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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: 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.

 

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

How evidence-based practice can improve nurse satisfaction

If a nurse is unsatisfied with their career or feeling burnt out on nursing, taking an evidence-based approach can help them rediscover their passion for nursing. Robert Hess Jr., PhD, RN, FAAN and co-author of HCPro’s Shared Governance book, recently wrote a piece about EBP and nursing careers; here are some ways to apply EBP in your career:

  • Update your practices. Nursing is changing all of the time! If you feel like you’re stuck doing the same thing every day for years, you’re probably not using the most up-to-date practices. Nurse scientists and researchers are studying and updating practices for nurse specialties all of the time, and these changes can benefit patients and nurses alike. Try joining your specialty group’s professional organizations, attend professional events, and subscribe to specialty journals to keep abreast of the latest practices in nursing. Changing up your routine and increasing your engagement can bring the excitement back to your career!
  • Use EBP in your career. Evidence-based research is not just conducted on healthcare practices. There is organizational research that provides indicators for when nurses should consider a career change, such as switching roles, going back to school, or even leaving their current job. Burnout has been measured for decades, and evaluating your own signs of job fatigue can be instructive for potential career decisions. Nursing has a plethora of opportunities outside of the hospital bedroom, and feeling burnout could be your signal to explore them.
  • Evaluate your environment. Research has found the workplace satisfaction can correlate with career satisfaction. Observe your colleagues; do they seem happy? Do they participate in work group activities, both at work and outside of work? Having coworkers that are satisfied with their jobs has a positive impact on your own satisfaction, and if you’re feeling career fatigue, sometimes your coworkers can fuel your enthusiasm.

For more tips about career satisfaction and burnout, check out these articles from the Strategies for Nurse Managers’ Reading Room:

Delegation prevents nurse manager burnout

RN satisfaction survey promotes positive change


How nurse executives can help tired nurses

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!

Hospitals trying out Pokemon Go in a clinical setting

Check out this article from Health Leaders Media:

A trial at the University of Washington Medicine Burn Center aims to find out if the game is more stimulating and engaging than the pain patients are experiencing.

Hospitals and health systems have been grappling with how to deal with Pokémon Go since the mobile gaming phenomenon hit earlier this summer.

Massachusetts General Hospital banned staff from playing the game on its campus, warning of possible privacy violations, and Allegheny Health Network asked the game’s maker to remove all of its locations from the app.

But some hospitals are finding that there are upside to patients using Pokémon Go.

Getting Patients Out of Bed

C.S. Mott Children’s Hospital in Ann Arbor, MI, has been urging its young patients to play the game in an effort to get them out of bed and socialize with other kids.

“It’s a fun way to encourage patients to be mobile,” J.J Bouchard, the hospital’s digital media manager and certified child life specialist, told USA Today. “This app is getting patients out of beds and moving around.”

A trial that University of Washington Medicine Burn Center researchers are conducting at Harborview Medical Center in Seattle, WA, is looking at how playing Pokémon Go may help keep patients moving while also taking their minds off the pain.

“Our challenge is to find something that’s more stimulating and engaging than pain they’re experiencing, so something like virtual reality that’s new or Pokémon Go that’s new, it’s more exciting and takes attention away from the pain,” Shelley Wiechman, attending psychologist in the Burn and Pediatric Trauma Service and Pediatric Primary Care Clinic at Harborview, told the local media.

The Pokémon Go trial isn’t the first time the hospital has tested augmented and virtual reality games for pain management, but it’s the first that allows patients to use their legs and keep their infected areas mobile.

Weichman said if patients using the game continue to show progress, the staff may begin using Fitbits to track patients’ steps.

So what do you think? Can mobile games help patients in your hospitals? Let us know what you think in the comments below!

Rock Your Health: Why Am I So Sleepy?

Just back from a relaxing weekend and about ready to put your head down on the desk and take a nap? Even this morning in Jazzercise, the person next to me said she was exhausted when she thought she would return all rested and energized. Right now I feel very tired myself, so I’m going to take a closer look at why I am so sleepy. I’ve found three good reasons, so read on and find out what they are.

