1. Teamwork and Collaboration: Teaching Strategies to Manage Challenging Communications Gerry Altmiller, EdD, APRN, ACNS-BC

2. Objectives • 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.

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

4. Sources of Difficult Communications • 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

5. Types of Difficult Communications • Interdisciplinary Interactions • Hierarchial relationships • Presence of an authority gradiant • Negative or disruptive behaviors

6. Types of Difficult Communications • Nurse-patient/patient-Nurse interactions • Angry patients • Angry nurses

7. Types of Difficult Communications • 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

8. History of Lateral Violence • 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

9. MANIFESTATIONS • 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

10. CONSEQUENCES • 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

11. Why address this? • 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

12. Expected Behaviors of Professionals • 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 • 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)

13. How can we change this?Strategy #1 • Cognition: obtaining, organizing & using intellectual knowledge • Self reflection both personal and professional • Liberate the oppressed by not letting it continue

14. Intervention: Cognitive Rehearsal • 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

15. How does it work? • 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

16. How can we change this?Strategy #2 • 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.”

17. Teamwork and Collaboration • SBAR for Safe Patient Hand-offs • Situation • Background • Assessment • Recommendation Effective Communication

18. How can we change this?Strategy #3 • 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?

19. Brief Clear Timely

20. Joint Commission Recommendations • Familiarize students with The Joint Commission expectation: Sentinel Event Alert 40: Behaviors that Undermine a Culture of Safety • Sentinel Event | Joint Commission

21. Exercise • Reframe situation/conversation using: • Cognitive Rehearsal • Safety Strategies • De-escalation

22. Summary • 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

23. References 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