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HFAP Ligature Standard Remain Same After CMS Memo

This first appeared August 23, 2018 in Hospital Safety Insider.

HFAP, one of the oldest accrediting organizations for U.S. hospitals, recently updated 13 of its standards to align with the expectations on ligature risk and other hazards that CMS outlined in a memo in December. The standards have been approved by CMS, but will not be revised again in light of the July memo, says Alise Howlett, AIA, CFPE, CHFM, HFAP’s emergency management, physical environment, and life safety standards advisor.

The July CMS memo states that surveyors would use Joint Commission ligature recommendations. Howlett says that the additional guidance is simply that, additional guidance.

The updated HFAP standards range from staff training on identifying patients for risk of self-harm to building safety policies and monitoring, from building security to life safety compliance, from privacy and safety concerns in a safe setting to requirements for environmental risk assessments.

“The HFAP standards have been approved by CMS and simply outline updates for accreditation expectations. They will be enforced per the direction of CMS which stated that AOs will use their judgment as to the identification of ligature and safety risks, what level of citation will be made for deficiencies, and the corrective action to be taken for mitigation and remedy. This is all outlined in QSO 18-21,” says Howlett.

HFAP was not part of The Joint Commission’s panel of experts, but “all accrediting organizations with deeming authority are working from the same playbook: the CMS regulations,” says Howlett.

IHI Launches Maternal Care Improvement Project

This first appeared August 22, 2018 on PSQH.

The Institute for Healthcare Improvement (IHI) has begun a three-year project that aims to improve maternal outcomes for women and babies in the U.S. Supported by a grant from Merck for Mothers, the project’s goals are to spread the use of evidence-based care practices to reduce complications such as hemorrhaging, hypertension, and blood clots. It also plans to implement strategies to reduce disparities in maternal outcomes, and partner with women, their caregivers, healthcare providers, and community initiatives to better learn and address factors to improve health outcomes for mothers and newborns.

“IHI has proven experience in helping healthcare providers adopt and scale up best practices that save lives across whole systems, regions, and countries,” said Trissa Torres, MD, MSPH, FACPM, chief operations and North American programs officer at IHI, in a release. “We believe that by forging partnerships with others working on these problems and combining existing expertise with IHI’s improvement methodology, we can significantly improve care delivery outcomes for new and expectant mothers.”

Annually, an estimated 750 women die in the U.S. as a result of complications of childbirth, with more than 50,000 suffering serious complications, according to the IHI. African-American women have maternal mortality rates estimated to be three to four times higher than those of white women.

Merck for Mothers is a 10-year, $500 million initiative to help improve maternal mortality rates. The program began in 2011 and has expanded to more than 30 countries.

CDC says Heparin Syringes may have caused bloodstream infection outbreak

From PSQH Magazine

The Centers for Disease Control and Prevention (CDC) has confirmed 14 cases of bloodstream infections in children that may be linked to syringes of heparin and saline made by Becton Dickinson and Co., Reuters reported. The cases were caused by the same strain of the Serratia marcescens bacterium.

The infections occurred in seriously ill children who received intravenous medications through a catheter or central line in Tennessee, Colorado, Minnesota, and Ohio. No deaths have been associated with the infections and the number of cases is dwindling, the CDC said.

Health officials started testing the Becton Dickinson products after discovering the syringes had been used to treat several of the infected children. Saline or heparin are often used to flush central lines to keep them clear.

Reuters reported that so far, none of the Becton Dickinson products have tested positive for the bacterium. In April, Becton Dickinson recalled 949 lots of its BD PosiFlush Pre-Filled Heparin Lock Flush Syringes and Pre-Filled Normal Saline saline flush syringes sold between February and December 2017.

All of the recalled products were made at Becton Dickinson’s facility in Franklin, Wisconsin.

Lead the charge for change and innovation

As leaders in healthcare organizations, it is often a nurse manager’s responsibility to be a driver of change. And while effective leaders work hard to help release creative energy within their facilities, staff must understand what is valued in order to support this.

