Critical Care Update! 4: 5 (1977)
(2) To explore nurses' feelings about certain "problem" patients, especially when those feelings interfere with patient care.
(3) To analyze administrative issues as they intersect the nursing and patient care spheres.
(4) To provide direct support for the leadership of the critical care unit.
The liaison function is accomplished partly through regular weekly group meetings of the entire nursing team. Two characteristic features of these groups are cohesiveness and natural leadership. They evolve spontaneously, paralleling the social structure of the work situation. Cohesiveness is established primarily as a result of the task-oriented nature of the group's interrelationships on the job. Natural leadership reflects the special relationship between the staff and the head nurse. Both qualities are transferred intact to the group meetings. In many ways, staff members and the head nurse relate to one another as in a family, with the head nurse in the parental role. The role of the psychiatrist, then, is not that of leader, but of facilitator; it is an avuncular role. Awareness of that distinction can help the psychiatrist avoid undermining the leadership position of the head nurse, which is essential in the working critical care unit.
The ground rules for group participation follow the cultural conventions of the work setting: the focus is on issues within the unit. External personal problems are minimized as topics for group discussion. Group participation is voluntary and is available to all members of the critical care unit team: nurses, ward clerks, therapists, dietitians, social workers, and students. The goal of the group meeting is not to change personalities or to uproot and expose individual neurotic conflicts. In that sense, it is not a therapy group. Nevertheless, promotion of understanding of emotional issues, clarification of the elements of interpersonal conflicts and emphasis on resolving work-related ambivalence are stressed. in order to successfully accomplish those tasks, it is essential for each nurse to develop a good knowledge of her own psychological make-up.
The professional setting is a major source of personal gratification for many nurses. Because of that, the liaison psychiatrist can help expand the nurse's sources of self-esteem by teaching new skills. New areas for professional gratification can be opened thus by the development of psychotherapeutic skills for working with patients who have psychiatric disorders. The nurse, because she is closest to the patient, is also the person who is potentially most able to provide timely crisis intervention. However, many nurses are not trained to work directly with psychological issues. Sometimes they even feel hostile toward patients whose emotional difficulty causes problems for others (including the nursing staff). For example, patients who reach a critical care unit as a result of a suicide attempt are often viewed contemptuously; a nurse may feel, "Why should I work my buns off to save her life when she did this to herself in the the first place-and it was probably only a manipulative gesture anyway!" Within the group, this kind of feeling is explored, the patient's psychological position is analyzed, and the principles of intervention are discussed. Most nurses thus prepared with understanding and technical skill are eager to participate in the rehabilitation of the depressed patient.
Physical illnesses are devastating to the individual suffering from them, of course, but the crisis is not theirs alone. Families and other loved ones are affected as well. in fact, the emotional trauma to family members can be greater than that to the patient. That fact is often a topic for discussion in the weekly group meetings, and, as a result, the study of family dynamics becomes prominent. Accordingly, psychotherapeutic techniques and theory relating to family crisis intervention are learned and applied by the nursing staff. Because of her pivotal position in the health-care system, the nurse is then able to become the one person to whom a family can relate throughout their crisis.
Case 1: Mrs G., a 39 year old married mother of four, was abruptly struck down by a quadriplegia of undetermined etiology, Because of respiratory embarrassment, she was hospitalized in the respiratory intensive care unit (RICU) and ventilated mechanically. Because of a prolonged convalescence, she was in the RICU several weeks. During that time, her case was discussed weekly in the group meeting. Over that period of time, the feelings of the nurses who worked closest with Mrs. G. evolved considerably. in the beginning, they were highly sympathetic with her, observing that they could identify with her and that they had come to know the family members personally. By the end of the second week, though, their feelings began to change and they became more critical of her. They remarked that they could see how she had been a highly manipulative and controlling person prior to her illness, basing their opinions on interactions between Mrs. G. and her family. At this point, the nurses began to identify with the family members and it was readily apparent to them that they too felt manipulated and controlled by Mrs. G. Nevertheless, they were reluctant to express any resentment on their part, reserving expression of that by feeling sorry for her family. in fact, the nurses maintained a position of sweetness, indulgence, and acquiescence with the patient. Concurrently, they were very eager to explore the reasons for the patient's manipulativeness toward the family in an attempt to understand her better.
