Nurse vs. Patient
Recently, we were presented with a typical frequent-flying crackhead who had the usual litany of complaints. The specific details don't really matter; I'm sure you know the type. Apparently one of the nurses on duty had some previously unpleasant experiences with this particular individual, and she seemed none too thrilled about her assignment. I, on the other hand, had never seen the patient before.
This patient was a bit irritable and paranoid, but there was neither obvious evidence of danger to self or others nor anything particularly abnormal on the examination. As I was charting my notes, I could hear some animated discussion coming from the room. The nurse was finally able to obtain some blood, but she was unable to start the IV. After I reviewed some of the previous records, I decided that I didn't necessarily want this patient to have an IV anyway, because I saw that on a previous visit the patient had eloped from the ER prior to disposition. So I ordered an IM injection of a sedative, which the patient agreed to accept, grateful that there would be no more IV attempts.
But the patient didn't want the nurse in question to give the injection, because the patient was now afraid of her. She tied the tourniquet way too tight on purpose, the patient claimed, and she was less than gentle with her multiple IV attempts, purposely "jabbing the needle into the bone." Unfortunately I still had a few other patients to see, and I really didn't have time for any nonsense. Whatever, I'll try to find a different nurse to give you the shot.
"Oh no you won't!" barked the clipboard-carrying nurse administrator who had been lurking vulture-like, eager to plunge her beak into the carrion this situation was becoming. "This nurse is assigned to the patient, and she is the only nurse that will be involved. The patient isn't allowed to change nurses, especially after being so abusive and uncooperative all these times. We're not going to play these games."
Fine, I said. I don't care who gives the shot, or really if the patient ever even gets the shot. It's not really an emergency anyway. I'm just waiting on the blood tests and trying to make the patient a little more comfortable and less agitated so everyone can chill out a little bit.
Of course the patient refused the shot from the "mean nurse" and continued to be angry and upset. A battle of wills ensued, in which each of the opponents tried to exert their dominance over the other. The patient used whatever ammunition was available, primarily the power to hit the call bell and to be generally defiant and rude. The nurse countered with her unwavering authority and adherence to policy. For example: the patient was claustrophobic and wanted the door to the room open. The nurse took it upon herself to be the door Nazi and kept closing the door, smugly quoting government regulations and patient privacy considerations.
Was this nurse really such a true believer in the closed door policy that she consistently applied it to all patients in every situation? No, she was just using the policy as a stick with which to poke this particular patient. There were some raised voices from both corners and a couple of visits from security, but nothing really exciting or disturbing. After they eventually tired of the battle, the nurses came to me for resolution of the problem.
"What are you going to do about this?" they asked.
My job is to diagnose and treat emergency medical conditions. Based upon my initial assessment, I determined that some tests were indicated, and my disposition will be based upon those results. If the patient wants to stay and be treated, then we should treat the patient. If the patient wants to leave, then I'm not going to stand in the way. I've got a couple of sick patients I'm dealing with right now, and the fact that this patient is annoying and doesn't want to follow your rules isn't high on my list of priorities at the moment. I'm not going to do anything that would make this situation more unpleasant than it already is, if that's what you're asking. I've been in that room three times, and I've been able to verbally calm the patient down each time. I recommend that you try to do the same instead of agitating the patient further.
I'm all about supporting nurses, but I will never support their blind adherence to bullshit policies and regulations, and I don't like it when they seem to purposely antagonize patients. I admit that I'll probably be less inclined to tolerate any misbehavior from this patient after a couple more visits like this one. But in this case, I couldn't shake the feeling that we all could have handled the situation better.
UPDATE: IF you want to know more about crackheads AND you need a laugh THEN go here ELSE die.
This patient was a bit irritable and paranoid, but there was neither obvious evidence of danger to self or others nor anything particularly abnormal on the examination. As I was charting my notes, I could hear some animated discussion coming from the room. The nurse was finally able to obtain some blood, but she was unable to start the IV. After I reviewed some of the previous records, I decided that I didn't necessarily want this patient to have an IV anyway, because I saw that on a previous visit the patient had eloped from the ER prior to disposition. So I ordered an IM injection of a sedative, which the patient agreed to accept, grateful that there would be no more IV attempts.
