Blowing Out The Fuse

Blowing Out the Fuse! Understanding The Angry Patient and Defusing Explosive Situations

University Community Hospital The Department of Spiritual Care Bishop Bruce Wright Ph.D. - Manager. Rev. 07/09

The Angry Patient

Understanding The Ingredients of an Explosive Situation

Inside the Patient Anxiety Fear Nausea Pain Loss of Control Why me?

On the Surface of the Patient Aggression Blame Placing Confrontational Intimidation Frustration Demanding Profanity Seizing Control Anger

The Fuse Matches Courtesy of Hospital Staff

(Remember...Perception IS Reality!)

Non-Caring Defensiveness Confrontational Condescension Evasiveness Inattention

The Equation for Disaster A (Patient’s Internal Emotional State) + B (Patient’s Aggressiveness) + C (Staff Defensiveness) equals….

Understanding Emotions “If you know how emotions emerge and change, you can make patients feel better about their lives, their health care experience and your health care organization.” Paul Alexander Clark

Emotions 1) Are chemical and neural reactions in the brain. 2) Are a constant experience. 3) Are formed from a combination of: a) An external stimulus b) Our subjective experience of that stimulus c) And any behaviors that result and our internal physiological response. Treating the Patient's Emotions By Paul Alexander Clark

We are “hardwired” to detect emotions in others. •Facial expressions. •Body language. •Tone of voice. •Implicit as well as explicit behaviors

We have the emotional need to have our emotions acknowledged and validated by others. When we do not feel that emotional validation, happiness subsides, despair intensifies, depression deepens, anger grows and internal emotional needs are unfulfilled.

Treating the Patient's Emotions By Paul Alexander Clark

And because emotions are biochemical in nature, they can and do influence physical, mental and psychosocial health.

ACE (Adverse Childhood Experience) Study • A major research study 17,421 participants. • Compared current adult health status to childhood experiences. • Results: subjects with ACE experience: 4-50 times more likely to have adverse health or disease as an adult • Adverse emotional experience was the biggest single factor in predicting adult health .Foege WH. Adverse childhood experiences: A public health perspective. Am J Prev Med 1998 May;14(4):354-5.

to 90% of physician visits are stress related . 60% Stress is linked to the six leading causes of death, which .include heart disease, cancer and suicide. American Psychological Association, 2008, Heart Pangs?

We must always remember… Every patient arrives carrying emotional baggage.      

Anxiety Fear Nausea Pain Loss of Control Why me?

And every experience, every staff interaction, every sight, sound, taste and smell stimulates and accentuates emotions in the patient.

Therefore we must make sure we’re aware of what emotions we are eliciting in our patients.

We must continually ask ourselves… What are my words, my posture, and my attitude saying to my patient?

Concern or disinterest? Empathy or irritation?

I care and you matter, or I don’t really care because you don’t really matter.

Am I showing empathy?

Am I demonstrating that I care?

For a few minutes, put on the patient's gown. How it would feel… “Think about what it feels like to wake up for a blood draw at 3 a.m.

How does it feel to hear you can't spend the night with your child, spouse or loved one?

For a few minutes, put on the patient's gown. How it would feel… How does it feel to cry and have no one notice? How does it feel to hear nurses laughing at the nursing station as you lie in your own vomit and continue to press the call button?” Paul Alexander Clark, Press Ganey Associates

Nursing Behavior that Triggers Anger Non-verbal triggers Tone of voice: sarcastic, condescending, disbelieving Body language: Arms folded across chest, looking away, looking at your watch, smirking, scoffing, rolling your eyes, drumming fingers Other trigger actions: Long wait times, not promptly addressing needs, passing the buck, inattentiveness

Nursing Behavior that Triggers Anger Verbal Triggers You’re wrong. It doesn’t help to tell customers that they’re wrong, even when they are. Just courteously state the facts, as supported by evidence. Let the facts speak for themselves. I’m sorry you feel that way. People can see through this old trick. Say sorry only when you’re sorry. Even when the customer is not completely right, identify what could have been done better, and apologize for those mistakes.

As I’d already said … As I’d said before Just repeat or paraphrase what you had said, without saying you’d already said it. That’s the policy … I can’t do that Instead…"That’s contrary to our policy, but I know what you mean. Let me see what I can do." No way ... Not gonna happen ... That's impossible Instead…"I tried to do that for another customer, but I really couldn't get it approved."

That’s not my job. It is your job. Take ownership of the problem. Calm down These words often have the opposite effect. You should have Instead…"In case this happens again, it might help you to” You have to . . .Instead…"Would you please …"

I assume or I guess Get the facts. Don’t assume, don’t guess. I’m going to have to end this conversation … You must leave the building Used only as the last resort. Used only when customers are truly dysfunctional.

Instead of lighting the fuses, let’s learn how to blow out the matches!

