Corporeality and its Affect on Nursing Care

1. Corporeality and its Affect on Nursing Care Ronald P. Ceppetelli MSW, LICSW, PsyaD(c) Sigma Theta Tau: Kappa Tau Chapter Research & Evidenced-Based Practice Symposium Evolution of Nursing Knowledge: Evidence into Practice December 5, 2009

2. Background • 18 month externship w/SNF residents • Several residents had dramatic improvement in quality of life including one case of elimination of “massive doses of haldol” and another resident who transformed from homicidal/suicidal diagnosis to “the ambassador of the SNF.” • Geriatrician asked if I could train aides to do what I do • By the 30 minute mark of the first group session the focus of my project shifted to why are these aides saying these disturbing things about helpless residents?

3. Dissertation Research • Conceptual Framework • Modern Psychoanalytic Theory • Terror Management Theory • Setting • Sample • Duration • Methodology • Outcomes • I propose that the findings are generalizable to other health settings and providers

4. Modern Psychoanalytic Theory Contact Function • Why is this person saying or doing this behavior? • All interaction with patients are based on finding out more about this question from the patients’ perspective.

5. Setting: Skilled Nursing Home • 50-100 Bed category • 5 Star rating • I have the greatest respect and strong affiliations with the staff • These findings are not a criticism of this nursing home, its staff or the nursing home industry

6. Sample/Methodology • Voluntary participation • Each of five nurses aides “listened” to one selected resident for 40 minutes weekly for six months • All five nurses aides participated in videotaped group sessions held for 90 minutes twice monthly for six months. • All five nurses aides were briefly acquainted with 4 modern psychoanalytic techniques.

7. Modern Psychoanalytic Intervention Receptive Listening • Create a safe place to express thoughts and feelings in language • Do not judge, value, try to change, or help Techniques • Joining • Mirroring • Reflecting • Object oriented questions

8. Outcomes :Five Themes Based on aides descriptions of interactions with residents only! • Environment • Corporeality • Managing feelings • Self-revelation/Identification • Listening

9. Theme :Environment • Primarily task-focused with distinct timelines and specific protocols to be followed • Quality care provided to the residents • No time or space for emotional communication

10. Corporeality • The body, body part, body condition or thing. • Ubiquitous when nurses aides describe negative interactions with residents. • Resident was antagonistic, helpless or hopeless.

11. Theme :Corporeality • (Female aide bathing a male resident) “I said, ‘Basho Crasho you’re such a stud’” • “She’s a dirty, dirty woman” • “Pictures on their doors when they were young and productive…not just an old person” • “She’s a manipulator • “I said, Woman, you are wicked, you are mean… I wanted to rip her head off” • “If he wasn’t demented, he’d be a good friend”

12. Theme :Corporeality • “[He’s] just like a little dog.” • “I can’t stand to look at her teeth!” • “Just Looking at her makes me want to vomit!” • “She’s a waa, waa.”

13. Theme :Managing Feelings • “When they die, I block” • “When I feel like that, “ I snap the curtain” • “When somebody is upset it is like okay how do I fix it… I want to make her feel better”… We are in and out of there and don’t have time…That is why I make those bath salts...They are getting calming and we are getting calming… It makes everybody else calm… Calm everybody down…in every room… That way you could do anything you want with them and they wouldn’t even know it…And we would be happy too. We’d be happy not doing anything”

14. Theme :Managing Feelings • “We don’t have time to hear anybodies stories we want to keep them quiet that’s why we give them drugs” • “I think this type of work is very draining because there are so many emotions…so many personalities,…the noise level gets to me too….it is exhausting… so irritating.. you just have to go somewhere… you can’t deal with it. Run down the hall.”

