Delivering Client-Centered Culturally Competent Care and Work

In this written assignment, you have the opportunity to share your thoughts about how to deliver client-centered culturally competent care and work collaboratively with others. The Case of Mrs. G. Mrs. G. is a 75 year old Hispanic woman who has been relatively well all of her life. She had been married for 50 years and had five children. Her children are grown with families of their own. All but one of her children live in other states. Mrs. G.’s husband passed away last year, which was devastating for her. She had been very close to him and relied upon him for everything. He was “the life of the party” she always said and was a loving and caring man. Since his passing, Mrs. G. has continued to live in the house they shared for 35 years. In the last month, Mrs. G. has fallen twice sustaining

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injuries, though minimal. Her home health nurse comes weekly to check in on her. Mrs. G. likes her very much and wishes she could come more often. Mrs. G.’s daughter who lives in the next town over, has been worried and decided with the urging of her siblings and the doctor to start looking for an assisted living facility for her mother. She found one last week and talked with the Director who said she would be happy to help in whatever way was best. The daughter decided to tell her mother that it was time for her to move, so she can be cared for and be safe. When she told her mother, Mrs. G. cried and said, “This will not happen ever. I plan to stay in this house of loving memories for the remainder of my life.” In 2 – 3 pages answer the following questions in APA format: 1. How would you best describe Mrs. G.’s feelings about her life, her family, her traditions, and her future? 2. Did Mrs. G.’s response to her daughter surprise you? Please explain your answer. 3. In what way do you believe her culture might be influencing her decision? 4. If you were Mrs. G.’s daughter what would you say to her that shows you are caring and have compassion for her situation? What nonverbal communication would support that level of communication? 5. Suppose Mrs. G. stands firm about not leaving her house. What resources and collaborations might be available and helpful so the daughter and other healthcare providers can keep her mother safe and make the most effective decision? For this discussion, describe how you typically communicate nonverbally in 300 words in apa format? 1. Do you have particular or unique patterns of nonverbal communication? 2. What have others said to you about your non-verbal communication? 3. How do you think your non-verbal communication impacts your effectiveness as a communicator? In what ways do you think your non-verbal communication patterns will influence your ability to provide client-centered care? Write 150 to 200 word response to response 1 and 2 in apa format Refer to text reference Reference Catalano, J. T. (2015). Nursing Now! Today’s Issues, Tomorrow’s Trends, 7th Edition. Excerpt from chapters are at the end of the page Response 1 Mume module 8 nonverbal communication 1. 2. 3. Facial expression and eye contact are the unique patterns of nonverbal communications that I have. When someone talks to me I always give them eye contact and nod my head to show them that I am listening to what they are saying. Others have told me that I am a good listener I always give them eye contact when they talking to me and my facial expression says everything before I even speak up. They also tell me that they love talking to me. I believe my non-verbal communication impacts my effectiveness as a communicator because I am a good listener and my body language always shows that I am listening and interested in what they are saying and also make people feel like they can tell me anything that is on their mind. Client-centered care is the ability to understand and use nonverbal communication effectiveness, which can be a very powerful tool that can help nurses or any other health care professional connect with patients in a positive way and reinforce mutual understanding and respect. I believe my non-verbal communication will influence my client-centered care towards my clients because non-verbal communication is a huge part of nursing care, you need to show your client you care about they are feeling without even having to tell them verbally. You need to show support when your client is confiding in you. Reference Catalano, J. T. (2015). Nursing Now! Today’s Issues, Tomorrow’s Trends, 7th Edition. Response 2 Garcia Communicating Non-Verbally According to the book, nonverbal communication makes up 55% of communication (Catalano, 2015, p. 291). I typically communicate non-verbally by smiling, giving eye contact, nodding my head, and having a positive body language. Having a positive body language makes you seem open-minded and welcoming. Smiling, nodding your head and having eye contact shows the other person that you are paying attention to what they are saying. I believe everyone had a particular or unique way of having nonverbal communication. I personally just try to look very positive and pay attention to what the person is saying. Sometimes being silent for other people to let their emotions out is also very helpful for them. When I was younger and very shy my dad would tell me all the time that I don’t really look happy sometimes when people would talk to me. Over the years I have gotten better with that because I know it’s something that matters in the career I would like to be in and life in general. Nonverbal communication impacts my effectiveness as a communicator because people want to know your listening to what they are saying and vice versa. Nonverbal communication is an important aspect of client-centered care because your clients want to know that you are welcoming and listen to what you have to say. A client wouldn’t feel comfortable talking to you if you came into their exam room with your arms crossed and if it seemed like you didn’t want to be there. Catalano, J. T. (2015). Nursing now!: Today’s issues, tomorrows trends. Philadelphia: F.A. Davis Company. 12 Communication, Negotiation, and Conflict Resolution Joseph T. Catalano Learning Objectives After completing this chapter, the reader will be able to: • • • • • • • • Explain the importance of understanding human behaviors • Describe conflict resolution and relationship tools • Identify communication styles • List the key elements of negotiation and explain each • Compare and contrast arbitration and mediation • Analyze and apply problem-solving and conflict-resolution tools • Discuss the use of the nursing process in conflict resolution THE NURSE AS COMMUNICATOR Good communication skills are often advertised as the answer to many of the problems encountered in everyday life. Television personalities, instructors, and psychologists promote improved communication skills as the answer to parental, marital, financial, and work-related problems. The nursing profession recognizes communication as one of the cornerstones of its practice. Nurses must be able to communicate with clients, family members, physicians, peers, and associates in an effective and constructive manner to achieve their goals of high-quality care. Good communication is essential for good leadership and management.1 In today’s rapidly evolving health-care system, registered nurses (RNs) are called on to supervise a growing number of assistive and unlicensed personnel. One of the keys to good supervision is the ability to communicate to people what they must do to provide the required care and, often, how the care should be given. It is not always easy. Many of the people whom nurses supervise have limited training, lack the theoretical and technical knowledge base of the nurse, and may display attitudes that make them resistant to direction. However, nurse supervisors can be and often are held legally responsible for the actions of those individuals who work under their direction. UNDERSTANDING COMMUNICATION Communication is an interactive sharing of information. It requires a sender, a message, and a receiver. After the sender sends the message, the receiver has a responsibility to listen to, process, and understand (encode) the information and then to respond to the sender by giving feedback (decoding). The encoding process occurs when the receiver thinks about the information, understands it, and forms an idea based on the message. Several factors can interfere with the encoding process. On the sender’s side, these can be factors such as unclear speech, convoluted and confused message, monotone voice, poor sentence structure, inappropriate use of terminology or jargon, or lack of knowledge about the topic. On the receiver’s side, factors that may interfere with encoding include lack of attention, prejudice and bias, preoccupation with another problem, or even physical factors such as pain, drowsiness, or impairment of the senses. For example, a staff nurse is in a mandatory meeting where the unit manager is discussing a new policy that will be starting the following month. However, the nurse is thinking about an important heart medication that her client is to receive in 5 minutes. The nurse’s primary concern is to get out of the meeting in time to give the medication. After the meeting, the nurse has only a minimal recollection of what was said because she did not encode the information well. The following month, when the new policy is started, the staff nurse is confused about what she should do and makes several errors in relation to the policy. “The encoding process occurs when the receiver thinks about the information, understands it, and forms an idea based on the message.” Effective communication requires understanding that the perceptions, emotions, and participation of both parties are interactive and have an effect on the transmission of the message. Nurses often encounter situations that require clarification of the information for accuracy and encoding.2 The following is an example of client teaching that requires a return demonstration: A nurse gave a teaching session to a client who was being sent home with a T-tube after surgical removal of gallstones from the common bile duct. After the nurse finished her instructions, she asked the client whether he understood how to empty the drainage bottle and measure the drainage. The client looked very confused, but mumbled, “Yes,” while shaking his head. The nurse recognized that although the verbal response was positive, the nonverbal responses indicated that he really did not understand. The nurse surmised that further explanation or demonstration was required for this client to encode the message properly. (For more detail on client teaching, see DavisPlus Bonus Chapter 3). Nurses should recognize the many barriers to clear communication and the benefits of clear communication. These are different from communication blockers discussed below. Once the barriers to communication are identified, they can be overcome, and the benefits of clear communication will follow. These barriers and the benefits that result when they are overcome are outlined in Box 12.1. COMMUNICATION STYLES There are three predominant styles of communication: assertive, nonassertive, and aggressive. Individuals develop their communication styles over the course of their lives in response to many personal factors. Although most people have one predominant style of communication, they can and often do switch or combine styles, depending on the situation in which they find themselves.3 For example, a unit manager who uses an assertive communication style when supervising the staff on her unit may revert to a submissive style when called into the nursing director’s office for her annual evaluation. Recognizing which communication style a person is using at any given time, as well as one’s own style, is important in making communication clear and effective. Assertive Communication Assertive communication is the preferred style in most settings. It involves interpersonal behaviors that permit people to defend and maintain their legitimate rights in a respectful manner that does not violate the rights of others. Assertive