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Dealing with Difficult Patients: Helping patients sleep better

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

A cat eats and sleeps. Then maybe it plays with some string. A cat eats and sleeps. Then maybe it stretches. A cat eats and sleeps. Then maybe it curls up on your lap. A cat eats and sleeps.

If only our patients were cats, sleeping and eating without any concerns. Unfortunately, our patients are people. And many people suffer from two very common conditions: problems sleeping and problems eating. As a nurse, you need to have a tool kit of helpful hints and tricks to help your patients.

Catch up on your zzz’s
The normal sleep cycle is about one-and-a-half hours in length and includes passing through five stages of sleep: Stages 1, 2, 3, and 4 are sometimes called non-rapid eye movement sleep, and are followed by a period of rapid eye movement (REM) sleep.

Stages 1 and 2 are periods of light sleep during which eye movement, heart rate, and breathing slow down. Stages 3 and 4 are deeper periods of sleep. People awakened during these stages often feel disoriented and groggy. It is the deeper stages of sleep—REM sleep—that refresh the body. It is a time when breaths quicken, the heart beats faster, muscles become immobile, and the person experiences vivid dreams.

In search of some rest
People of all ages can experience trouble sleeping. Parents complain that babies and children have erratic sleep patterns; teens are notorious for staying up all night and wanting to sleep during the day; adults complain of not getting enough sleep; and older adults complain that they have trouble staying asleep.

Activities that help promote sleep are the same throughout a person’s life­span. First, make sure your patients have careful and comprehensive assessments of their sleep problems. For example, if a person is having trouble sleeping because of allergies or enlarged tonsils and adenoids, these need to be addressed. People with restless leg syndrome or other limb movement disorders need to be evaluated and treated properly. Obstructive sleep apnea, a serious cause of sleep problems, also needs prompt attention.

Here is a list of hints that you can give your patients to help them sleep and feel rested in the morning:

Avoid stimulants. Cutting caffeine at least four to six hours before bedtime can help a patient fall asleep easier. Caution them to avoid using alcohol as a sleep aid. Alcohol may initially help a person fall asleep, but it also causes disturbances in sleep resulting in less restful sleep. Restrict nicotine, as it too is a stimulant.

Relax before bedtime.
Provide time for quiet activities in the hour before bedtime. Try reading something light or doing some light stretching. Many nurses use aromatherapy for its relaxant effect, and commonly used essential oils include oils of chamomile, jasmine, lavender, neroli, rose, and marjoram. Add a few drops to a warm bath or sprinkle a few drops on a handkerchief or pillow. It is important to understand the difference between essential oils and fragrances.

Other bedtime relaxation rituals that might work include asking the patient to gently wiggle his or her toes. You could also give him or her a head message, and/or ask the patient to apply lotion to his or her hands and feet.

Provide for a comfortable bedroom situation. Keep the patient’s bedroom as quiet, dark, and comfortable as tolerated. For many people, even the slightest noise or light can disturb sleep. Ear plugs and eye masks may help. Ideal room temperatures for sleeping are between 68°F and 72°F. Temperatures above 75°F or below about 54°F can disrupt sleep (Kryger et al.).

Eat right, sleep tight. Help the patient to eat sensibly during the day and to avoid heavy meals before bedtime. Foods high in tryptophan, such as milk, can promote sleep. The patient can also try a bit of carbohydrate in the form of cereal or a banana, and should avoid overeating, as this may cause indigestion.

Caution the patient to avoid drinking fluids after 8 p.m. Waking up to go to the bathroom may disrupt sleep and the patient may not be able to fall asleep again once disrupted.

Start a routine. Do not allow the patient to nap during the day. Waking up at the same time in the morning helps develop a sleep rhythm.

Just (help them) relax!
Progressive relaxation and relaxation breathing exercises can also aid in sleep. Progressive muscle relaxation (PMR) was described by Edmund Jacobson, MD, PhD, in the 1930s, and is based upon his premise that mental calmness is a natural result of physical relaxation. It is a deep relaxation technique that has been used to relieve insomnia as well as aid in the reduction of stress, anxiety, and pain. Simply stated, PMR is the practice of tensing (tightening) a muscle group and then releasing (relaxing) it, followed by moving on to another muscle group and repeating the process until you have systematically tensed and relaxed all muscles in the body.

