A nurse's recognition of what will be most beneficial often emerges from an intuitive process, an embodied knowledge, based upon years of clinical experienee and a broad knowledge base. This !'practical knowledge determines how the nurse proceeds in the care context and is largely invisible, Benner's (1984) seminal research has uncovered and described the clinical knowledge contained within nursing practice, "know how" skills, From ethnographic studies, Benner and her associates identified 31 nurse competencies (Figure) embedded in skilled practice,, classifying these competencies into seven primary nursing domains on the basis of similarity of function and intent. According to Benner, additional competencies await discovery as interpretative work continues.
Domains of Nursing Practice (Benner, 1984)
Four of Benner 's practice domains: the Helping and TeachingCoaching Roles, Diagnostic and Monitoring Function, and Administering and Monitoring Therapeutic Interventions and Regimens, richly depicted in the following exemplars, are particularly relevant for gerontological nursing with its emphasis on maximizing optimal functioning.
Benner purports that nursing is relational and therefore cannot be adequately described by strategies that leave out context, content and function. A major construct of her work is caring, the essential ingredient for expert practice and patient recovery: "Caring is primary because it sets up the condition of trust where help can be given and help can be received" (Benner & Wrubel, 1988). Nursing interventions generated by a committed and involved relationship with the patient, versus a detached or controlling stance, enable trust. From this type of "middle position" (Benner & Wruble, 1989), nurses operate in partnership with their patients, fostering autonomy and a sense of connectedness. From such an engaged stance, despite extreme pain, hope can emerge even when cure is not possible. Within a caring context nurses help patients and their families navigate the uncharted territory of an illness and/or dying journey, making the unfamiliar more manageable.
In Benner 's view, exemplar writing affords an opportunity to critically examine practical knowledge embedded in practice. She contends that such an examination is essential for developing and extending nursing theory. Additionally, she believes exemplars, exposing and recognizing nursing's extraordinary daily contributions to quality care, are especially important as skilled nurses are often undervalued.
Five staff nurse leaders on the Wills Eye Hospital acute care geriatric psychiatry unit describe a memorable patient who taught them something new. These paradigm cases stand out prominently in their minds as reference points for ongoing clinical practice, becoming part of their perceptual lenses and sustaining hope for the compassionate work they do. Following Bertner's (1984) approach, their exemplars challenge nurses to reflect on how their own knowledge, skill, uniqueness and caring make a difference.
The commentary following each exemplar highlights some of the competencies identified by Benner as being embedded in nursing practice: the nursing "know how" knowledge. The critique will also include the "know what" nursing strategies: knowledge derived from theory. It is not meant to override the reader's independent interpretations and analysis nor mechanize the truly remarkable processes demonstrated throughout each exemplar.
EXEMPLAR I: PAT WYNNE, RN, BSN
Jane came to our unit as a pleasant, delightful, albeit bewildered individual seeking treatment for dementia. It was her second admission. On the first admission, she responded well to the structured environment, enjoying the various groups. At that time she was receptive to using a memory log and staff redirection during anxious periods. Treatment was supplemented with an antidepressant and occasional use of Trazodone. Upon discharge, Jane spent several good months in mis phase until her disease progressed to the point of her becoming unmanageable at her personal care facility. She began to put toothpaste in her hair, walk the hallways unclothed, and wander out of the building.
On this second admission, her mental state was much more fragile; her agitation increased. We considered placing her on our dementia unit but in an effort to minimize her anxiety, we decided to keep her on our less impaired unit due to her familiarity with the milieu. She was comfortable with the transfer and immediately embraced the unit and the staff. Demonstrative in her affection toward us, her disease-induced disinhibition manifest, Jane often put an arm around my waist, holding my hand. I reciprocated with a squeeze of her hand or a quick hug, hopeful that it fulfilled a need for intimacy so longed for, yet neglected in human beings like herself. At times, she received a spontaneous embrace from me, for instance when she earnestly tried to educate me about her illness by saying, "You know, I have Alzheimer's," quickly adding, "but it's not contagious." At that time I validated her with a hug and reassuring words.
Jane had a gleeful, childlike quality which endeared her to me. Yet I was ever mindful of her self-esteem, never treating her as a child, never wanting to foster regressive behaviors.
This second admission was also different because Jane could no longer be readily engaged in unit activities. Groups, confusing and difficult to process, were anxietyproducing. After only five minutes in a discussion or activity group, she would wander off. Jane never had hobbies, so there was no memory bank to tap for previous interests. While being a homemaker and raising two children had given her happiness and fulfillment, it did not prepare her for the iniquity of her fate.
During her dark periods, Jane would roam the halls asking repeatedly for family members, the location of her room or, "How do I get out of here? Where do I catch the bus?" She was difficult to redirect and calm. The memory log held no interest for her. Anxious phone calls to her family provided short-lived gratification. Attempts at doing "chores" such as folding laundry, elicited comments like, "I don't want to, I did enough of that in years past." I agreed, never offering this type of diversion again.
One day as I walked with her for twenty minutes around the unit, she stopped in the middle of the hall with a confused and painful look on her face. At a loss for ideas, I asked her if she needed to use the bathroom. She responded, "Yes." As we approached her room, Jane looked at the room number which was 814A and read it as "W8TXK". Proceeding to sit on the commode, she placed her face in her hands and sobbed, "I'm losing my mind." I will never forget the anguish and torment that possessed her, as with teary eyes I tried to comfort her. It was a poignant moment for us both. I perceived her turmoil and grasped the reality of the plight of caregivers everywhere. I felt anger toward this nasty illness, helpless in dealing with such an irrational process.
