Criticism, Criticizing and being Criticized

I remember the first time I got reprimanded at work.

I started my first nursing job in November, and I got called into my supervisor’s office in March. I had no idea what to expect. There were two people behind the desk. They told me that my patient had been hospitalized for a stroke and I should have noticed and reported the symptoms. I was shocked and horrified that I had missed something so important. I asked a couple of questions about the details and then signed my write up. I couldn’t stop crying and had to desperately try to hide it because I had things to do before I left the office. When I calmed down I took a look at my calendar and realized that the dates that I was supposed to have noticed the client’s decline were dates that I did not have a scheduled visit. I was being reprimanded for symptoms that started after the last time I had seen the patient.

This was clearly not my fault. I didn’t know who to talk to, I tried talking to my supervisor and it didn’t help. Finally I called the in-house recruiter who had hired me. He was very sympathetic and listened to my complaint about their complaint. He even followed up with me. I appreciated that. I learned a valuable lesson from this experience. My supervisors and managers didn’t care about me. They only cared about covering their asses.

It was years before I was reprimanded again.

The next time it was a complaint made against me by a nurse from a facility. I was too aggressive, my attitude was pushy. My supervisor was wonderful. She consoled me and was very kind and understanding. I apologized and promised I would work on it. This complaint was made against me 3 more times over the next year and a half. Sometimes it was a patient, sometimes it was a referral source, but it was always the same complaint. One actually called me abrasive. My supervisor was always non accusatory. The last time she brought me into her office I actually got teary. I was genuinely embarrassed. Even through my tears I was grateful to my supervisor for being gentle with me. I promised her it wouldn’t happen again and I made a conscious effort to be more careful.

I have been at my new job for almost 6 months. I have been interviewing, hiring, reprimanding, and counseling from (literally) the first day. I have no experience being on the other side of the table in these situations. My only preparation for this role was my past experiences. As usual I have tried my best to learn from my previous encounters. As a result I am very deliberate with my tone, verbiage, hand gestures and body language so that the person I am speaking to feels the respect that I know I would want.

First, I now know not to talk to anyone while I am angry. Of course, in order to come to this realization I had to reprimand someone while I was very upset. Yes, it went badly. I don’t know what I was expecting when I called the nurse. Its true she dropped a non-ambulatory patient that was not supposed to be transferred. It’s true that she was disrespectful to the client and to the other nurse. Its true that she was defensive from the moment I got her on the phone and started yelling at me. But I never should have called her while I was so upset and embarrassed by what she had done.

I also know that each interaction that involves a reprimand should be clearly documented. I have a patient who lives at a facility that is super particular about dress code for our home health aides.I met with a home health aide at this facility and she was wearing a sweater over her uniform. I asked her take it off and her response was “Why? No one said anything to me about it.” I asked her again and she said “Are you serious?” I assured her that I was and that as her supervisor it is my responsibility to ensure that the dress code is adhered to. She made several other unprofessional and disrespectful comments. A couple of months later we had another issue with this caregiver and I used this incident as a president for her lack of professionalism. The absence of clear documentation from the previous issue meant that I had not followed policy and could not use it against her.

I recently had an incident where I needed to terminate a caregiver. This was the first time I ever had to do this. I promised myself I would be patient and respectful even though I was incredibly disappointed with the caregiver. I explained to the caregiver what her infractions were and why we weren’t going to be able to employ her. I was calm and direct. She asked to speak to the vice president and I gave her his number. I felt that I was fair. I hope that I was.

I need to talk less and really listen to the other side of the story. I need to document clearly and objectively. I need to put my opinions away and consider what the caregiver is saying.

The other new experience since I have been at my new job is being reprimanded by the patients’ families. I am the person that gets the call with any complaints.

In my effort to be empathetic I have done my best to validate the complaint and agree with the patient. A patient’s daughter recently told me she appreciates my eagerness to agree with her but it isn’t helpful. So I stopped agreeing when people called me to complain. Instead I decided to just listen and apologize. Then I either offer an immediate solution or tell them I will call them back shortly with a solution. I am trying really hard to stay with this plan.

My last blog post generated my first negative comments. I have truly honored that someone felt so strongly about what I had written. I was glad that I was able to read the comments for what they were and not take them personally. I don’t think that my writing is juvenile and I know that the stories I tell are meant to illustrate my points but are not exact replicas of what actually happened…so…I wasn’t insulted by the comments

I hope I am on my way to learning how to respectfully accept criticism and offer criticism. I hope that I can continue to learn from each experience and improve my techniques. I hope that I can listen honestly to what is being said to me and what I am saying to others.

