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Learning Scope #411
1 contact hour
Expires Dec. 10, 2014
You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.
Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
The goal of this continuing education article is to review the latest information on the book The Four Agreements and how it pertains to nursing. After reading this article, you will be able to:
1. Discuss the benefits of using The Four Agreements within the practice of nursing.
2. Describe what it means to become impeccable with your word.
3. Explain why it is important to not take things personally.
4. Describe the danger in making assumptions.
The author has completed a disclosure form and reports no relationships relevant to the content of this article.
We make agreements every day. Sometimes, we agree naturally with people. Other times, we need to work out an agreement that both parties can live with. Some agreements we make are legal and binding. Others are informal and can easily be changed by mutual consent.
We also make agreements with ourselves, sometimes calling them goals or our yearly New Year's resolutions. Some agreements we make with ourselves are made out of default by simply not paying attention to how we live our lives, developing individual behavioral patterns along the way. Some of these behavior patterns will prove to be helpful; others will have a negative impact on our lives.
In his book The Four Agreements, Don Miguel Ruiz writes that even though we make agreements with others, including God, "the most important agreements are the ones we make with ourselves. In these agreements, we tell ourselves who we are, how to behave, what is possible, what is impossible." Ruiz further explains self-agreements based in fear, such as negative, self-deprecating ones, can deplete our energy and diminish our self-worth.1
Self-agreements coming from fear can be more devastating to us than anything anyone else could say or do to us. They can take away our joy and create self-made discomfort and suffering. Negative agreements also can be described as negative self-talk. Examples of negative self-talk include sayings such as: "I will never be able to complete this paper on time"; "Who will hire me for the job of nurse manager - I am not even going to apply"; and "No one on the team appreciates me and I will never be able to make my opinions heard and implemented."
One way to change negative self-talk to positive is through the use of affirmations, or those sayings that replace a negative thought with a positive one. Changing the above negative self-talk into affirmations we would say: "I will complete a powerful and compelling paper by the due date"; "I have qualities that would be assets in the role of nurse manager"; and "My opinions are recognized by my teammates as helpful and worthy of implementation." Of course, through self-assessment, you might discover a trait that holds you back or recognize that you lack a certain skill needed for a position for which you aspire. In these cases, you need to take action. For example, you might choose to enroll in a management course to gain the skills needed to be a nurse manager, or take an assertiveness course so that you can share your ideas and opinions with confidence.
Like affirmations, making positive agreements with ourselves requires a change in how we view ourselves. In The Four Agreements, Ruiz describes four life-changing behavioral changes you can make to move toward a more fulfilling life. As with any change, you need to be ready to change. If you are ready, these simple yet powerful guiding principles can help you experience more self-assurance and self-respect and a higher quality of life. If you are not quite ready to change, reading The Four Agreements may offer you motivation to think about how making these changes can benefit you in your professional career as well as your personal life.1
The Four Agreements are not foreign to nursing and healthcare professionals. Nurse authors and others relate how the book can be applied to promote self-development and achieve a higher level of consciousness; to help reduce stress and create a friendlier environment for both patients and nurses; to inspire loyalty; and to help healthcare workers reconnect with the reasons they choose to work in healthcare and renew their sense of purpose. The Four Agreements have been used as a framework in recovery and relapse programs; and Doris Young, PhD, RN, known as "The Nurse Doctor" because of her desire to cure nurse burnout, called The Four Agreements a "breath of fresh air for our profession and everyone in it."2-7
Applying The Four Agreements
The Four Agreements are:
1. Be impeccable with your word.
2. Don't take anything personally.
3. Don't make assumptions.
4. Always do your best.1
Be Impeccable With Your Word
Although the word impeccable has its origins in Latin meaning "to be sinless," its contemporary connotations are that of being flawless. Being impeccable to Ruiz means using your words to honor, not to injure or defame; to speak what you believe to be truthful and helpful to others; and to avoid random chatter and never use your words to harm others. Abernathy and Kautz state it simply, "Stop and think before speaking and take the time to complete a self-check on what, how, when and why you say something."2
Being impeccable with your word also means not participating in gossip. When you think of it, nursing is too sacred a profession to lower itself to idle gossip. Thomas and Rozell write that we need to recognize gossip as a dynamic within nursing and develop ways to control it.8 Nurses can control gossip by monitoring the way we talk about patients and colleagues. When giving report, focus on facts and concerns, withholding judgment and value-laden comments. Nurses also can control gossip by holding themselves and their colleagues accountable to be professional in all interactions with each other.
