Messy Moments: Dial down the drama

© Elnur - stock.adobe.com

You ask the nurse in the examining room to help you with the patient. The nurse responds in an angry voice that her hands are already full. You excuse yourselves into the hallway. Without taking a breath, the nurse complains about your many demands. (The patient surely hears her.)

You know that even an apology won’t stop the nurse from reporting you in the SRS [Safety Reporting System].

This nurse has written up many people.

What can you do to defuse this situation? You’d really like to avoid the formal write-up process.

What do you want to happen here?

You want less drama. It’s exhausting. It wastes time. You wish she’d tame her emotions so you two could talk.

You want everyone to understand that civil conversation is critical for the work.

You also want this nurse and everyone to feel safe. Safe to do their jobs. Safe to speak up without being shouted at or belittled. You want all to feel part of the practice and treat others that way.

What do you need to do?

1. De-escalate yourself: You are rattled. Your first step is to find space beside your emotion so you can think!

• Pause and breathe slowly. Breathe deeply. If your mind or heart is still racing, take another few breaths. Let any thoughts go and simply sense the physicality of breathing in and out.
• Notice your physical stance: are you standing upright and relaxed? Is your body straining to remain still? Are you leaning into a war-like posture? Determine that your posture is neutral and you feel calm.
• Check your “temperature.” What is the intensity of the threat you feel?
  • Threat level 1: Productive manageable threat: these come from the broader environment. They don’t pose immediate danger. One’s alert but not alarmed.
  • Threat level 2: Frazzled distracted mind: the threat is in your neighborhood. One feels highly alert and somewhat alarmed.
  • Threat level 3: Panic, overwhelm: these threats are upon you. One’s highly alert and highly alarmed

Simply labeling emotions lessens their intensity. Naming what’s happening enables you to step aside to look at it. You’re no longer hostage to the emotional flood. Using words enables us to shift out of the emotion and gain cognitive space to consider what to do next.

Now name the source of the threat you feel to find the kernel of what is going on for you. Our brains continually worry about the following 5 threats. What is the most powerful source of the threat you feel now?

C.A.R.E.S.

• Certainty and clarity – They seem to see me as less important than others. Will I be treated fairly? Do I know the options here? Do I know how to resolve this?
• Autonomy – She’s telling me how to do my job. Do I have any choices here?
• Relatedness – He’s treating me like I am an unwanted migrant. Is this person with me or against me? Do we share any values or mission? Does he see me? Can I trust him?
• Expectations – Do I know what’s about to happen? Can I ask questions? Do they hear me? Am I safe from reprisals and humiliation?
• Status – He talks a lot…and takes up a lot of space in conversations and meetings. Is this person more or less important than me? Does he notice me? Will he listen to me?

2. Get curious quickly Your aim is to feel out the intensity of the other’s sense of threat and to find out what’s the core cause of that threat.

• The other’s behavior, volume and words likely give you a good idea of the intensity of the threat reaction.
• Don't guess about the source of their threat! Ask. Try to understand what’s at stake for the other right now. Please tell me what is happening for you here. What would you like to happen now? What makes this important to you?
• Then listen to her (especially what she says first) and her demeanor to truly understand.

TIP: Your tone and physical affect will be “heard” faster and more powerfully than your words. Look the other person in the eyes. Use their name. Relax your arms by your sides to open your body to listen. Speak slowly and calmly no matter what. Your physical awareness also helps your own self-regulation.

3. Dial down the threat

Tell her things that you appreciate in her to defuse her feeling threatened.

• “I understand this is difficult for you” or “I can see that you’re upset – I’d like to help”
• Name the competences you see in her usual performance. Appreciate how she takes initiative (Relatedness, Autonomy).
• Tell her she belongs in the room, the practice values her. Tell her something that reassures her about one or more of the CARES needs.
• Listen to what she says and acknowledge by summarizing her words (Fairness, Relatedness).
• Highlight your mutual aims for the patient and their experience. Tell her what’s important to you in caring for patients (Relatedness, Status, Expectations)
• Validation and appreciation tell her that what she has to say matters, that she matters. It’s not agreement. It’s recognition.
  • “I see that this upsets you. Our jobs are to continue the patient’s exam. Are you ready for that? What do you need to be able to do that?” Offer empathy without judgment or acceptance. Suggest that you continue the conversation later to resolve this together.

What does dialing down the emotions do for you? For your practice?

• Reduce time wasted while anger, sadness or withdrawal flood providers. Reduce their anxiety, their withdrawal and resistance because they must “walk on eggshells”to prevent another emotional explosion. Emotional reactions overwhelm cognitive capabilities. Self-regulation enable constructive conversations and getting more work done
• Reduce time spent to investigate complaints. These waste valuable time when they’re not about safety
• Improve decision-making, thorough thinking and focus by reducing the time hijacked by overwhelming emotion. Emotional self-regulation softens negative feelings that fuel judgment and conflict. Knowing how to dial emotions down increases everyone’s confidence to cope with difficult situations
• Enhance staff and colleagues’ sense of belonging because there’s more civil conversation and more people feel heard. Psychologically safety from verbal abuse and reprisal proves critical for dealing today’s many changes and uncertainty. It enables people to do what they need to do and to tell you what you need to know about your patients
• Improve the safety and experience of patients and their ability to stay calm and hopeful
• Increase productivity, collaboration, innovation and engagement because your providers feel comfortable sharing ideas and offering and hearing suggestions
• Reduce mistakes and near-misses because people are not scared to speak when safety issues arise

• Urgent need for more talking less emoting

Dialing down emotional reactions reduces the level and intensity of the threat in a ‘hot’ moment. The emotional heat shuts down the reasoning brain. Reducing the threat frees the brain to think.

This capacity now proves critical. Clinicians and staff feel threats from so many sources. Workplace uncertainties abound while complexity and patient numbers rise. These complicate the on-going earthquake of what-really-is-my-job, overwhelm from additional tasks, feeling inexperienced, being marginalized. People work in fear of being complained about, so they withdraw - when real patient safety requires that people speak up.It’s demoralizing to be surrounded by unhappy, fearful, exhausted, irritable co-workers.

This unprecedented disruption in care can overwhelm calm, respect and civil cooperation.

Reducing your own and others’ sense of threat powerfully nourishes the practice because it presumes civility and respect for everyone.

Training yourself and your staff to regulate emotions sets a norm – communicate and cooperate respectfully.