How do you deal with the name calling?

[pixierose]

I have had a long string of bad evenings. I work in psych. Apparently I'm not the only one; those in my new grad residency have had similar experiences on telemetry, ED, med-surg, etc floors. No guidance was given by our residency superior; more a gripe session which is a pity.

Last night I wasn't fast enough apparently with meds for a particular patient; she told me several times that I was going to hell. Ok.

Another patient stated, "you're a terrible nurse! Just get me my damn meds!" when I got to her. Went downhill from there.

Granted, I work psych. One of my patients is detoxing so I just let her ramble the insults, didn't respond, and left.

However, the other one? She is borderline and paranoid, yes. But she just kept going off as I was starting to scan her meds from the WOW no matter what I said (or didn't). How I was a liar, how I was going to hell, and a whole slew of names. I finally had enough; after asking her to please lower her voice the 2nd time (she was beginnning to shout) I placed the meds back in the WOW and stated that she could have them after she stopped shouting rudely at me.

I then walked back to the nurses station. She was extremely angry ... but she did knock it off. Eventually.

After speaking to my classmates, it seems like this happens quite a bit ... psych patient or not (and there have been a lot of psych patients on floors who haven't been medically stable enough to come to us).

So what do you do when the nastiness rolls in as you're providing something like their scheduled 8p meds/prn pain/Ativan med which comes up a ton? I used every therapeutic communicative technique I could think of. Nothing. Ignoring? Nothing. Attempting to validate? Nothing. I wasn't even late with meds. It just seems like some patients are bent on venting their frustrations onto the staff ... and here I am, gritting my teeth and wanting to just walk away. Last night it worked for a certain patient; I just don't know if I did the right thing. It's distracting!

[FolksBtrippin, BSN, RN]

I'm a new psych nurse also.

2 thoughts:

1. Can you pull meds in the med room so you are not distracted by pt behavior? If not, try to brainstorm some ideas for yourself so that you get the meds to the patient on time. Don't let the patient get you to withhold her meds, because that is a power struggle. She takes them or she refuses them. That's it.

2. Every day you meet safety goals is a successful day. Sometimes that is all you do. So if no patients and staff were harmed, you get bingo. Everything else is bonus round bingo.

[cleback]

Sounds like you established boundaries and then when you enforced them, she eventually calmed down. To me, that means you were successful.

If there is a patient with behavorial issues, are all nurses setting boundaries and uniformly enforcing them? In my experience, that is half the battle...

[DizzyJ DHSc PA-C]

I once had a patient call me a "blonde Russian *****". So, after work I found a white T-shirt and some markers and made a cool blonde Russian ***** shirt to wear. I'm not even Russian.

[pixierose, BSN, RN]

Thanks everyone -- great responses!

As far as I'm observing, everyone is enforcing the same rules. I work with good people (I'm pretty darn lucky).

As far as pulling meds, I pull them from the Pyxis, place them in my WOW, and bring them to her. I scan her bracelet after asking if she's all set with a drink (although I have my already filled water pitcher), and I scan and open, reading what I'm giving to her as I go (in a private area so she can have some confidentially with her meds). Our MAR is a little glitchy (go Epic), so I like to concentrate to make sure it picked up the scan, etc. (I doublecheck BP before I even get the meds, as one is a BP med).

As I scan and tell her, I ask if she has any questions. And off goes the tangents. But if I don't tell her, she goes off as well (plus that's just rude). The psych has given her printouts; she loses them. It's just a mess.

She's actually yelling out in the milieu now (I'm eating dinner and don't have her tonight). The nurse just calmly left, without giving her the desired tramadol she's been demanding (it's not time yet ... she knows that). It's really riling up some patients.

[angeloublue22, BSN, RN]

How do does your unit deal with privileges? We start taking away privileges with this kind of behavior. You seem like you are doing what you should be doing. After a while of working in psych, I came to appreciate the insults because they can come up with some pretty creative stuff. Just let them roll off but if she is disturbing the milieu than it's behavior that needs to be addressed. Do you have a treatment team with counselors that can possibly speak to her?

[NightNerd, MSN, RN]

After a while of working in psych, I came to appreciate the insults because they can come up with some pretty creative stuff.

True! Ooh, I would love a thread about the best names we've been called. My personal favorite was being referred to as a *******.

[78diho]

With personality disorders, I ignored it. I learned that if I responded, that I was feeding into it. It took a bit to stifle myself and bite my tongue. In such situations, its attention seeking in a very bad way. Responding to it in anyway, therapeutic or not, is giving that person a response/attention. And that's their goal.

