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Challenges Faced by Staf Nurses
in Dealing with Critically Ill Patients
Admited in General Ward
MARNICHELLE KY B. CLAMOHOY
WILMA GARCIA
SHERRY MAY S. JUNGCO
KRIZZIA KEMPIS
NATHANIEL MAKIPUTIN
MARIA CASHANDRA YAEZ
College of Nursing
Liceo de Cagayan University
Abstract - Using the qualitative approach, this research endeavored
to 1) to determine the respondents profle in terms of: age, sex, marital
status, and number of years as staf nurse; 2) to determine the work
and family-related concerns of the staf nurses in the ward of private
hospital; 3) to identify the strategies how staf nurses deal with critically
ill patients; and 4) to design an intervention. The respondents of this
study were staf nurses of three selected private hospitals in Cagayan de
Oro City. There were 10 staf nurses chosen from the selected hospitals.
All duty shifs were represented in this study. The respondents in each
hospital were chosen by purposive sampling considering who had
beter experience relating with critically ill patients and who can spend
enough time answering the questions. Based on the responses to the
queries to the selected staf nurses, the following surfaced along the
course of the investigation: 1) The majority of the staf nurses then
were 2125 years old, female, single and had a length of experience
of 15 years. 2) Most of the nurses complained of the changing work
schedule as their work-related concern while having less quality time
with their family was their family-related concern. 3) The staf nurses
experienced three types of behaviors among critically ill patients,
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namely: demanding, non-compliant and temperamental. The patients
demanded so much of their time and atention, are uncooperative and
non-compliant to their medications and temperamental and talked in
raised voice. 4) To maintain healthy nurse-patient relationship, the
staf nurses developed their own strategy in dealing with critically ill
patients. The nurses have distinct strategy for each kind of behavior.
For demanding critically ill patients, the nurses evaluate their
demands and grant them their reasonable demands. The nurses take
efort and time explaining to the patients why they cannot grant their
unreasonable demands. For non-compliant critically ill patients, the
nurses explain to them why they are required to do a routine or take
medicines. They also explain the consequence if they continue to
defy the order of the doctor. In the case of temperamental critically
ill patients, the nurses always remember that these patients are under
their care and are in need of their nursing service. They hold their
temper, keep calm and stretch their patients and refrain from talking
to them in raised voice. On the basis of the fndings, the researchers
conclude that handling critically ill patients pose a challenge to staf
nurses who developed strategies in dealing with them. Each strategy
is specifc to the behavior the critically ill patient has shown them.
These strategies are guided by their role as care provider.
Key words: Challenges Faced, Critically Ill Patients, Staf Nurses,
General Ward
INTRODUCTION
The reciprocal interaction that occurs between nurses and patients
in the context of providing and receiving nursing care is nurse-patient
interaction. Although the defnition of nurse-patient interaction has
not received careful atention, the focus has been on the verbal and
non-verbal behaviors of the nurse. Yet increasingly, patients are
being encouraged to take an active role in decision-making and the
nursing care. To develop innovative and supportive strategies to
foster collaboration in care and involvement in decision making, a
sound understanding of the nature of interactions between nurse and
patient, with the strong focus on the role of patient behavior in these
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interactions, if necessary (Botforf, 2005).
Nursing is a profession that is based on collaborative relationships
with clients and colleagues. When two or more people view issues
or situations from diferent perspectives, these relationships can be
compromised by confict Sportsman (2005) believes that the role of
the nurse is to support the client in achieving the clients health goals.
Behavior of the patient towards the nurse or his/her own situation can
impede the atainment of these goals.
Every nurse will experience caring for a patient who may exhibit
behaviors such as anger, aggression and other personality disorders
possibly requiring consulting a mental health professional. Negotiating
care with the patient may allay many of these behaviors. It is important
not to allow egos and power struggles to interfere with care of these
patients, a legitimate concern may be overlooked. Patients are not
concerned with how many other patients assigned to the nurse. If the
assignment is too demanding, the nurse should delegate asking their
colleagues for assistance. Education in dealing with these types of
patients will allow nurses to begin their shifs without a preconceived
impression of the patients (Morrison, 2000).
