The Subtle Art of Connecting with Patients: Lessons Learned from a Seasoned Diabetes Nurse
Submitted by Andrea Zides RN, BScN, CDE
“I was fine yesterday. I was fine. I feel fine! Now you’re telling me I have Diabetes?” The patient looked at me like I just stabbed him in the heart. My inner Nurse-strength needs to pull itself together today because I can tell it’s going to be that kind of Monday. ‘I love my job, I love my job…’ I tell myself over and over again. All I keep thinking is ‘Why didn’t his Doctor explain his diagnosis to him? Why do Doctors leave it up to the Diabetes Nurse to break the news? Why do I have to tell him that he does in fact have Diabetes, and deal with the fallout? Ugh, I have six other patients lined up before lunch and the waiting room is full. I’m already 20 minutes behind, all my afternoon patients are going to be upset and the coffee maker decided to break this morning! Someone please give me strength.
My patients are real people. Diabetes is real and so is living life with it. Patients do not like to come to a Diabetes clinic to talk about their disease, their diet, and certainly not their feelings. They want the Nurse to be real. They need me to be real. They want me to cut to the chase. They need to be able to talk to me and never be afraid. They need me to not just listen to, but to hear them. They have to get weight off their chests. All of them. Every last one of them. Every patient is different but they’re all the same. They want to know if they have to stop eating cookies. Do they have to give up fruit? What about chocolate? They want to know if this will involve needles. They need to explain to me that they really don’t overeat and they really do exercise. Honestly! They tell me that the lab tests can’t be accurate. They just know it. They need me to know that the doctor must have made a mistake. They are sad. They are angry. They are in denial. They want answers, they want them now but they’re afraid to hear them. That’s a real Diabetes patient. That’s real Diabetes Nursing. My name is Andrea and I am a real Certified Diabetes Educator.
Back to this particular Monday morning. There’s no manual to follow. There’s no script I get to read from. I have to connect with each patient in order to help them. Eye contact, let’s try some eye contact…with a touch of head tilt and definitely throw in a smile. “Yes sir, I want to understand how you are feeling about Diabetes. Can we discuss your thoughts about the disease?” If I succeed in understanding his feelings, I’ll be a better Nurse who provides more optimized patient-centered care. Nurses must grow and stretch continually in their roles. My job is to teach my patients about their Diabetes. Help them understand how to live with this disease. Teach them how to live successfully with this monkey on their back. That’s what they expect from me, but today is Monday and I’m on already on autopilot. That’s what happens somedays. That’s what real Nursing looks like. If you think you are doing your best, you need to do more. If you think you are at the top of your Nursing career, you should learn more. After doing this job for years and years, you can get numb. It’s important to fight the numbness and get inspired again. A Nurse can never be simply amazing at their job. It’s easy to see why there are so many disgruntled Nurses out there. Whatever you do in your job, it can feel like it’s not enough. You don’t work enough shifts when the team is low. You should be able to work three shifts and recover seamlessly. You should be strong enough to lift patients and handle any amount of stress that is thrown at you. The guilt presses on at every turn like a hamster stuck on a wheel.
In the few years after I graduated, I had more pep in my step than at any other time in my professional life. I wanted to race out of the gate and just run and run and run. I wanted to prove to everyone in my path that I was the best damn Nurse they’d ever seen. It didn’t matter that I was young, I truly wanted to be all things to everyone. I gave it my all. I worked the hardest, stayed the latest and gave my patients the most. It didn’t matter to me that in actual fact, one could never define what ‘the best’ Nurse really was. Most Nurses are innately special in their own way, but I didn’t know that back then.
I’m fortunate to have worked in a small-town clinic serving some of the most amazing patients. I went to school, then more school, then still more school to become a Certified Diabetes Educator. I’ve been Nursing for twenty five years and I’ve remained a student of some sort for much of that time.
