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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.

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: 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.

Study: Patients embracing telehealth, video conferencing

A new study suggests that patients are becoming more comfortable with telehealth solutions like video conferencing.

Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia published a series of qualitative interviews with telehealth patients, and the results were overwhelmingly positive. All participants indicated that they were satisfied with their telehealth visit, citing the convenience of receiving consultations from home, skipping office wait times and transportation costs.

One of the study’s authors, Rhea Powell, M.D., M.P.H., said that the video consultations could open up new opportunities for those who face barriers to medical care, and could be particularly useful for patients with chronic conditions such as diabetes and depression. Chronic conditions often don’t require a full exam, but they do require frequent short check-ins, which would be ideal for video conferencing.

The most surprising finding? Patients indicated a preference to receive bad news via video conference from their own homes. This goes against most clinical training, which teaches providers to deliver serious news in-person.

For more information about telehealth and nursing, check out the articles below from the Strategies for Nurse Managers’ Reading Room:

California Program Uses Telemedicine to Reach Medically Underserved

Telehealth provides opportunities to learn, educate and lead

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.

National Time Out Day

Today is National Time Out day! For the 12th year in a row, the Association of periOperative Registered Nurses (AORN) want to remind medical professionals to take a moment before every procedure to make sure they are “operating on the right patient, the right site and the right procedure.” The Joint Commission reports that wrong site surgeries occur five times every day in the United States, and AORN hopes to raise awareness of the issue and improve patient safety.

For more information or to see how you can participate in National Time Out Day, visit AORN’s official website.

Nurses uniquely qualified for hospital design

The role of nurses has expanded greatly over the past few years, as nurses are moving from the bedside into all facets of healthcare. Hospitals have started to use nurses’ expertise to help design their facilities, with impressive results.

Hospital design can have a profound impact for both nurses and patients, but facilities are just starting to include nurses in the design process. Health Facilities Management (HFM) reports that involving nurses in design planning can help executives and contractors keep patient-care priorities in mind during construction. Seemingly small decisions, like the placement of sinks, computers, or wall outlets, can lead to an increase patient satisfaction. Nurses have been behind some of the pioneering new hospital designs, such as single-occupancy maternity rooms and the acuity-adaptable patient rooms. As one nurse told HFM, “Nurses spend the most time with the patient… we have a responsibility to be the voice of the patient, family and each other.”

Looking out for each other is another great reason for involving nurses in hospital design. A study published by Hassell and the University of Melbourne found that hospitals designed to accommodate nurses have a better chance of attracting and retaining nurse staff. The researchers identified a link between hospital workplace design and efficiency, health and safety for staff and patients, and staff morale. These factors play a significant role in staff retention, and who better to ensure a facility is attractive to nurses than nurse leaders?

Nurse-led design choices improve conditions for patients and nurses, but they can also help the bottom line. Nurses are involved in many different areas of the hospital, and their input can make operations more efficient and affordable. In one example reported by HFM, nurses saved the Parkland hospital project millions of dollars by eliminating unnecessary equipment and cabinetry in emergency rooms.

Both the survey and HFM article note that despite these benefits, nurses don’t always get a voice in hospital design. But as nurse-designed hospitals flourish, perhaps more facilities will involve nurses in design plans.

For more about Nursing and hospital design, check out: Take Five: How renewal rooms revive stressed out nurses

Shared decision making has benefits for minority patients

New evidence suggests that shared decision making (SDM) can improve the patient experience for minority groups, particularly LGBTQ patients of color.

Shared decision making aims to include the patient’s perspective when making care decisions and better educate patients about treatment options. SDM acknowledges that each patient is unique, so creating a dialogue between the provider and patient should increase patient engagement and result in better outcomes. As one researcher describes the shift: “It’s going from ‘I’m the expert, take my recommendation’ to ‘I am going to inform you and respect your wishes.’”

This idea of respecting and listening to a patient is at the heart of caring for all patients, but minority patients particularly benefit from an SDM approach. As we discussed in our post about transgender healthcare, an open dialogue and respect for how the patient would like to be addressed goes a long way to build trust for the patient; the same principle applies across minority groups.

The University of Chicago and the Agency for Healthcare Research and Quality have developed a new project called Your Voice! Your Health! aimed at researching SDM’s influence on minority healthcare and facilitate healthcare improvements for the LGBTQ racial and ethnic minority community. The researchers note that the confluence of minority statuses make it particularly difficult for LGBTQ patients of color; as Monica Peek MD, MPH, Associate Professor of Medicine at the University of Chicago Medicine told ScienceLife: “Racial/ethnic, sexual orientation, and gender identity minority status are all marginalized social identities, so they act in concert to further marginalize people who are trying to navigate the health care system.”

Because there is little existing research on LGBTQ patients of color, providers may not have the proper framework or tools for addressing their needs. Peek and her team developed a new conceptual model to illustrate how the patient and physician’s social identities effect SDM. As ScienceLife describes the strategy: “In the end, establishing trust boils down to how well a physician acknowledges her own identities in relation to those of her patients.” According to the group’s research, differences in social identity didn’t matter so long as the provider was compassionate and encouraged an educated dialogue, the hallmarks of a SDM approach.

program, Massachusetts General Hospital (MGH) reviewed what made the initiative a success. At first they relied on physicians to order decision aids and educational materials for patients to encourage informed discussion, but they didn’t see immediate results. Once they trained all staff and involved patients directly, the use of decision aids increased substantially. Leigh Simmons, MD, medical director of the MGH Health Decision Sciences Center, said of the initiative: “There now is a big push toward more team-based care in medicine; and once we started to engage the entire team – including front desk staff, medical assistants and most crucially, the patients – we saw the use of decision aids take off.” Once the full staff and patients embraced the program, physicians reported that they had more advanced discussions with patients and they are able to focus on what’s important to their patients.

Do you use shared decision making practices in your facility? Do you find it easier to connect with patients using these techniques? We would love to hear about it in the comments below!

For more information on the Your Voice! Your Health! project and a useful tool for establishing a patient dialogue, check out the full ScienceLife article.