Strengthening Communication Among Healthcare Providers

Kaleida Health Mentor Program

What would it be like to go to work knowing that you are a part of a team and that your team won’t let your patient or you down?No matter what . . .

-Maude Dull, MD

Research supports

Patient care is negatively impacted when

healthcare professionals:• Engage in inappropriate communication and/or

behavior• Don’t speak up when confronted by disruptive or

problematic communication, behavior, decisions or actions of a colleague

Joint Commission

July 9th 2008 Publication:

• Supports previous research regarding the impact of intimidating and disruptive behavior on patient safety and staff satisfaction

Joint Commission: Poor communication

• Fosters medication errors• Increases the cost of care• Contributes to poor patient satisfaction and

preventable adverse outcomes• Leads to poor employee satisfaction and turnover of

staff

Employees who stay are likely to be less satisfied, engaged and productive

RN Perception Nationally: • 65% Nurses report verbal abuse experienced personally• 77% work with those who engage in it• 52% report it as often and frequent

(Critical Care Nurse,2006)

Kaleida Health:• 90% of RNs have experienced verbal abuse• Almost half rated their handling of the situation either “poor” or

“fair”• 45% of the incidents of verbal abuse were perceived to impact

patient care by the RN (RN Perception Survey, Kaleida Health, 2008)

Inappropriate/ negative communication is the result of:

• Oppression theory

• Low self esteem

• Immature coping skills

• Lack of interpersonal skills and/or conflict resolution skills

Even if we don’t engage in it, why don’t we speak up when we witness it?

• Subordinate relationships among healthcare providers

• “Not my job”, not in a management position• Afraid of confrontation • Low self esteem, lack of confidence in ability to

confront disruptive behavior or communication • Fear of retaliation

Failure to confront “witnessed” disruptive or negative communication or actions:

• Witnessing disruptive behavior or communication or poor or incompetent practice and DOING NOTHING is as problematic as those who engage in it

Can we choose to do nothing?

No, as healthcare professionals, our first obligation is to our patients!!!

Change the culture of silence

Initiate conversations immediately and directly when inappropriate behavior is demonstrated

Inappropriate behavior and/or communication

• Overt behaviors

• Covert behaviors

Overt behaviors

• Name calling• Bickering• Fault finding• Backstabbing• Criticism• Gossiping• Eye rolling

• Shouting• Blaming• Using put-downs• Raising eyebrows• Intimidation

Covert behaviors

• Unfair assignments• Sarcasm• Ignoring• Making a face• Refusing to help• Sighing

• Whining• Refusing to work with

someone• Isolation• Exclusion• Fabrication

How you deliver the message is as important as the message itself

• Non-verbal communication accounts for 90-95% of communication

Be aware of what you are saying non-verbally

Other Indicators of Inappropriate Communication in an Organization• Poor employee

satisfaction scores• High turnover rates• Morale issues

• Cliques• Numerous incident

reports• Absenteeism• Job hopping

Consequences of Consistent Inappropriate/Negative Communication (Suffering)

• Decreased self-esteem• Depression• Poor concentration• Forgetfulness• Fatigue & loss of sleep• Indecisiveness• Anxiety

• Migraines• Nightmares• Obsessive thinking

about a bully• Poor physical health• Suicidal thoughts

Consequences of Consistent Inappropriate/Negative Communication (Suffering)

The Bottom Line: Decreased optimal care for patients and increased incidents with increased risk for injury!

Impact on Retention?

New Nurses: Recruitment & Retention Research

“60% of all newly Registered Nurses leave their first position within 6 months because of some form of negative communication/lateral violence perpetrated against them.”

Griffin, M. (2004). Teaching Cognitive Rehearsal as a Shield for Lateral Violence: An Intervention for Newly Licensed Nurses. Journal of Continuing Education in Nursing, 35(6), 257-263.

Recruitment & Retention Research

Cost:• Turn-over has a huge financial impact on a

healthcare facility

• Cost of turn-over is 1.5 to 2 x’s the annual salary of the healthcare professional, i.e., the cost of losing an RN is $60,000 to $80,000

How do you change culture?

Who can change culture?

Communication and Conflict Resolution• Communication is a skill

• Communication starts with active listening

• Conflict resolution is a higher level skill built on effective communication and active listening plus….

Communication 101

DEPERSONALIZE: The more inappropriate communication is, the less you have to own it!!!!”

