Professionalism at its Best!

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To Be or Not To Be?

• Professionalism at its Best!

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Née-Nées No-Nos

• No booing,hissing, spitting, or visual display of
  middle-digits
• No snoring
• No throwing of sharp pointy objects

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PROFESSIONALISM
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Merriam-Webster dictionary
Professionalism is a way of exhibiting a
courteous, conscientious and generally
businesslike manner in the workplace.
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Objectives

• 1. Understand the impact Chronic Kidney Disease
  has on the patient both physically and mentally.
• 2. Understand what is needed from staff in order
  to work with difficult patients.
• 3. Look at the trends for Involuntary Discharge
  as a means of prevention.
• 4. Introduce Decreasing Patient Provider
  Conflict and Caring Communications as tools to
  assist with working with difficult patients.

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Our Patients

• Patients with renal disease are challenged by
  many stressors, including loss of biochemical and
  physiologic kidney functions, development of
  digestive and neurological disorders, bone
  disease and anemia, inability to function in the
  family and to maintain ones occupation,
  decreased mobility, decreased physical and
  cognitive competence, and loss of sexual
  function
• Kimmel, MD Peterson, MD
• Seminars in Dialysis, 2005

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From CMS.

• we believe that every dialysis facility has the
  resources and responsibility to work with every
  patient, including patients perceived to be
  disruptive or challenging
• -Conditions of Coverage

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ETHICS

• MAIN GUIDING PRINCIPLE FOR ALL PROFESSIONAL
  ETHICS IS?
• DO NO HARM!

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Relationships Personal vs Professional

• Purpose
• Balance of Power
• Focus

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Challenging situations are often the delayed
result of professional boundary violations.
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Common Problems Boundaries Crossed

• Becoming personally involved
• Gifts
• Showing favoritism
• Dual relationships

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Becoming Personally Involved

• Sharing that shifts FOCUS from pt to professional
• Lose ability to respond objectively
• React emotionally

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Gifts

• Unit policy against giving/receiving of gifts
• Federal regulations against giving to patients
• Protects pts from feeling that they need to pay
  extra for quality
• Protects staff from feeling they need to give
  extra attention

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Showing Favoritism

• Show that you favor one pt over another, or
  facilitate a pt favoring you over other staff
• Creates expectation that it will be done again
• Expectation that other staff will do the same
• Distrust of other staff

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Dual Relationships

• Exchange of goods or services

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SEXUAL MISCONDUCT

• Demeaning to the patient
• It is usually intentional
• It is a breach of TRUST
• Long-term effects can be devastating but may not
  be readily apparent
• THE BREACH OF TRUST IS USUALLY FAR MORE SERIOUS
  THAN THE ACTUAL SEXUAL CONTACT

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What are Boundaries?

• Boundaries
• Limits that must be set to assist professional
• to be helpful to the patient
• to remaining appropriately detached from the
  patient and his/her problems.
• Remember
• The professional sets the boundaries and
  standards.
• Once a patient, always a patient.

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Personal Vs Professional
Personal Relationships Professional Relationships
Limitless Has limits and boundaries
Equals Power differential can give and take away
No fees/money Money, fees, funding, etc
Mutual gain For purpose of client/patient gain
Mutually agreed upon levels of intimacy No physical intimacy
Mutually agreed upon confidentiality with no legal bounds Rules of confidentiality
Unlimited time frame Scheduled interaction, time limited
Anywhere, anytime Place designated, times designated
Not goal-oriented Well defined focus/goals health care
Not documented Documented
No defined roles Legally defined roles, licenses, codes of ethics
No code of ethics Code of ethics, values statement
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Crossing The Line

• Do you share personal problems or aspects of your
  intimate life with patients?
• Have you ever traded assignments to care for a
  specific patient?
• Have you ever spent off-duty time with a patient?
• Do you keep secrets with patients?
• Do you become defensive when someone questions
  your interaction with a patient?