communication is honest and direct and accurately expresses the person’s feelings, beliefs, ideas, and opinions. Respect for self and others constitutes both the basis for and the result of assertive communication. It encourages trust and teamwork by communicating to others that they have the right to and are encouraged to express their opinions in an open and respectful atmosphere. Disagreement and discussion are considered to be a healthy part of the communication process, and negotiation is the positive mechanism for problem-solving, learning, and personal growth.3 Box 12.1 Barriers to and Benefits of Clear Communication Barriers Benefits • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Unclear or unexpressed expectations • Confusion • Retaliation • Desire for power • Control of others • Negative reputation • Manipulation • Low self-esteem • Biased perceptions • Inattention • Mistrust • Anger • Fear or anxiety • Stress • Insecurity • Prejudice • Interruptions • Preoccupation • Clear expectations • Understanding • Forgiveness • Recognized leadership • Companionship • Respect • Independence • Realistic self-image • Acceptance • Clear direction • Trusting relations • Self-control • Comfort • Motivation or energy • Security • Increased tolerance • Increased knowledge • Concentration Assertive communication always implies that the individual has the choice to voice an opinion, sometimes forcefully, and to not say anything at all. One of the keys to assertive communication is that the individual is in control of the communication and is not merely reacting to another’s emotions.4 Assessing Self-Assertiveness Answer the following questions to determine your self-assertiveness: • • • • • • • • • • • Who am I and what do I want? • Do I believe I have the right to want it? • How do I get it? • Do I believe I can get it? • Have I tried to be assertive with a person I am having difficulty communicating with? • Am I letting my fears and perceptions cloud my interactions? • What is the worst that can happen if we communicate? • Can I live with the worst? • Will communications have a long-term effect? • How does it feel to be in constant fear of alienation or rejection? Rules for Assertiveness Anyone can learn to use an assertive communication style and develop assertiveness. When first developing this skill, people often feel frightened and overwhelmed. However, once individuals become comfortable with assertiveness, it helps reinforce their self-concepts and becomes an effective tool for communication. There are a few rules to keep in mind while developing assertiveness along with an assertive communication style: • • • • • • • • • • • • • • • It is a learned skill. • It takes practice. • It requires a desire and motivation to change. • It requires a willingness to take risks. • It requires a willingness to make mistakes and try again. • It requires an understanding that not every outcome sought will be obtained. • It requires strong self-esteem. • Self-reward for change and a positive outcome is essential. • Listening to self is necessary for identifying needs. • Constant reexamination of outcomes helps assess progress. • Role-playing with a friend before the interaction builds skill and confidence. • Goals for assertiveness growth need to be established beforehand. • Assertiveness requires recognition that change is a gradual process. • Others should be allowed to make mistakes. Personal Risks of Assertive Communication There are always personal risks involved in learning any new skills or in attempting to change behavior. Learning assertive communication is no exception. People often fear that they may not choose the “perfect” assertive response. However, even seasoned assertive communicators may err from time to time because every encounter is unique, involving different people and situations. The person who is new to assertive communication needs to recognize that it is a skill that takes practice. I Win, You Win Assertiveness does not mean that a person will always get his or her way in every situation, and it is likely the individual will handle some situations better than others. Remember that the goal of assertive communication is to prevent an “I win, you lose” situation and to encourage an “I win, you win” outcome.4 A win-win goal is achieved when both parties have the ability and willingness to negotiate even though they do not get all they want. However, there may be situations when personal goals are not achieved. Some questions to consider when this occurs are: • • • How do I feel about losing? • Did I express my opinion clearly? Why not? How could I make it clearer? • • • • • • Did I do the best I could do? How could I have done better? • Was I in control when responding to the situation? When did I lose control? What should I have done to regain control? • Did I stay focused on the issues? What side issues distracted me? How could I have avoided distractions? • Did I allow the situation to get personal? Did the other person initiate the personal attack? How could I have redirected it away from the personal? • Was what I asked for under my control? If not, why did I ask for it? What would have been more realistic? Reviewing these questions and analyzing the answers will help when you attempt to be assertive in future communications. For example, if the answer to the second-to-last question was yes, then during the next communication, a special effort can be focused on avoiding personal attacks during the encounter. Learning to communicate assertively is a process of continual improvement. Impact of Assertive Communication Another risk factor that quickly becomes evident when changing to an assertive communication style is the impact that it has on those who know the person best. Sometimes family, friends, peers, and coworkers become barriers to change. Change always produces some degree of stress. Those individuals who are closest to the person trying to initiate changes may feel uncomfortable because they have become accustomed to the old communication styles and behaviors over a long period of time. They can no longer anticipate and depend on the person’s responding and reacting in the usual way.5 In addition, they will have to develop new communication patterns of their own to match the changes caused by assertive communication. Sometimes family, friends, peers, and coworkers become so uncomfortable that they may try to sabotage the person’s attempts at assertive communication. It is important to recognize why and when these sabotage efforts occur and to remember that assertiveness is an internal, personal process. Everyone has a right to change, and it must be respectfully communicated to others that their support for these changes is important. It is also important to know and periodically review the rights and responsibilities of assertiveness to help reinforce the assertive communication process. The rights and responsibilities of assertiveness are listed in Box 12.2. Practice and reinforcement of assertiveness skills may be required, especially when preparing for an anticipated conflict negotiation or a confrontational meeting with another. Although a confrontational situation always produces anxiety, rather than being feared, it should be recognized as having the potential to be highly productive. Box 12.3 lists several behaviors that, if practiced and used, will help increase confidence and assertiveness skills during anticipated confrontational meetings. Box 12.2 Rights and Responsibilities of Assertiveness • • • To act in a way that promotes your dignity and self-respect • To be treated with respect • • • • • • • • • • • • • • • • To experience and express your thoughts and feelings • To slow down and make conscious decisions before you act • To ask for what you want • To say no • To change your mind • To make mistakes • To not be perfect • To feel important and good about yourself • To be treated as an individual with special values, skills, and needs • To be unique • To have your own feelings and opinions • To say “I don’t know” • To feel angry, hurt, and frustrated • To make decisions regarding your life • To recognize that your needs are as important as others’ Box 12.3 Assertiveness Self-Assessment Statement Communication Behavior • 1. I didn’t say what I really wanted to say at the last staff meeting. _________________________ • 2. I always express my opinion because it is better than everyone else’s. _________________________ • 3. I have the courage to speak up almost all the time. _________________________ • 4. I wish someone else would speak up at the meetings besides me. _________________________ • 5. I am not intimidated by the high-pressure tactics of supervisors, physicians, and/or teachers. _________________________ • 6. I have trouble stating my true feelings to those in authority. _________________________ • 7. I really put that know-it-all aide in her place last shift. • 8. After the last meeting with my unit director, I felt hopeless, _________________________ resentful, and angry. _________________________ Statement Communication Behavior • 9. I speak up in meetings without feeling defensive. _________________________ • 10. When I need to confront someone, I avoid the problem because it will usually resolve itself. _________________________ • 11. When I need to confront individuals, I address them directly. _________________________ • 12. When I confront individuals, I let them know in no _________________________ uncertain terms that they are wrong and need to change their behavior. • 13. When I’m reprimanded, I keep silent even though I’m seething inside. _________________________ • 14. The last time I was asked to stay over for another shift, I said no and didn’t feel guilty. _________________________ You can use the checklist in Box 12.4 to determine your own degree of assertiveness. Nonassertive Communication Nonassertive communication is also referred to as submissive communication. Submissive Communication When people display submissive behavior or use a submissive communication style, they allow their rights to be violated by others. Their requests and demands are surrendered to others without regard to their own feelings and needs. Many experts believe that submissive behavior and communication patterns are a protective mechanism that helps insecure people maintain their self-esteem by avoiding negative criticism and disagreement from others. In other situations, it may be a means of manipulation by way of passive-aggressive behavior. Box 12.4 Conflict Resolution Tips In nursing practice, good communication and conflict management skills are essential. The following tips may help resolve communication problems: Improve Your Conflict Management Skills • • • • Seminars • Books • Mentors Change Your Paradigm • • • Focus on the positive, not the negative. • Realize that appropriate confrontation is a risk-taking activity. Achieve Better Communication • • • • Improved relationships • Improved teamwork • Mentoring Understand Your Values • • • • • • • • • Focus on a win-win. • Be willing to negotiate and compromise. • Be direct and honest. • Focus on the issues. • Do not attack the person. • Do not make judgments. • Do not become the third person; encourage peers to go direct. • Do not spread rumors. Set Personal Guidelines • • • • • • • • • • • Confront in private, never in front of anyone else. • Confront the individual; do not report him or her to the supervisor first. • Do not confront when you are angry. • Start with an “I” message. • Express your feelings and opinions. • Allow the other person to talk without interruptions. • Listen attentively. • Set goals and future plans of action. • Let it go. • Keep it private and confidential. What Do You Think? Recall a recent exchange with someone (e.g., friend, instructor, parent, physician) in which you felt you “lost” the exchange. How did you feel? How did you respond? How could using an assertive communication style have helped? Box 12.5 Assertive Communication Suggestions • • • • • • • • • • Maintain eye contact. • Convey empathy; stating your feelings does not mean sympathy or agreement. • Keep your body position erect, shoulders and back straight. • Speak clearly and audibly; be direct