Discussion: Communication and Collaboration for Health Care Leadership

Discussion: Communication and Collaboration for Health Care Leadership ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: Communication and Collaboration for Health Care Leadership Discussion questions: Question 1: Tell us about a recent situation involving undiscussables as described in “The Silent Treatment Report.” Is this common at your workplace? What are the effects on patient care and on the overall culture? Discussion: Communication and Collaboration for Health Care Leadership Question 2: What are your thoughts after reading the memo and standards from this AACN study. What did you notice particularly as you read these documents? What reactions did you have? Question 3: Are you an effective communicator in writing, speaking and resolving conflict? Can you build trusting collaborative relationships in the many contexts of your work with – patients, other nurses, and other members of the Interprofessional healthcare team? Question 4: As a soon to be prepared leader, how do you envision using the strategies offered in the Disrespectful Behavior resource for assessing disrespectful behaviors, including silence? the_silent_treatment_report.pdf VitalSmarts, AORN, & AACN present: The Silent Treatment Why Safety Tools and Checklists Aren’t Enough to Save Lives David Maxfield, Joseph Grenny, Ramón Lavandero, and Linda Groah Silence Kills was conducted immediately before AACN’s national standards for healthy work environments were released10. It identified seven concerns that often go undiscussed and contribute to avoidable medical errors. It linked the ability of health professionals to discuss emotionally and politically risky topics in a healthcare setting to key results like patient safety, quality of care, and nursing turnover, among others. Imagine you are a nurse who has been given a set of new safety tools that warns you whenever your patients are in danger. That would be powerful, life-saving information, right? But what if nobody listened to you or heeded your warnings? This kind of breakdown is happening in hospitals every day. The quote below is one of 681 collected in the course of this research. “I think nearly every day we are faced with the hand-off allergy list. Frequently, the surgeons will order an antibiotic the patient is allergic to according to the safety checklist. When the patient is out of surgery, nurses have to call the surgeon, the anesthesiologist, and sometimes even the pharmacist before someone listens. Sometimes, we go ahead and give the drugs anyway, but when you really listen to the patient’s story, sometimes that is not the right thing to do.” Poor communication is deadly, especially in critical care settings1,2. When communication breaks down in intensive care units (ICU) and operating rooms, the result is catastrophic harm3,4,5,6 and even death7,8. The study examines an especially dangerous kind of communication breakdown: risks that are known but not discussed, or “undiscussables.” It builds on findings from research conducted in 2005 by the American Association of Critical-Care Nurses (AACN) and VitalSmarts9 as documented in the research Silence Kills: The Seven Crucial Conversations for Healthcare. The Silent Treatment shows how nurses’ failure to speak up when risks are known undermines the effectiveness of current safety tools. It then focuses on three specific concerns that often result in a decision to not speak up: dangerous shortcuts, incompetence, and disrespect. The Silent Treatment tracks the frequency and impact of these communication breakdowns, then uses a blend of quantitative and qualitative data to determine actions that individuals and organizations can take to resolve avoidable breakdowns. Background When communication breaks down, it breaks down in two very different ways. Business theorist, Chris Argyris ,groups these breakdowns into two categories: honest mistakes and undisscussables11. Each category has a different cause, produces a different range of outcomes, and requires different solutions. Honest mistakes include accidental or unintentional slips and errors—for example: poor handwriting, confusing labels, difficult accents, competing tasks, language barriers, distractions, etc. Somehow, the baton is dropped during handoffs between shifts, departments, specialties, or caregivers. Psychologist, James Reason, describes these honest mistakes as the human equivalent of gravity12— they are inevitable. So they must be guarded against. When healthcare organizations invest in improving communication, they usually focus on reducing these honest mistakes. Discussion: Communication and Collaboration for Health Care Leadership They implement handoff protocols, checklists, computerized order entry systems, automated medication dispensing systems, and other similar solutions all aimed at doing away with these unintentional slips and errors. These improvements are absolutely essential but they fail to address the second category of breakdowns, the undiscussables. When people know of risks and do not speak up, the breakdown feels more intentional. Someone knows, or strongly suspects, that something is wrong, but chooses to ignore or avoid it. He or she may attempt to speak up but quits when faced with resistance. It’s not a slip