Blood Sugar Effects

I remember eating a lot of hot dogs with white buns, chips, ice cream – all high glycemic carbs that enter your bloodstream fast and then crash your blood sugar just as fast. (Thank goodness I don’t eat like that all the time!) That leads to a groggy crashing feeling and if you eat like that all weekend, you can bet you will feel pretty sleepy. Did you eat like this over the weekend?

Hormone Effects

Once again, those high glycemic carbs are the culprit. They activate your brain to produce serotonin, a chemical that allows for calm and pleasant moods, while making tryptophan, the chemical responsible for sleepiness, more available to your brain. This is another reason high carb meals make you sleepy, says the National Sleep Foundation. So now you get a double whammy from eating all that junk food!

Overeating Effects

Overeating is one of the most common causes of sleepiness. After eating, your body routes more blood to your digestive system. Meals excessive in size require even more blood, which causes temporary deprivation of blood and nutrients in your brain and residual grogginess.

So that’s what caused me to be sleepy all the time! What about you?

Need some support around this issue? Email me and we can talk.

Rock Your Health: Lesson Learned When I Decluttered One Shelf

It’s time to lighten your load and start living clutter free!

  • You can avoid the clutter and stress out all you want, but nothing will change until you take action.
  • You can make a commitment to another person, so you will have to keep your word.
  • You can declutter efficiently and in less time by using the timer on your cell phone to keep you moving.
  • You can add energetic music to the process so if feels like fun; if you can trick yourself into feeling like you are having fun, you’ll feel like the best organizer in the world!
  • The best thing for me is admiring my work and wanting to keep that shelf looking this way every day. And now on to the next challenge – my desk!

 

What have you learned when you cleaned your office? Want some support with this issue? I’m an expert on clutter and can coach you thru this process. Email me and let’s talk!

Rock Your Health: If it’s not one thing, it’s another! The Art of Accepting the Inevitable

What does it mean to accept the inevitable? I’ve been pondering this lately as I’m getting older, but things are changing that I have no control over. For example, I can’t jump around in Jazzercise like I used to: I have to step in place because my knees will bother me if I don’t. I find that I need a little rest time in my day so that I can keep going on into the evening with activities. I find that I’m more assertive than I used to be – yes, I’m a bit mouthy – and don’t really care about the consequences.

Things are changing, and I’m encountering some of the same issues my mother experienced. I find that I have a better understanding my mother’s aging process as I get older.

The bottom line is it’s my job to accept my age changes rather than complain and resist. It’s just the way it is.

Now I know this isn’t easy, and for sure it hasn’t been for me (or my mother). I remember when I used to run for fitness, but after several years it was causing me a lot of back pain. So I had to stop running and just do walking. And of course that made me depressed, because I thought I’ll never be as healthy as I want to be from just walking. But eventually I realized that walking is a great fitness activity for me now!

But acceptance of a change might not come right away. But if you give it some time and appreciate the fact that this may be a new normal for you, then you can finally make peace with it and accept it.

What are you going through right now that is challenging you?

Here are my tips to help you with acceptance of anything that might be changing for you that you are starting to resist.

A – Allow the change to come into being instead of fighting it.

C – Communicate your feelings with family or friends so you don’t bottle things up.

C – Create new opportunities that will achieve the same benefit you’ve been looking for differently.

E – Eliminate negative feelings that arise and focus on how can you shift and move forward with your life.

P – Pretend everything is as it should be, and relax into these changes to allow your body and mind to relax as well.

T – Train yourself to keep moving forward instead of yielding to depression, regret, and anger.

A – Allow time to accept the changes and let your mind go through the stages of grief and loss.

N – Notice when you have shifted into accepting your new reality and celebrate your progress.

C – Collaborate with others going through a similar situation and get ideas on how they’re dealing with it.

E – Enjoy the process of change as another wonderful thing about being alive!

And finally, I love this reminder from one of my support groups – “When I got busy, I got better.”

So I got busy writing this blog and now I feel better!

If you need some support around acceptance, contact me for a quick laser coaching session to give you a boost.