When Mrs. G.'s posture of demanding, manipulative control was understood as her attempt to cope with her sudden illness, the nurses felt they were better able to deal with her themselves. Nevertheless, they had not yet acknowledged the full extent of their own anger toward this woman. That didn't happen until their behavior toward her contributed to a dangerous clinical deterioration. Mrs. G. required frequent turnings for pulmonary drainage, but being turned was quite painful for her and she vigorously protested each attempt to move her. For their part, the nurses were willing to go along with her demands for minimal turning, thinking that they were being nice to her through sympathy. As a result, she developed a persistent pneumonia. When the full extent of these interactions were explored in group meetings, it became clear to the nurses that their failure to turn Mrs. G. was not a result of sympathy and understanding, but quite the opposite—they were so angry at her they felt guilty by causing her pain. Their own anger toward her was unacceptable to them and they had therefore suppressed it. The nurses were genuinely disturbed prior to this clarification because they were aware that their "kindness" had led to her pneumonia. After their resentment toward Mrs. G. was recognized and acknowledged, though, those negative feelings were removed as interfering factors in the nursing care. Within a week after the nurses began turning Mrs. G.—despite her bitter complaints—her lung fields cleared and the nursing staff was abundantly rewarded for their work by Mrs. G.'s improvement.
As one result of interdepartmental chauvinism, the nursing staff is occasionally abandoned by the medical staff and is thereby isolated as the group of last resort for a given patient. When that happens, the nursing staff acquires the total responsibility for that patient's well-being, but not the corresponding authority to solve all the attendant problems. These situations are within the purview of the liaison psychiatrist for diagnosis and intervention. The psychiatrist's task is to identify the elements of the process with the goal of helping reestablish the proper network of shared responsibility. A complex case illustrating these principles follows.
Case 2: Mr. C. was a twice-divorced man approaching his forty-fifth birthday who was receiving dialysis three times a week while awaiting a kidney transplant. He had developed strong Fundamentalist religious beliefs about four years prior to his present problems, and had become heavily dependent emotionally upon those beliefs. His physical health was maintained well by dialysis despite his idiosyncratic diet and poor attention to his fluid intake. He had been discharged previously from another dialysis unit with the injunction that he was never to return; that discharge was a result of his unacceptable behavior. At the time Mr. C.'s behavior was presented as a topic of discussion in a group meeting with the liaison psychiatrist. He had been frightening members of the nursing staff, particularly focusing on one nurse, Mrs. H. He accused nurses of immoral behavior, being possessed by demons, and of trying to kill him. A few months prior to these discussions, he had been suffering from auditory hallucinations, rammed his fist through the window and nearly exsanquinated, The female members of the nursing staff had nearly unanimously perceived Mr. C. as menacing, threatening, hostile and potentially very dangerous. He had been demanding special privileges, was highly self-centered and grandiose, aggressively religious, and physically intimidating. The nurses as a group expressed their feelings that they wanted to provide competent medical care to Mr. C., but that they were genuinely terrified of his potential for violence. Their own fantasies were that he might come into the unit some day and start shooting.
Mr. C. was seen in consultation by the Chief of the Psychiatric Consultation Service prior to the introduction of his case in the weekly group meeting. The consultant diagnosed Mr. C. as a paranoid schizophrenic with a long-standing pattern of projection, grandiosity, religiosity, and hostility toward females. He also observed that there was no legal way the patient could be treated involuntarily because the consultant did not consider him to be imminently dangerous. He offered outpatient therapy to Mr. C., but Mr. C. refused consistently to keep appointments with the psychiatrist. Even though the consulting psychiatrist had done all he could under the circumstances to provide treatment for Mr. C., the nursing staff felt that they had been let down by the one person who might have been able to solve the problem. As a result, they funneled most of their anger about Mr. C. and his attendant problems on to the consulting psychiatrist. Although it was not a primary goal in the meetings, reversal of that scapegoating process evolved naturally as hospital-wide elements of the patient's management, or lack of it, became apparent.
Intrinsic to Mr. C.'s schizophrenic process were two primitive coping mechanisms that were manifest prominently: grandiosity and projection. He demonstrated projection by attributing to others his own sexual impulses and hostility which he refused to acknowledge in himself. He complained that the nurses on the dialysis unit tried to kill him by instilling formalin into his bloodstream. He also accused Mrs. H., an attractive young nurse, as being possessed by the devil and of being his chief malefactor. He accused her of being sexually provocative and terrorized her once by placing a page ripped out of the Bible on her windshield. The biblical passage, from the first chapter of Romans, said that God demanded death for those who participated in "sexual sins". Mrs. H. was extremely fearful that Mr. C. might follow through on the implied threat, carrying on "the Lord's work".
