Therapeutic Neglect

I learned a new word phrase today. It’s actually a nursing intervention.  The intervention is titled “therapeutic neglect”.

I also learned that perhaps I shouldn’t work on the oncology floor, or as a hospice nurse. Perhaps the O.R. or the E.R. is a better place for you, because then you won’t get too attached. You won’t carry the patient’s pain around with you, as though it’s your own. 

The words above came from a concerned and honest heart.

The words came from my clinical instructor, after hearing me give report on my patient. While we talked, she took note of my red eyes and rosy cheeks. She heard the sadness in my voice, and the empathy that rang so loudly from my heart. She watched me stand paralyzed (and unproductive) in the hall, in front of my portable rolling computer. I wasn’t completely unproductive though because in my head….in my thoughts, I was working hard as I tried to formulate a plan for my patient, and figure out the right words to say to him and his wife. I so badly wanted to find the right words, but they never came. My instructor is kind, sensitive and intuitive though, so she never called me on the carpet for what may have seemed like lack of productivity today.  No, this was strictly my own inner disciplinarian that yelled out, Lorena don’t stand there….do something!  

As I gave report to my instructor,  I first gave her the basic information:

I’m caring for the patient in room 8, door bed. He’s in his 50’s.  He has no significant past medical hx. He’s up out of bed independently, and ambulating the halls often. He’s NPO (nothing by mouth) until after his procedure today. He’s having an ERCP today at 1:30 p.m. He’s taking no meds, but has a prn (as needed) order for dilaudid (pain) and ativan (anxiety), but is refusing both at this time. I get the sense he’ll continue to refuse those two pills. He has an IV in his left forearm, running at 100 ml/hr, dated 1/22/15. He’s married, and his wife is sleeping in the convertible bed/ chair right next to him. 

My instructor asks me what brought him in. I proceed with not only facts, but my own thoughts about my patient.

My patient came into the ER last night with abdominal pain. It was Saturday night when the abdominal pain first began, and then he noticed yellowing of his sclera. Yesterday he was admitted and diagnosed with… ( I won’t state that here, in order to continue to maintain privacy of my patient, but I will say that it’s a grim diagnosis).  He will need surgery, which is not only difficult on the patient, but does not have a high success rate. Dr. D was in early this morning to see my patient, and this is when he gave my patient  his diagnosis. The surgeon explained to the patient that he would need a whipple procedure. Then the surgeon was gone. All of this happened this morning, right as I started my shift. The patient and his wife are newly married. They wed only months ago…still honeymooners. They’re in shock with this new news that they only received 2 hours ago. They walk the halls because they don’t know what else to do. They have no private place to go, as they’re stuck in a room with another sick patient. They aren’t talking much. It’s as if they fear talking, because then they may start crying. Instead they swallow the hurt right down, which must feel tight and achy in their throats (a feeling most everyone has felt before, when trying to keep from falling apart). The wife could no longer hold it in though because during morning rounds, she broke down in a very quiet and held back manner, and she couldn’t say much. She’s trying to be strong for him, but her emotions are beyond her control. They’re so beautiful. They’re so young. They’re so sweet. They’re so in love. They have plans. But now they’re in shock with this new news, and stuck in a hospital room, forced to push they’re emotions that want to explode out of them, right back inside. They’re in a public place with a roommate on the other side of the curtain, nurses who walk in and out, patients who roam the halls, and the anticipation that the transporter will walk in at any moment to wheel them down for the afternoon procedure. 

I then stop myself, and head back in the direction of giving my instructor the information I know she wants (my goals for the patient, my nursing interventions and so on),  although I can tell she’s interested in what I have to say.

I guess I’d have to say that the goals I have for my patient today would be to manage his pain, offer anxiety meds and most importantly  use therapeutic communication and active listening skills. I’ll be honest though, I haven’t really been in his room much today. I have’t even done his physical assessment yet. I think he needs space. He and his wife have been pacing the halls, hand in tightly clutched hand. It’s his wife who holds on tightly, almost as though if she were to let go, he may disappear. They don’t know what to do, how to act, or what to say, but they do know that they can’t sit in that room with their thoughts. It’s too scary for them right now. 

I continue by telling my instructor the nursing intervention that I think will have the most impact on my patient, and that intervention is nothing medical in nature.