and descriptive. • Be comfortable with silence. • Use gestures and facial expressions for emphasis. • Use appropriate location. • Use appropriate timing. • Focus on behaviors and issues; do not attack the person. Because of their great fear of displeasing others, personal rejection, or future retaliation, submissive communicators dismiss their own feelings as being unimportant. However, at a deeper level, submissive behavior and communication merely reinforce negative feelings of powerlessness, helplessness, and decreased self-worth. Rather than being in control of the communication or relationship, the person is trading his or her ability to choose what is best for the avoidance of conflict. Every communication by a submissive person becomes an “I lose, you win” situation. However, subconsciously it is more of “You may think you win, but I really am winning because I’m getting what I want or need.” Aggressive Communication Sometimes there is only a very fine line separating assertiveness from aggressive behavior and communication.4 Whereas assertive communication permits individuals to honestly express their ideas and opinions while respecting the other’s rights, ideas, and opinions, aggressive communication strongly asserts the speaker’s legitimate rights and opinions with little regard or respect for the rights and opinions of others. It easily becomes a communication blocker (see below). Aggressive communication—used to humiliate, dominate, control, or embarrass the other person or lower that person’s self-esteem—creates an “I win, you lose” situation. The other person may perceive aggressive behavior or communication as a personal attack. Aggressive behavior and communication are viewed by some psychologists as a protective mechanism that compensates for a person’s own insecurities, and others view it as a form of bullying. By demeaning someone else, aggressive behavior allows the person to feel superior and helps inflate his or her self-esteem. Aggressive communication can take several different forms, including screaming, sarcasm, rudeness, belittling jokes, and even direct personal insults. It is an expression of the negative feelings of power, domination, and low self-esteem. Although aggressive people may seem outwardly to be in control, in reality they are merely reacting to the situation to protect their self-esteem. Using appropriate methods of communication in conjunction with an assertive communication style enhances the communication and understanding by both parties. Developing an assertive communication style is important in using communication builders. (For more information, go to http://www.ncbi.nlm.nih.gov/pubmed/21248553). “Through active participation, workers have an opportunity to have an impact on and direct the changes that are being made. Some people mistakenly believe that if they do not become involved, the changes will not happen.” Verbal, Paraverbal, or Nonverbal Communication There are three primary methods of communication: verbal, paraverbal, and nonverbal. Verbal communication is either written or spoken and constitutes only about 7 percent of the communicated message. Nonverbal communication makes up the other 55 percent of communication and includes body language, facial expressions, gestures, physical appearance, touch, and spatial territory (personal space). Paraverbal is the tone, pitch, volume, and diction used when delivering a verbal message. How people say something is often more important than what they are saying. A sentence can have a completely different meaning by placing emphasis on different words. Paraverbal communication makes up about 38 percent of the total message and is often considered part of nonverbal communication.6 When the verbal, paraverbal, and nonverbal messages are congruent, the message is more easily encoded and clearly understood. If the verbal, paraverbal, and nonverbal messages are conflicting, the paraverbal and nonverbal messages are the most reliable. It is relatively easy for people to lie with words, but paraverbal and nonverbal communication tends to be unconscious and more difficult to control. For example, the nurse suspects that the mother of a newborn infant may be experiencing postpartum depression. The nurse asks the mother how she feels about her new baby. The mother responds in a quiet, very slow monotone (paraverbal message), “I’m so happy I have this baby” (verbal message), while looking down at her feet in a slouched-over posture with her arms folded (nonverbal message). The message from the mother is conflicting. The words are saying she is happy, but all the paraverbal and nonverbal signs indicate that she is sad and depressed. The observant nurse concludes that more assessment for depression is required. FACTORS THAT AFFECT COMMUNICATION People are always communicating something, in either a verbal, paraverbal, or nonverbal manner. There often is a degree of overlap among the three styles. Some of the things people do and say help build communication, but other actions or words break communication down. Anything done or said that interferes with communication is called a communication blocker. Actions and speech that encourage and build communication are called communication builders and are often referred to as therapeutic communication techniques Other factors, such as the environment the communication is taking place in, stress levels of the parties communicating, grief and change experiences, and people feeling angry can also block effective communication. Nonverbal Communication Builders • Eye contact. In general, in North American culture, using eye contact while communicating is a sign of interest in the person and says, “What you are saying is important to me.” However, there is a need to be cautious using it. It can turn into a staring contest and says, “I’m trying to dominate you.” Also, eye contact has other meanings in other cultures. Some tribes of American Indians believe that direct eye contact is an attempt to take the other person’s spirit. In some Hispanic groups, direct eye contact is a sign of hostility and aggression. • • • • Stop what you’re doing. This indicates that the other person is more important than the task that is being worked on and encourages more communication. Nod the head. Nodding while the other person is speaking indicates you are listening closely to what is said and that you either agree with them or accept what they are saying. Shaking the head can also be used as a communication builder if it is used when the person is describing a difficult situation they have experienced. Positive facial expressions. Smiling or looking surprised at appropriate times while the other person is speaking indicates that what the other person is saying is being accepted. The eyes are often the most expressive part of the face, indicating joy, approval, or excitement. Sitting or standing in close proximity. Being relatively close to the person speaking shows that they have your full attention and actually makes speaking easier. Leaning toward the speaker also achieves this purpose. This technique also has to be used with some caution. Violating a person’s personal space (about 18 to 24 inches in America) may make the person feel • • • uncomfortable. If they back away, then the distance is too close. Personal space also has a cultural component. People from the southwest United States tend to require a larger personal space as compared with persons from large cities or countries like India or the Middle East, where people experience close proximity in their everyday lives and tend to require much less personal space. Open posture, directly facing. An open posture, which means arms and legs are uncrossed while directly facing the speaker, says, “I am open to what you are saying—your thoughts are important to me.” Listening empathically. Pay attention to the message so that when the person finishes, he or she can say, “Wow, you really got what I said.” Light touch. Touching the other person’s shoulder, arm, or hand, particularly if they are communicating sadness, distress, or grief, can send a message of reassurance; however, there are major cautions with using touch as a communication technique based on cultural and personal preferences. Many Americans dislike being touched by others, especially by people they do not know well, although certain cultural groups within U.S. society such as Italians, Hispanics, and Russians are very open in expressing emotion through touching. Being aware of the speaker’s nonverbal and paraverbal communication. The messages delivered though facial expressions, gestures, body position, and special distance is as important as the verbal message be spoken. Paraverbal Communication Builders • • Silence. It might seem to be a contradiction to the concept of communication, but silence can be a highly effective communication builder. It is said that “nature abhors a vacuum and will try to fill it with something.” Silence is a communication vacuum, and most people abhor it and will not let it go on for more than a few seconds. Waiting for the other person to speak can be very uncomfortable for both parties; however, it provides the speaker with a chance to think about what they said and are going to say. How long is too long? There really is no hard or pat answer to that question, but using a verbal prod such as “Tell me what you are thinking about?” can open up the lines of communication again. Tone. A calm, soothing tone, particularly when communicating with agitated or hostile individuals who are speaking loudly or aggressively, can ease the situation. It is important not to respond in kind. A calm, even tone conveys the message that the speaker is in control of the situation and that the person who is upset also needs to gain control of their emotions. An assertive tone expresses urgency and a need to respond, particularly in emergency situations. An aggressive or hostile tone usually indicates anger and frustration. Verbal Communication Builders • • • Encouraging words. Short responses or interjections such as, “Okay,” “Right,” “Mmm-hmm” or “Tell me more” says to them, “I’m paying attention,” and encourages them to keep talking. Asking open-ended questions. These are questions that cannot be answered by one or two words and force the person to continue speaking. This type of question includes “Tell me about what made you angry,” “Describe the situation that put you in that position,” or “What is this person doing that makes you feel inferior?” Use “I” rather than “you” messages. People are less likely to perceive a communication as a personal attack when the conversation begins with an explanation of a personal view of the situation or even how feelings were affected. Statements such as “I thought it was done this way,” or “I heard something the other day,” or even “I feel hurt when people judge me” are more productive ways to begin an exchange of ideas and information. “People are less likely to perceive a communication as a personal attack when the conversation begins with an explanation of a personal view of the situation or even how feelings were affected.” • • • • • • Asking clarification questions. This type of question seeks more information and will keep the speaker talking. Questions such as “Could you explain that a little more? I didn’t quite get what you were saying,” or “I’m a little confused about your last statement,” are nonconfrontational and make the person feel comfortable speaking. Reflecting feelings and emotions. Sometimes called paraphrasing, this response should be used when there is a mismatch between what the person is saying and what their body language is saying. Always believe the body language; it can’t lie. These include questions such as “How did you feel about that?” “Why did that make you depressed?” “You seem to be angry (sad, anxious, afraid, etc.). Can you talk about that more?” Repeating what was just said. This communication builder is called restating and helps clarify what the person is saying. Lead into the statement with “Let me know if I heard you correctly. You just said …” Restating indicates good listening skills and helps keep the conversation going. Never, never interrupt. There is always a tendency