Almost anyone can learn PMR. Usually it is best to start at the head or the feet. For example, start at the head and work down through all the body muscle groups, or start at the feet and work up to the head. Practicing relaxation breathing at the same time you practice PMR adds benefit.

Many people like to practice PMR in bed just before sleep, but it can be practiced in a sitting position as well. Sometimes PMR is a useful technique to use during long and tedious meetings.

Here’s how to start PMR:

  • Inhale and contract all your facial muscles, squeezing your eyes together, puckering up your mouth, and scrunching up your face. Now exhale and relax your facial muscles.
  • Inhale and tighten your neck muscles, and then exhale and release.
  • Inhale and contract your upper chest and upper back, and then exhale and release.
  • Inhale and contract the muscles in your left arm and hand, and then exhale and release.
  • Continue working your way through your body, contracting each muscle group and then releasing.

During PMR, keep your breath calm and do not hold it. Breathe in when contracting or tensing your muscles, and breathe out during release. As you practice this technique on your own or with your patients, gradually pay more attention to the release of body tension, as well as emotional tension.

Relaxation or diaphragmatic breathing
Using the diaphragm and not the chest is the most efficient and relaxing way to breathe. Chest breathing elicits anxiety. Try it: Breathe only with your chest and see how you gradually become more and more anxious. Now, switch to breathing with your diaphragm, bringing in your breath through your nose, allowing it to slide through your chest without raising your chest, and continuing down to the area just above your navel. Some people have difficulty pushing out their abdominal area when inhaling and it may take some practice. But with practice, you and the patients you teach will find that it comes more naturally and that it results in a more alert and relaxed feeling.
To practice diaphragmatic breathing, try the following:

  • Put one hand on your chest and the other on your abdominal area. Spread your fingers open, put the little finger near the navel, and put the thumb near the end of the sternum.
  • Pay attention to your breathing. Breathe in slowly through your nose, allowing the breath to flow through the chest (keeping the hand over the chest still) and flow down toward the other hand, filling up the space under that hand.
  • Continue to breathe in and blow up that space below the diaphragm like a big balloon.
  • Now, exhale through the nose or mouth, sucking in the abdominal area to expel as much air as possible.
  • Do not hold your breath, but continue with an inhalation through the nose again. Repeat this process for five to 10 minutes to feel a relaxation response.

Caring for sleepwalkers
Most sleepwalkers are children, but occasionally a teen or adult will sleepwalk if he or she is sick, has a fever, is sleep deprived, or is under stress. Sleepwalkers tend to go back to bed on their own and don’t usually remember sleepwalking. However, sometimes nurses need to prevent injury and help a sleepwalker move around obstacles in their way. Sometimes nurses may need to help them find their way back to their bed, especially if they are in unfamiliar surroundings. Sleepwalkers may startle easily, so it is best to guide them back to bed gently without waking them.


Dealing with Difficult Patients: 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.

Spearing, M. (2002). “Bipolar Disorder.” National Institute of Mental Health. Available at

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.


Dealing with difficult patients: defense mechanisms

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

Using Freudian concepts to understand human behavior, one could say that the ego often has a hard time pleasing the id and keeping the superego in check. So, it has developed a way to reduce anxiety through the use of ego defense mechanisms, those things that unconsciously block or distort our thoughts and beliefs into more acceptable, less-threatening ones.

Defense mechanisms (sometimes called coping or protective mechanisms) are, in short, used to protect the ego from full awareness of the situation. Their purpose is to help the person cope with a situation that he or she might not be able to handle.

Using defense mechanisms is a common human trait. We all use them. Some defense mechanisms are considered to be more helpful than others. Others may cause more problems for the person using them, in terms of creating unhealthy or unfulfilled relationships or losing touch with reality.

Most nurses are very familiar with defense mechanisms, having learned them early in their nursing school careers. Let’s review a few of the most common ego defense mechanisms and see how they apply to patient situations.

  • Denial: Protecting self from reality. Example: Thinking the high cholesterol level was a lab error.
  • Repression: Preventing painful memories/thoughts from entering consciousness. Example: Forgetting what he or she was told about a chronic illness.
  • Rationalization: Justifying inappropriate behavior. Example: “I don’t come to every appointment late, traffic was just bad this time.”
  • Projection: Pointing the finger at others instead of ourselves. Example: “It’s your fault I didn’t take my medicine.”
  • Displacement: Taking things out on others. Example: Yelling at a nurse after being given a bad diagnosis.

