'Problem patients?' 2 - Appease me do (not)

Many of the aspirations of nursing are just that - aspirational.

Appeasement and other similar 'power' associated concepts helps explain some of the appeal of Hodges' model - with its inclusion of a POLITICAL care domain. The needs of the ONE (interpersonal care domain) are diagonally opposed by the needs of the MANY (political care domain).

Just because I may approach someone (*evidently*) abusing medication / alcohol, over-eating, risk taking ... does not mean I am prepared to continue to nurse them and hence support them in that behaviour. Attempts to engage can be made and (must be) documented, as subsequent referrals and care will build on those care encounters. There is a marked difference between those individuals above who are often socially excluded, risk takers and people who are preoccupied with their health and mental health state. (Are such people stuck in the 'sick role?) Such patients may well seek new drugs and then instantly question the medication they are taking, never satisfied, they may query their care record and care while in hospital by virtue of their personality and anxieties.

I can reject negative behaviours and attitudes, but not the person. As a member of the health care team I can explain clear terms for future engagement should the patient wish. At the end of the day we constantly review: do they have mental capacity and to what extent does their behaviour present a risk to themselves, or others...? There is also a role for specific care management to be effected, to screen and prevent people reaching emergency services when this is repeated and unnecessary. The combination of some conditions such as long term respiratory problems and anxiety can create acute management problems, both for the individuals concerned, their family carers and care providers.

People do have choices to make, and so must take responsibility for how they exercise those choices.

Crucially this also needs to be explained to referrers - e.g. general practitioners / family physicians. For effective care management the inclusion of paramedic, crisis, social and intermediate care services in care management communication and coordination is also essential.

So, there is absolutely no need for a "current model of appeasement based care".

(This is a wind-up - surely? If not I am available for career advice.)

Yours truly and the patient's (even if it hurts),

Peter Jones

'Problem patients?' 1

Nurse Philosophy list

'Problem patients?' 1 - Wimps and space to care

I responded to a mail list discussion around 'problem patients' which began with the following main points:

• a relatively new nurse
• surprise that a significant minority of (my) patients are pathological wimps;
• even prior to seeing them they can often easily be spotted by examining their medical records;
• for example, I frequently notice that wimps have an obscene (and often downright odd) amount of special meal requests;
• current nursing philosophy encourages nurses to be endlessly supportive of wimps. i.e. to follow the often demonstrably wrong idea that "the patient is always right.";
• IMO nurses who claim they benefit such patients using the current model of appeasement based care are co-dependent personality types who enjoy feeling needed more than they enjoy actually helping people.

My first response is copied below with some additional points a further post will follow:

Patients are always a challenge in that they come in lots of 'varieties'. This is why we recognise the need for individualised, person-centred care. One variety is physical trauma laden to which the full-complement of the multidisciplinary team must respond. These patients and *their* crises bring out the best in us in terms of the skills and knowledge, team work they force us to exercise.

Among the plethora of other varieties there are those who are viewed as 'problems'. Like the Pepsi ad of decades ago they are variously and pejoratively described as -

multiattendin, attentionseekin, patiencesappin, bedblockin,
buzzabuzz-buzzin, heartsinkin, timewastin,
symptomfindin, carenumbin
.... patients!

If I receive referral information or heads up information on diagnosis of a 'tci' (to come in) that suggests the above is on the way, has arrived or worse "is on your caseload" - what do I do?

• Brace myself for impact?
• Go off sick (suffering loss of job satisfaction)?
• Become purely task or disease focussed, give up on effecting +ve change and improved outcome?
• Share collective anecdotes in the office - staff changing as a way to cope, de-stress, inject some humour?

OR do I -

• Avoid labelling them, or use these labels in a re-constructive way?
• Ask why are they 'who' they are?
• Gaze into their 'life history' and help them learn from it?
• Refuse to make gross assumptions, even based on previous experience with client - patient?
• Look at the individual wholistically - socially, educationally, behaviourally?
• Believe you can still make a difference (be the fly-half you can be and play ball)?
• Side step being tripped by foibles, behaviours and blatant displays of -ve obstructive ...... attitude that offend 'me'?
• Enter their space and do my utmost to find room for manoeuvre (this is the hardest test)?
• Speak to my manager(s) very tersely about protecting 'me' as a scarce resource and shout "OK where the hell is the gate keeper!"
• Or, as a nurse do you boldly go and seek out new strengths and new opportunities in the same way that Kirk, McCoy, Spock et al. (2264) go and seek New Life, New Civilizations...?

You may have an impossible lock to pick (in its most severe form this has become known as 'personality disorder'), but the nursing challenge is there in all its personal and professional glory. Address this personal - under-the-skin - slant - seek supervision. Be aware of the pit that some people fall into. The trap for some people with life chances they may have completely:

missed, never had, were stolen, denied,
took for granted, spurned,
totally - wasted.

Around the pit is the zone of judgement, but beware it is a singularity (no perspective) and very slippery.

• Otherwise go do your job: Nurse.

Nurse Philosophy list

Reference:

Kirk, McCoy, Spock et al. (2264) The Caring Imperative, To Boldly Go..., Four Quadrant Galactic Care Journal, Integrated Galactic Care Publishing Inc. itess-cube: 1701u-care4mesafelyandnicely