Enjoy this excerpt from one of our published books.
The Basketball Coach:
“The alternative to violence is dialogue.”
It was a busier than usual Tuesday afternoon in the Emergency Department, and Dr. Jones was effectively running from one patient to the next. A fifteen-year-old girl named Megan presented with severe abdominal pain that morning, for which he had ordered several tests. Her latest test results were in, so he grabbed her chart and looked around hurriedly for her nurse, but she was nowhere in sight. Not having time to wait, he trotted over to the patient’s room, slid the curtain open abruptly and stepped inside, while still skimming the chart.
When Dr. Jones finally looked up, he saw the patient lying in bed and a forty-something looking woman sitting in a chair next to her. The patient and her guest were smiling and it was obvious that he had interrupted a pleasant and lively conversation. He felt a sense of relief that he wasn’t going to have to track down the parent to discuss his findings; and that both of them appeared to be in a good mood. The news he had wasn’t life threatening but it wasn’t pleasant either. With that in mind, Dr. Jones began his report.
“Hello again, Megan,” he began. Megan simply stared at him with a look of anticipation on her face. Then he glanced over at her guest and introduced himself. “Hello, I’m Megan’s Doctor. Her latest test results are back.”
The woman smiled brightly up at him and said in a pleasant tone, “Hello. Pleased to meet you. Megan’s been waiting patiently.”
Again, Dr. Jones felt relieved, as she appeared to be a pleasant woman and he had already dealt with a couple angry mothers that day. “Well we have good news, and bad news,” he continued. “Megan is not pregnant. However, she has two STDs, both of which are treatable. So it’s not the end of the world.”
The patient looked up at him with a familiar look of shock and fear on her face, so he just continued in an effort to calm her. “I have a social worker stopping in to talk to both of you about Megan being sexually active at such a young age. She will have advice on how to keep safe and answer any questions you might have. She will be able to offer counseling and help you figure out what to do next.”
All in all it seemed like the encounter was going well, at least up to that point. However, there was one serious issue with that patient contact, ultimately resulting in a formal complaint, due to violations of hospital policy, HIPAA regulations, and both CMS and Joint Commission regulations and rules. The woman sitting next to Megan’s bed was not her mother. She was, in fact, her basketball coach.
How could that situation have been avoided? One response might be to instruct healthcare providers to always introduce themselves, but would that have avoided this incident? Dr. Smith did, in fact, introduce himself. Perhaps the next step would be to instruct providers to always identify their patients, but hospitals are already doing that as well. They band each patient and instruct providers to check each patient’s band to positively identify them. Still, patient ID bands don’t prevent privacy issues with visitors. Maybe the situation could have been avoided if the physician had checked to see if the visitor had been wearing a parent pass. However, this particular hospital didn’t issue passes of any kind. Then the answer must be to tell all providers to introduce themselves to everyone in the room at each and every patient contact. Problem solved! Really? Unfortunately, it’s not that easy.
The Universal Greeting
Speech is a psychomotor skill. You can’t build psychomotor skills through a list of written instructions or policies. First you have to specify the skills required and then practice them. The skill that could have avoided this problem is the Universal Greeting. Simply stated, the Universal Greeting begins with a proper greeting, i.e., “Good morning”, or “Good evening” followed by the providers name and department. “My name is Dr. Jones” followed by your reason for addressing someone, “I’m here to discuss your lab results.” The next step is to ask a relevant question, which also gives the provider an opening to identify everyone in the room and determine who should be present or not.
Dr Jones: “Good Afternoon, Megan. It’s Dr. Jones. I stopped by to see how you’re doing and show you your
lab results.” Megan: “Good, I guess.”
Dr. Jones: “Hello, Ma’am, I’m Doctor Jones, Megan’s doctor.” Guest: “Hello, Doctor.”
Dr. Jones: “I’m the physician on duty in the Emergency Department today. And you are?”
Guest: “I’m Mrs. Brown.”
Dr. Jones: “It’s nice to meet you, Mrs. Brown. How do you know Megan?”
Guest: “I’m her basketball coach.”
Although medicine is a very emotional and high stakes profession, it is very task driven. Every encounter is timed and the demands of the next waiting patient are forever on a providers mind. Medicine is physically and psychologically draining and the hours are long. It is also an information-driven profession and a provider’s mind is always working at a fever pitch. The Universal Greeting would have avoided this very common but high stakes error. One that is committed everyday in hospitals all across America. The Universal Greeting has many benefits in all areas of medicine and preventing HIPPA violations is only one of them.
