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 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 1 st 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)   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 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), 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), Bowles C. & Candela, L. (2005). First job experiences of recent graduates: Improving the work environment. Nevada Nurses Association ISSN: