resource guide managing challenging situations

8/13/2019 Resource Guide Managing Challenging Situations

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Managing Challenging Situations

A Resource Guide for PhysiotherapistsSeptember 2007

In the course of providing patient care, challenging situations

arise. This guide describes Physiotherapy Albertas expectations

of physiotherapists in managing challenging situations that

arise with patients, a patients partner or family member or

another provider when providing patient care.


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Physiotherapy Alberta regulates and leads the practice of physiotherapy in Alberta. This guide describes

Physiotherapy Albertas expectations of physiotherapists when managing challenging situations that can arise

while providing patient care. The guide is a supplement to Physiotherapy Albertas practice standards, code of

ethics and other resources on www.physiotherapyalberta.ca. Physiotherapists requiring additional information

on managing challenging situations beyond that contained in this guide are encouraged to consult

Physiotherapy Albertas practice advisory service.

This publication was a collaborative effort between the College of Physiotherapists of Ontario and

Physiotherapy Alberta. The College of Physiotherapists of Ontario provided permission to quote and

adapt, in whole or in part, from their publications on managing challenging situations.

2007 Physiotherapy Alberta

Physiotherapy Alberta - College + Association

300, 10357 - 109 Street, Edmonton, Alberta T5J 1N3

T 780.438.0338 | TF 1.800.291.2782 | F 780.436.1908

[email protected]

* The College of Physical Therapists of Alberta operates as Physiotherapy Alberta College + Association.

/ / /

/ / /

/ / /
http://www.physiotherapyalberta.ca/mailto:[email protected]:[email protected]://www.physiotherapyalberta.ca/


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3

Introduction

5 Why challenging situations develop

6 Responsibilities + expectations

7 Strategies for managing challenging situations

7 Be proactive

8 Implement reflective practice

8 Develop a plan

9 Communicate the plan

9 Document it9 Monitor the situation10 End the relationship

11 Example scenarios

11 Addressing patients capacity

11 Managing inter-professional differences

12 Dealing with family members

13 Conclusion

15 Appendix I: Challenging situations within organizations16 Appendix II: Managing a challenging situation: decision tree

17 Appendix III: Establishing rapport

19 Appendix IV: Assertive communication21 Appendix V: Stages of change model

23 Appendix VI: Dealing with anger and hostility

24 Appendix VII: Dealing with a suicidal patient25 Appendix VIII: Styles of conflict management28 References

Contents


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4Physiotherapy Alberta

Managing Challenging Situations - A Resource Guide for Physiotherapists

Introduction

In the course of providing patient care, challenging

situations arise. For the purpose of this guide, a

challenging situation is a situation that may

interfere with a physiotherapists ability to

deliver quality care culminating in achieving

positive physiotherapy outcomes.

Many challenging situations involve interpersonal

issues that arise in the healthcare system due toa variety of factors including the availability of

resources, personal expectations and other

environmental or contextual factors. Behaviour of

professionals and/or patients and the healthcare

setting where treatment is delivered or the service

delivery model can all contribute to creating

challenging situations. Regardless of the cause,

physiotherapists are expected to manage each

situation in a manner that promotes safe and

respectful patient-centered care.

This guide discusses:

y Why challenging situations develop.

y Responsibilities and expectations

of physiotherapists.

y Strategies for managing challenging

situations.

The guide also provides supplementary information

to assist with understanding and managing

challenging situations and conflict.


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5

Why Challenging Situations Develop

Most challenging situations develop between a

patient and a physiotherapist; however, challenging

situations can also arise between a physiotherapist

and another health provider (Appendix I).

When a challenging situation develops between a

physiotherapist and a patient, it is often because

of differences in assumptions and expectations

about the physiotherapy care that will bedelivered. When challenging situations develop

between health providers, the unequal and

inherent hierarchical nature of the healthcare

system may be a significant contributor.

Different knowledge and experience in specific

issues, both ethically and legally, imparts unequal

responsibility and authority to providers with the

most relevant knowledge and experience.26

Sometimes the role of members on the team

(e.g., supervisor, team leader) contributes to theinequality. Because of differences in training and

experience, each member of the team brings

different strengths and all need to work together

to best utilize the expertise and insights of each

other for optimal patient outcomes.

Challenging situations

also can occur with a

patients partner or

family member.

Generally, partners

or family members

are interested in

being an advocate forthe patient. However,

in some instances, their view of their role in the

patients care and/or in their relationship with the

physiotherapist providing care is not consistent

with the physiotherapists viewwhich can lead to

a challenging situation.

Factors that can create challenges between a

physiotherapist and a patients partner or family

member are similar to those that can arise

between physiotherapists and patients. Given

different personalities, competing values andvarieties of experience, no two situations will


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It is the physiotherapists responsibility to identify

any interpersonal situation that may interfere with

the delivery of safe, quality care and the desired

physiotherapy outcomes.7Physiotherapists must

also consider other people in the environment who

may be impacted. These include, but are not

limited to, other patients, health providers and

administrative staff. When a challenging situation

arises, physiotherapists are required to bethoughtful in how they approach the situation and

manage it in a purposeful and timely manner so as

not to interfere with their ability to deliver quality

physiotherapy care (Appendix II).

When managing any challenging situation, the

physiotherapist should treat the other party in a

respectful and professional manner. A respectful

exchange of views may provide both parties with

new information, and lead to further learning or a

better understanding of the situation.26 In the best

situations, disagreement leads to a more complete

discussion of a patients care, resulting in a new

consensus about the best course of action.

