Do some patients give your staff headaches?
Counselor tells how to lower stress levels
Someone on your staff deals with a trying patient each day, whether it’s a patient who is agitated and quarrelsome or whether it’s someone who has Alzheimer’s Disease.
A Virginia counselor who has taught seminars on how home care professionals can cope with difficult patients says he often receives complaints about agitation.
"The patient could refuse to take medication, refuse to eat, refuse care in general, and the refusal can be related to agitation," says Michael Hoback, community support counselor at Highlands Community Services in Abingdon, VA.
Hoback suggests you teach your staff to first find the cause of the difficult behavior by looking for changes in the patient’s routine and by listening carefully to the patient’s complaints.
There are many reasons a patient might suddenly behave with agitation, and here are a few common causes:
• A change in aides coming into the home.
"Sometimes in the home care situation you might find a change in the personal care aide or a change in care," Hoback says. "That could cause a behavioral problem because the patient might feel left out of the process."
• A change in the patient’s daily routine.
"Maybe patients are used to a bath in the morning, and now they have to take it in the afternoon, and it upsets them," Hoback suggests, adding that the answer can be as simple as that.
• More or greater pain than usual.
"The patients could be suffering from pain, and they’re not able to express that pain," he says. "So first identify physical problems that could be causing agitation."
Hoback says aides and nurses sometimes will have to accept the fact that there’s no identifiable cause of the agitation, especially in the case of patients with Alzheimer’s Disease or other dementias. "It may be a reaction to their fear or an internal stimulus that you can’t manage."
Teach aides coping techniques
Education managers can teach aides and nurses various coping strategies to handling agitated patients at the times when the cause isn’t apparent, Hoback says. He uses a handout developed by the Ohio Valley Appalachian Regional Geriatric Education Center and the East Tennessee State University of Johnson City, TN. The handout describes various difficult types of behavior and gives tips on how staff can handle them. (See guide to difficult behavior, p. 96.)
Another strategy for handling unexplained behavioral problems could include chemical restraints or other medications, if prescribed by the patient’s physician. "The patient might be hearing voices, hallucinating, and might need medication," Hoback comments. "If they’re hearing voices or having psychotic problems, you’re not going to have luck changing it."
But in the less extreme cases, there are several strategies aides and nurses can take to help improve the patient’s behavior, he says.
These include the following:
• Listen carefully to what the patients’ needs are.
Hoback says it’s sometimes just a matter of taking the time to listen to what patients want and then addressing those desires as much as possible.
"Even if what they are saying doesn’t make a whole lot of sense, the fact you’re giving them the chance to express themselves will mean a lot to them," he says.
"Acknowledge that they have a right to have that problem, and give them an opportunity to talk about it," he adds. "If we don’t give people an opportunity to talk about their problems, it will make them angry."
• Communicate with patients about changes in their schedule and why these must occur.
Often health care professionals forget to discuss changes with patients, assuming that the changes aren’t significant. But to patients, any change might be very important, and they might feel as though they’ve lost control over their own lives if they aren’t informed about changes in advance, Hoback says.
"Inform them, and give them some warning about what will occur," he advises.
Listen to your patients
• Show the patient respect and courtesy with your body language.
"Good eye contact is a necessity," Hoback says. "And place yourself at the patient’s level. If they’re in a wheelchair, sit down next to them."
Also when a nurse or aide sits down with a patient, this gives the patient the impression that the person is really listening to them and isn’t eager to leave.
"Don’t act like you’re in a big hurry," Hoback says. "That’s real hard for home care aides and people on a tight schedule."
• Bring in a supervisor if the patient’s behavior is repeatedly belligerent or if it becomes violent.
If a patient behaves belligerently and in a threatening manner only once or twice, then the aide or nurse can have a talk with the patient and see if the problem behavior disappears, Hoback says.
But if the problem persists and maybe escalates into violence, then a supervisor needs to be brought in. "Aides need to protect themselves," he adds.
• Handle constant complainers by giving them choices and helping them understand that they’re responsible for their own problems.
"In any situation where a person is having a problem, we need to put responsibility back on that individual as much as possible," Hoback says.
"If there’s a problem at home, many times the patient likes to blame other people for difficulty, and we need to transfer ownership for difficulty back to the patient," he adds.
One way to do this is to give the patient greater control over his or her care plan. "We have to let patients make choices," Hoback says.
He gives an example of a patient at a nursing home who often complained and said he was very unhappy there. "He chose to leave and go to another institution," Hoback says.
"Within about three days he was calling and asking to come back," he adds. "He realized it wasn’t as bad there as he thought it was."
• Bring in a third person to referee and defuse emotionally charged situations between the patient and home care employee.
"When the patient’s emotions get involved and the provider’s emotions get involved, the agency should have a neutral party negotiate the situation," Hoback advises.
The best solution
"Sometimes, it’s a matter of listening to both parties and hearing what they have to say and trying to come up with a solution," he notes.
Hoback says the worst situations arise when the aide or patient’s feelings are hurt. "Sometimes there are differences that can’t be reconciled. Things have been said that you can’t take back."
Another worst case scenario is when a patient makes accusations, however groundless, against the aide. These could include accusations of the aide stealing from the patient.
Hoback suggests a home care agency not try to patch up those types of situations.
In these cases, a negotiator might suggest the agency find another aide to work for that patient because the problem can’t be solved. "That might sound like defeat, but it’s better to start over than to try to patch some situations."
• Find compromises and negotiate minor patient problems.
Hoback goes back to the example of the patient who is agitated because the bathing time has been switched from the morning to the afternoon.
Maybe the aide’s schedule makes it impossible to visit that patient in the morning. But it might be possible to visit a little earlier in the afternoon, so there’s room for compromise with what the patient desires and what is practical for the aide.
• Try to see the problem from the patient’s perspective.
One of the most effective strategies in dealing with difficult patients is showing aides how to see where the patient is coming from, Hoback says.
"Most of the patients we deal with and many in the home care agency have lost a lot of roles in life," he says. "They’re no longer the caretaker of their home; they’re no longer the caretaker of their children; sometimes they become the children of their children."
Hoback has found that aides will be more flexible and forgiving once they understand that patients have lost a great deal of their former lives.
"Then the other side of the coin is you need to help the patient understand the frustration of the caregiver who is trying to meet their needs," he says. "Help each person try to see the other person’s perspective, and then you go for negotiation. But don’t always ask the provider to give, that’s not fair to them."
It’s more than a laundry thing
• Respect the patient’s space and privacy.
Hoback recently visited a friend in a nursing home and watched his friend become very upset as an aide came into the room searching through his drawers for some laundry that had been misplaced.
"She made three trips into the room, and he was very frustrated and kept saying, These are my clothes. Don’t search through them. If you need something then ask me.’"
The woman was frustrated because she was new at the laundry job, and she had lost someone else’s clothing.
The patient was angry at this minor inconvenience because he had lost control of his life and environment when he was placed in a nursing home. "So sometimes people gain control through behavioral issues," Hoback says.
Hoback acted as a negotiator in this case and had a talk with the facility’s administrator, saying that the staff needed to realize these patients have a right to privacy and personal belongings, without fearing that some employee will intrude and search through their drawers.
"It’s real common in nursing home settings, but it also happens in the home," Hoback says. The best way to handle a similar situation is to tell the patient what you are looking for, and then ask if you can help them search for it.
"We need to respect that this is their environment, and we’re not going to take over their environment."
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