13 Handling difficult situations
• To develop an understanding of different types of behaviour and what factors may impact on how service users behave and interact
• To reflect on the impact of difficult interactions on you as a student nurse, and how to manage this within your practice
• To explore a range of therapeutic skills which can be used in a range of difficult interactions to support you in meeting the service user's needs
• To identify different interactions which can be perceived as difficult and explore specific strategies to support you in responding effectively
Introduction
As a student mental health nurse on placement, there will be times when you will come across what will be referred to in this chapter as ‘difficult situations’. These situations may involve a number of experiences related to working in mental health, including responding to self-harm, suicidal thoughts or managing aggressive or distressing behaviour. However, these difficult situations may also be times when you work with service users who, due to their complex experiences, feel very difficult to understand and engage with, for example working with service users given a diagnosis of personality disorder. The emotional response we have as a student mental health nurse impacts on how able we feel to cope and respond effectively to difficult situations.
This chapter will explore some of these situations and consider different approaches to understanding these experiences to allow you as a student nurse to react in a way that is safe and engaging. A number of scenarios and examples will be highlighted which you may encounter on your placements to help you explore different ways of responding within these difficult situations, and also support you in developing confidence to manage difficult or challenging service users.
The impact of past experience on current behaviour
An important aspect when exploring how service users behave is their early life and developmental experiences and how some of these experiences may be influencing their reactions and responses in the present. Young et al (2003) identify a number of core emotional needs to support the development of children into healthy adults. These core emotional needs include aspects such as:
– forming secure attachments to others
– having the freedom to express valid needs and emotions
– having the opportunity to act spontaneously and exercise self-control.
Throughout our early development it is important that these core emotional needs are met through either our parents or care providers. If these core emotional needs are not met, it may have an impact on how we view ourselves as an adult and how we view others and the world around us. The influence of early life experiences is particularly relevant for service users who may have experienced neglect, trauma or abuse within their early development and, as a result, may have difficulties relating to people within a position of providing care. As a mental health nurse, we may expect service users to perceive us positively. However, if a service user has grown up in an environment where their provider of care has been neglectful or abusive, they may develop an expectation that you as a nurse may be abusive or neglectful. If a service user has been abandoned as a child or experienced inconsistent parenting, then they may perceive you as being potentially abandoning or may expect you to reject them or provide inconsistent support. In light of this, they may be cautious of forming an engaging relationship with you. In order to address this, it is important to constantly reinforce your commitment to support the development of a healthy working relationship with the service user and remain consistent in your approach to reinforcing this message.
Managing and making sense of difficult situations
When faced with difficult or challenging situations, it is important that you are able to think about and reflect on what the service user is communicating alongside managing your own responses. This will enable you to support the service user with their individual needs and manage the situation effectively. In order to do this, a simple framework can be used which involves three key stages. First, it is important to try and make sense of what the service user is feeling. Second, it is important to be mindful and aware of your own feelings and then, by using both perspectives, the final stage involves exploring how to respond effectively. These stages are explored below in more detail using examples to demonstrate key points.
What is the service user feeling?
It is important when understanding behaviour to think about how the service user might actually be feeling. This can be viewed as an assessment process providing an opportunity to think about what specific factors may be influencing feelings and how this links to current behaviour. Key aspects to be aware of when exploring how a service user is feeling may include the following:
The service user's experience of services, both past and present
This is important to allow you as a student nurse to create a picture of what the service user's expectations of you may be.
The service user's early developmental experiences and past experiences of relationships
This may provide you with more information about how the service user reacts to specific situations and how they might perceive caring services.
How am I feeling?
When working with service users that present with difficult behaviour, it can cause a range of feelings and emotions and we can feel challenged on an individual level, both personally and professionally. The emphasis is often placed solely on how we respond to the service user rather than exploring what you as a student nurse might be feeling and the impact of this. If you are aware that a difficult interaction has made you feel anxious or scared, it is important to think about how this might influence your ability to provide support in an authentic way. Alternatively, if an interaction has made you feel frustrated or disappointed, it is likely that this may be evident in how you respond if you have not made sense of this and managed your response.
