Managing Challenging Patient and Family Behaviors: Introduction (10:52)
Social worker Latasha Ellis works with a hospital cardiopulmonary rehabilitation program and provides oncology distress screenings. She will address how culture and personality disorders affect patient and colleague relationships, and provide strategies for managing workplace conflicts.
Evolving Healthcare Environment (10:26)
Ellis discusses how insurance payers determine patient needs, not medical professionals. Economic downturns result in short staffed facilities and sicker patients. EMRs detract from doctor-patient relationships. Ellis outlines the lecture topics.
Managing Challenging Patient Behavior: Group Exercise (24:39)
Patients and families must be fully involved in their care; service provisions must be culturally responsive; all behavior is an attempt to meet a need; healthcare professional-patient relationships should enable patients to express feelings and get needs met; and health care professionals should practice teamwork and networking. Ellis gives participants 15 minutes to answer questions about each premise.
First Premise: Group Responses (15:00)
Participants share their experience of how patients and families must be fully involved in their care. Ellis provides examples of how to work with patients and family members, even if family members seem not to have the patient’s best interest in mind.
Second Premise: Group Responses (11:27)
Ellis discusses how service provisions must be culturally responsive; knowing patient background is important for understanding behavior. She shares her experience working with interpreters at the Virginia School for the Deaf, Blind and Multi-Disabled, and discusses medical interpretation challenges.
Third Premise: Group Responses (22:38)
Participants share their experience of how behavior is an attempt to meet a need and has meaning. Personal therapy can diffuse attention seeking behavior. Ellis provides examples of dementia patients and a diabetes patient who cannot afford medication and frequents the ER.
Fourth Premise: Group Responses (10:09)
Participants discuss how relationships between health care professionals and patients should provide opportunities for patients to learn appropriate ways of expressing needs. Examples include: rural transportation issues, elderly isolation, and patient empowerment when communicating with doctors.
Fifth Premise: Group Responses (05:54)
Participants discuss how patients are best served by healthcare professionals who believe in and practice teamwork and networking. Examples include communicating with family about long-term care and rotating physicians. Ellis discusses networking with services outside the normal team.
Patient Anger and Aggression (13:26)
Grief, illness, unrealistic patient expectations, and family guilt can cause anger toward healthcare professionals. Ellis urges participants not to take outbursts personally, to validate patient feelings, and dedicate time to them. She recalls working with a challenging schizophrenia patient.
Managing Patient Anger (09:37)
The VALID process of de-escalating an angry patient or family member includes validating feelings, asking for more information, listening for their need, initiating a plan with two choices, and delivering their preference. Ellis gives an example of communicating with an exhausted caregiver.
Patient in Crisis (09:10)
Crises can include violent or sexual assault, illness diagnosis, or witnessing a traumatic event. Ellis explains why reduce anxiety rather than problem-solving at crisis onset, and cites an example of new opportunities for a hospital in crisis.
Suicide Prevention (07:20)
Most people who commit suicide have a diagnosable mental disorder. Ellis reviews risk assessments, protective factors, and at risk groups. Caucasian males between 40 and 60 have the highest rates; Asian and Pacific Islanders prefer suffocation over firearms.
Self-injury can cause death, but is usually a cry for help. It can signal self-dislike, hypersensitivity to rejection, chronic anger towards oneself, and poor impulse control. Picking at wounds among the elderly can indicate suicide risk.
Psychiatric Diagnoses (15:02)
Ellis discusses major depressive disorder, anxiety disorder, PTSD, acute stress disorder, specific phobia, social phobia, obsessive compulsive disorder, and bipolar disorder. Integrative healthcare seeks to unite medicine and behavioral health. Relaxation techniques and alternative therapies help reduce stress.
Helping Bipolar and Schizophrenic Patients (10:09)
Medication compliance and stress management are critical. Ellis references the "Black Box" series featuring a character with bipolar disorder and talks about social stigma of schizophrenia. Social support is important for keeping patients off the streets.
Schizophrenic Patient Intervention (07:44)
Ellis recommends supporting the patient’s reality if they are frightened. Hallucinations can be soothing, but if they are frightening, healthcare professionals should help patients feel safe. Ellis provides examples of creatively supporting patient realities to make them feel comfortable.
Personality Disorders (16:29)
Personality disorders are life long, maladaptive patterns of relating. Ellis describes antisocial, narcissistic, histrionic, borderline, avoided, dependent, obsessive compulsive, schizoid, and paranoid personality disorders. She provides an example of a borderline personality disorder patient pitting staff members against each other.
Substance Misuse (10:04)
It takes seven attempts, on average, to cure addiction; steps include physical and mental detoxification and breaking habits. Ellis discusses a smoking cessation program creating negative associations with cigarettes. Patients are manipulative, prone to emotional outbursts, and can be verbally abusive.