The new consensus may require compromises

from each individual. Physiotherapists should

always have their patients needs as their primary

concern and avoid placing the patient in the middle

of a disagreement by suggesting they choose which

provider they prefer or by making statements that

may diminish the patients trust in another

professional.

When team members cannot arrive at a consensus

about what should be done, other measures may

have to be adopted. Seeking objective input from

another professional not directly involved in the

patients care team may be helpful.

In some situations a physiotherapist may decide

to discharge a patient from active treatment when,

despite repeated reasonable attempts to manage

the challenging situation over a reasonable period

of time, the situation has not changed sufficiently

and the physiotherapist has deemed that the

patient will not be able to achieve the desired

physiotherapy outcomes. Or when there is an

immediate risk of harm to the physiotherapist or

other individuals.

If a physiotherapist discharges a patient from

active care, they must do so in accordance with

their professional and regulatory obligations, code

of ethics and any other applicable rules or policies.

Responsibilities + Expectations

Respectful behaviour begins with listening to

and considering the input of other professionals,

evaluating each idea based on its merits,

acknowledging and discussing the similarities

and differences in views, and recommending

and negotiating treatment options.11, 12, 26

Respect is demonstrated through language,

action and gestures (Appendix III). Disagreement

can and should be voiced without detrimental

statements about other members of the team,

and without gestures or words that impart

disdain. Comments and remarks that draw

attention to a persons unique characteristics

should be avoided.

The appropriate use of humour can facilitate

communication, but should never be used at

the expense of anothers identity or self-esteem.

Both actions and language should impart themessage. Disrespectful behaviour from a colleague

does not justify disrespectful behaviour in return.

It can be addressed using other communication

techniques (Appendices III, IV). 5, 9, 22


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Strategies for Managing Challenging Situations

Be Proactive The response to these questions determines the

One of the best ways of managing challenging boundaries or extent of the partners/family

situations is to try and prevent them occurring. members involvement in the patients care and

the level of disclosure of health information a

Very early in the establishment of a therapeutic physiotherapist can provide. Whenever possible,

relationship, it is prudent for physiotherapists to physiotherapists should establish parameters

attempt to gain a broader understanding of the around matters a patient is comfortable having

patient beyond the specific problems for which them discus with their partner/family member.

they are receiving physiotherapy services. Often Lack of clarity among all parties regarding whatpatients come to see a physiotherapist with information can be discussed and exchanged can

expectations around how treatment will be contribute to the development of a challenging

provided, the types of services they will receive situation.

and who will provide it.

Another proactive measure is to inform patients,

Some of these expectations may arise from at the onset of treatment, of any organizational

previous experiences with other providers of policies or personal expectations with respect

physiotherapy services, cultural differences or to their behaviour that may impact on achieving

emotional state. Patient expectations can range desired physiotherapy outcomes. Examples include

anywhere from very reasonable and appropriate but are not limited to:

to unreasonable and inappropriate.

y Expectations/policies, written or unwritten,

Early identification and proactive management of that have monetary or continuity of

behaviours or expectations that could escalate or treatment consequences to the patient

interfere with achieving the desired physiotherapy (e.g., policies relating to failure to attend

treatment outcomes is the responsible approach an appointment without providing adequate

(Appendices II,IV,V,VI,VII). 15,22,27 notice or repeat cancellations).

y Expectations/policies, written or unwritten,When physiotherapists are aware that a partner/

that deal with appropriate behaviour orfamily member is actively involved in the care

decorum in the treatment environmentof a patient, it is prudent to determine the answers

(e.g., policies related to arriving for anto the following questions prior to establishing a

appointment under the influence of drugsrelationship with them.

or alcohol or the use of language that is

offensive, threatening or of a sexual nature).y Does the partner/family member have legal

authority to make decisions on behalf of thePhysiotherapists who passively tolerate situations

patient?arising from inappropriate patient expectations/

y Does the partner/family member have legal behaviour hoping the behaviour will cease on its

authority to make decisions on behalf of the own, or the patient will stop coming for treatment

patient? or will eventually be discharged, are not actively

managing the situation (Appendices IV, VIII).

7


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Implement Reflective Practice

to Know Yourself

An awareness of ones values, emotional hotbuttons and thinking style is a good way of

choosing how to respond to certain situations.

One way to influence your response to a

challenging situation is to understand how you

handle adversity in general (Appendix VIII). Do you

listen well or jump to conclusions, do you have

a set agenda or are you willing to discuss and

compromise? Tools such as a Resilience

Quotient Test,20along with strategies to prevent

and handle adversity (ABCs - Adversity, Beliefs,

Consequences) are techniques to learn how to:

y Listen to your thoughts.

y Identify what you say to yourself

when faced with a challenge.

y Understand how your thoughts affect

feelings and behaviours.

When considering your response to potentially

challenging situations, it may also be helpful to

be mindful of:

y

How you responded to previouschallenging situations/conflicts

and past experiences which may have

contributed to those responses.

y What assumptions you bring to situations

of conflict that may color your response.

y How secure you feel about dealing with

challenging and conflicting situations.

Some authors suggest that during conversations

with other people we assume we know all we

need to know to understand and explain things.

They suggest the benefits of a learning

conversation in which you want to understand

what has happened from the other persons point

of view, explain your point of view, share and

understand feelings, and work together to figure

out a way to manage the problem going forward.22

It is important for physiotherapists to be aware of

and understand their own biases, limitations and

personality while managing their emotional

responses to the behaviour (Appendix VIII).