Once, a Nursing student came to shadow me for a month at the clinic. She wanted to get some experience with the complex field of Endocrinology and she chose to tackle Diabetes as a starting point. After I pondered why on earth she chose to start with Diabetes, I gladly welcomed her to my world. The first few days she patiently observed me interacting to my patients with the usual organization and cut-to-the-chase approach that a Nurse adapts after a few years post-graduation. Her name was Lisa and she had a million questions for me at the end of each patient visit. Whenever she didn’t understand something, she wrote down her questions or comments to discuss with me later. It was apparent that she was loving her new profession and her enthusiasm was proudly displayed on her sleeve! Soon, we graduated Lisa to leading the patient interviews herself and I’d handle mapping out the Nursing plan of care. She was keen and excited and couldn’t wait to run the appointments herself. A short few weeks later she got her wish. With her steely sidekick in the room for support, she was ready to take the lead.
Her enthusiasm soon turned to utter bewilderment when the patients didn’t react the way she expected them to. She was so frustrated that she ‘couldn’t get the patients to do what she wanted’. She thought that if she told a patient with Diabetes to test their blood sugars twice a day that they should. She was endlessly disappointed when they came back weeks later in follow up and brought back their meter which still had the seal on the box, unopened. She’d tried so hard and enthusiastically asked each patient to ramp up their exercise regime. She was so keen and inspirational and she insisted everyone attempt to improve themselves. If she had a patient with no history of doing any exercise she’d sit down and assist them in making realistic short term exercise goals. If she was faced with an avid runner she’d challenge them to incorporate resistance training to their usual workout pattern. Her efforts were apparent but the patients weren’t always responding. She soon became jaded and vented to me more than once that she didn’t understand why more patients didn’t embrace her attempts in assisting their care. Why didn’t they listen to her? What was she doing wrong? Oh grasshopper…
I’m confident in saying that every good Nurse has doubted their skills at one time or another. No matter what school or program they went to, there’s no way a person can learn everything there is to learn about interacting with patients, understanding their health or illnesses and what role they are expected to have! You can specialize in so many areas but it is impossible to know everything. When a Nurse works in Pediatrics, Palliative Care, Trauma, Surgery or Obstetrics, there is a unique set of skills they must arm themselves with for each area of practice. This takes time and can’t be learned entirely in school. It is ongoing and it takes an open mind and thirst for knowledge. And it doesn’t stop there! Just when you think you’re a killer trauma Nurse at the top of your game, your Hospital may restructure and now you find yourself in a Pediatric trauma unit wondering what do I do now with this little one year old baby in front of me? If you think that you are the Diva of Diabetes, some pharmaceutical company will invent a new non-insulin treatment that you’ve never heard of! Or a new blood sugar meter with a robust computer attached is the latest tool! In Lisa’s case, it was my job to break the news to her that every patient is actually… newsflash…their own person. Lisa was frustrated that she couldn’t connect with patients in general, wondering if she’d chosen the right profession. I recall vividly, patiently explaining to her that patients have their own unique past and experiences and everyone’s past is different. Thus, every patient can’t be painted with the same brush. I reminded her that she is young and keen and some of her patients were in their eighties and nineties and are just plain tired. I remember reassuring Lisa that patients are smart and independent individuals who ultimately make their own health care decisions. I was an empowering mentor who was trying to ease her transition into the real world of patient care.
I had only a few days left working with Lisa before she started her first, brand new, shiny job as a floor nurse on a Medical floor. We were by now in a groove of effectively tag-teaming our patient care. Lisa was growing by leaps and bounds every day and I knew that she’d be a success at whatever position she chose. We were at the end of a long week when we met Josephina. Oh my, dear Josephina…
Josephina is a 77 year old grandmother who has had Diabetes for 10 plus years. Some patients just stand out in your career and she sure does.
“Hello Mrs. Mancuso. My name is Andrea and I’m a Diabetes Nurse. How are you today?” This is my standard greeting when I meet any patient for the first time. I extended my hand to offer a handshake. Mrs. Mancuso looked at me like I was about to administer a very large injection. No handshake from her, I guess. Okay, then… She looked me up and down then settled her stare on Lisa. “Who’s she?” Mrs. Mancuso asked unapologetically holding her stern glare on Lisa. “Allow me to introduce Lisa. Lisa is a Registered Nursing Student who is working with me this month to gain some experience into Diabetes care” I figured that ought to answer her question. Lisa certainly didn’t help any, as she stood in the corner of the exam room in disbelief at this patients’ temerity. I see that Lisa is choosing to take a pass on leading this appointment. Mrs. Mancuso took a seat on the chair, adjusted her shirt and pants, placed her purse neatly under the chair and looked me up and down, head to toe. She cleared her throat and spoke; “So you’re using me as your guinea pig?” her voice dripping with contempt.
