ASSESSMENT SKILLS IN A CRISIS SITUATION
WHAT CONSTITUTES A CRISIS
What is a crisis? Although objective definitions can easily be found, a crisis is a very subjective experience. One person’s crisis is another individual’s daily event and after a stressful week at work, running out of milk on Friday evening at Dinner can feel like a major crisis. We cannot define what another person will experience as an emotional crisis, nor do we have the right to judge their experience or apply our standards to determine if they are really experiencing a crisis. Factors influencing which life events are perceived as a crisis are many and may include: pre-existing stress level; family and/or cultural standards for experiencing and coping with stressful life events; reactions of significant others to the event; feelings about the event such as guilt, shame, blame, betrayal, etc.; violence associated with the event; if the event was anticipated or not; and previous coping skills for dealing with crisis. Basically, a crisis state exists when an individual’s usual coping abilities are inadequate to deal with a current stress.
In the health care settings crisis events are numerous. We as care providers may react to situations in our work as a crisis. We routinely encounter traumas, violence, deaths, human error, and human suffering in our day to day work. These meet the most vigorous crisis standards yet we are expected to remain detached, provide competent, effective interventions and then move along to the next patient and situation. Additionally we are often called upon to assist our patients and their family members deal with their crisis on an emotional level. And for many of us, this is just what we may feel least prepared to do.
WHEN DO NURSES NEED TO RESPOND TO EMOTIONAL CRISIS?
This section will discuss skills and techniques for response to the emotional crises, which health care providers are likely to encounter. But first, a few comments about our needs in the crisis laden health care environment. Not only must we be able to care for our patients, but we must be able to care for ourselves. We must develop awareness of our reactions to work related stressors; develop the ability to articulate our feelings; develop stress reduction skills which we practice routinely; choose work settings which are supportive and which care for the caregiver. We must also know which situations are most difficult for us and avoid them when possible. Nurses in trauma and critical care areas, in particular, are repeatedly exposed to sights, sounds, and smells that are intensely disturbing and stressful. Self care in these situations is essential to insure optimal performance and job satisfaction as well as to prevent burn-out. Very few people can care for others in crisis while they are experiencing crisis level stress themselves.
What are some of the crisis situations which health care providers encounter? Clearly we provide direct care to patients whose lives are threatened by trauma or disease. Some of these situations are acute, intense, traumatic, and rapid – others are slow, chronic, painful and exhausting. Some patients recover from life threatening crisis and others do not. We expect to care for our patients and usually feel prepared to care for the physical needs. However, we may feel less confident about dealing with the family member – at the bedside, with the ambulance, or in the surgical waiting room. Often, we are expected to comfort a grieving parent, spouse or child, for example, when we ourselves feel stressed or upset.
Another crisis situation nurses may encounter is the development of acute psychiatric symptoms in a medical patient. How do you cope with a patient who becomes depressed and suicidal or bizarre and psychotic? And again, how do you deal with this patients’ spouse or children?
How nurses are called upon to handle emotional crises varies not only from institution to institution, but from shift to shift as well. Obviously, every nurse needs to be familiar with the policies and resources of their particular setting. As the “round the clock” health care provider the ED night nurse may need to develop greater skills in assisting grieving family members than the day shift, ambulatory surgery staff nurse. It is essential that staff be aware of the support services their institution has available, when these services are available and how to access them. Armed with this information the nurse can begin to intervene in a crisis situation.
Grief is a universal life experience all but the most emotionally isolated individuals inevitably experience in their lifetime. Nurses are frequently confronted with grieving family members in the acute or extended care settings. Grief is the most immediate reaction to the death of a loved one and is comprised of sadness and emotional pain. When confronted with a grief stricken individual, may of us feel uncertain of how to respond and inadequate to meet their needs. Both these uncomfortable feelings uncertainty and inadequacy may stem from an assumption that we need to “fix” the grieving person. In reality, offering empathy and support are all we need to do.
Grief presents in many guises. It is a reaction to a very particular intense stress and an individual’s personal grief will reflect their personality style, coping abilities and cultural influences. A few typical grief reactions are:
- DENIAL – the individual is detached matter-of fact, distant, and maintains the stiff-upper-lip.
