As a student you learn that the nurse-patient relationship is critical for effective, humane, holistic patient care. You also learn that the communication necessary for a nurse-patient relationship is a two-way street. There is what we say... and there is what the patient hears. Both of these must be precise for optimal nurse-patient interactions to occur. Unfortunately, we all have deeply ingrained linguistic habits that too often garble our communication efforts... and we should NOT be OK with that!
I have noticed over the years that student-patient interactions are loaded with relationship killing words and phrases. The students are not being unkind. Rather they are speaking without thought or purpose.
Though I don't want students to feel stilted and confined and "fake" when they converse with patients I do want them leave linguistic tics and mannerisms at home. These are fine in "everyday life" but they impede the development of a therapeutic nurse-patient relationship in professional interactions.
The most common example of conversational "tics" is the way we (Americans, at least) punctuate much of what we say with "OK". "OK" is a multi-use tool in common speech. For example:
* We use it to end a conversation. ("OK, OK. I get it. OK?")
* Sometimes we use it to take the sting out of what we've just said. ("Honey, slacks with horizontal stripes are not a good look for you... OK?")
* We use it to determine if our listener is still with us. (Remember teaching lowest-common-denominator to your 5th grader? Having pointed out that 4 goes into 12 as does 3 you look at your child and say "OK?" And of course, their eyes are glazed over!)
But this tic is hugely counter-productive at the bedside. The most common way students use "OK?" seems to reflect some distorted sense of courtesy. For example I often hear students say something like:
"No, Mr. Andrews, those chips your visitor brought you don't go with your cardiac diet. OK?"
Think about what the student did in that interaction. Initially he/she was speaking as a nurse, conveying important information. Then instantly became a petitioner asking the patient if he would be "OK" with refraining from potato chips. The student turned a therapeutic relationship into one that was ambiguous. The patient, hearing this "OK?", is entitled to imagine the student is making a suggestion instead of giving him important information about living with congestive heart failure. This was a "teachable moment" and it was wasted. How much better if the student had said...
"Mr. Andrews... those chips have a lot of salt in them. You'll have to avoid salty foods at home and let me explain why... etc."
The habit of saying "OK?" is also insincere. Students commonly say things like
"Mr. Watson, we have to turn you to your other side now... OK?"
Well, no. In Mr. Watson's mind it is not "OK" because turning hurts. He knows it. The student knows it. And Mr. Watson also knows it's futile to tell the student "no". In this interaction, the student was not honestly asking Mr. Watson's opinion about turning. But... the student could have used this simple nursing task to give the patient some much needed autonomy. The student could have said
"Mr. Watson. It's time to turn. Would you rather face the door or the window?"
Note two things. First, this is a sincere question. As a result, the nurse-patient relationship is strengthened. And second, a previously helpless patient is invited to participate in his care. He is being treated like an adult.
There are times a patient may be going on at some length about a concern (Not uncommonly, this is a "problem patient". Often one the nurses prefer to avoid) For most students the impulse to nod and say... "OK." "Uh huh." "OK" is irresistible . Unfortunately, doing so adds nothing to the conversation and the patient eventually realizes the student nurse is trying to hurry her to the end of her soliloquy.
A much more therapeutic approach is to make eye contact with this patient and listen for recurring themes. (Things that she is telling you multiple times in different words.) These can then be reflected back at appropriate times. In this manner, the student is engaged and the patient knows it. This patient who was previously acting out (because no one would pay attention to her if she didn't)... now feels she has an advocate she can talk to, someone who understands. The nurse-patient relationship is strengthened.
In real life, all of these nursing measures don't work all of the time. But sometimes they actually do. On the other hand... without hesitation or equivocation... I can tell you that just reflexively saying "OK" when speaking to patients adds nothing to your plan of care and may actually impede it.
While I see your point in how it can be seen as uncertainty, I have to say that it is not black and white. It depends on the tone in which you convey the message.
Yes we are giving care and meds for their benefit but at the same time they retain their right to decide whether they want it or not. It is within their rights to refuse care or meds, which is why I personally use ok afterwards to assess whether they have a problem with it.
Please do not see that asking for permission is a sign of "I don't know what I'm doing" or as belittling them by treating them like a child because it's not. Just because we are health professions and know better, it doesn't mean we get to perform care on them, we still need permission otherwise it is battery. And when I use ok, it is not condescending in any way, rather I am informing them that they have a choice to refuse and a chance to let me know if they have any concerns.