In healthcare, conflict is common. That conflict is often the result of poor initial contacts. One contact that is all too common is the “who-the-hell-are-you” contact. This statement is one that signals things are starting to go wrong and it’s going to take a lot of effort to get back on the right track. The Universal Greeting can also eliminate this common pitfall in patient relations.
Factors that contribute to poor patient-staff interactions
Like we stated earlier, nursing is a very task driven profession. One of those arduous yet routine and high-stakes tasks is patient triage. It is not uncommon for triage nurses to serve a long line of irritable patients and impatient visitors. That said, the one variable that an individual nurse has primary control of is how each encounter begins.
In many cases, patients are greeted by harried and stern nurses who are still recovering from uncomfortable and even frightening encounters with other challenging patients. Day in and day out, they experience arguments and threats from a small number of patients during the triage process. It can be so bad in some ERs and clinics, that nurses even draw straws to determine who gets stuck with triage.
Still, in most cases, nursing units seem to know who are their problem nurses. They are the nurses who constantly get in arguments during triage and send back patients for treatment in a bad mood. In my career, I’ve sat next to many triage nurses and observed how they worked. The ones that had all the problems had a few attributes in common.
Usually, they demonstrated poor eye contact, by staring down at their triage sheet and rarely making eye contact. Secondly, they usually presented an inappropriate expression. That is, they wore their hearts on their sleeves and their moods on their faces. If they were tired, angry, disgusted, or just plain hated to be the nurse stuck at triage, they wore those feelings on their faces. Finally, they treated their patients not as patients, but as the next person in line. In those cases, the encounter often went like this:
Nurse: “Next please.”
Patient: “Yeah, I hurt my wrist at work.”
Nurse: “Spell your first name.”
Patient: “John Reed.”
Nurse: “Just spell your first name, please.”
Patient: “Look, my wrist really f***ing hurts!”
Nurse: “Just calm down, sir. We’ll take care of your wrist.”
Patient: “Don’t tell me to f***ing calm down! My f***ing wrist is broken!”
Nurse: “Sir, please just calm down and spell your name!”
Patient: “Are you telling me you don’t know how to f***ing spell John?!”
It seems obvious that the encounter could have gone better. You might also draw the conclusion that the man with the broken wrist was just a jerk or that he’s just behaving that way because he is in pain. Both may have been true; nonetheless, the entire initial contact should have and could have gone much differently.
Nurse: “Good afternoon, my name is Lisa. I am the nurse that will check you in. What brings you to the hospital today?”
Patient: “Yeah, I hurt my wrist at work.”
Nurse: “Oh my, I can see that. I’ll check you in so we can take care of that arm as quickly as possible. Can you please take a seat right here?”
Patient: “It really hurts a lot.”
Nurse: “Try not to move it. It may be best if we just cut your sleeve off.”
Patient: “I don’t care about the f***ing shirt, it hurts!”
Nurse: “I understand. We’re going to manage your pain as quickly as we can. Just be aware there are families around. Try not to curse or frighten them, okay? I know it hurts.”
Patient: “I’m sorry, I’m just upset.”
Nurse: “Perfectly understandable, I would be too. Please take a seat so I can look at your wrist and take your vitals. Thank you. Now let’s finish checking you in. How do you spell your first name?”
Patient: “My name is John”
Nurse: “Is John your full name, or Jonathon?” Patient: “Jonathon.”
Nurse: “Thank you. Now can you spell your last name?”
Patient: “Do you have to know all that right now?”
Nurse: “I have to find your records and register you, before we can order tests, see a doctor, or even prescribe medications. The sooner I check you in, the sooner we can see the doctor and get you out of pain.”
Patient: “Okay, whatever. My name is Reed. That’s R, E, E, D.“
Nurse: “Thank you. What is your middle initial?”
Setting the Stage for a Positive Interaction
By following the Universal Greeting, this nurse was able to set the tone for a better clinical relationship. Clinical relationships don’t really start at the door. They start with the first time a patient sees a provider’s face, hears their voice, and by the first words out of the provider’s mouth. Despite what we might think, patients don’t ultimately set the tone for a clinical relationship. Providers do that. It is the provider that is in a position of advantage when it comes to patient relationships, because providers are the ones wearing the scrubs, wearing the identification, and providing the skills necessary to treat a patient’s illness or injury.
Professionals of any stripe only lose their professional advantage if they surrender it. The way they surrender it is usually by the words they use or don’t use, and the styles in which they communicate. It’s not as much the words we use, but our delivery style that makes the difference.
