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Humanizing Health Care
Creating Cultures of Compassion With Nonviolent Communication
By Melanie Sears
PuddleDancer PressCopyright © 2010 PuddleDancer Press
All rights reserved.
A Crisis in Health Care
By many indications, all is not well in the emotional lives of health care workers. Studies show that the suicide rate for male doctors is about 1.4 times the general population, and female doctors commit suicide more than twice as often as women in the general population. Health care practitioners and technicians have a depression rate of 9.6 percent per year. This is 2.6 percent higher than the average for full-time workers. Why are doctors and health care workers so unhappy?
A 1996 Lancet study indicated that doctors and other health care workers commonly struggle with emotional exhaustion, depersonalization (treating people in an impersonal, unfeeling way), low estimation of personal accomplishment, work overload, and poor management and resources. Dealing with the suffering of patients and their distressed, angry, or blaming relatives on a daily basis is extremely taxing.
The doctors in the Lancet study reported their primary sources of job satisfaction were good relationships with patients, relatives, and staff, and having professional status and esteem. They said being understood by management contributed to their happiness, as did enjoying a high degree of autonomy, and performing a variety of tasks.
Significantly, only 45 percent of the doctors in the study thought they had received adequate training in communication skills, while all believed they had received adequate training in the treatment of disease and management of symptoms. As the report reaffirms, "The mental health of (doctors) may nevertheless be protected by maintaining or enhancing their job satisfaction ... through giving them autonomy and variety in their work, as well as providing effective training in communication and management skills."
It seems that at least some of the missing pieces in the wellness of health care professionals relate to the personal, human dimensions of their work rather than the technical dimensions: less than half feel adequately prepared to communicate effectively with others, which means less than half feel skilled at connecting in meaningful and effective ways with the people around them. Doctors are also terrified of giving empathy to a patient for fear that it will take too much time. That absence of meaningful connection is surely a contributor to the kind of alienation and depression that underlies the grim suicide statistics.
Health care institutions also feel the costs of these missing pieces. Low job satisfaction and high turnover are extraordinarily costly for hospitals, which shoulder an average cost of $60,000 for every employee turnover. No wonder many hospitals are looking for ways to increase retention and lower recruitment costs!
Some Hopeful Interventions
The evidence shows that health care institutions can successfully reduce retention and recruitment costs by millions of dollars by improving employee satisfaction, and that better communication is a key success factor. In particular, a communication model called Nonviolent Communication (NVC) has been implemented in several health care settings, with powerful results. Some examples include:
Mercy Hospital in Baltimore implemented NVC into several high-volume outpatient departments. They were so excited with the results that they hired a full-time NVC trainer to train the hospital's entire management team and work force. Since doing this, they have found statistically significant improvement in patient satisfaction, reductions in employee turnover, and improved worker performance.
Carla Corwith, RN-BA, MBA, and Donna Riemer, RN-BC, Certified Traumatologist, developed a program that included NVC onto the medium security forensic unit at Mendota Mental Health Institute in Wisconsin. Because of this, Seclusion and Restraints (S/R) incidents were reduced from 33 in 2003 to 6 in 2006. S/R hours were reduced from 92.57 hours in 2003 to 6.4 hours in 2006. Time loss from work due to serious staff injuries was reduced from several months to zero. The need for 1:1 staffing — costing tens of thousands of dollars each year — was eliminated.
In 2008, Donna Riemer went on to develop a similar program that included NVC and integrated it onto the maximum security forensic unit at Mendota, the final stop for the most violent forensic and civil patients in the state of Wisconsin. The results of this strategy were astounding. Staff and patients became partners in recovery. Patients learned how to empathize with staff and staff learned the same. Everyone attended NVC classes every week, and the NVC tools were used daily among staff and patients. The results were a drastic decrease in violence and a change from a violent culture to one of healing. Statistically, there was a 55 percent reduction in the use of the Emergency Intervention Team. This team is called to subdue patients who are acting in violent and destructive ways. The unit has now become safe for both patients and staff.
So, what is NVC? And why is it so effective in improving patient and staff satisfaction, reducing the costs of providing care, and creating cultures of healing?CHAPTER 2
Understanding Nonviolent Communication
What Is Nonviolent Communication?