SOURCE "Crossing the Line When Professional
Boundaries are Violated," National Council of
State Boards of Nursing Inc., 1998.
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Crossing The Line

• Have you ever given gifts to or received them
  from a patient?
• Have you felt possessive of a patient, thinking
  that only you could provide the care the patient
  needs?
• Have you ever flirted with a patient?
• Have you chosen sides with a patient against his
  or her family and other staff?
• Have you ever been verbally disrespectful to a
  patient for example cursed, raised your voice,
  intentionally ignored, disregarding what a
  patient was explaining to you?

SOURCE "Crossing the Line When Professional
Boundaries are Violated," National Council of
State Boards of Nursing Inc., 1998.
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• YOU HAVE CROSSED THE LINE WHEN

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Youve Crossed The Line When

• You talk to patients about your personal life
  (husband, children, siblings, and other family
  members) in depth.
• You tell patients where you live and give them
  your phone number or visit patients in their
  homes as a friend, not in your professional
  capacity.
• You plan activities with patients outside of the
  unit.

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Youve Crossed The Line When

• You complain to patients about
• other patients
• your own aches, pains, and illnesses.
• about other staff members.
• You accept gifts from patients.
• You feel compelled to fix a patients problem
  more than the patient does.
• You buy or sell items from or to patients.

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Reasons for Conflict

• Non-adherence
• Mental Health Substance Abuse Issues
• Cultural Racial Issues
• Complex Environment
• Communication Difficulties

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• Communication Conflicts

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Patients want from staff

• Kindness
• Recognition
• Comfort
• Emotional support

This requires Caring Communications
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Heart-Head-Heart CommunicationTwo Sides to a
Satisfying Service Experience
Heart
Head
Feelings, personal attention, caring Were so
busy the heart messages get lost.
Information, tasks Dialysis is so full of tasks
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Caring Communication Hints

• Acknowledge patients likely feeling.
• Share your good intentions How are your actions
  for the customers sake?
• Ask open-ended, not yes-no questions.
• Use the words for you.
• Express appreciation to the person.

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Messages Key to Patient Satisfaction

• You are not a number.
• YOU, uniquely YOU matter to me.
• I respect your thoughts and feelings.
• I want you to feel my support.
• Yes, Im here to care for you. And, I also care
  ABOUT you.

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• DPC CONFLICT Resolution Model

9 step program
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CONFLICT Resolution Model

• C-Create a Calm Environment
• O-Open Yourself to Understanding
• N-Need A Nonjudgmental Approach
• F-Focus on the Issue

• L-Look for Solutions
• I-Implement Change
• C-Continue to Communicate
• T-Take Another Look

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Create A Calm Environment

• In order to effectively address a conflict,
  you need to be aware of the physical
  surroundings, as well as the thoughts and
  feelings you are experiencing because of the
  conflict

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Open Yourself to Understanding Others

• When addressing a conflict, it is important to
  acknowledge the perspective and feelings of the
  other individual(s) involved

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Need A Nonjudgmental Approach

• As a dialysis professional, it is important for
  you to maintain an objective and professional
  approach as you address the conflict. Keep in
  mind that words exchanged in the heat of an
  argument are often not intended as personal
  attacks.

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Focus On The Issue

• When conflict occurs, there is a tendency to
  lose sight of the issue that started the
  disagreement. What starts out as a concern about
  starting dialysis on time can quickly become a
  disagreement about the facility staff, the clinic
  operations, or the physician care.

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Look For Solutions

• Not all conflicts can be resolved nor are all
  conflicts based on valid complaints. But working
  in collaboration with the patient will improve
  the likelihood of a positive outcome.

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Implement Agreement

• If you take the time to work through the
  conflict, it is likely that you will reach a
  stage of agreement when changes will need to be
  put into action.

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Continue To Communicate

• Effective resolution of a conflict requires
  follow up communication. This allows you to
  monitor the progress being made. And
  demonstrates to the patient your commitment to
  resolving the conflict.