There were times when her distress was unrelenting and it was necessary to medicate her, providing some relief from her emotional pain. It brought her and us peace for a time. At other times, she experienced happier moments, such as when she looked through an old photo album brought in by her family. I laughed when she innocently commented about one photo stating, "That was my best friend, she was so beautiful. It's a shame her two children are so ugly." Yes, I enjoyed her company and sharing a portion of her life through photos showing her as a vibrant young woman.
Jane was my first primary patient with dementia. She taught me, unwittingly, valuable lessons about the disease. I, in turn, gave her my best understanding, patience and respect.
Prior to discharge, Jane was placed on a new medication to help with her symptoms. She currently resides on the Alzheimer's unit at a different facility.
The first exemplar portrays how a nurse can allow a patient with a dementing disorder to share glimpses of her personal journey through the maze of Alzheimer's disease, enhancing her future clinical work with patients. Adopting an engaged stance, the nurse discovers opportunities to connect with her patient, Jane, in more meaningful, and thus responsive ways. In partnership with her patient, the nurse's presencing posture often alleviates Jane's distress, facilitating coping even when Jane's world becomes unfamiliar and common symbols, indistinguishable.
During anxious times the nurse provides her patient with opportunities to express intense emotional pain, or diverts her patient with enjoyable reminiscing, an important process for older individuals (Haight & Burnside, 1993). Where possible, the nurse follows Jane's lead, always endeavoring to create choices and a calming atmosphere. Validation techniques (Feil, 1982), capitalizing on whatever strengths the individual retains, are beneficial to Jane. The nurse's goal is not to correct errors, nor orient her confused patient to reality, but to identify personal situational meanings and make emotional contact (Abraham & Neundorfer, 1990).
As this exemplar demonstrates, the caring context that the nurse creates rather than the validation and reminiscing strategies per se, reinforces a sense of hope, enabling her patient to manage loss more effectively. The nurse's attentiveness also exemplifies a key gerontological nursing principle of attempting behavioral interventions before administering a potentially delirium-inducing psychotropic medication, carefully administering it only when Jane's emotional pain is beyond what the nurse can humanely offer her. Geriatric psychiatry nurses, like Pat, often try a broad range of behavioral strategies before finding something to relieve agitation generated by fear, an unmet need, such as the urge to urinate, or an emotional need, such as a desire for warmth and attention. In this case, Pat's caring makes a difference in Jane's ability to cope with this frightening illness journey.
EXEMPLAR Hi PENNT L MAKTIN, RN
Julie, a 74-year-old woman was admitted from a nursing home. This was her second admission to the geriatric psychiatry unit, with a diagnosis of dementia of the Alzheimer's type. On mis admission, Julie arrived on the unit on a stretcher, highly anxious and yelling out unintelligible words. We were giving a shower to another patient and heard her arrive with a scream and frantic words that we could not understand. I said to my nurse partner, "That can't be our patient," and with that she arrived in the room. On her previous admission Julie had talked excessively but with better control of her speech, so I was not expecting this frightened, screaming and much more debilitated patient.
The challenges for this stay were to increase her oral intake, manage her almost constant pressured verbalization, improve her sleep and decrease her need for heavy sedation. Daily care for Julie required many care procedure changes in order to find the most efficient and least anxiety-producing ways to assist her. Elimination, particularly bowel movements, was a source of increased anxiety. Her attention span was so limited that to sit on the toilet for more than thirty seconds was next to impossible. Thus, her ability to push out the stool was severely reduced. To preserve Julie's sense of privacy we tried to limit the number of staff helping. I found it best, when possible, to involve only female staff. The conventional way for giving an enema was too upsetting to Julie, who was unable to lie in bed and hold the enema. We used a shower chair with a removable bucket, giving the enema and then moving the chair over the toilet. During this time, she needed constant reassurance, such as rubbing her head, hand, and back along with singing and talking to distract her attention and keep her in the vicinity of the toilet.
Showering was also anxiety-producing and remained so throughout her stay. A towel placed on the shower chair, warm water running to take the chill off the floor, and starting the shower from the feet and moving upwards were some adaptations that helped during bathing.
During her hospital stay, Julie gained weight and often appeared to enjoy her food. However, in order to provide enough calories, meals were not only served on a mealtime routine. Staff had to make the most of occasions when Julie was less anxious, using these times to offer a maximum of food. Her inability to sit still made mealtimes especially challenging. We found that sitting in front of her with a hand on her arm and leg and gently patting or rubbing helped keep her seated. Sometimes we moved around with her while she ate finger foods.
Prior to and during the early part of this admission, Julie's sleep was poor, but this quickly improved. She did not like to be in bed during the day and this was advantageous, since she then associated bed with nighttime sleep. Upon morning awakening, a need to urinate made her impulsive. It seemed as though Julie went from a deep sleep to a wide awake state in less than a minute, attempting to slide quickly out of the bottom of the bed. A bed monitor would alert us mat we had to move fast to be there to greet her as she emerged from her bed.