But the patient didn't want the nurse in question to give the injection, because the patient was now afraid of her. She tied the tourniquet way too tight on purpose, the patient claimed, and she was less than gentle with her multiple IV attempts, purposely "jabbing the needle into the bone." Unfortunately I still had a few other patients to see, and I really didn't have time for any nonsense. Whatever, I'll try to find a different nurse to give you the shot.
"Oh no you won't!" barked the clipboard-carrying nurse administrator who had been lurking vulture-like, eager to plunge her beak into the carrion this situation was becoming. "This nurse is assigned to the patient, and she is the only nurse that will be involved. The patient isn't allowed to change nurses, especially after being so abusive and uncooperative all these times. We're not going to play these games."
Fine, I said. I don't care who gives the shot, or really if the patient ever even gets the shot. It's not really an emergency anyway. I'm just waiting on the blood tests and trying to make the patient a little more comfortable and less agitated so everyone can chill out a little bit.
Of course the patient refused the shot from the "mean nurse" and continued to be angry and upset. A battle of wills ensued, in which each of the opponents tried to exert their dominance over the other. The patient used whatever ammunition was available, primarily the power to hit the call bell and to be generally defiant and rude. The nurse countered with her unwavering authority and adherence to policy. For example: the patient was claustrophobic and wanted the door to the room open. The nurse took it upon herself to be the door Nazi and kept closing the door, smugly quoting government regulations and patient privacy considerations.
Was this nurse really such a true believer in the closed door policy that she consistently applied it to all patients in every situation? No, she was just using the policy as a stick with which to poke this particular patient. There were some raised voices from both corners and a couple of visits from security, but nothing really exciting or disturbing. After they eventually tired of the battle, the nurses came to me for resolution of the problem.
"What are you going to do about this?" they asked.
My job is to diagnose and treat emergency medical conditions. Based upon my initial assessment, I determined that some tests were indicated, and my disposition will be based upon those results. If the patient wants to stay and be treated, then we should treat the patient. If the patient wants to leave, then I'm not going to stand in the way. I've got a couple of sick patients I'm dealing with right now, and the fact that this patient is annoying and doesn't want to follow your rules isn't high on my list of priorities at the moment. I'm not going to do anything that would make this situation more unpleasant than it already is, if that's what you're asking. I've been in that room three times, and I've been able to verbally calm the patient down each time. I recommend that you try to do the same instead of agitating the patient further.
I'm all about supporting nurses, but I will never support their blind adherence to bullshit policies and regulations, and I don't like it when they seem to purposely antagonize patients. I admit that I'll probably be less inclined to tolerate any misbehavior from this patient after a couple more visits like this one. But in this case, I couldn't shake the feeling that we all could have handled the situation better.
UPDATE: IF you want to know more about crackheads AND you need a laugh THEN go here ELSE die.
Labels: nurses, patients, perception, questioning authority
posted by scalpel at 3:22 PM
36 Comments:
Why is a hopsital stay (or an ER visit) supposed to be a pleasant experience?
Sorry, this doc sides with the nurses. If you're 85 years old and septic, if you're 60 and having an MI, ir you're 22 and need a bone set, you can be mean to the nurse. Once or twice.
Muliple ER visits to the point where every nurse hate you is a sign of some serious social pathology. And is you've been that nasty to everyone I work with, then you don't get to make requests. You get care, nothing more, nothing less.
And by all means, if you don't want the care I provide, you're free to leave.
ah the unrestrained self-importance and ego of a CHARGE nurse...
looks like all those semesters learning about "treating the patient in a psycho-socially holistic manner" were maybe not so vital after all...
relax people, it's just a job.
I think it's best to try to diffuse a situation whenever possible, without caving to irrational and abusive behaviors. It's sort of a dance isn't it. Sure you want to stick it to the crackhead, but I don't think that will make you a better person in the end.
That being said, I tend to be more analytical and less friendly and compassionate, so I probably wouldn't make a good nurse. I guess it is hard for me to get past the lets fix this or that and into the, "oh how are you feeling."
I would probably have issues with crackheads.
Funny you should mention the CHARGE nurse. The patient didn't understand the term and was offended by it.
"She's not in charge of me!"
Many of our battles are caused or exacerbated by simple misunderstandings.
whitecap nurse says:
Well, this nurse sides with the doc. I have seen that behaviour between patients and co-workers and it is completely juvenile. Staff can so escalate a situation that it becomes unsafe for everyone. Why would anyone want to do that? Give him a shot from a different nurse and discharge him pronto!
