AORN education

Managing the manipulator in the OR We all use manipulation from time to time to achieve our goals. If it is only occasionally, there is little to be concerned about. If you employ manipulation as a frequent means to reach a goal, you should stop and consider alternative methods. In this article, I shall at- tempt to help you recognize an individual’s manipulative behavior and how manipulation develops. You may see yourself or some of your colleagues in the examples.

Man is a manipulator. In our fast-moving society, man has learned to twist the behavior of others to meet his own needs regardless of the consequence to the other individual. This pattern in man begins long before he is an adult frustrating people around him. It begins with a small child who uses strange and de- structive ways to gain his needs because no one has listened to his healthy requests. It begins with the child who has not had realistic, firm limits set on his behavior, or the child who drags his feet about doing his chores until someone finally does them for him because it is easier than arguing or coaxing. Do we see this nurse in the OR?

Manipulation is seen in the child who chroni- cally forgets his sweater at school, then sits back and enjoys watching his mother get up- set. Is this child getting even? Do we have this nurse in our OR? Such people are not help- less, they are simply playing games to manipu- late others to do their work for them.

As the child becomes a teenager, this ma- nipulation becomes more sophisticated. The

teenager who repeatedly says, “Nobody around here loves me. I’m going to run away from home” manipulates his parents through guilt until he finally gets his way. Do we have nurses who threaten to quit unless their un- realistic demands are met?

We are all familiar with the man-woman game. Man pursues while woman coyly teases him into a relationship. Do we have these physicians and nurses in the OR? Another example is the impersonal businessman who thinks only of the sale of his product and not of its effect on the consumer. Have you ever dealt with a persuasive salesman who makes you feel like an object as a means to an end?

The manipulator’s roots lie in fear and dis- trust. He avoids truth and intimacy because of the fear of being hurt. He manipulates to gain love and approval, a feeling of control over himself and his environment, or to alienate himself from others. He probably was reared in an environment where parental love, approval, and control were lacking. In the examples, it is easy to see that by using some firmly set limits, we would have told our child we love him enough to guide him.

A key characteristic of a manipulative indi- vidual is that he enjoys what he has done. He is exhilarated at having put something over on another individual. His behavior is usually of- fensive, and he is usually not capable of signif- icant loyalty to individuals, groups, or social values. A manipulator is often selfish, callous, irresponsible, and impulsive-definitely not an asset to your OR.

There are two kinds of manipulation- constructive and destructive. Constructive manipulation differs from destructive manipu- lation in that the exchange satisfies the needs of everyone involved, as in the teacher-student

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relationship. It is designed to promote the strengths and capabilities of all concerned. An example would be using your rapport with and respect for a colleague to motivate her to change undesirable behavior, such as wearing earrings in the OR.

To identify various manipulators in your OR, let us look at several prototypes listed by Shos- trom.'

Thedictator is someone who dominates and exaggerates his strength. He orders people around, is a know-it-all, has all the answers, and quotes the authorities. He is generally in- secure and needs to give orders to make him- self feel strong. He seeks high positions to control other people and power to counteract his internal feelings of powerlessness. In our ORs, this dictator type is called "doctor-know- it-all," "OR super-nurse," and "director of nurses." We hear them say things like: "This is my OR and you will do it my way." "I control the procedure. Thank you for your suggestions, but I will tell you how this will be done."

The weakling is usually the dictator's victim. He is hated by the dictator because he repre- sents how the dictator feels inside. The dictator knows that if his bravado should slip, he too could become a weakling. The weakling de- velops skill in dealing with the dictator. He exaggerates his sensitivity, avoiding conflict by appearing fragile and frail. We see the weakling in the nurse who, when she has to scrub with Dr Gruff, forgets things, doesn't hear, and is passively silent. She usually gets out of scrubbing with Dr Gruff because others feel sorry for her. She plays games of " I can't help it if I fail," and "poor me."

The calculator deceives, lies, and tries to outwit and control other people. Often suave, he IS sensitive to timing and figures out all the possibilities before he acts. "We'll get this pro- gram through, and nobody will know what happened." "We'll get around that sponge, needle, and instrument count by ignoring it." "Ignore her and she'll soon see it our way." "You do it so much better than I do, why don't you do it?"

The clinging vine exaggerates his depen- dency, wanting to be led, fooled, and taken care of. He lets others do his work for him. He is the perpetual child, the hypochondriac, the attention-demander, the helpless one. The nurse who is unable to do preoperative visits is

indicative of the clinging vine. He or she will say, "I've got a sore throat and can't talk." "I don't feel well, could you clean up for me?" "You are so good and I am so slow. Please do it for me."

The bully exaggerates his aggression, cruelty, and unkindness. He controls by threats, is the tough guy. We call this nurse the "bitch" and the nagger and tag her with the title "nurse-know-it-all.'' You frequently hear this nurse say, "You do what I say or your job or privileges will be on the line." "Let me remind you, I am the supervisor here."

