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Dealing with Difficult Patients: Suicidal behavior

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

Many nurses don’t feel comfortable completing a suicide assessment. Some nurses can’t imagine anyone thinking that killing him or herself is the best solution to any problem. However, many of the patients we serve have thought that way and some are actively suicidal, and we are not even aware of it. Being aware of the signs of suicide, and making a suicide assessment, can save your patient’s life. As with many other assessments, practice facilitates mastery. This chapter will give you lots of guidelines and tips to help.

It is important to remember that most suicide attempts are expressions of extreme distress, not harmless bids for attention. Also, any person who has expressed suicidal ideation should not be left alone and needs immediate treatment.

What if I think someone is suicidal?

One way to determine whether a person is thinking about suicide is to ask directly: “Are you thinking about suicide? Are you planning to kill yourself?” Doing this will not plant thoughts in the person’s head. Doing this will not cause the person to consider suicide if he or she was not thinking about it. Doing this will not cause the person to try suicide. By asking directly, you show you are not afraid to tackle the hardest of situations, and it is a way to show the patient that you can be trusted. Suicidal individuals seek out those whom they trust and feel connected to in some way. One of the most important factors in preventing a suicide is the presence of a supportive person.

Don’t panic: If a person does tell you that he or she is suicidal, here’s what you can do:

  • Stay calm and listen.
  • Let the person talk about his or her feelings.
  • Be accepting, and do not judge.
  • Ask whether the person has a plan, and if so, what it is.
  • Don’t swear secrecy.
  • Do not leave the patient alone. Take him or her with you if you must, so you can get help.

Don’t ignore the warning signs

All mentions of suicide must be taken seriously. Warning signs include:

  • Thoughts or talk of death or suicide.
  • Thoughts or talk of self-harm or harm to others.
  • Aggressive behavior or impulsiveness.
  • Previous suicide attempts, which increases the risk for future suicide attempts and completed suicide.

Assessing the possibility of suicidal thoughts

Ask the patient the following questions to assess the possibility of suicidal thoughts:

  • You have been through a lot lately: How has that affected your energy (appetite, ability to sleep)?
  • Many people in your situation may feel sad and blue or depressed: Do you feel that way?
  • Have you ever felt so sad and blue that you thought that maybe life was not worth living?
  • You have been in a lot of pain lately: Have you ever wished you could go to sleep and just not wake up?
  • Have you been thinking a lot about death recently?
  • Have you recently thought about harming yourself or killing yourself?
  • Have things ever reached the point that you’ve thought of harming yourself?

If the person says that he or she has thought about self-harm or suicide, the next step is to assess whether the person has a plan and the ability to carry out the plan. Ask questions such as these:

  • Have you made a specific plan to harm (kill) yourself? If so, what is it?
  • Do you have a gun (knife) available for your use? (Find out if the person has access to accomplish the plan.)
  • What preparations have you made? (This might include purchasing specific items, writing a note or a will, making financial arrangements, taking steps to avoid being found, and/or practicing the plan.)
  • Have you spoken to anyone about your plans?
  • Would you be able to tell someone if you were about to harm yourself?

Keeping the patient safe

Your next step is to make sure the patient is safe. Most facilities have policies about levels of observation or supervision for patients who are a suicidal risk. There is also a process for further assessment of the patient. Again, never leave a person who has expressed suicidal thoughts alone. Take him or her with you to get help. Always read and follow your facility’s policies.

In general, there are some universal safety measures to take with a person who is suicidal:

  • Keep the person on continuous observation, such as 1:1 or in your line of sight.
  • Restrict the person’s environment for safety. Ask the person to remain in a certain area where staff members can see him or her at all times.
  • Do not allow the person to be alone in a room.
  • Check the person at intervals of five, 15, or 30 minutes.

Staff supervision is necessary when a patient uses items such as sharps (nail cutters, razors, or scissors), cigarettes, and/or matches; is around potential poisons, such as cleaning supplies; uses the bathroom or kitchen; and/or goes off the unit for treatments, therapies, or tests.

