The nursing process:
We all know it. It is one part of the process of nursing. But lets go over it again anyways.
- Assess. What exactly is going on here.
- Diagnose. What is the problem? / What do I need to do?
- Plan: This is what I will do!
- Implement: Doing. Directing. Delegating. Documenting.
- Evaluate: Was my plan effective?
STOP: cultivating mindfulness during your shift.
I have posted before on using the STOP technique to anchor you to your environment. Washing your hands is the trigger to remind you to STOP.
- Stop what you are doing. Just take a moment to let the â€˜10 things you must do like 10 minutes agoâ€˜ drop away. They will still be there when you have finished.â€¨And I mean really stop. Stand still. Relax.
- Take a breath. Take it from right down in your diaphragm. When we are stressed and flummoxed we tend to breath from up in the tops of our chest.â€¨OK that first breath was just a flush. Take another one.
- Observe your environment (internal and external). This is the tricky part. Donâ€™t think. Donâ€™t analyze. Donâ€™t run that internal dialogue of lists and directives.â€¨Just experience the sensations in your body, its position, its movements, its feelings. Try not to label them as tension or pain or tingling, or stressed, or exhausted, just experience them non-judgmentally. Do the same for the feelings and sensations and sounds in the external environment.â€¨Take a third breath.
- Proceed. Return to what you were doing. Bring your attention to the very next thing that needs to be done. But try and cup that next thing within the context of mindfulness you have just experienced.
STEP-UP: and shine in a crisis.
STOP is all well and good to do whilst washing your hands. But what to do when the you know what1 hits the fan?
- Stop. OK we have an emergency here2. Recognising that something is wrong, and re-orienting yourself to the situation is half the battle won.
- Take a breath. It doesnâ€™t matter how rapidly things are going to shitâ€¦take a breath. Donâ€™t run away with your brian. Understand that your adrenals are probably dumping a bucket load of fight or flight into your bloodstreamâ€¦.and thats OK.
- Engage: This is the important bit. This is the step that separates you from the bystanders.
You must fully engage with what is going on.
What information do you have? What response is required? Are there any potential dangers3?
The trick here is to have practiced your responses, either in exercises such as ACLS training, or in your minds eye (often as you reflect on previous responses: â€œhow could I do this better next time?”)
Responding to emergency situations involves a whole set of skills that we learn over the course of our careers. Most of the responses are simple really, opening airways, CPR, setting up equipment, getting the right help at the right time, offering reassurance.
But fully engaging with these activities confidently, in the heat of crisis…..this is a skill that takes time and practice (and patience with yourself) to acquire.
- Proceed. Roger that. Remember, whatever you do now, it is going to be more capable and more amazing than the probable response of 95% of the people on this planet.
That is why you are a nurse.
- ————Crisis Resolves———————–
- Un-engage. Once the emergency is over, check in with yourself again.
Disengage from crisis level 10 and dial back to your coasting level 44.
Go and wash your handsâ€¦..and â€˜STOPâ€™.
- Proceed. Back to what you were doing before. Its a tough gig this nursing thing.
Being able to switch back to dealing with that person complaining that their finger dressing is too tight right after a team resuscitation of a 5 year old girl, AND giving them your full attention is not easy.
STAMP AID: dealing with violent behaviour.
STAMP helps you identify the potential for escalating violence.
- Staring. Staring is an important indicator of violence potential. That prolonged, intent, eye contact we have all experienced drilling into our backs as we go about our work, has been found to be one good predictor of increasing anger.
- Anxiety. The large number of emotional and physical stressors poking into the patient, can easily push them into a space where their behaviour is not in character or control.
Pain, loss of control, fear, alcohol or drugs can all induce an internal environment fueled by acute anxiety.â€¨Indicators such as rapid speech, flushed face and hyperventilation were identified as predicting trouble ahead.
- Mumbling. When combined with other negative cues, mumbling or slurred and incoherent speech, especially when composed of aggressive, negative statements about the waiting times or service was a another good predictor.
- Pacing. Patients pacing around the waiting room / ward or visitors pacing around patients beds has also been found to be indicative of mounting agitation.
So you have a pretty sure feeling that you and your patient are headed for conflict. What can you do? Well here is a tool I have come up with to minimize a situation of escalating violence.
AID stands for attend, inform, defence.
- Attend. One of the big generators of anxiety amongst patients and relatives is the feelings of *abandonment* they experience in the ED. Never mind if its the waiting room or a treatment area, patients often perceive that they are not receiving the level of attention they need.â€¨By making an effort give attention to these patients we can often diminish these feelings. Even if we cannot meet all their perceived needs the very act of exercising authentic concern may be enough.
Though it may not be an easy task, try not to avoid a patient that is beginning to show signs of STAMP.â€¨This simple act of attentiveness is often enough to de-escalate any anger and will often prove a far easier interaction than trying to manage a later situation of overt hostile aggression.
- Inform. Communication breakdown is another major cause of increasing aggression and contributes to feelings of abandonment and loss of control.â€¨When patients are waiting to be seen, or waiting for test results, or waiting for a ward bed to become available, keep them informed of the expected delays and any changes to their position in the queue.
Listen to any questions they may have.â€¨Tell them what has happened what is happening and what will happen.â€¨Many emergency departments now have hand-outs or notices explaining both the Triage process as well as preparing them to spend an extended time as they are treated in the ED. Make sure all your patients have an opportunity to access this information.
Patients should also be informed with signage and handouts that aggressive behavior will not be tolerated.
- Defence. Stay safe.
Never forget that even though we may be able to predict an escalation of emotions that may lead to violence, it is much harder to predict how that violence might be expressed.
With a sustained exposure many nurses have desensitized themselves to low-level violence and have a much higher threshold of acceptance than most people. This is a bad thing.
The fact is we should be promoting a zero tolerance for aggressive or violent behavior, period.
Agitated or aggressive patients are enveloped in a no-go bubble that extends the distance of their outstretched arms. Never enter their bubble unless absolutely necessary.â€¨ Never let an aggressive person come between you and your exit strategy. Talk in a calm, even, clear voice. Make any instructions short and unambiguous. Avoid prolonged eye contact if patient is agitated or paranoid.
As I have advised before: When interacting with a potentially volatile patient it may be helpful to try and see your self as an observer of the scene. Imagine yourself stepping *outside* the situation looking on dispassionately. Watch how the relationship between the other you and the patient is evolving. Remember all this anger is not yours unless you choose to react to it.â€¨Its not easy, but using this technique may help you from getting caught in the emotional wash from an abusive patient and feeding the escalation with your own reactions.
It should be part of your ongoing professional development to establish a set of skills and strategies for dealing with these sort of scenarios. Many hospitals offer courses on dealing with cases of professional assault which offer a combination of de-escalation strategies as well as simple self defence techniques.
- the medical term for this is shit. And right about now, that would make you a shit magnet. [↩]
- remember it could always be worseâ€¦it could be you lying on the ground in a pool of vomit / blood / faeces / snakes. [↩]
- dangers might include obvious hazards, occupational exposure risks [↩]
- Un-engage does not mean to suppress or sublimate what has just happened. De-briefing, reflecting and talking about your experiences either formally or informally is super important. But often in the real world of nursing this cannot happen immediately and you may have more work and more emergencies in storeâ€¦. [↩]