Members must be as professional and calm aspossible, regardless what the individual says or

does.

In addition to the need to be aware of, and prepare

for, the potential effects of emotions and thoughts

in advance of challenging situations, it is equally

important to do so after concluding difficult

situations. Emotions such as anger, guilt, shame,

and embarrassment may result after terminating

a challenging situation20and go on to cloud

professional judgment and the ability to function

as a professional. This isnt to suggest that

emotion is bad; however, physiotherapists need

to avoid emotion that clouds their judgment and

over-personalizes the interaction. This takes

practice. All challenging situations demand

significant time and energy. But if you know

yourself, know your patient, focus on the big

picture, are compassionate, and always set

limits, the next challenging situation may not be

so demanding.

Develop a Plan

Formulation and implementation of a plan toaddress a challenging interpersonal situation are

essential steps in actively managing the situation

(Appendix II). A plan may have many components

or may involve a single conversation with the party

involved. When physiotherapists develop a plan, they

should consider:

Early communication with the

parties involved to clarify the role +

responsibilities of the physiotherapist

in the patients care is helpful in

developing a common

understanding.


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y Severity of the behaviour. y Likelihood situation can be resolved in a

collegial and respectful manner.y Reasonability of plan in relation to

challenging behaviour to be addressed. y Being in a position to explain ones actions

if asked to account for them later on.y Safety issues.

y Time frame.

Documentation should contain:y Ability to achieve desired outcomes.

y Description of behaviour observed or

statements made including date and context.Communicate the Plan

The goal is to alter or accommodate the behaviour y Steps taken to address the behaviour including

to the extent possible in order to provide quality substance of any conversations, if applicable.

patient care and achieve the desired outcomes. y Plan description including expected outcomes

and dates they should be achieved by.

Once a plan has been formulated, the nexty Consequences if outcomes are not achievedreasonable step is to engage in a focused and

and with whom these were discussed.thorough discussion with the party involved

(Appendix IV) that provides the followingBefore documenting information about a

information:challenging situation in a patients health record,

y Identification of the issue or issues. physiotherapists should review and understand

their professional and regulatory obligationsy Explanation why it is presenting

regarding health records. Also review requirementsa challenge.

described in other relevant statutes that apply to

y Changes/modifications required. their physiotherapy practice.7

y Possible consequences associated withGenerally, the entry would be recorded in thefailure to make necessary changes or

patients health record if it was clinically relevant.modifications.If not clinically relevant, it might be recorded

elsewhere. In all situations, it is prudent forDocument It physiotherapists to document in a manner thatPhysiotherapists understand the importance demonstrates accountability for their professionalof creating and maintaining accurate and complete conduct.health records with respect to the physiotherapy

care they provide to their patients. In someMonitor the Situationinstances, it is also prudent for physiotherapists toMonitoring is important to help identify andhave accurate and complete documentation relatedactively manage a possible recurrence of the issue.to any challenging situation that arisesMonitoring level and strategy will vary dependingduring a patients episode of care.on the situation.

The decision to document in the health recordFor each situation, physiotherapists should assessshould be based on a number of factors.the risk or likelihood the issue will recur beforeFor example:deciding how they will monitor the situation. For

y Inherent risk in the situation. example, if a physiotherapist has a patient with an

acquired brain injury where the patient has ay Impact on the physiotherapists ability to

history of episodes of aggressive or violentprovide quality patient care and achieve

behaviour, the physiotherapist will developoptimal physiotherapy outcomes.

monitoring and intervention strategies reasonable

9


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for these types of behaviours. In contrast, another Physiotherapists who decide to discharge a

patient who is consistently late for appointments patient from treatment or transfer to another

will not require the same level of monitoring and health provider, are required to do so in

strategy development. In the first instance, the accordance with standards of practice and any

physiotherapist may decide to treat the patient in professional and regulatory obligations that

a location and at a time of day that provides the define their conduct or actions with respect to

greatest amount of safety for all parties concerned. these matters. Failure to do so may, in some

This plan could include developing a signal to instances, constitute professional misconduct.

cue staff for assistance.For example, in most circumstances a

In the case where the patient is always late, the physiotherapist should provide the patient with

physiotherapist may have a discussion with the information regarding where they can obtain

patient explaining why they should be on time for further services if needed. Also, in cases where

appointments and the consequences if the patient immediate discharge is not warranted (e.g.,

is unable to comply with this requirement. where safety or abuse is not in issue) and the

patient needs ongoing care, reasonable notice of

Whatever the case, monitoring is a fluid and intent to discharge may be indicated.7

continuous process adjusted according to the

observed changes in behaviour and the risk Where the patient is receiving needed services one

assigned to the situation at any given time. or more of the following criteria should apply for

discontinuation of services to occur:

End the Relationshipy Patient requests discontinuation.

There are instances when, despite reasonabley Alternative services are arranged.

attempts by a physiotherapist to actively manage

a challenging situation and provide quality care y Patient given reasonable opportunity to

to achieve the desired physiotherapy outcomes, arrange alternative services.

the only option is to conclude the situation byy Physiotherapist is unable to provide

discharging the patient from treatment. Theseadequate physiotherapy services because

situations often relate to, but not limited to,there are insufficient resources available

the following:to meet needs of community in question.

y Patient fails to make payment within ay High and immediate risk of emotional or

reasonable time for physiotherapy servicesphysical harm to physiotherapist or otherreceived. All reasonable attempts to facilitateparty.payment have been unsuccessful.

y Demonstrated inability on patients part toy Physiotherapist has reasonable grounds tocomply with plan to address challenging

believe patient may verbally, physically orsituation.sexually abuse them.

y Patients lack of co-operation or compliance

with treatment plan is such that services are

not effective.