Rational problem-solving is not a defense mechanism. Oftentimes, rational problem-solving is enough to resolve an issue. Then, the use of defense mechanisms is not needed.

Tip: A well-rounded person, a mature individual, usually has little need to use ineffective or maladaptive ego defense mechanisms. However, when people are sick, have just been given bad news, have a loved one injured, or are uncomfortable for whatever reason, even the most well-adjusted resort to the use of defense mechanisms to help them get through.

Find some common ground

How do you relate to a person who is using a defense mechanism?

  • Recognize that the use of defense mechanisms is to protect the mind from total awareness of the gravity of the situation.
  • Avoid hurrying someone along, as this only creates more frustration and confusion. Sometimes the person is able to develop awareness little by little.
  • Provide a safe environment for the patient so that he or she might feel more comfortable doing the emotional work that is needed given the situation.
  • Be aware of how you are reacting and try to maintain a professional stance. Don’t get hooked into the patient’s mini-drama.
  • Provide information that might help clarify the situation.
  • Stop giving information when you see that it frustrates or overwhelms the patient.
  • Maintain a quiet voice and comforting physical appearance.
  • Give the person some emotional space as well as the physical space needed to soothe him or her.
  • Provide for the patient’s basic needs.
  • Say things like “I am available if you want to talk about this more later.”
  • Work around the use of the defense mechanism if possible.
  • Avoid the tendency to take the use of defense mechanisms by others personally.
  • Be patient and wait to see whether the person is able to address the issue in a more mature fashion later.

Joan Monchak Lorenz, MSN, RN, PMHCNS-BC is an HCPro author and contributed to the book Stressed Out About Difficult Patients.


Dealing with difficult patients: Basics of behavior

The following is an excerpt from Stressed Out About Difficult Patients

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

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

We are unaware (of most) of what we do

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


Reward me!

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

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

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


Addressing our needs in order

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


Putting these theories to use

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

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

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

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.


Time Out Day for Patient Safety

June 14 is National  Time Out Day, a Joint Commission and Association of periOperative Registered Nurses (AORN) campaign to promote patient safety before, during, and after surgery. The organizations also implore healthcare facilities to commit to conducting a safe, effective time outs for each and every surgery.

This year’s theme calls on surgery staff to be a Time Out SUPERHERO; an acronym standing for nine elements of a surgical time out:

Support a safety culture
Use The Joint Commission’s Universal Protocol and AORN Surgical Checklist
Proactively reduce risk in the OR
Effect change in your organization
Reduce harm to patients

Have frank discussions about hazardous situations
Empower others to speak up when a patient is at-risk
Respect others on the surgical team
Openly seek opportunities for improving patient safety

“National Time Out Day is a powerful tool that supports surgical nurses’ ability to speak up for safe practices in the operating room,” AORN wrote in a brief. “It provides an opportunity to educate your community about this practice and become better informed patients (read more about this in Periop Insider). Time Out also demonstrates your role in patient care and commitment to patient safety as the perioperative nurse who cares for them.”

Wrong-site, wrong-procedure and wrong-person surgeries happen every day and surgical time outs are key to preventing adverse and never events. Everyone on the surgical team has to be  fully engaged, accountable, and empowered to speak up during the time out process to prevent never events.

The Joint Commission has a list of free tools and resources available on surgical time outs.

Four easy ways to provide patient education

The responsibility of educating patients and their families often falls to nurses, from explaining procedures to providing discharge instructions. This can be one of the most difficult parts of the job, and your staff may have limited time due to staffing issues or an emergency situation. Here are some tips to help educate patients quickly and effectively:

Handouts are your friend: Patients are often given a lot of information all at once, and it can be hard for them to remember every detail, especially in a stressful hospital setting. Having notes and props ready for them can save time and prevent miscommunication, especially when discharging patients. Have your nurses write up the specific instructions and go over them with the patient; use highlighters to mark the most important information. There are a lot of resources and tools available (we have some here) about common procedures and practices that you can use as handouts for patients as well.

Stay concise but informative: Patients are probably only going to remember one or two learning points, so try to emphasize the most important takeaways and leave the rest for your handouts.