or error; it’s a calculated decision to avoid or back down from the conversation. Information-based solutions like protocols, checklists, and systems don’t do much to solve the breakdowns in this second category. The literature on organizational silence13,14 suggests that solving undiscussables will require deeper changes to cultural practices, social norms, and personal skills. The Silent Treatment examines these calculated decisions to not speak up. It tracks how risks that are known but not discussed undermine many current safety tools. It documents the frequency and impacts of these discussions, and shows how individuals and organizations can make undiscussables discussable. Study Design and Sample Two survey instruments were employed: a Story Collector and a Traditional Survey. The Story Collector generated rich, qualitative data; the Traditional Survey produced purely quantitative data. Convenience sampling was used for both instruments. Members of the AACN and the Association of periOperative Registered Nurses (AORN) were invited via e-mail to participate in the study. The e-mail invitation included an online link that assigned respondents to one of the two instruments. The Story Collector was completed by 2,383 registered nurses, of whom 169 were managers; The Traditional Survey was completed by 4,235 nurses, of whom 832 were managers. Story Collector: This survey instrument asked respondents to share actual incidents—stories that described times when they were personally unable to speak up or get others to listen. The data obtained through the Story Collector is similar to what researchers otherwise might gather from interviews, but with several differences. First, the Story Collector methodology can reach more people than interviews allow. Second, Story Collector questions are standardized and presented in writing, so interviewer bias is eliminated. Third, respondents write their own responses, so transcription errors are eliminated. Fourth, people generally do not share more than a couple stories in writing—fewer than what a researcher might generate from an interview, so less data is collected from each respondent. Traditional Survey: This survey instrument was a more traditional Likert-scale questionnaire. It collected quantitative data related to three concerns: dangerous shortcuts, incompetence, and disrespect. Respondents were asked how often they face these concerns within their immediate work group, how they handle these concerns, and how these concerns have impacted patients on their units. In addition, the instrument included questions that explored personal, social, and structural sources that could influence how dangerous shortcuts, incompetence, and disrespect are handled. Discussion: Communication and Collaboration for Health Care Leadership Safety Tools and Organizational Silence— Story Collector Findings The Story Collector listed four survey safety tools that are intended to prevent unintentional slips and errors (Universal protocol checklist15, WHO checklist16, SBAR handoff protocol17, and druginteraction warning systems). The respondents (nurses) were then asked how often they had been in situations where one of these tools worked—where it warned them of a problem that otherwise might have been missed and harmed a patient. As noted in the chart below, 85 percent (2,020) of the nurses said they had been in this situation at least once, and 29 percent (693) said they were in this situation at least a few times a month. These results strongly confirm that safety tools work. Operating rooms and ICUs are fast paced, complex, and full of disruptions. Checklists, protocols, and warning systems are an essential guard against unintentional slips and errors. However, the Story Collector data documented that the effectiveness of these safety tools is being undercut by undiscussables: 58 percent (1,403) of the nurses said they had been in situations where it was either unsafe to speak up or they were unable to get others to listen. And 17 percent (409) said they were in this situation at least a few times a month. 90% control, or do you feel able to solve them or prevent them from happening again in the future? Ever 0.85 A Few Times a Month 80% Ever A Few Times a Month 70% 0.58 60% 50% All of the triple negatives were high-stakes incidents because they involved a risk to patient safety. Three quarters of the incidents involved confronting physicians, two thirds involved standing up to a group, and half involved disrespect, threats, and anger. 40% 30% 0.29 Below are three examples of the triple negative incidents: 0.17 20% 10% 0% Using this tool, the study documented 608 incidents, averaging 128 words each. Of these self-described incidents, 8 percent represented patterns that were described by the respondent as permanent, pervasive, and beyond his or her control—what the current study refers to as “triple negatives.” Triple negatives represent the kinds of communication breakdowns that systematically prevent safety tools from protecting patients. Safety Tool Warned Me of a Problem the Team Might Otherwise have Missed Safety Tool Warned Me. But I was Unable to Speak Up and Get Anyone to Listen The nurses who indicated they experienced these undiscussables were asked to describe the incident in some detail, and were given the following