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11

Example Scenarios

1.0 Addressing Patients Capacity to

Participate in Physiotherapy

Example

A new patient arrives for her physiotherapy

appointment and checks in with the receptionist.

The receptionist tells you she suspects the patient

may be intoxicated as they are slurring and have

alcohol breath.

Discussion

The receptionist already alerted you that the

patient may be intoxicated. However, it is

important to remain objective before you conclude

this is the case. There may be a medical reason why

the patient is slurring. The smell on her breath may

be from something other than alcohol. However, if

during the course of your interaction with the

patient you agree with the receptionists

assessment, it is reasonable for you to sensitively

discuss your concern with the patient.

Describing your observations provides the patient

with objective feedback without labeling the cause.

Informing the patient about your expectations with

respect to her demeanor and ability to fully

participate while attending future appointments

and reviewing any relevant organizational policies

help ground your expectations. It is helpful to

include a brief note in the patients record that

summarizes the key points covered in the

discussion.

2.0 Managing Inter-professional Differences

Example

A physiotherapist assesses a patient for a shoulder

problem. The clinical examination leads the

physiotherapist to suspect there may be a labral

tear that requires further diagnostic testing to

confirm the clinical impression. The physiotherapist

gives the patient a note for his physician that

suggests further diagnostic testing would help

establish an accurate diagnosis of the shoulder

problem. The physician writes the physiotherapist a

letter stating the patient should have been initially

directed to him for an assessment and it was the

physiotherapists duty to direct the patient to the

physician prior to seeing the patient.

DiscussionThe physiotherapist is

faced with a challenging

situation that, if manage

appropriately, is an

opportunity to establish

a respectful relationship

with the physician and

ensure the patient

receives the additional

diagnostic testing

required.

d

Upon reflection, the

physiotherapist concludes it may have been

prudent to have spoken with the physician directly

rather than send a note with the patient. A

conversation between both parties provides an

opportunity to immediately address any issues that

may arise out of individual assumptions around the

other persons behaviour or agenda. In this

situation, the physiotherapist would gain an

understanding of why the physician expects their

patients to see him before they access

physiotherapy services.

Once this is understood by the physiotherapist

they can develop a plan to manage the situation

to achieve the desired outcomes, ensure the best

patient care and an ongoing respectful relationship

with the physician.

While it is important

for physiotherapists to

acknowledge their

partnership with other health

providers, it is also reasonable

to remind other providers that

physiotherapists are trained

professionals with a set of

skills and knowledge.


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3.0 Dealing with Family Members physiotherapist and his daughter. Discussions with

all parties present where there is free exchange of

Example information does not necessarily imply that privateA physiotherapist working in the community is conversations between the daughter and the

treating an elderly gentleman who lives with his physiotherapist are sanctioned by the patient.

daughter. The gentleman is capable of making However well meaning the daughter may be, she

decisions about his physiotherapy treatment and may be making assumptions about her role that

personal care. The daughter is very attentive to her need to be actively managed by the physiotherapist.

father and is often present during physiotherapy For example, the physiotherapist cannot agree to

sessions. The father freely speaks about his withhold information from the patient. This

condition in front of his daughter and often situation could escalate into something more

includes her in his discussions with you. He has challenging if assumptions are not discussed openly

told you he is very comfortable discussing and a common understanding among all parties is

anything with his daughter present. not achieved.

You receive a call from the daughter asking that

her father be evaluated for a mobility aide

different from what he is currently using because

she believes it would be better for her father. She

is calling to discuss this with you privately because

she does not think her father will be receptive to

this because he doesnt like change.

Discussion

On the surface, this situation may not present itself

as being challenging. However, it should prompt

the physiotherapist to consider whether they have

clarified the daughters role is in her fathers care.

Including an understanding of limits to and type of

information that can be shared between the




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13

Challenging situations are an inevitable part of

working in health care. Physiotherapists are

expected to manage each challenging situation in

a calm, methodical and professional manner and,

when appropriate, document the situation in the

patients health record, including actions taken to

resolve the situation.

Where possible, physiotherapists should reflectand develop an awareness of their conflict

management style and strive to address the

personal, interpersonal and systemic factors that

may impact the delivery of quality patient care and

positive patient outcomes.

Most physiotherapists are able to manage

challenging situations and complete treatment

with positive outcomes. Whether or not treatment

can be completed, a challenging situation can

be a valuable learning experience. Physiotherapists

can use the experience as an opportunity to reflecton their practice and develop new strategies

to meet their responsibilities in situations that

may arise in the future.

Conclusion


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Appendices

15 Appendix IChallenging situations within organizations

16 Appendix IIManaging a challenging situation: decision tree

17 Appendix III

Establishing rapport

19 Appendix IVAssertive communication

21 Appendix VStages of change model

23 Appendix VIDealing with anger and hostility

24 Appendix VII

Dealing with a suicidal patient

25 Appendix VIIIStyles of conflict management


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15

Appendix IChallenging Situations Within Organizations

Intra-personal Intra-group

Involves a physiotherapist having conflicting Several parties/subgroups within a team may be

feelings about a personal course of action in conflict with each other (e.g., in a physiotherapy

with a patient or colleague. The physiotherapist department there are differences in opinion on

may feel conflicted about supporting a patients frequency of treatment visits provided to long-

choice to forego a treatment (e.g., patient term care patients assessed to receive

refuses recommendation to add acupuncture maintenance physiotherapy).

to their physiotherapy treatment program).