When attempting to create an environment that enhances change and supports innovation, consider the following questions:

  • Is there consistency in beliefs and assumptions among those who leave your facility?
  • Do staff members believe rewards are distributed equally?
  • Do management tempers frequently flare up?
  • Are management behaviors consistent, or do staff members always have to be alert for the decision of the moment?
  • Do you support innovation and change?
  • Is your approach consistent, or does it reflect the issue of the moment?

When trying to influence change it is also important to seek information and advice about best practices from outside your facility. If you are able to look objectively at yourself as a leader and at what you value, you will be more successful as a change agent.

What else should nurse managers consider when trying to create an environment that supports change?

Dealing with Difficult Patients: Helping patients sleep better

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

A cat eats and sleeps. Then maybe it plays with some string. A cat eats and sleeps. Then maybe it stretches. A cat eats and sleeps. Then maybe it curls up on your lap. A cat eats and sleeps.

If only our patients were cats, sleeping and eating without any concerns. Unfortunately, our patients are people. And many people suffer from two very common conditions: problems sleeping and problems eating. As a nurse, you need to have a tool kit of helpful hints and tricks to help your patients.

Catch up on your zzz’s
The normal sleep cycle is about one-and-a-half hours in length and includes passing through five stages of sleep: Stages 1, 2, 3, and 4 are sometimes called non-rapid eye movement sleep, and are followed by a period of rapid eye movement (REM) sleep.

Stages 1 and 2 are periods of light sleep during which eye movement, heart rate, and breathing slow down. Stages 3 and 4 are deeper periods of sleep. People awakened during these stages often feel disoriented and groggy. It is the deeper stages of sleep—REM sleep—that refresh the body. It is a time when breaths quicken, the heart beats faster, muscles become immobile, and the person experiences vivid dreams.

In search of some rest
People of all ages can experience trouble sleeping. Parents complain that babies and children have erratic sleep patterns; teens are notorious for staying up all night and wanting to sleep during the day; adults complain of not getting enough sleep; and older adults complain that they have trouble staying asleep.

Activities that help promote sleep are the same throughout a person’s life­span. First, make sure your patients have careful and comprehensive assessments of their sleep problems. For example, if a person is having trouble sleeping because of allergies or enlarged tonsils and adenoids, these need to be addressed. People with restless leg syndrome or other limb movement disorders need to be evaluated and treated properly. Obstructive sleep apnea, a serious cause of sleep problems, also needs prompt attention.

Here is a list of hints that you can give your patients to help them sleep and feel rested in the morning:

Avoid stimulants. Cutting caffeine at least four to six hours before bedtime can help a patient fall asleep easier. Caution them to avoid using alcohol as a sleep aid. Alcohol may initially help a person fall asleep, but it also causes disturbances in sleep resulting in less restful sleep. Restrict nicotine, as it too is a stimulant.

Relax before bedtime.
Provide time for quiet activities in the hour before bedtime. Try reading something light or doing some light stretching. Many nurses use aromatherapy for its relaxant effect, and commonly used essential oils include oils of chamomile, jasmine, lavender, neroli, rose, and marjoram. Add a few drops to a warm bath or sprinkle a few drops on a handkerchief or pillow. It is important to understand the difference between essential oils and fragrances.

Other bedtime relaxation rituals that might work include asking the patient to gently wiggle his or her toes. You could also give him or her a head message, and/or ask the patient to apply lotion to his or her hands and feet.

Provide for a comfortable bedroom situation. Keep the patient’s bedroom as quiet, dark, and comfortable as tolerated. For many people, even the slightest noise or light can disturb sleep. Ear plugs and eye masks may help. Ideal room temperatures for sleeping are between 68°F and 72°F. Temperatures above 75°F or below about 54°F can disrupt sleep (Kryger et al.).

Eat right, sleep tight. Help the patient to eat sensibly during the day and to avoid heavy meals before bedtime. Foods high in tryptophan, such as milk, can promote sleep. The patient can also try a bit of carbohydrate in the form of cereal or a banana, and should avoid overeating, as this may cause indigestion.

