Fledgling Nurse, Part 8: Boundaries and Abuse

I sat down to listen to a patient one day.  They were angry, frustrated that they had been suffering the effects of an illness for over a year and a half, now, with multiple trips to the emergency room, a gamut of tests, poor empathy responses from work/landlord/family/the world in general, familial stress, arguing with insurance, and the very real anxiety of the looming bills yet to be revealed.  This particular patient clarified several times that they were not mad at us, the nurses and techs, just that they were tired.  I sat down with them to listen for a while, validating the hell out of their feelings--that is a difficult place to be, that not-knowing space.  I want to think that they felt better to get some of that off of their chest--they were at least visibly a little less grumpy.

But this patient had not been particularly harsh to any one of us.  Not very conversational, maybe, but not outright rude.  I cannot say the same for other patients.  

"A Lapse in Perspective and Empathy," a short story:
Scene, nurse enters patient room.

Patient:  (clearly annoyed, sighing dramatically) "I put on my call light twenty minutes ago.  What took you so long to bring that water?"

Nurse:  (sets the cup of water down) "Oh, one of my other patients stopped breathing.  So sorry to keep you waiting!"

I have been intentionally hit in the face, smacked a few times in the arm, pinched, kicked, threatened, yelled at, called a number of names (variants of stupid and incompetent are favored choices), and once was patted on the butt like it was a compliment.  And I've only been a nurse since August.  I daresay every nurse or CNA has at least one story.

The bulk of these were confused persons with varying degrees of dementia; some were patients that fit into that category of "I feel out of control so I'm going to pick a fight to reestablish control."  So logically I know that some of my patients are not angry with me, that I just happen to be a convenient place to focus their anger; I can also recognize that some patients are demonstrating poor boundaries as part of a wholly valid medical reason.  That does not make that behavior okay.  Both the recognition that the behavior is affected by certain factors and is inappropriate exist in the same space.  It's also possible that the individual in question is simply an asshole.  

Yet, there is culture to accept a degree of this abuse.  I have the option to press charges, but whether I have cultural approval to do so is a different question.  From management, I have been told that I have the right to feel safe, that I don't have to be a martyr.  In the same breath, there is an unspoken pressure that there are some places I just need to have a thick skin, and it's difficult to calculate how thick this is supposed to be.  The thick skin is only needed because the microaggressions and then outright aggressions are common, again, because there is a culture formed in this environment, which means that patients know on some level that they can get away with it, becoming a self-perpetuating cycle.  Realistically, too, I know that patients with advanced enough dementia are likely waiting on placement in a facility, where they will be making decisions based on scores of how directable, violent, etc. the patient is, meaning that I might delay some options (certain medications, for example) or bend more than I might otherwise to not affect their chances.  

I have set boundaries with patients, a "I will not be spoken to that way," or "I will call security if we need to" and "I'm not going to engage in that argument."  I have also sat down and said directly, "I don't think you're actually mad at me--what's on your mind?" and start the conversation to the deeper places, find those actionable components from there.  I have also admittedly gotten caught in some of those unproductive arguments, attempting to persuade a confused, suspicious patient for the better part of forty-five minutes to do something (roll off a soiled pad, take their medication, sit back down because they have a history of falls, etc.).  There are times when I have to keep trying, because it is about their safety, and yet their agitation continues to rise as I continue to press, attempt a new angle.  As such, I'm working to refine some of these boundaries, because leaving these rooms six kinds of frustrated and an hour behind does not serve my other patients.  

There are circumstances where a patient has an order for medications that will help decrease agitation--when the patient is a danger to themselves or staff, it is an unfortunate but necessary option.  There are many specific checks and steps to creating these orders, not something that I can dole out because I find someone annoying.  If they cannot or refused to be talked down, again, we have to protect both them and ourselves, meaning that we are no longer asking.  And I usually call security for an assist (the presence of a uniform sometimes changing their demeanor immediately), since an agitated person is also not going to appreciate a shot in the arm.  I would much prefer a one-time dose of something than allow something to escalate to needing locked restraints or the patient falling and injuring themselves or any of the staff getting injured.  I have some cognitive dissonance on when it is okay to use these--I don't want to give someone a shot in the arm that doesn't want one, nor potentially make them more upset by doing so, nor inadvertently alter their options in placement.  Simultaneously, again, this is what the medication is here for, I want to protect the patient from themselves (as well as my fellow staff), acknowledging that allowing agitation to progress further is its own kind of negligence.  On a personal level, I don't have time to be threatened--I pick my battles with patients, but this is a steadily solidifying line.

"What not to do," a study

I shouldn't have to absorb abuse from my patients, whether they're in their right minds or not.  I acknowledge that an unspoken norm to expect this abuse exists, but I also recognize it is an unacceptable norm that needs addressing.  Of course, if it was an easy answer, we would have already figured it out by now.  For myself, I am working on setting cleaner boundary statements, that I am not there to absorb their anger for example, or that I will refuse to engage.  For patients that can be engaged, I can give them a space to vent what they're actually upset about instead of accepting passive-aggressive digs all day.  In other places, I become almost overly professional, stripping out my personality--if I'm going to be seen as a service then I will only be a service--which protects me.  For patients that are unable to engage due to dementia, temporary confusion, or other reasons, I pick my battles--I'm not terribly annoyed that they're pulling the sheets off their bed if they are not putting themselves in danger of falling; I will bring them a fresh ice water every hour if that helps them stay calm and feel they are attended to; I will wait to give them their daily medications until they are eating breakfast rather than wake them up to take them when I think it's more convenient.  

There is grace for a patient's circumstances; there is also recognition of my own emotional and safety needs.  I will not win a prize at the end of the day for absorbing X amount of patient frustration.  It will not make me a better nurse to fail to stand up for myself.  As a culture, it is important to challenge the idea that it's okay for certain workers--any workers--be receive a degree of verbal or physical abuse, whether they're ED staff, teachers, food service, or whatever else.  Right now, we're seeing a lot of discussion about teacher's autonomy in the classroom, but I can also remember when I was student teaching a conversation with a parent that was furious that we scored their child a zero on a project that the child openly refused to do, how rudely they behaved in that moment--in other words, the disrespect to the career is not a new thing, though it does seem to be continually getting worse.  And for food service staff, well, there are too many examples of those to count, and I will never understand why an incorrect drink or burger is a reason to go nuclear on someone.  

In short, we as a culture have collectively allowed this to happen, by not correcting the behavior.  That's an overly simplified statement, to be sure, particularly when we factor in the medical caveats in the hospital setting.  My goal in my practice is to ensure that the boundary is set, for my sake, the patient's sake, and the patient's family's sake.  For the patient and their families, an escalation of the situation will not have the excuse of ignorance, that they were unaware they had crossed a line.  For myself, reaffirming the boundary is an act of self-compassion, one that helps me make tough but necessary decisions and ultimately enforce them.  For my peers, I don't want to hand any of them over to a situation they don't feel safe in either by not deescalating where I'm able to or hesitating too long to call for additional hands.  I am testing my own balance between being gracious to the circumstances while also ensuring it is not at the sacrifice of my own needs.