Today an article on teaching and managing difficult students popped up on my Facebook news feed. It was written by Amy Murray, an early childhood educator in Canada, and posted on her blog Miss Night’s Marbles. The post is an open letter to parents, concerned about ‘that’ kid in their child’s class – the ‘naughty’ child, the one who kicks and screams, the one parents are worried is preventing their child from getting the best education and proper level of attention from the teacher. I highly recommend reading the full article here.
As a nurse, this article resonated with me. As I read it, I couldn’t stop my mind from swapping teacher and student with nurse and patient. In nursing, we often have ‘that’ patient; the one who is confused or agitated, the one who yells or cries out, the one who takes up most of the nurse’s time. These patients can disturb others in the room, or even the rest of the ward, disrupting sleep, interrupting cares and causing stress and anxiety.
As nurses, we do our best to try and calm these patients. We investigate the causes of their behaviour. We look for unmet needs. We try to accommodate them in single rooms. We work with the medical team to decide if one-on-one nursing is required. We consult with specialists as to the best way to care for the patient and keep them safe. Unfortunately though, there is a limit as to what we can do.
A few months ago, I was caring for an older patient (let’s call her Jane) who was very agitated. She was confused, pulling at her IV lines and her continual crying out for her family had kept most of the ward awake the previous night. Jane was extremely unsteady on her feet, yet would keep wandering around the room unaided, and as such was at a very high risk of falling. There was no single room available and the medical team did not think she needed one-on-one care. As the team leader on the ward, I made the decision to move Jane to a room closer to the nurses’ station, to allow not only for closer observation, but also so we could hear any movements or disturbances easier.
Before moving Jane, I thought it best to let the other patients in that room know what was happening and my plans for Jane to join them. I was not prepared for what happened next. The other patients in the room hit the roof. They yelled and swore at me, telling me in no uncertain terms that Jane was not welcome and asking why they should have to ‘put up with her’. I apologised to them for the disruption and tried to calm them down, going through why it was necessary to move Jane for her safety, offering to find them ear-plugs to help them sleep, explaining that her family had agreed to stay with Jane until she fell asleep that night. They weren’t interested.
Their replies ranged from ‘just knock her out with some drugs’ to ‘I’m not going to stay here and put up with this’. Again, I apologised and clarified that restraints, both physical and chemical, can do more harm than good and as such are a last resort only. I explained the suitable single room was occupied by an infectious patient, limiting my options. I agreed that it was not the best situation, but that I had to work within the limits of the system. I assured them that I would do my best to keep Jane calm and to minimise disturbances. Again, they weren’t interested.
At a loss as to what else I could say, I simply resorted to the line “there but by the grace of god go I” and yes took them all on a bit of an emotional guilt trip, posing the questions “What if Jane was your mum or your nan? How would you feel if she was treated this way?” Begrudgingly, after this talk, they accepted Jane coming into the room.
What I couldn’t say to them was that Jane had dementia that was complicated by an acute delirium. I couldn’t tell them that Jane had only just moved into a high care residential facility, and she was struggling to adjust to this change. I couldn’t tell them that Jane’s family were emotionally exhausted from watching their mother slowly fade away and the despair they felt knowing she was calling out for them to come and get her.
Situations like Jane’s happen often, but as nurses, we are bound by law and our professional codes to protect the privacy of our patients. This means that I cannot share with you why patients might act a certain way. I cannot tell you the young man had a traumatic brain injury and this has affected his behaviour. I cannot tell you that the woman in the bed next to you is an IV drug user with a history of alcohol abuse, and her agitation is due to withdrawal. I cannot tell you that the old man who constantly yells out swear words, had a stroke three years ago, before which his family says he never swore once. I cannot tell you the patient who just threw the water jug at the window comes from a residential mental health facility. While I know if I did tell you this information, you may be more understanding and forgiving of ‘that’ patient, I will keep it to myself, just as I do your information.
Nurses recognise that these are not ideal environments for rest and recovery, and please know that we all too well understand your frustrations, but we must work within the constraints of our healthcare system. A lot of patience and a little understanding from other patients, and their families, make the job a lot easier.
As for Jane, once again I wasn’t prepared for what happened. The other three patients in the room, all middle-aged men, took Jane under their wing. They kind of adopted her; looking out for her, buzzing for the nurses when they were worried she was uncomfortable, and helping her when she needed little things. One patient would often sit by her bed, pretending to be the son she kept calling out for, holding her hand and saying ‘don’t worry mum, I’m here’. I’m not sure those men will ever truly know how much they helped Jane over the next few days, or the how grateful Jane’s family were for how they made Jane feel safe and secure. I know that I will never forget the kindness they showed to ‘that’ patient.