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12 STEP PROGRAMME FOR SETTING LIMITS

1. SPECIFICALLY IDENTIFY THE PROBLEMATIC BEHAVIOUR

Think problem behaviour rather than problem patient. Focussing your attention on the behaviour makes it irrelevant whether you like the person or not. Clearly express the issues in the nursing documentation and in verbal handovers. 2. WHAT NEEDS DOES THE PATIENT HAVE?

After you have targeted the specific behaviour the next step is to work out what need the patient may be trying to meet. Many patients who display demanding or manipulative behaviours have learned early in life that this is the only way to get what they want and need and may find it difficult to understand or accept your objections. Your patient may be in pain or sleep deprived, feel anxious or out of control. Perhaps they have relationship/childcare problems. The behaviours they display may be an overt sign that all is not well and by finding out what their needs are might help change their behaviour. 3. GIVE YOUR PATIENT SOME FEEDBACK

Try presenting the problem to your patient in a non-threatening manner. I statements can be very useful and tend not to make your patient feel too defensive about the issue at hand. Examples might include:

When the buzzer is going off so frequently and I am running back and forth every few minutes it is difficult for me to meet your needs properly. Perhaps we can work something out together so that I can be more helpful
When I am confronted by shouting I cant understand what you need. Lets discuss this quietly, Id like to help When I hear abusive language/swearing I feel taken aback/hurt/upset. It is hard to listen and be helpful when I hear these kinds of words. I realise you are upset but lets start again Pointing out behaviour directly can cause some people to feel defensive. Further anger, abuse or an escalation of the behaviour may ensue. Making the statements about you rather than them can sometimes take the pressure off the patient so that they are able to calm down and see what is happening more clearly. Asking for their help in solving the problem may also be useful. It is surprising how often this works. If however you dont think the patient has understood the problems then more clarity is required. Be firm and kind in your explanations but above all be clear. If your patient has no idea of the issues then all your work will be for nothing.

4.

CONSISTENCY IS THE KEY

It is preferable that the same team of people deals with the patient. This provides consistency, allows trust and rapport to develop and minimises the risk of splitting. Create a predictable environment for your patient by making sure all staff are on the same page. When a difficult nurse/patient relationship exists issues related to trust are often at play. Endeavour to be consistent in everything that you do. If you say that you are going to do something or be somewhere make sure that you do and you are. If you cant deliver, then apologise, explain and reschedule.

5.

TRY TO ANTICIPATE NEEDS

Remember that some behaviours are motivated by low tolerance levels and anxiety. When on shift let your patient know you are there and where possible check in routinely. Anticipating needs and checking in regularly may help minimise anxiety and save you a lot of time. 6. ACKNOWLEDGE YOUR PATIENTS POINT OF VIEW

Many people feel they have lost control or that they have become a non person when they enter hospital. This can lead to behaviour that is difficult for the nurse to manage or to understand.

Acknowledging your patients point of view will show them that their opinion counts and that they have been heard. It is also a great demonstration of empathy. Examples might include: I realise you dont want to do this and I appreciate you trying I can see that being here is very hard for you. What can we do that might make things easier 7. TRY TO REACH A COMPROMISE

Sometimes in life we just want choice. Being told what to do and when to do it is hard for most of us. Rigid hospital routines can be uncompromising and not always necessary. Offering our patients a bit of choice in some aspects of their care can make a world of difference in how they feel and often in how they behave. Showering, getting up, dressing changes, certain meals or medication times may all be negotiable. For some patients fights over these types of issues become long-running battles that ruin relationships and create upset on a daily basis. Compromise, negotiate, offer choice and be fair. 8. ACCENTUATE THE POSITIVE

Focus on your patients positive behaviour. Give recognition, attention and praise where it is due. Sometimes just saying thanks to a patient that you are having a difficult relationship with can make a world of difference to them. 9. INVOLVE YOUR PATIENT IN CARE PLANNING

If you draw up a limit-setting plan, involve the patient wherever possible. Long-term, anxious patients often respond well to being included in drawing up a care plan for themselves. It helps them to feel more included, more in control and better grounded. As a last resort a contract may be useful. It should communicate clearly what you expect from your patient and what he/she can expect from you. It should contain a simple statement of what you will do and what the patient will do. This should be signed by both parties and a copy given to each. It must be remembered that these contracts are agreements and are not legally binding. 10. DOCUMENT AND COMMUNICATE Document your plan, review and update it regularly. Make sure all staff are aware of the issues and how you are managing them. If this means underlining the plan at every handover then do so. Give your colleagues opportunities to offer their opinion. It only takes one staff member to sabotage a plan. 11. CONDITIONS AND CONSEQUENCES Sometimes certain conditions and/or consequences have to be specified when the behaviour is very difficult to manage or simply unacceptable. Verbal and physical abuse, threatening and oppositional behaviour, constant non-compliance with treatment and sexual harassment are examples of situations where firm limits with consequences have to be set. Consequences and conditions may include police action, discharge from ward, move to another unit or hospital, involvement of hospital management, care carried out by two nurses at all times, limited time spent by nurses in direct patient care, NUM directly overseeing care or security staff involved in care. 12. LOOK AFTER YOURSELF Make sure that your goals and expectations are realistic and that you wont take it personally if your hard work doesnt pay off in the way that you want it to. Be self-aware. Be clear within yourself about how you feel in relation to this person/this work. Stand back from the situation frequently and ask yourself if you are ok, are you handling things well, do you need a break??? Remember that the patient is ultimately responsible for his or her own recovery.

Evans M, Boyle A, Smith J and Brunero S (2008) Liaison mental health nursing, Prince of Wales Hospital Sydney