An interesting element of exploring both your own and the service user's feelings is that there is often a parallel between these feelings. For example, when a service user is aggressive, they may be feeling anxious and scared and, as a result, you may also start to feel anxious and scared. By exploring both sets of feelings and experiences together, you may identify specific factors that have impacted on the interaction and create a more in-depth understanding of what has happened within the interaction.
You may be surprised by your reaction to some behaviours. This may be because a situation reminds you of a past personal or professional experience and evokes emotions which you were not aware were still present. You may also question if the way you are feeling is ‘appropriate’ in light of your role and the expectations you have placed upon yourself or the expectations you perceive others have of you. Many students describe feeling guilty that they didn't know how to respond to a difficult situation, unprofessional because they wanted to cry in response to an upsetting experience or cowardly because they felt scared by a service user's aggression. All too often these feelings are hidden and can result in negative ways of coping such as avoiding a service user, referring to them in a derogatory way or allowing the feelings to transfer to other aspects of life. The ability to recognise and acknowledge this requires a high level of self-awareness and can be processed safely in a clinical supervision setting or through personal reflection.
How to respond effectively
Once you have made sense of a difficult interaction, you will then be in a position to use this information to think about how to respond effectively. It is important to remember to see the behaviour or difficulty as a communication of an unmet need and respond to this rather than place judgement on the service user.
Specific skills in responding effectively
When working with difficult interactions, there are a number of skills that can be applied to help you respond effectively. The following framework identifies these skills, and you will notice that a number of them are expanded upon in previous sections of this book.
Effective communication
It is important to think about effective verbal communication such as tone of voice, pace and demonstrating active listening. During times of distress or frustration, be mindful of how you may project some of these feelings through your non-verbal communication such as body language.
Maintaining a positive approach to engagement
Whether you are supporting a service user experiencing high levels of distress or someone who is responding aggressively towards you, it is important to maintain a positive approach to engagement. Service users who present with difficult behaviours may evoke strong negative responses in you or your peers, and at times it can be hard to manage these responses which can result in a negative or, in some cases, punitive response towards the service user.
Validation
The main purpose of validation is to demonstrate that you recognise that the service user is experiencing high levels of distress and that, although your role as a worker is to try and alleviate this distress, you are not in any way minimising the effect of this distress or the nature of it.
Example
You are on placement in a community mental health team and have been working with a service user who has a diagnosis of anxiety and depression. When you attend on your next visit, she presents to you as extremely distressed about a break up in a relationship. You are aware from discussing this service user with your mentor that this has happened previously and that the relationship has been unstable for some time. It is more important to validate her experience by acknowledging the level of distress the break up may cause and to offer support in response to this. Once you have validated her distress, it may then be appropriate to encourage her to reflect on what skills or strategies she has used previously to manage this distress.
Demonstrating collaborative working
It is important to constantly be mindful of the collaborative nature of the therapeutic relationship and, even during times of distress, it is important to involve the service users in decisions that are made and management plans that are put in place.
Being clear about what support is available
When working with service users, it is important to be very clear at the outset about how much support and time are available from you within your role, and to identify access to further support when required, such as out-of-hours support. As you may only be on placement for a short time, it may be helpful to highlight this with service users so that they are clear from the start about the limits of your ongoing involvement in their care.
Consistency
By maintaining consistency, you will also help service users to know what support is available and in what circumstances they are able to access support. It is important to acknowledge that it is likely that service users will have experienced inconsistent support and engagement from some staff or services. This can be challenging for service users and may create more feelings of distress if they are unsure if support is available. It is your responsibility to be clear about the working relationship from the first interaction and maintain this consistency throughout your work as best as possible within the limits of the time you have available on your placements.
Self-awareness
It is important to constantly be aware of your own feelings and experiences within the therapeutic relationship. As we have explored earlier, when working with difficult situations your feelings will often parallel those of the service user, however it is important that you are aware of this and manage it effectively to enable you to support the service user with their experiences and emotions. It may be helpful to use a reflective model (such as Gibbs' (1988) reflective cycle or Rolfe's framework for reflective practice (Rolfe et al 2001)) during supervision or reflective practice to enable you to develop your self-awareness and manage your own feelings effectively. It may be helpful to explore this with your mentor when discussing your progress on your placements.
