Uncooperative Patients

[HappyMeNow]

Do you ever get patients who just don't want to do their morning care and ambulate because they don't feel well, but at the same time you've got to get it done or else you'd be in trouble?

How do you handle these situations?

[Boog'sCRRN246, RN]

Sometimes you just have to work on your patient's schedule and not yours. Who would you get in trouble with? They may not feel up to bathing and ambulating right at that moment, but sometimes if you give them some time, they'll be up for it later. You can offer to come back at a certain time with bathing supplies, and when you come back, don't give them the option to say 'no bath'...say 'would you like to get cleaned up in the bed or would you like to sit in the chair?' If they are still adamant about not bathing/ambulating, etc. all you can do is document that you offered on several occasions but the patient refused, and pass it on in report.

[SweetLemon]

Sometimes it also helps to try to address the issue less directly. I have found with a lot of patients its not so much they have problem doing what you want them to do, they just don't like being told what to do period. On the one hand I can understand that being an adult and having someone else dictate how you are going to structure your morning is irritating but on the other hand its just part of being ill and in the hospital. Reminding people of the benefits of whatever you need them to do sometimes helps, and every once and a while I simply level with people. Explaining that while they might not feel a shower/ambulating early in the morning is important I as well as the doctor have a schedule and would really appreciate the cooperation.

[rn/writer, RN]

You can often get better results if you tailor your approach to the individual patient. With some, they thrive on extra attention, so you can fuss over them a little and be a bit cajoling and coaxing as you would with a child. Others hate that kind of treatment and would prefer a more direct manner with clear choices. Some truly feel terrible and may need better pain management or a very gradual advancement. A few will drag their heels no matter what.

Sometimes the best thing you can do is just go ahead and ask the patient how the two of you can find a way to work together to get the necessary tasks accomplished. Pull up a chair and give them a few minutes of your time. This might seem like it would put you behind schedule, but making a connection and developing a plan can save more time than this few minutes will cost you.

Tell your patient what the goal is--getting them out of bed, hygiene, ambulation, giving them a clean bed--and ask if they have any preference as far as when and in what order these things occur. Do they want to walk first, then clean up or vice versa? Have they ordered breakfast yet? How long ago? Maybe you could help them with a shower and a nice clean bed so they can have an enjoyable breakfast.

Ask about when visitors might be expected. They might want to spruce up for someone else.

If you meet with resistance that doesn't lessen after a few nudges, ask with sincerity what is holding them back. Are they hurting? Are they fearful that they aren't strong enough yet or that they might pass out in the shower? Maybe they're feeling really down--this can happen after some kinds of surgery and it can be a physiological response as well as a psychological one. Ask what you can do to help them move forward and acknowledge every positive step they take.

When I have been hospitalized, my third shift body has had a hard time greeting the dawn. I usually explain this to my caregivers and we agree that I will do my "morning" routine just after lunch. Agreeing to this takes the pressure off everyone, and I have often had a nice time with staff when they're not so rushed. Putting this information up front puts an end to the tug of war. I do have a plan; it's just a bit delayed. Patients may not know they can voice such thoughts, so it's up to us to bridge the gap.

Keep in mind that people who are hospitalized may be suffering from a sudden, shocking loss of control that can cause them to "take a stand" over things that can seem petty to us. They often don't realize they are doing this. They only know they feel bad and they don't want some young chickie-poo telling them when to bathe. You can offer a gentle apology in the sense that you're sorry they're having such a tough time, not that you're doing something wrong by asking them.

At times, a little bit of humor can be just what the doctor ordered. You do have to be careful when and on whom you use it, but it can go a long way toward lightening a dark mood if done properly.

Finally, ask open-ended questions. "Can you tell me how you're feeling?" "What is something you're looking forward to when you go home?" "How can I help you get feeling better? No, asking me to leave the room isn't an option. :D"

Some of this is learned over years of experience, but most of it is nothing more than expressing genuine concern even as you have an agenda to fulfill. If you can put forward the idea that it's easier to be on the same side than to be adversaries, at least they will know you're trying to work with them.

Even in worst case situations where you get only minimal cooperation, let your patient know that you are still on their side and you hope the day improves for them.