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Bespoke care essential

Every patient is different; whenever one presents a particularly troublesome problem, meeting it with the specified precautions is critical. 

The way patients who present special difficulties are managed needs to be individualised, even with all the competing demands on nurses’ time, experts in the area say.

Susan Hendy, Health Education and Training Institute director of nursing and midwifery, says “It is important to just make sure that you look at the individual case, because often you could do something reasonably effective that will save a lot of time and grief in the future.

“Nurses obviously need to understand their patients and understand where they’re coming from but also the disease process and what’s going to happen to them,” she says, “You might use something successfully on a couple of patients and if you continue to use that and not be flexible and adaptable it might be the worst thing you can do.”

Dr Janice Gullick, co-ordinator of the master’s of intensive care and master’s of emergency nursing courses at the University of Sydney, agrees that nurses should avoid a one-size-fits-all approach to care and adds professionals should avoid labelling patients as good or otherwise. “We need to find ways to connect with them and find out what their individual concerns are,” she says.

Hendy says nurses need to be aware of their own limitations and recognise when they are not managing a situation well. “You have to … be professional and reflective enough to understand that and make sure that you get somebody else involved.”

She says using other team members to assist or take over can also be helpful. “We’re all human beings and some people are more adept at [handling] a certain situation than others,” Hendy says. She adds there may be some situations that nurses or midwives don’t feel comfortable with due to previous experiences. “Some might have a cultural [background] or a value set where they don’t feel comfortable in certain situations.”

Hendy adds it is not only the patient who may be difficult, but the carers as well. “Carers [are] going through a range of emotions or they might have just recently lost their loved one,” she says. However, carers can also be part of the solution. “Often they are the people who are objectively looking and can also help their loved one understand what’s going on and diffuse the situation.”

Nurses need to ensure that when putting theory into practice there is somebody there to guide them, manage the situation and reflect on it with them afterwards, Hendy says. She says debrief sessions after serious incidents are often useful.

In this issue of Nursing Review, we delve into some different types of patients nurses may encounter and ask experts how each group can be managed.

Anger issues

Gullick says instead of thinking about this type of patient as angry of difficult, nurses should bring it back down to the personal level and speak to them one on one without the notion of being the controller.

“You can bring it back to, ‘You are a person who has concerns and I’m a person who might be able to help you.’ And take the time to sit down and try to drill down to what their concerns are,” she says, explaining that it’s often related to anxiety around their condition.

The anger is often tied to time. “Perhaps whatever their concerns are were not dealt with in a timely manner because the system’s under stress,” she explains, adding having their concerns validated may often settle them down.

“It’s much easier if you take that time right at the beginning to work out the problem. It then sets up a way of working with that person down the track,” she says.

Trying to give pre-emptive care is another useful strategy, Gullick says. “There are not that many things patients complain about – they’re usually uncomfortable or they’re in pain or they don’t know what’s happening to them – so we can try to keep those basic things under control.”

She says whilst those things are easier said than done, these patients often can’t see beyond their own situation to the limits of the system. “Help them to understand the limits that we’re working in – not as an excuse but as a way to move forward and meet their concerns,” she says.

Language barriers

Another area of difficulty that may present itself in a clinical setting are patients from a non-English speaking background.

Gullick says, “They often come from different health systems or don’t understand what the hold-ups or the issues are because of a language barrier. It’s important to access the interpreter services that we have in hospital and to involve the family as much as possible.”

Hendy suggests getting help from somebody in the unit who can help with a language or cultural support.

Gullick says, “We have large populations of particular ethnic groups living in our society and we can’t ignore that anymore. We can’t expect people to just fit into our system; we need to realise that [they’re] part of our system and so part of our preparation as nurses needs to be about culturally specific care.”

She says this might involve understanding that in some cultures it’s important to have a lot of family around, so sticking to rules of having only one or two family members in the room at any one time can be problematic.

“[It’s about] thinking how can we accommodate the important cultural frameworks that people live within, but also make the hospital system work, rather than just having these hard, fast rules that we stick to.

“We need to consider some cultures have an importance on complementary therapies and that needs to be something we need to incorporate into our care,” she adds. “Other cultures might find hospital environments quite confronting; we often have areas of the hospital where we have men and women in the same clinical area as patients and that might be confronting to the patients.”

She says it comes down to understanding what the specific needs of cultural groups may be, “but also drilling down beyond that to what the individual sees as important – and the reality is we don’t know unless we ask them.”

drug and alcohol EFFECTS

Associate professor of emergency nursing at Deakin University Marie Gerdtz says this is a large and problematic group. “Anecdotally, when we see changes to the drugs available to the community, such as ice, we will see increasing problems with behaviour disturbances and aggression.”

When these patients enter an emergency department, nurses may not find out they are under the influence until the end of their visit, which can be challenging. Gerdtz says nurses can look for signs of substance use, such as pinpoint pupils or arm scratching.

In terms of managing these patients, Gerdtz says one of the most important things to do is identify when they are ready for discharge. “As soon as their health problems have been treated, they’re right to go, we don’t have to keep them there,” she says.

“When they’re distressed, they will want to do things that are outside the normal rules,” she says. “So it’s being aware of what the triggers of their aggression might be.”

One trigger that often sets up problems is setting boundaries that the patient doesn’t like. “A common one is wanting to go out for a smoke and then we say, ‘Well there’s no one to take you out’, and the person gets angry and aggressive.”

“We don’t want it to come to a point of locking horns with them around rules, rather just say ‘Look, you can’t smoke here, but it could be that you can be discharged in 15 minutes, 20 minutes. We just have to do these things and then you’re free to go outside have a cigarette.’

“It’s easier said than done because we don’t want to reward the kind of behaviour [by seeing and treating them quickly] when others are also in need and they don’t get that treatment,” Gerdtz says. “It’s a fine balance.”

Planning is another important aspect to managing patients affected by drugs or alcohol, Gerdtz says. She says identifying that the patient is at risk and developing an individual plan early on is useful.

She says this could involve an alcohol withdrawal plan for someone who is known to be a heavy drinker.

“It’s that planning, being proactive, and anticipating likely behaviours,” Gerdtz says. “The other thing is attending to basic care and comfort needs. Don’t let them get hungry if that’s a trigger for them.

“Pain management is another big one [for patients with drug or alcohol issues] from a clinical perspective, so if we know that the person has got a genuine injury, their pain needs to be well controlled because if it’s not then we’re going to get behaviour issues as well. The care plan should be more holistic.”

Cognitive impairment

Gullick says patients with cognitive impairment are often confused, frightened and unsure of what’s being done to them or what people’s motives are. It can be hard to reason with such patients.

“It’s difficult and frustrating for nurses because they’re obviously under time pressure and they’re trying to get things done and they’re concerned about the safety of the patient who might be doing things that put them in an unsafe situation,” she says. “It’s hard work for nurses because we don’t know what to do to fix their issue and so this is where the conflict arises.”

For this group, Gullick says nurses need to think about ways to minimise their anxiety.

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