- HYSTERIA – the individual cries profusely, may wail, call out to the deceased, moan or lose control of their behavior. In some cultures people will hit themselves, pull out their hair, or rip their clothes. This can make hospital staff that is unaccustomed to such grief very uncomfortable but it is often culturally appropriate. We should try to provide the family with privacy for their grief but it is also appropriate to insist they keep their voices and behavior within bounds that will respect the rights of other patients.
- WITHDRAWAL – the individual may shield their face, stop interacting, speak in monosyllables only when spoken to, and avoid eye contact.
- ANGER – this individual may project gilt and blame for the death onto the caregivers; they may be loud, rude and provocative. This person may criticize the MD or the ambulance team and attempt to get the nurse to agree with them.. They need to ventilate and be accepted but the care giver must not take sides or get in the middle and must resist taking the anger personally.
Typically, grieving individuals have decreased concentration. They may seem scattered and dazed; often they are unable to focus. They feel numb, thoughts may become blocked and interactions may be interrupted or incomplete. We can help with this by refocusing, redirecting, and prompting individuals to finish thoughts. The characteristic liability of grief can be frightening for people. They cry then recover, begin to speak or make a phone call and are then struck by another wave of grief just when they were beginning to feel a bit of control. Describing this process and explaining this a normal grief can be quite reassuring.
Merely remaining with a grief stricken individual is very supportive and helpful. Small comforts such as a cup of tea, a pat on the arm or hand, or a call to a neighbor are very helpful and often appreciated. Support the person to do as much as they are able for themselves but also ask them what they wish you to do. When you cannot stay with the person, check on them frequently or call on other hospital resources to assist them. Another empathetic offer is to see if the person wants the company of a priest, rabbi or minister. After a time, do ask if they wish to view the body. In some cultures the family will wish to prepare the body and even have a bedside service before the body goes to the morgue. It is a great kindness when our busy settings can be flexible enough to grant such comfort to a grieving family. Do prepare the family members for the appearance of the deceased by describing tubes in place, etc. and accompany them to the bedside. Stay with them until you feel confident they can be safely left alone. Finally, see that the person does not leave the hospital alone unless they insist. Offer to call them a cab if needed.
These very simple gestures are all that needs to be done in a grief crisis. When social service staff is available they may wish to provide resource information regarding bereavement or grief support groups, or information on other resources to families who have sustained special loses. These basic suggestions are empathetic and supportive to anyone attempting to cope with grief.
When a caregiver has taken these supportive and empathetic steps they have utilized the first 2 of 3 techniques of crisis intervention. These are:
- Develop an alliance
- Gather information
- Problem solving
By reaching out to the bereaved, spending time with them and offering a few caring gestures, you are usually able to develop an alliance. This allows the person to feel slightly less alone and isolated with their grief. Next, by gathering some simple information - “Would you like me to call your minister? … Tell me how I can help you?” – you help them to help themselves by articulating their needs. The final stage can begin when resources are offered but it may be premature to begin this until a few weeks after the death. (Literature or phone numbers may be provided to another family member or friend to offer to the bereaved after the immediate period of grief elapses.)
These basic steps can be used to intervene with other crisis situations which nurses may deal with in an acute care setting such as a change of mental status. Change of mental status may appear as confusion, suspiciousness, misperceptions, etc. Whatever is occurring, developing an alliance and gathering information are key to accurate assessment and, therefore, to effective intervention. These phases often overlap and, in fact, in gathering data you may actually develop your alliance with the patient. Often, caring, sensitive and perceptive questions convey sincere concern to a patient while indirect investigation of a situation can arouse suspiciousness and paranoia. These same techniques are used with a patient or a family member. Many crises in an inpatient setting affect your patient and their significant others as well. What information needs to be gathered in these circumstances? Some helpful questions include:
- Is there a precipitating event? Why is this change occurring now? What has recently occurred that feels threatening to the patient’s coping abilities and emotional equilibrium?? Have there been changes in meds or in laboratory values?
- Has the patient experienced similar changes in the past? You may ask – “Have you felt like this before?” and explore what was the precipitant then.