Inter-group

Inter-professional Most teams practice within a broader organization

Differences of opinion on patient care are to that may impose external pressures that

be expected; however, recurring differences ofproduce conflicts between programs and teams

opinion between team members may indicate (e.g., outpatient services team united in opinion

the need for clarification about roles or against a medical services team over required

inappropriate interaction that requires a staffing levels).

third-party mediator (e.g., physiotherapist has

a difference of opinion with another health Adapted from the American Geriatrics Society 2001.

professional over whether oxygen is considered

a drug. As result issues arise around the

physiotherapists role in adjusting the flow

of oxygen while the patient is exercising).

When managing challenging situations, it is helpful to view the level of conflict

from a systems perspective. The following framework classifies the types of conflict

that occur within organizations. When there is a recurrent theme to a challenging

situation, the physiotherapist is advised to discuss the situation with management.


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17

Appendix III

Establishing Rapport

Active listening is the act of consciously

participating and applying oneself to hearing

what another person is saying. Active listening

is an important component in establishing

rapport with another individual. Physiotherapists

can use the FIBER checklist to the right to further

develop active listening skills.

Establishing Rapport usingNeuro-linguistic Programming

Neuro-linguistic programming (NLP)4is playing

an emerging role in enhancing communication

effectiveness in health settings. Simply put,

it is the art and science of establishing rapport.

Neuro-linguistic programming is based on the idea

that neurology, language and behaviour interact

and specific techniques can be used to influence

these systems.9NLP techniques can be used

everyday and in challenging situations to establish

rapport with others. The techniques involve verbalcues and non-verbal gesture, eye contact and

postures to impart a message to another person.

In communication, most of the messaging comes

from non-verbal cues and tone of voice rather than

the actual content of the message.

The techniques of matching, pacing and leading29

have not only been used to successfully establish a

therapeutic relationship in health settings, but also

to diffuse potentially volatile situations.

Matching involves the subtle copying of the otherpersons posture, body weight distribution, small

hand, head and body movements, and breathing.

It also can extend to voice tonality, speed, volume

and rhythm of speech. Once a connection has been

made with the other person, a physiotherapist

can change their behaviour and it is likely

the patient will follow. Pacing and leading are

FOLLOWING

ICARE

BODY POSTURE

EYE CONTACT

RESPONSE

Are you attentive and following the other person?

Are you showing that you care and are interested

in what the other person is saying?

Are you responding with open-ended questions that

generate future discussion?

Open ended questions encourage speakers to

express their thoughts and feelings more

thoroughly than close ended questions.

Do you make appropriate eye contact with them

while they are talking?

Does your body posture let the other person know

you are alert and involved in the conversation?

Adapted from McAffer, Effective and Value-Based Leadership

Workshop 2004.

FIBER Checklist


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Patient

Coming here is frustrating because I

have to wait so long to get in to see you.

Physiotherapist

Okay, since waiting so long to see me is

frustrating, lets have you start your

exercises before I see you in the treatment

cubicle rather than waiting to do them after

the treatment.

techniques where once rapport is established,

changes in the physiotherapists posture, verbal

tonality, speed of speaking and phrase will leadthe patient to unconsciously follow.

An example of NLP is using the other persons

language style including their actual words,

pronunciation, jargon and preferred terminology

in similar phases or sentence length and tonality.

Another example is the use of positive descriptive

statements that indicate the desired behaviour of

the patient rather than behaviour you dont want.

Positive descriptive statements help patients

visualize the behaviour that is desired and

increases the likelihood of them understanding

what is required. Keep your feet shoulder-width

apart is more effective than dont cross your feet

for a patient with a total hip replacement learning

about their post-operative movement limitations.

Adapted from Bandler and Grinder 1975, Davis 2006, McAffer

Conflict Resolution Workshop 2004 and Young 2004.


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19

Appendix IVAssertive Communication

Managing challenging situations requires assertive

communication skills. Assertive communication

is a learned technique that involves getting

your message across without offending others,

using direct, congruent expression of thoughts,

feelings, beliefs, and opinions in a non-offensive

way.9

Assertive communication differs fromaggressive (behaviour in which you get your

point across but are perceived by others as

hostile, angry, offensive, sarcastic or humiliating)

and non-assertive behaviour (passive behaviour in

which you fail to get your message across).

There are eight types of assertive responses that

can be used in health settings:

y Being confrontational

y Saying no

y Making requests

y Expressing opinions

y Initiating conversation

y Disclosing self

y Expressing affection

y Entering room of strangers, willing

to get to know others + allow others

to be known.

DESCRIBE

EXPRESS

SPECIFY

CONSEQUENCES

Describe the situation

Express your feelings about the situation.

I feel...

Identify the results that will occur.

In that way...

Specify the change you want.

Id like you to...

The DESC Response and

Modified DISC Response

These models provide a framework for handling

any interaction where an individual needs to

express their point of view.5

The DESC format is used when there is an

established relationship with the other party and

some confidence that the other party will respondin a mature, respectful manner.

In some situations there is greater risk and less

certainty about the response from the other party.

In this case, the E is replaced with an I:

Indicate the problem the behaviour is causing.6,9


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CONSEQ

UENCES

CONSEQ

UENCES

Make exaggerated threats or use unrealistic/

exaggerated threats of self-defeating punishment.

Ask explicitly for a change in other persons

behaviour.

DO DONT

Express your feelings.