It is not unusual for patients to calm down when the doctor talks with them. The doctor is the one who decides whether or not the patient is going to receive medication or other treatments. The nurse does not have as much "power" as the doctor but is usually the one who has to deal with the patient's anger, bad manners, curse words, and demands. I don't think I have really observed a nurse exhibiting "blind adherence to bullshit policies and regulations" nor have I seen a nurse purposely antagonize a patient. We don't usually try to make the job any harder than it is when dealing with the type of patient described in your post.
I agree, kay, that patients often calm down when dealing with the doc but are rude and nasty to the nurses.
But it seems to me that many nurses only blindly follow the BS regulations when it suits them. The "one family member to a room" rule is a perfect example. Or the "no beverages in the nurse's station" is another. Mean, drunk, or annoying families will be banished to the waiting room. Helpful, quiet, polite families can have a couple of extra chairs in selected situations.
When nurses feel the need to wield the rules as a weapon, they do so. When they can bend the rules to their own advantage, they won't hesitate to ignore them.
I think rules are made to be bent as long as the bending doesn't adversely affect patient care. But the rules should be bent if bending them would improve patient care in a given situation. Patient care is what we're there for, after all.
Not the enforcement of administrative policies.
This nurse is going to side with the doc on this one. Of course, I don't know all of the details of the situation from the nurse's perspective. I can see an argument possibly being made for keeping the door closed because the patient was disturbing others, but that seems unlikely.
I don't take crap from my patients. I am a patient advocate and work to achieve the best outcomes, but I do it with an understanding that I am on their side. When they put me on the other side, I go willingly, but I'm not going to play silly games with them. Then again, most of my patients recognize that I'm working for them and that I care about how they are feeling and I really don't run into this type of problem too much (except for the inebriated ones who are not capable of rationalizing).
I also agree to an extent with the comment above that "why is an ER visit supposed to be a pleasant experience?" I think that part of the problem we face is that we allow ourselves to be used as a Doctor's office more than we need to. Don't get me wrong - I want my patients to be comfortable and happy, but ultimately that is up to their agency and choice. Somewhere along the way we have to take personal responsibility for our actions.
And that includes the nurse in this post.
"When nurses feel the need to wield the rules as a weapon, they do so."
That is a fact. I'm one hundred percent behind you on this one, Scalpel.
We get petty sometimes, (yes, I've done it, too) and we make things worse. It's not only counterintuitive, it's counterproductive.
I think whitecap nurse hit it right on the head, "Staff can so escalate a situation that it becomes unsafe for everyone. Why would anyone want to do that?"
I have had something like this happen - I just grabbed the haldol/ativan and injected the patient myself. I can't deal with that kind of bullshit either. I am like "JUST DO IT" - we all have to be "professional" and put our annoyances behind us to do what we have to do.
I think some of the most difficult people to deal with are the ones who are idiotic, but completely unaware. They honestly believe that the nurse is jabbing the needle into their bone! Conversely, these people are also the easiest to treat - play their game, make them think they won, and everybody goes home happy.
A nurse doesn’t have the right to be a jerk even if his or her patient is being an A-Hole. This nurse was putting herself in jeopardy. The patient could have assaulted her. If the patient wants another nurse to give him a shot, so be it, just as long as he takes his medication. Choose your battles wisely, and no one gets hurt.
MJ
Scapel,
Did you consider giving the injection yourself? Hey, I might be tempted to give one to the nurse too! Kidding!
I've never been to an ER, never needed to go to an ER, and I'm fully insured. Yet, I'm now scared shitless if I ever need medical care by any medical professional who hasn't already established a relationship with me.
Shocker! A crackhead antagonized someone?
I assume crackheads are going to antagonize me, make nonsensical statements, and, for instance, ask for a new nurse if they're not getting the drugs they want from nurse #1. Those things alone are not a reason to switch nurses.
Maybe I'd have compromised and allowed a different nurse to give the shot but not caved into the demands to change nurses entirely. That game can go on forever until every nurse has been "assigned" the patient. It's just counter-productive and annoying. Nurses are taught to put limits on this type of behavior.
I'd probably use the door-opening as a bargaining tool..."I understand you're claustrophobic, but I can't open this door until you speak quietly because there are sick little grandmas who have complained about the yelling and I'd not like to disturb them." The sick little grandmas line works pretty well.
