Coping with the "problem" resident.

Residents trying to "run the show" can sabotage their own care. Here's how one nurse reversed the process

Manipulative patients keep us hopping - and hoping that maybe they'll be transferred or assigned to someone else. Yet, deep down we know we're not giving the care we've been educated to give and end up going home feeling tired and discouraged. Fortunately, there is a way to turn things around.

Take the case of Mrs. Dorsey in room 306, and how an enterprising nurse managed to improve her situation. Mrs. Dorsey was manipulating her nurses and in effect sabotaging her own progress for the sake of controlling the behavior of others. How she went about doing this takes up a fairly sizable list. She:

* told untruths or half truths.

* made non-stop requests for assistance she doesn't need.

* threatened "I'll report you" or refused to budge when things didn't go her way.

* repeated questions without stopping for an answer.

* pitted staffers and shifts against each other.

* refused to make eye contact.

* spoke with a sarcastic, condescending tone.

* indulged in negativism and coercive demands.

* used loud name calling and unsafe behavior to gain attention.

One day, the charge nurse on 3-South threw her arms up and announced, "I have so many other patients today. Besides, since I'm designated charge nurse, I also have to handle the desk, the doctors, the ordering, and the calling. Couldn't someone else please take 306 -- please?"

Mrs. Jones, a newly transferred nurse from another unit, said she would.

Addressing the Challenge

Her first approach was to perform a complete nursing history. It was then that she began to understand Mrs. Dorsey's behavior patterns, history of physical or psychosocial problems, learned responses, medications, and her remaining capabilities. Her initial conclusion was that Mrs. Dorsey was in fact experiencing less-than-adequate management because of her learned patterns of manipulative behavior arising from inadequate problem-solving skills. It was clear to Mrs. Jones that, for the sake of Mrs. Dorsey and the staff, she had to intervene.

Developing Rapport 

First, Mrs. Jones had to develop a rapport with Mrs. Dorsey. Once a caring, trusting relationship had been established, she could begin to work with Mrs. Dorsey and teach her the skills she needs. (At some point Mrs. Jones would also need to call a staff conference to discuss and brainstorm possible solutions to Mrs. Dorsey's manipulative behaviors.)

While working with Mrs. Dorsey, Mrs. Jones decided she would:

* approach Mrs. Dorsey in a calm, gentle but firm manner;

* introduce herself and explain, "I am your nurse for today. I am here to help you achieve . . ." (goal);

* use good listening and communication skills to reinforce empathy;

* maintain eye contact;

* start fresh each day, forgetting any negative events or feelings that may have surfaced in the past;

* involve Mrs, Dorsey in the decision-making concerning her own care;

* explain all procedures BEFORE they are done;

* involve Mrs. Dorsey's family, friends, and all staff responsible for her care;

* avoid labels;

* praise and reinforce all positive comments made by Mrs. Dorsey and all her self-care and problem solving attempts.

After several days of interacting with Mrs. Dorsey in an open, non-judgmental manner, Mrs. Jones brought a mirror to Mrs. Dorsey's room and asked her to look into it and repeat: "I am capable of helping myself. What can I do today to help me?" This was a self-image reinforcement technique that was used on all three shifts, as specific steps to deal with Mrs. Dorsey's problems were taken.

Writing It Down

After making her initial breakthrough, Mrs. Jones' next step was to schedule 30 minutes of uninterrupted time, and bring in a blank care plan. She pointed out, in specific terms, the results of Mrs. Dorsey's nursing assessment. For example, "Physical therapy is scheduled twice a day, but because you have refused it for four days, that is eight important treatments you have missed." Or, "you called out from your wheel chair eight times during breakfast, even though your call light was working and in your hand.

"Mrs. Dorsey," Ms. Jones continued, "these are important problems and I truly need your help and support in trying to figure out some solutions. As a nurse, I am here to help you help yourself so that when you are discharged, you will be able to have control over yourself and your own health.

"I brought in the care plan. This is our chance, you and I, to tell each other what we are going to do. You can help us, we will help you, and all of us will work together to get you well.

"What do you want to be able to do? Out of everything else, what do you want MOST? And what could you do to make this happen? I have some suggestions, but it's more important that I hear from you."

Goals and Limits

After hearing Mrs. Dorsey out, Mrs. Jones listed several goals that she thought would be helpful to her; for example, she would:

* attend physical therapy;

* do own morning cares;

* try to finish meals in one half hour;

* dress herself;

* use her call light instead of yelling;

* consolidate requests so as to call upon staff no greater than once every hour.

"To make these goals happen, Mrs. Dorsey, you will need to do some things, and we the staff will do some things," said Mrs. Jones. "Let's list these together. After we write them all down, we will post them in your room and at the nurse's station so that everyone knows what to do. Every other day until discharge, you and I will talk about how things are going with our plan and with your progress."

Mrs. Jones knew that limits to manipulative behavior need to be set and met. She also knew that Mrs. Dorsey was an important, intelligent ally in accomplishing this. Working together, they developed several "rules of the road:"

* People should be held responsible for their own behavior (assuming a disease process or treatment problem has not intervened); no one can "make" another person swear, become angry, yell, pout, or refuse care.

* Attitudes held about self care will strongly predict the success or failure of hospitalization.

* Limit-setting techniques actually reduce stress and hostility for patients and staff.

* Patients who learn that they can control their own behavior develop essential problem-solving skills and a valuable sense of security.

* To successfully limit problem behavior, limits must be consistent and reinforced by everyone, including the family.

* For trust to develop between nurse and patient, commitments made by the staff need to be kept.

* Options need to be presented, but to simplify communication, should be narrowed to only two choices. For example, the nurse might ask, "Do you want the red dress or the blue dress? Do you want your cares now or in two hours?"

* A "cooling off" period can be effective and useful. If the patient yells or strikes out, the nurse could assertively say, "Though I want to give you the care you need, I am not able to be here when you yell and call me names. I will return in five minutes when you have lowered your voice." Hopefully, a more reasonable perspective will begin to set in.

Conclusion

Ignoring manipulative behaviors won't make them go away - they will only get worse. Mrs. Jones eased the feeling of being manipulated and gave Mrs. Dorsey the level of care both wanted by setting limits to her manipulative behaviors and involving her in the more positive, and eventually more reassuring, process of setting and achieving goals. Limits may be difficult to establish at first with patients such as Mrs. Dorsey, but they will more likely follow and appreciate them if given choices and as much decision-making power as possible.

Linda S. Smith, RN, MSN, is Editorial Director of ADVANCING CLINICAL CARE Journal and Psychiatric Nursing Instructor at Gateway Technical College, Kenosha, WI. She wishes to thank the Lakeland Nursing Home (Elkhorn, WI) staff for their assistance with the preparation of this article.