Managing a Challenging Communication Interaction in Clinical Practice - Research Paper Example

Managing a Challenging Communication Interaction Associated with an Angry or Aggressive Patient Introduction Reflection is an important tool in clinical practice. It allows practitioners to learn from their experience, review their actions, and reflect on the impact of these actions. In the process, reflection provides a basis for changes and improvements in the health care practice. According to Johns and Freshwater (2005), reflection refers to the process of assessing clinical practice through the appropriate and distinctive review of the standards of the practice with the goal of securing change and motivations for change. It is the process of establishing differences between theory and practice and how such differences may impact the patient’s care. Reflection helps improve a nurse’s practice as it helps hone the nurse’s skills and knowledge. In the nurse’s practice, however, there are often barriers and challenges she is likely to encounter, and many of these challenges refer to communication barriers. This paper now seeks to review an incident involving the management of a challenging communication interaction associated with an angry and aggressive patient. This reflection shall utilize John’s (2009) reflective framework model, which assesses the main issues of the situation and the different lessons gained from such an incident. Critical Incident During my placement in the surgical unit, I was assigned a patient, a retired male nurse who recently fractured his right hip. He had undergone partial hip replacement surgery and was awaiting admission to the rehabilitation unit. After he was wheeled out of the recovery unit, he was already irate because he was placed on his side after the surgery and was now hurting from lying on his wound site. He said that he should have been placed on his left side, not his right. The recovery nurse tried to explain that he was placed on his right side based on the orthopedic surgeon’s orders, but he did not believe the recovery room nurse and insisted that the nurse was wrong. In the surgery unit, doctor’s orders included vital signs monitoring, wound care, bedside care, infection monitoring, medication administration, and basic physical therapy with the physical therapist. Whenever I tried to monitor his vital signs, he was always uncooperative, refusing blood pressure monitoring and temperature checks. I coaxed him during these times, speaking in a calm, collected way in order to convince him to cooperate. When I was assisting during some of the physical therapy sessions (which included assisted sitting, standing, and walking activities), he was irate and insisted that it was too soon for him to try these activities. At one point, he even requested that a male nurse be the one to attend to him. We did our best to explain that the sooner he can move about, the faster his recovery would be. Again, he did not believe us. He also refused bedside care and assistance in his daily activities. At one point, he threw the hairbrush that I was using to comb his hair. In these instances of aggression, I did my best to remain calm and collected. Structured Reflection This structured reflection analyzes the significant interaction narrated above. This interaction portrays a situation where a patient is aggressive and refuses to cooperate with the nurse. John’s model specifies queries that assist student nurses and professional nurses in evaluating their experience and seeking better future outcomes (Johns, 2009). What Was/Were the Significant Issue(s), and What Was I Trying to Achieve in the Encounter? The relevant issue in the situation narrated above includes the difficulty of dealing with an aggressive and uncooperative patient. In this instance, I was trying to gain the patient’s cooperation by implementing nursing interventions. I was trying to overcome his aggression and understand the cause of such aggression in order to appropriately slip past his defenses. How Was I Feeling During the Encounter, and What Factors Were Affecting My Thoughts and Behavior? I was nervous during the encounter because I was afraid that the patient could become overly aggressive and bring harm to me, other health staff, his family members, and himself. I was also very anxious because despite his lack of cooperation and aggression, it was still my responsibility to administer patient care, and for as long as I could not progress beyond his aggressive actions, I would not be able to perform my job adequately. I was anxious about calming him down and avoiding his aggressive tendencies because I knew that this would make my job easier and ensure the delivery of his health needs. I also knew that calming the patient would help him relax and make him more cooperative in his recovery and rehabilitation process. Factors that affected my thoughts and feelings were mainly based on the fact that the patient was a former nurse and possessed a rudimentary knowledge of patient care. This made me highly conscious of my actions while caring for him. Did I Respond Effectively in the Encounter? In reviewing the incident, I can honestly say that my response and actions in the encounter were more or less effective. First, I responded in a calm and collected manner. I did not respond aggressively to the aggressive patient; instead, my calm demeanor manifested that I would not be significantly affected by the patient’s aggression. In this case, I maintained my objectivity. While communicating with the patient, I kept my voice neutral and spoke to him directly and reasonably. I also listened to his concerns and asked him about his opinions on his treatment. I tried my best to justify the doctor’s orders and reasonably explain to him why each treatment and intervention was being implemented on his behalf. I used simple words and kept comfortable eye contact. I sympathized with him when he expressed his fears and concerns. When he was displaying less aggression, I tried my best to continue casual conversations with him, asking him about his family, his experiences as a nurse, and similar