Image courtesy of Prawny on Pixabay.com
Sometimes, I wonder if people would interact differently with me if they knew I had: 1) a long-standing interest in making therapy more just, equitable, and beneficial for everyone; and 2) an active blog where I document incidents like the one last week.
I recently took over the case management of a 4 year old client with complex needs. She’s growing up in a primarily Spanish speaking household with the exception of all of us healthcare providers who are native English speakers. I took over this child’s case because the management of her care was a little too complex for the new grad who took over for someone else. And, because of the nurse.
This nurse is a “Karen” by every definition. And, like many “Karens”, it was the video she insisted would prove her right that was her undoing. She is very, very lucky she is assigned to this particular family and that the mom recognizes she is very skilled at the nursing tasks. Because, I think she should have been fired for what she did.
I knew from the new grad clinician that this nurse could be very challenging and would actively seek to sabotage therapy sessions. I knew that things had gotten to the point where the new grad clinician asked that the nurse not be present in the room for therapy sessions. I knew all of this before I saw the client for the first time in early February this year.
I should point out here that the client is a preschool-age child with a trachestomy, has a g-tube for nutrition and hydration (refuses to eat by mouth), is non-verbal and non-ambulatory, and lacks any symbolic communication system. On top of all of her medical issues, she is undergoing evaluation for autism.
During the first session, the nurse spoke to me at least. Her attitude was quite frankly pretty terrible, telling me that she did not know why the mother bothered to bring us in. She was very challenging and patronizing, stating, “Go ahead. Try putting anything in her mouth. I want to see it. This is entertaining.” She sat back and crossed her arms over her chest. The client was resistive to having anything near her mouth – a not uncommon issue with kids who have had feeding tubes placed when they were infants. I asked about the possibility of trying to work with oral care rather than feeding to work past some of the client’s oral aversions. I got the same reaction from the nurse. Her attitude was basically, “whatever you try with the client will be entertaining for me.”
A pretty poor attitude toward your patient, if you ask me.
A different nurse was present during my next session with the client. The client was visibly tired and did not want the nurse to leave her side. So, the nurse sat on the floor with us as I tried to engage the client. I talked with this nurse about her observations of the patient and asked for her suggestions as far as getting past the client’s oral aversions. This nurse was very insightful and helpful. After about 20 minutes, the client fell asleep and could not be roused. It happens sometimes with clients with complex needs.
At my next visit, the regular “Karen” nurse was back on shift. I was talking with the client’s mom about how the last two sessions had gone and was talking with her about what she wanted for her daughter. The Karen nurse came out of the client’s bedroom and launched into a tirade about, “I heard you and [the other nurse] let her sleep. She’s not allowed to sleep.” When I tried to explain that wasn’t the situation at all, the nurse continued to interrupt me, stating she was the other nurse’s “supervisor” and she would tell her the client wasn’t allowed to sleep during the day. Keep in mind, this is a 4 year old with complex medical and communication needs the nurse was discussing. At the end of that session, the client’s mom walked me out to my car and said she didn’t like the way the nurse had talked to me. She said she would address the situation with the nurse.
The very next session, the Karen nurse did not open the door until 5 minutes after the session start time. She refused to look at or to speak to me. The tension simply roiled off her. I made sure to speak to her pleasantly and then to basically ignore her for the duration of my session. Per my discussion with the client’s mother, I had the client sit at a child sized table and chair in her room for feeding therapy. In addition to severe oral aversions, the client had developed an aversion to the high chair the previous clinician used for feeding therapy. The client’s mom was fully supportive of my taking a different approach to feeding therapy as well as my taking a different approach to helping her daughter develop a symbolic communication system.
This situation continued for the last few weeks, with the nurse only opening the door on time if the client’s mom was home, refusing to speak to me when I spoke to her, and sitting in my sessions while brooding and scowling from her chair in the corner. The family installed an in-room video camera during this time. I was able to establish solid rapport with the client who began to make eye contact and reach toward me when I entered the room. She was beginning to access a light tech SGD AAC device to request more of preferred activities. She was beginning to tell me “I’m all done” or “stop” with the device rather than physically protest when she’d had enough of feeding therapy, requests which I immediately honored. The client’s mom showed me clips of my sessions with the client and told me how happy she was to see her daughter smile and participate in therapy sessions without crying.