to identify with the speaker’s recounting of an incident and interject something like “I had something similar happen to me.” They don’t want to hear about your problems. Just let them continue speaking. Reviewing what was said. This is different from repeating because rather than just repeating one thing that the person said, it requires analysis and synthesis of the key points, usually emotions, of the discussion, which is then summarized. Statements like “Okay, we’ve been talking for a while, and it seems like you have said that you are anxious because so-and-so keeps saying to you …” “Is that a correct summary?” Acknowledging what was said. Sometimes called validating, this communication builder is a combination of reviewing and identifying emotions. It makes the speaker feel that what he or she is saying has value and that someone cares about their issues. Using statements such as “I understand what you are saying,” or “I can appreciate your feelings about the situation,” validates the speaker. Environmental Communication Builders • Calm, nonthreatening environment. A quiet room with subdued lighting is the ideal location to help build communication. However, in the real world, a busy, noisy hospital room or hallway is more likely to be the environment for communication about important issues such as home medications and dressing changes. Nurses, as always, are required to do the best they can with what they have. Nonverbal Communication Blockers • • • • • Eye rolling. When people roll their eyes, they are sending a message of not caring about what the other person is saying. Teens are notorious for this behavior, but adults also use it at times, particularly if it has become habitual. Arm and leg folding. This generally is interpreted as an indication of disapproval or boredom. The person listening is closed to the speaker’s ideas, which are not considered very important. It sometimes can be a sign that the other person is feeling attacked and is trying to defend themselves. Slouching, hunching, turning away. These nonverbal communication blockers indicate that the listener is just not interested in what is being said. It says to the speaker, “Are we done yet? I’d rather be on the other side of the room.” Fidgeting. This includes picking at fingernails, drumming the fingers, playing with buttons or jewelry, frequent shifting in the chair, rolling and unrolling hair, taking off and putting on glasses frequently, doodling extensively on a pad of paper, frequent checking of cell phone, picking at shoe laces, and so on. It delivers the message that the listener is experiencing extreme boredom and can’t wait to leave. Deep, loud sighs. This message tells the other person that they are boring and should end the conversation quickly. What they have to say is not worth the time it takes to say it, and there are other more productive things to be done with the time. “An excessively long unblinking stare is a communication blocker that shows aggression and hostility.” • • • • Multiple watch or clock checks. Similar to deep sighs in that what the person is saying is not very important and the listener is about to die from boredom. Continuing with an activity while the other person is talking. The message is “I’m ignoring you because you are not that important. What I’m doing is more important.” Failure to make eye contact. This nonverbal technique can be used as a way to show disapproval but is often used when a person is hurt by another and is trying to hurt the person back. On the other hand, an excessively long unblinking stare is a communication blocker that shows aggression and hostility. Tuning out or failing to pay attention. Another way of saying, “I’m not listening—what you are saying isn’t important.” (For more information, go to http://www.ncbi.nlm.nih.gov/pubmed/24138223.) Verbal Communication Blockers • • • Automatic defensiveness. This communication blocker occurs when one person feels so threatened by the other that the first thing he or she says is of a defensive nature. For example, “It wasn’t my fault; the thing just broke,” “I really didn’t want to do it, but Alexis made me,” or “If you didn’t push me so hard to speak, I never would have said it.” Asking closed-ended questions. These are questions that a person can answer in one or two words. For example, “How are you feeling today?” Answer: “Fine.” “Did you practice your responses like we discussed?” Answer: “Yes.” Accusing or blaming. This is a type of confrontational speech and sends the message that the other person is wrong even before given a chance to provide his or her side of the story. For example, “If you knew how to read a map, we wouldn’t be lost in the middle of nowhere.” • • • • • • Using sarcasm. This sends the message that the other person is not respected and is untrustworthy. The statements are often said in a taunting tone with vocal over-emphasis. For example: A co-worker is playing a DVD very loudly in the break room. You comment: “Why don’t you turn it up a little? I don’t think they can hear it in Toronto!” Constant interruptions. Over the years, some people have developed a habit of interrupting without any sort of malice or intent to hurt. However, the message is the same whether it is intentional or not—the person interrupting feels that what he or she has to say is more important than the person who is talking. Judging, name calling, and diagnosing. This communication blocker uses “you messages,” indicating that there is something wrong with the other person. These also send the message that the person making the judgment or diagnosis is more intelligent and has a better understanding than the person with the problem. It denotes an air of superiority. It includes statements such as, “You’re such a perfectionist—no wonder you don’t have any friends,” “You don’t seem to understand that we need to finish the project on time,” “You know what your problem is?” “You really don’t care if this issue gets resolved,” “You made a mistake,” “You said this about me,” or “You always do this.” Stating opinions as proven facts. This communication blocker prevents the other person from expressing their opinions and discounts the importance of what they have to say. For example, “Everybody knows that the Affordable Care Act (ACA) allows death panels to decide who is going to get care and who will live or die.” Making generalizations, being patronizing, and offering vague reassurances. Statements such as “You always leave the break room in a mess,” “Don’t worry, everything is going to be all right,” or “It always works out for the best, doesn’t it?” makes the other person feel that what they have to say is not important. It also categorizes them in a box that they may not want to be in. Telling people how they should feel. This invalidates the other person’s feelings and shows a high degree of disrespect. This types of statements include “Don’t feel like that,” “Don’t let that bother you,” or “Getting upset is very childish.” “When people say, “I couldn’t get a word in edgewise!” it means that the other person totally dominated the conversation. Often the speaker is attempting to avoid confrontation, stress, intimacy, uncomfortable thoughts or feelings, or a difficult situation.” • • • • Changing the subject. Another indicator that what the person is saying is not important and not worth the time. Expecting mind reading. Sometimes other people expect you to know what they are thinking or to anticipate what they need or are going to say. People who have been very close for a long period of time sometimes get to a point in their relationship where they know the other person well enough to “mind read” (actually anticipate) what they are going to say. However, for the vast majority of communication, telling them what you are thinking, feeling, or wishing them to do is the best approach. Shaking or pointing a finger while speaking. This combines both verbal and nonverbal blockers. Much like yelling and getting in someone’s face, it is an exercise of power over the other person. The message is “You really are stupid and inferior.” Walking away. This is the ultimate communication blocker. If there is no one to talk to, there is no communication. Paraverbal Communication Blockers • • • Threatening, ordering, or getting in someone’s face. The message here is “I’m angry and I don’t care what you think.” People often use “clenched teeth speech” or yelling when being confrontational. It threatens other people and makes them keep their distance. People who use these blockers are often deeply insecure, and these techniques push other people away. They also use them to make themselves feel better about themselves. It takes away the need to understand the other person. Yelling, calling names, or hurling insults. This is a type of negative aggressive behavior that is immature and degrading. It shows a lack of respect for the other person and often creates deep emotional wounds. Yelling and name-calling can quickly rise to the level of physical violence such as pushing or even hitting. Nonstop, rapid talking. When people say, “I couldn’t get a word in edgewise!” it means that the other person totally dominated the conversation. Often the speaker is attempting to avoid confrontation, stress, intimacy, uncomfortable thoughts or feelings, or a difficult situation. In some people, it can become a habit over time and shows disrespect to other people. It may also be an attempt for the speaker to hide feelings of inferiority by showing how intelligent or dominant they are. Environmental Communication Blockers • • Experiencing change. Change can be a communication blocker in various ways. People may be afraid to ask questions about new procedures or policies because they fear that they might appear “stupid” in front of their colleagues. Fear of being criticized closes individuals off to positive suggestions and new ideas.7 Others may hesitate in sharing ideas because they are afraid of being labeled as confrontational. Nurses also need to keep in mind that the communication abilities of clients experiencing change will be blocked in much the same way as those of nurses experiencing change. For example, a nurse is reassigned from the medical-surgical unit to the intensive care unit (ICU). This nurse will initially be somewhat fearful in the new 13 Understanding and Dealing Successfully With Difficult Behavior Joseph T. Catalano Learning Objectives After completing this chapter, the reader will be able to: • • • • • Discuss the underlying issues that cause individual to display difficult behaviors • Develop successful strategies for communicating with persons displaying difficult behaviors. • Respond effectively to the underlying emotions that persons with difficult behaviors are communicating. • Successfully resolve problems associated with difficult behavior in both colleagues and clients. • • Formulate coping strategies to adapt successfully to people with difficult behaviors. UNDERSTANDING DIFFICULT BEHAVIOR Let’s say this up front: There are no difficult people; there are, however, people who display difficult behaviors. It is important to keep in mind that behavior is a form of communication. The term difficult people is so often used that it has become a widely accepted way to categorize people. Labeling people as difficult is really stereotyping, which may or may not accurately reflect reality. In dealing with the group labeled as difficult, our goals are to change our response to the behaviors and attempt to change the behaviors they are displaying.1 It is virtually impossible to change an individual’s basic personality; however, brain injuries, extreme traumatic events, and potentially lethal illnesses or injuries have been shown to significantly alter a person’s personality. The term personality is often misused to mean that an individual is outgoing, humorous, and generally friendly to other people. When you hear people say, “Joe has a great personality,” they are usually talking about the fact that he is pleasant to be around, outgoing, and readily engages in conversations. On the other hand, you might hear someone say, “Terry has no personality at all,” when they actually are talking about the fact that Terry is quiet, somewhat