A difficult exchange
Photo by Riccardo Chiarini on Unsplash
She was one of those patients who remind me of my own daughters, who make me consider up close what it would feel like to watch a terrible disease process insidiously take over my own child’s body. Her cancer had spread and she was struggling to breathe.
The team had told the parents it was likely we might have to give her a breathing tube before my shift was over. The parents were teary-eyed as I told them I would do my best to walk with them through a difficult day. They went downstairs to get food, at which point the patient, who had been dozing in bed, sat up and looked around. I went to her immediately, rubbed her back, and assured her that her parents would return shortly.
When her parents returned to the room, they brought more visitors than the three that our hospital policy allowed. I was a little anxious because I had already heard that this had been an issue overnight and that the parents had pushed back on efforts by another nurse to hold them to the policy.
I did my best to wait for a moment when bringing up the hospital policy would seem less jarring, but in the context of such an emotional morning, there was just no perfect time. At last, I took a deep breath and told them that it was great to see how much support they had, but to avoid overcrowding we could only have three visitors at the bedside at a time. The best option, I said, would be to rotate people.
The patient’s mother immediately grew angry, accusing me of lacking compassion and asked why I couldn’t simply turn a blind eye. When I said we had to go through the social worker to get an exception to the visitor policy, she called me “rule-bound,” at which point her husband stood and rushed forward until he was towering over me. “You know what,” he shouted, “I’ve always been a rule-breaker. Get out of this room! I don’t want you taking care of my daughter.”
Stunned, I paused for half a second, wondering if I could salvage anything of the situation, at which point the dad yelled, “Get out!”
Where do we draw the line on family behavior?
I understood that the parents were dealing with intense stress and big, difficult emotions. The leash for stressed and grieving family members is inevitably longer than the leash for stressed nurses, a reality that is both understandable and complicated. Our unit, and the hospital as a whole, had seen an uptick throughout the year in the number of incidents where family members were yelling and cursing at staff over all sorts of issues.
We understood the need to give space for the messy, complicated ways grief can manifest, but we also deserve to work in a safe environment. Were we to simply yield to the family’s demands to ignore the policy and remain nonconfrontational about their aggressive behavior, out of a desire to be sympathetic to their grief? At what point does showing grace become reckless and unfair for the healthcare staff who are now just tolerating varying degrees of abuse?
‘Thicker skin’ and our humanity
As my team came around me to support me in responding to this family, one of our physicians went to see how the patient was doing and to talk to the parents. The physician told the dad that I was an excellent nurse, cared deeply for their daughter, and had been brought to tears by the parents’ anger. The dad responded with, “You just need nurses with thicker skin.”
Thick skin is absolutely necessary in nursing. That said, nurses are human in our care toward our patients, and human in the bearing of our own personal struggles when we come to work. Nonetheless, nurses are expected to respond to our own heightened emotions with poise in our professional interactions, while patients’ families don’t necessarily carry the burden of this expectation. Although this is part of what it means to be a nurse, nurses can become worn down if they find themselves repeatedly on the receiving end of families’ anger and aggression.
The face of personal care and impersonal policy
Finally, nurses have to juggle their role as the frontline faces of compassion with their role as the face of an imperfect system’s policies. This becomes particularly difficult when you seem to be elevating a policy over the family’s emotions about an ill family member. Truth be told, I didn’t want to really fight the battle over the visitor policy, but I knew that the policy existed for the patient and unit’s safety, and nurse inconsistency with enforcement only makes everything more confusing and difficult for everyone in the long run.
This particular family had spent months in another floor of our hospital prior to coming to our ICU, which meant they were already aware of the visitor policy. I wanted support for them, and even though I offered to reach out to the social worker to make an official exception, this wasn’t the answer they wanted. The mom pointed out angrily that the nurse the previous day had let a lot of people in. “There are some people who are okay breaking the rules, but you’re not one of them. What would you want if this was your child?”
Unfortunately, the inconsistency they’d experienced with nurses over time set up the impression that some nurses were essentially for them as a family and some were against them. Despite having had some tender moments of connection with the patient and parents earlier in the shift, I found myself relegated to the “against” category as we clashed over this issue. This saddened me.
Practical support for nurses dealing with angry families
Support for nurses dealing with the needs of angry families should be built into both the unit/hospital culture and the system. The unit should have a consistent culture that agrees in the moment upon acceptable behavior and appropriate boundaries from family members. I was grateful for the immediate support of my charge nurse, colleagues, and physicians. We turned to our unit’s protocol to make it clear to the family that we as an entire team had empathy for them—and that we also had expectations of how they needed to treat our staff.
Given the recent hospital-wide uptick in upset families, our hospital has developed measures to support distressed staff, including consistent response to behavioral emergencies from the house supervisor, social worker, and security.
The emotional hangover
A difficult professional interaction can trigger or exacerbate other personal struggles. As much as we nurses can tell ourselves, “Don’t take this personally,” we must learn to show ourselves kindness when others’ anger feels hurtful and upsetting. Nurses come into close contact with an increasingly tense world, and it seems more important than ever to acknowledge how much emotional work is required to soothe both our patients’ families—and ourselves as well.
(The author’s previous post on this blog was “The Pitfalls of Being the ‘Nice Patient’: A Nurse’s Perspective“)
Been there on both sides. When my grandchild was in the NICU, which was divided into several pods with glass walls between them, there was a policy of no more than 1 person at a bedside; no children under age 14. Grandchild was the only baby in a 4-bed pod. In the next pod was a baby who had clearly been there for some time; there were young children running around, and three or four adults, almost all the time, lots of noise, food and drink being brought in. But the nurses would not allow me to sit quietly with my daughter and the baby in an otherwise empty pod.
As a new grad I had always felt duty-bound to invoke “policy,” but it didn’t take me long to learn how hurtful that was — and for what? So my policy was that if there were no other patients in the area and visitors were quiet and not affecting care delivery or pt privacy, I wasn’t counting noses.
When I was in labor, I was in a hospital midwifery unit in Seattle. We had thought that if it were a long labor, we might welcome the company of a couple with whom we were close, so I asked whether that would be allowed. The nurse smiled and said, “Honey, you can have the Husky Marching Band in here so long as it doesn’t disturb the other patients.” Good policy.