There are indeed patients who think that just because the doctor or nurse says so, they must do it. If they choose not to do it, then I will inform them on the risks and why it is to their benefit to do it but it is not my duty to force them to. It is my job to ensure that they have the information. And by using "ok" it allows the patient to voice their concerns. If they say no, they might say why, if they don't say why they don't want to then it is an opportunity to assess as to why they don't want to do whatever it is that you are SUGGESTING, not DEMANDING. And with that data you can try to come up with a plan that will appropriately address the issue.
But like I said it's not black and white, I agree in that those who convey it in an uncertain tone or condescending manner shouldn't do it but it's not absolute that students should get rid of "ok"
I agree with everything you say here and commend you for deliberately enhancing your patients' autonomy.
The problem is saying "OK?" is not the best way to do it. We use the term for so many purposes in our speech that the patient might easily not hear it the way you intend. If you want to give them the choice, do it overtly and clearly. "Mr. so-and-so... you haven't had a bowel movement for a few days and the MD suggests a stool softener would help. What are your thoughts about it?"
Oh yes! I remember someone apologizing for the weather, (4th of July party), I looked at her and asked her if she had ordered it.... she looked at me, a light bulb went on, and she said no, I didn't... and she was more at ease after, and less "I'm sorrys"
I think to add to this article Episteme, one is needed on the 'I'm sorry' epidemic. Everyone apologizes for EVERYTHING. And when you do, it makes you look insincere, especially if the person receiving the apology knows it's not something to be sorry for. Let's try to limit that one too, ok?!
Specializes in Peds/outpatient FP,derm,allergy/private duty.
What a great thread! I have made fun of scripting in the past, because the kinds of things nurses are required to say are often disingenuous (ie "I have the time" when all hell is breaking loose) or too cheerleaderish to fit the wide spectrum of personalities good nurses may have (gruff no-nonsense type required to say things more suited to Sarah Jessica Parker in LA Story) but discussing specific verbal strategies like this and nurses brainstorming ideas on what is most effective is really great, and got me thinking about how I use the word "OK" when talking to patients. I never use it in the "asking for permission" way, and usually use it in the "consent" way, but really these suggestions give me a lot of food for thought. Thanks, Episteme.
Thank you so much for pointing this out, I find myself doing it every week with my patients. I've never realized and no one has ever mentioned this before.
Just yesterday my patient asked for some pain medicine and I said, "Alright, I'll check and make sure it's alright to have some now, okay?" It makes me sound like I'm asking her permission to check the chart again. I HAVE to check the chart again! Yes ma'am, you say you had your last dose four hours ago, but I still have to check.
I understand what you are saying but I use it to make sure people have acknowledged and understood what I have said. It also gives people a feeling that they have a say in the situation and are not being ordered around. Like, I am going to give you a bath now, ok? I don't find it insulting or anything like that. I see it as especially with an elderly person sometimes they don't hear and comprehend what you are saying. If they nod their heads and respond, I know they heard me and know what is going to happen next. Also many elderly people feel that when they get older all of their rights are taken away and they are treated like children again. Saying ok to them let's them know they still have a voice and I am not rushing in and telling them what is going to happen to them, more like what I would like to happen. Although the nurse is the authority figure you have to speak to people in a way that they feel comfortable and are your equal. So I am sorry but I have to disagree your post. I do not find it insulting or that I would be talking down to someone. I think it is the exact opposite.
Thank you for this article. I know I am guilty of using "OK," but not necessarily due to lack of confidence. More in the sense of attempting to give the patient their opportunity to refuse. However, after reading this, I will definitely be more mindful, because your argument makes sense to me. As a new nurse, I am still learning to effectively communicate with my patients.
Nice post. It's hard to not use "ok", but it is important. "OK" implies a choice. In pediatrics I have learned that I cannot use okay when there isn't really a choice. I give options where there are ones available.
I understand what you are saying but I use it to make sure people have acknowledged and understood what I have said. It also gives people a feeling that they have a say in the situation and are not being ordered around. Like, I am going to give you a bath now, ok? I don't find it insulting or anything like that. I see it as especially with an elderly person sometimes they don't hear and comprehend what you are saying. If they nod their heads and respond, I know they heard me and know what is going to happen next. Also many elderly people feel that when they get older all of their rights are taken away and they are treated like children again. Saying ok to them let's them know they still have a voice and I am not rushing in and telling them what is going to happen to them, more like what I would like to happen. Although the nurse is the authority figure you have to speak to people in a way that they feel comfortable and are your equal. So I am sorry but I have to disagree your post. I do not find it insulting or that I would be talking down to someone. I think it is the exact opposite.