There are also critically ill patients who are at high risk for actual
or potential life-threatening health problems. The more critically
ill the patient is the more likely he or she is to be highly vulnerable,
unstable and complex, thereby requiring intense and vigilant nursing
care (classic.aacn.org).They are patients who require continuous,
comprehensive, and detailed intensive care because of the critical
nature of their disease or illness (www.merck.com).
Advances in medical sciences have allowed an increased number of
critically ill patients to survive the acute phase of their illness. Today,
there are growing numbers of patients whose ICU stays are prolonged
due to complications, comorbidities, and exacerbated chronic health
conditions. In 1991, Daly et al as cited by Carasa and Nespoli (July
2002) described these patients as chronically critically ill (CCI), and
documented the idea that this patient population has unique health
care needs exemplifed by their need for excellent, intensive, well-or-
ganized nursing care.
American College of Cardiovascular Nursing (AACN) defnes ad-
vocacy as respecting and supporting the basic values, rights and beliefs
of the critically ill patient. In this role, critical care nurses: 1) Respect
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and support the right of the patient or the patients designated sur-
rogate to autonomous informed decision making. 2) Intervene when
the best interest of the patient is in question. 3) Help the patient obtain
necessary care. 4) Respect the values, beliefs and rights of the patient.
5) Provide education and support to help the patient or the patients
designated surrogate make decisions. 6) Represent the patient in
accordance with the patients choices. 7) Support the decisions of the
patient or designated surrogate, or transfer care to an equally quali-
fed critical care nurse. 8) Intercede for patients who cannot speak for
themselves in situations that require immediate action. 9) Monitor and
safeguard the quality of care the patient receives. 10) Act as a liaison
between the patient, the patients family and other healthcare profes-
sionals (classic.aacn.org).
Moreover, nurses must be very careful labeling a patient difcult,
especially during shif report. Many nurses have a preconceived
impression of the patient prior to even entering the room. The
problem could have been related to other issues on the previous shif
or in response to a particular nurse. Silverman (2003) cited Dr. Michael
Lubin as stating, Just because theyre difcult patients doesnt mean
they dont have real concerns. You must never lose your temper. It
is helpful to ask for advice from other nurses who have had success
dealing with the difcult patient.
In addition to, nurses should not insist patients follow their routine
or set time of care but rather negotiate care at the beginning of their
shif. If possible, it is benefcial to do this on the initial contact. Haas
(2005) states, Negotiation is best if it occurs as soon as possible
following admission to the hospital, before the violence starts.
Unfortunately, once the anger and aggression start, most staf reacts
and get into a power struggle. The patient may be less tempted to call
the nurse before the negotiated time and will understand emergencies
may cause delays.
The researchers are nursing students who had encountered dif-
cult patients during their respective hospital duty. Being able to know-
how staf nurses interact with difcult patients had encouraged them
to undertake this research. From this study, laudable approaches may
be recommended to be institutionally adopted for the improvement of
handling difcult patients.
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FRAMEWORK
This study is anchored on Behavioral Model of Dorothy E. Johnson
(1980).The Behavioral Model have four major concepts:first, Johnson
views human being as having two major systems, the biological
system and the behavioral system. It is role of the medicine to focus on
biological system where as Nursings focus is the behavioral system,
second,Societyrelates to the environment on which the individual
exists. According to Johnson an individuals behavior is infuenced
by the events in the environment,third,Healthis a purposeful
adaptive response, physically mentally, emotionally, and socially
to internal and external stimuli in order to maintain stability and
comfort,andNursing has a primary goal that is to foster equilibrium
within the individual .she stated that nursing is concerned with
the organized and integrated whole, but that the major focus is on
maintaining a balance in the Behavior system when illness occurs in
an individual.
There are several layers of assumption that Johnson makes in
the development of conceptualization of the behavioral system
model (Johnson was infuenced by Buckley, Chin and Rapport) there
are 4 assumptions of system: First assumption states that there is
organization, interaction, interdependency and integration of the
parts and elements of behaviors that go to make up the system. A
system tends to achieve a balance among the various forces operating
within and upon it, and that man strive continually to maintain a
behavioral system balance and steady state by more or less automatic
adjustments and adaptations to the natural forces impinging in him.
