, but nothing more. Even if we can, it is hard for other people to relate to these descriptions. Interesting argument (See: Sociology: The Essentials)

I just matter of fact explain what is going to happen and why it is going to happen that way. Then see if there is something else I can do besides blinding doing what the patient thinks I should do. I may say I am sorry that I am unable to do what they want. Then I just go ahead with good nursing care and not let it bother me.

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