- What helped the patient in the past? Is there something the patient can do to help themselves? “What may I do to help?”, you may wish to ask.
- Why is this patient susceptible to this change just now?
- What resource does the patient have available? How can she/he access these resources? How can you assist the patient to get support?
You may have other questions that will be pertinent to the specific situation. Once information is gathered, it is essential the nurse know how to access the most helpful resources. Is there a psychiatric crisis nurse or a psychiatric liaison nurse who can be called in to consult, for example? Often with changes in mental status, intervention needs to be rapid to be effective as deterioration can occur all too quickly.
Again, nurses are often not in a position to proceed with the problem solving steps of intervening in a crisis. In situations where problem solving is appropriate, here are some techniques.
- Keep problem solving simple. Often as care providers we can get caught up in elaborate solutions – ones that actually go beyond the confines of the crisis as the patient perceives it. We need to take our lead from the patient and allow them as much action and control as possible. We assist them to act and do, not do for them.
- Set realistic goals. This means goals that are realistic for the patient given their abilities, previous level of function, their vision of the crisis, etc.
- Identify and focus on the patient’s strengths and abilities. This is not a time for the patient to develop new coping skills. We can help enhance their self-esteem by supporting their capabilities.
- Avoid advice. This can increase the patient’s feelings of helplessness or inadequacy. Explore options; help the client walk step-by-step through possible solutions; encourage them to “try out” alternatives but allow the patient to choose their solution.
- Know when to stop intervening. And refer to mental health professional. Know your limits and how to access other resources in your institution.
Another situation of crisis proportion is when a patient becomes violent while hospitalized. The combative or assaultive patient presents a frightening dilemma to nursing staff. There are a variety of underlying causes for this type of behavior, but regardless of its origin, care providers have an immediate responsibility to protect themselves, the assaultive individual and other patients. Although many assaultive patients are associated with psychiatric services, the nursing literature reflects a growing concern with violence in all areas of the hospital setting. While psychotic or psychiatrically impaired individuals may account for the majority of patient assaults, other patients on non-psychiatric services do become combative. Examples may include individuals who are under the influence of alcohol or other drugs of abuse; patients withdrawing from alcohol; patients who develop an ICU psychosis; and unusual drug reaction; or who are demented. Such situations can develop in the emergency department, critical care areas, med-surg and skilled nursing areas – in other words, just about any setting is occasionally at risk.
Assault is defined as any verbal or physical threat with the power at hand to commit harm. A patient who threatens verbally to hit at staff and raises a clenched fist is assaultive. Battery occurs when actual physical contact with the intended victim is made.
The problem of care givers being assaulted by patients is thought to be grossly under-reported nationally. Often staff doesn’t wish to deal with the paperwork involved in reporting such incidents or are unwilling to leave their unit to go to the appropriate area for an assessment especially when their unit is experiencing turmoil. While these sentiments can be understood, we are unfair to ourselves when we minimize or dismiss such a stressful event and do not care for ourselves appropriately.
There may be attitudinal reasons as well for the under-reporting of patient assaults. Often victims feel responsible when they are injured. assessment skills were inadequate or they waited too long to medicate the patient or that occasional situations of this nature are “part of the job” or even question if their heavy workload caused them to provoke the assault in some way. Such thinking represents classic “blame the victim” reasoning and can serve to compound the stress reaction which staff ay experience subsequent to the event.
Being assaulted by a patient is an experience which defies our expectations for our role as a care provider. In addition to causing emotional and often physical harm, assaults ma have significant symbolic meaning, Responses to such an event will vary depending on the level of threat perceived during the event and the extent of injury to the staff. Responses will also be influenced by the interpretation the nurse attaches to the event,. Do they view themselves as less competent because of this event; feel concern that peers will think less of them; or continue to feel unsafe at work? Any of these are normal early reactions that can cause lingering effects.
Later reactions occurring from several hours till days or even weeks later may include: decreased concentration, sleep disturbance including dreams of the event, intrusive thoughts about the assault, hyper vigilance, avoiding patient contact, decreased self-esteem, or changes in relationships with peers or family reactions of supervisors or administration; may experience concerns about their feelings toward the patient who injured them and wonder if it is professional to feel or verbalize negative responses. They may also experience a dilemma about pressing legal charges against the patient.