Caution the patient to avoid drinking fluids after 8 p.m. Waking up to go to the bathroom may disrupt sleep and the patient may not be able to fall asleep again once disrupted.

Start a routine. Do not allow the patient to nap during the day. Waking up at the same time in the morning helps develop a sleep rhythm.

Just (help them) relax!
Progressive relaxation and relaxation breathing exercises can also aid in sleep. Progressive muscle relaxation (PMR) was described by Edmund Jacobson, MD, PhD, in the 1930s, and is based upon his premise that mental calmness is a natural result of physical relaxation. It is a deep relaxation technique that has been used to relieve insomnia as well as aid in the reduction of stress, anxiety, and pain. Simply stated, PMR is the practice of tensing (tightening) a muscle group and then releasing (relaxing) it, followed by moving on to another muscle group and repeating the process until you have systematically tensed and relaxed all muscles in the body.

Almost anyone can learn PMR. Usually it is best to start at the head or the feet. For example, start at the head and work down through all the body muscle groups, or start at the feet and work up to the head. Practicing relaxation breathing at the same time you practice PMR adds benefit.

Many people like to practice PMR in bed just before sleep, but it can be practiced in a sitting position as well. Sometimes PMR is a useful technique to use during long and tedious meetings.

Here’s how to start PMR:

  • Inhale and contract all your facial muscles, squeezing your eyes together, puckering up your mouth, and scrunching up your face. Now exhale and relax your facial muscles.
  • Inhale and tighten your neck muscles, and then exhale and release.
  • Inhale and contract your upper chest and upper back, and then exhale and release.
  • Inhale and contract the muscles in your left arm and hand, and then exhale and release.
  • Continue working your way through your body, contracting each muscle group and then releasing.

During PMR, keep your breath calm and do not hold it. Breathe in when contracting or tensing your muscles, and breathe out during release. As you practice this technique on your own or with your patients, gradually pay more attention to the release of body tension, as well as emotional tension.

Relaxation or diaphragmatic breathing
Using the diaphragm and not the chest is the most efficient and relaxing way to breathe. Chest breathing elicits anxiety. Try it: Breathe only with your chest and see how you gradually become more and more anxious. Now, switch to breathing with your diaphragm, bringing in your breath through your nose, allowing it to slide through your chest without raising your chest, and continuing down to the area just above your navel. Some people have difficulty pushing out their abdominal area when inhaling and it may take some practice. But with practice, you and the patients you teach will find that it comes more naturally and that it results in a more alert and relaxed feeling.
To practice diaphragmatic breathing, try the following:

  • Put one hand on your chest and the other on your abdominal area. Spread your fingers open, put the little finger near the navel, and put the thumb near the end of the sternum.
  • Pay attention to your breathing. Breathe in slowly through your nose, allowing the breath to flow through the chest (keeping the hand over the chest still) and flow down toward the other hand, filling up the space under that hand.
  • Continue to breathe in and blow up that space below the diaphragm like a big balloon.
  • Now, exhale through the nose or mouth, sucking in the abdominal area to expel as much air as possible.
  • Do not hold your breath, but continue with an inhalation through the nose again. Repeat this process for five to 10 minutes to feel a relaxation response.

Caring for sleepwalkers
Most sleepwalkers are children, but occasionally a teen or adult will sleepwalk if he or she is sick, has a fever, is sleep deprived, or is under stress. Sleepwalkers tend to go back to bed on their own and don’t usually remember sleepwalking. However, sometimes nurses need to prevent injury and help a sleepwalker move around obstacles in their way. Sometimes nurses may need to help them find their way back to their bed, especially if they are in unfamiliar surroundings. Sleepwalkers may startle easily, so it is best to guide them back to bed gently without waking them.

 

Dealing with Difficult Patients: The importance of self-care

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Nursing is known as the caring profession. Nurses are known as caring individuals. Caring and anticipating needs are strengths of those in nursing. They are our best assets, and the assets most recognized by others.

