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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.

 

Dealing with difficult patients: Basics of behavior

The following is an excerpt from Stressed Out About Difficult Patients

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

Let’s face it, most people go about their day doing one thing: trying to get their needs met. They try to meet their physical needs by providing themselves with shelter, food, and clothing; their emotional needs by searching out feelings of love and emotional comfort; and their spiritual needs by participating in activities that promote greater understanding of why things happen and determining the purpose of their lives. Theories of human behavior and growth and development have attempted to answer the question of why we do what we do, and how we go about our day getting our needs met. Let’s quickly review some of the classic theories as a way to explain behavior.


We are unaware (of most) of what we do

Sigmund Freud’s concept of the conscious, preconscious, and unconscious mind, and how it resembles an iceberg, offers one example of how the mind works and influences behavior. The visible part of the iceberg is the conscious mind, what we are aware of at any particular moment: our present perceptions, memories, thoughts, fantasies, and feelings. Working closely with the conscious mind, and just below the surface, is the preconscious mind. It contains those things that are not in our awareness all of the time, but that can be brought into our awareness easily. The largest part of the iceberg and the part that is below the surface is the unconscious mind which contains all the things we are not aware of, including many things that Freud believed we can’t bear to see, such as the memories and emotions associated with trauma. According to Freud, it is the unconscious part of us that drives our behavior (Freud, Boeree).

 

Reward me!

B.F. Skinner believed that a person’s behavior was a result of past consequences of his or her behavior. Very simply, Skinner believed that people continue to do things for which they are rewarded, and stop doing things for which they are not rewarded.

Skinner also believed that individuals do things to avoid pain or punishment, which means that if a person is punished for a certain behavior, he or she will act in ways to avoid the punishment. An example is a nurse who learns not to be assertive with a certain supervisor because that supervisor responds negatively to assertive behavior. Instead, the nurse uses other ways to get his or her needs met. Sometimes these behaviors are adaptive, such as learning how to address concerns in an indirect way to the supervisor; or maladaptive, such as agreeing to something the supervisor requests, and then not doing it.

Skinner’s theory basically boils down to praising or rewarding behaviors you want to see again, and ignoring or punishing behaviors you do not want to see again. Sound familiar? These are fairly basic concepts reviewed in many different situations from child rearing, patient teaching, and self-care management.

 

Addressing our needs in order

Abraham Maslow placed an individual’s needs in a hierarchy, believing that certain needs must be met before others. According to Maslow, needs at the base of the triangle must be satisfied before moving upward, with each step in the triangle needing to be met in succession. For example, a person cannot reach self-actualization, or becoming everything that he or she is capable of becoming, before getting all of his or her other needs met. Nurses know that you cannot teach a person a new procedure for self-care if the person is hungry, or sleepy, or in pain. Basic needs are taken care of before other, higher-level needs are attempted to be met.

 

Putting these theories to use

Using these theories in combination, nurses can come to understand human behaviors. By combining the concepts presented in these theories, we can outline fairly accurately why people do what they do:

  • We do what we do to get our needs met
  • Our behavior is directed toward providing for our physical well-being, regaining emotional equilibrium, and answering questions of purpose
  • Some, or most, of what we do is usually outside of our awareness
  • We often respond to situations using behaviors that have worked for us in the past, and these learned behaviors may have become automatic responses for us; we use them even without thinking
  • Some of what we deal with on a daily basis may have more to do with past experiences than with the present moment
  • Taking care of basic needs is imperative, and focusing on higher-level needs occurs only after our most basic needs are met
  • Life is a series of growth opportunities, the outcome of which leads to maturity and moving on

Theoretical understanding is a way of trying to comprehend something. Not being right or wrong—or good or bad—the concepts of the theory can be used by nurses to understand behavior and develop strategies to handle it in helpful and fulfilling ways. By recalling the basic concepts of human behavior, and observing it through the lenses of these concepts, you look at human behavior objectively and do not take what patients do as anything directed to you personally.

Throwback Thursday: Your 10 Step Guide to a Rockin’ New Year

By Carol Ebert, RN, BSN, MA, CHES, CWP

The word TRANSITION means the passage from one form, state, style, or place to another – CHANGE!  Some of you are cringing thinking about change, but others are thinking – BRING IT ON!  How many transitions are you experiencing right now?  From holiday over-eating to New Year reckonings about weight?  From worrying about money to wondering what else you could do to increase your income?  From working in a job that is not a fit for you to wondering what else you could be doing? From leaving the workforce to enter the world of retirement and not knowing how to adjust? Transitions are everywhere at any time and can be perceived as negative or positive.  I prefer the latter and have some thoughts to consider.

T – Trust your instincts.  Rather than be caught off guard when things change, take the high road and note what your gut is telling you about what it going on. Keep in mind the change you are experiencing might be just what you have been secretly wanting!

R – Reset your eating and exercise program.  Have you been stuck and know you want to get healthier but not sure how to make the first move? I’m sure you have dealt with this before, so reflect on what helped you be successful in the past and recreate those steps.

