illustration by the author
The first sentence from Leo Tolstoy’s novel Anna Karenina is one of the most famous in literature:
“All happy families are alike; each unhappy family is unhappy in its own way.”
It can easily be applied to patients. Happy patients tend to love their doctors, feel they received the best possible care, and consider their nurses invaluable.
Unhappy patients are unhappy in their own way. The challenge for busy nurses is resisting the temptation to turn a deaf ear or feign listening, in effect reducing patients’ concerns to “waa, waa, waa.”
A common thread among unhappy patients is unmet expectations.
Sometimes the patient’s expectations are unrealistic because they’re based on incorrect assumptions—but they do not know this. Responding requires a willingness to listen and the patience to tease out why a patient is unhappy with their care. Let patients tell their stories. Most bedside nurses have limited time; it’s okay to enlist help from a case manager, social worker, or nurse navigator if necessary. However, investing time up front to improve communication with a patient may pay off in dividends by smoothing the rest of your shift.
Begin by listening. Sometimes, I’ll take a seat, and write what the patient says while they talk. This simple act conveys their complaint is taken seriously, and helps defuse the situation. Having an open mind while a patient explains why they are unhappy with their care has taught me a lot and improved my communication skills.
Patients who want their doctor called to manage their hospital care are an example. They assume when admitted that their primary care physician or medical specialist will continue to write their orders. They are unaware that many hospitals use hospitalists to manage patients, with protocol-driven care.
A patient with chronic hypertension, for instance, may become upset when their condition is managed differently in the inpatient setting than at home. They may not understand why the medications prescribed for home use are adjusted or even discontinued. They may want the doctor who originally prescribed the medication consulted.
One patient explained it like this:
“If I go to my primary care provider, and I need to talk about changing my blood pressure medicine, he tells me to make an appointment with the cardiologist who prescribed it. If I want to change my diabetic medication, that doctor makes me see my endocrinologist. If I’m sick enough to be in the hospital, why is only one doctor needed to take care of me?”
I have to admit, I see his point.
Another patient’s expectations are unmet because they did not understand the pre-hospital education they received. Use the teach-back technique to make sure a patient fully understands what you said. Patients who spend a great deal of time in doctors’ offices pick up medical jargon; while patient experience and insight should be respected, especially when it comes to chronic illness, some patients may sound like a pro without really understanding what the words mean.
I have a theory about this: chronically ill patients realize they need the good graces of their care providers and nurses to survive. They want to be “good” patients. Some of these patients may imitate our words and behavior so we’ll like them. It’s a coping mechanism. While educational level may play a role, as well as the nature of the chronic condition a patient has, patients with advanced academic degrees in other areas can also be unclear of the meaning of medical terms.
For example, in oncology, where reconstruction is commonly discussed, patients may automatically assume “plastic,” as in plastic surgery, means that an implant will be used. Often, this is the case, but in some procedures plastic refers to the supple, mutable properties of skin and tissue, allowing closure of a surgical site, say, or use of a bone graft.
I discovered this while talking to a patient who misunderstood the procedure he signed consent for before surgery. His understanding was he’d be awakened from general anesthesia during surgery, given the results of the quick-check pathology, and then decide if he wanted the big surgery or the smaller version. He used all the right terminology, but clearly he and his surgeon were not talking about the same thing. The surgeon was alerted, and the informed consent repeated. The patient chose the more minor surgery up front, thus heading off a potentially disastrous misunderstanding.
Some patients will remain unhappy despite all efforts.
Their unhappiness is not always the result of their hospitalization. Remember, it’s not personally directed at you. If it is, you may learn something, but don’t allow yourself to be abused. Set safe limits and boundaries on bad behavior.
Helping unhappy patients requires diplomacy: It’s never okay to appease a patient by throwing team members under the bus.
Each unhappy patient is unhappy in their own way. Find out why they are unhappy. Don’t assume you know or understand. Be ready to listen. Let them tell their story.
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