But our greatest assets can also be our worst liabilities. In other words, caring has two sides to it: Caring for others is noble and fulfilling, but caring too much, or using up all of our energy caring without caring for ourselves, can leave us tired and drained.

In order to take care of challenging patients, we need to make time to take care of ourselves. Nurses who do not take care of their own health needs are often the ones most likely to have problems caring for challenging patients. We need to face up to the reality that spending our work life caring for others is a heavy burden, and we must take some time to recharge, and refill our cupboards. We need to address the emotional toll our work takes on us.

Rethinking stress

Stress can be emotional, physical, or spiritual. The first step in handling stress is to make sure that we understand how we cope with stress.

As nurses, we can make the assumption that our personal life and our work life cause us stress. There is really no need to make a list of our stressors—this might cause us more stress. But it’s safe to assume that we have stress. We have all developed methods to handle our stress: Sometimes we develop adaptive ways and other times we use maladaptive methods. Start by listing some coping methods and separating them into those that help and those that hinder you. Then do more of what helps, and systematically eliminate or change those that hinder.

Sometimes the way we look at things causes us increased stress. Here are some ways of thinking that add to stress. Do any of these ring true for you?

Extreme thinking: Sometimes we see things with no middle ground or no gray. It is all black and white, all or nothing, good or bad.

Overgeneralizing/blowing things out of proportion: Everything is a crisis. “No one here knows what he or she is doing.” “I never get a good assignment.”

Mind reading/fortune-telling: You predict the future in a negative way: “This is going to be another rotten day.”

Jumping to conclusions without enough evidence or guessing about what other people are thinking about us: “They don’t know what it is like to work on the floor. This is just one more thing they thought up to make our days difficult.”

Personalizing: Jumping to a conclusion that something is directly connected to you: “Everyone knows I’ve been off work because I can’t cope.”

One way to reduce your stress is to change the way you look at things. Try these alternatives and see how they work for you:

Change extreme thinking into reality thinking. Look for the gray between the black and white.
Stop overgeneralizing and recognize that what is happening now is only what is happening now. Nothing lasts forever. Look for times when good things happen to you, such as when you do get a good assignment.

Stop mind reading. Ask for clarification and details. Check out the facts. What does the policy say? What does the procedure mandate?

Gather your data before making a conclusion. We all know we need to make a comprehensive patient assessment before a diagnosis can be made. Use the same principles when coming to a conclusion (diagnosis) about a situation that has caused you discomfort.

Come to grips with the reality that the world doesn’t revolve around you. Yes, sorry to say, most of the time other people are so concerned about themselves that they don’t even think about how their actions might affect you.

Change stress into relief

In her article “Break the cycle of stress with PBR3,” Becky Graner, MS, RN, IAC, shares a simple tool that aids in stress relief. PBR3 stands for pause, breathe, relax, reflect, rewrite. Let’s see how it works. Adhere to the process in the following table the next time you are in a stressful situation at work, or just before going in to take care of a patient who presents a challenge to you.

Pause: Simply stop thinking. You can continue doing something such as walking down the hall, washing your hands, or another activity that has become automatic for you. Simply stop your thoughts.

Breathe: Stop the chatter in your mind by paying attention to your breathing. Just focus on your breaths and count, say a prayer, or repeat an affirmation to yourself. Don’t try to control your breath. And don’t hold your breath.

Relax: Simply taking a pause and a few breaths, particularly diaphragmatic breathing, takes you out of a reactive state and into a more relaxed state. When you are relaxed, your thinking will clear.

Reflect: Debrief yourself. What was going on that led up to the situation that bothered you? If you felt angry, what was the feeling behind the anger? Was your response out of proportion to the situation? Were you thinking the worst?

Rewrite: Check yourself to find out where you may have been taking things too personally, making assumptions, or doing some of the other automatic thinking processes that cause more stress than not. Rethink or rewrite these into more realistic assumptions. Using humor, empathy, or compassion may soothe you.

Reference
Graner, B. “Break the cycle of stress with PBR3.” American Nurse Today, (2)5:56–57.