Nonviolent Communication (NVC) is a philosophy, a leadership technique, and a system of communication that empowers individuals to achieve greater empathy for others by developing their own sense of their feelings and needs. NVC can be used to heal emotional wounds, develop emotional intelligence, resolve conflicts, and create win-win solutions. It can be used in all relationships: at work, as a parent, as a partner, as a friend. It enhances one's sense of security so that other voices can be heard which opens up communication and creates understanding. Applying the principles and practices of NVC enables people to take control of their lives and to maintain integrity consistent with their deepest values.
Dr. Marshall Rosenberg, founder and director of educational services for the Center for Nonviolent Communication, developed the NVC model in the early 1960s. In search of ways to support peaceful desegregation of schools and other institutions, he began to study the practices of good communicators. His studies culminated in a four-step model of communication that emphasizes honesty, empathy, and awareness of the power of words to shape perceptions of reality. Today, Dr. Rosenberg travels all around the world teaching this process, resolving conflicts in war-torn countries, and helping people live peaceful, joyful lives by shifting their communication.
As he studied the question, "What keeps us connected to our naturally compassionate nature?'" Dr. Rosenberg began to understand that our patterns of communication literally create the world that we experience. The messages you deliver to yourself in your own head and the messages you deliver to the people you live and work with powerfully shape your perception and your relationships. In a workplace, these communication practices combine to create the culture you share.
When you act out destructive communication patterns without an awareness of doing so, you unwittingly become co-creators of dehumanizing cultures that never acknowledge or address the real needs of the people involved. But, when you become conscious of your communication patterns and develop choice in how you think and react, then you literally change the world in which you live. When you connect the words you use with your own honest feelings and needs and use them to make clear requests of others, you create meaningful connections with others and with yourself and create effective and lasting change. By implementing NVC, health care institutions can become life-serving environments that better meet the needs of both employees and patients.
How Does NVC Work?
NVC breaks down communications into four steps: Observations, Feelings, Needs, and Requests. Your habitual language often mixes these steps together and leaves out the feelings and the needs. In society in general, and certainly in workplaces, you don't discuss your feelings and needs, instead focusing your attention outward in patterns like: judging, analyzing, blaming, labeling, criticizing, and complimenting. All of these communication activities are oriented toward an outward focus of attention instead of an inward one. Learning to express yourself using NVC shifts your focus inward, allowing honest expression, healing, and growth.
Step One: Observations
The first step in creating clear communication is to be able to state clear observations without mixing in evaluations. Observations are things a video camera can pick up. They contain the observable facts. When the observations are mixed in with feelings, evaluations or judgments are created.
For example: "You are obviously too lazy to take out the garbage." is a statement that clearly combines an observation with an evaluation. By contrast, "I see you did not take out the garbage today," is an observation.
Step Two: Feelings
The second step is to express "Feelings" clearly without blaming or analyzing others. Many people find this step challenging, because they don't have a "feeling vocabulary." Words that mix feelings with analysis or other forms of evaluations are used far more commonly than "feeling words."
Some examples of common words that mix feelings and evaluation are: used, abused, betrayed, attacked, manipulated, neglected, rejected, and threatened. These words are more about analyzing what someone else is doing wrong than in expressing feelings. When you express yourself using these words, it will often stimulate a defensive reaction in others.
Feeling words, such as hurt, scared, sad, excited, happy, irritated, confused, and surprised will create connections instead of defensive reactions.
Step Three: Needs
The third step of the NVC process is "Needs." When someone speaks, they're meeting a need. When someone punches another in the nose, they're expressing a need. Uncovering what need the person is expressing allows you to connect with this individual and begins to unlock unconscious motives and moves the person toward self-awareness.
Often when you express yourself, you are not aware of what needs you are trying to express. One reason for this is that you have grown up in a society that has an outward focus instead of an inward focus, and you have become disconnected from your needs. Many of you have been punished for expressing your needs. You have been told that you are selfish or inconsiderate when you asked for what you wanted. In order to understand others' needs, it is important to become aware of your own.
Similarly, you don't often seek to understand the needs that others are expressing through their communication. By focusing your awareness on people's needs instead of judging them for speaking or acting in ways that you don't enjoy, you see the truth of who they are. This allows you to notice that they are not very different from you.