Combative or assaultive patients clearly pose two concurrent problems. One is that a safe environment is essential. Immediate interventions must occur to contain the combative patient and prevent them from harming themselves or others. The other problem is that any staff member who is assaulted at work must be cared for immediately as well. Both these problems must be handled as outlined in institutional guidelines and here again staff needs to be familiar with the policies related to such events.
Institutions generally have some method of gathering sufficient staff to safely contain an agitated, combative patient. There are however, general guidelines that can assist in these stressful and difficult situations.
- Always use the least restrictive interventions necessary to reestablish safety. This is a basic tenet of patients’ rights and a legal concept known as reasonable force. We must try firm voice commands first then proceed to a “show of force” before physically restraining a patient when at all feasible. A “show of force” can be quite effective with an out of control individual. When an agitated, combative person is confronted by a significant number of staff (4 - 6) and directed to stop a behavior or suffer certain specific consequences (such as application of wrist restraints): they may choose to cooperate. It is necessary to keep staff available for follow through however, until you are certain that this patient has reestablished self control. Often this can be assisted by administration of prescribed meds to decrease agitation or cause sedation.
- When a number of staff gather to physically contain, it is essential that one person lead and direct the intervention. Only this person should talk to the patient as well as to the intervention team. The leader should assign staff to restrain specific limbs and set up a “go-ahead” command for the team. To prevent injury, it is important that the team act in unison. Only the leader should speak to the patient. A patient who is confused or agitated enough to become combative cannot process multiple inputs.
- Keep direction to the patient and the team simple, specific and concrete. Think before you speak. Use short words and short sentences. Everyone in this type of situation is anxious and stressed; simple clear communications are essential.
- Keep patient safety a priority. Grab patients’ limbs above or below joints. Never sit on a patient. Use your weight to contain; lean into the restraining move. Always monitor the patients’ a airway. Allow time for agitation to diminish and for medication to work before moving the patient. Be sure restraints are applied securely but without compromising the patient in any way. Check the patient in restraints frequently – many institutions specify frequency in their policies on restraints.
If the injured nurse was not removed from the area before the physical containment of the patient, they must be attended to now. It is important that they report the incident and seek medical attention. A verbal debriefing is very helpful and peers or charge staff who was there for the incident need to insure this occurs. Assaults really challenge a staff’s cohesiveness and ability to deal with stress. Everyone on the unit reacts and it is important for management to support a non-evaluatory debriefing after such an incident. The injured nurse and all staff need an opportunity to discuss what happened, how they became aware of the incident, how it affected them and their responses. This is an opportunity to correct misinformation and clarify the actual incident as well as to discuss emotional responses. It can be a time to educate staff about normal responses to stressful events and how to manage stress. Often a psychiatric liaison nurse or other resource person can be used in this role. Although it is appropriate to use such events as a learning opportunity, it is never appropriate to blame the injured staff member for the inci threats or verbal abuse are serious events. As our culture becomes increasingly stressful and individuals utilize threats and violence more frequently to express their low self-esteem, despair and hopelessness, it is inevitable that health care settings will be disrupted by such events more frequently than in the past. Such stress, in addition to the routine but challenging stressors inherent in health care, will increase the incidence of burn-out among nurses. The phenomena of burn-out is generally regarded as the result of cumulative stress and is often discussed as a corollary of the co-dependency are processes more than events, the moment or situation which facilitates a nurse to self-identify oneself as either burned-out or co-dependent would quality as a crisis based on the earlier definition of usual coping abilities being inadequate in a current situation.
The literature on burn-out and co-dependency in health care professionals is voluminous and even a summary of it is beyond the scope of this section. However, prevention of these conditions or early awareness of the development of either phenomenon will be assisted by some of the recommendations on page 17, such as: self-knowledge about our reactions to job stress: routine practice of stress reduction techniques including regular exercise, and seeking and insisting upon support in the work place. Many nurses find support groups at their work site or in their community invaluable to their self-care and management of work related stress.