Teamwork and Collaboration: Teaching Strategies to Manage Challenging Communications

Gerry Altmiller, EdD, APRN, ACNS-BC

Learner will be able to identify types of difficult communications.

Learner will be able to describe manifestations and consequences of difficult communications

Learner will be able to describe strategies to use during difficult communications to improve patient safety.

Write about a situation/conversation where there was conflict that impacted patient safety-tell the story.

Hierarchical relationships Oppressive communication patterns

◦ Communication is the root cause of 66% of Sentinal Events 1995-2005 The Joint Commission

Complexity of care/Sophisticated technologies Heavy workloads-fatigue Time pressured schedules Stereotyping High stakes/high stress environment Organization’s failure to enforce code of conduct Concealment due to isolation

Interdisciplinary Interactions◦Hierarchial relationships◦Presence of an authority

gradiant◦Negative or disruptive

behaviors

Nurse-patient/patient-Nurse interactions◦Angry patients◦Angry nurses

Nurse-Nurse Interactions◦Lateral Violence: an aggressive &

destructive behavior of nurses against each other.

Woelfle & McCaffrey 2007

◦Results in injuring the dignity of another

◦Reduces one’s confidence and self esteem

Oppressed population concept Cyclical

Exclusion from the power structure Seen as “Right of Passage” “This is how people were to me when I was learning”

New-to-practice RNs and new-to-practice- area are at greatest risk

Talking behind one’s back Discouragement; humiliation Blocking chance for promotion Scapegoating; innuendo Belittling or criticizing a colleague in front of

others Isolating or freezing a colleague out of group

activities; exclusion Sabotage; withholding pertinent information In-fighting Failure to respect confidences and privacy Eyebrow raising, snide remarks, turning

away, making faces

Cyclical repetition Physical symptoms Use of sick days Extreme cases suicide Nurses leave the profession (1 in 3

internationally) 30% leave 1st new grad position within 1 year (Bowles & Candela, 2005)

Nurses aren’t at their best so patient care suffers

Lateral violence violates The Code of Ethics for Nurses with Interpretive Statements (ANA, 2001)

http://www.nursingworld.org/codeofethics Barriers impede knowledge & skill acquisition To improve professional practice life To stress for new to practice nurses To improve conflict resolution skills To attrition To stop new generations of nurses from being

socialized into negative practices The Joint Commission mandates change for patient safety in Sentinel Alert 40

Accept one’s fair share of the workload.

Respect the privacy of others. Be cooperative with regard to

the shared physical working conditions

(noise, temp). Be willing to help when

requested. Keep confidences. Work cooperatively despite

feelings of dislike. Don’t denigrate to superiors

(speak negatively about, have a pet name for)

Do address co-workers by their first name,

ask for help and advice when necessary. Make eye contact with co-workers when speaking. Don’t be overly inquisitive about each

other’s lives. Repay debts, favors, compliments. Don’t converse about a co-worker with

another co-worker. Stand up for the “absent member” in a

conversation when he/she is not present. Don’t criticize publicly.

Griffin, 2004

Cognition: obtaining, organizing & using intellectual knowledge

Self reflection both personal and professional

Liberate the oppressed by not letting it continue

Rehearsed direct responses◦ I see from your expression there is something…….◦ I learn most from people who communicate

directly..◦ When things are different from what I learned…..◦ It is my understanding that there was more

information…….◦ I don’t feel right talking about this….◦ I don’t feel right talking about him/her….

Griffin, 2004

◦Stops the automatic process of the event◦Consciously not responding or not reacting◦Allowing time to process information

previously taught The event is not a personal affront

◦Allows individual to respond differently to harmful inference of lateral violence

◦Liberates the oppressed by not letting it continue

Reframing conversation using safety strategies◦ Debriefing

Feedback whether positive or negative should always be an unbiased reflection of events and open the door to discussion of evidence-based practice

◦ Two Challenge Rule◦ CUS

Concerned, uncomfortable, safety◦ Check back◦ Time-out◦ Critical Language

“I need some clarification.”

Effective Communication

SBAR for Safe Patient Hand-offs◦ Situation◦ Background◦ Assessment◦ Recommendation

De-escalation techniques for aggressive behaviors

Take the focus off the power struggle Refocus discussion back to the patient needs Enlist the support of those more senior Identify those receptive to questions Listen to concerns of others End conversations where co-workers are being

discussed Reflection

Challenge yourself to remain civil in the face of incivility Ask yourself what went well? What went poorly? What could I have done differently?

Clear

Timely

Familiarize students with The Joint Commission expectation: Sentinel Event Alert 40: Behaviors that Undermine a Culture of Safety

Sentinel Event | Joint Commission

Reframe situation/conversation using:◦Cognitive Rehearsal◦Safety Strategies◦De-escalation

Difficult Communication patterns are a patient safety threat

Creates fear of ridicule for asking questions Strategy: Always bring focus back to the patient

Education has a positive effect◦ Empowers nurses to know that it is not personal◦ Breaks the cycle; it can be stopped◦ Contributes to making team members accountable

to each other◦ Encourages a professional dialogue

Woelfle, C. & McCaffrey, R. (2007). Nurse on nurse. Nursing Forum, 42(3), 123-31.

Griffin, M. (2004). Teaching cognitive rehearsal as a shield for lateral violence: An intervention for newly licensed nurses. The Journal of Continuing Education in Nursing, 35(6), 257-263.

Bowles C. & Candela, L. (2005). First job experiences of recent graduates: Improving the work environment. Nevada Nurses Association ISSN: 0273-4117