Communication 101

• Being able to depersonalize inappropriate communication and/or behavior allows us to effectively begin the process of conflict resolution

• When we do not feel diminished or upset we can focus on the goal

“No one can make me feel inferior without my consent” Eleanor Roosevelt

Communication 101

Two goals of any conversation

including conflict resolution:

• Good working relationships with co-workers

• Safe and optimal patient care

Conflict resolution 101

• Make positive assumptions• Keep goal of communication in mind• If you meet with resistance…”I don’t know what

you’re talking about”, “whatever”..,” you’re crazy”, don’t respond to the words, respond to the feelings and keep focused on goal, “You’re getting upset, that’s not my intent”.

• Repeat goal of conversation

Communication ToolsL isten to others perception

E xplain your perception

A cknowledge differences and similarities

R ecommend an action

N egotiate agreement

Communication Tools

D escribe the situation

E xpress concerns

S uggest alternatives

C onsequences of actions

Disruptive Physician Behavior• Results from unfair demands placed healthcare

professionals• MDs feel impact of reimbursement changes, decreased

LOS, increasing malpractice rates, frequent interruptions and longer work hours

• MDs often feel they have to “defend” decisions to everyone: nurse, pharm, attendings, and patients and families threatening to sue

• MD and nurses often feel they operate from two different perspectives

Communication Breakdown

Reasons for communication breakdown between nurse and physician

• Disagreement over discharge orders

• Disagreement over treatment plan

• Misunderstanding the other’s rationale for action or for delay in meds or treatments

Disagreement over discharge orders

Focus on:

• Patient safety, danger or harm to patient

• Ethical considerations

How to change the communication outcome

• Know what you are going to do and say prior to calling• Identify yourself and the patient• Have current labs and vital signs ready• Use critical thinking skills, know what is needed• Be direct, ask for what your patient needs and you want• Repeat orders out loud and summarize conversation

and decision(s)

SBAR

• Communication tool developed to ensure healthcare professionals communicate effectively and deliver safe and quality care

• Ensure that information given by the nurse is clear and concise

SBAR

S ituation - what is going on with the patient

B ackground - clinical context, information

A ssessment - what you think the problem is

R ecommendation - how you think the problem should/can be corrected

If you had the tools to cure a critical illness,

wouldn’t you use them?

-Maude Dull, MD

If communication remains disruptive

If inappropriate communication continues:• tell MD that you need to hang up or stop the

conversation until able to do so without raised voice or inappropriate behavior, as the conversation is not productive

• Hang up or end the communication• Notify your charge nurse, manager or

supervisor of the conversation

Enhance effective communication between nurse and physician

Strategies include:• Request that MDs call nurses by name• Develop strong, professional relationships with

physicians• Focus on shared goal: patient safety and quality care• Become skilled at SBAR and assist new nurses in its

use• Role model effective conflict resolution techniques

Strengthen communication between nurses and physicians

• Help educate physicians on nurse’s role• Remind physicians we are on the same team with

shared goals• Keep patients the focus of conversations and

specifically quality care and safety• Promote solidarity within nursing staff• Acknowledge positive relationships with physicians• Take personal responsibility for communication

breakdowns and use tools• Promote nursing, professionalism via education and

certification

Take Control• Empower Yourself• Create the kind of work environment you want

to work in• Deal with conflict proactively and professionally• Address the behavior, not the person• 99% of all conflict is miscommunication• Learn to be an effective communicator

Attitude is Everything!

Expected Behaviors of Professional Nurses• Do not gossip, do not listen, do not have conversations

with “absent participants”• Work cooperatively despite feelings of dislike• Don’t denigrate team members • Be willing to learn and help• Be respectful of everyone• Put patients first• Focus on outcome goals when conflict arises

Conclusion: New CultureIt is up to every employee to create a new culture of safety where the promotion of value and respect is everyone’s responsibility

Conclusion: New Culture

Joy at work, creating a community of caring for each other as well as our patients and families is possible if each employee sees ending inappropriate communication as an opportunity to change and improve our culture

Stop being a victim, empower yourself• Our deepest fear is not that we are inadequate. Our deepest fear

is that we are powerful beyond measure. It is our light, not our darkness that frightens us. We ask ourselves, who am I to be brilliant, talented, gorgeous, fabulous?

• Actually who are you not to be. Your playing small does not serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you. We are all meant to shine, as children do.

• And as we let our own light shine, we unconsciously give others the permission to do the same . As we are liberated from our own fear, our presence automatically liberates others.

“A Return to Love ;Reflections on the principles of A Course in Miracles”, Marianne Williamson, used in a speech by Nelson Mandela

Create a new culture.

Don’t let up. Be relentless.

Empower.-John P. Kotter