As nurses, we want to provide quality and appropriate health care to our patients. In the correctional environment, we understand that our patients can’t just decide to go to another practice or bring themselves to the urgent care or emergency department for their symptoms, and so it is even more important that we collect the necessary subjective information and complete a thorough physical evaluation so that we can determine what is needed for the patient. We want the patient to leave the encounter knowing that we have provided the best care possible. However, I am sure that we have all had an experience where a patient comes to sick call reciting symptoms right out of a medical book and requesting a specific medication or treatment. They may even say that they are allergic to other treatment options or that only this one medication will work. Sometimes the requested medication has high abuse potential or is a valuable commodity on the unit. Thus, correctional nurses may interact with demanding patients with unreasonable requests to whom we need to be comfortable saying “no.”

Here are four suggested ways to say “No” while still helping your patients.

Say “No” After

When you are familiar with the patient population and in a rush, it is easy to think a few steps ahead. Rather than listen to what you expect will be a “story,” there is a tendency to immediately say “no.” While this may seem time effective, it is neither caring nor good practice.

Instead, allow the patient to fully explain their symptoms and reasons for the request. Document their subjective information as comprehensively as possible and conduct an appropriate, thorough evaluation of the complaint. Listening and documenting have several advantages:

• Discovering the ‘why’ of the request
• Documenting assessment findings for future comparison and evaluation
• Revealing discrepancies in presentation and symptoms, if any
• Confirming to the patient that the request is being seriously considered
• Allowing the patient to feel heard and validated

Say “No, But“

Once your patient has provided all the information, your clinical decision may still be to turn down the request. Rather than stop at “No,” include a “but.”  Tell the patient you must decline the request, but state what you can do. Here is an example: “Mr. Meyers, we won’t be sending you for an MRI of your ankle at this time, but here is what I will do. I’ll wrap your ankle and order ice packs for three days, and I will set up an appointment for a return visit next week to see how you are progressing.” Providing a “No, but” shows that you are responding to the request, just not in the manner the patient wanted.

Say “No, And“

Like the “No, but”’ approach, the “No, and” approach provides something to your patient, although it is not the specific request. At the conclusion of your assessment and listening, you may have discovered some misinformation or misconceptions held by your patient. While you are declining the specific request, clarify the misinformation and misconceptions to help your patient understand the reason for the denial. Avoid using rules and regulations as a reason for not proceeding with a request (See Higher Authority below). Here is an example: “Mr. Thomas, I can see you are uncomfortable with your cold symptoms and I am going to give you some medications to help with them. Colds are usually caused by viruses. Antibiotics do not affect viruses, only bacterial infections, so there is no need to schedule you to see the provider at this point. Let’s see how you do with the medications I can order through our Nursing Protocols, and I will schedule you for a follow-up visit in 5 days.”

Use “I Don’t” – not “I Can’t”

While either can be effective, saying “I don’t” rather than “I can’t” indicates your control over your professional practice. Nurses can sometimes play the victim card and use words that indicate powerlessness. For example, instead of saying “I can’t give you that cream” say “I don’t provide cortisone cream unless there is redness, inflammation, or swelling.”

Call in a Higher Authority

While we don’t need to be victims, we do work within a nursing scope of practice. Some patient requests are outside of evidence-based practice guidelines or beyond licensure boundaries. This is the appropriate time to seek a higher authority. For example, you might say: “Mr. Cooper, I see that you want to be placed on a medical diet. The general prison diet meets national nutrition standards. You have not been diagnosed with a chronic condition like diabetes that would require a different diet.”

Don’t Argue

Depending on your personality, one of the hardest actions when dealing with a demanding patient is keeping your cool. It is easy to react defensively or in frustration when confronted by some patient personality types. Remember, this is not a battle and you don’t need to weaponize your responses to inappropriate requests. Be firm, fair and consistent.

Use Empathy and Encouragement

When it seems like every patient wants something from you, it can be hard to be empathetic. There are many incarcerated patients who are not trying to work the system and are in significant need of care. They may have low health literacy. They may have been told by other incarcerated persons that the only way to get health care is to demand it. Being confrontational may be a way-of-life for them; both behind bars and in their neighborhood. They have few comforts in their current living situation. You can be seen as a gatekeeper to getting what they think they need.  Showing understanding and encouragement, even when the answer is ‘no’, can improve the outcome.

How do you say ‘no’ to your patients? Have you developed ways that work to say “no” while still maintaining a therapeutic relationship with your patient? Share your thoughts in the comments section of this post.