To be effective, providers must appear confident to their patients. That said, there is a huge gulf between arrogance and confidence, although it is easy to confuse these two very different states of mind. The Universal Greeting is the first step to establishing yourself as a confident and competent provider. Competent providers are happy to introduce themselves and state their business. Arrogant, indecisive, fearful, or incompetent providers are not. Even if the provider is highly competent, their communication style will determine their patients and peers perceptions. That is why the Universal Greeting is inexorably tied to a provider's non-verbal communication. Again, it’s all about perception. A provider’s visual presence, signaled by their scrubs, identification cards, stethoscopes and other “badges of office”, are the first element of the provider’s presence. Worn, faded, unkempt clothing and poor hygiene are the obvious issues most providers already have well under control, but even the absence of an identification card can chip away at a provider’s professional presence.
Hand washing is an important part of patient care and I think most everyone in healthcare gets that, now. But the hand washing ritual is not just an important part of infection control, but of professional presence as well. That’s precisely why some hospitals and healthcare systems have wisely instructed their providers to wash their hands first and in the presence of their patients when they arrive in the room. It is a general rule that, if it doesn’t happen in a patient’s presence, it doesn’t happen at all. Ironically, providers should assume their patients don’t assume anything! So, something as simple as washing your hands in front of them goes a long way to earning a patient’s trust and confidence. Whenever providers are in the presence of their patients they are on stage. Things as simple as taking the time to sit when you talk with patients or showing them their x-rays and explaining them, are all part of a provider’s stage presence.
Wearing the appropriate expression or showing your on-stage face (Showtime Mindset); and using a supportive and confident tone and volume of voice are all part of effective communication. Combined with a Universal Greeting, these things are how we begin to establish more therapeutic relationships. It is also how we avoid relationships that are compatible with uncooperative and ultimately violent behavior.
The Social Contract
Have you ever seen a fight in a church? How about a bank? Probably not. Have you ever seen a fight in school? How about at a bar? If you went to school as a kid or spent much time in local taverns, you probably have seen a fight. At the outset, the answers seem obvious. Kids fight and so do drunks. But is that all there is to it?
If you’ve ever worked in a hospital, you possibly have seen a fight. I’ve spent years in hospitals and I’ve seen scores of them. Why? Is it just because the stakes are so high in hospitals? Certainly illness and issues revolving around life and death contribute to the level of conflict in hospitals. That said, perhaps there is more to the story.
Do you think people fight a lot in libraries? It seems like a silly question, and the answer appears to be obvious. In fact, fights are unusual in libraries. I’ve spent hundreds of hours in libraries and I’ve never seen one. Why not? Is it simply because the stakes are lower than in a hospital? After all, it’s just a library. Or is it because only peace loving people read books? Let’s examine that premise. What kinds of people go to the libraries these days?
Libraries are much different places than when I was a kid. I used to ride my bike to the library along with a lot of other kids. In those days, the only things there were books and magazines. One of the things that make them so different now is computers. In any given library, there are several computers. Even in small branch libraries in large cities, there are typically rows of computers.
These days, many libraries are only about half stocked with books. Instead, their shelves are stocked with DVDs and CDs offering hundreds of movies and musical recordings. Along with all that media are new clientele who previously would never have set foot in a library. But also there are all those computers and WiFi connections for laptops.
What exactly are all those people doing on those computers? Perhaps doing homework or searching for employment? No doubt a few are using them for sensible purposes. A lot of them are accessing social media and email. A significant portion of them are accessing or trying to access pornography. In some libraries, pornography and its overt exposure to other patrons — even children — have become unbearable. The public library in many cities has also become a default homeless shelter. But given all these challenges, fights are still relatively rare in libraries. Why? The answer lies in the Social Contract of the library.
What happens if you talk above a whisper in most libraries? What happens if your cell phone starts ringing in your pocket? The first thing that happens is that everyone around you turns and looks at you disapprovingly. You experience the disapproval of the herd.
So what would happen if you continued to talk loudly despite everyone looking at you disapprovingly? The librarian would likely approach you and ask you to be quiet. That’s the next layer of the Social Contract, the intervention of the leader.
By then, most people would get with the program. But what if you told the librarian to mind her own business? Would she just go away? In all likelihood, she would ask you to leave. And if you refused she would call the police — the enforcer. When the police arrived, if you refused to leave when they asked, they would arrest you — the consequence. In essence, you got arrested because you were loud at the library!
The reason arguments and fights are rare in libraries is because many of the gateway behaviors that lead to arguments and fights are loud and violate the Social Contract of libraries. Silence in libraries is an expectation of behavior that is universally understood. Indirectly, the expectation of behavior in a library works to create an iron clad Social Contract that is incompatible with violence. That is, a social contract that is set, supported and sustained by four elements: the herd, the leader, the enforcer, and the consequence.