Dear Heather...
I absolutely agree with you about respect for patient autonomy and patients themselves. Especially the most dis-empowered patients (frequently the elderly). We walk a fine line as nurses, don't we? We need to be "the adults in the room" and from time to time exercise some authority to protect patients who are relatively helpless. But on the other hand, we have to be keenly alert to avoid fostering unhealthy dependency in our patients.
Nevertheless, I believe your use of "OK"... used with the best motives... is not the best way to accomplish what you identify as your professional ethos of respect. Especially with the elderly. Especially with the hearing impaired elderly.
"OK" is such a brief transition between "I must do this to you" and "with your permission". I propose an experiment. Use your method of communicating with an elderly person and after you say "OK", pause and say nothing. Don't nod or pat their shoulder or change your facial expression or in any other way cue them to the response you want.
What you will discover is that a relatively high % of these patients will just stare at you. You'll find that without additional prompts, they have no idea that you handed them their autonomy and asked them to make a decision. They are still two or three phrases back, trying to process what you just said.
My point is that "OK" is such an ambiguous (and habitual) phrase, we cannot be sure how it is perceived by the patient. ALSO (and this is a big hazard...) in our culture, when one person says "OK???" it is almost reflexive for the person being addressed to respond with "Oh, OK." We are seriously programmed that way. Your patients are programmed just like you and I are.
So if you want to give a relatively helpless patient some much needed respect I would recommend the following.
Sit down on the bed or pull up a chair so that you're very close to them and making good eye contact. (This literally puts you on "an even plain" with the patient, and puts your voice close enough that they can hear you.) Make the first part of your statement. "Now would be a great time for us to clean you up with a bed bath, Mrs. Smith." Pause. "How would you feel about that?"
Take all of your best intentions... and make them intentional.
Specializes in Cath/EP lab, CCU, Cardiac stepdown.
Episteme, you are absolutely correct that there are better ways, as demonstrated by your post to both mine and Heather's. However I just wanted to show that while it is not the best way to ensure autonomy, it is far from being a bad thing. Many posters have shared their experience and have stated that they would like to avoid using it as though the use of "ok" is a bad thing, but I believe that it is not.
My post was just to illustrate to students that if they used "ok", it is (winkwink) okay, that they haven't made a grievous error in therapeutic communications. I wanted to show that using ok is appropriate while not optimal. But I totally agree that there are better ways to go about it
Episteme, you are absolutely correct that there are better ways, as demonstrated by your post to both mine and Heather's. However I just wanted to show that while it is not the best way to ensure autonomy, it is far from being a bad thing. Many posters have shared their experience and have stated that they would like to avoid using it as though the use of "ok" is a bad thing, but I believe that it is not.
My post was just to illustrate to students that if they used "ok", it is (winkwink) okay, that they haven't made a grievous error in therapeutic communications. I wanted to show that using ok is appropriate while not optimal. But I totally agree that there are better ways to go about it
No, no, NO! I never want you to think you've done or said anything sub-professional!!! If saying "OK" were bad/harmful, why every nurse in the nation would lose their license (and I'd be in that number!)
Here are some of the things I do that are wrong... I go too fast. I string too many clauses together and make long sentences, I use med-speak, and yes, sometimes I say "OK?" It's about the time I say the "OK?" and I get the glazed eye-look, that I correct myself. Stop, back-up, get a chair, make eye contact, break it down into short phrases, go as slow as the patient needs me to go and finish by asking that open ended question... "how would you feel about that?"
Oh, yeah... we all do it. But I've learned to correct myself and make SURE the patient heard/perceived what I was trying to communicate. How do you think I learned that "OK?" was not effective? I learned when I started double checking myself. I do it less and less now, and I'm starting to work on some of my other "linguistic" tics that can confuse my patients.
Episteme
1 Article; 182 Posts
I agree with everything you say here and commend you for deliberately enhancing your patients' autonomy.
The problem is saying "OK?" is not the best way to do it. We use the term for so many purposes in our speech that the patient might easily not hear it the way you intend. If you want to give them the choice, do it overtly and clearly. "Mr. so-and-so... you haven't had a bowel movement for a few days and the MD suggests a stool softener would help. What are your thoughts about it?"