Question

Olivia is a nursing student completing a practicum at the local hospital. She is shadowing Nina, a long-time RN on the Medical-Surgical Unit. As the two nurses begin their shift, Nina gives Olivia a brief history of the first patients they will be assessing. Mr. Musick, aged 44, who is being treated for pancreatitis, has been on the unit for 3 days. He has a history of cigarette smoking (20 years) and a history of gallstones. He denies being a “heavy drinker,” but admits to having one or two drinks after work most days and more on weekends.

                  During his stay, Mr. Musick has repeatedly raised his voice, cursed, and even screamed loudly at various nurses and other staff. At times, he is angry about an invasive procedure, such as when the night nurse needs to restart his IV in another vein. At other times, Mr. Musick’s anger seems random. As Nina explains to Olivia, “He just blames everyone else for how miserable he is. And since it’s everyone else’s fault, then he figures everyone else ought to fix it—now.”

                  During the change-of-shift report, Olivia learned that earlier this morning, Mr. Musick became extremely irritable for not being allowed to smoke anywhere in this “damned place.” The nurse explained that the patient got up from his bed as though “he thought he was heading to a smoking lounge,” pulling out his IV in the process. When the nurse told him he couldn’t be up and walking, Mr. Musick screamed, “Doesn’t anybody realize that I just need a drink to calm my nerves?” When the nurse called for help, Mr. Musick threatened to “take out” anyone who touched him. The nurse was able to calm him down and convince him to get back into his bed, but she said he continued to be verbally abusive throughout the shift.   

                  As Nina leads Olivia down the hall to Mr. Musick’s room, he is heard yelling at a nurse, “You people are incompetent. That’s why I’m still here after three days! I’m getting worse, not better!”

1. How would you characterize Mr. Musick’s coping skills? Does he seem to be a patient with healthy coping skills who is simply overwhelmed by current circumstances? Or do you think he had marginal coping skills before coming to the hospital? Explain.

1. If Mr. Musick continues to verbally abuse the nurses, do you think it would be more effective for the nurses to try to ignore his outbursts to avoid further escalation or to challenge his behavior? Explain.

Answer 1

Mr. Musick has very bad coping skills. This behaviour can be continued from before admission and might have worsened after admission into the hospital. He was a reguler smoker and drinker and now that those are not available inside hospital, he might go into withdrawal which might further worsen his mental state.

Withdrawing from nearly any substance can result in behavioral changes. Along with a wide array of other withdrawal symptoms, many people will act out aggressively as their body is adjusting to changes without drugs or alcohol. With strong cravings, aches and pains, many people will lash out at their loved ones or care takers showing signs of aggression due to post-acute withdrawal syndrome.

Post-acute withdrawal syndrome can last from a year to several decades, or indefinitely, with the symptoms entering into periods of relative remission between periods of instability. Symptoms often include:

mood swings

agressive behavior

anhedonia (the inability to feel pleasure from anything beyond use of the drug)

insomnia

drug craving and obsession

anxiety

panic attacks

depression

suicidal ideation

suicide

cognitive impairment

2.)It would be more effective if the Nurses try to avoid his comments and abusive language and remain calm. The patient will only worsen if the nurses challenge him.

Many hospitals and medical practices have an acceptable behavior agreement or contract like the one my mother had to sign. No one should have to bear the abuse that angry, intoxicated and mentally-ill patients heap upon them. These agreements normally outline:

• Inappropriate patient behaviors

• The impact these behaviors have on nurses, doctors and other staff

• How the behavior can impact healthcare delivery

• Consequences delivered if behavior continues

When explained that this behavior agreement is a tool to help both patient and staff, rather than a punitive measure, patients can respond surprisingly well. Many do not have a good grasp of the impact their behavior has on others. Caught up in their own emotions, they act out to dispel feelings in the only way they know how. Once reminded that their medical professionals are vulnerable, too, they may gain a new outlook.

The types of patient behaviors nurses should not tolerate include:

• Demanding, controlling or manipulative statements and requests

• A patient’s refusal to listen

• Lack of cooperation

• Verbal abuse

• Threats

All of these fall short of violence, which requires more aggressive responses, including the “Code Gray” call for an out-of-control, combative patient. Still, the nurse may not be able to handle this patient alone and shouldn’t feel the need to do so.

Every hospital has harassment and anti-violence policies that travel nurses will probably review during orientation or before. Travel nurses should confer with other nurses, their supervisor or nurse manager for specific questions.

Reviewing these policies empowers nurses to know when patients cross the line and what steps to take. These policies also help nurse managers quickly determine how to respond to a nurse’s complaint, while being backed up by administration. The prepared nurse can then approach each patient with confidence.