In the spirit of showing Lisa that not every patient encounter has to end in disappointment, I decided to show off a few of my best patient connection tricks. Let’s just hope that Mrs. Mancuso is willing to cooperate.
“Mrs. Mancuso, you are not a guinea pig. Not in the slightest. Your family doctor, Dr. McGregor, has asked me to discuss your Diabetes with you. Today, Lisa and I would like to learn a bit about your history of Diabetes and your health in general. We’d like to ask you some questions and determine if we are doing everything that we can for you. We will make a plan for your care that will suit your needs, and meet your goals in the best ways possible. At the end of the appointment we should have time left over for any questions that you may have. Does that sound alright with you?” I am genuinely a rock star according to the look on Lisa’s face who is finally relaxed enough to sit down and breathe.
With the confidence of her 77 years, Mrs. Mancuso bluntly stated; “I’m old and I’m tired. I’m not going to take the needle. Period. No insulin. I’m not kidding here. Do you hear me? When my mother started the needle, she died before the end of the year. Now, I need to make sure I can still help my daughter with her son and her baby on the way. I’m a mother and a grandmother and a lot of people need me. I told my doctor I don’t want to change anything, nothing! Now he’s sicking you two on me. Listen to me, I have a half hour before I have to check on my sauce for dinner. I have eight people for dinner tonight and they’ll go hungry if I don’t feed them. So, say what you’ve got to say, but make it quick.” She folded her arms triumphantly. She got it off her chest and just delivered us her own version of the State of the Union address. Lord have mercy, please let this woman know that I’m here to help her!
“Mrs. Mancuso, may I call you Josephina?” I’m able to make eye contact at least.
“Yes, you may.” She acknowledged.
“Josephina, I’m very glad that you shared with me your feelings. When I know what your concerns are, it really helps me to help you. Your doctor sent you to us to try to ensure that we are doing everything for your Diabetes that we can. We know that often once we get a patient’s Diabetes under good control, the rest of your health often falls into place.”
“Why do you keep calling it ‘Diabetes’? Why don’t you just call me a Diabetic like a normal person?” She is clearly showing me that she’s in charge. She’s my senior and making sure I know it. She’s lived with this diagnosis for ten years and she’s making sure that I realize that she knows darn well how to deal with it already.
“If I may, I’d like to answer that for you” Lisa piped up from the corner. Oh dear. Cardinal Rule number one; When a difficult patient is finally starting to connect with someone, don’t interfere! Josephina swung her head so fast at Lisa that if looks could kill she’d be dead. Lisa was entirely unaware that she was in the middle of undoing this precious connection I’d just started to build. She didn’t see that she just forced us two steps back. Sometimes that’s the game in Nursing, connecting with patients is like taking one step forward and two steps back. There is a distinct art to inviting people to relate to you, and to enable them to trust you with their healthcare, their vitality, their life. It’s a gift when you can connect with a patient. It is an honour. At the end of the shift after truly helping a person, a Nurse can hold their head high and know that they’ve made a difference. That’s the sweet spot, that’s the altruism of making a difference.
Lisa continued with her inexperienced attempt; “Josephina, we try not to label people with Diabetes. We know that you are an individual. We want to separate you from this disease. You are a patient who happens to have Diabetes, it doesn’t have you. It’s like having cancer, we don’t call a patient with cancer a ‘Cancer-etic’. It’s the same thing.” The satisfied smile on Lisa’s face told me she was most pleased with her explanation. Like a proud student in a classroom who put their hand up and got the answer correct. She was waiting for praise from Josephina.
