Thursday, November 26, 2009

In came a spanner to the works

Case continued...
Ok so i had thought that the case was all sorted and that he would be discharge home and that would be that...
No that was the ideal.
Reviewing the notes and talking to my colleagues, it appeared that the patient was complaining and communicating his concerns about going home.
He did not agree with my decision that he steps were safe for him to get up and down on his bottom or by using the rail/ledge.
He was concerned about other things as well, and didnt appear to be able to problem solve his way though situations.
I had heard that he had been giving other staff members grief and so i expected that he would give it to me as well.
In hindsight I should have completed more in-depth education with him, and helped him to problem solve, but i new he had told the PT's that he wanted to do it his way.
He was not going to stop arguing with me so i decided to leave the situation and seek support.
The staff and my colleagues were amazing. They talked over the whole case with me, and offered advice of how to deal with his complaints.

Reflecting on the whole thing now...
This case could have been better managed by myself, but i realize that this man was particularly difficult.
How could i have managed the case better?
Perhaps got the PT, RN and or SW to visit the patient with me to coordinate the discharge better and facilitate question and answering sessions with him.
Perhaps think about defining my role with him, so that it was clear from the start e.g.that one of my roles was to assess from a professional opinion about his home environment safety, not to provide him with an alternative house/situation.

Overall, we got it sorted, I double educated him and provided him written advice or recommendations for managing at home.
I had amazing support from the ward staff and OT's - and it really reflects that new graduates do need support with clinical reasoning even when you think its a simple case


Wednesday, November 25, 2009

My communication

I have been reflecting on my communication style over the last week. I have realised the following...

Sometimes i often miss out detail when talking with people that is important. I wonder if this is to do with being in a hurry, or just my ability to remember all of the detail and verbalize it. I wonder if i may experience some anxiety and freek myself out when communicating with certain people, causing me to give a brief response. Actually i wonder if the problem is that i have so much to say, that i try and say it all and forget what it is that is the most important to communicate.
So... i guess i need to slow my processing down, and provide a prompt for myself so that i communicate the essential without rambling off the topic nor missing things out.
Think il give this a try......

Sometimes I switch off when listening, as hard as that is to admit its important that i do so that i can work on it. Who knows what important information i dont pick up on, or what the other person thinks of me when I switch off.
Listening is an essential part of communicating with others. I wonder why i have trouble maintaining attention. Its likely to be do do with nutrition, hydration and sleep...all of which im working hard on!
I guess my attention span is also influenced by taking regular breaks throughout the day, which is also important, and i have successfully managed to take morning tea breaks for a while now with the MDT members.
Unfortunately sleep is the best currently, however it can only get better!
I wonder if there are any other influences that make me switch off and not listen well. I definitely dont just switch off because i dont want to listen...talking about cases with my team members interests me and the information is definitely worth while knowing. Hmmm... This makes me sound awful - THIS DOES NOT HAPPEN ALL THE TIME!

Also... i have noticed that sometimes i cut people off before they are finished speaking! This is definitely rude and i try very hard not to do it! But sometimes i get carried away with my thoughts and what to express them then and there! Thats when its hard for me to keep listenning and remember what i was going to say. Man it sounds like my brain doesnt function very well at all.
How am i meant to listen and recall at the same time - this is a skill i have yet to master! However again it doesnt happen all the time.
I either listen and totally forget what i was going to say, or dont listen and then talk...How can i remember and listen!???

On a more positive side of things...I do communicate essential and relevant information to my team members, and i notice that they appreciate me doing so. It helps us work better as a team, sharing information and problem solving though situations. All in all it makes discharge planning a smoother process.

So just the basics i need to work on i think! And to finish up

-Done some reflection through self awareness

-Worked out what influences my interactions

-Starting to work on my communicating and well-being!


Case review

Yesterday, I had an interesting case that seems to be keep popping up in my head. Kind of a confusion - that i havn't quite figured out why the patient was like he was.