Providing a feeling of safety for the service user through containment
When working with service users, it is important as a student nurse to provide a feeling of safety to support them with their difficult experiences. This has been referred to as offering containment or containing a person's feelings. In Bion's (1962) early work, the concept was referred to as a mechanism for managing distressing or unmanageable feelings. The container is referred to as a space to take unmanageable emotions and experiences and transfer them into something manageable. In the context of working with service users, the container is the relationship between you as the student nurse and the service user. Service users who may be extremely distressed or experiencing difficult symptoms may not be able to make sense of their experiences due to the unmanageable nature of them. By offering support and helping the service user make sense of these difficult experiences, you are containing their distress.
Maintaining boundaries
It is important for you as a student nurse to be very clear about the boundaries of a relationship and ensure the service user is aware of these boundaries. The term ‘boundary’ has been referred to as a therapeutic frame which defines the characteristics of the therapeutic relationship (Gutheil & Gabbard 1993). However, in mental health, assumptions are made regarding boundaries and who asserts them and there is often a lack of clarity about what these boundaries are and who defines them. When boundaries are ‘crossed’ or ‘broken’, the blame can often fall on the service user who has been perceived to ‘push the boundary’ or ‘cross the boundary’. However, often service users are not aware of the boundaries in place, and therefore may struggle to understand the consequences of when boundaries are broken. It is unfair to expect service users to maintain therapeutic boundaries in the relationship without being involved in any discussion regarding these boundaries. Therefore, it is important to be clear about the boundaries of engagement with service users at the start of a relationship and continue to explore these with the service user throughout the period of the relationship.
Examples
Claire is 28 years old and has a diagnosis of borderline personality disorder and was recently discharged from an acute ward where you are currently on placement. Claire contacts the acute ward by telephone within the last 10 minutes of your shift and asks for some support. Initially you are unsure as you are aware your shift is due to finish, however you feel you need to offer Claire support to ensure she is OK before you leave. Rather than offer unlimited support, you explain to Claire that, although you are concerned about her distress, you are due to finish your shift shortly. You identify that you can offer 5 minutes now before you leave and, alongside that, you can either identify who is available on the next shift to give support or arrange a time when you are next on shift to offer further support. By approaching the situation in this way, you have validated Claire's distress, reinforced the boundary of how much support you can offer and also provided alternative suggestions for accessing support if Claire requires this.
Responding effectively to specific difficult situations
Having explored some of the interventions and approaches that can support you to manage difficult interactions that you might experience with a service user, the following section of this chapter will highlight specific issues in relation to a number of interactions commonly experienced with mental health service users. Remember to refer back to the previous section and explore how these skills can be used in all your interactions with service users.
Making sense of, and responding positively to, anger or aggression
Working with service users who display aggressive behaviours can be extremely challenging for student nurses and can cause you to experience a range of emotions. In order to work effectively with service users, it is important to see this form of behaviour as any other form and try to read what the service user is trying to communicate. Quirk et al (2004) identify that service users take an active role in making a safe environment for themselves and are not passive recipients of care. This is a result of feeling unable to rely on staff to ensure their safety. In light of this, service users may be aware of how to keep themselves safe during difficult times and it is important to engage them in this process. Carlsson et al (2000) have identified a number of themes in supporting the management of aggression including respecting your own fear and respecting the service user. They also highlight the importance of providing stability for the service user during times of distress and aggression.
A number of the skills previously discussed may be helpful in managing these interactions and experiences, for example effective communication and validation. However, there are also a number of specific issues to be aware of when responding effectively to service users who appear angry or aggressive:
• Try to use your understanding of the framework discussed earlier to think about what the service user might be feeling and what messages are being communicated. It is also helpful to think about other factors that might be impacting on the interaction such as the environment, other service users and previous experiences.
• It is always important to remain calm in your own posture and position within the environment and try to respond positively. Try to maintain a supportive but non-confrontational posture.
