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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.

Why Do Healthcare Workers Report to Work When Sick?

By John Palmer
This article originally appeared in PSQH.

It’s no secret that that healthcare can be a dirty profession. So why is it that despite the warnings about the dangers of not wearing appropriate protection around hazardous drugs and infectious diseases, workers still choose to put themselves in danger?

It’s an interesting conundrum, and wearing the proper Personal Protective Equipment (PPE) is just as much for the protection of the patient as it is for the worker. In fact, a report published in the November 2017 issue of the American Journal of Infection Control found that as many as 4 out of 10 healthcare professionals show up at work even when they are sick with flu-like illnesses.

The study makes the assertion that illness transmission by healthcare employees represents a grave public health hazard.

Lead researcher Dr. Sophia Chiu called the findings “alarming” and cited an earlier study that showed patients exposed to a medical worker who is sick are five times more likely to get a healthcare-associated infection. “We recommend all healthcare facilities take steps to support and encourage their staff to not work while they are sick,” she added.

The survey of nearly 2,000 health workers during the 2014-2015 flu season interviewed doctors, nurses, nurse practitioners, physician assistants, aides, and others who self-reported flu-like symptoms at work such as fever and cough or sore throat.

“Healthcare personnel (HCP) working while experiencing influenza-like illness (ILI) contribute to influenza transmission in healthcare settings,” the report’s authors wrote. “Influenza infections are associated with thousands of deaths in the United States each year. Transmission in healthcare settings, where there is a higher concentration of elderly persons and individuals with immunosuppression or severe chronic disease, is a major concern.”

According to the report’s findings, of the people surveyed 414 (21.6%) of the workers reported flu-like symptoms, and 183 (41.4%) reported working with the symptoms for at least three days at a time. Pharmacists (67.2%) and physicians (63.2%) had the highest frequency of working with symptoms suspected to be the flu.

By work setting, hospital-based workers had the highest frequency of working with flu symptoms—more than 49%. The most common reasons given for working while sick included still being able to perform job duties and not feeling bad enough to miss work. Among workers at long-term care facilities, the most common reason was inability to afford lost pay.

Suggested solutions

So, what does this mean? Well, perhaps most revealing about the study is the prevalence of healthcare workers who think it’s acceptable to show up for work when they aren’t feeling well.

“Training to change social and cultural norms of HCP, such as the expectation to work unless experiencing severe symptoms among clinicians, might address these misconceptions,” the authors wrote. “Different strategies for modifying norms might be needed for different healthcare occupations. For example, physicians develop their sense of professional identity and adopt professional norms and values over a long period of training, which may differ from the experience of nonclinical HCP.”

In addition, the authors of the study came up with several suggestions that healthcare facilities can use to try to fight the problem of workers coming to work sick.

Make workplace policies clear. After listening to the reasons workers gave about why they came to work sick, including the ubiquitous “I could still perform my job duties,” and “I wasn’t feeling bad enough to miss work,” it became clear that individuals may not be the best ones to make the decision about whether they should work. For that reason, the authors stressed that there should be a clear policy and culture that stresses the importance of infection control in the healthcare workplace.

“Employers can convey that the perspective of infection control at the institutional level is important for HCP to consider when deciding whether to work during (an illness),” according to the report. “For example, one academic medical center instituted a triage system requiring HCP with fever or upper respiratory symptoms to undergo evaluation and viral testing. This system provided symptomatic HCP with more information regarding their risk to others. This institution also instituted mandatory absence from work for at least 7 days if testing was positive for influenza.”

Make it easier to take sick time. Many healthcare workers interviewed in the survey said did not take time off from work when they were sick because they were could not afford to lose pay for time off. This may mean that you need to consider a change in policy for sick time. The reports authors suggested institution-level resources to accommodate sick leave, including a “jeopardy system” in which some workers are held in reserve to back up sick colleagues.

This “may help reduce common perceived barriers to taking sick leave when the risk of transmission to others is taken into account,” the report said. “Such barriers include difficulty in finding coverage and desire to not burden colleagues.”

Make the flu shot mandatory, but remember that it isn’t a guarantee. Many facilities encourage their workers to get the flu shot every year, and in fact some make it mandatory. The report’s authors claimed that the fact that a worker received the flu vaccination at any time during the 2014-2015 influenza season may have contributed to the decision to come to work, even with symptoms. In other words, their perception is that there is no way they could have the flu if they’ve gotten the shot, which of course is not the case. Workers should be educated about the flu vaccine, and again, should be encouraged not to come to work if they feel sick.

