Why do I let them get under my skin?!

merlee · Feb 15, 2011

I'm not sure I understand - the pt became abusive because you brought the ordered meds to the bedside - - is that what you are saying? Then complained because you had poor technique while administering the meds? Was the doc not invited to re-address the meds prior to administration?

If the pt was abusive just because you brought the meds in, that was the time to get the charge nurse/supervisor and/or doc. I personally would not have wasted my breath trying to convince the pt to take the meds.

If your documentation is clear, you should not be concerned.

Best wishes.

EmergencyNrse · Feb 15, 2011

Sorry about your bad experience. I firmly believe that patients come in wanting help or they don't want help. They don't get the choice of how and they certainly do not get a free pass to be abusive verbally or physically. Know this, their behavior isn't something that just manifested itself during your encounter it's something they do with regularity. They practice it. "The squeaky wheel gets the grease", right?

You get a "feel" for the manipulative ones. Most of the time they are frequent fliers with established history of acting the same way.

I put on my professional act of telling the patient that I am there to help and ask if there is anything I can do to make her more comfortable.

Start of action:

Dr. orders meds that the patient doesn't want/expect. Then I reinforce that I don't "order" the medicine I just administer it. There is no negotiation and no convincing the patient to take it. I give the meds if they want them or return the meds and chart patient refused Dr. notified. I stay focused on my role and ask again if there is "anything I can do to make her more comfortable" (after all that is in my scope).

Next, when the patient "goes off" I try to be convincing by acting like I care and get the charge nurse involved. Then you can wash your hands of the ordeal by saying that you have lost rapport and can no longer be her nurse.

This usually ends by either the charge nurse begging the doctor to give them what they want or counseling the patient on how patients don't get to pick and choose their medicines without first going to med school. Really depends on your department's "personality". Either way you are usually out of the picture and off doing something else.

Sometimes...every now and then:

If you have a good working relationship with your doctor and this patient has an established record of "narcotic seeking behavior" you can have your patient committed for detox and their "addiction". This is a really fun passive-aggressive way to get back at them for being pain-in-the-@$$es. Then the behavior becomes aggressive and you get to use haldol, ativan and geodon until all they can do is sit in the corner and drool on themselves.

(Aaaaah, sometimes it's the little things that make it all better)

emtb2rn, BSN, RN, EMT-B · Feb 15, 2011

B52 cleared for landing......

Have a witness, document, delegate upwards to charge.

Paravell · Feb 15, 2011

I'm not sure I understand - the pt became abusive because you brought the ordered meds to the bedside - - is that what you are saying? Then complained because you had poor technique while administering the meds? Was the doc not invited to re-address the meds prior to administration?
If the pt was abusive just because you brought the meds in, that was the time to get the charge nurse/supervisor and/or doc. I personally would not have wasted my breath trying to convince the pt to take the meds.
If your documentation is clear, you should not be concerned.
Best wishes.

To answer the first questions, yes, yes, and yes!!!! I notified the charge nurse after the second round of screaming, and the doc was onboard the entire time.

And, the problem is that I do waste my breath! I'm working on not letting people treat me like that, you know, become one of those no nonsense type of nurse that does not put up with the bs. I think I documented clearly, and was pleased to read the md documentation that backed me up. So at least he's not throwing me under a bus!! Thanks for the reply:)

Paravell · Feb 15, 2011

Sorry about your bad experience. I firmly believe that patients come in wanting help or they don't want help. They don't get the choice of how and they certainly do not get a free pass to be abusive verbally or physically. Know this, their behavior isn't something that just manifested itself during your encounter it's something they do with regularity. They practice it. "The squeaky wheel gets the grease", right?
You get a "feel" for the manipulative ones. Most of the time they are frequent fliers with established history of acting the same way.
I put on my professional act of telling the patient that I am there to help and ask if there is anything I can do to make her more comfortable.
Start of action:
Dr. orders meds that the patient doesn't want/expect. Then I reinforce that I don't "order" the medicine I just administer it. There is no negotiation and no convincing the patient to take it. I give the meds if they want them or return the meds and chart patient refused Dr. notified. I stay focused on my role and ask again if there is "anything I can do to make her more comfortable" (after all that is in my scope).
Next, when the patient "goes off" I try to be convincing by acting like I care and get the charge nurse involved. Then you can wash your hands of the ordeal by saying that you have lost rapport and can no longer be her nurse.
This usually ends by either the charge nurse begging the doctor to give them what they want or counseling the patient on how patients don't get to pick and choose their medicines without first going to med school. Really depends on your department's "personality". Either way you are usually out of the picture and off doing something else.
Sometimes...every now and then:
If you have a good working relationship with your doctor and this patient has an established record of "narcotic seeking behavior" you can have your patient committed for detox and their "addiction". This is a really fun passive-aggressive way to get back at them for being pain-in-the-@$$es. Then the behavior becomes aggressive and you get to use haldol, ativan and geodon until all they can do is sit in the corner and drool on themselves.
(Aaaaah, sometimes it's the little things that make it all better)