Fast forward to last Tuesday. The client’s mom wasn’t home. I ‘cop knocked’ on the door when I arrived at the set appointment time. I waited five minutes and ‘cop knocked’ again. I waited a couple more minutes, then texted the client’s mom. She immediately called me back, then texted the nurse who said she’d been in the bathroom. The nurse finally granted me access to the home and the client 13 minutes after the start of my scheduled appointment time. I said, “Hi, how are you?” to her as I always did, knowing I would be met with a frosty silence and intentional avoidance of eye contact. As I took my shoes off and got ready to walk down the hall, the nurse said in a very nasty tone of voice, “You need to use the high chair if you’re going to do feeding. If you’re not going to use it, then you’re not doing any feeding today. Mom said so.”
This was clearly a lie, so I asked, “Why? What happened? She really hates the high chair and we’re making progress with her seated at the table in her room?” I got back, “Do you want to call mom? She eats in the high chair or she doesn’t eat. End of discussion.” I replied, “Let’s call her mom. I want to hear what she thinks.” Of course, the nurse didn’t call the client’s mom. By this point, we’d reached the client’s bedroom. The nurse again made comments about not seeing the need for speech-language therapy. At this point, I told the nurse that I’d been nothing but nice to her despite her childish behavior toward me. I asked her to leave the session and sit outside the room as she had done with the previous two therapists. As can be seen on camera, the nurse physically lunged toward me while screaming, “End of discussion!” and putting her headphones in her ears.
The client’s mom returned home a few minutes later and came into the room where the nurse sat absolutely seething while I was trying to at least get some therapy time in with the client. I asked the client’s mom if I could speak with her after the session about the concerns the nurse had raised and that I did not feel that the current situation was appropriate for her daughter. After the session, I asked the mom if it would be possible for the nurse to wait outside the client’s bedroom with the door open as she had done with the previous two clinicians. I confirmed with her that she was on board with the way I was approaching feeding therapy to help her daughter get past some of the aversions she had developed with the high chair. I confirmed with her that she was happy with the way therapy was going in general. It was a good discussion and I appreciate that the client’s mom was willing to listen and to come up with other solutions.
I saw the client again last Thursday. Her mom was present in the home, but the nurse was not. I’ll be perfectly honest and admit I felt a ton of relief when I saw the nurse’s car was not in front of the home when I arrived. It was a good session with the client.
Afterward, her mom came in the room and asked me when I had arrived at the home two days before. I stated I thought it was exactly on time. She showed me the video feed from the in room camera where the nurse clearly heard me knock both times and then sat back down. There was also footage showing the nurse getting the text from the client’s mom and responding back that she was in the bathroom. The entire 13 minutes is documented on the in-room camera footage. I told her I didn’t think it was the first time the nurse had been intentionally slow to answer the door, just that this was the most egregious. The entire interaction between the nurse and me, including her physical lunge toward me and putting in her headphones is documented. The client’s mom told me the nurse showed her the text the nurse said she sent to my “company.” (I’m an independent contractor, so I don’t work for a company like the nurse does.) She asked if I’d heard from the woman who owns the company about the situation. I told her I hadn’t. The client’s mom then said she knew the nurse was the reason the new grad clinician had asked to have someone else assigned to her daughter’s case. She then asked me if I would leave, too. I told her what I’d told her before – her daughter was my priority and we could figure out another arrangement with the nurse. I told her the owner of the company was fully aware of the issues with the nurse and that I had been warned ahead of time. The client’s mom explained all of the difficulty she’d had in getting a competent nurse to take care of her daughter during the week. I agreed that this nurse had great nursing skills, that it was just that her attitude was causing problems. The client’s mom told me she had asked for another nurse to present on Tuesdays and Thursdays when her daughter’s PT, OT, and ST therapy sessions are scheduled.
I’m grateful that the client’s mother is so understanding. I’m grateful that I have a good working relationship with her and that she is pleased with how therapy is going. It makes me happy to see the progress her daughter is making with both communication and with feeding.
It makes me sad to know there are people in this world like the nurse who are in positions with just enough power that they can abuse it. It makes me wonder what is going on in this nurse’s life to make her this way. It makes me wonder if she realizes the only people she hurt in this situation were: 1) the client by forfeiting her therapy time; and 2) herself by losing 16 hours of work per week. She used her positionality as she perceived it to interfere in a position where she ultimately was the loser.
I offer the following meditation for the nurse: May you be well; May you be happy; May you find peace. May you find it in yourself to be more humble and accepting of the help others offer to the clients in your care.
As always, thanks for reading. I look forward to your comments!
Outside The Box 