Simply offering a harrowed family member a cup of coffee may make a difference. Sitting patiently as they express their fears or ask questions means so much.

—Fiona

I struggled with concerns about what I might miss, not so much when I was adjunct faculty and working as both a clinician and an educator, but when I went to full-time teaching. I loved clinical and the close contact with patients and it was really hard for me to give up that kind of relationship. When I worked with students in the clinical area, the patients were not “mine” in the same way. I still had responsibility for them but it was different. I finally convinced myself that my students were “my patients” and I would make an important difference that way by helping them learn to take care of patients.

Think about how you feel you make a difference for your patients as a clinician. Describe an incident that reflects your ideas about how you can make a difference for students as they learn new clinical skills.

Although my patients (sick neonates) could not verbalize to me that I made a difference, I have received comments and cards from their parents who felt positively affected by my care. Interestingly, however, there were never any remarks about how proficiently I hung the IV drips, or managed the infant on the ventilator, or how I accurately interpreted their child’s lab results. Granted, these are important and necessary skills to possess, but these are not what the parents identify as making a difference. What parents remembered and articulated were instances of caring behavior that [were] perceived as genuine, honest, and open (e.g., staying long past shift change to support and talk to the parents, asking about their other children, acknowledging personal sorrow when the outcome is not good, or just being friendly and positive).

I am currently working with a young male patient, whom I will give the pseudonym Brian. Brian suffers from a multitude of psychiatric diagnoses, which include bipolar disorder, borderline personality disorder, attention deficit disorder, and he is addicted to crack cocaine. He was admitted to the unit after cutting his wrists with a broken crack pipe in an attempt to kill himself. At only 22, he has been in and out of psychiatric treatment and drug rehab since age 13. Even for the most experienced and empathetic PMH [psychiatric mental health] nurse, this presentation, history, and combination of diagnoses could equate to an inability to succeed in treatment. I met Brian 2 days after his admission and worked hard to establish a trusting rapport—the first intervention a PMH nurse must use if one expects any further interventions to be successful.

Although Brian would easily talk to me, it took several days for him to trust me and for me to trust him. Throughout the course of his admission, he had several episodes of yelling and screaming, refusing to participate in group therapy sessions, extreme mood lability, and high levels of anxiety. He required much time from the nurses, either seeking reassurance, medications, or preventing crises.

As Brian and I worked together, he allowed me into his world—a young life emotionally abandoned from childhood with no feelings of belonging or self-worth. He continued a life of drug addiction because he felt that was all people ever thought he would be. Even though he wanted to think otherwise, he had been written off for years by family and treatment providers as nothing more than an emotionally unstable crack addict. In listening to report and team rounds, I found that members of our own team felt the same way—they figured that Brian’s history and difficulty aligning in treatment meant he was unmotivated and manipulative. Even though I appreciated Brian’s potential ability to manipulate situations (he admitted he had done so in the past) and was not sure if he had the maturity to be able to handle the intense emotional crises he was currently experiencing, I knew it was my job to believe in him. If I, as a PMH nurse, could not believe he could succeed in treatment, then he would never believe it himself, and he never would succeed.

He is now preparing for discharge to a long-term dual diagnosis treatment facility, and although fearful and apprehensive, he now smiles when I give him positive feedback and acknowledges his progress in treatment thus far. He has practiced doing things he does not want to do, like go to AA [Alcoholics Anonymous] meetings, and has practiced regulating his own mood lability through artwork, music, and anxiety-reduction techniques. He is beginning to learn the skills needed to manage his bevy of psychiatric diagnoses. Even though I cannot guarantee he will indeed succeed in treatment, I hope that my influence will help him whenever that time comes. I feel I have done the very best job I could have done as Brian’s nurse simply because I believed in him. I hope I have made a difference in his life.

My patient was 32 weeks pregnant with an abruption that resulted in IUFD [intrauterine fetal demise], excessive antepartum hemorrhage, and DIC [disseminated intravascular coagulation]. Many professionals with different areas of expertise were present and were helping to manage the patient. She called me closer and told me how she felt so thirsty and dehydrated. I gave her ice chips, which made all the difference. She thanked me so much and verbalized to me how she felt and the only big thing she remembered was eating the ice chips. It was joyful to watch a smile on her face. I made the difference.

One of these incidents happened about 4 years ago. I was working as an evening charge nurse on a research child psychiatry unit. A 10-year-old boy was admitted to our unit for observation of child-onset schizophrenia. The family was from Vermont. They were very liberal, did not like rules, and were heavily involved in an alternative lifestyle. Well, a family that doesn’t like and disregards rules on a psych unit is bad news for anyone. The staff could not stand the family. The father was the worst. He would get his son from the dinner table, turn him around in the same chair and then turn on the television—even though there were other children still eating and staff was right there. Every evening he would come in and test some limit. He would wait for the staff to react and then roll his eyes, blow out of his mouth, and make a snide remark about how unintellectual the staff was. I have to say—he was by far one of my least favorite people. Every time the door buzzer would go off and I saw him on the other side of the door, I could feel my mind and body chemically react to his presence. But, I was the charge nurse and was determined not to let him affect me professionally.

Well, one evening, the father was on the unit and the usual scenario played out. The father tested a limit on the rules and the nurse needed to address the situation—nothing new. But, out of the corner of my eye, I saw the father heading—or shall I say “storming”—out the door. I knew there was something wrong. The easiest thing to do was to let him go and enjoy the rest of my evening. Although I could not stand the guy, I knew I had to do something. I ran to the end of the hall and met him in the threshold of the entrance to the unit right before the door was closing. I said, “Mr. Smith—you don’t look happy. What happened?” Initially, he looked completely shocked—shocked that anyone actually cared about how he was feeling. After about a 10-second silence, he told me that he didn’t like the nurse working with his son, she was too harsh and she was chewing gum (Nicorette) and it was just making him angry. He just started flooding. I told him that I understood how he feels and that actually the whole staff understands the tremendous sorrow and heartache he has every day when he sees his son and knows that he will never have a normal life. I assured him that we did not see his son as a patient, but as an adorable kid with a sweet and quirky sense of humor who is here helping us out with our research. After our little chat, there was a brief smile from him. His son was with us for 6 additional months. His father never had a problem with the staff or the unit rules after our talk. In fact, he was quite pleasant.

This incident has stayed with me. It’s because I faced one of my fears—confrontation—and went forward and dove in and addressed the problem (even when there was an easy way out). The outcome was the best possible—a content parent and a happy staff. I also learned a valuable lesson: Do not assume that the patient on the unit is the only one who needs care. Yes, I know—we learned about caring for the whole family in nursing school, blah, blah, blah.… But, this gentleman was in his mid-30s, in good physical health, and gainfully employed—not patient or “I need help” material. Unfortunately, his behaviors were so unappealing that the staff just distanced themselves from him because he caused so much angst on the unit. What really needed to happen was for the staff to get closer to him and not distance themselves from someone who initially came across as “difficult.” But how was I ever going to experience this success first-hand if I didn’t leave my introverted world of pleasantness? People do not want to step out of their comfort zone. But, I made such a difference stepping out of my comfort zone…it is important to not get too comfortable or you may miss something—like I did with Mr. Smith. This is why I remember this incident very clearly. It was one of my shining moments.