You see, the big mean angry biker from the Introduction knows exactly how to behave in church. If he goes to church, whether just for family functions, for holidays, or regularly, he sits when told to sit, stands when told to stand, sings when told to sing, passes the collection plate, and greets his neighbor when prompted by the pastor. This is the very same person who probably manages all his relationships, both personal and professional, through intimidation.
When he walks into a bank, angry about his paycheck being short and the bills piling up, he simply gets in line and quietly walks through a maze, waiting his turn to see a teller. There is not a whole lot of active reinforcement for the Social Contract of a bank, but everyone knows what will happen if you start yelling and cursing. The police are sure to be called and your account will likely be closed.
So why do so many people go to hospitals and start yelling, cursing, and even threatening? Is it because people aren’t sure how to behave? Are hospitals and clinics themselves partly responsible for all that bad behavior? What is wrong with the social contract of healthcare and why is it seemingly so compatible with anti-social behavior and ultimately violence? If the elements of an enforceable Social Contract are: the herd, the leader, the enforcer, and the consequence, what parts are missing from healthcare? The best way to illustrate that is through another story. A story I’ve used many times in training.
Establishing a Healthcare Social Contract
On one occasion I was called to conduct a risk assessment on the father of an infant admitted to the NICU. He had reportedly made several threats toward staff on the unit. They were described as implied or “veiled” threats. While investigating the complaint, I attempted to interview as many involved staff as possible.
One nurse said that the father was “grumpy”, always glaring at the nurses and seeming to stand guard outside his baby’s room. He would just stand there, with his arms folded and scowl at passersby. He rarely spoke, but when he did, he was always brief and “intense” as she put it. Once as she walked by he asked her, “Who is that guy?”
She said, “That’s the charge nurse? Do you need to talk to him?”
“No, just tell him to stay the hell out of my baby’s room,” he replied threateningly.
I asked her what she did and she said she did nothing. She also didn’t report it or even record it. I asked her if she told the charge nurse. She said yes, but they both laughed it off. I asked the charge nurse myself about it and he said, not surprisingly, that such remarks from parents are, “part of the job.”
Another nurse I interviewed had a lot to say about the grumpy father. She complained that he was always there and always keeping vigil, as described by the other nurse. She said he asked her once for a doctor’s name, while pointing her out at the nurses’ station. Thinking it odd, she asked him why he wanted to know her name. She said he answered, “So I know who to shoot if my baby dies.” Almost surprisingly, she didn’t report that to the doctor in question. She did discuss it with her fellow nurses who decided that it was a hollow threat and, you guessed it, “part of the job.”
Finally, a young nurse noticed the grumpy father standing vigil outside his baby’s room and asked him if she could get him anything, perhaps some coffee or some juice. She said he replied, “How about a gun?” After that final remark, the nursing supervisor on duty decided to call security.
My background investigation hadn’t revealed a criminal record, so after my investigation it was time for me to address the grumpy father. I requested a back-up officer to assist me for safety reasons and when I voiced my intention to some of the nursing and medical staff on the unit, they objected. They worried that confronting him would just make him angry. After some discussion to reassure them, I approached the patient’s father.
While he was standing guard at his son’s door, I approached him wearing a friendly smile. At 10 feet away, he noticed me approaching. We made eye contact and he watched me cautiously as I drew closer.
At about five feet away, well outside of arms length, I began my initial contact.
“Hello Mr. Smith. My name is Joel and I work for hospital security. I heard you were upset today and I wanted to stop by and see if I could help. How is your baby doing today?” I asked about his baby in an attempt to focus his attention toward his baby and away from the stress and anger he might be feeling. This is a form of distraction that will often keep people centered on what’s most important. We can use this method of distraction, during our Universal Greeting, as the relevant question to begin non-escalation. Questions like, “How are you feeling today?” or “How is your wife, is she resting better?” will often refocus someone’s attention away from their anger and stress. It also is an important method of showing empathy.
“He is doing okay,” he replied, maintaining his cautious expression.
“That’s great!” I said smiling. “Are you going to get to take him home soon?”
“We don’t know for sure, yet.” he replied. “But they may be moving him to another floor soon.”
“Well that sounds encouraging. If he’s leaving the NICU, then he must be getting better,” I said cheerfully.
“I guess so,” he replied for the first time smiling a little.
We continued with a little small talk and I asked him how his wife was holding up, as I could see her in the room attending to her baby. After that, I broached the subject for which I was making the contact. “So I understand that you’ve been a little tense, while your son’s been with us. The reason I am here is because of some concerns about some comments you’ve made.”