15. Theme :Self-revelation/ Identification A Resident not visited by her children …. • Aide #1-”Maybe its her fault…I won’t talk to my grandmother until she apologizes to me” • Aide #2- “I don’t visit my grandparents very often” • Aide #3- … “my son doesn’t talk to me”

16. Theme :Self-revelation/ Identification • “I understand where she is coming from …Its really shitty living in here…it’s a prison” • “I’d be one that yelled and screamed” • “I’d kick someone too if I lived like that”

17. Theme :Self-revelation/ Identification • “I would hit people with canes, too… I don’t know if I could deal with it…Oh, I would probably hit the staff…I am going to be one of these people that take my clothes off and pee on the floor”

18. Theme: Self-revelation/ Non-identification “There are some that are really accepting of living here. I couldn’t be one of those. Not me. [Aide puts fingers to forehead in shape of a gun] Kapow!...Yea put a brick on the gas pedal of your Corvette and head for the cliff”

19. What was missing? • Voice of the resident • Curiosity about resident • Perspective of the resident

20. Themes Emerged from Receptive Listening • Perspective of the other • Curiosity • Self-esteem • Identification

21. Listening: Perspective of the Other “She doesn’t like eating breakfast until noon…I always find myself going,..”if you get your butt out of bed when you are supposed to… Then when you think about it, why are they supposed to?…I would hate to be disturbed.”

22. Listening: Perspective of the Other “It gives you a little better understanding of them…now that B [aide] has said those things about X [resident]…[I]actually think, what’s gonna make me act more respectful to her… to know more about what these people want…instead of…they’re a pain in my ass”

23. Listening: Perspective of the Other “I told him I would call S(secretary), you know, after working ten hours – shit! Before I began listening, I would have said, “Forget about the watch!…but doing this [listening] I actually did go out and ask S if she had found the watch. Things that are important to him, you know,… you look around his room and what has he got in his room?.. a couple of pictures, not much!”

24. Listening: Curiosity “When I went to talk to X [resident w/ Alzheimer’s], he remembered the whole conversation…I was shocked....for him to remember that and…say something like that…I am wondering what his problem is…if he had dementia, he wouldn’t be able to remember the conversation two seconds ago…”

25. Listening: Self-esteem • “It is just as important as getting your lunch… Let me talk to C. I will pull C. aside to see what she can work out. You know, you learn so much when they are walking.” • “It’s really neat she stopped me in the hall and said when are we meeting again.” • “She asked me can we do this twice a week, that was cool!”

26. Listening: Identification • “Another thing she told me she was a tomboy and I was too. I could relate to her.” • “We’re like a couple of buds sitting at a bar.” • “I feel like…going to your neighbors and having tea.” • “So it sounded like my life. I related to her, you know. I told her too…that sort of bonded us.”

27. Conceptual Framework • Modern Psychoanalytic Theory • Explains why there is this problem and what caused it • Provides interventions and techniques to address this problem • Terror Management Theory • Uses empirically designed studies to explain why nurses aides speak or act negatively toward residents and other staff

28. Terror Management Theory (TMT) • Humans are self-conscious animals who have deeply rooted instincts for self-preservation, sophisticated cognitive capabilities, are immensely adaptive, but also know that we are going to die one day. • If we were consciously aware of our own death it would cause us great fear and horror

29. Terror Management Theory • According to TMT, humans mitigate this fear through the development and maintenance of a dual-component anxietybuffer consisting of a meaningful cultural worldview and self-esteem. • Cultural worldview is a set of beliefs about the nature of reality that consists of morals and values that tell people how to achieve a personal sense of significance. • Self-esteem is the sense that one is living up to the standards set forth by the cultural worldview.

30. Terror Management Theory • Cultural beliefs and world views include • Religion, Icons • Professions • Virtues • Morals • Children • Teams • and the productive, beautiful, human body

31. TMT Research: Evidence Based • > 200 empirically based studies. • Support the hypothesis that when symbolic images or beliefs are challenged, unconscious death anxiety is increased. Humans then use self-esteem raising defenses to buffer that anxiety. • These defenses are often self-destructive.

32. TMT :Creatureliness • Humans go to great lengths to appear different then animals – “creatureliness” • The symbolic human body has vitality, productivity and desire • Old, frail, failing or grossly morbid bodies challenge the symbolic belief of the human body

33. TMT and the Human Body: 4 tenets I. When with people similar to ourselves or with similar beliefs, we have high self-esteem and feel good. II. When with people dissimilar to ourselves or with dissimilar beliefs, unconscious anxiety increases.

34. TMT and the Human Body: 4 tenets III.When unconscious anxiety is further increased by additional conscious or unconscious anxiety, we buffer it by making self-esteem increasing comments. IV. We increase our self-esteem with dissimilar people by converting, derogating or separating them through our comments.

