Difficult communications

1. Gerry Altmiller, EdD, APRN, ACNS-BC

2.  Learner will beableto identify typesof difficult
communications.
 Learner will beableto describemanifestationsand
consequencesof difficult communications
 Learner will beableto describestrategiesto use
during difficult communicationsto improvepatient
safety.

3.  Writeabout asituation/conversation wheretherewas
conflict that impacted patient safety-tell thestory.

4.  Hierarchical relationships
 Oppressivecommunication patterns
◦ Communication istheroot causeof 66% of Sentinal Events
1995-2005 The Jo int Commissio n
 Complexity of care/Sophisticated technologies
 Heavy workloads-fatigue
 Timepressured schedules
 Stereotyping
 High stakes/high stressenvironment
 Organization’sfailureto enforcecodeof conduct
 Concealment dueto isolation

5.  Interdisciplinary Interactions
◦ Hierarchial relationships
◦ Presenceof an authority gradiant
◦ Negativeor disruptivebehaviors

6.  Nurse-patient/patient-Nurse
interactions
◦ Angry patients
◦ Angry nurses

7.  Nurse-NurseInteractions
◦ Lateral Violence: an aggressive&
destructivebehavior of nursesagainst each
other.
Woelfle& McCaffrey 2007
◦ Resultsin injuring thedignity of another
◦ Reducesone’sconfidenceand self esteem

8.  Oppressed population concept
 Cyclical
 Exclusion from thepower structure
 Seen as“Right of Passage”
 “Thisishow peoplewereto mewhen I was
learning”
 New-to-practiceRNsand new-to-practice-
areaareat greatest risk

9.  Talking behind one’sback
 Discouragement; humiliation
 Blocking chancefor promotion
 Scapegoating; innuendo
 Belittling or criticizing acolleaguein front of others
 Isolating or freezing acolleagueout of group activities;
exclusion
 Sabotage; withholding pertinent information
 In-fighting
 Failureto respect confidencesand privacy
 Eyebrow raising, snideremarks, turning away, making
faces

10.  Cyclical repetition
 Physical symptoms
 Useof sick days
 Extremecasessuicide
 Nursesleavetheprofession (1 in 3 internationally)
 30% leave1st
new grad position within 1 year
 (Bowles& Candela, 2005)
 Nursesaren’t at their best so patient caresuffers

11.  Lateral violenceviolates The Co de o f Ethics fo r Nurses
with Interpretive Statements (ANA, 2001)
 http://www.nursingworld.org/codeofethics
 Barriersimpedeknowledge& skill acquisition
 To improveprofessional practicelife
 To stressfor new to practicenurses
 To improveconflict resolution skills
 To attrition
 To stop new generationsof nursesfrom being socialized
into negativepractices
 TheJoint Commission mandateschangefor
patient safety in Sentinel Alert 40

12.  Accept one’sfair shareof the
workload.
 Respect theprivacy of others.
 Becooperativewith regard to the
shared
 physical working conditions(noise,
temp).
 Bewilling to help when requested.
 Keep confidences.
 Work cooperatively despite
feelingsof dislike.
 Don’t denigrateto superiors
(speak negatively about, haveapet
namefor)
 Do addressco-workersby their first
name,
 ask for help and advicewhen necessary.
 Makeeyecontact with co-workerswhen
 speaking.
 Don’t beoverly inquisitiveabout each
other’slives.
 Repay debts, favors, compliments.
 Don’t converseabout aco-worker with
another co-worker.
 Stand up for the“absent member” in a
conversation when he/sheisnot present.
 Don’t criticizepublicly.
Griffin, 2004

13.  Cognition: obtaining, organizing & using
intellectual knowledge
 Self reflection both personal and professional
 Liberatetheoppressed by not letting it
continue

14.  Rehearsed direct responses
◦ I seefrom your expression thereissomething…….
◦ I learn most from peoplewho communicatedirectly..
◦ When thingsaredifferent from what I learned…..
◦ It ismy understanding that therewasmoreinformation…….
◦ I don’t feel right talking about this….
◦ I don’t feel right talking about him/her….
Griffin, 2004

15. ◦ Stopstheautomatic processof theevent
◦ Consciously not responding or not reacting
◦ Allowing timeto processinformation previously
taught
 The event is no t a perso nal affro nt
◦ Allowsindividual to respond differently to harmful
inferenceof lateral violence
◦ Liberatestheoppressed by not letting it continue

16.  Reframing conversation using safety strategies
◦ Debriefing
 Feedback whether positiveor negativeshould alwaysbean
unbiased reflection of eventsand open thedoor to discussion of
evidence-based practice
◦ Two Challenge Rule
◦ CUS
 Concerned, uncomfortable, safety
◦ Check back
◦ Time-o ut
◦ CriticalLanguage
 “I need someclarification.”

17. Effective Communication
 SBAR for Safe
Patient Hand-offs
◦ Situation
◦ Background
◦ Assessment
◦ Recommendation

18.  De-escalation techniquesfor aggressivebehaviors
 Takethefocusoff thepower struggle
 Refocusdiscussion back to thepatient needs
 Enlist thesupport of thosemoresenior
 Identify thosereceptiveto questions
 Listen to concernsof others
 End conversationswhereco-workersarebeing discussed
 Reflection
 Challengeyourself to remain civil in thefaceof
incivility
 Ask yourself what went well? What went poorly?
What could I havedonedifferently?

19. Clear
Timely

20.  Familiarizestudentswith TheJoint Commission
expectation: Sentinel Event Alert 40: Behaviorsthat
UndermineaCultureof Safety
 Sentinel Event | Joint Commission

21.  Reframesituation/conversation using:
◦ CognitiveRehearsal
◦ Safety Strategies
◦ De-escalation

22.  Difficult Communication patternsareapatient safety
threat
 Createsfear of ridiculefor asking questions
 Strategy: Alwaysbring focusback to thepatient
 Education hasapositiveeffect
◦ Empowersnursesto know that it isnot personal
◦ Breaksthecycle; it can bestopped
◦ Contributesto making team membersaccountableto each
other
◦ Encouragesaprofessional dialogue

23. Woelfle, C. & McCaffrey, R. (2007). Nurseon nurse. Nursing
Fo rum, 42(3), 123-31.
Griffin, M. (2004). Teaching cognitiverehearsal asashield for
lateral violence: An intervention for newly licensed nurses.
The Jo urnalo f Co ntinuing Educatio n in Nursing, 35(6), 257-
263.
BowlesC. & Candela, L. (2005). First job experiencesof recent
graduates: Improving thework environment. Nevada Nurses
Asso ciation ISSN: 0273-4117