A behavioral system, which both requires and results in some degree of
regularity and constancy in behavior, is essential to man that is to say,
it is functionally signifcant in that it serves a useful purpose, both in
social life and for individual. The fnal assumption states that system
balance refects adjustments and adaptations that are successful in
some way and to some degree.
The integration of these assumptions provides the behavioral
system with the patern of action to form an organized and integrated
functional unit that determines and limits the interaction between the
person and his environment and establishes the relation of the person
to the objects, events and situations in his environment.
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Assumptions about structure and function of each subsystem are:
from the form the behavior takes and the consequences it achieves
can be inferred what drive has been stimulated or what goal
is being sought Each individual has a predisposition to act with
reference to the goal, in certain ways rather than the other ways. This
predisposition is called as set. Each subsystem has a repertoire of
choices or scope of action. It produces observable outcome that is
the individuals behavior.
Each subsystem has three functional requirements: System must be
protected from noxious infuences with which system cannot cope.
Each subsystem must be nurtured through the input of appropriate
supplies from the environment. Each subsystem must be stimulated
for use to enhance growth and prevent stagnation.
Nursing is an external regulatory force which acts to preserve the
organization and integration of the patients behaviors at an optimum
level under those conditions in which the behaviors constitutes a threat
to the physical or social health, or in which illness is found (Johnson,
1980). Based on this defnition there are four goals of nursing are to
assist the patient: whose behavior commensurate with social demands.
Who is able to modify his behavior in ways that it supports biological
imperatives. Who is able to beneft to the fullest extent during illness
from the physicians knowledge and skill, and whose behavior does
not give evidence of unnecessary trauma as a consequence of illness.
In one American study, doctor-rated difcult patients were associ-
ated with: psychiatric disorders (particularly multisomato form dis-
order, panic disorder, dysthymia, generalized anxiety, major depres-
sive disorder and probable alcohol abuse or dependence), functional
impairments, high use of health care, and lower satisfaction with care
(Hahn et al, 1996).
Not every difcult patient presents a problem that is purely annoy-
ing. Remember:
pain may impair their ability to behave in a socially acceptable
manner, they may have a mental disorder that modifes their ability
to be courteous, they may feel aggrieved about previous care (if it
failed to relieve their symptoms), the patient may be having a bad
day, the patient may feel ofended or fobbed of by the GP or staf or
the patient may simply be rude or ignorant. Every problem patient
presents a unique dilemma (Lilley and Lambden, 2005).
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Nield-Anderson et al. (1999) support that any patient may become
aggressive, depending on the circumstances. Another perspective on
this topic is There is no difcult patient for as long as you understand
the uniqueness of a patient. Empathizes with him/her, provide the
patient with information relevant to the condition fnd out and
correct misconceptions and allay his/her anxieties. Explain every
activity carried out on him/her, providing counseling and support
and maintains good interpersonal relations. Responding to an article
in a journal, a reader (McEntee, 2000:16) expresses her concern that
medical staf may inappropriately label patients behaviours as being
difcult. Before starting to label patients, it must be made sure that
the standards of good nursing care had been met.
Patients whom an organization may consider difcult are more
than just those who negatively afect staf satisfaction. Difcult
patients are also those who require increased resources, have a greater
risk for negative encounters and outcomes (which could lead to
future litigation), and tend to have prolonged lengths of stay (www.
hcmarketplace.com).
Patients do not necessarily follow the advice given to them by
health care practitioners. This mismatch between what is prescribed
in terms of medication or lifestyle changes and what patients actually
do is commonly referred to as noncompliance. Non-compliance is
encountered to various degrees in all felds of health care, involving
an estimated 38% of patients on short-term treatment; 43% of patients
on long-term treatment; and 75% of patients advised to make lifestyle
changes in the United States of America (USA) (DiMateo 1994).
In Australia, McElduf et al. (2001) calculated that incidence of and
mortality related to heart atacks could be reduced by 40% if health
promotion targets were met. Such statistics serve to focus atention
on the problems associated with non-compliance. Certainly there is
a problem; and working out what to do about it has produced a vast
literature in the medical, nursing and allied health disciplines.