topics of conversation. I also calmly explained to him that since he retired, there have been some changes and new practices in health care, and these changes would explain some of the newer practices to which he was subjected. I noted the times when he did not want his personal space invaded and to what extent he was comfortable with the intrusion of his personal space. I made appropriate adjustments in these circumstances. Each patient is permitted personal preferences in relation to personal space, and observing nonverbal gestures in the patient can help determine the patient’s comfort zones (Lindh et al., 2009). Knowing such comfort zones can help prevent and manage aggressive responses from the patients. I noted, however, that I was too nervous sometimes in dealing with this aggressive patient, and there were times when the patient noticed this. What Were the Consequences of My Actions on the Patient, Others, and Me? My actions helped reduce the patient’s aggression and relatively calm down his emotions. My actions set forth a professional attitude; to some extent, the patient became more assured that what I was doing was in his best interests. I was able to gain the trust of other health professionals in handling aggressive patients. I also helped assure the family that I was competent in handling their aggressive family member. My actions increased my own confidence even in the face of my nervousness and anxiety. Critical Reflection Aggression can sometimes manifest among patients for a variety of reasons. Aggression was a problem, in this case, because it was preventing the adequate delivery of health services to the patient (Morgan, 2005). It also potentially exposed the nurse, other health professionals, and other patients to physical harm or danger. It caused the patient additional emotional and mental stress. For most patients, stress can delay recovery. Duxbury and Whittington (2004) discussed two perspectives from which aggressiveness can be viewed. Nurses sometimes view mental illness as a cause of aggression. External factors, however, are the most common causes of aggression. Some patients often feel that they are being treated like prisoners in the hospital, and this often triggers their aggression (Duxbury & Whittington, 2004). Other contributory factors may add to the aggressive behavior, including poor communication and nurse’s ineffective listening skills. Poor communication and poor listening skills also communicate the message to the patient that he is not being respected (Duxbury & Whittington, 2004). In this case, I believe that part of the trigger for the patient’s aggressive behavior was the poor communication he experienced with the recovery nurse and other health staff in the OR. The process of his recovery was not properly explained to him, and he believed that the actions of the recovery room nurses were wrong. If the procedure had been properly explained to him, he would not have grown angry or suspicious of the actions of the health staff administering his care. The patient’s aggression in this case was also caused by his fears and anxieties. He was anxious about the surgery and about breaking his hip, and he partly lashed out at other people as a means of letting out his frustrations. Fagen-Pryor (2003) discussed how internal factors, which include feelings and cognition, often trigger aggression. Interpersonal stressors include various personality traits and abrasive words as well as financial issues and the intrusion of personal space. In the case of this patient, his personal space may have been intruded when I attempted to assist him in his activities of daily living. At times, he emphasized that he did not need any help brushing his teeth or combing his hair. For the patient, he may see this as an intrusion of his personal space and a blow to his ego. He is also an older adult with traditional views of male and female roles, and he may feel it a significant blow to his ego to have a female brush his teeth for him or even comb his hair. The fact that he requested a male nurse to attend to him may also indicate his gender preference. Some patients may also feel threatened by their environment and feel that they have no control over their lives and what other people are doing to their body (Duxbury & Whittington, 2004). Pain can also trigger aggression. Pain can sometimes cause irritability and anxiety, which can trigger aggression on the part of the patient. Pain can also make a person feel helpless and frustrated, and this can further trigger aggressive attitudes (McPhee & Papadakis, 2009). Failure to deliver the appropriate care for this patient due to his aggressive behavior is a cause for concern because the patient was recently wheeled out of surgery. In the aftermath of any surgery, there is a need to implement proper monitoring activities in order to check the patient for bleeding, infection, increase in blood pressure, and any other significant changes in vital signs (Kingsnorth & Bowley, 2011). These are important elements of post-surgical care and crucial in preventing complications of surgery. The nurse must therefore try her best to avoid the patient’s aggression and implement the appropriate nursing interventions. Strategies for Improvement There are different ways of dealing with an aggressive patient. One of the more popular ways of dealing with these patients is the use of seclusion and restraints (Gudjonsson et al., 2004). These methods usually apply for those patients who become violent and pose a significant danger to themselves and other people. In the case of my patient, there was no apparent need to use such methods because he was not violent and did not pose a significant danger to himself and other people. The use of medications to manage aggressive patients was also suggested by different studies; however, even if their use is favored by health practitioners, many patients reject their application (Duxbury & Whittington, 2004). One of the main strategies in the management of patient aggression is related to the sufficient application of pain management techniques. Proper communication techniques can be applied