Direct Patient Care Always Involved Some RN Mental Health Skills

July 26th, 2012

By Jennifer Olin, BSN, RN

To some extent all nurses in direct patient care are psych nurses. We may work on a med/surg floor, or in the operating room, or in a community clinic. We may deal with people facing end of life issues or pregnant women facing new life issues. No matter the problem or experience at hand there is stress. Helping patients deal with stress makes us all mental healthcare providers.

In nursing school we are all given some instruction on dealing with anxious or angry patients and their families. Hospitals employ social workers, clergy, full customer service departments to help clients and families cope with the stressors of hospitalization and illness. However, none of those folks show up until the nurse calls. What that means is you, as the RN, are first on the scene.

Stress can have physical, emotional, intellectual, social, and spiritual consequences. Usually you find some combination of these traits since stress affects the whole person. It is often the job of the nurse at the bedside to determine if a patient is suffering from a stress related symptom and if so the nurse must employ the nursing process to help alleviate those symptoms.

The psychologic manifestations of stress include:

• Anxiety – Mental uneasiness, apprehension, dread, or foreboding.
• Fear – A mild to sever feeling of apprehension.
• Anger – An emotional state consisting of a subjective feeling of animosity or strong displeasure.
• Depression – A common reaction to events that seem overwhelming or negative.
• Cognitive behaviors – Thinking responses that include problem solving, structuring, self control, suppression, fantasy, and prayer.
• Motor responses – There are many but among them are crying, verbal abuse, laughing, screaming, hitting and kicking.
• Unconscious ego defense mechanisms – These include denial, rationalization, compensation, repression and regression.

Some of these coping patters are actually helpful; others, not so much. In fact, anxiety is often considered a response to a stressful situation rather than a coping mechanism, since it may impeded action to remove the stressor.

How can anxiety be a coping mechanism? Well, all people experience some degree of anxiety at some time in their lives. Mild or moderate anxiety is needed to accomplish developmental tasks and motivate goal directed behavior. In this sense, mild anxiety is an effective coping strategy. For example, mild anxiety motivates students to study. It is excessive anxiety that has destructive effects.

Although coping behavior may not always seem appropriate, the nurse needs to remember that coping is always purposeful. Short-term coping strategies can reduce stress to a tolerable limit temporarily but in the long run are ineffective ways to deal with reality.

Helping Clients Overcome Anxiety and Other Stress Symptoms

Nurses can help clients recognize stress and support effective coping strategies or teach the client new and more effective ways of handling stress. To be able to turn the patient’s coping strategies into an effective, safe tool the nurse must first assess what is a normal coping pattern for the patient. This will include questioning the patient and members of their support system.

There are several NANDA-I diagnoses relating specifically to clients experiencing stress including: Anxiety and Ineffective Individual Coping. It is now up to the nurse to develop a plan (in collaboration with the patient and significant support persons) for ways to change the existing responses to the stressors.

This is where we get to implementing the plan, which is of course the best part. This is the time where with skill and a little bit of luck the nurse will actually help the patient feel (emotionally at least) better.

• Communication – Number one on the hit parade is keeping the patient in the loop. There are so many ways you can communicate caring, that recognize the patient’s own anxieties and fears, and will help them deal with their current situation.

  The list is long with suggestions on how to do this. Start with orienting the patient to the facility and how it works, that includes everything from visiting hours and meal times to who is in charge and when they are there. Make sure to repeat information when the client has difficulty remembering. Take a minute to listen to the patient express their feelings and thoughts on their current situation. When listening make sure you are communicating competence, understanding, and empathy rather tan stress and anxiety. It’s the difference between taking a seat and standing in the doorway repeatedly looking at your watch.

  Finally keep a smile on your face and maybe a few jokes in your pocket. Humor is a great means of coping with stress.

• Relaxation Techniques – Relaxation techniques have been used to reduce high stress levels and lessen chronic pain for centuries. From the simplest instruction of take a deep breath, hold and release slowly to progressive muscle relaxation, a nurse can really help a patients settle in or settle down.

  Progressive relaxation requires the client to tense and then relax successive muscle groups, usually working your way up or down the body. This technique can result in decreased body oxygen consumption, metabolism, respiratory rate, cardiac rate, muscle tension, and even the lowering of blood pressure.

• Guided Imagery – This technique involves using positive images to achieve specific health-related goals. Images often evoke more than one sense. For example, the image of waves breaking on the beach can be visual, auditory or even include the smell of the salt air. Such images focus the mind away from the body.

  The client’s religious and/or spiritual beliefs should be considered when determining helpful images. Images of religious or spiritual bliss can produce physical relaxation and mental peace.

When we are new nurses dealing with a patient’s anxiety, our lack of experience may actually provoke anxiety. This passes. With time, we all find the ways that work with our own skill sets and personalities. Ultimately it is better for the patient and improves the quality of the care we give.

In the pre-operative holding area I often have patients who are really worried about their surgery. They often express this as “they just don’t know what they are going to do.” If they seem approachable with humor I almost always tell them the same thing. “There’s nothing for you to do, you are going to sleep through the most important stuff. Worry about if I am going to get my lunch.”

Not only do they usually laugh but we change the focus of their stress from having surgery to how soon will they get to eat when they are done. A much more pleasant thing to focus on.