The second patient, a.k.a. the parent

Imagine finding yourself in an overwhelmingly stressful situation. Then imagine having no control over said situation. I have to keep this in mind each day that I venture to work and am faced with a difficult parent or family member.

Working in a pediatric facility, I have the added challenge of not only caring for the ill child, but caring in a different way, an emotional way, for the parents of their ill child. This adds a dynamic to my job like no other, part of which I love and part of which throws its curveballs.

Scenario #1: “Lucy” thinks she is having a normal pregnancy. Everything has gone along as planned although due to work constraints, she has missed a couple of her doctor appointments, one being the most recent ultrasound. Lucy finds herself doubled over with contractions at 34 weeks and despite attempts from the hospital staff, they are unable to stop the labor. Lucy delivers a beautiful baby girl, but this baby girl is a dusky shade of grey upon arrival to the world and is rushed off to the neonatal intensive care unit for a cardiac workup. Lucy finds out two hours later that her baby has been born with Hypoplastic Left Heart Syndrome, a serious congenital heart defect that will require her baby to have emergent surgery. While her baby is in surgery, Lucy also learns that after this surgery her baby will be at high risk for sudden death but will be sent home to grow until she is about six months of age when she will have another open heart surgery that will keep her goal oxygen saturations in the low 80s. Subsequently, she will require a third surgery in her toddler years that generally extends a child’s lifespan to pre-teenage years where she will then most likely need a heart transplant.

Stressful? I’d say so…

Scenario #2: “Lucy’s” baby is now two years old and returning to the hospital for her third stage surgery, called the Fontan procedure. Lucy’s baby has a very rough post op course after her second surgery and incidentally had some mild brain hemorrhaging resulting in mild right-sided weakness. Despite her delays, Lucy’s toddler JUST started to walk, and now she has the added stress of bringing her in for another surgery that will very likely set her daughter’s development back for months. After surgery, Lucy, being the experienced parent that she is, does not feel as though her daughter’s pain is being well-controlled. Her daughter is fussy, gassy, and is not sleeping well at night, leaving Lucy overly exhausted and fatigued because she is putting all of her strength into the care of her child. The night nurse accidentally woke Lucy’s daughter up when she was taking vital signs and then the phlebotomist came into the room and turned on the lights to draw labs right when the toddler had drifted back to sleep. The day shift nurses enters the room to perform her morning assessment and finds mom first aggressive, then defensive, then in tears.

These scenarios are such that I see on a weekly basis at work. Although it can sometimes be very difficult to remind myself that these parents are under an exorbitant amount of stress when tempers flare up, nurses must remain objective and sensitive. The burning question is, how do you deal with difficult parents when you enter a room and you can cut the tension with a knife?

1. Enter the room quietly and respectfully. Especially if encountering the parents in the early morning hours. Although you have been awake for hours now, these people may not be and unless the lights are already on, I always enter in the dark and make my introductions prior to flipping the switch. Tired parents are much more likely to be receptive if not awakened with a start. Of course, an emergency situation negates all instances of trying to be respectful of sleep- get to the patient as quickly as possible.

2. Inform the parents of the plan and goals for the day. Even if the goal is as simple as bathing the child for the first time after surgery. Allow them to have input in the plan and even write their goals down so they feel as though you are all a team. But an important part of this step is to make sure parents are aware that plans may change and goals may not be met, but then proceed to keep them informed of changes throughout the day. Having a child in the hospital has been described to me as being the most out of control experience, because there is nothing the parent can do at that very moment to make their child feel better. Giving the parent some of that control back help to develop a rapport that is vital for maintaining an effective relationship.

3. Be an active listener. You have no idea how many compliments I have received for pulling up a chair after assessing the child and asking what I can do for the parents that day or asking if they have any concerns they would like to share with me. This opens up the lines of communication immediately and puts you in the support system role, which is part of our job as nurses. However, this can get you into some trouble when you have an overly loquacious parent and a busy day ahead, but being honest with them and saying you will return after you see your other patients should make due, until you have to go back in. At that point I suggest having a coworker call you in exactly 15 minutes saying there is an emergency if you haven’t emerged from the room…

4. Treat their child as if he/she were your own. Be gentle, love on the baby, give the parents lots of compliments on how beautiful the child has gotten since the last time you saw them. When removing tape, use adhesive remover- parents and children love that stuff. When starting IVs, give the baby a sucrose pacifier and swaddle them so they aren’t left to kicking and screaming. When you are finished examining the patient, ask mom if she wants to hold the baby, and if not, wrap the baby back up tightly and only leave when they are settled. Showing the baby respect in turn makes the parents feel respected.

5. Give the parents a break. Even if it is just a five minute break to walk around the floor. Offer to listen out for the baby until they return and tell them to go out to dinner. This scenario gets tricky because nursing staff can easily get taken advantage of and suddenly you find yourself transformed into a babysitter. But as long as ground rules are set and the parent knows they can’t just drop the baby off at the hospital and leave, parents truly appreciate some time away for their sanity, which in turn leads to sanity for the nursing staff as well.

6. Be an advocate for your patient. Probably the biggest piece of advice I could give. If you don’t agree with something the doctors have ordered, or if you feel as though the parent’s concerns are not being heard, do something about it. You want to make sure that the medical team is being presented as a united front, but if that united front is not effectively caring for the patient, you have a duty to act as that patient’s advocate to speak up. This will make parents confident that you are working with them for the benefit of the child.

If, after all of these things, a parent is still rude, demeaning, inappropriate, aggressive, condescending, etc. just continue to remind yourself that they are going through a very hard time and perhaps they are taking out their frustrations on you because there is no other outlet. Not to say this is appropriate behavior or that any nurse should be treated poorly, but while in the room kindly smile, excuse yourself, and if it persists, have the assignment changed. I have been in the situation where I have felt so uncomfortable entering a room because of the parent that it hindered my care of the patient, which is not only unfair to me but the patient as well. Bottom line, don’t take it personally. The potential for a strong relationship developing between a nurse and a parent is a likely one, and a sought after one for many nurses. The second best thing to making an ill child’s day better is making their parent’s day better by sharing with them your knowledge and your commitment to their child for that shift. Do your best to foster these relationships, because I know if I was in the same situation, I would want my nurse on my side too.