Crucial Conversations with a difficult patient

Crucial Conversations with a Difficult Patients

    Working on the Burn/Trauma surgical unit, we are faced with a diverse population of adult patients that have experienced a variety of traumas.  Patients are faced not only with life altering traumas, but are thrown into a completely new structured environment where they have very little control over their daily routine. The majority of our patient’s were independent with activities of daily living (ADL) from a variety of racial and ethnic backgrounds; many of them lived risky lifestyles prior to the trauma.  Patient’s suffer from loss of control in their life due to the sudden paradigm shift from being independent to dependent: relying on nurses to reposition in bed, assistance in transferring to a chair, help getting washed or going to the bathroom, bedpans, and dressings changes. As nurses, we try our best to support this loss of control patients feel, but many times patient’s act out or lash out in anger causing emotional strain on our staff. Advocacy is an integral part of our professional role.  We Advocate for ourselves, for our patients, for our colleagues, and for our profession across continuum of employment settings and roles (Tomajan, 2012).  When dealing with a difficult patient, it can be challenging to find that voice to not only advocate for your self, but for that patient as well.  Crucial conversations with a difficult patient can be frustrating to say the least.

Below are some helpful tips on how to resolve conflict with difficult patients (Guiliana, 2006):

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• Body language: Be aware of what your body is saying, body language can reflect what your mind is thinking, not the words you are saying
• Eye contact: Make eye contact and show your interest!  When you fail to make eye contact, it leaves room for patients to question their importance, your truth, or your confidence.
• Mouth: When you are not speaking your mouth can give subtitle clues that can leave the patient wondering if you are holding something back.  Be sure to smile, even if you do not want to!
• Position of your head: Be sure to keep your head straight up, this will help you appear to be confident and authoritative.
• Arm placement: Do not cross your arms or fold then over your chest.  The patient may receive the wrong message and think that you don’t care or disagree with what they are saying.
• Movements: Try to control hand and leg movements, a lot of movement can demonstrate nervousness.  At the same time crossing your legs can look unprofessional and even interpreted as arrogant.
• Distance: Positioning your self too close or too far away can portray the wrong message.  Space can be tricky and difficult to get right.  Some patients feel standing too close you are trying to get into their face and others feel that too much distance represents that you are being rude or do not have time for them. The only advice I can give you here is to listen and look for clues from your patient to determine the appropriate distance.
• Speed and volume of your voice: If you talk really fast or loud it may make some patients escalade as well. As the conversation gets faster and louder, people often get carried away and say things that can be harmful or hurtful.  Slow, steady and soft should be your approach. For me, the louder a patient speaks the slower and softer I reply.
• How To Be Assertive: Assertive means taking control of the conversation, make your statement quick that the behavior was inappropriate then refocus the conversation back to the issue.  Be aware of your body language and again do not hesitate to get support from your leadership team, we are here to help. 
• Win-Win Scenario May Not Be Realistic:  It is not about who is the “winner” or “winning” the conversation, it is about resolving the issue.  Most people feel there has to be a “winner” in all situations, realistically there will probably be no winner.  Focus your energy on the resolving the problem.

Guiliana, J. V. (2006). How to resolve conflict with difficult patients.  Podiatry Today, 19(1) 76-82.  Retrieved from http://www.podiatrytoday.com/article/5033?page=3.

Tomajan, K. (2012). Advocating for nurses and nursing.  The Online Journal of Issues in Nursing, 17(1), 1-9. Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No1-Jan-2012/Advocating-for-Nurses.html.

Crucial Conversation with your nurse leader/manager

How to have a Crucial Conversation with your nurse leader/manager

Conflict or confrontation on any level can be difficult, especially when it involves leadership.  It is important that all nurses feel empowered to voice concerns or issues to both nurse leaders and nurse managers.  As nurses, advocacy is an integral part of our professional role.  We advocate for ourselves, for our patients, for our colleagues, and for our profession across continuum of employment settings and roles (Tomajan, 2012). Our job as leaders is to be a resource for staff, support and encourage staff, support open communication, provide education, create a healthy work environment, and be viewed as a role model for our staff.  As your nurse leader, it is important that I am informed in a positive and constructive way if there are any concerns, issues, or conflicts with any member of our team (this also includes me personally).   Nobody is perfect, but change cannot happen without a voice.  As nurses, it is crucial that we develop that voice and have that crucial conversation to advocate for ourselves, patients, and colleagues.