The good news is I have plenty of opportunities to practice.

Lessons I’ve Learned:

  1. Take a deep breath
  2. Document, document, document
  3. Just Listen

My Work Personality

My brother, Lee, was making fun of me last night. He said I was using my “work” voice, or more accurately, my “clinical tone” with our parents.

I guess we all have are tones/voices/personas. We act differently with our co-workers, bosses, family, parents, friends, husbands/wives…This is a necessity, especially for me, because I am naturally pushy and “in your face”. It has been a life long challenge for me to learn how to use those parts of my personality appropriately. Lee however, seems to think I use my work voice too often when I’m not at work.

I have to admit, when my kids start to frustrate me I sometimes practice my customer service skills on them. Is that so wrong? Can I use that voice with my parents also? Why not? (Hopefully my mother doesn’t take offense to this) Lee says I’m coddling them. I don’t  think so. I’m being supportive. Is that so terrible? Believe me, I know how to speak my mind. If I say it in a super respectful tone of voice and my parents feel respected, is that so terrible?

I think not! Sorry Lee, I think you’re wrong here.

tone-of-voice3When I teach a class on dementia I always say, “Never argue with a patient with dementia.” Then I pause for a second and always follow-up with, “Don’t argue with any of your patients.” It’s not our job to be right, its our job to help our patients make better decisions. We can’t force them to do anything.

Don’t even bother and try.

This is another thing I practice on my kids. I can try to force them to do things, but I know better. From my 3-year-old to my 22 year old, I can only make suggestions (threats). If I try to put the 3 year old in a coat she doesn’t like, she may just take it off, no matter how many times I put it on her. If I try to force my teenage daughter to wear her clothing a certain way (that I find acceptable) she is still going to do what she wants. There have been suggestions that this practice makes me an ineffective parent, but I know how to choose my battles.

I am not going to insist that my child wear a winter hat or eat their vegetables. I try my very best to be a model of good behavior and I try to find other ways to help them see my point of view. It’s in these situations that I use my tone of voice to help appeal to their sense of reason.

As a salesman and a parent I am sure that Lee would agree that your tone of voice and how you say something can often make all the difference.

Its important when I use my work voice that it should never sound fake. After all,  I don’t want to sound insincere. I want to sound super intelligent, patient, empathetic and professional. In fact, now that I think about it, maybe I should be using my work voice all the time.  After all, intelligent, patient, empathetic and professional isn’t bad in any situation I can think of.

Now I’m confused.

The way I see it, we can’t force people to do things, but if we say things in the right tone, we have a better chance of success and getting our point across.

At work, my job is a sort of nurse-ish-customer-service-y type of position.

One of my patients called me recently to tell me she wasn’t feeling well. I had to use both my nurse skills and my customer service skills to assess the situation. After several questions I determined that she was experiencing symptoms that could be life threatening. While sounding intelligent, patient, empathetic and professional I had to convince (force) her to seek immediate medical attention. It was not easy.  I called her cousin to enlist his help ( More work voice here). I had to calmly relay the information to the cousin without freaking him out but yet I still needed to communicate the seriousness of the situation. Then my patient explained to me that she would not go the hospital unless her physician was aware and ready and waiting for her upon her arrival. After trying to convince her otherwise I promised to call the physician. I called the doctor’s office and was immediately put on hold. This was actually an emergency. Eventually someone came back on the line and put me on hold again. When someone finally asked me why I was calling I was told that the physician wasn’t in the office until later that day. I asked (hopefully), “Is he at the hospital now?” The secretary said he was. I continued to explain why I was calling and she said to call 911.

Duh.

I called back the patient happy to tell her that the physician is in fact at the hospital and I once again explained to the patient that her symptoms could be something serious and that she really should call 911 , I even offered to call for her. Again she refused, leaving me with no choice but to use my work voice to (threaten) convince her of the need to go to the hospital. My work tone was very important here. I was desperately trying to force someone to do something with my special work voice.

You see, it’s a balance. While I usually work as nurse-ish-customer-service-y type, sometimes my job does involves life and death. So while  it important that I come across as super intelligent, patient, empathetic and professional, it’s also super important that I keep my patients alive by almost any means necessary.

So, its complicated. Yes, I have a work voice, but its a necessity. When I go to work in my suit and heels it may not look life and death, but sometimes it is. Yes, most days I am just a regular plain old nurse supervisor. But on some days I have to break out my work voice to keep people from doing things that could kill them.