Traumatic Brain Injury and Webinar Feedback (11:20)
Visual, nonverbal communication is helpful for easily overwhelmed patients. Ellis responds to comments on the five premises for managing challenging patient behavior, including responding to demented patients asking about deceased family members. She keeps personal notes separately from patient records.
Ellis discusses the importance of teamwork in providing patient care with limited time and staff resources. Hear strategies for alleviating boredom or loneliness among cognitively challenged patients. Ellis covers Alzheimer's, vascular, and frontotemporal dementia, and encourages developing safe spaces for wandering patients.
Agitation Causes in Dementia (05:14)
Pain, discomfort, moving location, caregiver changes, misunderstanding care, and frustration with memory loss can agitate patients. Treating patients as adults while their cognitive function declines is challenging. Ellis outlines strategies for improving sleep.
Documenting Dementia Behavior (07:44)
Ellis explains how to record the antecedent, behavior, and consequence (ABC) analysis. She provides examples of creative strategies to keep wandering patients safe.
Dementia Case Study (09:46)
An elderly patient admitted to the hospital for a fractured pelvis declines medication and lashes out at nurses. Ellis applies the five premises of challenging patient behavior, including family involvement, interpreting cultural norms, decoding behavior, building rapport, and using teamwork effectively.
Building Compassion and Understanding (10:43)
Ellis shows a Cleveland Clinic video depicting inner thoughts and experiences of patients, family members, and hospital staff members. Afterwards, participants discuss personal and situational factors potentially affecting patient behavior.
Family Categories (13:31)
Families may be validating, overprotective, or unsupportive; hear possible explanations for their behavior. Support groups can help them cope with their loved one's diagnosis. Ellis recommends tactfully ending unproductive family member meetings, being mindful of cultural differences, and including patients when possible.
Care Provider Recommendations (07:11)
Ellis discusses the importance of self-awareness, managing bodies and emotions, taking personal time, and getting adequate sleep. Compassion fatigue is common in acute care nursing and rare in hospice nursing; Ellis explains why.
Emotional Intelligence (12:38)
Ellis explains personal competence in terms of self-awareness and self-management, social competence in terms of social awareness, and relationship management skills for handling challenging patients. She provides examples of responding to angry family members and patients in crisis during a difficult personal day.
Agitated ER Patient Case Study (09:50)
A 27-year-old man with an injured arm insists on being seeing ahead of other patients. Participants brainstorm how to calm him down, validate his feelings, get information, and assess his condition. Calling security can create an unsafe situation.
Blending Technique (17:31)
Ellis discusses the martial arts concept of using an opponent's force. Care providers can guide patients, rather than resisting them and creating conflicts. Hear strategies for addressing a dementia patient who wants to leave the room. Ellis discusses non-verbal, verbal and physical blending techniques.
Prevention Strategies (02:17)
Learn warning signs of anger or aggression. Ellis discusses helping patients meet their own needs and looks at Maslow's hierarchy of needs in terms of helping patients feel safe.
Avoiding Power Misuse (14:03)
Patients perceived as difficult have different expectations from clinicians. Professionals should be aware of situations in which patients feel powerless. Ellis describes an ethically challenging scenario in which a psychiatrist and social worker disagree on a patient's right to self-determination.
Communication Skills (06:02)
Patients should express needs in a non-offensive manner. Professionals should use active listening, validate patient feelings, use self-disclosure when appropriate, try not to assume anything, and pay attention to non-verbal communication. Ellis covers passive, aggressive, and assertive communication styles; assertiveness takes others into regard.
Interaction Model and Motivational Interviewing (09:49)
Ellis discusses a model of interacting with patients positively and therapeutically, rather than in an exploitative manner. Motivational interviewing helps patients understand the difference between goal achievement and problematic behavior; Ellis provides an example of a weight loss patient.
Process of Change and Intervention Strategies (06:30)
Ellis talks about planting seeds with patients; healthcare professionals should not assume failure the first time. Resist "parenting" patients, understand their motivation, listen with empathy and encourage expression of their ideas. Hear ways to reduce escalation or conflict between patients and address their needs.
Effective Behavior Management (06:36)
Healthcare professionals should look for opportunities to encourage nurturing behavior among patients. Give choices, use positives, and use past successes to point out strengths; respond, rather than react. Debrief with staff members after an incident. Ellis outlines organizational benefits to effective behavior management.
Blending with Resistance (04:57)
Healthcare professionals should determine patient motivation for resisting to build a rapport. Ellis provides an example of working with family of a dementia patient who was discharged to a long-term care facility with a negative reputation.
Managing Challenging Patient and Family Behaviors: Conclusion (01:01)
Three factors contribute to challenging patient behavior: the patient and family member, the provider, and the environment or situation. Blending is an effective behavioral technique. Identify the reason behind the behavior and use prevention.
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