power struggles

[TerpGal02]

I just do not get how so many of our adult staff cannot grasp the concept of not getting involved in power struggles. Urgh. Case in point. We have 2 pts on the unit veeeery Axis II, antisocial PD males that just rub you the wrong way. Well every time staff has to redirect them, they get into arguements with them about what actually happened and then want to argue some more after the fact. We had one guy got from his room to Tue bathroom shirtless. The staff wanted to make a big deal about it. I just went down and said, "Hey I can't have you in the hallway without a shirt on". He apologized I started to walk away biut staff still wanted to have a go with him. I just had to tell them "let's go". If he did it again, he was warned and we'd step up to losing privileges. I don't understand what is SO HARD about this. The C&A staff is pretty great at being firm but fair with the kids.

[MDMBSNRN]

Sorry to necro this thread, but I found it while googling the issue and figured this was better than starting a new one. Out of curiosity, how do you deal with those "little voices"? I usually consider myself a huge proponent of least restrictive environment, but I have a button or two like any person, and I've found that patients refusing care pushes them. The patient might be belligerent about it, jerking away from me or yelling... or they might be perfectly polite, but they're simply not going to take those meds tonight, thank you. It drives me nuts that I even have this button! It feels very un-nurse-like. But each time it happens I find myself trying to cool down afterwards. Obviously I'd never force a patient to do anything, or perform something they'd refused against their will unless it was an emergency (we do very occasionally have emergency orders for things like IM antipsychotics). But from the other side of you guys' discussion, how do you deal with the urge to stay on the hill and fight?

I worked psych for a little over a year in between stints in ICU. My unit was primarily made up of thought disorders and patients too violent for other facilities, with a nice mix of geriatric psych thrown in. When I first started in psych, I felt as though it was my obligation to ensure that all patients took their medications. At times, I, like you, felt angered over a patient's refusal. Other times, I tried to bargain/reason with patients regarding their medications.

As I progressed in my psych career, I realized that some battles simply can't be won, and aren't worth fighting. I also quickly learned the phrase "not the hill you want to die on." I got to a place where I refused to argue with patients, but I was also firm. I frequently had patients who attempted to refuse their scheduled sleep aide (normally Trazodone) in hopes that they could receive PRN Ativan or Xanax later on in the night. To these patients I would say, "it is your right to refuse medications, however, if you refuse to take this medication, and attempt to let it work, I will not be automatically administering Ativan or Xanax when you complain of insomnia in a few hours."

For patients who refused all medications, I would explain to them (calmly) that this is part of the way we are trying to improve their condition, and that refusing medications only hurts themselves, and impedes progress towards being released from the inpatient setting.

In the end, I simply had to learn to refrain from being reactionary related to the behavior of a patient, and to refrain from feeding into any ploys for attention.

[Jusween]

Many people scoff at trauma informed care but having worked in psych since the 80s I believe it is the single most efficacious model for nursing, behavioral or medical. Trauma informed care essentially says that people are almost always trying to control their environment and that this is a healthy and normative trait that should be encouraged. Axis II patients have often experienced a skewed background in which they have never learned how to self soothe and they don't have the skills to tolerate pain, frustration or intimacy. This means they go about meeting their needs inappropriately. It is important to acknowledge the inappropriateness of their methods while validating their pain and fear. When I can look at a patient and really understand how scary it is to feel out of control, it makes it easier for me to avoid power struggles and to work to provide an environment that allows for as much autonomy as possible. I also like to point out to my borderline patients the tragedy of pushing people away by being provocative when they are feeling most distressed. Confrontation doesn't have to be accusatory or punitive. When you set limits compassionately and only when necessary you are more likely to get cooperation. The most important thing about psychiatric nursing is understanding your own buttons as well as holding yourself accountable for your own needs for power and control. Google "parallel process" for more on staff counter-transference.