This patient was in his 50's, prev very fit man, with little medical hx. He lived alone and worked full time.
He had # his foot, quite a nasty crush injury that required surgery and grafting.
When i went to see him, he was mobilizing quite well, however PT notes had reported some anxiety about thinking he was going to fall.

When i went to meet this patient he appeared to be quite onto it, new exactly what he wanted and was very direct with his discharge "needs".
When talking to him about returning home he was very insistent that i sent someone out to look at his stairs. He described this come as a stable, and he lived in the top of it, like an attic. He was determined that he was not going to be able to access his house, however when asked he had no other solutions and no other places to stay. Was he providing a barrier to return home or was he sincerely concerned?
The PT was trying the stairs with him later that day- on his bottom also.
One would expect a person of his age, structure and his previous function to be able to get up stairs on his bottom.
So I had come across a break in the road towards discharge. This demonstrates why OT should have become involved with the patient prior to the expected day of discharge. However, who would have thought that this would have happened. The PT only started working with the patient the day prior, i guess they had expected it to be a straight forward case also. But essentially we were delaying the discharge.
I decided to ask our therapies assistant to do an environmental visit, and to install the equipment he required all in one as he had "no-one" who could take the equipment home.
As it turned out, the stairs were steep, but not unsafe or inaccessible on his bottom or holding the rail and ledge. I handed this information over to the PT, and they had no concerns about the patients ability to get up and down the stairs on his bottom or on his crutches. PT had discharged the patient, as he was independent mobilizing on the ward and going up/down stairs.
So together, we had sorted out this discharge, and the ACC package of care was being processed.
The only thing left now, the patients anxiety or was it anxiety? This is hard to know...
Was there anything else i could have done with this case? Something id like to talk about with a senior...


Tuesday, November 17, 2009

Thinking about my time on ortho/surgery now

Ive been thinking about how things work on the ortho ward... As usual it is fast paced and busy at times and I try my hardest to see all patients with an occupational need!
But of course there are times when that is not possible and I cannot see patients that are lower priority e.g. awaiting a bed in rehab.
At present the process is, that once on the waiting list for rehab the patient is definitely going to have a period of rehab no matter what performance gains they make in the period on the acute ward.
I feel that if a patient could be discharged from the ortho ward and return to the community with support without a period of rehab, then this is appropriate. However there have been a few cases recently where patients have gone to rehab reluctant of whether they really need to.
I'm trying to think about if it is feasible to provide intense input on an acute ward, whilst managing the elective patient, influx of surgical referrals and the other acute patients.
In a perfect situation, all patients could be OT sorted from the acute ward if they are making great gains in their mobility, and their cognitive function is intact enough to be aware of their occupational performance and accept the support they need to make gains in their occupational performance in the community.
The first thing I need to think about is what type of input is necessary to enable a safe discharge for a patient, and not necessarily having a period of rehab.

Lets try an example -A common occurrence

An elderly patient, say an 80 year old patient that lives alone, and has previously been quite independent, and is cognitively intact.

The patient has had a fall and has fractured their NOF. Day 1 after surgery they are referred to rehab, based on the fact that they were previously quite independent, and a period of rehab will help them return to their previous level of occupational performance.

Day 2 the patient is up and mobilizing with the physio and requiring 1 or 2 people to assist them. They are also having some assistance with their personal cares.

Day 3 the patient is accepted for rehab and put on the waiting list, hoping to get over to rehab within a couple of days.

Day 3 or 4 the occupational therapist could do one of three things
a) notice that the patient has been accepted for rehab and try and see them if they can to smoothen the transition from acute to rehab wards


b) not have any time to see the patient because of other patient demands


c) assess the level of occupational performance, set goals and begin working on increasing independence and safety with ADL's

Ideally, c) would be the aim. Either way the patient would be benefiting from commencing OT input.

We have the odd patient, who at day 4 gets up, the pain is under control, they are mobilising quite well and they are having minimal assistance with ADL's
This is when i think it would be appropriate to determine whether the patient could get home from the acute ward, or whether rehab is needed.

Unfortunately, we have limited control, as they are called up for a rehab bed, the patient and family thinks they are going to rehab, and the rest of the MDT are going along with the fact the rehab is the plan.

