RSSArchive for January, 2018

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.