A 2001 on-line survey from the American Nurses Association found
that 17% of nurses had been physically assaulted in the past year and
more than half (57%) were threatened or experienced verbal abuse. To-
days short-stafng pressures add fuel to the fre. These shocking sta-
tistics illustrate that one cannot take his physical safety on the job for
granted. Violence is more than physical assault; it also encompasses
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threatening behavior and verbal abuse, such as obscene phone calls,
threats, hiting walls or throwing things, and intimidation. Under Oc-
cupational Safety and Health Administration (OSHA) guidelines, even
slander is a form of violence (Distacio, 2004).
Management depends on the nature, frequency and seriousness of
the problems that occur. You may consider: ignoring a single episode
of inappropriate behaviour, writing to the patient about it, speaking
to the patient about it or asking the senior partner to do so, in serious
cases, arranging for the patient to be removed from the practice list.
Each of these approaches has advantages and disadvantages. Patients
ofen refuse to accept that their behaviour was in any way difcult,
particularly if they did not think that they actually were (Lilley and
Lambden, 2005).
Many nurses have tried various strategies to solve the problems
associated with caring for difcult patients and families. Ofen they
rely on tactics that have worked in the past or avoid the situation if at
all possible. Nonetheless, the circumstances associated with managing
difcult patients remain a challenge. Specifc nursing interventions
may work beter than others to improve difcult patients situations.
The use of such interventions could help patients and nurses elimi-
nate the label of difcult and thereby turn the situation around so
that deteriorating events are replaced by win-win situations (Wolf et
al, 1997).
Difcult patients are not those with difcult medical problems but
rather those who are violent, demanding, aggressive, rude and who
seek secondary gain (Steinmetz & Tabenkin, 2001). Patients with mul-
tiple non-specifc complaints and those with psychosomatic problems
are also difcult for the family physician. Appropriate use of patient-
doctor communication skills and an efort to improve relations with
the patients through empathy, tolerance and non-judgmental listening
were suggested by the physicians as ways of making difcult patient
encounter easier.
OBJECTIVES OF THE STUDY
This study was pursued guided by the following objectives: 1)
to determine the respondents profle in terms of: age, sex, marital
status,and number of years as staf nurse, 2) to determine the work
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and family-related concerns among staf nurses in the general ward of
private hospital; 3) to identify the strategies how the staf nurses deal
with critically ill patients; and 4) to design and intervention.
RESEARCH FLOW
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SIGNIFICANCE OF THE STUDY
The fndings of this study will be benefcial to a number of sectors
in the health care system.
This study will alarm the hospital administrators of the possible
occurrence of nurse-client confict. They will be motivated to investigate
if the same is happening in their respective hospitals. Serious nurse-
client confict can then be addressed and strategies can be put in place.
The head nurses can also beneft from the results of this study. The
fndings of this study will guide them in developing strategies on how
to deal with critically ill patients in order to promote a healthy nurse-
client relationship.
The results of this study will give insight to staf nurses on how to
beter handle critically ill patients. The herein cited literature will give
them more information about these patients, their nature and behavior.
The fndings of this study will alarm nursing students the existence
of critically ill patients in hospital wards. This will prepare them when
they encounter such patients in the work environment.
SCOPE AND LIMITATIONS OF THE STUDY
This study dwelt on the challenges faced by staf nurses in dealing
with critically ill patients among the staf nurses in selected private
hospitals of Cagayan de Oro City. It also investigated on the profle
of staf nurses in terms of age, sex, marital status, number of years as
staf nurse as well as their pressing concerns in terms of work-related
and family-related concerns. This study covered the period from
November 15 to December 31, 2009.
MATERIALS AND METHODS
This is study that intended to describe the challenges faced by staf
nurses inhandling critically ill patient used the qualitative research
design. Qualitative research methods are ofen used to explore a
phenomenon that has not been previously well described. The results
are then used to develop survey instruments. The survey instruments
yield results that can be analyzed statistically. It is interpretive and
textual type of research (Risjord et al, 2001). A great deal of qualitative
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material comes from talking with people whether it be through formal
interviews or casual conversations.
The mean data gathering instrument that was used in this
study was an interview guide. The interview initially inquired on the
age, sex, marital status, number of years as staf nurses, pressing work-
related and family-related concerns. The interview guide inquired also
on the strategies of staf nurses in handling critically ill patients.
