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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: 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.

 

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.

 

The dangers of compassion fatigue

Nurses are the frontline of patient care, making them the most susceptible to compassion fatigue, a state of mental exhaustion caused by caring for patients and their family through times of distress. It’s important that nurse managers are aware of the risks, identify the signs in their staff, and provide guidance to nurses that need it. While the increase in stress and unhappiness caused by compassion fatigue are evident, some of the other consequences are less obvious:

Increased medical risk: Compassion fatigue can lead to an increase in medical errors due to a lack of communication or inability to react. Nurses suffering fatigue can become unsympathetic, self-centered, and preoccupied, to the detriment of a patient’s care. To read more about this connection and how to counter it, check out Reduce Nurse Stress and Reduce Medical Error from HealthLeaders Media.

Decreased retention: The increased stress and potential trauma associated with compassion fatigue can drive new nurses away from the field. The American Association of Colleges of Nurse reports that 13% of newly licensed RNs work in a different career within a year of receiving their license, and 37% said they were ready to change careers. Many reported that the significant, ongoing emotional stress was a factor in their dissatisfaction.

For more information on combating nurse fatigue, check out the Health and Wellness section of the Strategies for Nurse Managers Reading Room:

Don’t underestimate damage caused by burned out nurses

Preventing nurse fatigue
Beat nursing stress and stay calm and collected

What providers can do this National Suicide Prevention Week

National Suicide Prevention Week is September 10-16, bringing awareness to the 10th leading cause of death in the United States. This week is a time for physicians, nurses, and other providers to learn more about how their healthcare organizations can help suicidal patients.

In 2013, 9.3 million adults had suicidal thoughts, 1.3 million attempted suicide, and 41,149 died. Even more worrying is that the rate of suicides has increased 24% between 1999 and 2014. And as of March 2017, Joint Commission surveyors have been putting special focus on suicide, self-harm, and ligature observations in psychiatric units and hospitals. Surveyors are documenting all observations of self-harm risks, and evaluating whether the facility has:

  • Identified these risks before
    •    Has plans to deal with these risks
    •    Conducted an effective environmental risk assessment process

To learn more about suicide prevention in healthcare, check out the following websites and articles.

Resources

Study: Nurse fatigue on the rise

A new survey indicates that fatigue affects 85 percent of nurses, and more than half of nurses have experienced burnout.

The study, conducted by Kronos Incorporated, surveyed 257 nurses currently working in U.S. hospitals. Nearly all of the respondents (98%) said their work is physically and mentally demanding, and 63 percent reported that their work caused nurse burnout. 44 percent worried that their patient care would suffer because of their exhaustion, and 41 percent considered changing hospitals in the past year because of their burnout.

Nurse fatigue has a number of causes, and can occur during any shift. An excess of fatigue without proper coping mechanism can cause burnout, an exhaustion that can cause your staff feel alienated from their work and cause diminished performance.

The best way to counter burnout in your staff is to create programs that encourage self-care and raise awareness about the symptoms of nurse fatigue. For more tips about coping with burnout, check out the following articles from the Strategies for Nurse Managers’ Reading Room:

Preventing nurse fatigue
Take Five: How renewal rooms revive stressed out nurses
Don’t underestimate damage caused by burned out nurses
Stop requiring nurses to work overtime

Educating staff about compassion fatigue

While many nurses know about compassion fatigue, they might not know exactly what it is, why it happens, or how to identify it in themselves. In a recent blog post, Jennifer Lelwica Buttaccio tackled some of the most common myths associated with compassion fatigue.

Not me!
One of the most common misconceptions about compassion fatigue is that your compassion is a limited resource, and if you can still feel compassion for a patient, it must not pertain to you. More likely, you will experience symptoms in other aspects of your life, such as physical or mental exhaustion, dreading going to work, worrying and dwelling on possible errors, or becoming easily frustrated with coworkers. So even if you feel empathetic while you’re with a patient, you could still be suffering from compassion fatigue.

Work harder! Nurses tend to throw themselves into their job head-first, but that approach can be detrimental when dealing with compassion fatigue; your instinct to work harder to overcome challenges at work will not help you here. It’s important to maintain a work-life balance, and compassion fatigue is often caused by overwork and neglecting yourself.

Patients first! Nurses take great pride in the care they give to their patients, but it should not come at the cost of caring for yourself. The best way to provide consistent and outstanding patient care is to take care of yourself first, by taking time for yourself, away from alarms, patients, and colleagues. Make sure that both you and your staff take their breaks and use their time off.

Check out the articles below for more information about compassion fatigue and solutions to your health and wellness problems.
Preventing nurse fatigue
Take Five: How renewal rooms revive stressed out nurses
Worker Wellness: Fatigue and Burnout

Free Excerpt from HCPro’s new Critical Thinking book!

Avoiding Autopilot

CTB Cover

Rarely are we genuinely thoughtless—that is, without thought. But often we are not giving our thoughts much consideration. In today’s world, there is much distraction and sometimes we are guilty of distracting ourselves just to prevent our minds from focusing on the things that are most important (electronic devices proliferate and give us many opportunities to engage in mindlessness). So, to be genuinely able to think about thinking, we must avoid going onto autopilot.

Autopilot is the state of being where we are largely going through the motions, not thoughtfully engaged in the activities of life. It is when we arrive at our destination but cannot remember the traffic on our commute, or taking the last turn or even whether we stopped for the traffic signal or not—it happens to all of us, and that is autopilot. The key is in recognizing when it is happening and being willing and able to intercept your unconscious mind and instead coax it to be present in the real-life situation you’re living. It is learning to move our conscious mind from nowhere to now here—a subtle but essential difference!

Being present in the moment is the essence of mindfulness, and it is powerful! Mindfulness wakes us up to sensations we have been failing to notice. It reveals patterns in our activities that we’ve become blind to. It permits us the full engagement in the reality happening in front of us and even within us, silently, steadfastly, sacredly. Mindfulness may enable us to improve our health, connect more successfully to other people, enlarge our thinking, focus our perception, and even strengthen our intuition. Mindfulness is the polar opposite of autopilot!

To read more, visit the HCPro Marketplace

 

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.

For more articles about avoiding burnout and developing your career, check out the Health & Wellness section of the Strategies for Nurse Managers Reading Room!