“I’m just sticking up for my baby!” he said now getting a little agitated, but not shouting or being inappropriate.
“I understand, that’s our job as parents, right?” I asked.
“Yes, that’s right. I also want to teach him to stand up for himself,” he replied.
With that, I stretched out my arm and pointed down the hall towards a conference room. “I respect that, Mr. Smith. Why don’t we take a seat over here and discuss what’s bothering you.”
“We can talk right here,” he replied.
“We could do that, but I don’t want anyone else hearing your business. We can talk privately over there,” I replied.
After a moment’s deliberation, he shrugged and said, “Fine. I don’t know what this is all about, but we can talk.”
When we arrived at the conference room, I motioned for him to enter first. My back up officer had been instructed to remain outside of the room, but in earshot. Staying close behind, I pointed to a chair at the other side of the table for Mr. Smith to take a seat, saying simply, “Take a seat over there, please. We can talk privately in here.”
Previously, I had removed all chairs but two from the room. I placed one chair in the corner of the room and left the empty space at the table, nearest the door. That gave me the opportunity to retrieve the cornered chair and place it closest to the door for myself, so I was between him and my exit. That way, if things got out of control, I could easily escape. I then closed the door, but left it cracked. This gives the subject the feeling that we aren’t totally alone. It also gives him the feeling that that he is not isolated or trapped. This is a common safety routine that I teach my students. After setting the stage, I continued my initial contact with Mr. Smith.
“Thank you for joining me in here, Mr. Smith. Like I said, I wanted to talk to you about some comments you reportedly made to some of our staff on the unit.” He remained silent so I continued, “It’s been reported that you made some threats. Can you tell me what has you so upset and why you might threaten our staff?”
“I didn’t threaten anyone,” he said sheepishly.
“Did you ask what a doctor’s name was and said that you wanted to know who to shoot if your baby dies?” I said calmly with a look of concern.
“I didn’t mean any of that. I’m just sticking up for my family!” he said tersely.
“I appreciate that, but you can’t threaten to shoot people. You understand that, right?”
“Yeah, I know, but I didn’t mean it. It’s a free country and I can say what I want,” he said defiantly.
“Well. Mr. Smith, you can’t threaten to hurt people. And it’s been reported to me that you’ve threatened to hurt people a couple of times, are intimidating to the staff, and even asked one of them for a gun. You may have been trying to be sarcastic, Mr. Smith, but you are scaring people and we can’t have that,“ I said.
As the discussion continued, we discussed his concerns. The interesting thing was that he didn’t have any specific complaints about his baby’s treatment or the staff. He was very young, under stress, obviously, and didn’t appear to have very good coping skills. He advised me that he and his wife had no family support. I explained that he had the right to complain to nursing supervisors and seek assistance if needed from hospital counselors, chaplains, and patient relations staff. I also set limits on any future behaviors, stating that if any more threats were made he could lose the right to visit his own baby in the hospital. This of course shocked him.
“You can’t stop me from visiting my own baby!” he replied.
“Sir, that’s not what we want. But if you threaten our staff, the police become involved. Your wife and baby need you here with them. So if you have problems, I’m showing you the right way to handle them so you don’t get in trouble and lose your visitation rights.”
After our discussion, he assured me that there would be no more threats. Also, his baby’s health was progressing nicely, eliminating any apparent motive for violence. Based on his apologetic tone and demeanor, I was satisfied that his threats weren’t genuine. That said, I filed a safety plan for nursing staff, which included a zero-tolerance for threatening or intimidating behavior, requiring an immediate security response. I then completed a routine security risk assessment for the medical record.
He asked to speak to a counselor, so I put in a social work referral. I reassured him that we had no intentions of pressing any charges; based on the information we had at that time. A routine police report was made, so I advised him that a police detective, as a matter of routine, might question him.
When we stood to leave the room, the grumpy father stretched out his hand and offered it for me to shake, “Thanks for not throwing me out. I’m really sorry for all this. Please tell everyone I’m not that kind of guy.” I shook Mr. Smith’s hand and wished him well.
The Smith family had been moved to another unit while their baby recovered and within a few days their baby was discharged. While they were there, I checked in with the nursing staff, all who had nothing but good to say about the Smiths. I even popped in on Mr. Smith to ask how things were going. I even got to where I looked forward to our brief meetings and I like to think he did as well. A couple days after their discharge, the nursing unit received a card from the Smith’s. They also sent one to the NICU where all the threats had originated. In the cards they heaped praise on the staff, thanking them for their care.