Things I’ve Learned: 

  1. How something is said can be more important that what is said
  2. I really respect my brother
  3. Sometimes he’s  wrong

 

Why Hospice is Good

When I was growing up I had never heard of hospice. When I was in nursing school it was mentioned only briefly. I didn’t learn anything about hospice until I started my second real home care job. I learned a couple of important things:

  • This patient is definitely not getting better
  • Never call 911
  • Try not to talk about it

Unfortunately, I didn’t really have any direction and these were just things that I figured out on my own (obviously). After a few years the agency I was with decided they wanted to open their own hospice. This was great because they hired people to train the staff and all of a sudden I had an expert at my fingertips.

I volunteered for extra training and I had the opportunity to learn more about the attitude of hospice. Sheila was the instructor and I really liked her. I liked how genuine she was and I felt her passion when she was teaching me things. She tried to teach me how to talk less and listen more. It was a shock when she told me that, and I am still struggling with it.

I still didn’t have a great understanding of what hospice was and why it was so great, but I definitely had gained some insight from Sheila.

When I started teaching classes to home health aides for orientation and inservices, hospice was one of the topics. It was in these classes that I started to perfect my “Why I love hospice” speech. I know Sheila told me to stop giving speeches but this was a really good one.

What is hospice? Hospice is an insurance benefit. In order to be eligible to get unemployment, you have to qualify. In order to get disability, you have to qualify. Hospice is an insurance benefit, like other insurance benefits you have to qualify for the benefit. There has to be a doctor that “signs off” on your medical needs in order for you to receive the insurance benefit. In order to qualify for hospice you have to have a doctor sign a paper that says; if your disease runs its normal course your life expectancy is six months or less. You agree to stop receiving curative treatments and not use 911 or the emergency room for treatment. Hospice is a BENEFIT. You get medications, medical supplies, 24 hour nursing support, weekly home health aide hours, access to clergy, therapists and volunteers. There are people who will read to you, sing to you and paint with you. It is interdisciplinary. If you qualify for hospice, you qualify for all of the benefits associated with it. It does not mean that you are somehow hastening death, or happy with the impending death. This we cannot control. What can we control? Pain, comfort and dignity. When you deal with hospice, you are dealing with experts. Yes, experts in “end of life”, experts in death. What a blessing to have a group of professionals who are experts in dealing with all the issues at this crucial time. If you have a problem with your heart, you see a heart specialist. If you have a problem with your lungs, you see a lung specialist. That is all hospice is. Death speacialists. And we, as the caregivers, have an awesome responsibility to provide guidance and support during this terrible time. Because it is probably the family’s first experience with hospice, the family looks to the caregiver for reassurance and support. Don’t refuse to take a hospice case because it is “hard” or “sad”. Be honored that you are invited into this family’s life during this very difficult time.

I often get choked up when I give this speech, and I have given it many, many times. I truly believe that caring for a hospice patient is an gift. It is a gift to the patient, and it is a gift to the caregiver. A couple of weeks ago I was taking care of a patient who was recently admitted to hospice. After we were finished discussing their services I looked at the patient and said, “Do you want me to cut your nails?” The wife emphatically said, “YES!” I was surprised that she wouldn’t do it herself, and I had never cut another adult’s nails in my life, but I realized that I was being given an opportunity to really care for this patient. His nails were gross. When I was done, they looked great.

I come from a long line of strong-opinioned, strong-willed, somewhat pushy women. These days I mostly tell it like it is. I try to be totally honest with my patients without hurting their feelings.

I have always tried to be honest with my children. I have learned (from my mother) to answer all questions matter of factly and in a way that the child will best understand. In my almost 19 years as a parent I have answered questions about sex, babies, circumcision, masturbation, viagra, pregnancy, abortion, relationships, abuse, pride in one’s body, eating healthy, breast milk, child birth, cesarian sections, death, burial…you get my point.

Recently my 18 year old daughter told me an acquaintance of hers has had a reoccurrence of his cancer. She told me that he is on hospice. She asked me if he has a chance of being ok. I told her no. 

At the home care company where I work I have treated more hospice patients in the past 3 months than I have in the past three years. I learn something new from each patient.

One daughter told me that all she wants is to get to talk to her father before he passes. I made sure to share that with the nurses caring for the patient and they knew to wake the daughter if the patient was having a moment of lucidity.