 

Dealing with Difficult Patients: High-octane energy

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Mania or an elevated mood is hard to miss. People who are manic have lots to say; have lots of places to go; have a wealth of ideas to share; and just don’t have enough time to explain all of their theories, schemes, and plans. Much like the Energizer Bunny, people with mania keep going and going, often after all of those around them have dropped with exhaustion, or walked away seeking quiet and solitude.

People with mania, especially those who have hypomania (a milder form of elevated mood and elation), love their episodes when they can say “I get so much done,” “I become super creative,” or “I am on the top of my game.” An episode can go something like this:

At first, when I’m high, it’s tremendous . . . ideas are fast . . . like shooting stars you follow until brighter ones appear. All shyness disappears, the right words and gestures are suddenly there . . . uninteresting people and things become intensely interesting. Sensuality is pervasive. The desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria. You can do anything . . .

But then things take a turn:

The fast ideas become too fast and there are far too many of them. Overwhelming confusion replaces clarity . . .  you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened. Everything is now against the grain. You are irritable, angry, frightened, uncontrollable, and trapped (Spearing).

And therein lies the problem: While in manic episodes, people deplete all of their own bodily reserves, and the reserves of others. Those caring for the manic person become exhausted themselves, generally depleting all of their emotional as well as physical energy reserves.

Making sense of manic patients

Don’t panic: When we are faced with dealing with a manic patient who is out of control, it can easily make us feel out of control too. Here are a few things to keep in mind:

  • The patient is being controlled by his or her disease. Control of behaviors and feelings is simply not possible.
  • The patient lacks any insight into his or her behavior. People in manic states do not realize they are sick, and they are unaware of the consequences of their behavior. They reject any idea that any illness is involved, and they find excuses to try to make sense of what is going on around them.
  • The patient with mania becomes frustrated, often with others who cannot keep up with him or her. The patient may lash out and show his or her frustration in inappropriate ways. It often appears that the patient knows exactly how to push your buttons, or knows the exact things about which you are most sensitive.
  • The patient with mania is hyperalert. People in manic states are hypervigilant and are often aware of things going on in the environment that others do not pick up on.

Ways to prevent cycling
When working with manic individuals, you need to help them prevent the exhaustive cycles they live through. Although that is not always possible, you can help them identify and attempt to avoid the triggers that may lead to a mood swing. One of the most important aspects of managing manic episodes is to stick to a routine.

You can also help patients:

  • Set realistic goals. Having unrealistic goals can set up the individual for disappointment and frustration, which can trigger a manic episode. Advise the patient to do the best he or she can to manage his or her symptoms, but expect and be prepared for occasional setbacks.
  • Get help from family and/or friends. Everyone needs help from family and/or friends during a manic episode, especially if he or she has trouble telling the difference between what is real and what is not real. Having a plan in place before any mood changes occur can help the individual’s support network to make good decisions.
  • Make a healthy living schedule. This is important for those with mood swings. Many people with manic episodes find that sticking to a daily schedule can help control their mood. Some examples include regular meal times, routine exercise or other physical activity, and practicing some sort of relaxation each night before bed. Also, you can help to provide a balanced diet for the patient, focusing on the basics: fruits, vegetables, and grains, and less fat and sugar. Exercise uses up some energy and helps a person sleep better. Help the patient develop an exercise plan that fits his or her lifestyle. While in the hospital, taking walks around the unit during the day may benefit the patient.
  • Get enough sleep. Getting a good night’s sleep may be a challenge for a person with mania. Being overtired or getting too much or too little sleep can trigger mania in many people. While the patient is under your care, make up a schedule for rest and relaxation before sleep. Have the patient go to sleep and get up at the same time every day, and relax by listening to soothing music, reading, or taking a bath. Do not allow the patient to watch TV in his or her room.
  • Reduce stress. Anxiety can trigger mania in many people. Ask the patient what helps him or her relax. It might be calming music or a meditation tape. Avoid those things that hype people up, such as watching violent shows on TV or listening to loud music. Helping the person reduce stress in general at home and at work might help prevent episodes. Advise the patient to ask for help: A young mother may ask her spouse, family, or friend to take care of some of the housework. If the person’s job is proving to be too much, he or she can scale back some responsibilities. Doing a good job is important, but avoiding a manic mood episode is more important.
  • Avoid stimulants, alcohol, and drugs. Many people with mania may turn to substances to try to avoid a manic episode, or stimulating substances to elevate their mood. Up to 60% of people with mood disorders also have substance abuse problems. This self-medication may give them some temporary relief, but it will make their condition worse over time. Tell the patient to eliminate the use of caffeine, alcohol, and recreational drugs (Spearing).
  • Stick with treatment. It’s essential for people with mania to continue their medication and get regular checkups. It can be tempting to stop treatment because the symptoms go away. However, it is important to continue treatment as prescribed to avoid taking risks or having unpleasant consequences associated with a manic episode. If the patient has concerns about treatment or the side effects of medicines, talk with him or her and caution the patient not to adjust the medicines on his or her own.