The respondents of this study were 10 staf nurses of three
selected private hospitals in Cagayan de Oro City. All duty shifs
were represented in this study. The respondents in each hospital were
chosen by purposive sampling giving considerations on who had
beter experience relating with critically ill patients and who can spend
time answering our questions.
Face to face guided interview was conducted with the respondents
during their most convenient time using a pre-formulated guide
questions consistent with the objectives of the study. Their responses
were transcribed, clustered and themes were established to serve as
bases for the analysis. During the conduct of the interview, ethical
principles such as honesty and trustworthiness were strictly adhered
too, including confdentiality of responses. The respondents were
assured anonymity of their identity. No mention was done on the
names of the hospitals.
The analysis of the gathered data was facilitated through the use of
frequency and percentage.
RESULTS AND DISCUSSION
Profle of the Staf Nurses
Among the 10 staf nurse-respondents, 5 or 30 percent were 21-25
years old, 4 or 40 percent of them were 26-30 years old while 1 or 10
percent was 31 to 35 years old. Three (3) or 30 percent of the staf nurses
were male while 7 or 70 percent were female. Six (6) staf nurses or
60 percent were single while 4 or 40 percent were married. In terms
of length of experience as staf nurse, 8 or 80 percent had a length of
experience of 1 to 5 years while 2 or 20 percent had been a staf nurse
for 6 to 10 years.
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The majority of the staf nurses then were 2125 years old, female,
single and had a length of experience of 15 years.
Table 1. Profle of staf nurses
Variable Categories Frequency Percentage
Age 21 25 years old 5 50.0
26 30 years old 4 40.0
31 35 years old 1 10.0
Total 10 100.0
Gender Male 3 30.0
Female 7 70.0
Total 10 100.0
Marital status Single 6 60.0
Married 4 40.0
Total 10 100.0
Length of 1 5 years 8 75.0
Experience 6 10 years 2 25.0
Total 10 100.0
Pressing Concerns of Staf Nurses
Three (3) or 30 percent of the respondents had low salary as their
work-related concern. Four (4) or 40 percent of them complained of
their changing work schedule while 3 or 30 percent lamented that they
had heavy work load.
Unable to augment family income was the family-related concern
among 3 or 30 percent of the respondents. Their being unable to atend
important occasions, data gathering and even to atend to sick relatives
was the concern of 5 or 50.0 percent of the nurses while making their
parents worry about their safety when they are on night shif was the
concern of 2 or 20 percent of the nurses.
As revealed in Table 2, most of the nurses complained of the
changing work schedule as their work-related concern while having
less quality time with their family was their family-related concern.
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Table 2. Pressing concerns among the staf nurses
Concerns Responses
Low salary One of my big problems in my work is my salary. My
work is hectic but my
salary is not enough to buy my needs
Work-related The salary that I receive is not enough to sustain my
needs, not commensurate with the nature of my job.
Concerns My work load is very heavy but the salary not
compensating
Changing duty I dont get much rest because of my schedule of duty.
I dont even get enough sleep especially if I am on
11pm7am duty.
Shif
I have a hard time adjusting to rotating schedule of
duty. There are duty
Schedules when works to do are plenty.
Because of the changing schedule of duty, it is not
only my health that is afected but my time with my
family also.
There are cases that I have a morning duty, the next
duty shif I am assigned to afernoon duty.
Heavy Work At the end of the day, I feel so drained and exhausted
because more ofen there are plenty of works to do.
Load
Because the hospital is under-staf, the nurse-patient
ratio is too high. I have more patients placed under
my care.
I have a busy schedule because the hospital is under-
staf. There are more works assigned than what I can
efectively handle.
Failure to help Because my salary is not enough, I failed to give my
share in the family expenses.
the family
Family- fnancially I am ashamed to my husband because I cannot give
my share in defraying family expenses.
Related
Concerns My husband and kids are already complaining
because I am lef with not enough quality time that I
can spend with them..
Inadequate I cannot anymore atend personally to the needs of
my family because of the demands of my job.
time for the
Family Inability to atend important family gatherings that
require my atendance wreunions, family day, etc.
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Unable to important occasions as birthdays,
anniversaries, festas, because
I cannot just be absent from my job.
My parents are already complaining that I cannot
give them my time especially when a family member
is sick.