A wife recently told me that her husband just wants to die. I made sure to share that with the nurses caring for the patient and they knew to give the maximum medications that can be safely administered as per the doctor’s orders.

A son shared with me that his mother needs to be in charge. I made sure to share that with the nurses caring for the patient  and they knew to check with the patient regarding all care needs and issues.

These, and many other, patients taught me that each life (and death) is different. I always ask the client or their family member, “What are your priorities for care?”. I also ask them to let me know if there is anything else I can help them with, or do anything else for them. Inevitably, I am given the same answer.

“Please make them better”.

If only I could.

Lessons I’ve Learned:

  1. It sucks, but death is a part life. 
  2. Take the services that are available to you. 
  3. Don’t be afraid of the truth. 

 

 

 

How to Make Your Patient Happy

 

I’ve been a people pleaser for a long time now. I’m not entirely sure when it all started. I distinctly remember being an annoying, pain in butt kid and teenager.

Whenever it began, it is a large part of the adult me. In my yearbook I was noted at “best known” for my “perkiness”. Without analyzing why I feel the need to make people happy ( I will do that in a later post) I have to admit that I really, really enjoy it.

I currently work in home care. My patients range from basically healthy in need of companionship to end of life hospice. I feel responsible for the happiness of my patients and their families. I accept this responsibility with…

…happiness (of course).

  1. Call ahead- I always give a one hour window for my visit. I always call if I’m running early or late. I also ask if there is anything they need while I’m “out”. The patient often asks me to stop and pick something up for them. I’m happy to help.
  2. Arrive on time-See above.I am very careful about predicting the time of my arrival. Even if they patient is a little old lady who sits in her chair all day, she appreciates knowing what time to expect me.
  3. Listen-For real. I can’t just pretend to listen. When they talk about their hobbies or their kids or whatever, I listen. The next time I speak to them I will reference our previous conversation. They love that. They know I was really listening.
  4. Smile-A genuine smile can be hard if I’m not really happy. That’s ok. I’m practically always happy.
  5. Laugh-When I laugh with my patient, or make them laugh, its like a gold star that I earned.
  6. Ask good questions-It is so important to ask the right questions. I have learned to stop asking “How are you?” because I have received the response “How do you think I am?” one too many times. now I ask, “What’s new?”. To gather accurate information about the patients health and state of mind I have to ask smart questions. “Are you having any pain?” is just not enough. I also ask about discomfort and weakness. Then I ALSO ask about specific types of pain; back, knee, joint, etc. I know that a lot of patients don’t want to “complain” but I beg them to be honest with me.
  7. Give good answers-The answers are as important as the questions. The most important is when I don’t have the answer. If I really don’t have an immediate solution I promise to follow up, and then I do.
  8. Follow up-See above. Follow up is annoying for me, but I know how important it is for my patients. They are so happy when I get results and report back to them. Almost like they’re surprised that I actually did what I said I would do.
  9. Anticipate outcomes-This is where we use our crystal ball that is really our clinical experience, to predict the future. That is what I have to do every day, every minute.
  10. Remember the childrens’ names
  11. Remember the grandchildrens’ names
  12. Remember the pets’ names-I write them down in the patient’s paperwork. Yes, it is that important.
  13. Notice what is hanging on the walls-So much of what I want to know is hanging on my the walls. Are they a veteran? Are they married? Do they have children? Are the paintings on the wall all painted by the same artist? This is something that I actually look for. If so, I ask about the artist, which is usually the patient themself, or a family member.
  14. Do the laundry-How difficult is it to throw in a load of laundry? Even offering is a truly appreciated gesture.
  15. Wash the dishes-See above.
  16. Ask about hobbies and interests-My patients tell me about the most interesting hobbies; breeding horses (see previous post), keeping bees (stay tuned for this post), needlepoint, painting, gardening… 
  17. Take good notes-I take notes about everything. Sometimes the minute details are necessary to reference later. A seemingly unimportant statement or issue can become significant later.
  18. Bring gloves-You can never have too many boxes of gloves. This makes the patient and the caregiver very happy.
  19. Respect them-I am an invited guest in the patients home. I offer to take off my shoes, I ask permission before I sit. My patient is the boss. They deserve respect.
  20. Don’t argue-There is no situation I can think of where this would be appropriate or acceptable. Just don’t do it.

 

Lessons I’ve Learned:

  1. Its the details that count.
  2. Never underestimate your ability to change someone’s day. 
  3. Be present-whatever is going on in your life doesn’t matter when you’re with a patient.