The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [151]
It is helpful to view denial as a process and to see its expression along a continuum. This needs to be acknowledged in the assessment process.
Repeated assessments of denial may help us to understand how various factors might influence denial and to better understand its dynamic nature.
Denial can generate discomfort and uncertainty in staff. Recognizing and understanding it can help healthcare professionals cope with the challenge of caring for a patient who is using denial as a coping mechanism.
Principles table 5.3 Supporting a patient in denial
Principle Rationale
Healthcare professionals should aim to provide honest information to patients with the use of good communication skills, to the depth and detail the patient requests. This enables patients to have control over the rate at which they absorb and integrate news and information that may have life-threatening implications for them (Maguire 2000, R5).
Useful skills are those of listening, reflecting and summarizing. This will establish a supportive relationship which in the future may provide the patient with the security to acknowledge the gravity of the information they have been given. E
If denial is affecting a treatment regime or decisions for the future, it may need to be gently challenged. This can be done by either
questioning any inconsistencies in the patient’s story or asking if at any point they have thought that their illness may be more serious. These questions may help the patient get closer to knowledge they may already have about the seriousness of their illness. With the right support, they might be able to face their fears and be more fully involved in decisions about future care and treatment. E
If the patient remains in denial it shouldn’t be challenged any further (Dein 2005). ‘Confrontation, if pursued in an insensitive or dismissive way or in the absence of adequate trust and support mechanisms, may increase denial, may reduce treatment compliance, or may even precipitate a complete breakdown in the health care professional – patient relationship’ (Goldbeck 1997, p.586; Maguire 2000, R5).
The delivery of bad news and information giving needs to be recorded clearly. The degree to which the patient accepts the information is variable and needs to be respected and carefully documented. Good communication can help prevent patients receiving mixed messages. E
Complications
Balancing the reality of the illness with reasonable hope is often difficult for all concerned. When working with patients whom we think are in denial, the challenge for healthcare professionals is not so much the confrontation of denial but rather the avoidance of collusion with it (Houldin 2000).
Collusion can leave healthcare professionals, patients and relatives feeling confused. Recognizing collusion, challenging it and discussing our concerns with colleagues is important. Working with our multiprofessional team helps to improve communication and to ensure a collaborative approach to care. Drawing on the richness of experience of others can help.
Clinical supervision can provide a safe reflective space for healthcare professionals to explore their practice. It is an ideal place to explore the complex phenomenon of denial and collusion, as well as find support and if necessary challenge.
Anxiety
Definition
Anxiety is a feeling of fear and apprehension about a real or perceived threat. The source of the feeling may or may not be known (Kennedy Sheldon 2009).
Anatomy and physiology
Anxious feelings can result in physical symptoms related to the flight or fight response as physically the body responds to the threat, real or otherwise. The sympathetic nervous system releases adrenaline that is responsible for an increase in heart rate and therefore palpitations and raised blood pressure, faster, shallower breathing (hyperventilation), dizziness, dry mouth and difficulty swallowing, relaxation