to manage patient aggression (Arnold, 2007). These techniques include the clear and adequate communication of health education details to the patient. The more the patient knows about his disease, the less he would be anxious about it and the more he would understand about the interventions carried out on his behalf. A better understanding of the interventions leads to more cooperation on the part of the patient and less aggression (Arnold, 2007). The nurse must take the time to educate the patient and evaluate whether or not the patient understood his condition and the interventions it requires. In communicating with patients, a nurse must be patient during the process in order to deliver the message that his welfare matters (Arnold, 2007). It gives the patient a sense of importance to be treated in such a manner and motivates him to cooperate in his care and all necessary tasks for his recovery. Communication is an essential tool in clinical practice. When used in the proper manner, it can potentially assist the nurse in achieving favorable patient outcomes. De-escalation methods can be used in order to communicate with aggressive patients (Cowin et al., 2003). De-escalation refers to the process of slowly resolving the possibly violent situation with the application of verbal and non-verbal tools of communication, tools mostly based on making the patient feel respected (Cowin et al., 2003). In order to de-escalate the patient’s aggressiveness, the Egan model of helping can be used in order to guide the process of de-escalation. This model would start by asking the patient to express and narrate what happened to him and what he is feeling. In this process, I would be able to understand his needs and frustrations (Duxbury, 2000). I would listen to him and be attentive in the process, manifesting the appropriate facial expressions, nodding, showing sympathy, and making appropriate eye contact. I would also review the patient’s expectations of other health professionals and me. I would then assist the patient to reach his goals for recovery (Cowin et al., 2003). This process would assist in establishing a trusting relationship with the patient. In effect, it would make the relationship between the patient and the professional more comfortable and more open. With clearly defined roles, assumptions are reduced, and unreasonable expectations can be avoided. Nurses must be able to implement de-escalation activities and carry these out from a place where they themselves are calm and collected (Cowin et al., 2003). In these instances, sometimes, it is best to bring patients in a room where there are minimal interruptions and distractions. It must basically be a calming room. Other staff members must be informed that the patient will be brought to the room in order to ensure staff safety. In this situation, a calm conversation must be undertaken with the patient, speaking slowly and clearly. It is important to use open-ended questions to gain as much information as possible. In the process of asking questions, an authoritarian manner of speaking must be avoided, and becoming angry must also be avoided at all costs (Cowin et al., 2003). Getting angry only serves to aggravate the situation, making the patient angrier and more uncooperative. In the process of communicating with the patient, non-verbal cues must also be observed. These cues can help establish whether or not the patient understands the information about his disease whether agitated, angry, nervous, guarded, in pain, or wary about my presence. In effect, it is important for me to be conscious of these nonverbal cues and make the necessary adjustments in my behavior based on these cues (Stevenson, 2001). More importantly, while caring for the patient, I must establish and secure a trusting relationship with him. This relationship can be established first by securing rapport with the patient by seeking the patient’s trust and confidence. This can be ensured by being an attentive listener and being sympathetic towards the patient even when he is sometimes unreasonable (Harkreader & Hogan, 2004). Once a trusting relationship is built, the therapeutic relationship between the patient and the nurse can be secured. Everything else would follow. The patient would be more comfortable in this setup, opening up to his nurse and acknowledging his need to cooperate with the health professionals. As a nurse, I must also do my best to maintain such trust and rapport. In effect, I must be sincere in my sympathies and try my best to ensure quality care (Kathol, 2003). Conclusion This reflection gave me the chance to review my actions in communicating with aggressive patients. In the process, I learned that by applying effective communication techniques, I can establish productive communication with the patient. In the process, communicating with the aggressive patient can help secure patient education and improved cooperation—and eventually reduced aggression. I have learned that it is important to review my actions in the practice because I can learn from them and gradually improve them. References Arnold, C. (2007). Developing Therapeutic Communication Skills in the Nurse-Clients Relationship. In E. Arnold & K. Boggs, Interpersonal relationship: Professional communication skills for nurses (pages of chapter). Missouri: Saunders Elsevier. Cowin, L., Davies, R., Estall, G., Berlin, T., Fitzgerald, M. & Hoot, S. (2003). De-escalating aggression and violence in the mental health setting. International Journal of Mental Health Nursing, 12(1), 64–73. Duxbury, J. (2000). Difficult patients. Oxford: Butterworth-Heinemann Publishers. Duxbury, J., & Whittington, R. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469–478. Fagan-Pryor, E., Haber, L., Dunlap, D., Nall, J., Stanley, G., & Wolpert, R. (2003). Patients’ views of causes of aggression by patients and effective interventions. Psychiatric Services, 54, 549–553. Gudjonsson, G., Rabe-Hesketh, S., & Szmukler, G. (2004). Management of psychiatric in- patient violence: patient ethnicity and use of medication, restraint and seclusion. 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