Recognising and managing conflict between patients, families and health professionals.

Hi all!

I recently attended a course, it was half a day long and was all about recognising and diffusing situations before conflict occurs.

This was the best training I have attended since graduating as a Band 5 physiotherapist. It was a mixture of teaching and workshops, we did role play of certain situations and it really highlighted areas of my communication I should improve in.

I learnt a lot about communicating with parents and patients and what type of thing to avoid. Sometimes you can make a situation much worse, by offering what you see as a useful comment, which just drives a person mad! This course did a great job of highlighting some things health professionals do and say within paediatrics that don't help!

By highlighting these issues and suggesting ways to improve I really feel I have become a better communicator and have helped patients and parents feel happy and understood when difficult situations come up.

 

Here are my key learning points:

-In paediatrics communication is mainly with the parents, but throughout all discussions it is important that the patient has a voice and there needs always need to be considered outside of the parents’ wishes.

-Respond to cue (emotive) words, for example if someone says "I'm really angry we can't have the operation" you respond to the word angry. You engage with the patient and understand what is making them angry. You can only begin to improve a situation once you fully understand the issue! Sometimes people just want to rant and feel understood, let them don’t interrupt.  

-Don't ask people why they are upset it can be quite accusatory, ask them what is making them feel that emotion.

-Don't just offer premature assurance, using the example above saying to the patient/parent "oh it's okay you will probably get it on Monday" is not helpful and will make the situation worse, listening and understanding the situation and then possible discussing reasonable ways forward is a much better option.

-Listen to them and pick up on their emotions, use these to be empathetic towards them, and let them know they are valued by your team.

-Be prepared, there is nothing worse than trying to solve a situation or listen to someone about their problems when you come blind into a situation. Make sure you know the background and know what you want to do and who you want to help. It also saves you asking the same questions every single person has asked before you.

- Similar to the NHS 5 year forward view, prevention is better than cure, so be constantly on the lookout for ways to prevent conflict occurring and if you see a potential issue address it before it escalates!

I would like to thank the medical mediation foundation for running this course, they are doing a lot of great work and have changed my practice.

As a side note, my mother is having a stressful time at work at the moment and always comes home and talks about it, I started asking her about her emotive words, not offering pre-mature assurance and at the end she remarked how great I was to talk to and how she felt much better than she normally does after talking to me! (Hopefully she won’t read this and find out)

Liam

A busy paeds day

Well that was a busy day, I finished an hour late and have just eaten a super healthy Burger King, I was so hungry!

I was on the late shift today and from 18:15 to 20:00 I was the only physio working so you have manage alone. 

During this late shift I treated two patients with two seperate consultants, I have never treated with a consultant before it was great learning and a great experience discussing my clinical reasoning with them. 

I had two patients who were very unwell and both needed a lot of help clearing their secretions! Both had lots of additional problems, but not extensive past medical history's and their sudden illnesses had come a little out of left field. 

One had chicken pox, and actually chicken pox can be really scary, we have had two patients on intensive care with chicken pox recently and both have become really unwell, this current one is taking breaths of approximate 2ml/kg, that works out at a total Tidal volume (size of breath) of 30ml of air. A normal tidal breath for this age would be 140-150 ml/kg, a huge loss! This makes getting oxygen in and CO2 out really difficult, obviously a big issue!

The main challenge this presents is remaining positive whilst treating, parents are often at the bed, and when children become unwell, you cannot afford to show any sign that you are worried whilst they have placed their child's  life in your hands. With physiotherapy this is particularly difficult because in respiratory intensive care the techniques you use do not look comfortable or pleasant and they would hurt you as an adult. Often parents have asked me if their ribs will be broken and even when they know they are mainly cartilage and can't really break it is still very upsetting. So I have found looking confident and remaining professional whilst treating really helps the parents to trust you, and as a new band 5 this is really important.

