Last year, I published a post about a topic crucial to all nurses: 8 Ways You’re Begging to Hear “NO” From Patients.
It reviewed psychological reactance and how to deal with it. My metaphor for it has long been the Mule:
It’s a style of interaction that we all use sometimes, some of us more often than others. Mules are the very picture of noncooperative. Mules wear you out, waste your time, frustrate and thwart you. Mules are ornery and stubborn, mean and unpleasant. Mules kick and bite and spit at you for no good reason. They wander off when you want them to stay put. When you want them to move, forget about it: they’re going nowhere. They live to say “No!” and give you grief: real pains in the Ass! (Forgive me. I’ve a weakness for puns)
The Mule is my metaphor for what psychologists call psychological reactance: a powerful, instinctive desire to prevent anyone from limiting our freedom or tell us what to do. Basically, it’s a technical term for the ” You’re Not the Boss of Me!!!” instinct. Imagine the ‘Terrible Twos’: that developmental stage feared by all parents, when a child’s favorite word is “No!,” when they suddenly do the opposite of everything parents ask, and want the opposite of everything offered. Terrible! That’s pure Mule. Teenagers are also famous Mules: push them one way and they go the opposite. What parents praise, they hate. What parents discourage, they want. What parents know, they disparage. That’s the Mule!
Notice that in both cases, you see much more Mule when a person feels a need to assert themselves. Two-year-olds are just beginning to realize they’re individual people and want to test it out. Teens want to try out asserting their independence from their parents. I mention this point because hospital patients also feel more Mule, as hospitals typically strip them of most of the freedom and power they take for granted.
Why go over this territory again? Looking at the last post, I noticed I didn’t provide much detailed advice. Here we’ll clear up those loose ends.
At least eight factors invite and incite the Mule:
5) Hurt pride,
6) A sense of lost control,
7) A sense of lost dignity, and
8) Hearing “NO” to a request.
Notice that hospitals offer much fear and confusion in a threatening, unfamiliar setting. Patients feel vulnerable and powerless: lost control and hurt pride. They don’t know who they can trust in a large, shifting crowd of strangers: staff members. They’re often asked to get naked in front of strangers or wear butt-baring Johnnies: lost dignity. Hospitals offer lots of random rules that often seem arbitrary to patients: more lost control, and lots of “No.” Hospitals typically offer at least six or seven items on the list. It’s a wonder patients coöperate at all!
We can improve on this situation considerably, and thereby see much less of the Mule. Some suggestions:
1) Fear: Try to think about particular concerns and address them. Patients often love a little education about the mysterious ways of the hospital. Show off your knowledge and help them relax. I explain why we do pain scales, for example: to keep humorless regulators off our backs. Anxiety meds also help.
2) Confusion: see above. Anxiety meds do NOT help confusion, and often make it worse. If people seem confused, ask about it. Quick microeducation often clears it right up. When delirium seems possible, I often offer some reassurance and education: mainly that it’s medical and completely curable. Confused people often worry about dementia or brain damage.
3) Distrust. Simple: earn their trust! Smile, show friendly eagerness to help. Eye contact. Introduce yourself, find out how they want you to address them. EXPLAIN what you’re doing and especially, WHY. When you decline a request, explain why: highlight how you’re protecting them from harm.
4) Dislike. See above. Find honest ways to give compliments: make a habit of it. Make them feel important in any little way possible. Give them more time than usual the first time you meet them: you’ll establish your reputation with them for the rest of your relationship. It’s a huge opportunity to build rapport and trust that will make everything else you do with them quicker and easier. Make good use of it!
5) Hurt Pride. Find things to be impressed about. Acknowledge that patients are adults in a fee country and hospitals are a weird, challenging experience for anyone. I often tell angry, demanding people with power issues that take-charge people used to authority and respect find being a hospital patient especially irritating. (It’s true, by the way) The more irritated they are, the more complimentary this news. Don’t look down on them or talk down to them. I even try to get eye level with them. Standing over someone is often very irritating. Back to pain scales: of course people lie. Why get into a battle that offers no benefit? I often point out to patients their status as the World Expert on their own pain, as pain scales are the gold standard assessment, imperfect but still the best we have. It helps boost their ego a little.
6) Lost sense of control. Instead of giving commands, make requests: “Can I give you your meds now?” instead of “Take your meds.” Give choices, even trivial stuff, like when you’re leaving the room, lights on or off, door open or shut. Any choices you can offer boost perceived control.
7) Lost dignity. Show some respect, even when it may not exactly be deserved. Use their name, and use whatever version they prefer, even if it’s a nickname.
8) “NO.” First, minimize “no”s as much as possible. Second, reword it. I often use “Yes, but”: I’m happy to help, but I can’t because it’s against a strict rule, or some such. It takes away much of the sting and emphasizes I want to help. In any way you can, be gentle about it, diplomatic. A blunt clumsy “No” is about the single best way to meet the Mule. It’s well worth avoiding.
In general, you want to weigh how much time and effort to invest in such efforts against the time you have to spend, AND the time you stand to save as a result of less Mule time. I spend heavily easing these factors, because I know from decades of experience that the payoff is huge and persistent. Sometimes I even address groups of patients, further increasing the bang for my buck.
With people work, time management must account for people’s reactions to your actions. The best way to waste time and have a bad day at work is to cut corners with people. Think you’re too busy for politeness or diplomacy? I think you’re too busy NOT to pursue these effective time-savers and energy-savers.
Give it try!