There were times I failed to spend enough time
during my husbands and childs birthday.
Parents worry My parents worry for my safety especially if I am on
11pm7am shif.
during night My parents have to stay awake until I get home
during my 11pm7am shif.
Strategies of Nurses in Dealing with Critically-Ill Patients
There were three cited behaviors of critically ill patients: demanding,
non-compliant and temperamental. Each of these behaviors, the nurses
had specifc strategies. For demanding critically ill patient, one nurse
granted the patients reasonable demands and leting him understand
why unreasonable demands cannot be granted. One nurse said, he
atended to the patients demands as much as possible and explained
to him why some of his demands cannot be granted. Another nurse
provide the patients demands if the same are within her capability
and explained to him that some of his demands cannot be granted
because it will only harm him more. Another nurse evaluated frst
the demands of her patient. She granted the reasonable demands but
the denied the unreasonable ones explaining to her why they cannot
be provided.
For non-compliant critically ill patients, one nurse was guided by her
role as Angel of Mercy as such she had to show that she empathized
with him and assured the patient that the pain will subside in due time
and for the meantime he has to take his medications. Another nurse
explained to the non-compliant critically ill patient in detail why she
has to take her medications and what they are for while explaining to
her what will happen if she fails to follow the doctors order. Another
nurse, explained to the critically ill patient that what the doctor requires
is the good of her, at the same time leting her aware the consequences
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if she will not obey.
For temperamental critically ill patient, a nurse ignored her patients
behavior and continued with her job striving not to get afected while
bearing in her mind that he is her patient and he needs her care.
Another nurse considered the behavior of the patient as a challenge
and remained calm and unafected by the patients behavior. Despite
the temperament exhibited by the patient, one nurse tried to approach
the patient with humility and calmness, maintaining her own temper
and refraining raising her voice when talking to the patient.
Table 3. Strategies Used of Staf Nurses in Dealing
with Critically Ill Patients
Behavior of
Critically Ill Patients
Strategies
Reasonable demands are provided to the patients as soon as
possible. For unreasonable demands, I make the patient
under stand why I cannot grant them
Demanding I atend to their needs as much as possible, if they are
reasonable. If they are not, I explain to them that doing so is
not within my means.
I focus to my work. Provide him with what he demands, if
they are within my capability and explain to him if giving in
to his demand harms him more.
I evaluate if her demands are reasonable. I will provide her
the if it will not harm her. If explain to him if granting her
demand is not advised due to her condition.
I remember that I am an Angel of Mercy. I empathize with
him and tell him that the pain will subside in due time. In
the meantime, he has to take his medication.
Non-compliant I explain to her in detail why she has to take medications
and what they are for. Ill give her the scenario on what will
happen if she continuously defy the doctors order.
With so much understanding and patience, I explain to the
patient that the things that the doctor requires her to do is
for her own good and tells her what will happen if she will
not obey.
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I just ignore his behavior and continue with what I am
supposed to do for him and strive to get afected with his
actions. I have to bear in mind that he is my patient and he
needs my care.
Temperamental I extend more understanding to the patient and considered
the patientsbehavior as a challenge on my part. I remain
calm and unafected by the behavior.
With so much humility and calmness, I approach the patient.
I maintain my temper and extend more patience. I never
raised my voice in talking to her
CONCLUSIONS
Based on the fndings of this study, the researchers conclude that
handling critically ill patients pose a challenge to staf nurses who
developed strategies in dealing with them. Each strategy is specifc to
the behavior the critically ill patient has shown them. These strategies
are guided by their role as care provider.
RECOMMENDATIONS
Based on the fndings and conclusions, the researchers give the
following recommendations:
1. Management of critically ill patients should be made a part of the
classroom discussions in the colleges of nursing so nursing students
are prepared beforehand in dealing with these patients when they
work. Focus should be made on approaches and strategies that can be
used in enhancing nurse-difcult patient.
2. Seminars on handling critically ill patients should be initiated by
hospital administration especially among new nurse recruits to make
them prepared in the event they meet such kind of patient in the wards.
3. Future researchers are encouraged to replicate this study in wider
seting using quantitative approaches. Critically ill patients may be
categorized into very difcult, difcult and less difcult. Independent
variables as age, socio-economic status of the patient may be used.
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