Additionally, being impeccable with your word means you should choose your words wisely. Some nurses choose dramatic-sounding words to get their point across, hoping to make an impact. We need to consider how these words impact others. The sounds words make have an impact beyond the meaning of the word. Think about the sound of "brat" as opposed to "delicious." Brat sounds harsh and delicious rolls off your tongue - they're two different word experiences.
Nurses learn communication skills early on in their student careers. Often we apply good listening and communication skills in conversations with our patients but neglect to follow the same guidelines when speaking with colleagues. Telling a nurse she "really messed things up this time" is a lot different than saying: "Looks like things didn't turn out the way you thought they would. May I offer some suggestions that might help?"
Being impeccable with your word also means being honest with yourself, taking responsibility for your actions and not blaming or rejecting ourselves or others. In addition, being impeccable means maintaining confidences: Keep things private that need to be kept private. Ruiz says actions and words need to be consistent, and when your actions and words are consistent, others perceive you as reliable, honest and worthy of respect.
Don't Take Anything Personally
Personal reality is subjective. The way we respond to any given situation is based in part on our past experiences. Since we cannot know what everyone's past experiences have been, we have no clue how someone will react to something we say or do. We only find that out after we have spoken or acted. So with this in mind, we are reminded to not take things personally.
In nursing, much that occurs during our workday is outside of our control: colleagues call in sick, the radiology department has a piece of broken equipment and appointments are running late, or a patient scheduled for surgery needs to be cancelled because of an emergency procedure. Sometimes it is easier than others to not take things personally. At other times, when these unexpected things keep cascading on us, we begin to think, "Why me?" and may begin negative self-talk about how unfair life is being to us. Starting down this road leads to negative conclusions and often disrupts our positive relationships with others. How do you react when you sense things are unsteady in your immediate surroundings?
Let's remember too that for the most part each one of us wants to do the best we can. The colleague who loses her cool and snaps at you is probably behaving the best she can at that particular moment. See her behavior as an example of how she reacts when under stress instead of taking it as a personal affront. Is this easy? Of course not. It takes practice. According the Ruiz, not taking things personally helps any potentially stressful situation. Remembering "nothing others do is because of you" relieves us of the burden of blame and responsibility for others' actions. Knowing that, we can concentrate on our own behaviors and begin to respond with compassion with both our words and actions.1
Not taking things personally puts things in perspective. Not everything is about you. Not taking things personally relieves us of guilt and anxiety, helps reduce conflict, and promotes collegiality. It helps us allow others to have their own point of view. It helps us acknowledge another person's point of view without feeling like we need to defend ourselves or belittle or correct him.
Don't Make Assumptions
Assumptions are tricky: We assume something and then we believe it. Not making assumptions is a two-way street. Don't make assumptions about why others say and do what they do. Don't assume someone else knows how you think or feel about something. Not making assumptions takes the mindreading out of relationships.
The first step in the nursing process is assessment. We assess our patients' physical condition as well as their understanding of the condition. Nurses do not assume our patients and their families know what their diagnosis is, how to treat it or why they are taking the medications they do. Recently, a family member asked me why each healthcare professional involved in the evaluation of her son first asked her what she thought about his difficulties. She asked me, "Don't they read the chart and the materials I gave them?" I explained that those involved in the evaluation asked her for her impressions to find out firsthand her perception of her son's situation.