How's it working out?
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Take Another Look

• Handling a conflict, like successfully
  performing dialysis related tasks, requires
  practice, understanding, education, and
  monitoring. Regardless of whether a conflict is
  minor or major, reviewing the steps used in
  addressing the conflict will be beneficial.

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Benefits of Professionalism
Staff

• Professionalism makes us feel good.
• It makes us feel that our job is valued.
• It gives us a code of conduct so we know what is
  expected of us.

• It promotes mutual respectstaff to patient,
  patient to staff, and staff to staff.
• It makes us feel in control.
• It promotes independence.
• It builds confidence in us.

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Benefits of Professionalism

• Patients
• It makes our patients feel safe.
• It makes our patients have confidence in us.
• It helps with patient satisfaction.
• It makes the patient feel respected.
• It supports the delivery of good care to the
  patient.
• It supports the patients independence rather
  than dependence.

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Assessing Professional Behavior

• Ask yourself these questions
• Can this be documented in the medical record?
• Are you willing to do this for all
  patients/staff?
• Would this be allowed in another setting?
• How does this activity relate to care needs?

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How Do We Respond When Others Are UN-Professional?
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Step 1 Determine Your Involvement

• Determine if you are truly involved in this
  situation, and if so, to what level you are
  affected.
• Often, we find we are annoyed by behaviors that
  are not directed at us. In those situations,
  change your perception and reaction to the
  behavior, and let it go.

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Step 2 Understand The Other

• Resist the temptation to moralize.
• Instead, try to understand where they are coming
  from.
• Take a deep breath, and really listen.

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Step 3 Influence His/Her Attitude

• State specifically, in a non-confrontational way,
  how/why the behavior has breached a professional
  code of conduct.
• Do not try to place blame or find fault rather,
  focus on preventing the problem from recurring in
  the future.

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Step 4 Recover And Move On

• Once the problem is addressed, let the incident
  go and move on.
• Dwelling on it will only increase your levels of
  stress and frustration.

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Reflection Action Planning

• What do I want to do to improve my professional
  style?
• Notice your own actions that exhibit a lack of
  professionalism.
• Carefully evaluate your behavior in light of
  beliefs and assumptions .
• Challenge whether the belief or assumption is
  valid.
• Create an action plan to work on bringing more
  coherence between actions and beliefs, creating
  greater integrity and authenticity.

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WOW Way Of Work
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• Presented by
• Treneva A. Butler, LCSW, NSW-C
• Patient Services Coordinator
• ESRD Network 14
• Borrowed from
• Mid-Atlantic Renal Coalition

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Mid-Atlantic Renal CoalitionReference

• Brown, Elizabeth B. Living Successfully with
  Screwed-Up People. Fleming H. Revell, 2006.
• Burns, Godfrey C. "Empowering Dialysis
  Professionals in the Management of the Aggressive
  and Disruptive Patient." Dialysis
  Transplantation Vol. 4.4 Apr.1995 184-186.
• Centers for Medicare Medicaid Services.
  Decreasing Dialysis Patient-Provider Conflict
  (DPC) Toolkit. 2005.
• Caraulia, A. Steiger, L. Nonviolent Crisis
  Intervention, 1997.
• Mason, Sherry J. "The Role of the Staff in
  Managing Problem Patients." Dialysis
  Transplantation Vol. 24.4 Apr. 1995 178-197.
• Harvey, Sean. "Mental Health Syndromes." Chicago,
  IL. 22 Sep. 2005.
• "Malpractice Watch Your Tone of Voice." Medical
  Economics. 18 Aug. 2006. ltwww.memag.comgt.
• Schwartz, Merney, and Horace Batson.
  "Understanding the Psyche of the Disruptive
  Patient in the Dialysis Facility." Nephrology
  News Issues Feb. 2000 40-43.
• Academy for Educational Development (AED), and
  Mid-Atlantic Renal Coalition (MARC).
  Communication for Dialysis Care Quality Training
  Modules for Patient Care Staff. June 2004.