Due to impulsivity and unsafe ambulation, we at first found a need for a geri-chair with tray to insure Julie's safety. We kept geri-chair usage to a minimum, however, because this type of restraint usually increases a demented patient's anxiety. A more effective way to decrease Julie's anxiety involved arm-in-arm ambulation, sometimes as many as six to eight laps in a circular pattern around the unit with a return to an unoccupied area where we would sit and feed her vanilla ice cream while gently rubbing her arm and playing heart beat tapes. If all went well, she would then remain safely seated and take a nap without the need for a geri-chair tray or medication.
When walking in the hallway, staff members would greet Julie, telling her how nice she looked. She would, in turn, often tell staff how nice they looked. She responded well to our conversation, smiles and hugs, often returning our hugs saying, "Thank you, thank you."
With a patient like Julie who cannot communicate in sentences, it is important to find out about her life, including work, interests and hobbies. This provides information for making sense out of words and movements as a basis for being able to provide validation and capitalize on assets. Having formerly enjoyed cooking for her husband and two sons, "reading" a cookbook brought in by her husband, Jim, gave her a sense of comfort. Showing and putting on favorite pieces of jewelry provided sensory stimulation and a sense of security which also calmed her. She would often say, "Oh you found it, I love you," and reward you with a smile.
Julie will long be remembered by staff for her phrase "Chubba chubba." She used this at various speeds and decibels, depending on her mood and level of anxiety. During calm periods, we would ask her what this meant. Sometimes she would say, "I don't know," at other times she would pinch our cheeks, smile and say, "You know, like a chubby baby."
Taking care of Julie and getting to know her family was a combination of challenge, sadness, privilege, frustration and satisfaction. I felt that I was able to make what turned out to be the last few months of her life more comfortable. Julie had a supportive family and they were comforted by seeing her response to staff. We provided Julie and her family with some happy times. Her husband, permitted to be with her for extended periods of time, brought in family pictures which became the focus for reminiscing. In one particular validation group, she was able to tell her son, "You were always a good son." And he was able to reply, "You were always a good mom."
Besides visiting his wife and participating in our validation group, Julie's husband became involved in our family support group. He also spent a lot of time talking to me. Sometimes Julie would sit calmly or nap as he reminisced about earlier, happier times. Even though Julie did not join in the conversation, she seemed to benefit from just hearing Jim's voice. We hung pictures of their wedding day, granddaughter and dog, Duke, in Julie's room. We grew to know and to understand Julie much better because of Jim. As he became more involved with staff. he also had a chance to be heard, and receive support for his grief. Jim continued to participate in our caregiver support groups after Julie left the hospital.
After leaving, Julie stopped eating again and began a steady decline. Jim said that she stopped saying "Chubba-chubba" shortly after discharge from our unit and in fact said almost nothing. He and their sons made a very tough decision to have Julie receive only comfort care, permitting her to die without extraordinary measures. Right before she died, Jim told us that she became very clear, telling him, "I love you."
Jim is still finding it difficult to adjust to the fact he no longer has JuUe. He tells me that there is a big void. Although dementia changed the lives of family members, Jim still had a sense of purpose while Julie was alive.
When he visits the unit now, it seems to help him to talk to those of us who cared for Julie. He is staying connected to our unit and to nursing home staff, where he now volunteers. He is also getting out with friends and planning to visit extended family. We are sure our staff made a difference in Julie's last months, and in Jim's ability to grieve in healthy ways.
The second exemplar describes a patient with a more severe dementia. In this late phase of her disease, the patient has lost most of her ability to know and reason about the world. WiUi cognitive impairments in the discrete areas of memory, praxis, language and visual/spatial perception brought on by the degenerative process of Alzheimer's, Julie manifests the disease's "four A's": amnesia, opraxia, aphasia and agnosia (Steele, 1989). Visual cues and a structured activity routine, pacing exercise and rest minimize Julie's stress from her amnesia and inability to understand what she is supposed to be doing.
Likewise, the nurse's attentiveness in devising less anxiety-producing rituals, such as warming the shower floor make the unfamiliar less frightening for this confused patient. Due to apraxia, the inability to access learned motor movements, Julie is unable to manipulate common every day materials like buttons, zippers, toothbrushes and feeding utensils, walk with a steady gait or assist in her ADLs. The nurse maximizes her independence by utilizing care routines that potentiate optimal functioning, like providing her with fìnger foods.
Julie's receptive aphasia prevents her from comprehending verbal instructions which in some care settings may be labeled as uncooperative. Her expressive aphasia prevents her from being able to communicate fear, pain, or where she wishes to go. Rovner and colleagues (1992) find "uncooperative" patients like Julie are more frequently restrained and prescribed neuroleptics. However, attentive nurses, like this one, find more creative solutions for handling disruptive behaviors such as their patients' striking out in frustration. The nurse's tone of voice, facial expressions, touch, and hand gestures become important cues for reassuring and re-directing Julie. Likewise, the nurse speaks slowly and simply and takes the time to differentiate meanings underlying Julie's behaviors. For example, this nurse and outers like her remain alert for cues (indicating physical pain such as facial grimacing, or the need to urinate, such as, pulling at trousers) a demented patient may give, responding moment to moment.
Julie's agnosia prevents recognition of her environment, although at times some people and objects are still familiar to her. This disability often leads to extreme behavioral reactions when Julie is afraid. The nurse's actions convey how a skilled nurse takes cognitive deficits into account, assuming helping and coaching roles to avoid "catastrophic" reactions. Catastrophic reactions occur when cognitive capacity is overwhelmed by pressing on with a complex task, rushing a patient, or maintaining an over-stimulating environment. Demonstrating how a skilled nurse adapts procedures necessitated by situational context, this nurse changes traditional nursing and medical routines, creating some effective, though unorthodox rituals to match her patient's rhythms.