withdrawn, and doesn’t easily engage in conversations. The truth is that everyone has a personality, and although defined differently by different schools of psychology, an individual’s personality is generally recognized as all those elements, both genetic and learned, that go into making them who they are at present.1 A personality includes strongly held beliefs, attitudes, emotions, and behaviors. Most people have identifiable personality traits soon after birth. Just ask nurses who regularly work with newborn babies. There are some babies who are mostly quiet and seem content except when they are hungry or need to be changed, and there are others who cry all the time and never seem to be content. All children are genetically stamped in the womb with innate emotions that help them survive in a world that they really don’t understand and is very frightening to them.1 Feelings of anger, jealousy, selfishness, and self-centeredness, along with their behavioral expressions, help children manipulate adults, particularly the parents, and cope with what is to them a big and hostile environment. One of the primary goals parents have in raising their children is to teach them adult coping skills to deal with problems and help them outgrow the immature and childish coping mechanisms of manipulation and exploitation of others. It is evident that this outcome is not always achieved. Some people go through their whole lives using childlike coping mechanisms and behaviors to deal with the adult world.1 These mechanisms don’t work very well, and often they get labeled as difficult people. For whatever reason, they never learned or accepted adult coping mechanisms. For example, being able to forgive is a learned adult behavior that counteracts the self-centeredness that children use as a survival mechanism. People who have never learned to forgive others, forget about insults, or let go of much of anything are sometimes afflicted, as adults, with conditions such as chronic fatigue and depression. And it’s no wonder they act in these ways; they are carrying around a heavy burden of emotional baggage from a lifetime of perceived or actual events in their lives, and every day they are alive, they add another bag to the pile. “Labeling people as difficult is really stereotyping, which may or may not accurately reflect reality. In dealing with the group labeled as difficult, our goals are to change our response to the behaviors and attempt to change the behaviors they are displaying.” You can observe this type of behavior in a 60-year-old woman who seeks to get revenge for the way she was treated by a relative 30 years before at a wedding. She has been carrying that baggage for a long time. Often this behavior manifests itself in activities such as hoarding. They don’t have to be extreme hoarders such as seen on the TV show Hoarders, but they tend to collect a lot of junk and pile it around the house. If you ask them, “Why don’t we throw out these 10-year-old magazines? Everything is online now,” they will likely respond, “No, there might be something in one of them that I’ll need someday.” If you look at many of the difficult behaviors discussed below from the viewpoint of what a child does to get his or her way, you will see a great deal of similarity between the two. People who display difficult behaviors are everywhere. They are found at home, at work, and in the health-care setting. It is pretty obvious that communicating with them requires a special set of communication skills. Because communication is such a major part of quality health care, it is an essential requirement that nurses be able to understand why a client is using difficult behaviors and learn the skills that will allow him or her to communicate effectively.2 The skills learned in resolving conflicts or negotiating often are used when dealing with difficult people. Of course, difficult people are not limited to just clients in the health-care settings. They may also be the family of the client, nurses, physicians, and other health-care workers. Pretty much anyone can become a difficult person under the right set of circumstances. Who knows, you might even be a difficult person. Identifying People With Difficult Behaviors What exactly is a person with difficult behaviors, or in common language, a difficult person? To some extent, a difficult person is one of those “you’ll know them when you see them” individuals. Also, it is important to recognize that identifying someone as “difficult” is a matter of perception. One individual’s difficult person is another’s “Oh, old Uncle Freddy acts that way any time there are people around.” Generally, when a person is displaying difficult behavior, they are hard to communicate with or their behavior is such that it makes it very difficult to work with them to achieve a goal or finish a task. Difficult peoples’ personalities have been described as “prickly” because if they are touched verbally, they sting back with sharp vocal barbs.1 They often use many of the communication blockers discussed in Chapter 12 to achieve their goals. Identifying what goals difficult people are trying to achieve, whether they are a client or a coworker, is one of the keys to understanding them and communicating with them effectively. In the health-care setting specifically, there are two primary groups of difficult people: coworkers and clients. Although the techniques in interacting with either group overlap to some degree, there are important differences between the two groups that need to be considered, particularly the cause for being difficult and the outcomes they are attempting to achieve. Also, although difficult coworkers can make life on the unit uncomfortable, there is no ethical or legal requirement to interact with them. However, heath-care providers’ relationships with clients require that nurses do everything they can to establish and maintain effective communication with them, no matter how difficult they are, to achieve the goals of quality care (Box 13.1). Improved Understanding All nurses recognize that obtaining a thorough history and understanding the underlying disease processes better prepare them for the physical care of their clients. Similarly, in working with difficult people, a knowledge of their backgrounds and understanding of their needs and goals better prepares the nurse to communicate in a positive way. It would seem that nurses should be adept at handling conflict and difficult people because a large part of their education includes an understanding of the cause and effect and the intricacies of human nature. These are skills that nurses use daily in the care of clients. “All children are genetically stamped in the womb with innate emotions that help them survive in a world that they really don’t understand and is very frightening to them.” Shifting the communication paradigm from instinctual or “knee-jerk” responses to one that uses the communication building techniques discussed in Chapter 12 in combination with the nurse’s relationship skills should make interacting successfully with difficult people a less imposing task. The behavior displayed by a difficult person is really a symptom of a deeper underlying problem, just as an assessment of shortness of breath is a symptom of a respiratory disease. Identifying the cause of the problem and the outcomes the client is attempting to achieve permits the nurse to treat the disease rather than just the symptoms.3 The problem is never cured by merely ignoring it or dealing only with the symptoms. In the long term, the “leave it alone” approach usually only amplifies the difficult behavior. (For more information, go to http://www.oscehome.com/Communication-Skills.html.) Box 13.1 Seven Principles of Communication • • • • • • • 1. Information giving is not communication. 2. The sender is responsible for clarity. 3. Use simple and exact language. 4. Feedback should be encouraged. 5. The sender must have credibility. 6. Acknowledgment of others is essential. 7. Direct channels of communication are best. Source: Adapted from Whitehead DK, Weiss SA, Tappen RM. Essentials of Nursing Leadership and Management (4th ed.). Philadelphia: F. A. Davis, 2006. Basic Principles There are several basic principles to remember when attempting to work with a person displaying difficult behavior: • 1. No change. Keep in mind that it is highly unlikely that a difficult person will change his or her behavior very much, particularly if that person is a coworker. However, one of our goals in teaching and caring for clients is to change behavior even if they are displaying difficult behaviors. The key to remember here is that we need to change our own perceptions and the • • • • • • way we approach a difficult person.2 Difficult people tend to make us anxious, frustrated, and angry, but we cannot show them these feelings. 2. No reinforcement. It is a basic tenant in psychology that reinforcing a behavior will cause the behavior to be repeated (e.g., Pavlov’s dogs). It is interesting that the reinforcement can be either positive or negative. Providing punishment for something someone is doing is often the payoff the difficult person is looking for, and he or she will repeat the behavior to get additional payoffs. The most powerful reinforcement is intermittent reward or punishment. This is where the behavior is rewarded or punished one time and then ignored the next. It keeps the behavior going because the person is wondering when the next reinforcement will come. 3. No action. There is an old saying that “doing nothing is doing something!” This means that when dealing with difficult people, if we do nothing, we are in reality reinforcing their behavior. 4. No anonymity. Identify the particular behaviors they are displaying as difficult and call the behaviors by name. “Letting it go” actually reinforces the behavior (see #3). 5. No ashes. Another old saying is “Fight fire with fire”; however, the result of this approach is scorched earth and ashes. Again, this may be the outcome that the difficult person is seeking. He or she wins when nothing is left but ashes! 6. No condemnation. The difficult person had probably developed this type of behavior over a long period of time and is doing the best they can. Although it may not seem so, they usually are not malicious or hateful, and condemning them as such really misses the point.3 Difficult people lack the basic communication skills to interact successfully with others and are constantly seeking to fulfill a need or achieve an outcome by their behavior. 