Balancing Patient-Focused Care and Required Nursing Tasks
by Sharon Strand Ellison
Developing the ability to balance the many tasks required of RNs and at the same time to maintain a focus on patient-centered care is a struggle. Historically, getting the tasks done has been the primary definition of a nurse's job. Give the bath and the medication, fill in the charts. To depart from this old definition of nursing and assume the authority to work in a way that balances compassion for patient’s emotional needs along with the essentials of physical care is a challenge. We still have a long way to go to recognize the degree to which the psychological state of the patient influences motivation to follow regimes for recovery and in fact to heal.
Making a Patient-Focused Decision and Being Defensive about It
When Angela came in to give Deborah Jones her bath, she found that Deborah had had a very painful night and was unable to sleep. She said to Deborah, “Well, let's get your bath and then you can relax and rest. Deborah responded, “Oh, no, please, I just can’t do anything right now, I’m too exhausted and upset. Angela had thought Deborah looked worried and distraught when she came in, so she sat down and asked her what she was upset about.
“I’m so worried about how long it will take me to get back to work after this hip replacement. I’m afraid I’ll run out of sick leave and I can’t afford it. I’m also helping my daughter get through a program to become a dental assistant.”
Angela talked realistically with her about how long rehabilitation can take and advised her of some of the things she could do, both to heal as quickly as possible and to protect herself from doing too much and damaging her hip in the process. After they finished talking, Deborah felt much better and was motivated to do the routine she needed to do to strengthen herself.
When Faith came on duty later, she was angry at Angela for not having bathed Deborah. “What happened?! Why didn’t you give her a bath? Now I have to do it and it will put me behind!”
Angela defended herself, “She was exhausted, she didn’t sleep well and she didn’t want a bath.” “Ha!” Faith jabbed back at her, “Nobody sleeps well in a hospital!”
Frustrated, Angela said, “Look, she was upset and needed to talk,” to which Faith retorted, “That shouldn’t stop you from doing your job.”
One of the reasons so many RNs are afraid to focus on patient-centered care is because they fear the judgment of their peers, who may see them as “not doing their job.”
A nurse who attempts to depart from the physical routine to focus on other patients needs is likely to get defensive when other nurses get angry or react in judgment. That’s what just happened in this scenario. First, Angela defended herself by saying the patient was too tired, then by saying she was upset and needed to talk.
When we defend an action in response to someone’s criticism, even if our reasons are completely justified, we will look like we are making excuses. We give the other person the power to be the judge while we are on trial.
Making a Patient-Focused Decision and Staying Confident
What can we do instead? First, I believe that we should never explain why we did something unless we trust that the other person has an open mind and an open heart. This is the case even if the person is asking a question, such as “Why didn’t you bath her?!” That question is not a real bid for an answer; it is a way of using the question and a harsh tone to pass judgment.
Asking Non-Defensive Questions
Instead, you can respond with a question to clarify the other nurse's (or any person’s) intention. “Are you asking me that because you want to understand why I chose not to bath her or to let me know that you are upset that I didn’t do it? By asking the question, Angela does not put herself in the position of defending. She can keep her confidence while still being respectful.
Making Predictions that Set Clear Boundries
If Faith is rude in responding, “Well, what do you think!?,” then Angela can give a prediction, saying, “If you’d like to know the reasons, I’d be happy to explain. If not, I don’t want to just try to defend myself for a decision I made with care.
Now, if Faith says “OK FINE, tell me,” but her tone is still unfriendly, Angela must still hold to the prediction, saying something like, “If you ask for information in that tone, then I’m not willing to try to talk to you. If you ask in a way that lets me know you’re really willing to listen, then I’d like to explain it."
Setting this kind of boundary may feel awkward at first. However, in order to keep personal authority, I believe we must change how we interact, so we aren’t always in the position of either giving in, acting pleasant when we are angry, or getting frustrated and snapping back.
Giving a Non-Defensive Statement
If Angela is in a position to state her reasons and Faith has agreed to listen, Angela can use four steps.
One: Angela can let Faith know what she thinks Faith is trying to communicate.
The “I hear you saying” response can be said using many phrases. Angela might say, “I think you are upset with me and think it doesn’t matter whether Deborah was tired and upset. I just should have bathed her because that was my job and now you are stuck with it."
Two: Information you have that contradicts or is different from her view: “At the same time, I think there is also a philosophy of patient care that is different, that says that we should also really be focused on the patient's emotional needs as well, and leave some room for variation on tasks that are not essential."
Three: Angela can continue: "I think you are coming more from a place of focusing on getting each task done and not leaving any tasks for another nurse, no matter what is happening with the patient."
Four: "I am meticulous about the essentials — making sure meds are given and logs filled in. I believe the talk I had with Deborah is far more important that whether she has any bath at all today. She feels safer and motivated to do her exercise, which she had been resisting, partly because of her fear. I want to be able to make this kind of decision and not feel judged. I also want you and all of us to be able to make this kind of decision."
You may initially think this statement is “too long.” However, if you were to time it, I think you'd find it would take less time that the brief argument that Angela and Faith had in the earlier version.
Another Possible Prediction: You might end with one more prediction, such as, "If you do have time to bath her during your shift, I think that would be great. If you don’t have time, I think it's fine to skip it."
In each interaction, we can begin to build our relationships in a different way. We make them clearer and stronger, better able to balance the delivery of essensial tasks with the patient's emotional needs, as well as relieving some of the stress on nurses.
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Powerful Non-Defensive Communication is a trademarked name. © 1994-2016 Sharon Strand Ellison