Thanks for your reply!!! Your advice is spot on..although in our ER there is no "losing rapport" to change patients :) My charge nurse is great, but she was extremely busy and couldn't really take over the patient for me, nor did I really want her too, I didn't want to spread the problem around :) I really wish we could have PEC'd her for delusional behavior!!! 3 days in an empty room may have given her perspective :) Looking back, I think that what actually made it worse is that I did empathize with the pt in the beginning, so I guess she thought I was an idiot and could magically get the doc to order the dilaudid and phenergan iv. Sometimes being nice makes them think that you don't "know the game" and they will really try to take advantage, then get all the more indignant when it doesn't go their way. I've asked my charge nurse if we can wear flags like referees do and use them...I would call it the troll flag :rolleyes: Don't think administration would approve of that one...

Paravell · Feb 15, 2011

B52 cleared for landing......
Have a witness, document, delegate upwards to charge.

I think that if this patient had been in the main ed, around everyone, they would have either a)called security to remove her from the ed, or b)ended up giving her b52 after they told her she needed to watch her mouth or leave. :)

Unfortunately, although we don't have a dedicated fast track, the 4 rooms we have are situated down the hall from the main ed, so that didn't happen!!

bsyrn, ASN, RN · Feb 15, 2011

You will never be able to please everyone...just keep doing what you're doing, the majority of your patients appreciate you I am sure. Keep your chin up

Altra, BSN, RN · Feb 15, 2011

Sometimes being nice makes them think that you don't "know the game" and they will really try to take advantage, then get all the more indignant when it doesn't go their way.

Lesson learned.

When she started to tell you her life story, it was because she was reeling you in as one of the *special ones* who is going to do something as a favor to her. Next time ...

RN: "The doctor has ordered these meds so that we can get your headache under control. They often work pretty well for migraine-type headaches."

Patient: ... tirade ... dramatics ... wailing ... etc.

RN: "These are the meds the doctor has ordered, but I certainly don't push medicine on anyone. If you'd prefer not to take them that is absolutely your choice. I can let the doctor know you don't want the meds and we'll get you going on your way."

How far the patient ups the ante at this point will depend on his/her past history, the culture of your ER and what behavior s/he has found to be most effective. What helps you to remain calm is to be secure in the knowledge that this has absolutely nothing to do with you personally. The patient is simply repeating behavior patterns that have been successful in the past. Let it roll off of your shoulders, document carefully using direct quotes, give the heads up to the provider and your charge nurse, and move on.

enchantmentdis, BSN, RN · Feb 15, 2011

People in general are not to be trusted, and pt's have way too much power--management ALWAYS sides with the patient. I also had a pt accuse me of being a schizo and he was the one who had bipolar, depression, anti-social personality disorder, masturbated in front of the nurses, made us give his pain meds every hour, chatted us up something fierce (beware when they chat you up--these folks are extremely manipulative, and if they get wind that you are a bit exasperated with them, their fragile egos can't handle it and they will cry like Nancy Kerrigan to management until they get you fired.). They cannot tolerate that hard-working folks like us are on to their game. They do not care that they have the power to destroy a nurse's life, if even for awhile. This is the NUMBER ONE reason why i left acute care.

enchantmentdis, BSN, RN · Feb 15, 2011

I'm not sure I understand - the pt became abusive because you brought the ordered meds to the bedside - - is that what you are saying? Then complained because you had poor technique while administering the meds? Was the doc not invited to re-address the meds prior to administration?
If the pt was abusive just because you brought the meds in, that was the time to get the charge nurse/supervisor and/or doc. I personally would not have wasted my breath trying to convince the pt to take the meds.
If your documentation is clear, you should not be concerned.
Best wishes.

Even with great documentation, management usually blames the nurse.

josinda421 · Feb 15, 2011

So sorry this happened to you. It's just one of those bad days. And believe me....plenty more to come. Just try not to get stressed out over it. On the otherhand, I have experienced a bit of what the patient is going through. I also had severe migrianes and receiving meds like toradol, made it even worse for me. I felt like my head was going to explode and started hallucinating. I would've rather dealt with the migraine than feeling the way I felt.