So here comes my thoughts.

At day 4 we have a better understanding of the impact of the injury on the patients occupational performance and mobility. Is it not more appropriate to assess whether or not rehab is required then? I think so!
Their are political influences currently, that we cannot really change that stops us from saying hang on a minute - they dont really need rehab!

So the patient ends up going over for rehab for a minimum of 10 days - some times not appropriate at all.

Where should our resources be used?
Spending the time - maybe a couple of days in the acute wards more than usual to work on increasing occupational performance, confidence and mobility?
Or should we send the mobile patients that are struggling a little over for 10 days of input?

This is where, i believe we should give patients more time on the acute wards...
But again we come back to the this feasible??

I dont think this is an easy question to answer, and I dont think in the interim we are going to sort this out.
But perhaps for what it is worth, when we have time to spend more time with the patients awaiting for rehab we should monitor what gains we are making and record if we think patients could have been discharged from the acute ward.

Then we come to the issue of time management on the ward. Definitly, at times we can have more input with the patients awaiting rehab than at other times. It depends on a variety of things...usually whether or not the surgical ward has referred alot of patients for us.

That is another kettle of fish! The referrals from there i mean..
Perhaps some education and setting up some processes for the surgical ward would make us be able to manage the referrals from there alot better, and cut out alot of the inappropriate referrals.

I think thats the place I need to start, then figure out whether or not their is time to sort patients from the acute wards

The patient in the example above, the patient who has had a NOF - fixed with a DHS - no precautions. Can be treated just like any other patient. Depending on the patient, a home visit is not always essential, yes assessing their function and working on activity tolerance and activity performance is needed, but I think it is definitely achievable.

Something to keep thinking about I think


Monday, November 16, 2009

Communication styles

I have found this great website on communication.
I have chosen to look at my communication style, and look at my interaction with colleagues at work.

It is important to understand how your communication style is interpreted by others to avoid miscommunication and misunderstandings. The goal is communicate with assertion and avoid an aggressive, passive-aggressive or passive style of communication.

Aggressive Communication is classified by:

__You choose and make decisions for others.

__You are brutally honest.

__You are direct and forceful

__You are self enhancing and derogatory.

__You’ll participate in a win-lose situation only if you’ll win.

__You demand your own way.

__You feel righteous, superior, controlling – later possibly feeling guilt.

__Others feel humiliated, defensive, resentful and hurt around you.

__Others view you in the exchange as angry, vengeful, distrustful and fearful.

__The outcome is usually that your goal is achieved at the expense of others. Your rights are upheld but others are violated.

__Your underlying belief system is that you have to put others down to protect yourself.

Passive Communication

__You allow others to choose and make decisions for you.

__You are emotionally dishonest.

__You are indirect and self denying.

__You are inhibited.

__If you get your own way, it is by chance.

__You feel anxious, ignored, helpless, manipulated, angry at yourself and/or others.

__Others feel guilty or superior and frustrated with you.

__Others view you in the exchange as a pushover and that you don’t know what you want or how you stand on an issue.

__The outcome is that others achieve their goals at your expense. Your rights are violated.

__Your underlying belief is that you should never make someone uncomfortable or displeased except yourself.

Passive-Aggressive Communication

__You manipulate others to choose your way.

__You appear honest but underlying comments confuse.

__You tend towards indirectness with the air of being direct.

__You are self-enhancing but not straight forward about it.

__In win-lose situations you will make the opponent look bad or manipulate it so you win.

__If you don’t get your way you’ll make snide comments or pout and be the victim.

__You feel confused, unclear on how to feel, you’re angry but not sure why. Later you possibly feel guilty.

__Others feel confused, frustrated, not sure who you are or what you stand for or what to expect next.

__Others view you in the exchange as someone they need to protect themselves from and fear being manipulated and controlled.

__The outcome is that the goal is avoided or ignored as it cause such confusion or the outcome is the same as with an aggressive or passive style.

__Your underlying belief is that you need to fight to be heard and respected. If that means you need to manipulate, be passive or aggressive, so be it.