Mr. C.'s grandiosity was demonstrated throughout the hospital in even more spectacular ways. He directed his associates outside the hospital to telephone him on the unit, referring to the dialysis unit as his office. The frequency of those phone calls was so high it was disruptive to the unit's activities on some days. Routinely, after leaving the dialysis unit on the days of his treatment, Mr. C. made 4 4 rounds" in other parts of the hospital. He delivered bibles and sermons to anyone that he felt may be needing salvation or ministration. He reported that he was "Assistant Chaplain" in the County Correctional System. in the course of his hospital "rounds", Mr. C. roamed the entire hospital like a doctor, disturbed patients and preached at them like an apostle, and demanded protracted audiences with the hospital's highest administrators like a trustee.
The hospital administration did nothing to disillusion Mr. C. or to confront him with the unreality of his grandiosity. Obviously, the hospital was doing nothing to protect the other patients from this man's intrusiveness either. Yet his unacceptable behavior persisted and the responsibility for controlling him was implicitly abdicated to the nursing staff on the dialysis unit. The nursing staff, in turn, was completely frustrated because they did not have the authority or the power to deal with the total problem presented by Mr. C. As a result, they decided the best way to solve the problem would be to discharge the patient to a nearby VA hospital. The medical staff was nonsupportive to nursing, preferring to deal with only the renal aspects of the patient's condition; thereby ignoring the impact of his psychosis.
The nursing department represented the only area of administration which concerned itself with Mr. C.'s problems, but administratively, those problems were much more comprehensive than just nursing problems. Accordingly, recommendations from the liaison psychiatrist encompassed more than recommendations for nursing alone. Within the dialysis unit, it was recommended that the nursing staff set clear limits for Mr. C.'s behavior that were commensurate with limits expected of any other patient. Then, if his behavior was unacceptable, his dialysis treatment would be discontinued immediately for that day. Mr. C. would be informed of the reason, and he would be escorted out of the unit. The measures recommended for Mr. C.'s management outside the unit were based on his aggressiveness and intrusiveness toward other patients. It was pointed out if such violation of patients' privacy was not already prohibited by hospital rules, such rules should be established immediately. it was then recommended that security personnel be available to monitor Mr. C.'s actions after he left the dialysis unit and escort him from the hospital if necessary. Because of Mr. C.'s action in placing the Bible page on Mrs. H.'s car, it was also recommended he not be permitted to loiter in the parking lot.
The recommendations above were implemented and worked very smoothly. Each day Mr. C. came for dialysis, a security officer met him in the parking lot and escorted him directly to the dialysis unit. The officer then remained in the vicinity of the unit for the duration of Mr. C.'s treatment and subsequently escorted him back to his car. Mr. C. responded well to the firm limit-setting, registering his objections verbally rather than physically. Despite their success, though, those procedures didn't last long. Since the responsibility for Mr. C. was now being shared with nursing by other departments, the real cost of providing his care became obvious. As a result of making explicit,+keimplicit cost of caring for Mr. C., a rapid solution was agreed upon by all parties. Happily, Mr. C. was moved from a very low priority on the kidney transplant list to a very high priority. As a result, within a few weeks, he received a transplant, which has been successful nearly a year.
The morale of the unit as a whole also depends upon the morale of the head nurse. Again, this is a result of the pivotal emotional role she accepts. Accordingly, the head nurse needs the support—emotionally and administratively—of her supervisor. In some cases, the dual role of the confidant/supervisor creates a bind for the head nurse. In those instances the liaison psychiatrist in his avuncular role can be helpful because he has no administrative authority within the unit or the nursing service. Yet, because he is a trusted member of the nursing team, the liaison psychiatrist is in an excellent position to provide support and counselling for the nursing leadership through private consultations arranged as they are needed.
In conclusion, the activities of the liaison psychiatrist are appropriate at several levels: the nursing group and the individual nurse, the patient; the patient's family, and the hospital as a whole. He can help the nursing staff recognize that the emotional issues surrounding illness and death in the hospital are of the highest intensity and can feed secondary problems in a broader spectrum. He can also participate in the development of solutions to those problems. The benefits of the liaison service accrue to the individual nurses by increasing their sense of accomplishment and self-esteem; to the patient who received better medical care; and to the hospital as an insitution by improving its public image and by mitigating the threat of liability actions that commonly arise from angry, thoughtlessly-treated patients and family members.