We need to move him and his wife to a private room. They need a place to cry alone. They need a private place to grieve. They need a place to share their feelings, fears and emotions. I have asked the nurse I’m working with if we can make that happen, and she agrees that this is essential right now. She’s mentioned it to the charge nurse and we plan on moving him to a private room, hopefully by the time he gets back from his procedure. 

Then I learned of a nursing intervention that I had never heard of before, and that sounded rather odd at first, but made sense later: “therapeutic neglect”. My instructor explained to me that during a time of shock or grief, some patients need time alone. Time to process. Time to grieve. They need to be intentionally neglected, which is a very hard thing for a nurse to do. But, that’s what I did. And, it was at that moment that the earlier thoughts I carried in my head of- Lorena, don’t stand there…do something….say something…get to work and stop standing paralyzed in the hallway, suddenly made me realize that I did the right thing. I was therapeutically neglecting. I knew they needed time, because after all, they had only received this news this morning. My inner intuitive self stopped me from invading my patient’s space today. I have to remember to listen to my inner intuitive self, because this is a gift I possess. I have always most always  been able to read people. To know when to say something, and when to listen. To know when to give space and when to be available. But, in the clinical setting, and when I’m being observed and graded, I almost ignored that intuitive part of my self today for the sake of doing something for my patient, and to look like I was a contributing member of the team. This is ridiculous too, because my instructor is awesome, and she does not impose this kind of pressure on me. This was just the self disciplinarian/overachiever side of me speaking. Don’t get me wrong though, there is also a time to be present as well, but later in the process. That’s when the sharp intuitive skills of the nurse comes into play, and that’s when the nurse has to decide what his/her patient needs; space or presence. There’s a time to therapeutically neglect, and a time to be present and available, and today my patient needed space.

The transporter came to get my patient for his procedure right before we headed down for lunch. I helped him get comfortable on the bed and reassured him and his wife that I’d see them when they returned. Then I watched as he was wheeled down the hall, holding tightly to his wife’s hand.

When we arrived back on the floor after lunch,  for our last hour, my patient and his wife had still not returned from the procedure. But, I was given the o.k. to move his belongings to a private room. Thank goodness for Ali, because she was my rock today. She’s one of my best friend’s and she was the one who cared for me today. She escorted me off the floor for a 15 minute coffee break this morning, when I almost broke down crying on the floor. She also joined me whenever I had to go into my patient’s room today, in order to support me and distract me from losing it in front of my patient. But most importantly, she helped me move and set up the private room that my patient was being moved into. It was a nice room, but it was nicer by the time we left. We made the bed with new sheets, and then folded the sheets down. We left a newspaper sitting at the foot of the bed. We removed every evidence of “hospital room” from  the room,  such as the bedside commode and bed alarms. We stocked the room with plenty of chairs, and re-situated them in front of the window, like you’d see in a hotel suite. We moved the convertable chair bed in a spot right next to the patient’s bed, but on the side away from the closet, so they could still access the closet. We adjusted the TV, so that both of them could watch together.  We did search the floor for a tall plant that could stand between the two chairs that sat in front of the window, but we had no luck. That would have added a nice warm touch. We asked the tech that would be taking care of my patient and his wife to give them extra TLC and space.  And, because they still had not returned by the time we had to leave the floor, we left a handmade “Thinking of You” card on the bedside stand, signed from Lorena and Ali.

I learned a lot today. I learned that it’s ok to leave the patient alone, although I kinda already knew that. I learned that I may need to work on a less emotional floor. But then again, maybe people need a person who will cry and feel with them?? I’m reminded again of how much I love Ali. You were my rock today, and thank you for the cappuccino and cheese danish. You know what makes me smile. I’m also reminded that I love what I do.  Even though it’s hard at times (emotionally),  I get to be the person who not only cares for the physical needs of the patients under my care, but I also get the privilege to be the person who holds a hand, listens quietly,  or cry’s with the patient, in those dark and scary hours. Nursing interventions are not always medical in nature, and that’s why the term “holistic care” is used so often.

 I’m really not sure how I’ll handle my upcoming Hospice rotation, but I need to experience this and remember to heed my intuition, be who I am,  and recognize  that it’s ok to feel and cry with those who are hurting.

Kiss the one’s you love,  and never take them for granted. That’s what I’m doing.

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