Additionally, the nurse's sensitivity to her patient's needs and fears, such as issues surrounding Julie's sense of privacy, illustrates how a patient's dignity and personhood can be maintained even in advanced dementia cases. Realizing that her patient is susceptible to a host of physical problems, such as infections, pneumonia, skin breakdown, dehydration, anemia and constipation, the nurse establishes ambulation and exercise rituals, skin protocols, bowel and bladder programs and special feeding procedures.
Perhaps Julie's "chubba chubba" pays highest tribute to the warmth and compassion generated by this nurse and her staff. Contributing to this patient's comfort and dignity in the closing chapter of her life, the nurse makes a difference not only in Julie's quality of life, but in that of her family. For example, always remaining approachable to Jim, Julie's husband, the nurse encourages him to reminisce and grieve openly. Although illness events and death are often avoided in our society, Penny offers the entire family avenues of understanding, affording a sense of acceptance and permission, increased control, and even triumph in the illness' downward spiral.
Dying can be lonely if the dying person and close family members are unable to talk about meaningful family relationships and the impending death (Neidhart & Allen, 1993). As a natural process often experienced in gerontological nursing, nurses like Penny develop comfort levels in being able to help and coach dying patients and their griefstricken families. They take care to avoid allowing patient and family emotional needs to be pre-empted by physical tasks. The moments for closure in validation group the nurse and her staff offered Julie and her son illustrates an intuitive grasp of a situation which enabled an affectionate interaction between the two family members. It serves as a model for courageously mediating the dying process by fostering intimate family conversation. According to Bowen (1978), opening communication during a death event can be the most therapeutic intervention provided to a family. Nurses like Penny foster healthy mourning, offering patients and families opportunities to talk about the meaningful relationships enriching their lives and difficulties in the process of letting go.
EXEMPLAR III: RARBARA J. SUNER, RNC, MSN
Ellen, a 69-year-old married female suffering from major depression and agitation was admitted from an extended care facility. She and her husband had lived there for the past three years; her husband living independently, and she, in the nursing home section. Wheelchairbound, she needed complete assistance with her ADLs. Her medical history was significant for three heart attacks, high blood pressure and heart failure. Only recently had she received outpatient psychiatric care.
I remember that morning vividly. I was wondering to myself, "Why is Ellen in the nursing home section? Why is she bound to a wheelchair?" Uttle in her medical history afforded answers to these questions. My curiosity was further raised by her medication history. She was allergic to barbiturates, narcotics, and phénobarbital, and although Arivan had been recently reduced, she had been taking it for the past 10 years. Through my work experience and the literature, I know that an agitated depression in older adults is often treated by targeting the associated anxiety. Moreover, medications used to reduce anxiety are beneficial only for short-term use, as prolonged usage tends to diminish functioning, further increasing feelings of incompetence.
As I entered Ellen's room for the first time, I saw a woman who appeared frail and much older than her stated age. She was very restless, with significant psychomotor agitation; sitting up, then lying down, turning from side to side, all the while asking if it was time to get up and if I would take care of her. I can remember thinking, 'Of course I'll help you, but you will also have to help me to understand why." I felt that somehow she had been cheated out of a more peaceful life. I was sure that if she had been afforded the opportunity she would be capable of managing greater independence and functioning. I had the hope that Ellen could and would be able to return not only to the extended care facility, but to the independent living section where her husband lived.
As I approached her that first morning to help her out of bed, I brought her walker to her. Reflecting back, I guess I did this for two reasons: to assess her gait and balance, but also to begin challenging her in small ways, thereby slowly increasing her level of independence. Ellen reacted with anxiety, but she also responded to the support and empathy I showed while I coached her through the process. She did not ask for her wheelchair but accepted instead the challenge to use her walker. I saw potential to move toward greater competence and autonomy.
On the third morning after her admission, Ellen was presented in a case conference. I remember smiling to myself when one of the first questions was, "Why do you live in the nursing home section?" Her answer, indicative of her depression and associated perception of incompetence was, "Because I can't take care of myself." At that moment I reflected back on how I had always felt "drawn" to geropsychiatric nursing. Since graduation from nursing school 13 years ago, I had always wanted to be a part of a team that would make a difference in the quality of elders' lives.
Ellen's behaviors botti exhausted and challenged me. I felt able to "see through" her behaviors and understand her intense fear, anxiety and sense of helplessness. At first she would not attempt to bear weight nor to transfer. While seated on the shower chair or toilet seat she swayed and shook from side to side as if she were going to fall. "I can't," were words she spoke often. While walking, she shook and rattled her walker, at times lowering herself to the floor.
From the first day, I had challenged her in small ways; to use her walker instead of the wheelchair, to get washed at the sink instead of having a bed bath, to take a shower instead of a sponge bath, to participate in dressing herself instead of being completely dressed by the nurse, and to increase the distance she walked each day. AU the while, I gave positive feedback to increase her confidence.
As our relationship developed, Ellen began to share her life history and recognize more of her strengths. Her dreams for her retirement were to travel with her husband and spend more time with her children and grandchildren. Yet she seemed to believe that she had to live the rest of her life in the nursing home. Slowly accepting and becoming empowered with a belief that she had control over her future, Ellen began to realize that years of suffering from an untreated depression had resulted in her nursing home placement. Now, with the proper treatment, she felt she could still attain some of her dreams.