Reference
Spearing, M. (2002). “Bipolar Disorder.” National Institute of Mental Health. Available at www.nimh.nih.gov/publicat/bipolar.cfm.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.

 

Dealing with Difficult Patients: Suicidal behavior

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Many nurses don’t feel comfortable completing a suicide assessment. Some nurses can’t imagine anyone thinking that killing him or herself is the best solution to any problem. However, many of the patients we serve have thought that way and some are actively suicidal, and we are not even aware of it. Being aware of the signs of suicide, and making a suicide assessment, can save your patient’s life. As with many other assessments, practice facilitates mastery. This chapter will give you lots of guidelines and tips to help.

It is important to remember that most suicide attempts are expressions of extreme distress, not harmless bids for attention. Also, any person who has expressed suicidal ideation should not be left alone and needs immediate treatment.

What if I think someone is suicidal?

One way to determine whether a person is thinking about suicide is to ask directly: “Are you thinking about suicide? Are you planning to kill yourself?” Doing this will not plant thoughts in the person’s head. Doing this will not cause the person to consider suicide if he or she was not thinking about it. Doing this will not cause the person to try suicide. By asking directly, you show you are not afraid to tackle the hardest of situations, and it is a way to show the patient that you can be trusted. Suicidal individuals seek out those whom they trust and feel connected to in some way. One of the most important factors in preventing a suicide is the presence of a supportive person.

Don’t panic: If a person does tell you that he or she is suicidal, here’s what you can do:

  • Stay calm and listen.
  • Let the person talk about his or her feelings.
  • Be accepting, and do not judge.
  • Ask whether the person has a plan, and if so, what it is.
  • Don’t swear secrecy.
  • Do not leave the patient alone. Take him or her with you if you must, so you can get help.

Don’t ignore the warning signs

All mentions of suicide must be taken seriously. Warning signs include:

  • Thoughts or talk of death or suicide.
  • Thoughts or talk of self-harm or harm to others.
  • Aggressive behavior or impulsiveness.
  • Previous suicide attempts, which increases the risk for future suicide attempts and completed suicide.

Assessing the possibility of suicidal thoughts

Ask the patient the following questions to assess the possibility of suicidal thoughts:

  • You have been through a lot lately: How has that affected your energy (appetite, ability to sleep)?
  • Many people in your situation may feel sad and blue or depressed: Do you feel that way?
  • Have you ever felt so sad and blue that you thought that maybe life was not worth living?
  • You have been in a lot of pain lately: Have you ever wished you could go to sleep and just not wake up?
  • Have you been thinking a lot about death recently?
  • Have you recently thought about harming yourself or killing yourself?
  • Have things ever reached the point that you’ve thought of harming yourself?

If the person says that he or she has thought about self-harm or suicide, the next step is to assess whether the person has a plan and the ability to carry out the plan. Ask questions such as these:

  • Have you made a specific plan to harm (kill) yourself? If so, what is it?
  • Do you have a gun (knife) available for your use? (Find out if the person has access to accomplish the plan.)
  • What preparations have you made? (This might include purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid being found, and/or practicing the plan.)
  • Have you spoken to anyone about your plans?
  • Would you be able to tell someone if you were about to harm yourself?

