Staff have an assortment of concerns about caring for people who are experiencing extreme emotions. Here are some of these with ideas we hope you find helpful.
If I’m chatting with a patient, it will look like I’m not working.
If we’re ever going to progress our care and skills we have to get rid of this idea – it is a large part of our work to talk to patients. That’s what makes them feel safe and that they’re treated as an individual. Remember the Disney priority of Safety – this is our priority.
It will look like you’re really getting to know patients and that you are actively helping them not just cope with being in hospital, but progressing from whatever stage of their illness landed them there. Even if it’s ‘just’ a simple social chat, this is a really valuable part of building up a relationship, and trust, with a patient. It’s not about avoiding other duties – chatting with a patient IS a duty, as valid as any other.
How safe am I with a patient who’s mentally ill?
The answer is as safe as with any other patient. However, there will be some exceptions such as where a patient is very disturbed by psychosis, dementia or delirium – they’re not sure what is real and may become very frightened. The classic is the frail old lady who has the strength of Tarzan when you approach her to take her to X-ray because she thinks you’re burglars who want to beat her up. Reading the sections on these conditions will help. Also have basic safety awareness – make sure you are between the patient and the door so you have a quick exit strategy; know the emergency number for security back up; when approaching some patients you may want security back up but of course always spend enough time talking with the patient first to try and establish rapport.
There are some great new guidelines ‘Meeting Needs and Reducing Distress’ with training scenarios by NHS Protect, 2014
What do I do about a patient who self-harms?
The key here is to always get to know your patient – chat to them find out basic things eg do they like music? What bands do they like? What star sign are they? Do they read Heat/OK magazines? What work do they do or did they used to do? Get to know them as a person; this is reassuring for the patient as well as for you.
In our experience, generally the more severe the self-harm the more traumatic the past life experiences of the person this may include bullying; cyberbullying; neglect; physical and sexual abuse. Many but not all people who self-harm have a diagnosis of Borderline Personality Disorder – see section 25.
You don’t have to know the person’s full history however. If the person has very bad scarring you could say ‘You must have had a very difficult time and felt very bad in the past’. This simple acknowledgement that you recognise how emotionally painful their life has been can help generate trust and understanding. Ask the person if they feel safe (i.e. not in immediate risk of self-harming); ask them if they have any strategies that they use when they have an urge to self-harm (eg listening to their music, having a relaxing bath) and implement these if at all possible. Take practical precautions eg don’t wear scissors; watch for anything that could be used as a ligature; remove sharps bins etc from the area; don’t leave the drug trolley unattended in their sight even for a moment – the urge maybe too strong to resist these opportunities. If the patient feels unsafe they may need close observation, having a nurse with them at all times.
As you get to know the patient there may be a mental health assessment which you can read to understand their past history and current problems. Individuals who self-harm severely can have a voice/voices telling them to self-harm. It’s important that we know this as we can try to help them resist the voice, possibly by using distraction eg by talking, reading a magazine together; giving medication if prescribed.
What do I say to a patient who is suicidal?
This is one of our greatest fears, that a patient will say: ‘There’s no point in living I want to end it all’. Because of this many staff can avoid talking in any depth with a person who we know is feeling down and desperate and may already have a diagnosis of clinical depression. We’re frightened of opening a ‘can of worms’ and that we won’t know how to respond.
There’s no magic answer except to remember that this person is in a very dark place and feels a profound hopelessness; any warm interaction with a member of staff who seems caring is going to help. The key here is warmth and hope – the person has lost hope and we help by giving them some hope back.
There is no harm in asking about suicidal feelings, by asking and not ignoring you are showing the patient you understand how awful they are feeling. You can respond: “You said you want to ‘end it all’ what do you mean by that?” said in a low, calm, warm tone of voice. If the patient responds ‘I want life to finish’ check by gently asking: “Do you mean you want to end your life?” If the patient responds yes say something like “You’re in a very dark, hopeless place at the moment and you need help, we would like to help you. I can ask my colleagues working in mental health to come and see you. I’ll carry on working with you – we don’t have to talk about this but I’ll be aware of how awful you feel and if you just want a chat I’m here.”
As you can see this isn’t a great sophisticated intervention but it’s telling the patient that you’re here and you understand how hopeless they’re feeling. The next time you talk to the patient take your cue from them they may just want to chat about the TV or weather as a distraction – go along with that. If they want to talk about how they feel, get a chair, sit next to them and listen. You can’t change their life or resolve major life problems but as we know (Section 4) listening alone is a powerful, therapeutic tool.
As the patient has said they feel suicidal they need an immediate referral to liaison psychiatry; tell senior staff who will organise this. If the patient says ‘I’ve got something I really want to tell you because I trust you BUT you mustn’t tell anyone else’, you have to respond “I’m sorry but I work in a team and will have to discuss any care issues with them, to make sure you get the best care.” Confidentiality never applies to suicidality.
Always debrief with another member of staff after talking and listening to a suicidal patient – this situation can be very difficult but also very rewarding as you are genuinely making a difference.
Admitting mistakes and saying sorry.
If staff say or do something ‘wrong’, they can worry the patient could sue the hospital. For example if staff know that something’s gone wrong with a patient’s care it can feel impossible to admit it. Staff don’t know who has spoken to the patient, have they been told there’s a mistake been made? If staff admit liability can they be sacked? This is what the NHS Litigation Authority says: ‘Saying sorry when things go wrong is vital for the patient, their family and carers, …. Of those who have suffered harm as a result of their healthcare fifty percent wanted an apology and explanation’.
Who should say sorry?
If you lose a patient’s glasses or false teeth you say sorry and look for them. But what about the more complex cases? You or colleagues may be ‘…unclear about who should talk to patients when things go wrong and what they should say; there is the fear that they might upset the patient, say the wrong things, make the situation worse and admit liability’ (NHS Litigation Authority 2014). NHSLA say that all hospitals should have a local policy that states who is the most appropriate member of staff to give both verbal and written apologies to patients. The decision about who does so relates to seniority, relationship to the patient, experience and expertise. PALS services are available at all hospitals and you can advise patients that they can go there.
The point is made very clear that saying sorry is not an admission of legal liability; it is the right thing to do.
Remember Disney priorities – Safety is first. The NHS want to be an organization where all staff are motivated and encouraged to report safety incidents and staff should be supported to do this. Just like the airlines.
Nevertheless, as Sir Elton so wisely said (and tunefully sang…) ’Sorry seems to be the hardest word.’ It can be ridiculously difﬁcult to apologise. Some of the reasons why everyone can sometimes ﬁnd it impossible to squeeze out that word that rhymes with lorry include:
- We don’t want to admit we were wrong. This usually underlies whatever else may be preventing us from releasing that simple word which might instantly make the situation much better.
- We think as a professional we should always be ‘right’ or we lose our credibility
- We don’t want to look, or feel, ‘weak’ especially if we feel it’s important to be seen to be in a strong position of authority in relation to the other person
- We might worry that the other person will ‘take advantage’ of the situation
Q.1 Thinking about a time, at work or home, when you probably should have said sorry but couldn’t manage to:
- Why do you think this was?
- How might things have turned out differently if you had said sorry?
- Do you think you were being mind-aware, in particular about what the other person was thinking and feeling?
Q.2 How do you feel when someone apologises to you when they’ve made a mistake?
Q.3 Whatphrases do you use,or might you use in future to say sorry?
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