7. No robbery. You must believe that you are 100 percent responsible for your own happiness, because you are. Happiness comes from within yourself, and it is not up to others to make you happy. Similarly, it is up to us to control our unhappiness. Sometimes it is the goal of some difficult people to rob us of our happiness because they are unhappy (misery loves company). Don’t let them do it! Find happy people to hang out with! Find some fulfilling activity outside of the work setting. “Because communication is such a major part of quality health care, it is an essential requirement that nurses be able to understand why a client is using difficult behaviors and learn the skills that will allow him or her to communicate effectively.” Remembering Maslow Maslow’s hierarchy of needs is often one of the first important theories that is taught in nursing programs. It is typically introduced in the first nursing course and then reinforced in psychology courses. The primary reason it is taught is because it is one of the most effective ways of prioritizing client care (Fig. 13.1). The needs on the bottom of the triangle, particularly the physiological and safety needs, are necessary for the client’s survival and maintenance of life. These needs must always be met first. The higher needs, such as love and belonging, self-esteem, and self-actualization, cannot be met if the person is not able to fulfill the basic needs to stay alive and remain safe.4 Figure 13.1 Maslow’s hierarchy of need Maslow’s hierarchy can also be used in understanding and interacting with people in the health-care setting who are displaying difficult behaviors. Understanding what causes people to behave in a difficult manner is directly related to the hierarchy of needs and differentiates the causality between difficult coworkers and difficult clients. Because the causes are different for each of these groups, interacting successfully with them also requires a different approach. It is pretty safe to believe that physicians, nurses, pharmacists, and other health-care workers are having their basic physiological and safety needs met. The needs that are producing coworkers’ difficult behaviors are generally related to the higher level needs of love and belonging, self-esteem, and self- actualization. In the cases of difficult clients, their illnesses, injuries, or surgeries often threaten their basic needs for merely surviving physically. Difficult Coworkers Anyone who has been employed in or even associated with the health-care setting for any length of time soon becomes aware of a variety of personality types among the staff members. These personality types can be identified by their predominant behaviors. The behaviors vary to some degree based on how they are attempting to meet their needs. Although there are several types of difficult personalities in the work setting, the two most common types are the persecutor and the sneak. They require different strategies for communication and dealing with their behaviors. Keep in mind that these are stereotypes that tend to batch individuals into groups on the basis of predetermined behaviors.5 In reality, people may have combinations of or overlapping behaviors that may require combining strategies for communication. The various types of stereotypes are all interrelated and based on individual behaviors and communication styles. An increased awareness of the various identifying characteristics and communication strategies will help develop the coping skills and communication techniques necessary for communicating with difficult people. “The most powerful reinforcement is intermittent reward or punishment. This is where the behavior is rewarded or punished one time and then ignored the next. It keeps the behavior going because the person is wondering when the next reinforcement will come.” Also, it is possible for individuals to have true personality disorders, which are diagnosed psychological conditions. Some of these disorders, such as a narcissistic personality or the avoidant personality, may present with the same types of behaviors as seen with difficult people but are more pronounced and extreme.1 If a person has a true personality disorder, it is likely beyond the floor nurse’s skill set to interact with these individuals successfully, unless the nurse specializes in psychiatric practice. These clients are best left to the mental health professionals. However, one of the characteristics of these types of disorders is that the person does not believe there are any problems and rarely seeks help for them. The Persecutor Also called the dictator, these people generally display an attitude of being superior to others and being in control. They attempt to humiliate, intimidate, threaten, or demean other individuals or groups with the goals of overcoming their own lack of confidence, feeling more powerful, and inflating their low selfesteem. This behavior is probably habitual, being repeated over and over for a long period of time, and becomes the person’s primary mode of communication. The persecutor has self-esteem needs that are not being met and may also have love and belonging issues. The goal of their behavior is usually to coerce or intimidate another person into doing something they do not want to do. However, sometimes the goal is to merely humiliate a person or group due to some perceived difference or weakness because it makes them feel better about themselves.5 Persecutor Tactics Persecutors attempt to maintain control by putting others down and ruling from a command post. They often have minions working for them who are fearful of getting on their “bad side” and will help persecutors when they engage a new target. Persecutors have learned over time that being inconsistent (i.e., easy to deal with one day and demanding the next) keeps people off balance and helps them maintain power to achieve their goals. They usually will be unable to accept ideas that are different from theirs and often may use loud speech and treats to keep the other person from expressing a new idea. Persecutors may attempt to provoke the other person into an angry defensive outburst and enjoy the flare-up because they’ve achieved one of their goals. These are some of the messages they are attempting to convey by their behavior: “If you don’t do what I want, I’ll make your life miserable,” “If you do what I want, I’ll stop harassing you,” and “If you give into my wants, you can become one of my minions and help me demean others.” What Do You Think? Recall a recent exchange with someone (e.g., friend, instructor, parent, and physician) in which you felt you “lost” the exchange. How did you feel? How did you respond? What could you have done differently? If the dictator is in a superior position such as a charge nurse or supervisor, this type of behavior is called vertical violence. When the dictator is a fellow employee at the same authority level, the behavior is referred to as lateral or horizontal violence. (See Chapter 16 for more detail.) It is important to remember that the persecutor’s self-image is fragile, and attempting to destroy it will be ineffective. In actuality, it will make them more defensive and will escalate their behavior. Taming the Persecutor Using the basic principles discussed above is essential in taming the behaviors of the persecutor. Communication skills can also be coping skills in interacting with these individuals. Everyone develops coping skills as they mature and use them when confronted with complex situations. These coping skills can be used to resolve crisis situations, deal with anxiety, and resolve difficult issues of communication. This basic set of coping skills can be used as the foundation for adding to or building new coping skills to deal with difficult people.5 Just as developing communication skills requires a willingness to change and a lot of practice, so does the development of coping skills “The persecutor has self-esteem needs that are not being met and may also have love and belonging issues.” Also, remember that perception is a significant part of dealing with the difficult behavior of people.6 However, a lot of people really don’t understand what their own perceptions are or how they affect their actions and thoughts when confronting a persecutor. When confronting a persecutor or any difficult person, it is essential to understand one’s own motives, preferences, beliefs, and biases. Dealing with difficult people requires a high level of personal confidence and inner strength: They have learned how to quickly identify weaknesses in others and to use those weaknesses in their attempt to maintain control. Success in dealing with persecutors in particular also requires high degrees of selfawareness and emotional self-control. The only way to develop emotions strong enough to resist the attacks of the persecutor is through self-knowledge. Some of the particular actions that can be used in taming the persecutor include the following: • • • • • • • 1. Set the stage for communication. This is an environmental communication builder. After a decision is made to deal with a difficult issue or person, it is important to set the stage for a positive experience. The location for the exchange should be private. The format of the meeting needs to be established ahead of time, including an explanation to the other person that both parties will take turns expressing their opinions and feelings without interruption. 2. Listen to what is really being communicated, including body language and paraverbal clues. Often persecutors will reveal hidden messages or indications of what their real goals or needs are nonverbally while giving a much different verbal message.5 You can use the nonverbal communication builders when interacting with persecutors, but be sincere. Persecutors have learned how to quickly detect dishonesty. In some situations, merely allowing a person to vent emotions by using active listening reduces the levels of anger and animosity and sometimes even solves the conflict. Also, when intelligent people are allowed to speak openly and freely, they may be able to develop a new solution to the problem that they had not considered previously. 3. Use assertive but not aggressive communication. If the persecutor is in a highly animated state and speaking rapidly and loudly, your message will not penetrate the tirade. Never yell back or argue with them. Rather, say to them, “You are upset now; we can discuss this issue later.” Then walk away. 4. Use a line of discussion that will get their attention and not make them defensive or lower their self-esteem. A statement like, “Joanne, this project you have been working on shows what a hard worker you are; however, I am assigned to it also, and we need to figure out how to work together to make it the best possible.” “Liz, our relationship feels strained. I would like a good working relationship with you. What can we do to improve it?” “Alexis, I noticed that you excluded me from meetings and communications. I feel left out. Can we talk about this?” Using the person’s name eliminates a chance of misunderstanding to whom the statement was directed. 5. Remember persecutors are acting the way they do because of something they lack in their lives or because of internal feelings of low self-esteem,1 so don’t take what they are saying personally. They probably say it to everyone. Also, never react emotionally in front of them by crying or sulking. It shows vulnerability and that is an outcome they are seeking because it makes them feel better about themselves. 6. Avoid doing nothing. Persecutors want people to leave them alone so that they can continue their behavior without confrontation. After you’ve walked away, walk back when they calm down. Identifying their behavior to them calmly and directly is the first step in dealing with the behavior. Their behavior is not likely to change very much, but they will know that you know what they are doing. They probably will take you off their target list and seek a new target. 7. Avoid personal attacks. Separate the person from the behavior by focusing on the issues without attacking their personality. Having the facts about the specific behavior to be addressed makes people much more receptive to resolution of the problem than attacking their personality.5 Remember, persecutors have fragile egos and attacking them will only invite a more vicious counterattack. When situations are made into personal attacks, people feel defensive, responsible, or persecuted, and communication is either blocked or closed off completely. Avoid becoming personally or verbally abusive.6 “Dealing with difficult people requires a high level of personal confidence and inner strength: they have learned how to quickly identify weaknesses in others and to use those weaknesses in their attempt to maintain control.” For example: During shift report on a particular client, the 11:00 p.m. to 7:00 a.m. nurse forgot to tell the 7:00 a.m. to 3:00 p.m. charge nurse, Gail L, RN, that the client had fallen out of bed during the night shift. Later in the day, the client’s physician and family confronted Gail to find out what had happened and why the client was not placed on “fall protocols.” Later, when Gail confronts the night nurse about the omission, she has two options for initiating the discussion of the incident with the responsible night nurse. Which approach would the night nurse probably take as a personal attack? • • • • • Option 1. Gail: “I was taken off guard and was ill-equipped when the family and physician asked me about this client’s fall, and I felt unprepared to explain the problem or provide a solution to them. My lack of knowledge about the fall really made me feel incompetent.” Option 2. Gail: “You failed to tell me about his fall last night. Because of you, I was not aware of the incident and was not prepared to answer questions. You always make me look like a fool!” 8. Avoid judging what a person is doing or what they should have done by your own standards. This type of statement becomes an arbitrary judgment call. Instead, ask the person for his or her ideas on how the situation could have been handled differently or what other options were available. 