In many places, it’s still not legal to require flu shots for employees, and if unions get involved it’s a much more complicated issue. Many people still have religious requirements, or moral protests against required flu shots. But the truth is that the flu shot has been proven to be safe and extremely effective.

Therefore, employees who work with patients should be encouraged to get a flu shot each year. In most cases, the flu vaccinations are free, and they really will make things healthier in your facility. Statistics show that those who get the shot stay healthier with very little risk of side effects. That translates to healthier workers who can come to work and not get patients sick. At the very least, there must be a very strict policy in place preventing patient contact when workers are sick, and in all cases, they must wear face masks when working anywhere around patients with compromised immune systems.

During the winter months, you should encourage workers to stay healthy. Your staff cannot help patients when they are not well, so encourage them to keep healthy by living a healthy lifestyle. They should be washing their hands regularly, eating well, and getting plenty of sleep—and staying home when they are sick. They should be getting plenty of exercise, downtime, and time to spend with their families and pursuing hobbies.

Make PPE mandatory, and train more. It should be common sense, and common practice, for anyone who works in healthcare that PPE is part of the job. Yet for some reason, workers still come up with every excuse not to use it.

Over the years, PPE—and standards from OSHA and other regulators—have been developed to help reduce and prevent workers from getting hurt or sick on the job. Yet, every year, we hear more about how healthcare workers have some of the highest workplace injury rates in any industry in the United States. To make things worse, every so often an illness rarely, if ever, seen in the U.S. makes its way into the country’s healthcare facilities (think MERS in 2012 or Ebola in 2014) and changes the way the healthcare community looks at PPE. In addition, training often takes a back seat because of shrinking budgets and lack of time.

“PPE does not remove the hazards; it protects the individual,” says Marjorie Quint-Bouzid, MPA, RN, NEA-BC, who currently serves as vice president of nursing at Parkland Hospital and Health System in Dallas. “Healthcare organizations must continue to attempt to mitigate potential hazardous situations or practices as the first line of defense.”

The trouble doesn’t stop with infection control. Pharmacists who handle hazardous drugs, and the nurses who then administer them, are at high risk of occupational exposure. These exposures can cause acute health effects, from sore throats to hair loss; allergic reactions; cancer; and reproductive toxicity—including an increased risk of miscarriage.

A 2011 National Institute for Occupational Safety and Health (NIOSH) survey reported that the most common reason given for failing to wear gloves was that “skin exposure was minimal”—an opinion at odds with various biological measures of worker exposures.

In 2011, NIOSH surveyed 2,069 healthcare workers—most of them nurses—who had administered one of more than 90 specific antineoplastic drugs in the previous week about their adherence to safe work practices. According to the survey, which was published in the Journal of Occupational and Environmental Hygiene in 2014, workers reported that they had engaged in risky activities or been exposed to hazardous drugs by incidents that included:


  • Failing to wear a nonabsorbent gown with closed front and tight cuffs (42%);
  • Priming intravenous (IV) tubing with the antineoplastic drug (6% had done this themselves; another 12% reported that this was done by the pharmacy);
  • Taking potentially contaminated clothing home (12%);
  • Spills or leaks of antineoplastic drugs during administration (12%);
  • Failing to wear chemotherapy gloves (12%); and
  • Lack of hazard awareness training (4%).

When NIOSH asked healthcare workers why they did not wear their personal protective equipment (PPE), including double gloves and gowns, while compounding or administering hazardous drugs, it found that workers were essentially shrugging off the risk. “Skin exposure is minimal” was the most common answer to the question, followed by “not part of our protocol” and “not provided by employer.” The researchers concluded that “there is a perception among respondents that chemotherapy drugs pose a minimal exposure risk.” In addition, workers reported that employers failed to implement safe work practices and provide PPE in many cases.


Consider how personal bias affects peer review

Human nature contributes to bias by allowing us to use psychological “shortcuts” to reduce complexity and ambiguity in the world. We all wish that life were simpler, and our brains try to accommodate this wish by finding shortcuts to decisions by relying on past patterns of thinking. This enables us to provide a rational response within the context of a simpler and less-threatening world. The two main types of bias related to human nature are personal bias and group bias.

