When the Nurse Is the Problem

From The Floor

When the Nurse Is the Problem

While patients and their families can be difficult, sometimes the fault lies with a nurse on a power trip.

By Genevieve M. Clavreul, RN, PhD
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During a nurse’s career, he or she will encounter at least one difficult patient or overbearing family member.  An impossibly difficult patient can drive a nurse to consider re-assignment, and in worse case scenarios, may lead her to quit nursing altogether. But what happens when the nurse is the cause of the problem? Or, what if she causes the patient to respond negatively, thereby making the patient appear to be “difficult”?  There may be some readers who find this unlikely, believing instead that when there is a conflict, it is always due to a difficult patient, and that the nurse plays no role in the problem. However, in my experience, there are occasions when the nurse instigates the difficult behavior and the patient is simply responding to the stimulus. When this occurs, the patient or patient’s family suffers, the “bad” behavior does not get corrected, and the nurse continues to be unaware of her role in the drama.

Example One: Mopping During Wound Care

Nurses are caring for a patient who has been hospitalized for nearly a year in ICU; he has had multiple surgeries and a large, gaping, open abdominal wound. The family is involved in this patient’s care, and are very interactive with the nursing team, asking questions and, when the need arises, doing their own research.  

One day, while the children are visiting with their father, the nurse comes in to change the dressing of the open wound, and, not wanting to interfere with her work, they wait for the nurse to complete her task. Meanwhile, the cleaning crew comes in and begins mopping and dusting the patient’s room. The family briefly interrupts the nurse, commenting that perhaps the cleaning crew should not be there while she is redressing an open wound. The nurse ignores their comments, completes the wound care, and then leaves. The cleaning crew finishes their work shortly thereafter and then leaves the room as well.         

This incident repeats itself for several more days while the family is present. Concerned that appropriate protocol to minimize infection is not being followed, the family complains to the charge nurse. As a result of their complaint, the family is barred from the room whenever the nurse is present—she, in turn, complained that the family was making her work difficult.

Who do you think is at fault in this particular scenario? If you identified the nurse, you would be right. The nurse actually escalated the situation by choosing not to address the family’s valid concern.  She should have asked the cleaning crew to come back at another time, or at the very least stopped what she was doing to return after the cleaning crew had left. Cleaning and redressing the wound while people were mopping and dusting placed the patient in a threat position for further infection (he had already had multiple infections).

Indeed, the nurse probably felt “picked on” when the family went to her boss to lodge the complaint, but if she had responded appropriately when the family expressed their concerns originally, the matter would likely have been handled without involving the nurse’s supervisor.

Example Two: Cultural Insensitivity and a Nurse on a Power Trip

It’s a very busy night in a hospital NICU unit. It is change of shift and the nurses are preparing for the start of the 7P – 7A shift, which includes weighing and bathing each infant.  As is common in so many NICU units, there are a limited number of scales and the nurses race to lay claim to a scale so they can weigh each infant at the start of shift (it’s important to note that at this hospital there is no written policy that the infants are to be weighed at the start of the night shift, just that they are weighed and that weight notated in the chart).

One of the infants is the first-born child of a young, but traditional, Middle Eastern couple. As is the custom for them, the father assumes all the care of the newborn for the first few weeks, leaving the mother to rest and recuperate (during this time the mother is considered “dirty”). The father takes his responsibility seriously and in addition seems to enjoy being the primary caregiver as he arrives in the NICU to feed and bathe his daughter. The nurse assigned to the infant refuses to let the father participate, insisting that she must weigh and bathe the infant at that precise moment and that he would have to return later that evening.

The father explains the custom of his people. He asks again for the nurse to let him feed and bathe his infant daughter, suggesting that the nurse could return to weigh his daughter after the feeding. The nurse refused, called security, and had the father removed under the pretext that he was a belligerent family member.  He was then barred from returning to the NICU for the reminder of that night.

Was the father being belligerent? Not at all. He was responding to the lack of cultural sensitivity being exhibited by the nurse, as well as her absolute unbending desire to do what she wanted when she wanted, even though there was no emergent need for the infant to be weighed and bathed at that precise moment. This is a classic example of a nurse on a power trip.

However, there was a happy resolution. Once the charge nurse learned of the cultural traditions of the family, she reassigned the infant to another nurse, in this case me, and I had the opportunity to work with the family.  Unfortunately, due to the nurse’s inflexibility, a family was wrongly labeled as being “difficult” and they were exposed to an unnecessarily stressful hospital stay.

The two above examples illustrate how there can be moments when the nurse is actually the instigator of seemingly  bad patient behavior. In many cases, a good manager can ascertain whether it is the patient acting out or whether the nurse  is causing the situation. Without a doubt there are difficult patients and difficult family members in every hospital; but there are times when it is the nurse who is the underlying cause of the problem.

Take the Time to Listen to Your Patient

When the nurse fails to recognize her role, the problem not only escalates, but the nurse fails to learn how acting differently may have prevented the situation in the first place.  The next time you are faced with a difficult patient, first assess if the patient is being difficult just for the sake of it (which is a common enough experience) or if the patient is responding to some other negative stimulus.

Take the time to sit with your patient or the patient’s family at the beginning of your shift. Review the care plan with them, ask if they have any questions, and provide them with substantive answers to those questions. Will this take time out of your shift?  Yes; however, the end result will often be a happier and calmer patient or patient’s family, who will then find less reason to constantly pepper you with questions and demands throughout the remainder of your shift. This is a habit that I have always used since the earliest days of my nursing practice and it has rarely failed me. But, it does mean that you must set aside the time to speak with the patient or family.

In today’s hospital work environment, many nurses feel overwhelmed with all the tasks confronting them. However, setting aside a few moments to speak with each of your patients and their families provides the following benefits:

• Patients and their families know that they can go to you to address problems. This means they will seek you out first to resolve problems without feeling the need to go over your head.

• The patients will see you as an individual, rather than just one of the many nameless people who come through their room every day.

• It also allows the patient and the patient’s family to feel more involved in the care process, thereby making them feel proactive rather than reactive.

• As indicated above, making time for your patient and their family before problems arise is one of the best investments a nurse can make to pre-empt a difficult patient experience.   

Geneviève M. Clavreul is a health care management consultant. She is an RN and has experience as a director of nursing and as a teacher of nursing management.

This article is from workingnurse.com.

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