By promoting her self-esteem and helping her identify independence as a personal goal, Ellen reached a point where she began to challenge herself. She became more engaged with her children and grandchildren, calling and writing them. She decorated her room with her grandchildren's artwork. She began setting her hair, taking care of her nails, and using makeup. Eventually, Ellen was showering, dressing and walking independently with her walker. She then progressed to make her bed and do her laundry. As her self-confidence developed, she began to socialize more and became more actively involved in the hospital community. Before long she was the one encouraging others.
Within five weeks Ellen wanted to walk without her walker and move back to the independent living section of her life care community near her husband. She was now ready for discharge. The extended care facility, however, would not evaluate Ellen's appropriateness for independent living until she returned to the nursing home. Although anxious about her ability to pass the evaluation without my immediate support, she allowed me to coach her to maximize her chances for success.
Three months after her discharge, I followed up with a phone call to ask the staff how Ellen was doing. I was excited to hear she attained her goal and now lives on the same floor as her husband in their care facility's independent section.
Through this experience, Ellen taught me a great deal. E>espite her depression and anxiety Ellen kept her wonderful sense of humor. I learned how, as a care provider, to capitalize on a patient's sense of humor as well as utilize my own to encourage and motivate patients. I also learned how to nurture with empathy while at the same time challenging patients to draw on their own strengths, competence and sense of self-worth. I learned the value of struggling through that process, and to enjoy a patient's sense of accomplishment as he/she smiles and says goodbye.
Depression, like dementia, is not a normal response to the aging process. This exemplar shows how late life depression not only robs the afflicted of pleasure, but confines an elder to bedrest leading to further medical complications. Although Ellen does not attempt suicide, she gives up the hope of dream fulfillment, living far below her potential. As this exemplar poignantly depicts, a caring relationship with a nurse as well as correct diagnosis and treatment of depression promotes recovery and Ellen's reconnection with the larger world.
After the nurse discerns Ellen's interpretation of her illness, she is able to provide her with a different way of looking at her situation. Her teaching enables Ellen to understand the illness of depression, its course and effects on her life. Along with other members of the team, the nurse provides hope for recovery. Beginning with small challenges, and slowly building successes while her patient's competence and selfesteem increases, she maximizes Ellen's participation and control in her treatment regime. She intuitively chooses strategies that empower and motivate Ellen to press forward. The nurse's attentiveness and continuous feedback on practical goal achievements ultimately unleash Ellen's autonomous goal setting.
According to Butler (1974), the major developmental task of old age is to clarify, deepen and find use for what has already been obtained in a lifetime of learning and adapting. Nurses, like Barbara, attentive to when her patient may benefit from looking back in order to find meaning for the future, utilize life review. Affirming Ellen's emotional pain while reinforcing past strengths and current abilities, the process affords a joint search for life meanings. As a result, Ellen's caring is successfully rekindled, as is her confidence to consider new possibilities for herself.
The nurse also facilitates change by mediating for her patient with the nursing home. Upon successfully completing the nursing home evaluation, Ellen is able to return to the independent living section, a major achievement.
As a result of the vision and compassionate care provided by this caregiver team, successful aging is now more of a possibility for this patient. Moreover, the nurse's openness and flexible stance enables her to learn from her patient and utilize humor more successfully on behalf of future patients.
EXEMPLARlV: FRANCES CUNNINGHAM, RN
When I received the initial report from another psychiatric unit about Peggy, my first reaction was, "How can we deal with this patient?" The report stated she was totally out of control. Due to extreme and violent outbursts, Peggy had spent her last evening in four-point restraints at another facility.
When Peggy arrived on our unit, all my fears were actualized. Physically and medically, she was stable, but emotionally and mentally, she was in turmoil. With little or no control over her behaviors, she created bedlam for staff and other patients.
Peggy's daughters, son and husband were emotionally drained. They had tried their best to care for Peggy and deal with her acting-out behaviors. As the family matriarch, she had worked and cared for family members and was always in control. There appeared to be a desperate need for her to retain some control from a stroke leaving her dependent and impulsive. Her husband and children were unable to place limits on Peggy's temper tantrums and unpredictable behaviors. She attacked them verbally, hit them, pulled hair and ruined household property. Attributing all of her behaviors to her disease rather than to underlying depression and grief, the family felt guilty about setting firm limits. My goal for Peggy's family was to coach them in developing ways to set limits and deal with her calmly. My goals for Peggy were to help her identify and learn to cope more effectively with her feelings. I also wanted to help her recognize unacceptable and intolerable behaviors.
The task I had set for myself proved more difficult than I had anticipated. Despite 30 years of nursing experience, I was unprepared for this patient's enormous challenge. Peggy evoked just about every emotion in me, and for the first time in my professional career there were moments of defeat. No other case had challenged me like this. Unlike many dementia patients, Peggy retained some strengths I felt I could tap, if only she would let me get close enough to her. Together, I believed we could make her assets work for her.
Unfortunately, initially Peggy did not respond to the nursing team's various interventions to allay her agitation. Our way of dealing with most patients is to give as much control as safety warrants, but mis strategy did not seem to increase Peggy's sense of security. Frequent angry outbursts were directed toward staff, other patients, and family members. She threw furniture and food, struck staff and her family, and was usually verbally abusive when she did not get her way.
