Fledgling Nurse, Part 11: Patient Teamwork

I have catchphrases, certain ways that I'm falling into a pattern in how I talk about things at work.  As I am repeating back to a patient what they have asked me to bring them from the supply room, I'll ask, "What else can I add to my shopping list?"  When appropriate, I tend to ask as part of my morning assessment of the patient "what else can I have on my radar for you?" as a means to open the door for their particular goals.  I like to ask my peers as they're walking by, "are we having fun yet?" which is met with a variety of replies, all of which are interesting.  When a patient tells me that they're in pain, I'll say "I'll see what I have on tap for you," which can get awkward when I have a patient in with alcohol withdrawal--yes, I'm trying to phase this one out, but it has taken quite an insidious root.  

I do these for multiple reasons.  

• First and foremost, I have my own way of talking that I'm a bit set it--I won't deny that this is my script in those places. 
• They can help establish rapport, set a tone that is approachable and welcoming so that we might be in a strong, therapeutic relationship.
• They're also a bit of a litmus test.  I can be a fast talker, and I know I have a compendium of weird idioms--if I am met with confusion on these, I back down a bit on the strange phrasings, speaking a bit more directly and with less, well, personality.  If English is a second language or our cultural perspectives are different or they have some kind of medical reason to not keep up with me, I now have an idea that I need to change my speech to be clear, slower, simplified, and/or without any non-standard added frill.  
• They're definitely a litmus test to mood.  If I get a smile or a chuckle or even a snarky reply, I know that we can joke with each other a bit.  A sigh in response, (non-friendly) rolling of eyes, and I can shift to a more sterile sort of professional or otherwise gentle prod for further insight to their low mood.  
• It makes me smile, to and for myself.  

I want to especially highlight "therapeutic relationship."  I need honesty between my patient and myself, firstly that they can tell me information important to their care and that they know in return that I will follow through on what I tell them I will do.  This trust is vital.  

There is a bit of power imbalance.  On the one hand, the patient is a client, the person being served; on the other hand, I have the connections between them and medication, advocacy with their doctor, etc.  As such, boundaries are imperative as well.  A patient that tries to dictate everything I will or will not do and when I will do it impedes their own care, specifically by not allowing me to exercise my clinical judgement and experience.  I want patients to have self-advocacy--I encourage it--and in the same breath I also have my own timings and needs and limitations, such as caring for other patients.    

From my experience as a patient with chronic illness and now as a nurse, the best situation is a collaboration between the healthcare team and the patient.  The patient is the one that is suffering, that literally has the most to gain or lose--they should be involved in their own decisions (where they are legally and practically able to).  However, that individual has called upon a team of experts in order to hear that counsel, to seek that guidance.  As a patient, I dug into my case, sought very specifically to understand my options and the reasons behind different treatments:  I recognize that not everyone is as interested in some of the specific mechanisms of action behind their medications, but I am disheartened when I find patients cannot even tell me what condition X medication is for or even the name of their condition they've had for years.  

The patient is part of the team.  The healthcare providers are recommending a course of action.  Questions and ideas are shared.  No side is a complete dictatorship.  

The patient is a part of the team.  

I have difficulty working with patients that are not interested in their part of the team.  On the outside, it seems that they expect wellness to simply happen to them, acting as though being in the hospital will magically make them back to better than they were before once the right magic elixir comes along.  While finding the right medication(s) is a brilliant help, there is still work to do:  working with physical therapy to prevent deconditioning, dietary changes, follow-up appointments, walking (to the bathroom, in the hallway, etc.) or some level of activity, at least moving in the bed to prevent pressure ulcers.  Truth:  some people still leave the hospital feeling crummy, but they are stable enough to continue healing at home.  At the VERY least, acknowledging that this is not a five-star resort so, no, there is nothing I can do about the quality of the food nor will I tell lab to stop collecting blood we need for additional testing nor will I ignore hospital safety protocols because they are inconvenient or stop muting the TV when we need to have important conversations.  I have had a few patients by this point, now, that fall into this group, that are grumpy about needing to be in the hospital (understandable) but then cross a line by taking that grumpiness out on staff.  Sometimes this then translates to refusing to participate in their own care seemingly out of spite.  

The specific patients I'm thinking of, I have heard them say that they want to get better, but their actions tell me otherwise.  I feel like I'm actively being lied to and then held responsible for withholding the magic wand from them, that I am culpable for their unrealistic expectations.  I've given discharge teaching and been told directly "yeah, I'm not doing that," and I appreciate and am simultaneously exasperated by their candor.  I feel a very specific frustration in these places because I have fought for so very long and fervently for my own current degree of health.  

The patient is part of the team.  The patient should not be all of the team, but the patient should not be physically carried through every metaphorical hoop that they could walk through.  Yes, it's exhausting to be sick--I know this viscerally and fully--yet that does not excuse the responsibility.  It's okay to rest; it's okay to have moments of frustration and grief; it's okay to ask for others to help advocate in the spaces you cannot.  To say that they're not giving up with one side of their mouth and then refuse all interventions, again, I simply do not believe what they are saying.  There are definitely times where the right thing to do is wait, but waiting is not a passive thing.  And doing nothing is still a choice.  

When I encounter these patients, I have to pause to remind myself that I cannot force them to choose to help themselves.  It is also not my job to carry them (except for a few places where it literally is).  I will coach and guide and cheer.  I can walk alongside and nudge people directly, where it seems appropriate to do so.  And I rejoice in the interest of anyone that wants to understand more about their condition, yes, even when it leads to an avalanche of questions.  In other words, I will support a team with the patient and their caregivers.  I cannot, however, be the knight slaying the dragon for a kingdom that doesn't care that it's burning, not when I've been handing out fire extinguishers that are sitting unused by the door.  

Pause.  Breathe.  Let it go.  Move my energy to the next patient.