• Show your concern and use validation to empathise with the service user before trying to manage the situation. By doing this you are acknowledging that the service user is trying to communicate a difficult experience and you are demonstrating that you are willing to work with the them to help with this experience rather than make a quick judgement about their response.
• Try to guide the service user to a place of safety within the environment where it may be appropriate to spend time and offer support.
• Be mindful of your non-verbal communication and how this may be perceived by the service user.
• Once the service user has accessed support and appears calmer, it may be helpful to explore with them the cause of the aggression by encouraging them to reflect on what factors may have impacted on their behaviour.
As a nurse, your role is to support the service user to make sense of their experiences. Therefore, following a difficult interaction, once this has been resolved and the service user has accessed support, it is important that you explore with the service user what happened and help them to make sense of why they responded in the way they did. By doing this, you are helping the service user to use the framework in a helpful way which may support them in their recovery process.
Susan is 37 years old and has been in contact with services for a number of years, both as an in-patient and in community services. Susan has recently been readmitted to an in-patient ward and is approached by one of the staff nurses on shift to try and complete an assessment. In response to questions asked by the nurse, Susan becomes aggressive and starts shouting at the nurse: “What's the point in answering these f**king questions when you are only going to try and get rid of me as soon as possible?”
Use the framework discussed above to explore what is happening within this situation. What factors might be influencing this interaction?
Validate Susan's distress by acknowledging that the assessment process can be frustrating or appear intimidating.
Reinforce your commitment to offer support in helping Susan with this process by offering to work through the assessment with her.
Encourage Susan to move to a quiet area away from other service users on the ward so you will be able to offer support.
Suggest you complete part of the assessment together now and negotiate another time to complete the assessment when Susan feels more comfortable.
Working effectively with self-harm
Working with service users who self-harm can be a complex process and, as a student nurse, there may be times when you feel overwhelmed by the responsibility of managing this type of risk. However, it is important to try and remember that the same principles of engagement apply when working with self-harm, and the skills we discussed previously can help you in working with such service users. It is also important to work collaboratively with your mentor to explore how to work positively with different types of risk in a safe and contained way.
Motz (2009) highlights the importance of understanding self-harm as a form of communication which requires an urgent response. Self-harm is a way of coping with the extreme levels of distress an individual may be coping with. It may also be a result of the service user being unable to regulate their emotions in such a way as to manage the unbearable feelings they are experiencing. Motz (2009) identifies that, although the process of self-harm can be perceived as negative, the message behind it can often be of hope and a will to stay alive. A number of studies have been completed exploring the views of service users who self-harm and the results indicate that, in all circumstances, people need an empathic non-judgemental approach to their self-harming behaviour. This should be based on practitioners having an understanding of the issues involved alongside the functions self-harm may fulfil for that individual (Royal College of Psychiatrists 2010). In light of this, the first key aim of engagement is to respond in a way that validates the experience of the service user and carries no judgement regarding your views regarding self-harm.
Key issues to remember
• Collaborative assessment to explore the service user's experiences and feelings is essential and will act as a basis for any further support and intervention. A biopsychosocial assessment is recommended to be completed by an experienced practitioner as highlighted within the National Institute for Health and Clinical Excellence (NICE) guidelines (2004). Assessment should seek to identify developmental aspects that may highlight particular experiences the service user is struggling with and other mental health symptoms or experiences. Particular triggers or precipitating factors during times of high distress should also be explored to try and develop support mechanisms where appropriate. As a student nurse, you may be in a position to support this assessment process, but should seek support from a more experienced nurse to complete the full assessment.
• Develop a care plan with the service user highlighting specific triggers and factors that might precipitate self-harm and helpful coping strategies that can be implemented to minimise harm.
• In response to assessment, the service user should be provided with appropriate support, both directly linked to the physical self-harm in terms of pain minimisation and also support with the specific areas of distress highlighted during the assessment process.
• It is important to access support and supervision to help make sense of some of your emotions associated with working with service users who self-harm. This will enable you to support the service user effectively by managing your own experiences.