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

 

Dealing with Difficult Patients: Behaviors that drive you bananas

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

Does a certain group of patients simply drive you bananas? Sometimes you can’t put your finger on it. Something just doesn’t fit for you. Then, someone points it out to you by saying, “Don’t you see how he or she is manipulating you?” Oh, that’s it! He or she is a manipulator and the problem is solved. Or is it? What is manipulation? How does it get in the way? Can it ever be a good thing?

Persuasion, influence, and manipulation: What’s the difference?
Persuasion and influence are often seen as positive traits. We look at people who seem to be able to encourage others to get things done and wish we could be more like them. Indeed, very popular books have been written that teach others how to persuade or influence others. For example, there is a famous book by Dr. Jerome Frank—now updated by his daughter Julia—called Persuasion and Healing. It elucidates the positive influence of therapeutic relationships and other psychological healing  techniques. In addition to this classic for healthcare providers, numerous pop books on the market give lots of hints on how to stop arguments by persuasion, get projects completed by influence and persuasion, and further your career by using your influence and persuasion.

Bothersome behaviors
Rather than using the label “manipulation,” let’s refine the definition and talk about the specific behaviors that drive us bananas. Then, let’s look at ways to handle these behaviors in our work situations.

Whether we see them in patients or our peers, the following are some behaviors that cause distress in the workplace.

First, we have the overt types of behavior that come across as verbal violence. These are often easier to handle because they are so overt. It is hard to miss them. They include:

Making demands: “I must have this weekend off to attend my cousin’s graduation,” or “I can’t go to x-ray until after I have my shower and shave.”

Violating rules and routines: A staff member consistently comes back from break or lunch late. A patient’s family member brings in food from home, even after being told that the patient is presently on a very restricted diet.

Making threats:
“I’ll throw this food tray at you if you come any closer.”

Then, we have the more passive types of behavior that are meant to persuade you to do what the person wants. These might be harder to spot. If you grew up with adults who used these, you may even think they are healthy behaviors. Once pointed out to you, however, they may become more obvious.

Eliciting pity:
The staff member who says, “You just don’t understand how hard it is for me to take care of that patient . . . ,” but says this often about all kinds of patients. Or the person who is abusing drugs: “If you had my horrible upbringing you would take drugs to numb your pain, too. Can’t you see how tough my life has been?”

Ingratiating and flattering:
The person who is always commenting on your clothes, your jewelry, and how good you look. Or the patient who says, “You are the best nurse on this floor. I don’t know what I would do if you took a day off.”

Evoking guilt feelings: When people say, “If you had called me over the weekend like you said you were going to, this would never have happened,” or “If you had made your rounds earlier like you usually do, I wouldn’t be in this mess.”

Abusing compassion: When patients say, “You acted like you were a caring person and said that you would have a hard time on a restricted diet, so why are you making such a fuss over my wife bringing me food from home?”

Attempting to exchange roles: When someone says, “I see that you have a problem with your weight. I am a fitness trainer and can help you with a personal plan to get you in shape. When you get a chance, come back and we’ll start on it.”

Pitting people against each other: When a peer says, “That night shift is something else. I don’t see them making rounds or doing any of the things I know they should be doing at night. You guys and gals on the day shift are top-notch.” Or when a patient says, “Who is that young doctor who came in here yesterday anyway? I bet you know a heck of a lot more about my condition than he does.”

Questioning competence or authority: When a patient says, “Now, honey, you just go take care of your other patients, and send in the charge nurse. I need a real nurse in here to answer my questions.”
Being overly dependent: People who allow others to do for them, do not accept self-responsibility, and then skirt responsibility if things go wrong. They say things such as “I am sure you know best. Just take care of that for me. I rely on all you nurses to make sure I get better.”

Using avoidance: People who change the subject when it comes up, avoid being around people they dislike, or are silent rather than open with their opinions. When they do speak, it is in order to avoid: “I can’t be on the same team as Susan. We don’t work well together.”

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

Challenges and Opportunities for Nurse Leaders

Looking forward, the difficulties we face include overcoming the bias that nurses are not prepared to lead, especially in interprofessional teams. This is a perception that nursing itself must change, first in the arena of self-image and then in the eyes of other powerful professional groups. If other clinical partners do not see the nurse as pivotal for ushering in change, then they are likely to use that bias to slow the rate or pace of change considerably.