A – Adjust your thinking from I CAN’T to I CAN.  See yourself healthy, happy and whole.  Send time every day imagining yourself being your best and being grateful for all that you are and have.  Hang up pictures to visually represent what your goals look like so you can start living in that body even before you get there.

N – Notice what you need right now. Go outside right now for a walk.  Yes – right now!  By yourself!  Take a notepad and pen along because great ideas are sure to surface while you are walking and you may want to write them down before you lose them.  Focus as you walk on what you really need right now to move forward thru this transition. This will be your starting point.

S – Set goals in alignment with your values to create the life you love.  Have you ever taken the time to really ask yourself what you want? Yes, you know what your mother wants for you, what your kids want, what your partner wants, and what you “should” want.  But what do you really want?  Write down 3 dreams you have for a more complete life and post it where you can ponder it.

I – Integrate all your skills into a single focus.  By now you have probably acquired a lot of great life and work skills that make you the fantastic talented person you are.  During this transition, you might find that it is time to put them all to good use and see what emerges.  Write down a list of everything you are great at – write until you can’t think of anything else – at least 30 things.

T – Train yourself for new skills.  After I had acquired all the skills I thought I needed in life, I opened up myself to what might be next for me – the key – being open to possibilities.  What showed up for me was “wellness coaching”, or some people call it “life coaching”.  When I was searching for “what’s next for me”, a friend coached me and after just 2 sessions, I had a new direction, a plan, and I was on my way again.  I loved the experience so much, I was trained to be a coach as well as a coach trainer.

I – Invite new opportunities.  When I was transitioning out of the workforce and into my own independent wellness business, I needed to figure out how to earn money while still doing the work I am passionate about.  Because I remained open to new ideas, I was presented with a way to help people get healthy as well as make passive income that could grow over time.  The key was to stay open to new ideas and give them a chance to see if they could work for you.

O – Own up to what is best for you. Not sure what direction to take as you transition?  Your guide should be how you “feel” about what you decide to do.  As they say, if it feels right – do it?

N – Now is the time to reinvent yourself.  I wrote a whole chapter on this in the book Wise Women Speak – Choosing Stepping Stones Along the Path.  My gift to you is a free download of this chapter by logging on to my website http://carolebert.com/meet-carol/free-ebook/

Enjoy the process of your transition.  Remember, it’s about the journey not the destination.  Fun times ahead!  Contact me at any time for support – carol@carolebert.com.

Tips for recommitting to nursing in the new year

The new year is often a time for retrospection and reflection, especially when it comes to your career. If you’re starting to feel burnt out on nursing but not quite ready for a career change, here is some advice to freshen things up in the new year.

  • Reflect on your past: Sometimes the best way to go forward is to look back. What drew you to nursing in the first place? Why was a career in nursing right for you? Think about the positive experiences you’ve had as a nurse that reaffirmed your career goals. Treat your next shift like it’s your first day; what excites you? What makes you nervous? Sometimes asking these questions can reinvigorate how you approach your work.
  • Connect (and disconnect): If you’re feeling down about your job, sometimes the best solution is to ask for help. Reach out to your peers and develop a support system to help yourself and others. If you think there’s something that could make you happier at work, talk to your managers about it; sometimes a small change can have a profound effect. It’s also important to let go sometimes. Being a caregiver, interacting with patients at some of the worst times in their lives can negatively impact your outlook and make your job even more difficult. Try to focus on the good you’ve done for patients and don’t take it personally when a patient struggles or suffers.
  • Commit to the new: Even though it doesn’t always feel like it, taking on new challenges can be a great way to energize your career. Seek out new experiences and opportunities; take the frustrations of the day and channel it toward learning a new skill or pursuing additional training options. Reflecting on your weaknesses can be difficult at first, but identifying them and working towards improvement can be satisfying and build you confidence. Another great way to embrace the new is working with nursing students or new nurses. They bring energy and enthusiasm to the job, and becoming a preceptor or informal mentor can be a great way to grow your own enthusiasm while furthering your career.

 

Q & A: Ending Nurse-to-Nurse Hostility

Editor’s Note: Strategies for Nurse Managers recently sat down with Kathleen Bartholomew, RN, MSN, author of Ending-Nurse-to-Nurse Hostility, Second Edition to discuss strategies to end hostility in the workplace. The following is an edited version of our conversation.

Strategies For Nurse Manangers: What inspired you to write Ending Nurse-to-Nurse Hostility?

Kathleen Bartholomew:
I wrote “Ending Nurse-to-Nurse Hostility” because of my deep love and respect for Nursing. The intimate and poignant moments that nurses share with their patients as well as their high level critical thinking skills have always blown me away. Yet I also witnessed occasions when nurses took each other down – mostly in subtle ways. I wanted to understand why. I wanted to discover and illuminate these unconscious learned behaviors so that we could all lift each other up and show the world the best of humanity.

SFNM: What is nurse-to-nurse hostility?