9. Ask clarifying questions that validate the person’s concerns, feelings, and perceptions. Validating will help ensure that the responses address the real issues. Also, avoid reflex-type reactions to hostile or aggressive statements. It is a human instinct to become defensive when attacked and to attack back. However, this behavior only escalates the anger and tension and blocks effective communication. 10. Ignore trivia. Always make a conscious decision about the importance of the issue that needs to be discussed and stick with it. It is a very human tendency to become preoccupied with trivial and unimportant issues. If people spend large portions of their energy dealing with trivia, they will have little energy left to deal with major issues when they come along. Identifying the causes and needs of people displaying difficult behavior can sometimes be complicated and time-consuming. Often they will try to direct the conversation away from issues they believe are painful and toward topics that are more comfortable.7 They do not accept criticism well, even constructive criticism. By having a clear idea of the outcomes you wish to achieve, you can redirect the conversation when the person attempts to lead it in another direction. The Sneak Another type of coworker with difficult behavior is called the sneak because of the devious, underhanded, and often malicious attacks they use to fulfill their self-esteem needs and achieve their goal to be in control. They are also called double-crossers or backstabbers. Unlike the persecutor, who enjoys direct confrontation and watching others feel uncomfortable under their attacks, the sneak will attack when you aren’t looking and gets his or her reward by watching your discomfort and confusion in not knowing where the attack came from. Although they really don’t have minions like the persecutor, they often will elicit the help of others who are afraid of them and gang up on a person as a group behind his or her back. This process is called gossip, and it is a primary source of recreation and entertainment on many nursing units that should be eliminated. The methods sneaks use are really forms of manipulation, which demonstrates that they are insecure and unsure of where they belong in the work setting. Interestingly, their behavior has the same underlying causes as the persecutor—a need to feel in control, low self-esteem, and love and belonging issues; however, they use different methods to build up their self-esteem and sense of control.5 “Shifting the communication paradigm from one of instinctual ‘knee-jerk’ responses to one that uses the nurse’s relationship skills should make dealing with difficult people a much less difficult task.” What Do You Think? Have you ever been in a situation in which others have intentionally sabotaged your work? What was the situation? How did you feel? How did you deal with it? Did you try to retaliate? Sneaks often have very few true friends and are generally fearful of close friendships because they don’t want others to know what they are really like. Often sneaks subconsciously feel they lack the talent, intelligence, or skills to be successful and use covert manipulative behavior to gain promotions and advance their position. They often will behave in a way to gain attention from a superior and feel a strong sense of jealousy when the superior gives the attention or promotion they want to another person. They will work hard to bring that person down. They are very sensitive to criticism and often feel slighted and angry at people who may have unintentionally said something that hurt their feelings. Sneak Tactics Methods commonly used by the sneak to achieve his or her goals include personal digs, rumors, accusations, allegations, finger-pointing, and innuendoes. Sneaks often appear very friendly when they are communicating face-to-face with you, but they do not have your best interests in mind and are looking for a weakness they can exploit to lower your esteem. They will use any underhanded means to discredit a person, and by making that person appear inferior, they feel superior. They also go out of their way to avoid confrontation. Sneaks like to keep the workplace in a state of uncertainty, tension, and disorder. One of their favorite tactics to achieve this goal is to divide and conquer. For example, the sneak knows that Bill and Cindy have a strong work alliance and friendship and rely on each other to provide high-quality care on the unit. The sneak will try to break up this alliance by first going to Bill, on Cindy’s day off, and saying, “Don’t repeat this, but did you hear what Cindy said about you? She said you were incompetent and shouldn’t be working as an RN.” Then when Bill isn’t around, the sneak would go to Cindy and say, “Don’t repeat this, but did you hear what Bill is saying about you? He said you were too fat to be working on such a busy unit and provided really poor care.” And the pot gets stirred! One of the most powerful tools they use is a mixed rumor, which contains just enough truth to make it completely believable.7 For example, Aleshia is an RN on the unit who was selected by the hospital to attend an expenses-paid workshop in another state because of her interest in geriatric nursing. Anne, who is an infamous sneak, started a rumor while Aleshia was away by saying, “You know that Aleshia went to that workshop paid by the hospital? Well, I heard that she skipped most of the breakout sessions and spent her time in the bar drinking with strange men!” The truth is that Aleshia did go to the workshop; the rumor is what she did there. There is just enough truth in the rumor to make it credible. Some of the messages that sneaks send out by their behavior are that no one should confront or tangle with them because, when you are out of earshot, they will put you in your place. Also, because of the covert nature of their attacks, they believe that they are unstoppable and that they are the only ones honest enough to tell the truth about other workers. Unveiling the Sneak Using the basic principles discussed above in conjunction with some of the techniques for dealing with the persecutor will work, up to a point, with the sneak; however, there are several different techniques that must also be used to be successful. As with the persecutor, perception and self-knowledge are significant elements in dealing with the sneak’s behavior. You need to understand how and why you react the way you do when suffering the aftermath of a sneak’s attack. Your reaction is a behavior that you can and need to change. It’s unlikely the sneak will change his or her behaviors to any great degree. Understanding your own motives, preferences, beliefs, and biases can help in softening the devastation you feel after the attack.5 Methods for showing up sneaks for who they really are include the following: “It is a very human tendency to become preoccupied with trivial and unimportant issues. If people spend large portions of their energy dealing with trivia, they will have little energy left to deal with major issues when they come along.” • • • • 1. Make the decision to talk to them about their behavior. They won’t change on their own and may not change anyway, but it’s worth a try. Talking to them takes a high degree of courage and resolve because the exchange is going to be difficult. Do this only after you have settled down from the effects of the attack and are calm and certain of what you want to do. If you display excessive emotions while talking with them, the sneak wins. They are highly manipulative and will try to make you feel bad about yourself and sorry for them. 2. Let them know that you know. Catching them in the act is the best way to let them know you know, but this is often difficult to accomplish. They are sneaky, after all. Pretending that you didn’t hear them and doing nothing is what they want you to do. You can say something like, “Anne, you were the only one who knew that I went to that workshop. How come everyone else is talking about what I supposedly did there?” It is important that you talk with others to confirm what you heard. Make sure you have your facts straight when you do talk with the sneak or he or she sneak will pick apart what you are trying to say and turn the attack on you. 3. Let the group know that you heard what the sneak said. Using a statement like, “Did everybody hear what Anne said about me?” will gain you support among your peers. 4. Don’t show your hostility toward the sneak in front of a group. Avoid being rude and aggressive. Like the persecutor, sneaks do have fragile egos and low self-esteem. Unlike persecutors, who will immediately attack back when confronted, sneaks will use the incident to • • • • make themselves seem like the “victim,” which is another type of manipulative behavior. They revel in the “poor me” role because it garners sympathy from the other staff members and gives them more ammunition against you. “Did you see how mean Sarah was to me?” 5. Stay on point when you finally speak with them. They will try to turn the subject back on you to break your train of thought. Just keep saying, “We’re not talking about me; we’re talking about your behavior,” and then continue with your train of thought. They are expert distracters, so you might want to make a list of things you want to say and take that along. Also, don’t laugh at them, don’t agree with them, and don’t let them gain control of the conversation nor let it go. 6. Try to treat them with empathy and understanding, not resentment and anger. Like the persecutor, they have developed this type of behavior in response to something that is missing in their early lives. This has become the only way sneaks can gain attention or exercise any control in their lives. They never developed adult communication skills, and it is likely they’ve been using these manipulative behaviors for many years in all aspects of their lives. That is probably one of the reasons why they have few friends. Sneaks tend to be negative all the time, and most people steer clear of negativity. Many people already probably have enough negativity in their lives and don’t need any more from a coworker. 7. Listen carefully to their response. If you are able to complete your thoughts and finish what you are saying without them walking away, it is important to listen to how they respond. It is important to remain open-minded and to be prepared to understand what motivated them to use the behaviors they use. You might discover that you did or said something unintentionally that they took as a personal insult that triggered their behavior. Sneaks often display paranoid tendencies. You might actually need to apologize to them. Even though you did nothing to deserve their negative behavior, be prepared to listen to what they have to say. They probably need someone to talk to, someone to confide in, and in some peculiar way, you might just be the person who is their first real friend in many years. You might be the first person who has been prepared to really listen to them and not just turn you back on them or try to get revenge. 