However as a new band 5 it's really important that you are confident of what you are doing and you don't put yourself in a situation that can cause a patient harm, because unlike being a student you are solely responsible. Whenever I am a bit concerned about treating a patient or I'm not confident, I will always ask to see the patient with a senior member of staff, luckily we have a very experienced team which allows us to do this. 

To end I will tell you a little secret of mine. A not so little part of me absolutely loves having to treat an ill patient who really needs my help, I haven't experienced anything quite like it before, you are really changing their life you know!

A typical Paeds day...

So on paediatric respiratory, like many areas of physio, our days have a specific structure. 

Our shifts start at 08:30 and finish at 18:15. We have a late shift that runs from 10:15-20:00.

At 0830 we split up and get handover, some of us will go up to the wards, check the patient list and then check with the nurses to see if anyone needs respiratory physio, and to get an update on any of our current patients. Others will go round each bed space on Paediatric intensive care (PICU) and ask about each patient to see if they need physio.

Let's pause here; for those of you who don't know physiotherapists don't just deal with bad backs! I turned up to a patient the other day who had a large volume of secretions and needed assistance clearing them, one of the parents asked me if I could assess their back whilst I was there, unfortunately I didn't have a plinth so I couldn't. But they were amazed that physiotherapy could help children clear phlegm from their lungs!

So back to the day! 

We then all meet together for handover and discuss all our patients and decide who is going to see them, this all takes about 45 minutes as we cover about 100 patients in total! 

Then we treat patients until about 12:30 which is lunch time and we aim to see all the patients once by then. After lunch we treat patients until the end of the day. We also get time for teaching and if a day is particularly quiet we get to do joint treatments with senior members of staff. 

Joint treatments are great because you can test your clinical reasoning talk it through with a senior and they can educate you in what to do better. I really enjoy working with them because they are all so knowledgable and all love sharing their knowledge. 

Our days can range from being really busy (7 patients each) to quite quiet (3-4 patients each +doubles) both days are great because you learn a lot on both types of days and they keep you on your toes. 

I have been here for approximately 2 months now and I can safely say that if I was to stay here for 20 years I would never stop learning! 

 I treated a patient today, they were very excited for physio and I spent about 5 minutes pushing them around the ward in a toy wooden cart, they were laughing a lot.....but it made them cough, treatment successful. 

Liam

On-Call

So I have started my On-calls!

At the trust I am working at we have separate Rota's. As my current rotation is within paediatrics I am on the paediatric on-call rota. I only see paediatric patients and it's great because I know all the patients I could potentially see! This makes my on calls much less stressful and gives me a really nice start to on call life.

I actually don't mind on-calls, a lot of people I have spoken to have always disliked on-calls because you don't get an evening and you could be knackered the next day. For me, as we get a room to stay in, it means a much shorter commute, and I have been lucky and not had many call outs so I'm not that tired!

For my first on-call I was actually quite excited, I was someone who could be useful in the hospital. I start at 20:00 and I got called at 20:06, Started with a BANG! we had a new retrieval so I didn't know the patient and I was treating on and off until 00:00. First off I had to assess, they were an intubated asthmatic, the tube then had to be moved lower down because it was too high, then I did some standard chest clearing using manual techniques and Saline. Then I had to help instil a medication called DNAse (I didn't put it in, but it has a low dispersal factor so we have to shake it up and move it about for it to work) you then leave it for half and hour and it breaks down all the DNA in the secretions to make them looser and easier to clear out. I then came back cleared it all and wrote my notes. 

It was a long process.

But if I hadn't done all that the pH of their blood could dramatically change and they could have become very unwell, and I helped stop that. 

I then went back to my room and slept on and off for 7 and half hours, I woke up feeling refreshed and ready to go for the next day (I was working a long day).

How to summarise on-call....you are there to help change a situation, as a physiotherapist you can make a huge difference or sometimes you just can't, but you tried. 

Liam

Paediatrics

So I rotated at the end of February and have been rubbish at posting.

