The Essence of Nursing

Those of us who practice in cities or towns with diverse populations must be highly sensitized to how complex multicultural and cross-cultural issues can be in the hospital setting. Particularly in the ICU, patients and their families are often highly stressed and may sometimes say things they either do not really mean or would not normally say. Patients and families are often fighting for attention from an overworked and understaffed multi-disciplinary team, and may become frustrated if they feel their needs are not being met with appropriate alacrity. Although much has been written about providing care with dignity for patients (as there should be!),^1–3  it is much more difficult to find literature that focuses on ensuring the clinical staff is treated with dignity. This is wrong.

Of course, as professionals we are trained not to respond emotionally when patients or their family members say or do things that we as the treating clinicians may consider to be inappropriate or offensive. Perhaps they are just afraid or stressed and taking it out on us, the professionals who are trying our hardest to help them or their loved one. But just as importantly—in this era of nursing shortages and terrible burnout—it does not mean that we must suffer silently when what is happening clearly verges on what can only be termed “abuse.”^4–8 

As nurse Tolarba elegantly reminds us, it not only acceptable, but of the highest imperative that we recognize when our patients are hurt, in pain, stressed, upset, or delirious and provide them care and comfort to the best of our abilities. In addition, we also must stand up for ourselves when we feel our patients are “taking advantage” of us and not providing us the dignity and mutual respect we all deserve as part of the multidisciplinary team.

There are multiple important reasons why the vignette by nurse Tolarba is so important. First and foremost, in this era of profound nursing shortages and nationwide attempts to recruit nurses and prevent burnout, the story as described above is a classic example of a situation that could easily lead to strife, conflict, and burnout. The main reason most of us went into health care was to help people, and when we run into a situation in which the patient is becoming abusive to the health care provider, how that conversation is handled can make the difference between a meaningful interaction or yet another person leaving the field of nursing.

One of the most important take-home messages from Tolarba’s story is to remember that moment of reflection after the hurtful sentence or sentences have been said. Doing or saying the “right thing” at that moment takes a profound level of courage and maturity. Sometimes the patient is (perhaps on purpose, perhaps not) attempting to poison the all-important clinician-patient relationship, and we, as consummate professionals, must rally the strength to find the good in someone even as he or she may be putting us down. This is often incredibly difficult to do, but as was so gracefully demonstrated in this story, it can be done, and sometimes with beautiful results.

Tolarba did what we should all strive to do: to see past the indignity, and to gently pull the kind person out of the person who may be berating us. It is important that we remind ourselves of the asymmetric nature of the relationship, and that we assume all of our patients are good people who are very sick and emotionally stressed. The technique that he used was to “cure with a touch.” His technique is powerful, but it takes a great deal of professionalism and maturity to go up to someone who has just insulted you and tell them that despite the fact that you have insulted me, I am going to rise above it and provide you with the tender and professional care that you deserve.

The most magical aspect of this nurse’s story was that he not only retained his own dignity, but in doing so (saying very little), he pointed out the ridiculous and hurtful nature of the words initially spoken by the patient. We wholeheartedly applaud nurse Tolarba and any ICU clinician who has ever responded well to a similar situation. He took a painful circumstance—teetering on the brink of disaster—and used training, professionalism, and experience to provide highly dignified care for the patient and to help maintain a dignified work environment for all of us.

The most valuable element of this account is that it can be applied to each and every ICU clinician. We all care for patients and their families when they are at their sickest and most stressed; sometimes those families take their anxiety, frustration, and anger out on the team that has chosen to help them. Stories like nurse Tolarba’s remind us that what we do is extremely important, but often incredibly challenging. This tale describes the true essence of nursing: to care when it isn’t easy, to find joy when others cannot, and to rise above the ordinary and see the extraordinary.