Moreover, Peggy did not respond to 1:1 and/or prn medication. It seemed like the more attention she received, the more her behavior deteriorated. We attempted at first to use the geri-chair and quiet room for inappropriate behavior. When this isolating intervention was used, however, instead of becoming calmer, Peggy screamed continuously. Although she could understand and communicate, parts of her illness disinhibited her behavior. We were unable to find a way to help her find inner control; attempts to set limits were met with angry outbursts. We decided the ultimate strategy was to have her family leave each time she mistreated them. But this approach was failing, most likely because her family was not convincing enough. Our creative juices were running thin.
One evening, as Peggy persisted in verbally battering staff and patients in sexually-oriented ways, I felt something more needed to be done. "What would shock her into reality?" I thought to myself. "She is now endangering others and something more needs to happen if we are going to reach her." I spoke to the team about my idea to place her in four point restraints. My biggest fear was that this procedure would incite negative physical and emotional effects. I had to tell her mat we made this decision because she did not seem to hear us tell her that she could not continue to batter others. Would she hear this? To try restraints was very disheartening for all of us, since we pride ourselves in maintaining a restraint-free environment.
What happened next was a shock to me. Not only was I going to shock her, but I guess she was going to shock me, too. She cooperated with the procedure to the point where she calmly directed us to how tight to make the restraints. Each restraint was tightened to her expressed desire. She lay quietly during the whole procedure. I thought to myself, "Why doesn't she fight us now? Did she really need this much external control?" I am still unclear about this reaction. I still would have liked to have found a different solution.
The family backed up our decision to restrain by choosing not to visit her that evening because of her behavior. The rationale for this decision was discussed with the patient. As Peggy lay in the restraints, someone sat within eyesight at all times to assure her safety. I continued to evaluate her readiness to be able to hear and discuss the events leading up to our decision. I needed to be assured that she understood that her behaviors were going to get her nowhere but into a state institution. I did not want this for her, she had too many cognitive and physical assets. Could she understand that if she wanted to go home, she would have to respect the boundaries of others? Her family wanted their mother and wife back, not this person who battered them.
After three hours of continual attempts to have an honest discussion with her, I saw a glimmer of hope. She made a contract with me, where I once again outlined clear expectations and limits. This time, she realized we all meant business. I explained that the staff as well as the family needed to see some change.
Peggy fell asleep in her room soon after I released her from her restraints. The next evening, I received a good report about her. I was again hopeful mat we could now get on with the task of recovery!
Once again, the family was asked to set immediate limits for any outbursts and to coach her about successful ways to respond. Although this advice was still met with lots of emotion, especially fear and guilt, the staff worked with family members until they achieved results. Consistently, Peggy received feedback from her family; if she could not treat them with respect, they would leave and return only when she could be calm. Over the next several weeks, she persistently tried to bribe staff, "I'll treat you well when I leave. I'll buy you something expensive." After a while, our coordinated efforts to be consistent met with success. Peggy started to realize inappropriate behaviors resulted in unbeneficial consequences. Medicated only with Inderal at this point, she slowly progressed, increasingly able to attend to tasks and link behaviors with outcomes.
Staff tension was easing, we were beginning to see the light at the end of the tunnel. We were able to begin dealing with some of Peggy's issues as she shared more of her fears. She became more directable and approached staff and family in more appropriate ways. As Peggy progressed, the feeling of a job well done was felt by all team members. She began to attend groups and apply make-up. Family visits became more pleasurable. Interventions and efforts produced positive results. We now were seeing the patient and her family on the road to recovery, gaining a new sense of control through their developing ability to accept and manage Peggy's disease.
Peggy finally was discharged. She is presently doing well in an outpatient rehabilitation program designed to further improve cognitive and motor skills. She functions well at home, and recently called to say, "Hello." I can say, "Job well done." Although we exhausted just about every strategy, we finally discovered what worked for Peggy. I feel I made a difference in the lives of Peggy and her family.
Depression, one of the most common reversible psychiatric disorders in the medically hospitalized elderly (Koenig, 1991), often accompanies a stroke. Feelings of fear and aloneness may ensue as a person experiences changes in the ability to think, speak and act autonomously. Before understanding and learning to accept and endure the disease, feelings of anger, disappointment and sadness are frequently acted out. Such an illness challenge may be overwhelming to an older individual, especially if independence and control have been important aspects of self-image, as in Peggy's case.
The illness event also greatly affects the family; to them their loved one is not the same. In Peggy's situation, enmeshed family members are unable to perceive how their lack of limits contributes to her declining sense of security. Only with the nurse's coaching is her family able to regain hope and set realistic limits, ultimately facilitating Peggy's sense of security.
This exemplar demonstrates how trials, even errors, can eventually lead to positive results when nurses, like Fran, maintain hope and persist in finding patient assets not readily apparent to others. Fran works with determination to help her patient realize her potential. As she attempts to establish realistic expectations for Peggy, this nurse undertakes the difficult job of differentiating intentional behaviors from the unintentional behaviors caused by faulty information processing resulting from her stroke.
Before determining a potential cause for a disturbing behavior, the nurse observed antecedents, the behavior itself and its consequences for Peggy. Insight into cause is gained by her analysis of recorded environmental observations of what is associated with Peggy's disturbing behavior; such as, the time of day, the patient's level of consciousness or any potential medical causes. Armed with this information and her intuition, the nurse hypothesizes triggers and changes care routines in attempts to eliminate or modify her patient's counterproductive behaviors.