Personal bias has two aspects: emotion and thought. These biases come from our view of the world that is created by the sum of our individual experiences: where we grew up, our parents’ values, how our friends act, and how we were trained. Although we might make conscious efforts to overcome personal bias, we all retain some degree of it as part of our individuality.

Personal bias is more likely to affect peer review when individuals are not accountable for their decisions. This is not because these are bad people—they are simply good people in a flawed system. The case studies in this book provide several examples of peer review structures and procedures that, prior to redesign, increased the likelihood of personal bias, such as having a department chair conduct the entire case review process from case screening to decision. To reduce personal bias in peer review, consider requiring reviewers to provide a written rationale for their findings (even on care-appropriate cases), having a committee make the final decision on all cases, and implementing clear conflict of interest practices.

Group bias occurs when a group of individuals has a shared set of beliefs or experiences that result in a relatively predictable way of thinking or responding. This concept of “groupthink” results in the group tending to accept information that meets its common paradigm and reject, or at least not consider, information that doesn’t fit within it.

Lack of diversity in a group can create this bias. Therefore, to avoid group bias, structure the group to ensure that other views are included. There are two types of group bias that tend to affect peer review: professional bias (e.g., physicians think differently than nurses) and specialty bias (e.g., surgeons think differently than internists). One of the main reasons that medical staffs implement some form of multi-specialty peer review committees is that such committees reduce the likelihood of groupthink by bringing all perspectives to the table.

Source: Peer Review Benchmarking

Nurses file for collective action over lunchbreak dispute

Nurses at Methodist Health claim that the hospital docks lunch pay for breaks they aren’t able to take.

Robert Straka, a nurse at Methodist Health in Dallas, filed a collective action lawsuit in August against his employer. The issue in question is the hospital policy that dictates that nurses should be allotted 30 minutes every shift to take an uninterrupted break. He argues that nurses are still expected to care for patients during their break, and would often get pulled away to perform duties. Straka filed on behalf of almost one thousand nurses across Methodist’s five facilities.

Meanwhile, Methodist argues that this is not the case, and questioned the plaintiff’s interpretation of the rules. They’ve requested that the charges be dropped in a response sent last week. The judge in the case has mandated that each party meet and produce a report next month, that would outline settlement options and hopefully come to a resolution.

Do you get a dedicated lunch break in your hospital? Send me an email at and I’ll share the results (anonymous, of course) with your colleagues.
Read more here.

Registered nurses not immune to industry influence

There’s been a concerted effort over the last few years to provide transparency for medical industries interaction with doctors, thanks to the Physicians Payments Sunshine Act instituted by the US Senate in 2010. The Sunshine Act requires medical manufacturers, such as drug and medical supply companies, to report payments and gifts given to physicians and teaching hospitals; the goal is to ensure that doctors are not swayed to make care decisions based on financial gains and prevent conflicts of interest. Last fall, two senators proposed a bill to amend the Sunshine Act that would include nurse practitioners (NPs) and physician assistants (PAs) as well, acknowledging that NPs and PAs wrote 14% of all drug prescriptions in 2014 and require the same transparency as doctors.

A new study released this week suggests that even registered nurses (RNs) without prescribing authority could be subject to these sort of interactions with the medical industry. All of the RNs that participated in the study said they had interacted with industry over the past year, averaging 13 one-on-one meetings over the year. Many also participated in sponsored meals or events, received gift offers and product samples, and some received payments for speaking, consulting, and market research work. Most interactions were with medical device and pharmaceutical companies, but some reported interactions with health technology and infant formula industries as well.

Though RNs don’t have prescribing authority, many nurses are part of purchasing committees for their facility. RNs play an integral role in decision-making throughout their facility, and there are no regulations for transparency between RNs and medical industries. Though the sample size is small (56 RNs participated in the study), the authors of the study think the results warrant additional research and regulation. As the largest and most-trusted healthcare profession in the US, it’s important to make sure RNs maintain their trustworthy reputation with their patients.

You can read the full study here, and an editorial accompanying the study here.

For more information about open payments data, check out CMS’s open payments site.

Are your nurses getting their flu shots?  