For nurses to see themselves as capable of transforming healthcare, they must see themselves as equal partners at the table, able to negotiate and recommend, influence, and activate change initiatives at the local level and beyond. For some, this is an unimaginable role, but fortunately for others, this is a logical next step in fulfilling the promise of their education and preparation to lead. Stevens (2013) reminds us that there are four skills that the nurse leader must bring to this interprofessional table:

  • The redesign of healthcare systems through creativity and mastery of teamwork
  • Persistence in ensuring the education of nursing’s future workforce, with an eye focused on improving our systems of care
  • Moving beyond our current and comfortable programs of research, and learning to engage systems so that applications to larger platforms are possible
  • Inviting and ensuring multiple voices and perspectives are heard so that the transformation of healthcare is broadly focused on the needs of the larger population

It is our work not only to care for patients and to work diligently to improve the efficiencies and effectiveness of the system where we practice, but also to touch the lives of patients around the world by engaging in a readiness to move evidence-based practices into the mainstream of our thinking and our actions. To embrace change and actively implement those strategies which are best for patient outcomes will keep us focused firmly on the future and prevent us from being stuck in our past.

Source: Critical Thinking: Tools for Clinical Excellence and Leadership Effectiveness

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

Free Webcast: Techniques to improve critical-thinking skills

HCPro is celebrating and recognizing nurses all week long with special giveaways, prizes, and promotions.

OnDemandWebcastEnjoy this FREE webcast on us!

Critical Thinking and Patient Outcomes: Engaging Novice and Experienced Nurses

Join renowned critical thinking expert Shelley Cohen, RN, MSN, CEN, for a 90-minute webcast for nurse managers, educators, and nursing professional development specialists about strengthening nursing staff’s critical-thinking skills.

This program provides practical strategies for developing critical-thinking skills in novice and experienced nurses. It discusses how to foster an ongoing program that emphasizes critical-thinking skills and how improved critical thinking can impact patient outcomes.

To access this FREE webcast, enter discount code EW323823 at checkout.

And be sure not to miss…

Yesterday’s post has links to a 20% discount code on all nursing products, a BOGO on books and handbooks, and other activities of interest…

Live webcast: Onboarding New Graduate Nurses

HCPro will present a live, 90-minute webcast on Tuesday, September 18, 2012 at 1:00-2:30 (Eastern). Onboarding New Graduate Nurses: How to Overcome Hurdles and Retain New Nurses demonstrates how the onboarding process for new graduate nurses will increase retention and speed up professional growth.

Join nursing professional development experts Diana Swihart, PhD, DMin, MSN, APN CS, RN-BC, and Jim Hansen, MSN, RN-BC, as they provide strategies for helping new graduate nurses navigate their first job hurdles through the onboarding process, from pre-hire to a successful transition into professional practice. Moving new graduates beyond academic theory and technical skill to become competent, confident, professional nurses begins with onboarding.

Here’s a look at the agenda for the webcast:

  • Pre-hire onboarding: Externships, selective hiring, BCAT, physicals, medication administration exams, and interviews
    • Workplace demographics and roles of new graduates in workforce metrics
  • General and unit-specific orientation: The roles of internships, preceptorships, and unit orientation
    • Cultural and social integration
    • Trusting clinical decisions through critical thinking and clinical judgment
    • Early career support
    • Developing skills in organization, prioritization, and delegation to build professional competence and confidence
  • Transitioning into the professional role best practice: a Nurse Residency Program
    • Essential knowledge, skills, and abilities for their new role: Moving beyond technical skills to professionalism

There will also be a live question and answer session following the program.

This webcast promises to be a great resource for nurse managers, assistant nurse managers, nurse leaders, charge nurses, directors of nursing, patient care managers, directors of patient care, directors of staff development, nursing professional development specialists, chief nursing officers, VPs of nursing, VPs of patient care services, and nurse residency coordinators. Sign up now and pay one price for your entire staff!

For more information or to sign up for the webcast, please visit www.hcmarketplace.com.