Express them calmly.

State feelings in positive manner, relating

to a goal to be achieved.

Address specific offending behaviour, not

whole person.

EXPRESS

Request a small change.

Request only two changes at a time.

Specify concrete actions you would like to see

stopped and those you want to see performed.

Take account of where other person can meet

your requests without suffering large losses.

If appropriate, specify which behaviour you are

willing to change to help resolve the issue.

SPECIFY

Make consequences explicit.

Give positive reward for change in desired

direction.

Select goals/objectives that are desirable for

other party.

Select meaningful positive consequence. Provide

sufficient support to maintain behaviour change.

Select consequences you are willing to carry out.

DESCRIBE

Describe other persons behaviour objectively.

Use concrete terms.

Describe specific time, place and frequency

of the action.

Describe the action, not the motive.

Deny your feelings.

Unleash emotional outbursts.

State feelings negatively making a put-down

or attack.

Attack entire character of the person.

EXPRESS

Merely imply that youd like a change.

Ask for too large a change.

Ask for too many changes.

Ask for changes in nebulous traits or qualities.

Ignore other persons needs or ask only

for your satisfaction.

Consider that only the other person has

to change.

SPECIFY

Be ashamed to talk about positive and negative

consequences.

Give only punishment for lack of change.

Select something only you may find rewarding.

Offer positive consequence you cannot or will

not deliver.

DESCRIBE

Describe the emotional reaction.

Use abstract, vague terms.

Generalize for All the time...

Presume the other persons motives or goals.

Adapted from Bower 1976, Davis 2006, and McAffer Effective and Value-Based Leadership Workshop 2004.

There are some dos and donts of good DESC conversations. To be successfully expressed,

it is equally important to attend to the DONT as the DOs.


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21

Appendix VStages of Change Model

Also known as the Transtheoretical Model of y Potential for conflict: Patients are oftenChange, this model views behaviour change as a characterized as being resistant or

process that can be supported with stage-matched unmotivated to change.

interventions. Embedded within the model are two

key concepts: Contemplation:

y Characteristics: Patient thinking about1. Self-efficacy- is a belief about ones ability

changing in near future. Intends to taketo perform a particular behaviour at a certain

action in next six months. Aware of benefits of

level. changing but also the cons. Balance between

2. Decisional balance- is a component of the two is not great. Simply put, the cons

decision-making theory that involves people outweigh the pros.

weighting the importance of pros and cons

and then adopting a behaviour based upon y Matched intervention:Motivate patient,their evaluation of the cost benefit encourage specific plans and decrease cons

associated with the change. of changing.

y Potential for conflict: Ambivalence aboutThe Transtheoretical Model of Chang is applicable

behaviour change keeps one in this stage for ato health behaviours such as exercise, weight

prolonged period. Patients may be perceived asreduction and smoking cessation. It is not clear if

chronic contemplators or procrastinators.this model applies to populations with pain.

Preparation and Commitment:Precontemplation:

y Characteristics: Patient making plans toy Characteristics: Patient not aware they

change, intends to take action in next 30 days.have a problem, nor do they intend

Some significant behavioural steps in theto take action in the foreseeable future

desired direction have occurred.(usually defined as the following six months).

Or, patient tried to make changes ay Matched intervention:Help patient develop

number of times and has become their action plan and set goals.demoralized about their ability to change.

y Potential for conflict:At this point decisionaly Matched intervention: Increase patient balance is paramount. Pros and benefits must

awareness of need for change, to personalize be perceived as outweighing cons such as costsinformation on risks and benefits, while and risks behaviour.promoting the benefits of changing.


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Actiony Potential for conflict:Generally, patients ability

y Characteristics:Patient implemented action

to maintain the change of behaviour is high.

plan and changed behaviour for less than six Patient can be motivated and challenged.

months. For adoption of healthy behaviours

such as exercise, the pros outweigh the cons.Termination:

y Matched intervention:Provide feedback,

y Characteristics:Patient adopted new behavioursupport, reinforcements to help with

and can hardly remember having done the oldproblem solving.

behaviour.

y Potential for conflict:There is usually ay Matched intervention: Continue providing

criterion level of behavioural change requiredmaintenance-matched interventions as necessary.

for a positive change in health and reduction

of risk.

Regression and relapse:

Maintenance:y Characteristics:Can occur anywhere in the

continuum.y Characteristics:Patient has changed overt

behaviour for more than six months.y Matched intervention: Patients rarely regress to

pre-contemplation but often regress toy Matched intervention: Help patients prepare

contemplation or preparation stage.for, avoid or handle relapse. Help with

coping, reminders, finding alternatives when

faced with challenges, and continue matching

interventions.

1. Prochaska, JO., DiClemente, CC., & Norcross, JC. (1992). In search of how people change. American Psychologist, 47, 1102-1114.

2. Prochaska, JO., Velicer, WF., Rossi, JS., Goldstein, MG., Marcus, BH., Rakowski, W., Fiore, C., Harlow, LL., Redding, CA., Rosenbloom,

D., & Rossi, SR. (1994). Stages of change and decisional balance for twelve problem behaviors. Health Psychology, 13, 39-46.

3. Prochaska, JO., Velicer, WF. (1997) The transtheorectical model of health behaviour change. American Journal of Health Promotion,

12, 38-48.