More healthcare personnel (HCP) are getting their flu shots, according to a Centers for Disease Control and Prevention (CDC) study, but there are still large gaps in immunization. During the 2014-2015 flu season, 77% of HCPs were vaccinated against the flu, a 14% increase from the previous season. The highest rates of immunization—at 90.4%–was  with HCPs working in hospitals.

While the increase is a positive step, it was also revealed that only 75% of nonclinical personnel had received the vaccine, including food service workers, laundry workers, janitors, housekeeping staff, and maintenance staff. The numbers were even lower for aides and assistants, with only 64% immunized. [more]

Free webcast on incident-based nursing peer review

Nursing Peer Review in Action: Experienced Nurses Share Best Practices and Lessons Learned

Thursday, December 3, 2015 at 1:00-2:00 p.m. Eastern

HCPro is hosting a free webcast on December 3 about formal, case-based nursing peer review. Join Sarah Moody, DNP, RN, NEA-BC, and June Marshall, DNP, RN, NEA-BC, for a free 60-minute webcast on how incident-based nursing peer review benefits an organization and elevates nurse practice.

These experienced speakers will clarify the difference between formal, incident-based nursing peer review and the type of review that involves peer evaluation of nurses’ performance. They will demonstrate how incident-based nursing peer review can elevate quality and the professionalism of nursing through sharing case studies and lessons learned.

Moody and Marshall have many years of experience leading nursing peer review committees as incident-based nursing peer review is mandated by the Texas Nursing Practice Act.

For the full agenda and to register for this free webcast, visit

Incident Reports: What You Need to Know (Part Two)

Incidents reports are a pain to fill out, but vital for documenting what happened and for protecting yourself and your staff. This week, we’re republishing a popular post full of best practices, provided by Patricia A. Duclos-Miller, MS, RN, CNA, BC.

incident graphic2Yesterday we looked at the purpose of the incident report and the value of documenting facts as well as the patient’s responses to care in the nursing progress notes (see Incident Reports: Part One). Today we’ll look at eight risk reduction recommendations you should follow to limit the number of incidents you face. We’ll also give you a check list of tips for writing incident reports should adverse events occur. (I’ll make the checklist available as a PDF download in a few days, so check back for the link.)


  1. Be sure that everyone is clear as to who is managing the patient. This is especially critical in complicated cases with numerous consults. One of the major factors in adverse events is fragmentation or lack of clear communication between providers. Therefore, use the medical record as a communication tool for all providers and encourage your staff to read notes from other providers and disciplines.
  2. Be sure staff understand and utilize the chain of command when necessary. They are considered patient advocates and must speak on behalf of the patient to ensure quality patient care. Documentation of the chain of command process should be factual and blameless.
  3. Advise your staff never to create notes at home concerning the event. They should not discuss the event with other care providers without having someone from risk management present, unless the discussion is in a quality-review process or in the presence of the facility’s attorney.
  4. If an adverse event occurs, the staff must know that attention to patient needs is first and foremost. If a patient is injured, nursing and medical interventions take precedence over everything else.
  5. Follow the organization’s policy on medical-event disclosure. It is important that staff understand who is designated to inform the patient/family. Documentation should include who was present during the discussion, what information was discussed, and all of the patient/family responses.
  6. Ensure that the patient/family receives compassionate care and that everyone involved maintains a professional relationship.
  7. If an adverse event occurs, contact the risk manager. Discuss the case discretely, because conversations are not protected under a quality statute or attorney-client privilege, and therefore may be discoverable.
  8. Work with the risk manager. The risk manager can help you and your staff promote patient safety and proactive strategies to avoid injuries.


Incident Reports: What You Need to Know (Part One)

Incidents reports are a pain to fill out, but vital for documenting what happened and for protecting yourself and your staff. This week, we’re republishing installments of a popular post chock full of best practices, provided by Patricia A. Duclos-Miller, MS, RN, CNA, BC.

incident graphic2If you and your staff think that incident reports are more trouble than they’re worth, you could not be more wrong.

We work in high-stress, fast-paced environments. It is your responsibility as a member of the nursing management team to understand the importance of incident reports, to ensure that your staff completes them, and to investigate incidents to avoid any further occurrences. Your investigation will also provide possible defense if during your investigation you identify a system failure and take the necessary corrective action(s).

The purpose of the incident report is to refresh the memories of both the nurse manager/supervisor and the staff nurse. While the clinical record is patient-focused, the incident report is incident-focused. The benefit to you and your staff is [more]