It is very difficult to communicate with an angry patient. This conclusion came from the case of a motorcycle accident victim. The motorcyclist lost his lower right leg through surgery. The twenty-three-year-old young man loved riding motorcycles. He had a Harley-Davidson tattoo on his right shoulder. In addition, he had a biking club tattoo on his left arm. Both his biking leather jacket and helmet had his initials. On the day that he had the accident, the young man was riding his motorcycle on the outskirts of the city. A truck failed to stop at an intersection and ran right into the young man. In the process, the truck ran over his right leg and smashed his bones. He experienced a minor concussion, which is a common occurrence in motorbike accidents. Amazingly, he did not have any more serious injuries.
The decision to amputate his leg came after consultations with his family because he was in an induced coma, and he needed surgery urgently. He woke up from the coma three days later. It was then that he discovered that he had lost the lower section of his right leg. This made him very furious. Understandably, he was still very young and energetic, with a passion for outdoor living and motorbiking in particular. He was not in the wrong when the accident happened, and hence it was painful enough that the truck hit him. It was possible to justify his anger.
I was the first nurse to attend to him after he woke up from a coma. The surgeon in charge had just briefed him about the events that led to the amputation of his leg. His wounds were due for a change of dressing. As I got into his ward, he hurled the hospital blanket at me while shouting that he wanted his leg back. What followed was a tense fifteen minutes where I sought to calm him down. It was the most challenging communication interaction with a patient in my nursing career.
Reflection Using John’s Model
Johns’ model of reflection identified four stages that reflective practitioners should use for reflection (Johns, 2009). The first step is the identification of key issues and goals the practitioners have in the communication encounter (Johns, 2009). The key issues in the case presented were that the patient had lost his leg through a series of events that he had no control over. He became angry as a result and wanted the reversal of a process that was irreversible. On the other hand, my duty to him was to change the dressing to minimize the risk of infection. After the patient’s angry outburst, my immediate goal became to calm the patient down to proceed with my clinical objective of changing the dressing.
The second stage in Johns’ model required practitioners to identify their feelings during the encounter and the issues that influenced their thoughts and behaviour (Johns, 2009). The most recognizable feelings I had during the encounter with the patient were fear and empathy. His muscular build and violent actions during the initial contact made me feel as though I was at risk of personal injury. The risk of injury is an acceptable reason for medical staff to make choices to protect themselves in the process of delivering healthcare services (Pratt, Gill, & Barett, 2007). At the same time, I felt empathetic with him because he had not done anything to deserve what happened to him. I chose to calm him down rather than run for help because I understood how he got to where he was. I thought that running away would have made him feel abandoned. Since he was not a mental patient, I was confident I could calm him down (Freshwater, 2006).
In the third stage of reflection, Johns’ model required practitioners to consider the effectiveness of their response to the encounter (Johns, 2009). By staying and engaging with the patient, I was able to calm him down over a fifteen-minute period, after which he allowed me to change his wound dressings. I achieved my objectives in the encounter. However, it was risky for me to decide to stay on despite his violent and angry outburst. It was entirely possible that he could have hurt me by hurling something at me. It would have been safer for me to call for help while calming the patient down. On this count, I feel that my response was not entirely effective because I exposed myself to a certain degree of personal risk.
The final stage in Johns’ model of reflection called for a practitioner to consider the consequences of their actions on the patient, on others and on themselves (Johns, 2009). The patient calmed down and became responsive to further care. This included counselling and physical therapy. The other patients who were in nearby wards may have felt afraid at first by the angry outburst. However, since I remained in control of the situation, they felt secure that the hospital could take care of them. Personally, I moved away from that situation, feeling more confident in my abilities.
Critical Reflection on Key Issues
In the incident under review, the most critical incident was the accident and the loss of a limb that the patient suffered. Adjusting to the new reality proved too much for the patient, especially because life-changing issues had taken place without his knowledge. The American Psychological Association recognizes amputations as “devastating, and anxiety-producing events” (p. 561). In this case, the patient was not dealing with an amputation only, but the shock of surviving a potentially fatal accident. His life changed from being an active biker to an amputee in a very short time. Carnegie (2009) stated that there is potential for violent reactions from patients who have not had sufficient time to prepare for the amputation. Another reason why the patient reacted angrily was that amputation affects the self-image of a person (Carnegie, 2009). An active biker in their early twenties must attach a lot of value to their self-image. In this case, the muscular build shows that the patient was a bodybuilding enthusiast. In addition, the initials of the patient’s name on his helmet and biking jacket show that he valued his image highly. Losing a limb posed a significant threat to this self-image.
In addition to all this, the doctor that talked to the patient was not a counsellor or a psychologist. He was the head surgeon who had conducted the amputation. It is likely that the doctor did not handle the patient’s psychological needs but concentrated on the clinical elements of the situation. As a surgeon, he needed to explain to the patient what had happened and why the patient’s lower limb was missing. While the decision to amputate the limb did not directly involve the patient, it was necessary to save his life because of the high risk of infection. Normally, such decisions involve close family members if the patient cannot make the decision. This predisposes the patient to extreme reactions upon regaining consciousness. This is what took place in the situation involving the patient.
On my end, I reacted the way I did because I needed to change the dressing as part of the treatment the patient needed. Secondly, I felt that I had a responsibility to calm the patient down, primarily for his peace of mind, and thirdly, I wanted to protect other patients from further anxiety caused by the amputee’s outburst. Many patients expect a hospital to have a peaceful and quiet surrounding. The factors that contribute to this surrounding include “order, consistency, and quietness” (Coyne, Timmins, & Neill, 2010, p. 15). These three issues underlie the sub-issues that played a role in this encounter. The primary role of a nurse in a hospital is to provide nursing services to patients as they proceed towards recovery. Their presence correlates to the degree of well-being and the speed of recovery of patients (Goldstein, Zivin, Habyarimana, Pop-Eleches, & Thirumurthy, 2009). The role of dressing wounds is a primary part of a nurse’s job. Nurses also make sure that patients stick to their medication regime as prescribed. However, it is impossible to execute nursing duties without a general concern for a patient’s welfare. Nurses show compassion to patients and deal with all factors that contribute to the well-being of the patient. This includes creating an environment fit for recovering patients.