At this juncture:
1 point nurse
6 points doc
1 either way
I vote for the doc, get it done, get him out....next.
Being a nurse, I have to say that we have to take a stand and be assertive with patients that 'try' us. But you're right, it becomes a power play and a battle of egos. Some nurses can just let the patient be and feel some sort of power if they (the nurse) is in charge. There's no reason why someone else could have given that IM. Give me a break.
Gotta love those power struggles.
In the long run, does it really matter if the patient's door is open or closed?
I always ask myself: Is this the hill I want to die on? Most of the time the answer is no.
This nurse sides with the doctor. You shouldn't have to deal with that sort of nonsense.
What's the point of being so punitive to the patient anyway? You'll never change their behavior.
Why not just order a pill instead of a shot anyway?
"The patient isn't allowed to change nurses"
Ms. Lawyer nurse needs a CLE brush-up. And, short of that, should probably look over her hospital's patient "bill of rights".
UPDATE: IF you want to know more about crackheads AND you need a laugh THEN go here ELSE die.
I'm glad someone gets my nerd-humor. No need to kill your readers off for merely not clicking the link though.
;-)
From a patient:
For those of us who are not crackheads -- probably just suffering from some other pathology that allows you all to pigeonhole each and every one of us cash-cows ... er, patients, so we can be compartmentalized as a bundle of symptoms and behaviors rather than a human being that you might have to treat with dignity -- actually, we've been turning down your care in increasing numbers because the service sucks. Because, as consumers, we can no longer accept your unconscionably horrible service. You all sound like a bunch of buggy whip manufacturers arguing amongst yourselves at the turn of the (last) century. Stop feeling sorry for yourselves and fix your business model. Oh, sorry ... too soon? See you in the breadline in 10 years.
And yet, anonymous, you still come to the ER....in droves.
Oh, and I only do my buggy whip job on weekends so I can be fresh as a daisy for my ER job taking care of the crackheads, and of course my meticulous pigeonholing.
Keep telling yourself that. Enjoy mowing my lawn in 10 years.
Sorry, that was just mean. I thought it would be more gratifying poking a wounded tiger in a cage, but alas, no. There is a serious discussion to be had here. I think the first questions is ... how can one stand back to gain perspective and see the ship going down? There are medical professionals out there blazing trails with non-traditional business models. Maybe because I'm not in the business, it seems more obvious to me that medicine is going to be as different in, say, 20 years, as it was, say, 100 years ago. So where will everybody be? (Sincerely, sorry about the lawnmowing comment)
I think the doctor should always be the boss in the ER.
I disagree that she WAS adhering to a policy. If a patient chooses to give up their right to privacy and have the door open that is their right. The patient gets to be as uncooperative as s/he he wants...the nurse, does NOT. It's her JOB to provide good service to this client, and sometimes that means making concessions you don't want to make. If that situation went to HR she would loose. What if the patient requested a male nurse vs. a female nurse to be more comfortable? It's the same thing.
scalpel. 100% with you. lots of folks i work with on the provider side and nursing side are still into the 'gotcha' medicine and i've just quit caring. did you ask nazi nurse to do the injection? just curious.
Geez - seems like the hostile nurse would have had a MUCH easier shift if she'd just found a way to get the patient the sedative - whether by being nice to the patient or having another nurse help her out. Seems ridiculous to ask the doctor "what are you going to do about this?" when you'd written for a sedative hours ago and they just wouldn't give it. Smarten up, people.
I eventually changed the order to an oral medication and the patient was discharged soon thereafter.
The uninformed anonymous commenter must not be aware that ER visits are increasing, particularly among insured patients. Our ship isn't going down, our business is booming.
In 20 years, where will everybody be? In our waiting rooms, of course. Unless you choose to go to Wal-Mart instead. Good luck with that.
Oh, and patients can't demand to be assigned a nurse of a different gender either. Sorry.
if we are going to provide patient centered care we need to give patients have the right to refuse care from providers whether they are med students, doctors, associate providers, or male or female nurses. if there was only one nurse on, and the patient didn't wish to get an injection from them, then the doctor should offer to give it if he is comfortable giving injections. I don't think we should be in the business of punishing patients.
We aren't offering "patient-centered care" in the ER....we're providing emergency care. Big difference.
