I recently went back to work after having 4 really wonderful months with the cutest kid (go on, click it!) on earth. (This kid is a close 2nd!). It was nice to be back, despite the usual frustrations (of which I may blog about at a later date).

I had been encouraging my post-op patient to cough and deep breathe all shift. Although we like to get most surgical patients out of bed the next day to promote mobility and prevent pneumonia, my patient (for reasons I will not get into) was not able to be out of bed, even 3 days after surgery. Thus, coughing and taking deep breaths was extra important.

He was not the picture of health to begin with: rather serious lung problems, still smoking, diabetic, overweight, heart diseased and now rather immobile, he was a ticking time bomb for complications. Despite this, or maybe because of it, he was not really cooperative with the idea of having to exercise his lungs. He tried at first, but was understandably cautious due to the fact that his breastbone had been wrenched open and then wired back together. I get this, I really do. I provided ample pain medication, a pillow to splint with, and reassurance. And yet all I was getting was “eh eh eh” instead of “COUGH COUGH COUGH.”

I had a busy assignment and that, coupled with being a bit rusty (read: totally unorganized), meant that I was not able to spend as much time as I would have liked in this patient’s room encouraging him to cough. And I tend to be more of a gentle encourager rather than a forceful one. Alas, towards the end of my shift, he was requiring more oxygen and was feeling a little short of breath.

I was discussing this with some other nurses, and one of them brought up an interesting point. Maybe the patient was requiring too much encouragement from me to do what he needed to do to recover from major surgery. He “signed on” for this surgery and all it entailed, after all. At what point does the nurse’s responsibility end and the patient’s begin?

Over the years, my patients have run the whole spectrum of compliance and willingness to take part in their own recoveries. Some are fabulous. I think I’m so used to having to “make” patients do their incentive spirometers that I sometimes find myself wondering “what is that noise coming from my patient’s room?”… only to find out that the patient has actually heeded my advice and is doing it all by themselves! Some are completely helpless (although technically competent) and require massive amounts of encouragement, pep talks and scare tactics to do what they need to do to prevent complications. Some nurses are very gentle about this, and some aren’t. I’ll spend countless minutes explaining why the patient needs to get out of bed and convincing them to do so while some of my counterparts have the patient’s legs dangling off the side of the bed before the patient can so much as protest. Maybe I’m too caught up in the idea of patient autonomy. It makes me feel bad to “make” a patient do something, even if it’s for their own good. I guess it’s a form of tough love. Like parents to their children, nurses are not meant to be their patient’s friend.

Of course, a better outcome is preferable to making nice with the patients, even if the nurse comes off looking like the bad cop. (Actually I have used that tactic before. I’ve come into the room with one of the forceful encouragers and we good cop/bad cop the patient – my colleague helping me physically get the patient out of bed as I crone soothing words of encouragement while they insist that they aren’t ready to get up yet. It works rather well.) After giving birth to my son, getting out of bed the next day was the absolute last thing I wanted to do. I was exhausted. Everything hurt. My nurse flew into my room first thing in the morning and in no uncertain terms told me that I would be getting up shortly. She took my vitals and then said that it was time to get out of bed. I think it’s hard to convey the manner in which she did this, but it was definitely in more of a “bad cop” sort of way. She did everything as though she was mentally ticking off tasks in her head and was anxious to get to the next one. There was absolutely no reassurance or easing into moving with this new body of mine… it was just “get up, get going, and do it now!”

I don’t think it was necessary to be that aggressive. I wasn’t refusing to get up. I didn’t even verbalize my hesitation – she didn’t really give me time. Maybe that’s what bothered me. She acted uninterested in the notion that I might be uncomfortable and want to take my time. If I’d been less tired and more focused, I would have told her in no uncertain terms that I would be getting up, but that I’d be doing it as slowly as I darn well pleased. Instead, my frame of mind prevented me from sticking up for myself and I just did what she told me. I know that there are times when I’ve acted this way towards patients, but I always reserve it for the really super-stubborn ones. And always after I’ve expressed that I understand they are afraid. So would I have gotten up if I’d had a more patient nurse? Of course, and I probably would have felt more supported. Maybe patients try to stall and my nurse learned to head us off at the pass. She did not endear herself to me, however. But maybe this story doesn’t even belong in this post – her demeanor did not prevent any complications for me personally. Maybe I just needed to get it off my chest :-)

Everything turned out okay for my patient. His family came in, I explained the importance of breathing exercises and they badgered him relentlessly into doing them. I wonder if anyone’s done a study on outcomes for patients that have families who participate as opposed to families who are more hands-off. I truly believe that without his family, he would have not been able to be cajoled into cooperating with my plan to prevent pneumonia. After all, he did sign up for the surgery. I believe that it does ultimately come down to the patient, as long as they’ve been sufficiently educated about how to participate in their own recovery.