Keeping the patient safe

Your next step is to make sure the patient is safe. Most facilities have policies about levels of observation or supervision for patients who are a suicidal risk. There is also a process for further assessment of the patient. Again, never leave a person who has expressed suicidal thoughts alone. Take him or her with you to get help. Always read and follow your facility’s policies.

In general, there are some universal safety measures to take with a person who is suicidal:

  • Keep the person on continuous observation, such as 1:1 or in your line of sight.
  • Restrict the person’s environment for safety. Ask the person to remain in a certain area where staff members can see him or her at all times.
  • Do not allow the person to be alone in a room.
  • Check the person at intervals of five, 15, or 30 minutes.

Staff supervision is necessary when a patient uses items such as sharps (nail cutters, razors, or scissors), cigarettes, and/or matches; is around potential poisons, such as cleaning supplies; uses the bathroom or kitchen; and/or goes off the unit for treatments, therapies, or tests.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.

 

Dealing with Difficult Patients: Behaviors that drive you bananas

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Does a certain group of patients simply drive you bananas? Sometimes you can’t put your finger on it. Something just doesn’t fit for you. Then, someone points it out to you by saying, “Don’t you see how he or she is manipulating you?” Oh, that’s it! He or she is a manipulator and the problem is solved. Or is it? What is manipulation? How does it get in the way? Can it ever be a good thing?

Persuasion, influence, and manipulation: What’s the difference?
Persuasion and influence are often seen as positive traits. We look at people who seem to be able to encourage others to get things done and wish we could be more like them. Indeed, very popular books have been written that teach others how to persuade or influence others. For example, there is a famous book by Dr. Jerome Frank—now updated by his daughter Julia—called Persuasion and Healing. It elucidates the positive influence of therapeutic relationships and other psychological healing  techniques. In addition to this classic for healthcare providers, numerous pop books on the market give lots of hints on how to stop arguments by persuasion, get projects completed by influence and persuasion, and further your career by using your influence and persuasion.

Bothersome behaviors
Rather than using the label “manipulation,” let’s refine the definition and talk about the specific behaviors that drive us bananas. Then, let’s look at ways to handle these behaviors in our work situations.

Whether we see them in patients or our peers, the following are some behaviors that cause distress in the workplace.

First, we have the overt types of behavior that come across as verbal violence. These are often easier to handle because they are so overt. It is hard to miss them. They include:

Making demands: “I must have this weekend off to attend my cousin’s graduation,” or “I can’t go to x-ray until after I have my shower and shave.”

Violating rules and routines: A staff member consistently comes back from break or lunch late. A patient’s family member brings in food from home, even after being told that the patient is presently on a very restricted diet.

Making threats:
“I’ll throw this food tray at you if you come any closer.”

Then, we have the more passive types of behavior that are meant to persuade you to do what the person wants. These might be harder to spot. If you grew up with adults who used these, you may even think they are healthy behaviors. Once pointed out to you, however, they may become more obvious.

Eliciting pity:
The staff member who says, “You just don’t understand how hard it is for me to take care of that patient . . . ,” but says this often about all kinds of patients. Or the person who is abusing drugs: “If you had my horrible upbringing you would take drugs to numb your pain, too. Can’t you see how tough my life has been?”

Ingratiating and flattering:
The person who is always commenting on your clothes, your jewelry, and how good you look. Or the patient who says, “You are the best nurse on this floor. I don’t know what I would do if you took a day off.”

Evoking guilt feelings: When people say, “If you had called me over the weekend like you said you were going to, this would never have happened,” or “If you had made your rounds earlier like you usually do, I wouldn’t be in this mess.”

Abusing compassion: When patients say, “You acted like you were a caring person and said that you would have a hard time on a restricted diet, so why are you making such a fuss over my wife bringing me food from home?”

Attempting to exchange roles: When someone says, “I see that you have a problem with your weight. I am a fitness trainer and can help you with a personal plan to get you in shape. When you get a chance, come back and we’ll start on it.”