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23

Appendix VIDealing with Anger and Hostility

Hostile and angry people exhibit predictable accident and epidural steroid injections, non-opioid

behaviour patterns involving a cycle of escalating and opioid medications have all been unsuccessful

anger/rage for short periods then slowing down, in resolving his pain. Physiotherapy treatment has

escalating anger/rage and slowing down.3 had limited success, with pain scores remaining

7/10. No significant increases in function have been

During the rage phase it is important to remain identified using outcome measures. Gerald has a

calm, and demonstrate active listening skills and history of substance abuse and family conflicts.

not attempt to intervene. It is during the slowing Your clinic just received notifice that the insurer

down phase of the cycle that interventions and will no longer fund Geralds visits. The notice didreasoning are effective. Gently redirect the person not arrive in time to contact Gerald him before

to a more private environment. Use supportive todays scheduled appointment.

phrases that convey kindness and reassurance,

such as I know this must be difficult for you, Gerald presents to the reception area and is told

If that happened to me, I would be angry too, his visit today will not be paid by the insurer. The

to show you are hearing the patient. clinic would like to establish who will pay for his

treatments. He reacts belligerently, shouting and

Being supportive does not mean you agree with verbally abusing the receptionist stating she should

the patient, it is simply a technique to defuse have contacted him earlier. Gerald demands to see

escalating emotional response.9 When the patient the clinic manager.

has finished their outburst, try to reach a solution

and conclude the meeting with a plan for action. DiscussionFinally, record all relevant information in the The receptionist pages the clinic owner, Tanya, who

patient record.16 comes to the reception desk. She moves to the

patient area of the waiting room, ensures her body

Try using the Five As when dealing with angry language and eye contact demonstrate she

patients:14 understands Geralds dilemma. When it appears

that his outburst is subsiding, Tanya asks Gerald

1. Acknowledgeproblem. to move from the reception area to her office. A

reasoned discussion about the value Gerald places2. Allowpatient to vent uninterrupted

on continuing physiotherapy services follows. Hein a private place.

shares his perspective on the outcomes he felt3. Agreeon what problem is.

were met and the implications of being able to

4. Affirmwhat can be done. pay for future treatments. They agree on a plan in

which Gerald will take two weeks off to assess any5. Assurefollow through.

changes in pain intensity or function levels.

Example He is given appropriate outcome scales to monitor

Breaking news about funding his status and agrees to return for a reassessment

Gerald is referred following failed back surgery for if there are any changes.

treatment of low back and right lower extremityAdapted from the American Hospital Association 1983. Davis 2006,

pain. He sustained the injury in a work-related Potter 2003, Princeton Insurance, and Wasan 2005.


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Appendix VIIDealing with a Suicidal Patient

Over the lifespan of a career, physiotherapists Suicidal intent should be taken seriously, despite

will encounter patients who experience suspicion the individual is engaged in attention

severe, unrelenting pain and other significant seeking behaviour. Suicide attempts when disclosed

losses of physical health or mobility. Some of should be discussed openly. Coordination with the

these patients may express suicidal intent. While attending physician or licensed mental health

it is not the role of the physiotherapist to treat practitioner is essential.

the underlying root of the suicide intent, it is

ethically appropriate to address suicidality. For crisis situations, patients must be informed of

any limits of confidentiality and the necessity ofThe ethical conflict that arises from appropriately active consultation with other parties trained to

addressing suicidality is the conflict between deal with patients in crisis.

duty to warn and maintaining confidentiality

of the patients health information. A health When dealing with someone in crisis the following

professionals duty to warn arises when there steps can be followed:

is reason to believe a patient may cause seriousEvaluate suicidal intent and lethality.harm or death to an identifiable person or group. y

y Establish existence and feasibility of

In Alberta, there is no legislation that imposes a suicide plan.

a positive duty to warn on health professionals.y Identify evidence of self-destructive

Privacy legislation establishes the circumstancesbehaviour and past suicide attempts.

in which personal information can be disclosedwithout a patients consent, where the disclosure y Attempt to establish alliance with patient.

is necessary to prevent harm to a person. y Consider a contract for safety.

y Refer to mental health specialist trained inPhysiotherapists should not hesitate to

suicidal evaluation and treatment. Or escortfollow-up on patients who express suicidal

or arrange an escort to a hospital emergencythoughts and intent. Questioning will not

room for further evaluation.increase the chances of self-harm. Instead, it

demonstrates to the patient that the y Document communication with patient,

physiotherapist is concerned about them and their treatment strategies and contacts with other

well-being. That in itself can be a mitigating factor health providers.

in decreasing the chances of attempted suicide.

Find more information on suicide risk assessment

at www.rmf.harvard.edu.

Adapted from Montgomery Emergency Service Inc and Wasan 2005.


http://www.rmf.harvard.edu/http://www.rmf.harvard.edu/


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25

Appendix VIIIStyles of Conflict Management

Individual response to conflict management

generally fall into one of five categories:

1. Competing

2. Accommodating

3. Avoiding

4. Compromising

5. Collaborating

Responses are based on a model that views

conflict management responses from the

perspective of varying levels of assertiveness

and cooperativeness (Figure 1).

While it is suggested a collaborative approach

is the desired method for resolving conflict, the

other four responses can also be used when

circumstances warrant.16It has been demonstrated

that gender may impact ones conflict response.

Men and women differ in how they perceive and

handle conflict. Men prefer strategies involving

social influence and persuasion. Women prefer

strategies involving negotiation and mediation.10

Women often respond using avoidance and

compromise and reject competition, whereas men

often use a competing/dominating response.

