resource guide managing challenging situations
TRANSCRIPT
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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
* 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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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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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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Managing Challenging Situations - A Resource Guide for Physiotherapists
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).
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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
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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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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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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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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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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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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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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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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.
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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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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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