35. TMT Framework/ Nurses Aides • Compassionate, living nurses aides are caring for helpless dying residents. • Residents who accept life and compassionate care in SNF help aides manage unconscious anxiety. • These residents behaviors are similar to aides internal mental beliefs. • Residents who respond negatively to care increase aides anxiety and are dissimilar to internal mental beliefs.

36. TMT and the Human Body Tenet I: When with people similar to ourselves or our beliefs, we have high self-esteem and feel good. “Yeah, because look at Y. Like she is one of the nicest ones of all times and I will spend hours in that room getting her ready and she won’t complain one single bit!”

37. TMT and the Human Body Tenet II: When we are with people who are dissimilar to ourselves or our beliefs unconscious anxiety increases. “… absolutely disgusting. You are looking at a skeleton… a tinker toy…hips like a skeleton… a sheet covering a skeleton…a sucked in sheet covering the skeleton… it is nasty…. Oh my god!... She used to have this gorgeous red hair.

38. TMT and the Human Body Tenet III. When unconscious anxiety is further increased by additional conscious or unconscious anxiety we buffer that anxiety by increasing our self-esteem “I get pissy. She makes me angry…I have a handicapped son and I have bent over backwards to not be manipulated by him.. he does not manipulate people. …She is the mistress of it…I don’t like being manipulated… now, my responses to her are I am very sarcastic…One day she’s talking about her skin and blah, blah, blah…I had piles of work on my desk. I was so busy…I told her to eat a cheeseburger and I got reported. So, I have to be careful”

39. TMT and the Human Body Tenet IV. We increase our self-esteem with dissimilar people by converting, derogating or separating them. “and there is frigging X, he can’t hear and he can’t talk, who just wants everything, he is so needy and he is so obnoxious, when what he wants really isn’t so hard, but he is just a pain in the ass you don’t want to even look at him…He wants to talk to his daughter but I won’t call her!”

40. Outcomes of Similar versus Dissimilar Anxiety and Creatureliness • “The spider was slowly beginning to suck the blood out of the peoples pores…The Jew is a true blood sucker that attaches himself to the body of the unhappy people.” Adolf Hitler, Mein Kampf

41. Healthcare Environments • When we walk into, or even think of, a hospital or nursing home, unconscious death anxiety increases. • Death anxiety cannot be avoided. • When anxiety is buffered by similar beliefs, self-esteem is OK. • When anxiety is increased by dissimilar beliefs, anxiety-reducing buffers are enacted to increase self-esteem. • Are disruptive behaviors examples of self-esteem raising?

42. Disruptive Behavior Unchanged after TJC Crackdown • Degrading comments and insults 84.5% • Yelling 73.3% • Cursing 49.4% • Inappropriate joking 45.5% • Refusing to work with colleague 38.4% • Refusing to speak to colleague 34.3% • Trying to get someone unjustly disciplined 32.3% • Throwing objects18.9% • Trying to get someone unjustly fired18.6% • Spreading malicious rumors17.1% • Sexual harassment13.4% Physical assault2.8%Other10.0% American College of Physician Executives (2009) Doctor-Nurse Behavior , Physician Executive Journal, November/December 2009

43. Nurses at Risk? • Nurses are 14 times more likely to experience abuse than are other healthcare professionals. (Johnson et al 2009, p.291) Critical Care Nursing Quarterly

44. The Unique Vulnerability of Nurses • Immediate full and ongoing (24/7) impact of the stress involved in providing care to (corporeal) patients and their families. • Additionally, doctors, families and other staff, who have their own raised anxiety, impact your environment continuously.

45. Proposed View of Disruptive Behavior • What on observation appears to be “disruptive, negative or disturbing behavior” in actuality is primary process-focused attempts to reduce unpleasurable feelings (irrational behavior) • or “thoughts by an unthinker” (Bion 1962). • What looks like a physiological experience (nursing practice) is in reality an emotional encounter.

46. Implications of Receptive Listening for Nurses • Increase retention of nurses • Improve communication skills • Address/reduce disruptive behavior, bullying, moral distress. • Provide the liminal space for creativity and discovery that would facilitate intrinsically motivated self-esteem.

47. Current Project: Receptive Listening in a Nurse Residency Program (NRP) Themes from 9 months of facilitated small groups for 98 nurse residents, their program evaluations, and feedback from 7 nurse facilitators indicated that discussion and management of negative feelings among experienced nurses is imperative to creating a healthy and vibrant work environment.