Test understanding: It’s important not to assume that your patient is well-informed about their own condition. Even if you think something is obvious, say it anyway! Once you go over the key points, make the patient repeat them back to you; it’s one thing to listen to an explanation, but quite another to have to explain it yourself.

Encourage questions: Even if a patient seems to understand, it’s important to leave time for questions. Ask if they have any concerns about medications or follow-up care; this will help prevent confusion going forward and negative health outcomes.

You can go here for more advice about patient education.

Virtual reality a potential solution for pain management

This year has seen the release of multiple virtual reality (VR) headsets aimed at the home consumer. As they are becoming more affordable, hospitals and companies are researching the benefits in a healthcare environment, and the early results are positive.

Cedars-Sinai Medical Center and Children’s Hospital Los Angeles are conducting studies using the software, and the early results are positive. Cedars-Sinai researchers found that 20 minutes of using the VR software reduced patients’ pain by almost 25 percent; patients had an average pain score of 5.5 out of 10 before the VR experience and an average score of 4 after using the software. The researchers say this is a dramatic reduction, and not far from the effect of narcotics. At Stanford Children’s Health, they speculate that VR can be valuable for helping children get through tedious or uncomfortable procedures, such as physical therapy or imaging studies.

Though providers are cautiously optimistic about the possibilities, there are still some hurdles to overcome. It is difficult to find developers who want to target medical issues, because of the unclear path to profitability. One startup company, ApplieVR, is building a library of content designed to help patients “before, during, and after medical procedures” It’s also important to determine when the technology can helpful and when it can’t; some patients won’t respond to the applications as well as others, and researchers are careful not to oversell the value of VR at this early stage.

For more information, check out the MIT Technology Review article.

Do you think VR might replace Opoid use eventually? Let me know in the comments!

How nurses can reduce patient anxiety

Nurses face challenging patients and their families every day, but understanding the causes of patient stress can reduce the patient’s anxiety and ultimately make your job easier.

Healthcare can be confusing and distressing for many patients. Being admitted to a hospital for any reason can be one of the more stressful events in a person’s life. Because of this, it is important to remember that anxiety is the root cause for many conflicts in healthcare settings; so a difficult patient or family member isn’t necessarily a rude or ornery person most of the time, they may just be experiencing symptoms of anxiety.

The first step in mitigating a patient’s anxiety is to introduce yourself and explain your role in their treatment plan. Explain everything you are going to do and why you are doing it. Patients are inexperienced in healthcare procedures, and it can be easy to take your knowledge for granted. Come armed with hand-outs and as much information as you can; the more knowledgeable the patient feels, they more comfortable they will be.

Next, it is important to listen to your patient and take their needs seriously. Active listening techniques, such as asking open-ended questions, taking an interest in their lives, or checking in on their feelings, can be a vital lifeline to someone suffering from anxiety. Check in with them often, and give them a venue to voice their concerns.

Instead of instructing the patient to relax, demonstrate it! Your demeanor can have a profound effect on a patient’s emotional well-being, so staying cool and collected can relax them in turn. Consider using relaxation techniques like breathing exercises to help them cope with anxiety.

For more tips, click here.

House calls can benefit patients and cut costs

Two of the lasting images of early healthcare professionals is the doctor with their big bag making house calls and a midwife rushing to a family home to facilitate a birth. As healthcare has advanced, we’ve moved away from this home-based model toward the consolidated approach of the modern hospital. However, some practices have returned to house calls, with some positive results.

Independence at Home, a program created by the Centers for Medicare and Medicaid Services (CMS), seeks to identify patients that would benefit from homecare or cannot be helped in a hospital setting. The project sends mobile interdisciplinary healthcare teams, lead by physicians and nurse practitioner, out to the homes of these patients and provide care.

According to a recent Medscape article, the program reports a few different benefits. The patients receive more attention and care from providers, and the setting can foster trust between patient and provider. Hospitals and nursing homes can be difficult places for many patients, and they would prefer to get treatment in their homes. Terminal patients particularly benefit from this; as one provider notes, hospitals are not where people want to die.

The providers benefit from the more personalized patient relationship as well, but there are also financial incentives for homecare. CMS reports that they saved $25 million by using this system and $11.7 million of that went back to the providers. Because the system targets some of the most expensive Medicare patients, hospitals can save a lot by providing in-home care in this system. In addition to the CMS program, Veterans Affairs Medical Centers report that providing home care for some of their patients cost 12% less than standard care.