“What the hell is wrong with this girl?” Josephina’s voice was now raised and she faced me square on. “Is she trying to tell me that I have cancer? Why would she say that to me? Is she trying to give me a heart attack? Doesn’t she know that I’m an old woman? A canceretic! What the hell is a canceretic? You got a lot to learn little girl! You should change your profession for one thing! I’m about finished here and I can promise you that Dr. McGregor is going to hear an earful about you! Shame on you!”
With that, Josephina collected her things in her now shaking hands and stormed out of the office. Lisa’s eyes were welling up as we could still hear Josephina muttering as she walked through the hallways of our small office to exit. It was time for a debrief, stat.
Lisa learned one very big lesson that day. I think that every single Nurse has to learn the lesson at one time of another, sooner or later. The thing about patients is that they are humans filled with feelings. Even the ones who appear tough and stoic on the exterior; sometimes they’re the hardest. Every patient is a person, a person who has decades of life experience. Just because we are trained in Nursing, doesn’t automatically give us license to be authorities. You have to earn it. You have to earn that trust. You have to listen, really hear, and pay very close attention.
Eventually, long after Lisa had left our office, Josephina did thankfully return. She did complain ad nauseam to Dr. McGregor and myself about the way that Lisa treated her. It took a lot of time, but I was able to repair the trust of an elderly woman with significant health issues. Her A1C was rising steadily over the past year and her renal labs were serious. I owed it to this woman to show her that with appropriate treatment, we could get her disease in target and help her to have more energy every day and an improved quality of life.
After two subsequent appointments, Josephina started to come around and eventually trust that I was trying to help her to help herself. We spent our appointments talking about recipes and grandchildren, gardening, meal planning and of course, Diabetes. Josephina wanted to talk about everything but herself. Her Family Doctor was starting to pressure me to get her on track. Her Diabetes was not well controlled and I knew that we could and should do so much better. I heard all the times about how she had low energy and how tired she was. She told me how much she struggled to take care of her grandchildren lately. How cooking was her first love, but sadly, had become a burden. She said that her herb garden has become a bed of weeds because she was too exhausted to tend to it. She was slowly letting me in. She was showing me her honesty. She was involving me in her health care. She just didn’t realize it. Thankfully, I did.
I spent an inordinate amount of time educating her on her treatment options. In the ten years since she was diagnosed with Diabetes, she has tried every oral medication out there. She takes the maximum amount of oral medications recommended yet this still isn’t enough to keep her blood sugars in control. Josephina feels like she can’t eat anything because it makes her blood sugars too high. She doesn’t like looking at those high readings on her meter. She struggles to diet and yo-yo’s like crazy. In response, I spent countless time explaining that she can’t blame the food for her blood sugars or for her Diabetes. I patiently told her that our bodies require food to exist and she can’t simply cut out food in an attempt to control her blood sugars. I counseled that Diabetes is a progressive disease and despite our best efforts, year after year, this disease continues to decline. I repeatedly reassured her that she did not cause her Diabetes, her pancreas had aged and was no longer producing the insulin that it once did. I worked hard to remove the blame and guilt she was placing on herself. I was in the home stretch of optimizing that precious patient relationship and nothing was going to stop me now.
For Josephina, the solution boiled down to insulin. This woman fought and fought with me and refused to consider insulin at every single attempt. Her Doctor couldn’t sway her. I couldn’t sway her. I had tried everything. I educated her, I gave her handouts, I showed her video clips, I showed her studies touting how much insulin would improve her quality of life, I tried everything. She had her mind made up, like so many patients out there, that insulin is the last step before the grave. How this effective treatment got such a bad rap is staggering. I’ve encountered too many patients who would rather die than start insulin. It is an enormous struggle for any professional working in the field of Diabetes. Josephina came close so many times, she would listen to me, hear me out only to refuse insulin once again. Month after month, I vowed I’d find a way to help this woman. I pledged that eventually I’d get her to come around.