Below are helpful tips to utilize in having crucial conversation with your nurse manager (O’Keeffe, 2012)

Do	Don’t
Write an email or personally request for a private sit-down meeting with your leader/manager	Confront your nurse leader/manager in the hallway or at a staff meeting and start discussing the issue or concern.
Offer to your nurse leader/manager if there is anything you can do to help or change the situation	Just make statements like: “why do you not like me?”
It is important that you remember that we are all humans who have feelings	Attack or lash out in a personal manor
Ask your nurse leader/manager for their view or see if they have any suggestions to help the situation, in order to create an positive result both parties’ opinions should be bright to light	Try not to overrun the entire conversation
Communicate that work relationships and creating a health work environment are important to you	Dismiss or attack your nurse leader/manager’s ability as a leader
Communicate that your work is important to you and that you take our job very seriously	Lead your nurse leader/manager to believe that you are not serious about your job or your responsibilities
Give specific examples to deliver your point	Go off on tangents or make general accusations without facts to back it up
End the conversation in a positive note or with a handshake, even if it did not go the way you had expected.	Just walk out or end the conversation in a negative manor

References:

O'Keeffe, M. (2012). Difficult conversations: Getting along with the boss. Nurse.com. Retrieved from http://scrubs.nurse.com/blog/?p=541.

Tomajan, K. (2012). Advocating for nurses and nursing.  The Online Journal of Issues in Nursing, 17(1), 1-9. Retrieved from http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-17-2012/No1-Jan-2012/Advocating-for-Nurses.html.

Crucial conversations: Gossip Amongst Nurses

Crucial Conversations: Gossip amongst nurses

Crucial conversations are often conversations that need to take place when the stakes are high, opinions vary, and emotions run strong (Ulrich, 2009).  In a research study conducted by VitalSmarts (2005), seven crucial conversations were identified that health care workers continue to fail to have, which include: broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement.  Gossip amongst nurses can have devastating affects on the staff by creating a negative environment contributing to poor teamwork, disrespect and formulating a sense of lack of support.  Gossip is commonly overlooked or ignored when the comment is about someone else, but what if the gossip was about you? What is your role inside of gossip? Do you stand up and be apart of the solution or do you stay silent and be part of the problem?

Below are tools to utilize in creating crucial conversations:

Stand Up, Take Action

• Redirecting the conversation: As easily as gossip can be started, gossip can be squashed.  By redirecting or stating that you are not comfortable contributing to the conversation can demonstrate leadership and helps to create a positive healthy work environment.
• Speak up: Speak up, but speak the truth to anyone that will listen, charge nurse, nurse leader, CNS, or nurse manager.  We are all here to support a positive culture and gossip only brings negativity.
• Confront the offender: Politely ask the specific peer to step away from patients and other co-workers so you can talk about what is going on.  It is important that you do not add to the problem by engaging in passive-aggressive behavior of complaining or include a third part that cannot help to resolve the issue.
• Make sure it’s not you: You do not want to stoop to their level so ensure that your behavior does not bring hostility, instead remains professional. 
• Arm yourself:  Education is never a bad thing.  Educate yourself by reading books like Crucial Conversations: Tools for Talking When Stakes are High and others suggested by the American Association of Critical-Care Nurses’ (AACN) Healthy Work Environment Initiative.
• Create shared values: Help build a unit philosophy with colleagues and leadership that clearly states acceptable and unacceptable behavior and the unit’s values, where people can be held accountable for their actions.
• Enlist management’s support:  Establishing a health work environment starts with the vision of our leadership team.  We need to know when negative behavior like gossiping is happening so that we can be part of the solution.
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**It is important to us as leadership that every employee is held accountable for his or her behavior.  We want our unit to be a positive healthy environment where our nurses feel safe and respected.  We need all employees to stand up and engage in the crucial conversations to sustain positive healthy environment.  Our leadership tam has an open door policy and we are always here to support you.**

References:

Lampert, L. (2012). Gossip on the nursing floor: Solutions for coping. Ausmed Education, retrieved from http://www.ausmed.com.au/blog/entry/gossip-on-the-nursing-floor-solutions-for-coping

Maxfield, D., Grenny, J., McMillan, R., Patternson, K., & Switzler, A.  (2005). Silence kills.  VitalSmarts L.C., Retrieved from http://www.aacn.org/WD/practice/docs/publicpolicy/silencekills.pdf.

Nursing Link. (2014). How nurses can help end horizontal hostility in three easy steps.  Retrieved from http://nursinglink.monster.com/benefits/articles/5836-how-nurses-can-help-end-horizontal-hostility-in-three-easy-steps?page=3.

Ulrich, B. (2009).  Engaging in crucial conversations.  Nephrology Nursing Journal, 36(6), 583.