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.
The aspirations and goals of the service user and what they hope to achieve from the therapeutic relationship
This will help you to understand how the service user may perceive the relationship and what aspects they may find challenging.
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.
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