As this exemplar illustrates, nurses like Fran are "milieu shapers". She creates a culture of caring, validating Peggy and her family and mediating between her family, other patients and staff. In so doing, the nurse potentiates a healing environment, enabling Peggy to integrate her loss within a coordinated treatment regime matched to Peggy's pace. Despite the nurse's own anxiety, induced by this patient's unpredictability, she is able to retain a committed stance enabling her and other staff to withstand Peggy's verbal abuse and thoughtless behaviors.
At the same time, permitting patient autonomy within limits, Fran allows Peggy to experience logical consequences of her behavior. Ultimately realizing that recovery and control are in her hands, Peggy finally understands the decision is hers. According to Benner (1984), this nursing stance rather than the strategy per se, reduces stress and tension, thus permitting new possibilities for patient self-definition. This nurse deflects recovery responsibility back to her patient most strikingly when, as an ultimate control, she institutes restraints. In most cases, restraint leads to negative sequelae resulting in emotional and physical stress and a patient's demise (Evans & Strumpf 1989, 1990; Miles & Irvine, 1992). In this rare instance, Peggy trusted Fran to not harm her, and it was this trust that prevented the usual turmoil and distress following a restraint episode.
Additionally, Peggy's need for restraint might have been circumvented if Peggy and the family had participated in more intense family therapy at the outset of treatment. As is often the case when a family member is out of control, a solution providing the needed momentum for change generally emerges from the family therapy process. In this case, however, the restraint, shocking not only the patient but the family, may have supplied the catalyst needed for initiating alternative options, solutions and growth. In a different context, however, the outcome may have led to the patient's further decline.
Institutionalization seems to loom before Peggy, as it does for many older individuals wishing to remain in their homes. Peggy's family brings her to our unit because they are overwhelmed by caregiving. Institutionalization is the logical next step if no improvement is forthcoming. With careful timing, the nurse capitalized on Peggy's fear, motivating her to make necessary changes to avoid nursing home placement. Recognizing that Peggy and her family want home discharge, the nurse works hard to achieve this goal long after other staff have given up hope. Peggy's discharge to her home pays tribute to the nurse's expertise and caring. A more functional lifestyle and family interactions are now a reality for Peggy and her family. The nurse's expertise at recognizing and planning beneficial solutions successfully enabled the closing off of useless options and the creation of new possibilities for this patient experiencing a debilitating convergence of medical illness and comorbid depression.
EXEMPLARY: SHARIE P. BIGDEU, RN, BSN
I first learned of Regina's condition from the admissions coordinator. A 72-year-old white female had fallen down her stairs, sustaining injury to her cervical spine. In a halo she was barely able to do anything without assistance. My first thoughts were, "How will the other patients on the unit receive her? Will she evoke too much anxiety from other patients and staff? How will she adjust to the halo? Will she be able to help herself? What is the best way I can help her?" When I met her briefly that afternoon she proclaimed, "I'm a very difficult patient, I need a lot of help. You have to do everything for me." My impression at that moment was that she was trying hard to cover her fears.
The next day at morning report, I was anxious to see how she was received her first day on the unit. In evening and night reports she was described as demanding, needy, uncooperative and stubborn. Promising myself not to get frustrated, I sat there trying to "psych" myself up in order to be patient and understanding of her dilemma.
When I entered her room, Regina seemed frozen in bed. Moving her entire body as a unit, she repeatedly demanded her wants and needs, refusing even to rub Vaseline on her dry lips.
I asked her if she would tell me how she felt about her halo. With anger and frustration she retorted, "How would you feel? It is a nightmare to walk around with this thing. You think it is easy people staring at you?" Tears welled in her eyes, "What am I going to do now? How am I going to live with this for eight weeks? Who is going to take care of my husband and my grandson?" She told me that her daughter is an alcoholic and drug user.
I assured her I would help her find some answers to support her through this. I also told her that we would have to slow things down, to make things easier, I shared with her my impression that she appeared weary and overwhelmed with a million thoughts racing through her mind at once; that she seemed to feel as if she had lost all control. "Yes, that is how I feel." She seemed surprised that somehow I understood. She spoke of her feelings about drinking. In an attempt to find out whether she would associate her drinking problem with the accident, I asked her how her fall had occurred. At that moment she did not admit that she was a heavy drinker. Instead she stated, "Only one beer did this to me."
She also believed that her halo was responsible for her debilitation. I felt that it was Regina's fear, anxiety and substance dependence that interfered with her physical and intellectual functioning. As we began working toward improved physical strength, I realized that she feared falling again. Persisting, I explained the importance of moving slowly and taught her safer ways to manage independently. Noticing every disadvantage, she made my work twice as hard. For example, if I asked her to feed herself, she would insist she could not see the food. The halo prevented her from doing any ADLs! I challenged her when she was afraid to try small tasks, and provided praise with the smallest accomplishment.
An occupational therapy evaluation showed she was capable of doing much more. Together, the occupational therapist and I helped Regina learn safe ways of performing ADLs despite the halo. The plan was to gradually advance her activity. Eventually, more limit setting was necessary as we negotiated our way through each small step.
In coordinating a team effort with the attending physician and other disciplines, I included Regina in several team meetings. There we set up tight contracts, sharing responsibilities between her and the staff.
