Creating a Culture of Safe and Supportive Communication PDF

Creating a Culture of Safe and Supportive Communication Kim Stiles, PhD, RN, CNE, AHN-BC Sources of Difficult Communication Patterns Hierarchical relationships Deference to physicians or those “in charge” Revenue-generating physicians are often treated leniently Oppressive communication patterns com...

Creating a Culture of Safe and Supportive Communication Kim Stiles, PhD, RN, CNE, AHN-BC Sources of Difficult Communication Patterns Hierarchical relationships Deference to physicians or those “in charge” Revenue-generating physicians are often treated leniently Oppressive communication patterns communication was the root cause of 66% of sentinel events (1995-2005) (The Joint Commission) Protocol issues: protocol seen as “too picky” or unnecessary especially when staff are tired or rushed, failure to follow it. OR knee jerk response by admin to create/add additional steps to protocols when an error has occurred instead of addressing the root of the problem. Contributing Factors         Complexity of care Sophisticated, constantly changing technologies Time pressured schedules Stereotyping High stakes/high stress environment Heavy workloads: fatigue Organization failing to enforce code of conduct Concealment due to isolation in some areas. History as a Factor  Lateral violence: aggressive and destructive behavior of nurses against each other. Seen in oppressed populations.  Seen as a “right of passage.” “Paying your dues.”  “This is how people were to me when I was learning.  New-to-practice are at greatest risk. http://www.youtube.com/watch?v=2sTAolw9VDE  Cyclical in Nature      Most people don’t realize they are behaving this way (unconscious pattern). Most don’t intend to behave this way. Some even think they are helping you! Which means: Do NOT take behavior personally! Incivil Workplace Behavior          Talking behind another’s back Refusing to help someone when they need it (ex: doing procedure for the first time) Blocking chance for promotion Scapegoating, innuendo Criticizing a colleague in front of others Freezing a colleague out of activities Not relieving people for breaks Eyebrow raising, turning away, making faces Sabotage: deliberately setting up a negative situation (patient assignments). Consequences  Harm to patients  Increased use of sick days (absenteeism)  Physical and psychological symptoms of stress: anxiety, depression, feelings of powerlessness, HTN, sleep disturbances, headaches, GI distress.  Higher staff turnover (cost to replace a nurse is $82,000 to $145,000).  One U.S. study reports it occurred in 31% out of 511 nurses. Expected Behaviors of Professionals               Accept one’s fair share of the workload Address coworkers by first name. Respect the privacy of others. Keep confidences. Ask for help and advice when necessary. Be cooperative with shared physical work environment (noise, temperature, etc.) Make eye contact with coworkers when speaking. Be willing to help when requested. Don’t be overly inquisitive about each other’s lives. Repay compliments and favors (ex: shift coverage) Don’t talk about coworkers behind their back with others. Work cooperatively despite feelings of dislike. Don’t criticize publicly. Don’t denigrate others (have pet names, speak negatively about superiors) Do stand up for “absent” members in conversations when he/she is absent. Professionals Monitor the Whole Situation  They monitor themselves: IM SAFE  They monitor patient situations.  They monitor colleagues (are they stressed, do they need help? Do they need a break? What is their level of experience? Etc.)  They monitor the environment (does this equipment need to be repaired? What resources are available to help with all these new admits? Etc.) Cross Monitoring An error reduction strategy that involves: monitoring actions of other team members. providing a safety net within the team. ensuring mistakes or oversights are caught quickly and easily. “Watching each other’s back.” Cross Monitoring Link https://www.ahrq.gov/teamstepps-program/ resources/additional/cross-monitor.html How to Change the Culture Stategy 1: Cognitive Rehearsal Some possible 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 there was more information…” “I don’t feel right talking about this…” “I don’t feel right talking about him/her…” How it works:  Stops the automatic process of the event.  Allows time to process information previously taught: the event is not a personal affront.  Allows individual to respond/change behavior/clarify.  Liberates the oppressed by not letting oppressive behavior continue.  It is a conscious response.  http://www.youtube.com/watch?v=NujWmw8z7sg (2.47) Strategy 2: Two Challenge Rule  You present information that is ignored, minimized, questioned, or not heard the way you wanted it to be…  You have an obligation to speak up a second time!  This is a MUST for patient safety, no matter who you are or who the receiver is.  http://www.youtube.com/watch? v=EMwZLYJsKgU Strategy 3: Check back, Time out  Use closed loop communication for unfolding situations, emergencies, procedures, orders.  Unclear about next steps? Check back! Ask questions in report. State key points/next steps you will take. “I need some clarity”  See something happening that is unsafe? “Stop the line” until it is corrected.   Team unclear? Take a time out to discuss it, preferably before seeing the patient. This is called a huddle (see video below).  Huddle:  https://www.ahrq.gov/teamstepps-program/resources/additional/ huddle-emergency.html Checkback: https://youtu.be/ekX289e3-Uo https://www.ahrq.gov/teamstepps-program/resources/additional/callout.html Strategy 4: CUS! (politely)  Concerned  Uncomfortable  Safety  Combine the above words in a statement:  Ex: “I am concerned about Mrs. Smith’s low blood pressure and am uncomfortable giving her blood pressure medicine because it could be unsafe for her. https://www.ahrq.gov/teamstepps-program/resources/additional/ cus-equity.html Strategy 5: De-escalate  When team members disagree about what should be done:  Take the focus off the power struggle by refocusing discussion back to patient’s needs.  Enlist support of senior members of the team.  Identify those receptive to questions.  Listen to concerns of others.  Challenge yourself to remain civil in the face of incivility. See next slide for link to video SBAR video example:  https://www.ahrq.gov/teamstepps-program/ resources/additional/sbar.html