Nursing Center - Journal Article

MR. CRAWFORD, age 68, has just been admitted to the ICU with severe respiratory distress. He was diagnosed with chronic obstructive pulmonary disease 2 years earlier. As his condition worsened, his daughter Debra took over his daily care at her home.

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When he arrives on the unit, Debra walks into her father's room giving orders to the nursing staff, including you. She aggressively asks why you're not doing specific tests, then yells that you don't know what you're doing. You ask Debra to step into the waiting room so the staff can get her father settled in his new room and stabilize him as quickly as possible. She reluctantly leaves the room, complaining bitterly about the staff as she walks away. You've just met the controlling daughter.

This article takes a look at family members who want to be in control to the detriment of patient care. It discusses where they're coming from and provides practical advice for dealing with the disruptive behavior so your patients get the care they need.

Who's in control?

Mr. Crawford's daughter was exhibiting a behavioral response to stress.1 Stress is common among caregivers, with significant increased risk for depression, anxiety, and health problems.2,3 Because of stress, Debra felt compelled to be in control when dealing with her father's illness. Many controlling family members have some type of healthcare experience, whether it's caring for an ill family member or employment in healthcare. Like Debra, many have been the patient's primary caregiver and have carefully followed instructions given to them by the healthcare provider or home healthcare nurse. They want to make sure the hospital staff knows about the care they've been giving, but they may do so in an aggressive or disruptive way.

Typically, family members who are fully engaged in the care of their loved one behave in certain predictable ways. They may want to visit their loved ones at a time that's convenient for them, regardless of visiting hours, other unit activities, or patient confidentiality issues.4 They may insist on being allowed to stay with the patient at all times. They may also want to speak to the outgoing nurse regarding the patient's status during the shift, or catch the healthcare provider in morning rounds. These family members may turn to the Internet as a resource and ask you why information they find there says one thing but the care plan says another.

Questions and requests like these can be reasonable and appropriate, but family members who feel out of control may make requests in an inappropriate manner or at an inappropriate time in an attempt to regain control. In extreme cases, they may bully, intimidate, and even threaten the staff.4 All of these behaviors disrupt the unit and interfere with patient care.

The root of the problem

Understanding why controlling family members feel the need to set the patient's agenda can help you diffuse difficult situations. The root of controlling behavior is fear, anxiety, and possibly guilt if the patient was in the family's care before admission. They may inappropriately shift the blame to those trying to help.5 You may hear comments like, "You didn't do as I said and now my mother is dying!!" or "You want to kill my father!!"

In Mr. Crawford's case, Debra's behavior was fueled by fear and stress. Her father is chronically ill. Because she was caring for him by herself at her home, she felt guilty about not taking care of him "well enough" to avoid hospitalization. Whether or not these feelings are valid, her fear and stress have overwhelmed her ability to cope. What's required to diffuse the situation is a shift from problem-focused blame to solution-focused cooperation.6

Lend an ear

Helping family members like Debra can be difficult if their behavior is intimidating. You might be tempted to confront them or to avoid them altogether, but neither response is effective.

The first rule is to avoid taking the behavior personally. Remember that in most cases, they're speaking from fear and aren't being intentionally aggressive.

Focus on developing a therapeutic relationship with your patient's family. Pull them aside and invite them to tell you everything they're worried about. Be patient; the most important thing is to listen. Don't become defensive, even if their points seem irrational or unjustified. Let them know that their opinions and knowledge of the patient are valued and will be used to provide the best care.

Understand that family members may feel that they're the only ones who know how to care for the patient properly. Take advantage of this attitude by making them feel they're valued members of the patient's healthcare team. This in itself will reduce their stress and help them regain a sense of control in a positive way.

Realize that no matter what concerns family members have, even seemingly trivial ones, the concerns are valid and must be addressed.7 If you can't answer a question, find a colleague who can, or address it with the patient's healthcare provider.

Family members may have acquired erroneous information from the Internet and other outside sources. This is an excellent opportunity to educate them about the disease process and treatment and refer them to reliable consumer-oriented websites such as WebMD.com, http://AHA.org, http://Mayoclinic.com, or the National Institutes of Health (http://www.nlm.nih.gov/medlineplus). If appropriate, offer to arrange for them to meet with the healthcare provider to discuss questions and concerns they have about diagnostic studies and management strategies prescribed for the patient.

How to handle yourself

When speaking to controlling family members, maintain a comfortable distance. Focus on your breathing; as they get more agitated and demanding, breathe more slowly and deeply. Staying calm and focused often has the effect of relaxing them as well. Don't get agitated.8

Be alert for cues to potential violence, such as glaring, pacing, agitated behavior, and clenched fists.8 (See Top 10 behavioral cues to potential violence.) Know your organization's protocols for safe nursing, and plan for the possibility of violence.9 (See Staying safe.)

United we stand

One common element of controlling behavior is an attempt to "divide and conquer" by pitting colleagues against each other.10 For example, the person may state that "nurse so-and-so allowed me in after visiting hours" to obtain an exception to the rules. The staff should come together as a group to assess the situation, determine needs, and devise approaches to encourage more appropriate methods of communication. Gather the staff for problem-solving meetings and develop uniform responses to various controlling behaviors. Designate one or two nursing care "spokespeople" for patients to reduce the risk of presenting conflicting information and to verify status, plan of care, and other pertinent information to share with family members. The spokesperson is in a good position to cultivate a therapeutic relationship with the family, giving them a trusted professional they can look to for information.

Plan ahead

Controlling family members make caring for patients difficult, but when their fears are addressed, they may be transformed into invaluable assets to the patient care team. Having a well-thought-out plan in place can alleviate stress, educate family members, and facilitate their integration into the team so that patients get the care they need.

Staying safe

When dealing with an agitated person, protecting yourself from harm must take top priority. Follow the general guidelines below and call for assistance when appropriate, as required by your facility's policies and procedures for preventing violence.

* Keep a comfortable distance between you and the agitated person.

* Stay near the door. Don't allow the person to get between you and the door.

* Speak calmly and softly.

* Keep your arms loose and at your side.

* Stay at eye level but don't look directly into the person's eyes.