8. Plan for future interactions. After you’ve listened carefully to them and provided responses to questions or further explained your feelings, set the direction for your future relationship. Make them believe that their behavior must change or you will take whatever actions are required to guarantee that they will never undermine you again. If it becomes clear that the relationship will not work, let them know that you will treat them in a civil and professional manner but the relationship will go no further. “They are also called double-crossers or backstabbers. Unlike the persecutor, who enjoys direct confrontation and watching others feel uncomfortable under their attacks, the sneak will attack when you aren’t looking and gets his or her reward by watching your discomfort and confusion in not knowing where the attack came from.” • 9. Forewarned is forearmed. Now that you know what types of behaviors can be expected from the sneak, you can be more cautious about leaving yourself open to future attacks. You are much less vulnerable when you can keep a close eye on the individual and head off covert attacks before they happen.5 Clients With Difficult Behaviors Clients displaying difficult behaviors are in some ways similar to coworkers with difficult behaviors, but in other ways very different. The nurse is legally and ethically bound to provide the best care possible for all clients, even those who are displaying behavior that makes communication or care difficult. Although some clients may actually be persecutors or sneaks in their everyday lives or even have undiagnosed personality disorders, the majority of clients displaying difficult behaviors are acting that way as a response to their illnesses or injuries. Their needs and goals are different from persecutors or sneaks. Above we discussed the effects of grief on individuals. Although we usually think of grief as being associated with a loss such as the death of a loved one, clients who are severely ill, severely injured, or who have had major surgeries, amputations, or loss of internal body parts or who may be facing death also often go through the stages of grief: denial, anger, guilt, depression, and resolution. The traditional five stages of grief were first presented by Dr. Kübler-Ross, who had investigated grief and suffering for many years before developing her theory on grief. Some more recent theorists believe that Ross’s fivestage theory is too simplistic and have added several additional stages to the process and changed their names.8 However, Ross’s five stages remain the gold standard and is the theory that is most often taught to nursing students. The nurse has two primary goals in caring for clients who are working through the grief stages: (1) to provide the best care possible so that they will survive and recover from their illness (meet their physiological and safety needs) and (2) to help these clients work their way through the stages of grief until they reach resolution.9 The ideal is to achieve both goals simultaneously, but that is not always possible. Goal 1 will always have the highest priority. How each client experiences grief is highly individual, and there is no right way to resolve grief. Some clients move rapidly through the stages, some skip stages, and some are unable to move on from the stage they are in. They also don’t always go through them in order. The stages of grief are really guides to help determine where the client is in the grieving and mourning process. The key to understanding this is to observe their behavior. It is also important to consider the effects of medications and pain on the client’s behavior. Unfortunately, our health system of today often sends people home well before they have had a chance to complete the grief stages. However, if the nurse is able to start the process and move it even one stage, the other stages will progress more easily at home. Earlier we saw that coworkers with difficult behaviors had need-fulfillment issues at the upper levels of Maslow’s hierarchy of needs. However, severely ill clients are often attempting to meet the needs of the lower levels of the triangle—physiological survival and safety. Maslow believed that if the lower level needs are not met, the person is unable to move to the higher level needs fulfillment. Severely ill clients, in some ways, are starting over in their needs development.3 It is a key responsibility of nurses to aid clients in maintaining their physiological and safety needs so that they can move back up to their prior levels of adjustment. Even more so than working with a difficult coworker, perception on the part of the nurse plays an important part in understanding and adapting to client behaviors. Quickly stereotyping a client by saying something like “Oh, he’s just an old grouch,” “She’s a real whiner and complainer,” or “He doesn’t like nurses. He won’t do anything I want him to do” completely disregards the underlying issues that are causing the client to behave the way they are behaving. Often, once a client is labeled, the care provided to him or her is based on that label and the client’s real issues are never addressed or resolved. “It is important to remain open-minded and to be prepared to understand what motivated them to use the behaviors they use.” Establishing Trust Establishing trust is key to any successful relationship. In the nurse-client relationship, it is the foundation upon which all nursing care is built and is particularly important when dealing with difficult behavior. In most relationships, it takes a considerable amount of time to develop trust between two people; however, in the health-care setting, time is limited and trust has to be built quickly. Nurses have a head start in trusting relationships with clients. The annual Gallup Poll surveys the nation’s population asking which profession they trust most. For the past 10 years, that profession has been nursing. Respect Trust can be established by a show of respect for the other person’s opinions and ideas and letting them know you accept their behavior even though you do not agree with it. Always be honest with the client even when it isn’t pleasant to do so.10 If clients find out that you have been less than honest with them, it is almost impossible to regain their trust again. We sometimes are tempted to be less than 100 percent truthful because we don’t want to hurt their feelings, make them angry, or upset them. By focusing on what is going well with the client rather than criticizing them or pointing out the problems in their behavior, you can soften the impact of a negative statement and show them that you are not being judgmental about them or their condition. Consistency Another important element in building trust is being consistent in what you do and say. The client will be able to relax if he or she knows what is coming next. Being reliable and doing what you say you will do, even in small things, acts as a foundation for trust. If you tell the client you will be back to check on them in 30 minutes, make sure you come back on time. If they can trust you in the small things, they will trust you with the more critical things. Generally nurses should not make promises to clients. Health care and health-care outcomes have too many variables to be certain about much of anything; however, if you do make a promise to a client, make sure you keep it. Even promises about small issues like promising to get the client some juice after finishing the client next door can have a huge impact on a person whose world is currently limited to a hospital room. Confidentiality In order to trust you, the client needs to know that you will keep his or her confidence. Nurses are bound ethically and legally to maintain confidentiality of client information, but nurse-client communication is NOT considered privileged communication as exists between priest and penitent or lawyer and client or physician and client. (See Chapter 8 for more detail.) Personal secrets that do not affect the client’s health care are easier to keep and should remain secret. Information that is important to their treatment or recovery should be revealed to the physician. If a client tells you something in confidence—for example, “Don’t tell anybody, but I have seizures from time to time”—and it isn’t on their medical record, you need to inform them that the information is 21 Spirituality and Health Care Roberta Mowdy Learning Objectives After completing this chapter, the reader will be able to: • • • • • • Develop a working definition of spirituality • Distinguish spirituality from religion • Describe what is meant by the nursing diagnosis “spiritual distress” • Describe research that supports the health benefit of spiritual practices • Describe the relationship between spirituality and one alternative healing modality used within nursing ROUGH SPOTS ALONG THE TRAIL The road of life often is filled with twists and turns, ups and downs, and precipitous waysides. People who are facing potentially long-term or debilitating illnesses, confronting acute health crises, or suffering from loss and grief may find themselves reexamining the foundational beliefs they have held since childhood. Usually, at no other time in a person’s life is he or she so focused on evaluating the spiritual self than during such crises. Yet the times when clients are most vulnerable also can be opportunities for personal and spiritual growth. Nurses have the unique task of working with clients at various points throughout their life journeys. Often nurses encounter clients during the “rough parts of the trail.” The holistic nursing perspective requires nurses to view each person as a bio-psychosocial being with a spiritual core. Each component of the self (i.e., physical, mental, social, and spiritual) is integral to and influences the others (Fig. 21.1). Nurses spend more time with their clients than do other healthcare workers. Therefore, the spiritual needs of clients must be recognized as a domain of nursing care. Holism cannot exist without consideration of the spiritual aspects that create individuality and give meaning to people’s lives.1 Thus, nurses must be sure to address the spirit along with the other dimensions to provide holistic care. NURSING AT LIFE’S JUNCTURES It is universally true that the human life cycle is marked by a rhythm of transitions: birth, the entry of a child into society, puberty, sexual awakening, entry into adulthood, marriage, parenthood, illness, loss, old age, and death. In all cultures there are other rhythms that people honor, such as the solar and lunar cycles, the agricultural cycle, and the reproductive cycles. These cycles constitute the rhythm of human life. Figure 21.1 Components of the self. Developmental Crisis All people recognize the importance of transitions and in some way have ritualized them through their religions or through custom. People learn from their own cultural groups how to behave during each transition, and each cultural group has conceptualized an understanding of these human experiences. Their importance is universally recognized. Nurses primarily have contact with clients in the health-care setting within the context of these transitions. Developmental crisis theory holds that transitions are times of anxiety and vulnerability for families. Therefore, nurses are required to treat people who are going through transitions with great tenderness and care. It is a sacred trust for nurses to be allowed into a family system in transition. Clients and families may seek spiritual support or may feel spiritual abandonment. Ideally, nurses can help people identify and find the spiritual support they require. Science as Magic Over a long period of time, from the Enlightenment of the 17th century to the dawn of the 21st century, political leaders and educated people in Western cultures came to believe that all the answers to human suffering could be found in science and technology. For example, early in the 20th century, antibiotics were thought of as “magic bullets” that cured diseases and reduced suffering. People were eager to take part in research studies to solve their health-care problems. It was in this context that the nursing profession embraced the Western scientific method as the measure for defining itself. Nurses believed, and some still do believe, that rigorous research involving testing of hypotheses would provide the theoretical base for the practice of professional nursing. SOCIAL AND SCIENTIFIC EFFECTS ON SPIRITUALITY More recently, the horrors of terrorism, global warming, major natural disasters, space exploration, and the mapping of the human genome are among changes that have given urgency to reconsideration of the question, “What does it mean to be fully human in the universe as it is now understood?” It is evident that science and technology cannot offer the solutions to all human problems; in fact, they have contributed to many of them. What Do You Think? Make two lists: a list …
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