Pitting people against each other: When a peer says, “That night shift is something else. I don’t see them making rounds or doing any of the things I know they should be doing at night. You guys and gals on the day shift are top-notch.” Or when a patient says, “Who is that young doctor who came in here yesterday anyway? I bet you know a heck of a lot more about my condition than he does.”

Questioning competence or authority: When a patient says, “Now, honey, you just go take care of your other patients, and send in the charge nurse. I need a real nurse in here to answer my questions.”
Being overly dependent: People who allow others to do for them, do not accept self-responsibility, and then skirt responsibility if things go wrong. They say things such as “I am sure you know best. Just take care of that for me. I rely on all you nurses to make sure I get better.”

Using avoidance: People who change the subject when it comes up, avoid being around people they dislike, or are silent rather than open with their opinions. When they do speak, it is in order to avoid: “I can’t be on the same team as Susan. We don’t work well together.”

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.

Dealing with difficult patients: defense mechanisms

By Joan Monchak Lorenz, MSN, RN, PMHCNS-BC

Using Freudian concepts to understand human behavior, one could say that the ego often has a hard time pleasing the id and keeping the superego in check. So, it has developed a way to reduce anxiety through the use of ego defense mechanisms, those things that unconsciously block or distort our thoughts and beliefs into more acceptable, less-threatening ones.

Defense mechanisms (sometimes called coping or protective mechanisms) are, in short, used to protect the ego from full awareness of the situation. Their purpose is to help the person cope with a situation that he or she might not be able to handle.

Using defense mechanisms is a common human trait. We all use them. Some defense mechanisms are considered to be more helpful than others. Others may cause more problems for the person using them, in terms of creating unhealthy or unfulfilled relationships or losing touch with reality.

Most nurses are very familiar with defense mechanisms, having learned them early in their nursing school careers. Let’s review a few of the most common ego defense mechanisms and see how they apply to patient situations.

  • Denial: Protecting self from reality. Example: Thinking the high cholesterol level was a lab error.
  • Repression: Preventing painful memories/thoughts from entering consciousness. Example: Forgetting what he or she was told about a chronic illness.
  • Rationalization: Justifying inappropriate behavior. Example: “I don’t come to every appointment late, traffic was just bad this time.”
  • Projection: Pointing the finger at others instead of ourselves. Example: “It’s your fault I didn’t take my medicine.”
  • Displacement: Taking things out on others. Example: Yelling at a nurse after being given a bad diagnosis.

Rational problem-solving is not a defense mechanism. Oftentimes, rational problem-solving is enough to resolve an issue. Then, the use of defense mechanisms is not needed.

Tip: A well-rounded person, a mature individual, usually has little need to use ineffective or maladaptive ego defense mechanisms. However, when people are sick, have just been given bad news, have a loved one injured, or are uncomfortable for whatever reason, even the most well-adjusted resort to the use of defense mechanisms to help them get through.

Find some common ground

How do you relate to a person who is using a defense mechanism?

  • Recognize that the use of defense mechanisms is to protect the mind from total awareness of the gravity of the situation.
  • Avoid hurrying someone along, as this only creates more frustration and confusion. Sometimes the person is able to develop awareness little by little.
  • Provide a safe environment for the patient so that he or she might feel more comfortable doing the emotional work that is needed given the situation.
  • Be aware of how you are reacting and try to maintain a professional stance. Don’t get hooked into the patient’s mini-drama.
  • Provide information that might help clarify the situation.
  • Stop giving information when you see that it frustrates or overwhelms the patient.
  • Maintain a quiet voice and comforting physical appearance.
  • Give the person some emotional space as well as the physical space needed to soothe him or her.
  • Provide for the patient’s basic needs.
  • Say things like “I am available if you want to talk about this more later.”
  • Work around the use of the defense mechanism if possible.
  • Avoid the tendency to take the use of defense mechanisms by others personally.
  • Be patient and wait to see whether the person is able to address the issue in a more mature fashion later.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.