Identifying skills to improve care for patients with co-occurring medical and behavioral health conditions.

1. Manage Well
~Manage yourself Well, Manage Your Patient Well
Identifying skills to improve care for patients with co-
occurring medical and behavioral health conditions
“Whenweareno longerableto changea situation- wearechallengedto changeourselves.”
~Viktor E. Frankl
1

2. Presenter
Gina Napolitano, LCSW, CCFP
Current Position:
Manager of Behavioral Health, UCH Emergency Department
 Licensed Clinical Social Worker & Certified Compassion Fatigue Professional
 Chair Person for Governor’s Mental Health Advisory Board for Service Standards and Regulations
 Member of International Association of Trauma Professionals (IATP)
2

3. Objectives
 This presentation will offer practical, therapeutic techniques in identifying
and managing a patient with behavioral health issues.
 Participants will gain knowledge about ways to manage themselves and
their work environment in order to safely provide medical care to patients
with behavioral health issues.
 Participants will leave with more confidence in their ability to provide care
to patients experiencing behavioral health issues.
3

4. Outline
 Introduction
 Becoming Self-Aware
 Physiology of Fear and Stress
 Communication and Establishing Boundaries
 Avoiding Power Struggles
 De-Escalating the Agitated Patient/Family Member
 Self-Care
4

5. Becoming Self-Aware
 What type of patient/behavior/situation
do you find most difficult?
• Quick body scan
• Relax
• Tune into environment
• Have a plan
• Be the canine
Elements of a therapeutic relationship include:
 Consistency, reliability, safety, respect
 Non-judgmental attitude, validation, compassion, empathy
 Alliance, support, meeting needs, working “with the patient”
**Establishing a therapeutic relationship does not mean condoning, allowing unhealthy
or problem behaviors
“Knowing yourself is the beginning of all wisdom”
~Aristotle
5

6. Fear, Stress, Our Brains & Nervous System
Prefrontal Cortex: Responsible for
executive and cognitive functioning-decision
making.
Amygdala: Controls the limbic system-fear,
stress and arousal response and triggers
a hormonal surge.
Sympathetic = Reactive = Stress = Diminished Functioning = Exhausting
(Fight – Flight – Freeze)
Parasympathetic = Intentional = Comfort = Optimal Functioning = Increased Energy
(Relaxation – Safety)
• Staff’s reaction, patient’s reaction, family/friend’s reaction
6

7. Communication
and
Establishing Boundaries
 Establish boundaries when patient/situation is calm
◦ The purpose of establishing boundaries is to align expectations, not to punish
 Clearly state your role
◦ e.g. I am your nurse until noon, part of my job is to keep you safe and comfortable, I will be
checking your vitals every hour-this is one way I can make sure you are medically safe, you
have no medications scheduled during my shift. This is John he is part of our team and will be
in your room at all times making sure you are safe. I have 4 other patients that I care for but
you are John’s only patient.
 Offer choices if reasonable
◦ e.g. I can check in on you on the hour or the half hour, which do you prefer?
 Consistency and follow through, communicate with all staff
7

8. Avoiding Power Struggles
 Set clear expectations (boundaries)
◦ It seems like you’re upset and having difficulty communicating with me, I’ll give you a few
minutes to calm down so we can have a more productive conversation.”
 Speak calmly and respectfully
 Try to avoid becoming part of the struggle, identify the issue and
work with the patient to find a solution
◦ “How can I help you be an active partner in your care?”
 Avoid the ‘right’ and ‘wrong’ scenario
◦ “That sounds frustrating.”
 Assess patient’s understanding of what and why something is
happening
 Look for patterns of behavior
◦ e.g. patient seems to escalate at shift change
8

9. De-Escalating the Agitated
Patient/Family Member
 Safety is a priority
◦ Do you need additional staff before engaging?
◦ Scan environment for safety
 Leave 2 arms length distance between yourself and patient
 Position yourself in a direct line with an exit
 Are there objects that can be thrown or used as a weapon near the patient?
• Quick body scan, are you remaining relaxed?
 Be mindful of:
◦ body posture and motion (yours and patient’s/family member)
◦ personal space
◦ your para-verbal communication
 tone, cadence, volume, facial expression, muscle tension, attitude, eye contact
• Encourage patient/family to speak slower, softer so you can understand
their needs
• Model how you would like the patient/family member to behave
9

10. cont’d
 Anxiety drives many problematic behavioral symptoms
AnxietyAgitationAggression
• Avoid the attitudes and behaviors that increase patient anxiety and
frustration
R: restrict
E: escalate
A: avoid
C: coerce
T: threaten
10

11. Self-Care
“Theexpectationthatwecanbe immersedinsufferingandlossdailyandnot betouchedby it isas
unrealisticasexpectingto be ableto walkthroughwaterwithoutgettingwet”
~RachelRemen
• Develop a self-care plan
• Utilize co-workers/supervisor
for support/de-briefing
11

12. Utilize Your Support System
 Teach the people in your life how to
support you.
 Utilize co-workers, managers, professional
counselors.
12

13. Summary
 Both medical and psychiatric illnesses can exacerbate each other; it is
important to maintain awareness.
 Consistency among shifts with difficult patients/family members is
imperative.
 A caregiver who is mindful and takes care of themselves is better able to
care for patients and feel fulfilled by their
chosen profession.
13

14. Resources & Tools
 Employee Assistance Program (EAP)
 24/7 Comedy FM Radio Station 103.1
 Anschutz Health and Wellness Center
 Meetup app
 Meditation app
 Fitbit challenges
 Audio books
 Be Colorado-MOVE Program
 Volunteer
 Classes/Education not related to profession
 Your BHE team
14

15. Remember…
 This is not your job.
 This is your chosen profession,
Revisit why this is your chosen profession.
 A profession needs to be approached with intention and purpose in order to
be fulfilling,
Revisit your intention and purpose.
 Be responsible for the energy you bring to the place of your chosen
profession.
 Be mindful of the energy you take home from your chosen profession.
~GMN
15

16. Questions? Comments?
16

17. References
 Gilbert, Sara Barr. Psychiatric Crash Cart: Treatment for the Emergency Department. Advanced
Emergency Nursing Journal. 31(4):298-308, October/December 2009.
 Stefan, Susan, Emergency Department Treatment of the Psychiatric Patient: Policy Issues and
Legal Requirements, Oxford University Press, 2006.
 National Alliance for Mental Health, www.nami.org
 Psychiatric Services, www.psychservices.psychiatryonline.org
 Help Guide, www.helpguide.org/mental
 Crisis Prevention Institute (CPI), www.crisisprevention.com
 Hospital Corporation of America (HCA), www.healthstream.com, Medical Center of Aurora
 Setting Boundaries With A Depressed Person, Dale Kiefer, March 29, 2012
 National Association of Social Workers (NASW), www.socialworkers.org
 De-escalation Skills For Nurses, Ian Miller, December 10, 2013, www.thenurspath.com
 Limit Setting: A Useful Strategy In Rehabilitation, Julie Sharrock, RN; Nonie Rickard, RN; Australian
Journal of Advance Nursing, 2002 Volume 19, Number 4
 Certified Compassion Fatigue Professional Training, Eric Gentry, Ph.d, LMHC; Premier Publishing &
Media, www.pesi.com
 National Center for Trauma-Informed Care and Alternatives to Seclusion and Restraint (NCTIC),
Substance Abuse and Mental Health Administration (SAMHSA), www.samhasa.gov
17