prompt: Please describe a specific incident when a tool warned you about a possible problem, but it was either hard to speak up or hard to get others to listen and act. We want to understand what happened. Please relate this incident as if you were telling us the whole story from beginning to end. What kind of tool/checklist/warning system were you using? What was the possible problem you discovered? Who did you need to convince and collaborate with to solve it? What did you do? How did they react? What made it difficult? What happened in the end? What conclusions did you draw as a result? Each nurse then rated the incident he or she had described using three dimensions: • “A special graft was ordered and due to arrive at 10:00. Discussion: Communication and Collaboration for Health Care Leadership The surgeon insisted the day before he had to have this particular graft. The day of surgery the graft was not yet physically in the building but the surgeon insisted we put the patient to sleep. My stand was that unless you were prepared to use something else we should wait until it arrived. All of our checklists and protocols require that all implants and necessary items are available before the case begins. The surgeon said he would [get the graft] if necessary. I felt we were jeopardizing patient care, setting a poor example to the staff and why do we go through all these things in the first place?” • “As a cost saving measure, the institution I worked for looked for the lowest priced generic item, so the same medication ordered looked different every time you dispensed it. The bin on the shelf might have four different shaped and colored vials all labeled as the same item. I took one of the administrative safety people through our medication room to show them how easy it was to make an error when no two vials of the same medication looked the same. After that we saw much less substitution and greater consistency.” • “Inserting central line at bedside in ICU. Used checklist but surgeon refused maximal sterile barrier and in fact, ridiculed me and hospital staff for instituting (this precaution) when there is no ‘proof’ it works. Hospital does not allow RN to stop procedure so it was inserted without maximal sterile barrier.” • Permanence: Was this experience a one-time event, or is it part of a continuing pattern in how people treat each other in your work environment? The incidents above capture the kinds of high-stakes and emotional differences of opinion that occur within operating rooms and ICUs. These differences become dangerous when they become undiscussable. • Pervasiveness: Was this experience isolated to only one part of your work life (for example, experienced with just one physician, one caregiver, one manager, one patient, or one kind of problem) or is it widespread across all areas of your work? Three Undisscussables: Traditional Survey Findings • Lack of Control: When incidents like the one you just described happen, does it feel as if they are out of your As noted earlier, the 2005 Silence Kills study examined seven concerns that often go undiscussed, and linked the ability to discuss these emotional, risky topics to key results such as patient safety, quality of care, and nursing turnover. The 2010 study examines three of the seven concerns found in the 2005 study, using the same Likert-scale survey items. These three concerns—dangerous shortcuts, incompetence, and disrespect— are not necessarily prompted by any of the safety tools examined with the Story Collector. Instead, they tend to emerge over time, as people observe each other on the job. Findings from nonsupervisory nurses who completed the current study’s Traditional Survey are summarized below: 1 Concerns about dangerous shortcuts. • 41% have spoken to their manager about the person whose shortcuts create the most danger to patients. • 17% have spoken to the person taking the dangerous shortcuts, but haven’t shared their full concerns.Discussion: Communication and Collaboration for Health Care Leadership • 31% have spoken to the person taking the dangerous shortcuts, and shared their full concerns. 2 Concerns about incompetence. a. Incompetence is common. • 82% work with people who “are not as skilled as they should be (for example, they aren’t up-to-date on a procedure, policy, protocol, medication, or practice or are lacking basic skills).” a. Shortcuts are common. • 84% work with people who “take shortcuts that could be dangerous for patients (for example, not washing hands long enough, not changing gloves when appropriate, failing to check armbands, forgetting to perform a safety check).” b. Incompetence is dangerous. • 31% say that incompetence has led to near misses. b. Shortcuts are dangerous. • 26% say incompetence has affected patients, but without harm. • 34% say that these dangerous shortcuts have led to near misses. • 19% say incompetence has harmed patients. • 27% say shortcuts have affected patients, but without harm. c. Incompetence is often left undiscussed. • 48% have spoken to their manager about the person whose missing competencies create the greatest danger to patients. • 26% say shortcuts have harmed patients. c. Shortcuts are often left undiscussed. • 11% have spoken to the person, but haven’t shared their full concerns. Silence Kills: The Seven Crucial Conversations For Healthcare found that seven categories of conversations are especially difficult and, at the same time, especially essential for people in healthcare to master. These seven conversations include: broken rules (including dangerous shortcuts), mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. The study showed that a majority of healthcare workers regularly see colleagues take dangerous shortcuts, make mistakes, fail to offer support, or appear critically incompetent. Yet the research reveals fewer than one in ten speak up and share their full concerns. • 21% have spoken to the person, and have shared their full concerns. 