Hand her the meds with a blank expression on your face. Grit your teeth and move on.

This is setting limits. Try not to let yourself feel guilty over this because she is manipulating you....and it sucks to be manipulated.

[Natasha A., CNA, LVN]

Hi OP, I work in a psych unit and walk in your shoes. Have you looked into taking a NCI training course? The verbal/nonverbal communication section of the course is really helpful to teach how to deescalate situations as well as help staff cope in a behavioral psychiatric environment.

It has topics on how to set limits, how to assess/identify the different behavior levels and how to respond to patients with the following behaviors: (anxiety - level 1 using support, defensive - level 2 using directive, risk behavior- level 3 using physical intervention as last resort, and tension reduction-level 4 using therapeutic rapport. It also teaches how to identify challenging question vs informative questions (not to answer challenging questions and allow silence) and how to use negotiation properly. And using critical judgment when to remove the resident from an environment with an audience because it causes a domino effect to the other patients.

Also, has topics on staff coping skills such as taking extra breaks, knowing your own triggers, staying calm and saying a mantra like "its not about me" and having empathy for the residents because you do get to go home after your shift while they have to stay there. The best part of the course is learning reflective thinking. "What could I have done better? "What can I do next time?" This course uses a teamwork approach on how to assess, plan, anticipate and use direct communicate with psych patients. The more knowledge you have about your patient population and training the better the outcome. i highly recommend.

[JKL33]

Hi OP, I work in a psych unit and walk in your shoes. Have you looked into taking a NCI training course? The verbal/nonverbal communication section of the course is really helpful to teach how to deescalate situations as well as help staff cope in a behavioral psychiatric environment.

It has topics on how to set limits, how to assess/identify the different behavior levels and how to respond to patients with the following behaviors: (anxiety - level 1 using support, defensive - level 2 using directive, risk behavior- level 3 using physical intervention as last resort, and tension reduction-level 4 using therapeutic rapport. It also teaches how to identify challenging question vs informative questions (not to answer challenging questions and allow silence) and how to use negotiation properly. And using critical judgment when to remove the resident from an environment with an audience because it causes a domino effect to the other patients.

Also, has topics on staff coping skills such as taking extra breaks, knowing your own triggers, staying calm and saying a mantra like "its not about me" and having empathy for the residents because you do get to go home after your shift while they have to stay there. The best part of the course is learning reflective thinking. "What could I have done better? "What can I do next time?" This course uses a teamwork approach on how to assess, plan, anticipate and use direct communicate with psych patients. The more knowledge you have about your patient population and training the better the outcome. i highly recommend.

Great recommendation; it would be wonderful for nurses in many different areas, I'd think.

[pixierose, BSN, RN]

Great posts, keep them coming...

I have taking the 16 hour (for newbies) NCI course.

She doesn't meet restraint criteria as she doesn't have a plan for one, nor do we place our hand on her to guide her anywhere -- that's a guaranteed trigger for imminent explosive behavior. Using silence I think makes things worse ("what, you're not talking to me?" "Got nothing to say to that, dummy," "yeah, I knew you had nothing ...") but I use it a lot because using words a lot is difficult as well.

This thread has been helpful though in reminding me of those points I did learn in NCI: my own trigger points and improved reflective thinking. That and, " it's not about me." Because I think I was beginning to take it personally.

The doctor on call last evening was very frustrated with this patients psychiatrist (which I guess made me feel a bit better but a lot worse); this patient has escalated (again) and another patient reacted (again) and the doc felt she should really be directed to her bedroom when she becomes that way in the milieu (swearing loudly, yelling at staff, yelling at other residents). Her psych thinks that's seclusion, so he doesn't agree. Meanwhile ...

[pixierose, BSN, RN]

True! Ooh, I would love a thread about the best names we've been called. My personal favorite was being referred to as a *******.

Oh, I'm using my imagination here!

We need a "best of" thread.

[pixierose, BSN, RN]

How do does your unit deal with privileges? We start taking away privileges with this kind of behavior. You seem like you are doing what you should be doing. After a while of working in psych, I came to appreciate the insults because they can come up with some pretty creative stuff. Just let them roll off but if she is disturbing the milieu than it's behavior that needs to be addressed. Do you have a treatment team with counselors that can possibly speak to her?

We sadly don't use privileges on our unit. Maybe it's time we do so.

Her treatment team speaks to her for several moments at a time ... then ask her to leave because it rarely goes as planned. She picks and chooses the meds she wants to take and this doesn't help.