Being out of touch with your own needs and those of others creates disharmony and prevents conflicts from being resolved. When you express your needs and hear others' needs, you discover your common humanity. Barriers between you dissolve. Conflicts are resolved when both parties can hear each other's needs. Trying to solve problems or conflicts before getting clear on what the needs are will create disharmony and negative feelings.
There are many different needs that all people have in common. Manfred Max-Neef, the Chilean economist and environmentalist, has organized them into the following nine categories: Sustenance, protection, affection, understanding, participation, leisure, creation,
Step Four: Requests
The fourth step is the "request.'" Becoming conscious of what you want back from others when you speak creates safety and self-responsibility. It also improves efficiency. Requests can also be thought of as the strategy for meeting the need. I often hear people use many words when they speak, and they repeat what they are saying. They are not clear what need they are meeting by speaking and what they want back from the person they are speaking to. If they were aware that they needed empathy (for example), then they could ask for that directly and the connection would likely be more satisfying for everyone involved.
There are two types of requests: 1) the Connecting Request and 2) the Solution Request. The first one creates connection between you and others. An example of that request may sound like, "How do you feel about what I just said?" The second request creates a solution to a problem. It could sound like, "Would you be willing to take out the trash?" Requests are action-oriented and "doable" in the present moment.
Putting It All Together
By separating communications into these four steps, you become smarter about how you get your needs met. When you begin to habitually:
Separate observations from evaluations,
Identify and express your feelings,
Determine and express the needs that drive your feelings, and
Make clear requests using positive action language,
you take responsibility and control of your own experience in a striking new way.
Beyond the Four Steps
The four steps — observations, feelings, needs, and requests — are the cornerstones of the practice of NVC. To fully understand NVC, however, you must also take a look at four principles from which these practices arise:
1. Each of you is responsible for choosing your reactions to people and events;
2. Each of you is also responsible for your own feelings;
3. Your needs are a gift, not a burden, to others;
4. The experience of empathy is at the heart of effective communication.
Principle 1: Each of you is responsible for choosing your reactions to people and events.
I'm sure you have heard the expression, "you create your own reality." This belief may feel debatable during the course of a day when you are affected by people and situations that you seemingly have no control over.
You may not be able to control people and events that you encounter, but you can control how you react to them. When Nelson Mandela was in prison, he chose how he wanted to react to the violent treatment. Instead of being angry and filling himself with hate, he acted compassionately, maintained his dignity, and gained the respect of his guards and fellow prisoners.
Anyone can choose how they want to react to situations and the language you choose can help you stay connected to your inner intentions. Language contains a panoply of philosophies and values. By choosing your style of language, you change the way you react to situations — and often the strategies you use to meet your needs. The language you choose can create cooperation and empowerment for others, or it can create resistance and hostility. The language choices you make will determine the results you get.
Principle 2: Each of you is also responsible for your own feelings.
There are some myths around feelings that need to be cleared up before communications can flow. One of these is that "other people cause your feelings." When you think about this myth logically, it is easy to see that other people don't cause your feelings. Other people can stimulate your feelings, but your feelings are caused by your needs. If your needs are being met, you have positive feelings. If your needs are not being met, you have negative feelings.
Consider the example when someone says, "No." If it is your two-year-old saying, "No," you may feel frustrated because you want to get to work on time. If it is your boss who says, "No," you may feel hurt because you want recognition for your ideas. If it is a friend who said, "No," you may feel happy because you are glad your friend feels safe enough with you to express her truth.
The key insight here is that it is not the other person but your inner needs that create your feelings. And the inverse is also true: You do not cause feelings in others. Their feelings are expressions of their own internal experience.
Often you learn that it is OK to have certain positive feelings but that you are judged if you have negative feelings. People judge you because they don't know how to respond to feelings in other ways. Also, hearing feelings will often trigger unresolved issues in others. You are taught to take responsibility for other people's feelings, so it is frightening to express feelings or to hear another's feelings.
From the perspective of the NVC model, feelings are neither good nor bad; they are simply expressions of the internal experience. When you realize that you don't cause other people's feelings, you can begin to be honest about your own feelings and needs. If you express your truth and someone has a defensive reaction to what you say, you know that his or her reaction is about him or her and not about you. You quit taking things personally.
Excerpted from Humanizing Health Care by Melanie Sears. Copyright © 2010 PuddleDancer Press. Excerpted by permission of PuddleDancer Press.
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