Patients can refuse our emergency care if they are competent to do so, but their choices are usually "take it or leave it," instead of "what can we do to make your stay more pleasant?"
"Would you like the Caucasian doctor today, or the ethnic physician? The pretty young nurse, or the old grizzled veteran?"
Barf.
I always enjoyed the term "patient-centered care" because it's so stupid if you think about it.
You have to be pretty off your rocker to be in a room with a patient and a bunch of equipment and/or family members and start providing care to someone or something other than the patient.
False dichotomy. I think it is "patient-centered" as opposed to "doctor-centered" or especially "nurse-centered." Care is both given and received. It can be centered around the (convenience of the) provider or the (welfare of the) recipient.
Having worked in management over a critical care unit I can tell you that if there were a patient and nurse on my unit who were "incompatible", I would immediately change the assignment. I totally understand that the opportunity for "bullshit" by the patient exists but rather than add more of the same by the nurse and mentally masturbate over it for hours such that the physician had to be involved as well as the care of all of the other patients in the E/R be compromised, I would choose the lessor of two evils.
As a former manager and speaking to this case, I would also have a difficult time assigning the nurse who was the "CHARGE NURSE" to that position for some time and only after he/she was more experienced at defusing situations rather than allowing them to escalate for her own gratification and that of the nurse involved in the direct care of the patient. Just because the patient acts like a child doesn't mean that you have to act like one--all you need to do is learn how to deal with them.
Finally, whether or not the patient has the "right" to refuse treatment by any of their healthcare providers, and I believe they do, imagine if the patient had an illness that was masked behind their "typical behavior" such that they coded and there was a "negative outcome".
Any medical malpractice attorney would have a field day with this one. Looking at it in that regard I can only imagine the questions asked to the staff while they were under oath and on the stand.
"So the patient was anxious and asked to be cared for by another nurse and you refused? Let's go over the timeline here, so it took you how many hours while you were arguing with the patient to diagnose (pick you own medical emergency but AAA sounds good)? The patient came into the E/R at X hours, lets go minute by minute what was done for the patient from the time he came in? In your professional experience, do patients with X illness ever exhibit signs of "being an asshole" with X illness being a contributing factor above and beyond the patients inherent asshole level.
If I were the nurse manager, I would be embarrassed that the nurses who worked for me drew the doctor in to this fiasco. If I were the doctor I would have added benedryl to the cocktail of ativan and haldol and make it "the holy trinity", and and then TELL the nurse to draw up the medication and I would give it myself. (I have a friend who is a board certified forensic psychiatrist and JD and former RN and she does it all the time). I would then immediately call the nursing supervisor and tell them that I expect them to deal with the situation and that one option is NOT allowing the same nurse to care for the patient and in the meantime, the supervisor can give the shot if I had not already done it myself. If the nursing supervisor was not sympathetic to the excalating situation and refused to change nurses, I would then place a call in to the administrator on call and hope that they have more horse sence then the nurse, the charge nurse, and the in house supervisor and I would briefly explain that we had a nurse/patient incompatibility that was affecting the care and smooth running of the emergency room and that I would like them to ORDER the nusing supervisor to change the assignment and stop this silly shit.
I would then deal with the situation after the shift was over to prevent it from happening again, and would start with the director of nursing and go upward from there if necessary, and heads would roll. I would also ask for clarification from in house counsel re the right of patients to ask that the nurse assigned to them be changed so that question would be answered conclusively.
Nice. You start out by admitting to no previous history with this patient and then you pile on the nurse for refusing to be manipulated and played. I might have asked a coworker to give the shot if it would make my life easier, but there is no way I would dump the assignment on someone else.
You come to the ER, you get what's offered. If you don't like it, assuming mental competency, then good bye. If Crackhead didn't have any life threatening complaints an administrative discharge would be completely appropriate.
What's funny is that a lot of the commenters here are the same ones who came to the defense of King Drew Hospital last year when the triage nurse watched a patient die on the waiting room floor. Then it was all "she was a drug addict" or brought it on herself or was abusing the system. Hypocrisy much?
The patient, er Crackhead, described here is exactly the kind of person that needs limits set from the first moment. I don't have time to bust balls on every patient who steps over the line, but with some you need to do it or pay the consequences.
It'll be funny when your crackhead starts asking for you on return visits.
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