3 Concerns about disrespect. a. Disrespect is common. • 85% work with people who “demonstrate disrespect (for example, are condescending, insulting, or rude— or yell, shout, swear, or name call).” b. Disrespect causes problems. • 46% say that disrespect undercuts respect for their professional opinion. • 19% say that disrespect makes them unable to get others to listen. • 20% say that disrespect is making them seriously consider leaving their job or profession. c. Disrespect is often left undiscussed. • 49% have spoken to their manager about the person whose disrespect has the greatest negative impact. • 16% have spoken to the person who is demonstrating disrespect, but haven’t shared their full concerns. • 24% have spoken to the person who is demonstrating disrespect, and shared their full concerns. The data presents a convincing case. Organizational silence leads to communication breakdowns that harm patients. Discussion: Communication and Collaboration for Health Care Leadership 1. More than four out of five nurses have concerns about dangerous shortcuts, incompetence, or disrespect. 2. More than half say shortcuts have led to near misses or harm. 3. More than a third say incompetence has led to near misses or harm. 4. More than half say disrespect has prevented them from getting others to listen to or respect their professional opinion. 5. Fewer than half have spoken to their managers about the person who concerns them the most. • “A cardiovascular surgeon was putting in an arterial line at the bedside. We have a checklist that must be completed for line placement that includes full barrier, washing hands, etc. The M.D. refused the sterile gown, mask, hat, and drape, and used only sterile gloves. The nurse offered the full barrier again telling him that all lines were put in with full barrier in our unit. He continued with the procedure. The bedside nurse did not feel empowered to stop the procedure. She later took the problem to the unit manager. No action was taken.” This study shows that taking problems to a manager, and assuming he or she will handle them, doesn’t produce the kind of immediate and reliable results needed in healthcare. 6. And fewer than a third have spoken up and shared their full concerns with the person who concerns them the most. The data also shows that nurses are more likely to take their concerns to their managers than they are to speak directly to the person they are concerned about. Since working through the hierarchy is often assumed to be the appropriate way to address a problem, it is important to examine how well this strategy works. Results from Nurse Managers The responses from the 832 nurse managers who completed the Traditional Survey were reviewed separately from the nonsupervisory nurses. A surprising finding was that managers do not appear to be a reliable path for resolving concerns about dangerous shortcuts, incompetence, or disrespect. Only 41 percent of the nurse managers reported that they had spoken up to the person whose dangerous shortcuts create the most danger for patients. Equally troubling is that only 28 percent had spoken up to the person whose missing competencies create the most danger for patients, and only 35 percent had spoken up to the person whose disrespect has the greatest negative impact. The data above comes from the nurse managers, themselves. They admit their failure to address these important patient safety issues. The Story Collector data provides dramatic confirmation from the subordinate’s perspective. • “During the surgical safety checklist, we realized the permit and the scheduled surgery did not match (wrong side). We tried to stop the doctor (plastic surgeon) and he said the permit was wrong. The patient was already asleep and he proceeded to do the wrong side against what the patient had verified, which had matched the permit. We could not get any support from the supervisor or anesthesiologist. The surgeon completed the case. Nothing was ever done. “We felt awful because there was no support from management to stop this doctor. What is the point of having a checklist when it is not consistently followed? We felt absolutely powerless to being an advocate for the patient.” Differences Between 2005 and 2010 Studies In general, the results from The Silent Treatment 2010 study are in line with the Silence Kills 2005 data. But there are a few differences that need to be explained. More of the nurses in the 2010 study have concerns about dangerous shortcuts, incompetence, and disrespect; more have seen patients harmed; and more speak up about their concerns. The authors of the … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10