I have started on a paediatric respiratory rotation and I am absolutely loving it! It was my favorite placement as a student so I was concerned that I was getting overexcited but no, paediatric intensive care is where I want to be! 

More on paediatrics another time.

This was my first experience of seven day working. So I work 08:30 in the morning to 6:15 . It works really well for the patients and looking at our contact data we have reduced on-call call outs considerably, so that's good! I am enjoying seven day working, I have a 1 hour 30 minute commute so on 7 day working I work less days which means less commuting and more days off! The difficulty is my days off can be at any point in the week, so working at rugby and getting into a routine is more difficult. But I still prefer it to 9-5 mon - fri, and it makes a big difference to the patients! 

So far I am loving being a band 5 and I am really excited about the variety of areas I can work in. I'm really lucky that I am in a teaching hospital and have some amazing and knowledgable clinicians above me who take time to teach me. At the beginning of this rotation I had 3 weeks of training to prepare me for on-call. This made me confident in treating patients and allowed me to settle in well. 

More soon. 

Hopefully.

Liam

Dementia

This was my first experience of a person who had (for want of a better word) obvious dementia. I've seen plenty of people with early stage dementia who forget the odd thing, but this is different.

A bit of background.

As a student I never treated a person with dementia, I had lectures on dementia and heard stories of people with dementia, but nothing can really prepare you for the patience you need, the communication difficulties and the struggle with any form of rehabilitation when they just decide they don't want to.

The amputee I was treating was also blind which did not help, as they believed they were at home and all the noises of a ward further added to his confusion. They forgot that they had an amputation and when being asked to stand they would try and place the end of the stump on the floor. You cannot weight bear through cut bone and he was at a huge risk of falling.

As a physiotherapist treating this patient has been difficult I will admit, I was not prepared for the different challenged involved and the complete change in expectations of a session. Sadly this patient has deteriorated mentally whilst at hospital due to a urinary tract infection, and whilst writing my notes on a session for him which to sum up simply said "completed 5x sit to stands using a rota stand, patient declined any further rehab continuously" was really difficult, I felt like I had achieved nothing. Luckily I have really supportive senior staff and after discussing this with them they were really positive about how much I had managed to complete, which made a huge difference to my view on it. 

The single most useful tool whilst treating this person was their "My name is" booklet, It was great! for those who don't know, it is a book with things they have done in their life, the job they used to do, what they enjoy, who their family are and it is brilliant, I would look in it have a read and then throughout the discussion just chat about things that interested my patient throughout the session, it significantly improved his willingness to take part and made the sessions much less stressful. If you are ever in need grab it and have a look.

This person really opened my eyes to the struggles of caring for people with dementia, and the incredible patience and perseverance the staff within the NHS have.  I will never forget the struggles and challenges presented to me whilst treating this person and I believe I have become a better physio for it. 

Liam

18/01/17

It's a new year but there was no Christmas holiday!

It's something everyone has to get used to, no 4 weeks off to fill your time with nothing!

I was really lucky and my rotation currently doesn't cover bank holidays so I at least had 2 bank holidays over Christmas which was great! 

I'm loving amputee rehabilitation, I'm learning loads and really getting to grips with some really intense rehab. This is hands on intensive rehabilitation, with 2 sessions a day the patients really progress.

I am enjoying prosthetic rehabilitation and teaching patients how to use these exciting new pieces of equipment they havnt seen before. There is so many ways of teaching that's it's a really good place to experiment with how you deliver information and I'm working out what's I find works best, with the help of some excellent colleagues!

The training on this rotation has been great, coming into a specialist area was daunting but I have been allowed to learn and grow my skills. I have had regular in service training and as we all treat patients in the same room lots of tips and help whilst I'm doing sessions. All of the therapists have been so much fun to work with! 

So let's talk about a few great story's, one patient has been on crutches for 3 years and now that their leg has been amputated they can walk inside without crutches and use a walking stick for long distances, such a massive change for them but so good! When they left and said it was all thanks to me, I felt that really summed up why I became a physiotherapist.