How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 96
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Whilst communicating, or in order to do so effectively, nurses had to regulate their own emotional
responses to what patients were doing and saying. They deemed it most important not to display any
anxiety in the face of acute psychotic symptoms, patients’ psychological distress or their overt
hostility and aggression. Being calm and receptive in the face of such patient behaviours was
deemed more likely to reduce them – becoming anxious more likely to amplify them. Similar
recommendations were given about becoming frustrated or irritable with patients
uncooperativeness, lack of progress or resistance to actions which would benefit them. Finally an
optimistic outlook was considered valuable and motivating for patients (as well as fellow nurses).
Attempting to get things done with patients (e.g. get them to get up or go to bed, eat, drink, wash,
take their medication etc.) required a whole range of additional and different interaction techniques,
including making suggestions rather than ordering patients to do things, giving reasons for the task,
being flexible, maximising choice, prompting, encouraging, giving positive feedback, rendering
assistance, and in some circumstances being assertive and forceful. When resistance was based
upon delusions, a degree of collusion was allowed by some nurses if balanced by the patient’s needs
for care. For thought disorder, using gestures as a means of communicating what was to be done
was considered helpful.
Talking about symptoms with patients was the single largest domain in the interviews. Absolutely
fundamental to all symptom areas was the need for nurses to hear what patients’ experiences were,
accept them, and seek to enter and understand their effect on patients with caring and respect. This
was clearly a foundation for nursing practice, and was the starting point for all other interactions
about symptoms. Following this, for apathetic or withdrawn patients, it was judged helpful to
mutually explore causes, agree a care plan, develop a routine and purpose, and then take a step by
step approach. For hallucinating patients, stress management, distraction, bolstering coping and in
some cases casting doubt or challenging the hallucinatory content were considered good
approaches. Gentle questioning or direct challenge were also sometimes deemed appropriate for the
deluded patient. Collusion was not recommended, however sometimes it was considered
appropriate to ignore the delusions or find workarounds so that patients’ needs could be met. In the
case of upset and distressed patients, interviewees talked about staying calm, keeping patients
talking, persisting to find out the cause, and taking action to relieve the cause or exploring other
solutions with the patient. Responses on agitation, overactivity, irritability and aggression were not
clearly distinguishable and were therefo re considered together. The expert nurses recommended
exercise, distraction, relaxation, avoidance of confrontation, explaining the reasons for actions and
rules, negotiating advance directives and forceful containment.
Novel findings?
This study set out to uncover any tacit or traditional knowledge amongst practicing nurses about
how to communicate well with those in a state of acute psychosis. The first assessment of the results
must therefore be on what or whether anything new has been discovered. How much of the material
above simply repeats the content of nurse training, reflecting the zeitgeist of psychiatric nursing
practice, and how much hidden expertise has been uncovered? How much is the above information
novel, and how much is an elaboration of the recent knowledge history covered in the introduction?
The pattern of responses and themes in the interviews does indicate that the contents are not widely
known. While some techniques were present in two thirds of the interviews, many others were only
present in one third or less. And those interviewed were nurses considered to be particularly expert
at dealing with patients suffering from acute psychosis. This does not prove the contents are new or
undocumented material. It does prove that there is likely to be a considerable number of the
techniques described above which are not known by most psychiatric nurses (and therefore not
utilised). The low numbers of expert nurses reporting some techniques also indicated that further
interviews might yet find additional material of value. Those low numbers additionally indicated
that our findings might be of significant use to nurse educators in the future.
We specifically asked our interviewees not to tell us about ‘textbook communication skills’, as
these were felt to be already widely known by nurses and a significant part of nurse training. These
were still mentioned in passing by most nurses, supporting our assumption that they are well known
and have been well assimilated into practice. However our research interest was to move beyond
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