We’ve all had that patient. For one reason or another their motivation just isn’t there. No urgency to participate in therapies. No desire to help with repositions. Some choose to be incontinent. So now what? How hard do you push? To the point of agitation? To the point of aggression? What battles do you choose? Medications? Therapies? Hygiene? What will you allow to slip by the wayside just to keep the patient in a good mood?
Speaking with a colleague on this topic after both caring for a patient of this nature, we agreed that ultimately we’re left with a choice. To be a “good nurse” and make the patient get up to the chair three times a day, engage in therapies, and set expectations. Or, to be a “bad nurse” and let the patient run the show by sleeping in until 2pm, declining therapies and repositioning, and not participating in hygiene cares. However, the first choice often results in an upset patient and risks potential of “being fired” as their nurse for the day, while the latter pleases the patient and avoids any conflict. The disconnect is rooted in us knowing what is best for the patient and them either not agreeing, not caring, or not understanding.
So how do we navigate? Yes, sometimes you can fall back on “well, this is what the doctor ordered” and hope that provides enough leverage. Paging the doc to come bedside and chat with the patient if they need to hear it for themselves. Other times providing a choice of when is enough to give them the feeling of control, “are you going to get into the chair at 9 or 10 o’clock?” rather than “do you want to get into the chair today?”. Only caveat is that you have to follow through at the designated time. Believe me, some will be surprised and upset that you do. If family is bedside or able to speak with them, get them involved and on your side. Sometimes the patient may need a better “why” than just because the nurse wants them to. Finally, try tough love if that’s your style. Tell them the harsh consequences and very real set backs that are likely to happen if they continue to neglect themselves and not participate. Whether that means mentioning a SNF on discharge instead of home, a feeding tube to improve intake, or the prolonged hospital stay due to slowed healing process.
Well, I shouldn’t have said “finally”, because there is one more alternative: let them decline, and document document document. Get therapies, consults, and the team on board. Tell them to do the same. Ultimately you cannot force someone to do something if they are in their right mind. All we can do is fully explain the potential consequences of their actions, or lack there of. Yes, it will make for a long 12 hours. No, the patient probably won’t be your biggest fan. But at the end of the day your job is to help. Your job is to heal. Your job is to leave your patient better than you found them, if you can help it.
But somedays, all you can do is try your best.
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