About a year after I first met Josephina I called her in to review her latest labs. She had Diabetes labwork drawn every three months and her results were in steady decline. Her latest results were drastically worse. I decided to cut to the chase. Today was going to be the day. I was going to save this woman from herself. I was going to play Bad Cop. I admit that I’m aware that there’s supposed to be a Good Cop when you play ‘Good Cop-Bad Cop’ but I didn’t have that luxury. Today was the day that I was going to get her to agree to try insulin. After she saw her lab results which were so very far out of target, Josephine appeared tired. She didn’t want to fight today. This disease was causing her fatigue. I told her so in no uncertain terms. I also told her that we’d been at this for over one year now and she was only getting worse. I asked her to be honest with me when I asked her how she was feeling. She flatly said; “Like death” Just like that, she admitted it. “I feel like death. I’m tired. I can’t look after my new grandson. I feel old.”
Here was my window, my chance to help her help herself.
“Josephina, it’s been over a year now. I’ve listened to you tell me that you refuse to try insulin. I’ve heard all of your reasons and I’ve accepted how you chose to treat your Diabetes. I have been patient and supportive. I’ve told you countless times that this disease is progressing and is going to continue to progress. You will need insulin to replace what your body is no longer producing. Humor me today. I challenge you. Try it my way. Try it for ONE week. Give insulin a chance for one week and if you don’t feel like it’s helping you then you can stop taking it. Give me the benefit this one time that maybe I know what I’m doing. Let me teach you what to do and agree to try it for one week. Just one needle a day. That’s it.” I looked at her with quiet calm and gave her time. I held her stare and let her process my challenge. In that moment, I believe it was the first time that Josephina ever saw me as a professional. I wasn’t just a kind face to chat with, I was her Diabetes Nurse. “Will you give it a try? What do you say?” I felt like Superwoman in that moment. I was holding every single fear that she had for so many decades in my arms. She placed her fears onto me and let me lead. “Fine. I’m too tired to fight. One week. That’s it. Now let’s hurry up and show me what to do because I have to make supper and I don’t have all day.”
Three days and forty patients later, I was charting at my desk when the receptionist interrupted to tell me that I had a delivery at the front desk. I asked her to sign for whatever it was, please. She told me “It’s not that kind of delivery. You’d better come see for yourself”.
In the waiting room, which was packed with over 20 patients, there was Josephina holding a pot that had to be as big as her entire chest and partially covered her head. She was quite a site wearing her large green oven mitts and an apron in the middle of the waiting room. I couldn’t even make eye contact with her because the pot was so big! I opened the door from the waiting room and showed her back to my office. “Josephina, what is all this? What are you doing? This must weigh a ton!” She put the hot pot down onto the counter and she gave me the most heartfelt hug a patient has ever given me.
“Andrea, I made you my sauce. My good sauce with the ribs and sausage. I want you to enjoy it with your family for dinner. I just want to say thank you to you.”
“Thank you for what?” I asked.
“For starting me on the insulin of course! I feel great! I’ve never felt better! I have so much energy. It’s like it woke up my heart. For three days I’ve done more at home that I’ve done in the past year! I can’t believe what you’ve done for me and I wanted to make you my special sauce to say thank you.”
I did it. It took me a full year, but I did it. I finally got this elderly woman to stop giving excuses and to start feeling like living life again. This is the power of Nursing. Right here. This opinionated, prickly, senior citizen who was convinced she was dying finally trusted me enough to try things my way. For every single clinician out there who is right now having warm, fuzzy feelings all over; proud and satisfied recalling all the times you too have had similar experiences helping patients; don’t get too comfortable. The story doesn’t end here. After helping Josephina with her 10 pound enormous pot of sauce to the back kitchen, she still wanted to talk.
She looked at me squarely, put her feisty hands on her hips and said; “I did want to ask you something else while I’m here…”
“Sure, of course. What did you want to ask me?”
“I’ve literally never felt better! Now I’m kicking myself because I wasted all of last year feeling poorly and unwell. So now I have a bone to pick with you!”
Josephina was dead serious. She was chastising me with the authority of a septuagenarian.
“What bone do you have to pick with me? What did I do?” I asked.
She answered seriously, “WHY didn’t you start me on this insulin sooner? What took you so long? I could have felt better all year!”
I couldn’t help but laugh out loud. A year I spent worrying about her, working on establishing her trust and finally achieving a therapeutic patient connection. Yet here we are. Oh, the irony. You’ve got to be kidding me. I love being a Nurse, I love being a Nurse…
*Names have been changed to protect anonymity.