The nice guy exaggerates his caring and love and kills you with kindness. He wants to please, is nonviolent, noninvolved, virtuous, and helpful. He "butters up" the grouchy supervisor, saying, "I know you're stern, but I realize you need to be." "I know others don't understand you, Dr Gruff, but I appreciate your problems." "Gee, I really like you." The nice guy expects a payoff in the end.

The judge is overcritical, distrustful, blame- ful, resentful, and slow to give praise and rec- ognition. He shames, compares, and gossips. "Boy, they sure don't make nurses like they used to." "Where did all the good old super- visors go?" "Did you see her scrub dress?"

The protector is nonjudgmental at all costs, is overly sympathetic, and exaggerates his support. He does not allow others to advance. This nurse is the mother hen, defender, martyr, helper, unselfish one, often the "kind-hearted super" who protects the nurses from the physicians. This nurse says, "Trust me, 1'11 help you out. 1 won't let anyone know you broke technique."

The first step to managing the manipulator is recognizing the behavior, which often is dif- ficult to do. Key behaviors you need to watch for are those people who are

constantly attempting to assume leader-

forming special, private friendships with

demanding and asking many questions focusing on aggressive issues and con-

testing against rules, routines, and proce-

requesting special privileges pitting one person against another

0 making stipulations and threats

ship roles

people

tinuing to harp on them

dures

X40 AORN Journal, November 1977, Vol26 , N o .5

0 acting out, dawdling, being overly friendly

0 smiling all the time and continuously talk-

Manipulators are commonly full of reprimands and derrogate themselves and other people. “I don’t know what makes me do things this way.“ “Why does this always happen to me?”

Recognizing your own feelings can make you aware you are being manipulated. One of your first feelings may be one of being used. You may experience feelings of suspicion, dis- trust, resentment. The aggressiveness of the manipulator will leave you angry and defen- sive. You may find that you do not like the manipulator, and you will feel guilty for such feelings. Early recognition of the manipulative individual will make management of the situa- tion somewhat easier. Documentation of specific questionable incidences is imperative because ultimately employment of many of these people must be terminated from the ORs.

Having recognized the behavior and your own feelings, you are ready to manage the manipulator. You may want to discuss specific situations with a colleague for validation; ulti- mately, you will need to set limits on the de- structive behavior. You will need to indicate very clearly what behavior is acceptable in your OR and what behavior is not. “You may not wear earrings of any type in the OR.” “You must scrub on the assigned case.” Having made this clear, you will need to stick consis- tently to your limit. Again, you must document deviance from your limit.

Another technique that works to change be- havior is to ignore the individual when the be- havior is troublesome but not beyond the rules. For example, if you have told someone you don’t appreciate his or her gossiping, ignore it from then on. Some fun for the individual will soon be lost. Sometimes group validation is helpful, particularly if the individual is in an authority position and skilled at making you feel like you are in the wrong. A group consen- sus and possibly a group approach to confront- ing the behavior can work well. A small group of staff nurses can talk with a head nurse about her rigidity and tendency to “lord it over them.” Perhaps the head nurse is unaware how dis- tressing this is, but if the behavior does not change, you have an obligation to inform his or

and solicitous

ing.

her supervisor. Be certain to take your documentation with you.

Having set your limit, be prepared for the manipulator to react. The consequences may be anger, defiance, innocence, and further de- nial and manipulation. Don’t allow yourself to become further manipulated; stick to your principles. I believe you cannot allow a chronic, destructive manipulator to work in your OR. You are the patient advocate; you must con- sider his safety and well-being. You must also consider staff morale, and a manipulator can make it pretty low.

It takes courage to tackle a manipulator. You make yourself vulnerable to a person skilled at winning at all costs. Make certain you are pre- pared with your support system and documen- tation.

Bonnie Payne, RN, MS Associate director of education

Notes

(Nashville, Tenn: Abingdon Press, 1967) 12. 1 . Everett L Shostrom, Man, The Manipulator

AHA meeting includes nurses ’ sessions Developments in basic and clinical cardiac research and advances in patient care will be presented at the 50th Scientific Sessions of the American Heart Association (AHA) in Miami Beach, Fla, Nov 28 to Dec 1 . Scientific sessions for nurses from Nov 28 to 30 will be held in conjunction with the general conference. Nurses’ sessions will feature reports on scientific research by nurses, cardiovascular conferences, and “how to” sessions.

The general scientific program is open to scientists, physicians, nurses, medical students, other health workers, and laymen interested in heart and blood vessel diseases. Approximately 1,000 research papers will be presented orally and in poster sessions; invited experts will deliver lectures, participate in symposia, and conduct postgraduate training seminars. There also will be scientific exhibits.

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