Recall that not every nurse on the team views nursing the same way, nor does each nurse define his or her role in the team in the same way. Don't assume others view the situation as you do. Just as we find out firsthand the impressions of our patients and their family members, we need to find out firsthand the views of our colleagues. Not making assumptions and asking others their perspective, belief or opinion helps us learn about the other person and enriches the time we spend working with them.
Ruiz advises us to have the courage to ask questions of others to understand their point of view as well as to express ourselves letting others know what we truly feel and think about any given situation. Doing this requires that we learn to accept how the other person thinks and feels about the situation.
Not making assumptions challenges us to become inquisitive, communicating clearly without the distraction of high drama or intense emotion. Only by asking questions and listening to other peoples' stories do we learn about life, about other people and about ourselves. Sharing our beliefs and opinions helps us replace "you should have known" with mutual understanding and respect.
Always Doing Your Best
According to Ruiz, doing your best varies depending on how you are feeling at the moment. Some days we just feel better and our work reflects that. Other days we seem to drag through the day. However, each day we need to agree to do our best. When we strive to do our best, we give ourselves the gift of never needing to regret that we could have done better. Doing our best gives us personal freedom and promotes personal self-respect.
Doing your best is all about taking action. "Action is about living fully," Ruiz writes. "Inaction is the way that we deny life. Expressing what you are is taking action."1
Doing our best protects us from going through life on autopilot, that is just moving along not really present in the moment. To always do your best, you need to like what you are doing. If you have lost the thrill you once found in your work, you may decide to talk with someone who can give you supportive feedback. You may need a change in position or role to keep you fresh and challenged.
When doing your best, recall it is also important to not go overboard. Don't push yourself beyond your capabilities. Keep things in perspective.
Make the Agreements Work for You
This article is just a summary of The Four Agreements. To really comprehend the full impact of the book, you need to read it. However, it is very understandable and can be read in short sittings. Try keeping one handy in the nurses' stations, staff bathroom or breakroom. Perhaps The Four Agreements can be a topic for a journal club or a unit-based share governance team. Nursing management may consider it as a useful set of self-agreements to advance their management skills and motivate those they supervise toward personal growth and professional advancement.
When a team decides to use The Four Agreements as a foundation for their work together, they can help each other make self-agreements that add to the team as a whole and to each member individually. Helping each other change negative self-talk and fear-based agreements with affirmations and positive agreements requires a change - a change that can lead to everyone experiencing more joy in their work and becoming more self-assured and confident in their lives.
1. Ruiz, D.M. (1997). The four agreements: A practical guide to personal freedom. San Rafael, CA: Amber-Allen Publishing Inc.
2. Abernathy, R.G. & Kautz, D.D. (2012). Finding personal freedom in nursing. Nursing, 42(2), 59-61.
3. Hill, R.Y. (2011). Nursing from the inside-out: Living and nursing from the highest point of your consciousness: transform yourself and impact your nursing practice through the art of self-care. Burlington, MA: Jones & Bartlett Publishers.
4. Hickey, M. & Kritek, P.B. (2012). Change leadership in nursing: How change occurs in a complex hospital system. New York: Springer Publishing Company.
5. Four agreements in healthcare. Accessed May 5, 2012 from the World Wide Web: http://www.newagreementshealthcare.com/index.shtml
6. Landon L. Workshops for clients in recovery. Accessed May 5, 2012 from the World Wide Web: http://lindalandon.com/recovery-4agreements-workshop.htm
7. Doris Young Associates. Four agreements. Accessed May 5, 2012 from the World Wide Web: http://savethefirstdanceforyou.com/wp/?p=10
8. Thomas, S.A. & Rozell, E.J. (2007). Gossip and nurses: Malady or remedy? Health Care Manager, 26(2), 111-115.
Joan M. Lorenz is a clinical specialist in psychiatric mental health nursing for adults. Throughout her career, she has held a variety of clinical positions, including patient safety manager, nurse manager, staff development educator and patient education coordinator. She currently provides consultation and workshops on a number of issues designed to empower work teams to make changes needed to put more joy in their work environments.