Assertive Communication

__You choose and make decisions for you.

__You are sensitive and caring with your honesty.

__You are direct.

__You are self-respecting, self expressive and straight forward.

__You convert win-lose situations to win-win ones.

__You are willing to compromise and negotiate.

__You feel confident, self-respecting, goal-oriented, valued. Later you may feel a sense of accomplishment.

__Others feel valued and respected.

__Others view you with respect, trust and understand where you stand.

__The outcome is determined by above-board negotiation. Your rights and others are respected.

__Your underlying belief is that you have a responsibility to protect your own rights. You respect others but not necessarily their behaviour.

An important aspect is self awareness>

Employers no longer just look for a set of industry related skills. They look for leadership potential and that includes a high level of emotional intelligence (EI). The competencies that make up EI include self-awareness, social awareness, self management and relationship management.

Being aware of your emotional triggers and why they trigger you is key to practicing emotional intelligence principles. Emotional triggers are events or personality types that cause an intense emotional response.

Common emotional triggers are:

Blatant incompetence
Poor executive leadership (no demonstration of values, inconsistent, poor decision making, unavailable or unapproachable)
Being overlooked for credit, accolades or promotions
Arrogance or inflated egos
Patronization or micro-management of subordinates
Back stabbing
Verbal attacks
Lack of communication
These are things that will frustrate and upset the best of us. The important point here is to see if they trigger intense, long-lasting reactions with ramifications that make it difficult to remain rational.

Handling criticism with grace is a skill that will get you promoted. It is important to understand how to disarm your critics and to be able to listen and not take it as a personal attack on your character.

Emotional outbursts impact those around you. Understand that your fluctuating moods and passionate reactions to things can affect productivity and morale.

Also found this great site on teamwork and communication

3. Do your team members feel free to disagree with you?

Some leaders feel that subordinates that disagree are showing disrespect and being insubordinate. Certainly if they are disagreeing without cause, that can be a sign of insubordination but no one is perfect and encouraging staff to present an opposing viewpoint and the rationale behind the argument can prevent costly mistakes or poor decision making. Frequently frontline workers have valuable insights as they are the point of contact with customers. It is very important to open the lines of communication so that you can receive this customer feedback. Try to not be defensive when your decisions are challenged and instead ask questions so that you fully understand why they think you are making the wrong decision. The more information you have, the better.

4. Do you have an open door policy?

How approachable you are will influence how many surprises you receive. If you are constantly finding out information too late, it may be because your team does not feel free to communicate with you. How have you created a climate based on fear? Do you threaten them with loss of their jobs, loss of resources or increased overtime? Do you lose your temper frequently over mistakes? Threats delivered overtly or subliminally will only create a climate of fear and a total communication breakdown.

In the next article, Change Management and Innovation: How a leader can effectively communicate change initiatives and encourage innovation in a team, we'll look at the questions:

5. Do your team members react to change initiatives well?

Improving self awareness>

Reacting with your gut is reacting when you are at an emotional peak. Try to take the time needed to regain emotional composure so that you can respond from your head i.e. allow time for the adrenalin and other chemicals to subside so that you are at a place of logic and reason. Generally this takes about 20 minutes. In some circumstances however, you may need to sleep on things and look at them fresh the next morning.

I think now that i am more aware of the types of communications i need to reflect and become more aware of myself.

So i have some questions that i want to reflect on over the next week, when communicating with my colleagues.

1. In times of miscommunication, how has this affected my work?
2. Has my communicating enabled others to be informed consistently?
3. Have I been direct and forceful with my communication?
4. How have others communicated with me?
5. Have there been times of emotional change when others have communicated with me?
6. Have I allowed others to make decisions for me?
7. Do others get confused or frustrated when communicating with me?
8. How do I handle situations that don’t go my way?
9. Do I feel valued and respected within the team?
10. Do I respect others opinions when I disagree with them? How do I communicate that I disagree? How does this impact the working relationship?
11. Am I approachable? Do I make myself available to communicate with?

Reflections to follow in 1/52 ish