KB: A formal definition is: “…any behavior that interferes with effective communication among healthcare providers and negatively effects performance and outcomes.” (The Center for American Nurses)
An informal definition would be: Any interaction or behavior that leaves you feeling ‘less than’ the capable, skilled, caring person that you really are – like eye-rolling. Some people unconsciously try to make someone feel smaller so they can feel bigger (remember middle school?).  Some other examples would be: raised eyebrows, making faces behind someone’s back, withholding information, bickering, fault-finding, back-stabbing, intimidation, put downs, ignoring someone’s greeting, blaming or an unfair assignment. These are all unconscious behaviors.  No one thinks to (themselves, “I’m going to roll my eyes at her right now”. The insidious nature of these hostile behaviors is what makes them so dangerous because we don’t even realize that we are taking each other down.

SFNM: How does it differ from regular bullying? 

KB:
In the United States, bullying is a term used to describe someone a power level above you like a manager or physician who uses overt and covert behaviors to ‘put you in your place’. “Horizontal” hostility refers to the way your peers try to take away or under-mine each other’s power. It is more common in a unit where the manager has an authoritarian or laisse-fare style of leadership and where nurses do not have the resources or staffing to do their job.

SFNM: What are some examples of hostility in the workplace that are often overlooked?

KB:
Many nurses don’t recognize that talking about someone when they are not present is a form of hostility. Gossip erases trust as the underlying message to our psyche is “If they are talking about people who are not here, then they are probably talking about me when I am not here. “
Other covert forms of hostility are withholding information (let’s see how good she/he is), refusing to work with other people, and cliques. If you have cliques in your department, then you are not a team – and high reliability standards have consistently proven that only collegial teams can keep patients safe. People join cliques for two reasons: to elevate their own self-esteem, and/or to stay safe. So become inclusive by letting everyone belong, look for the good in each other, and compliment freely.

SFNM: What can a manager do to prevent bullying and horizontal hostility in their department?

KB: These three strategies and tactics set the foundation for trust and therefore civility:

  1. Say what you see.  If you see someone rolling their eyes, stop and say, “I noticed that you rolled your eyes…”   These covert behaviors lose their power when we call them out into the open.
  2. Dismantle the hierarchy. We may have different roles, levels of education and paychecks, but each and every single person is a critical member of the team.  The fastest way to even the power play is to ask for feedback by individually asking his/her staff: What do you like that I do well? And what would you like to see more of?

    Another way to equal the playing field (which is critical to Millennials especially) is to job shadow. This sends a strong message that you care about their world when you ‘walk in their shoes.”  And if you walk onto the unit and everything is chaotic, ask the charge nurse what you can do and then do just that.

  3. Nothing About Me, Without Me. Gossip undermines trust. If someone comes into your office to complain about someone else, ask them to go get that person and explain that you would do the same for them. This is the most fundamental leadership behavior because it sets up the conditions for trust. Furthermore, it emphasizes that we are adults who should be able to bring our concerns or observations to each other. The AACN standards say that we must be as competent in our communication skills as we are in our clinical skills – but we are not. Encourage, roll play and coach staff to speak with each other about the important stuff.

SFNM: Do you have any suggestions for a manager that suspects their staff is experiencing hostility?

KB:
Yes! I can’t tell you how many managers ask their staff is a problem and the group says “no”. Group think doesn’t allow it. The best way to evaluate the presence of hostility is to send out a simple Survey Monkey (there are two short surveys in “Ending Nurse-to-Nurse Hostility”). After you have compiled the results, share them at a staff meeting. As managers, we need to hold up a virtual mirror so that staff can see how their behaviors affect each other and patient care.

The second step would be awareness training. There are three free educational videos, each only ten minutes long on my website complete which end with a question for the group. Show one each month at a staff meeting; or include in your annual education and new hire curriculum.

SFNM: What advice would you give someone who was experiencing horizontal hostility in the workplace?

KB: Every month someone emails me with a story expressing the shear pain of being rejected from the group. Their letters are heart breaking. It is difficult to understand how in a profession based on caring, how nurses could be so downright mean.

My advice is to know without a doubt that it’s not about you. Horizontal hostility is a symptom of an unhealthy group. If you quit, they will just do the same thing to the next person. If you are different in any way, you become a vulnerable target. When humans work closely together under stressful conditions, have low self-esteem, have a bully for a manager, or a manager that doesn’t care what they do, or plays favorites, you can be certain that staff will be hostile.

About Kathleen Bartholomew
Kathleen Bartholomew, RN, MSN is the author of HCPro titles: Ending Nurse-to-Nurse Hostility, second edition, Speak Your Truth: Proven Strategies for Effective Nurse-to-Physician Communications, along with the Team Building Handbook: Improving Nurse-to-Nurse Relationships. Additionally, Bartholomew has recently published “The Dauntless Nurse: Communication Confidence Builder” with co-authors Martha Griffn and Arna Robins along with the Dauntless Communication Tool app on iTunes.