I challenged her to meet simple goals well within her physical tolerance and ability. Her first contract included eating meals in the dining room with the other patients. The next day, she agreed to stay out of her room for longer periods, even if it meant staying in the piano lounge by herself. Eventually, she began to participate in group activities, adding one new group each day. She would watch the clock furiously, meeting each goal with determination, not giving an extra minute to the required task. Calling out to me in an angry voice she would remind me when it was time for her rest period. By the second week, she was attending the entire program and staying out of her room longer.
As she slowly began to do more for herself, she continued to talk about her past life, interests and the emotional issues she faced. She was the primary caretaker for her 14year-old grandson. Her husband was also dependent on her. I tried at these times to support her while pointing out her husband's and grandson's abilities to manage their own lives more independently. At other times, because she enjoyed joking around, I would laugh with her about the difficulties of dressing over a halo as we walked in the hallway for exercise.
Her anxiety and dependence on alcohol was my greatest challenge. Toward the end of her stay, I encouraged her involvement in Alcoholics Anonymous, and made a contract requiring her to attend a first meeting accompanied by a staff member. During her second meeting, a staff member would wait outside. Eventually, she was transported to Alcoholics Anonymous without staff in the immediate vicinity during the meeting. I offered empathy for the difficulty of attending these meetings and supported her when she returned. I admired her strength and punctuated her courage. I encouraged her husband and grandson to visit more often, requesting they bring larger size clothes for her comfort. They followed through with both suggestions. Their visits lifted Regina's spirits.
My overall goal was to increase Regina's independence as much as possible, teaching her to manage her pain, anxiety and depression more effectively. Nursing staff played relaxation tapes and offered warm milk at night. Other nurses also taught her other relaxation techniques and healthier, enjoyable ways to utilize her time. For instance, because Regina liked bingo, evening staff provided additional opportunities for her to take part in bingo games.
By discharge she was able to control her pain with regular Tylenol instead of narcotics. She was utilizing peer socialization, relaxation techniques, and distracting activities to reduce anxiety. Her mood brightened. And she became totally independent in all ADLs, even walking with a walker unassisted by staff. Becoming more optimistic and confident, she even began to encourage her peers.
Regina's discharge plan included a short-term stay in a nursing home until the halo could be removed. I phoned the nursing home staff, suggesting a hospital meeting for pin care instruction. This was the only thing that she could not do for herself, and her husband was too overwhelmed to learn the technique and thus handle Regina's direct discharge to their home.
When the nursing home staff visited the unit for pin care instruction, I introduced them to Regina. I reviewed what Regina had been doing, recommending she continue making efforts to socialize with others and be responsible for self-care. A plan was also made for her to continue attending Alcoholics Anonymous meetings while at the nursing home to develop more self-reliance.
I feel I really made a difference in Regina's life. This is often the reward in nursing, to know that you can make a difference.
Regina is not a typical older alcoholic because she does not live alone nor does she conceal her drinking from others. However, her history includes the usual antecedents of drinking, loss and stress associated with aging, loneliness, depression and social isolation from peers and extended family (Schonfield & Dupree, 1989). Like many other older adults. Regina drinks to alter mood and alleviate loneliness and depression. As is often the case with older substance abusers, a fall injury raises the physician's suspicion (Egbert, 1993) and a referral is made for psychiatric evaluation.
This exemplar richly demonstrates an involved nurse and patient relationship as well as an expert nurse's "future think" stance. By anticipating patient care needs, problems and solutions from admission through discharge, the nurse fosters biopsychosocial and spiritual recovery in this depressed and physically ill patient addicted to alcohol. From the moment the nurse hears about her patient, she anticipates realistic problems the halo might cause for Regina, peers and staff, mediating by presenting a series of viable solutions broken down into workable steps.
By taking time to learn about Regina's interpretation of her disease at the outset, the nurse commences treatment from where the patient is, as opposed to her view of where the patient should be. The nurse's synchronization with her patient affords Regina with opportunities that foster healing such as ventilating her feelings and reflecting on the nurse's questions as a basis for fostering receptivity to learning healthier coping strategies. The nurse also helps Regina express feelings of anger and grief in ways others can understand and tolerate, and coaches her in ways of interacting more successfully with other people. She does not confront Regina about her alcoholism until she determines her patient's capacity to hear it. Employing a strategy proven to be most beneficial to the late life alcoholic, the nurse begins with a broader context, focusing on aging issues and ways to meet socialization needs without reliance on addicting drugs. She anticipates Regina's resistance to Alcoholics Anonymous participation, setting up contingency plans for attendance at meetings in the more structured hospital and nursing home settings.
Considering Regina's family as her client and an important resource for her patient's recovery, the nurse involves Regina's husband and grandson in treatment goals to improve family relational functioning. Moreover, her timing in selecting goal levels also contributes to Regina's progress. Ultimately, this elderly woman left the hospital with a renewed sense of hope and possibility. The nurse's attentiveness, vision and caring made a difference in this patient's life.
This exemplar demonstrates an expert nurse's keen ability to think critically, prioritize and proactively respond to her patient's most urgent problems. She consistently anticipates patient needs, initiating plans to avoid unnecessary stress and crisis in her patient, family and staff. She is able to determine which aspects of the care situation are more or less important, concentrating on those variables that impact the most on her patient's recovery.
According to Benner (1984), people with a sense of salience, a perceptual stance or embodied knowledge, selectively ignore less important aspects and remain sensitive to the nuances that might influence the more significant aspects. Regina's successful outcome pays tribute to this nurse's expertise.
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Domains of Nursing Practice (Benner, 1984)