The peace of mind of patients is among the issues nurses strive to achieve. A restless patient is difficult to aid towards recovery. Every nurse has a duty to ensure each patient has peace of mind to make the recovery process smoother. One of the important ways that nurses achieve this is by setting the tone of the hospital’s environment. There are human qualities such as warmth, compassion, and the showing of concern. There are also physical elements such as the general cleanliness of wards, quietness, and peaceful surroundings. Nurses must foster a sense of “order and security” in the hospital (Coyne, Timmins, & Neill, 2010, p. 15). As I talked to the amputee who was demanding their leg back, I was fully aware that other patients were becoming anxious and agitated by the outbursts. I was concerned about the noise because “noise is one of the most insidious environmental stressors found in the hospital environment” (Rubert, Long, & Hutchinson, 2007, p. 28). By calming the patient down, I was able to restore the balance that the patient wanted. This shows how I had a different set of motivations for the actions and why I instinctively engaged with the patient, as opposed to running for more help.
Strategies for Improvement
The goal of reflection is to develop strategies for improvement of reaction to similar events in the future. While the situation with the amputee resolved itself amicably, there are lessons from it that can improve the outcome of such occurrences. One of these strategies is the therapeutic use of self. The definition of self is central to the understanding of the concept of the therapeutic use of self (Rossiter, 2007). Rossiter proposed that there was a need to look at self “within a framework that centralizes a conception of the self as constructed within relations of power and enacted through patterns of dominion and privilege” (p. 21). The therapeutic use of self is “the use of oneself in such a way that one becomes an effective tool in the evaluation and intervention process” (Mosey, 1986, p. 199). The phrase describes “how the nurse can facilitate some form of healthy change in the patient through the nurse-patient relationship” (Miller & Webb, 2011, p. 66). Warchol illustrated the concept of the therapeutic use of self, using the idea of “action and reaction”. The idea is that when someone acts in a certain way, it causes others to react. There are three events in the action-reaction process. The first one is “initial behaviour”, which is the event that prepares the way for action (Warchol, 2011). The second event is “action”, which is the act that the person does, setting the stage for a “reaction” from the first party (Warchol, 2011). In this sense, depending on the situation that initiates contact, how a person responds becomes the action that is a prelude to the reaction. Some of the scholars opposed to the therapeutic use of self view it as a process that is “highly personal, individualized, and subjective” (Duncan, 2008, p. 127).
In the case under reflection, the initial behaviour was the throwing of the towel and outburst by the amputee. The action here refers to my actions following the decision to stay on and engage with the patient. His calming down and accepting treatment is his reaction in this series of events. From Warchol’s description, I learned that I have the opportunity to predetermine the patient’s reaction at a psychological level by how I act based on the initial behaviour the patient displays.
If I have to handle a similar experience again in my career, I will do my best not to be afraid or in any way to let fear be a primary reaction. Fear in this situation only made it tense for the patient and me in the first few minutes. This made it difficult for me to calm him down initially as he shouted at me, demanding his leg back. However, as my confidence grew, the patient started trusting me more. I realize that if I chose to respond without empathizing with him, I would have reprimanded him for making noise in the hospital. This would only have increased his aggression, and it would have made it difficult for me to dress his wounds. In as much as the main thing I did in the first fifteen minutes was talk, I realized that I was physically shaking all the time as I talked to the patient. I am sure this made the patient feel more dominant.
Other considerations in this situation include the fact that I was male, just like the patient. What played out in those fifteen minutes could have had a gender dimension. As a muscular person, the patient must have seen me as a threat. The surgeon who talked to him was male, and so was the truck driver. Hence, the patient may have associated the male gender with the situation he found himself. However, when I showed him the compassionate side of the hospital and when he sensed my desire to empathize, he calmed down. It may have been easier for a female nurse to get through to him.
As raised earlier, my professional training influenced my actions. I understand my role as a nurse to include the pursuit of the general well-being of all patients. This made me decide instinctively to stay and calm down the patient primarily for his own good but also for the general well-being of the other patients in nearby wards. This shows me that training has a role to play in my role as a nurse. It prepares me for situations that may not be a direct component of the training. I recognize that “conscious use of self is greater than rapport” and that it requires training to perfect (Mosey, 1986, p. 199). As a rule, I realize that “some degree of self-disclosure is inevitable, but such disclosures can become boundary violations when they are not made for the benefit of the patient” (Pope & Vasquez, 2010, p. 250). In addition, I feel that I should take advantage of more training opportunities in other areas related to nursing because it will equip me to do my job better. After all, the quality of medical care improves when health professionals understand the psychological condition of the patients (American Psychological Association, 1989).
Finally, the need for the therapeutic use of self in improving the welfare of patients comes out as a valid way of improving the general well being of the patients. It includes “reflection done independently, with a supervisor or team, or through journaling” (Mandell, 2007, p. 8). Involving the patient in the recovery process makes it easier for them to recover from their ailment. In this case, a practitioner makes an effort to connect to the patient at a psychological level and guides the patient along in the recovery phase. The amputee needed a lot of psychological care after the drastic events that led to his limb loss. He was a perfect candidate for the therapeutic use of self to make him more responsive to treatment.
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