Non-verbal De-escalation Techniques The most important aspect of de-escalation with angry patients. ➙ 65% of communication - nonverbal communication & vocal qualities of speech. ➙ 35% of human communication through the spoken word. Using Body Position to Defuse Angry Peopl, Loo, http://www.hodu.com/defuse.shtmlTristan Loo

During a hostile confrontation between two people, both parties will naturally, and often unthinkingly, assume either defensive or aggressive nonverbal behavior. • Finger pointing (very aggressive) • Glaring Invasion of personal or even intimate space (4” and closer) • Arms crossed Widening of stance • Hands on hips • Fingers clenched into a fist • Increase in the volume of voice Using Body Position toDefuse Angry People, Loo, http://www.hodu.com/defuse.shtmlTristan Loo

De-Fusing Through Non-Verbal Cues Instead of further igniting the situation through our body language, we can also train ourselves to promote peace through nonverbal cues that express peacefulness.

Using Body Position t oDefuse Angry People, Loo, http://www.hodu.com/defuse.shtmlTristan Loo

Palms Up! The single biggest nonverbal gesture that conveys peace is by placing your palms up so that they are facing upwards. This feels entirely unnatural when we are confronted with a hostile person, so it requires practice, but you can practice this during any conversation. Open palms not only convey submissiveness, but also honesty.

Using Body Position t oDefuse Angry People, Loo, http://www.hodu.com/defuse.shtmlTristan Loo

Triangle Body Pointing When someone becomes angry at us, it is common for them to turn their body so that it is directly facing our own. Instead, orient your body position angled in such a way that if you were to draw a line in the direction that both of you are facing, it would intersect at an imaginary third point. Provides a feeling of openness during the conversation. Creates that imaginary third point which acts like an escape route. Using Body Position t oDefuse Angry People, Loo, http://www.hodu.com/defuse.shtmlTristan Loo

Lower Your Voice! When angry people speak louder. Our response is to raise our own voice. Vocal competition fosters conflict. Instead speak in a gentle, calm, and soothing tone. … just a few notches higher than barely audible.

Eliminates competition They can’t respond to something that they can’t hear so they lower their voice in response.

Using Body Position t oDefuse Angry People, Loo, http://www.hodu.com/defuse.shtmlTristan Loo

Head Tilting Most animals, including humans, are programmed to minimize exposure to their necks because this is a vital area that can be attacked. Head tilting is a peaceful gesture because by tilting your head, you expose your neck. Has the psychological effect of disarming the other person by making you seem less threatening. Using Body Position t oDefuse Angry People, Loo, http://www.hodu.com/defuse.shtmlTristan Loo

Respect Their Personal Space. Entering an upset person's personal space can intensify his or her emotions. Three feet is adequate for most situations, however allow up to 6 feet for aggressive and confrontational people.

3 - 6 feet

Healthcare Training Weekly, October 25, 2007 www.hcpro.com/NRS-78059-975/Use-nonverbal-cues-to-ease-angry-patients.html

An Open Stance Caregivers should assume a stance in which they slightly turn their body at an angle to the patient while keeping their hands open and in plain view. Angry patients will perceive this stance as less threatening.

Healthcare Training Weekly, October 25, 2007 www.hcpro.com/NRS-78059-975/Use-nonverbal-cues-to-ease-angry-patients.html

Appropriate Eye Contact and Facial Expressions. Your face and eyes convey a direct message to the patient. You should maintain general eye contact, but not stare at the other person.

Healthcare Training Weekly, October 25, 2007 www.hcpro.com/NRS-78059-975/Use-nonverbal-cues-to-ease-angry-patients.html

Therapeutic Responses to Anger The goal is to establish or reestablish a collaborative relationship.” (Simms, C. (1995). How to unmask the angry patient. American Journal of Nursing, 95(4), 36-40.).

Rather than focusing on the stressful emotion of anger alone, nurses must focus on the patient and the fears he is facing Focus on interacting with the patient rather than reacting to the anger. Dodaro, D.C. (1988). Beyond the wall. Nursing, 18(4), 96.

Be calm and reassuring. Seek to understand any underlying problems.

Acknowledge their feelings of anger. Focuses on empowering the patient, and redirecting the energy once used for anger for more productive means. Murdach, A.D. (1993). Working with potentially assaultive clients. Health and Social Work, 18(4) 307-312.

Take an active role in this situation by addressing the patient's actions Provide a safe and supportive environment for the patient to express his feelings Refuse to be disagreeable.

Most Importantly….. When you have an angry patient, remember...

A - Apologize

•No matter who's to blame; apologize anyway. •You are not accepting blame, you are simply saying, "I'm sorry about the problem." •Be completely sincerity. Be sure that tone of voice matches words.

S - Sympathize •Identify with his feelings. Validates his feelings

A - Accept Responsibility • Let him know that you intend to make things right. •You can't help what has already happened, but you will come up with a solution to the problem or you will find someone who can.

P - Prepare to Take Action •Decide what to do •Do it •Report back to the patient

Blowing Out The Fuse!

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