• Inspiring hope within the service user is increasingly important when working in mental health and with service users who self-harm. It is your responsibility as a student nurse to nurture hope and, even in times of uncertainty, to retain this and model this for the service user.
• Although we have highlighted that self-harm and suicide are different, it is important to remember that self-harm is a risk factor for suicide and research has suggested that 30–40% of people who have died by suicide have self-harmed within the previous 2 years (Gunnell et al 2005). Therefore, when working with service users who self-harm, assessment for risk of suicide should always take place.
Further support and guidance on working with service users who self-harm can be accessed by the NICE guidelines for self-harm (2004).
Working effectively with service users expressing suicidal thoughts
Although self-harm and suicide have often been referred to in the same light, it is also important to acknowledge that they are very different and, though they clearly have links, should be managed as separate issues and may require different approaches. As previously identified, self-harm is a risk factor for suicide, and assessment is fundamental in ascertaining the underlying factors that may be causing the service user to feel such high levels of distress or hopelessness. However, Szmukler (2003) highlights the complexity of assessing suicide risk accurately and, in light of this, emphasises the importance of psychosocial assessments completed through engaging with the service user on an individual level and hearing their experiences rather than relying on complex tools.
Furthermore, Burke et al (2008) highlight that what is most helpful in working with service users is the development of a relationship in which they are listened to and supported and that judgements are not made regarding the intent for suicide. Further, he suggests that ensuring boundaries are clear about the relationship can provide a framework for support. Other areas to be aware of when working with service users are highlighted include the following:
• Expression of suicidal thoughts should always be taken seriously, even if you have worked with a service user on another placement and have seen similar expressions that have not been acted on.
• Assessment of suicide risk is important and should be an ongoing collaborative process when working with service users expressing suicidal thoughts. Refer to Chapter 12 on assessing and managing risk to ensure an appropriate risk assessment has taken place and all factors that may indicate suicide risk have been explored.
• Access support from your mentor to ensure you feel able to manage interactions with the service user. It is important to work collaboratively within the wider team to ensure a consistent approach to responding to these issues and to ensure you are aware of any care plans that are in place to respond to increasing levels of risk. Effective communication and documentation to ensure all areas have been considered is imperative to maintain the safety of the service user, yourself and the wider team.
• Try to engage the service user and ensure the therapeutic relationship is maintained to provide an open forum to explore some of these issues in a meaningful way.
• Don't be afraid to explore the issues with the service user as this will demonstrate to the service user you are aware of their experiences and you are available for support. It may be helpful to support the service user in identifying potential triggers increasing their distressing thoughts and also protective factors that may manage difficult feelings.
• When working in the community, referral to the crisis or out-of-hours service may be needed to ensure the service user has access to support if you have concerns about their safety outside of your placement hours.
• Access supervision and support from your mentor or link tutor to help you manage difficult interactions or feelings associated with service users who express suicidal thoughts.
Knowing when to engage further support or services
Although there are a number of skills that can be helpful in working with service users during difficult interactions, there will be times when the skills you have developed or the interventions you have implemented may not be helpful or may not be enough to support a service user in times of distress. In light of this, you may need to explore support from your mentor, other staff members working in your placement area or other services to ensure the service user and you remain safe and that the service user has access to the required support. Knowing when to access further support or engage other services is an important skill for a developing nurse and should not be underestimated. If you are working with a service user and have concerns regarding your ability to provide enough support or how effective your approach is, it may be helpful to consider one or more of the following options:
• Seek guidance and support from your mentor or a more experienced member of the team regarding your approach. This could be approached on an individual level or through a forum such as handover or group supervision.
• Explore opportunities for further input within the team in terms of specific therapeutic interventions or approaches. There may be a member of the team who has worked with service users experiencing similar difficulties before who may be able to offer support and guidance.
• Co-work with or shadow a more experienced member of the team to provide support and guidance when working with a service user that you are finding difficult.
• If you have concerns about the safety of a service user outside of your placement hours, there may be the opportunity to refer the service user to a crisis team or relevant out-of-hours service.
• Refer to specialist services if a clear rationale is available and inclusion criteria are appropriate for the specified service.
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