Front-line nursing staff and nursing administrators

typically respond using avoidance, accommodation

or compromise as preferred conflict management

styles.20Collaboration is rarely used. Competing

strategies are generally rejected. Nursing conflict

management patterns differs from male-dominated

groups, mainly attributed to the fact the

profession is female dominated.19It is thought

other factors inherent in the health system, such

as the power imbalance between professional

groups (i.e., physicians), influence the conflict

management response of individual nurses.19

Physiotherapists

must know their

preferred conflict

management style

and understand

that successfully

managing a

challenging situation

sometimes requiresadopting a different

conflict management

style.

When working in

teams, physiotherapis s

must be aware various factors have the potential

to impact the teams coherence in adequately

addressing critical issues (e.g., ones own conflict

response style, the mix of health professionals on

the team and teams gender composition).

It is incumbent on physiotherapists to use

appropriate strategies to voice concerns about

individual physiotherapy programs and the

overall contributions of physiotherapy to care

service delivery models.

Conflict Management Response

1. Competing

This power-oriented strategy involves meeting

ones own needs, often at the expense of other

individuals. The goal is to win, sometimes at all

costs. This strategy often involves dominationthrough formal use of authority, physical threats,

manipulation ploys or ignoring others.

The competing style is useful when a person has

to take quick action, make unpopular decisions,

handle vital issues, or when one needs protection

t


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in a situation where noncompetitive behaviour can Repeated use of avoidance results in issues

be exploited. This style requires the ability to argue never being addressed from a strategic planning

and debate, use rank and position, assert opinions perspective. Issues are typically allowed to fester,and feelings, and the ability to know your own remain unresolved and ultimately contribute to a

opinion and stand your ground. breakdown in team member communication.

Decisions on crucial patient care issues tend to be

Overuse of this style leads to lack of feedback, made by default.

reduced learning and low empowerment. People

overusing this style often use inflammatory Avoidance strategy conflict management outcomes:

statements due to a lack of interpersonal skillsy Lose-lose

training. While ones needs are met, the otherUnassertive, uncooperativeparty may feel defeated. Overuse results in errors y

in the implementation of a task. y Short-term resolution

Underuse of this style means concerns regarding3. Compromising

patient care may not be expressed, heard or are In order to find common ground, both parties

overridden. Competing strategy conflict make sacrifices to arrive at a solution. Often the

management outcomes: end result is partial satisfaction.

y Win-loseThere is considerable practice application to a

y Assertive, uncooperativecompromising response. Situations of moderate

y Short-term resolution importance may be quickly resolved to both

parties satisfaction with the sense that equality

2. Avoiding guided the decision-making process while

Avoidance neglects the interests of both parties by relationships remain intact.

sidestepping the conflict or postponing a solution.

One party does not pursue its own concerns Compromising skills include the ability to maintain

or those of another party. The goal is to defer a dialogue about an issue and to assign value to all

confrontation, escape responsibility or delay. aspects of the issue.

Avoidance may be appropriate for issues of low In the long term, compromising does not address

importance, as a cool down mechanism to reduce solutions for good patient care based on merit and

tension or buy time. It is also a useful response has the potential to undermine long-term strategic

for those in a position of low power who have little goals. Compromising overuse results in one being

control over a situation and/or when one wants perceived as having no firm values, who

others to deal with the conflict. consistently concedes to anothers desires without

addressing an issues root cause.

In some situations it is desirable to develop skills

related to knowing when to withdraw and sidestep

issues. Avoidance is best used when time is not a

factor.




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27

4. Accommodating 5. Collaborating

One party neglects their own concerns to satisfy A collaborative response involves seeking to fully

the concerns of others, seeks to maintain satisfy both parties concerns with a goal of findingharmonious relationships by emphasizing a win-win solution. This problem solving approach

similarities, minimizes differences and is used to find solutions to the issue without

self-sacrifices. The goal is to yield. It is appropriate assigning blame or fault. Collaboration is

in situations where you want to show that you are considered the most efficacious conflict

reasonable, develop performance, create good will, management strategy, appropriate for use in team

keep the peace, retreat or for issues of low environments as it is good for dealing with

importance. critical issues and for long-term resolution of

conflict where time is not a factor.

Accommodating skills include the ability to Promoting collaboration involves integrating

sacrifice, the ability to be selfless, to obey orders solutions, learning, merging perspectives, gaining

and yield. commitments and improving relationships. This

style supports the open discussion of issues, taskThe accommodating style is useful for routine proficiency, equal distribution of work amongst

issues, when one is wrong, when an issue is team members, better brainstorming and creative

more important to the other party, when one is problem solving. Collaboration skills include the

outmatched, to preserve harmony or to teach ability to use active or effective listing, confront

others. situations in a non-threatening way, analyze input

and identify underlying concerns.

Overuse results in ideas getting little attention,

restricted influence, loss of contribution and Overuse of collaborating can lead to focusing on

anarchy. One of the main desires is to keep trivial matters, diffusion of responsibility, being

everything the same and may include self-sacrifice. taken advantage of and becoming overloaded with

Patient care or concerns around physiotherapy work. Under-use results in quick fix solutions, lack

service delivery may never be brought forth. of team member commitment, dis-empowerment,

and loss of innovation.

Accommodating strategy conflict management

outcomes: Collaboration strategy conflict management

outcomes:y Lose win

y Win winy Unassertive, cooperative

y Fully assertive, highly cooperativey Short-term resolution

y Long-term resolution

Adapted from Ruble and Thomas 1976, Whetten and Cameron

1995, Davis 2006, MIT Collaboration Toolbox 2001, Valentine

1998 and 2001.


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