Part I A nurse at an acute care hospital is caring for a patient who is not doing well. The patient is a 65 year old male who was originally admitted four months ago follow

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Beginning the Journey to Skilled Communication

AACN Advanced Critical Care

Volume 17, Number 3, pp.266–271

© 2006, AACN

Denise Thornby, MS, RN, CNAA

As a new manager in a surgical intensive care unit (ICU), I quickly noticed that

multiple times each week one of our vascular surgeons would show up at my office door asking, “Who is the nurse taking care of my patient?” I would patiently walk him to the large assignment board in the unit, identify who his patient’s assigned nurse was and then walk with him to the bedside. The nurse was not at the bedside, and when I inquired where the nurse was, I was told she was on break. After multiple episodes and multiple in- quiries, I found that some of the nurses were coping with what was perceived to be a “dif- ficult, aggressive surgeon” by going on break once he arrived on the unit. In my follow-up conversations, a number of my staff talked about how they felt frightened and unsafe in

communicating with him about his patients’ conditions, their assessments, and needed in- terventions.

The situation above might illustrate an ex- treme example of conflict avoidance, but it is not all that unusual in an environment where critical care nurses are not skilled in communi- cating concerns and differences or confronting individuals or issues. It also exemplifies a work environment that is not healthy and thus places the care of patients at risk. Intimidating behavior and deficient interpersonal skills cre- ates a culture of silence, where there can be

Intimidating behavior and deficient inter-

personal skills create a culture of silence,

where there can be a breakdown in team

communications and an inability to collabo-

rate and achieve high-quality outcomes. A

study from VitalSmarts (Provo, Utah),

Silence Kills: The Seven Crucial Conversa-

tions for Healthcare, described 7 crucial

conversations healthcare professionals

struggle with that contribute to patient harm

and unacceptable error rates. The American

Association of Critical-Care Nurses’ first

standard (from AACN Standards for Estab-

lishing and Sustaining Healthy Work Envi-

ronments: A Journey to Excellence), skilled

communication, states: “Nurses must be as

proficient in communication skills as they

are in clinical skills.” Once it is accepted that

being competent in skilled communication

is essential to excellent patient care, it then

takes skill development and added courage

to hold crucial conversations and address

difficult situations. The first step begins

with a self-assessment to determine cur-

rent effectiveness as a communicator and

manager of conflict and to realize opportu-

nities for growth. Three key strategies to

begin the development of skilled communi-

cation include: (1) understanding the im-

portance of a climate of safety, (2) acknowl-

edging one’s mental stories, and (3)

realizing that the only people we control

are ourselves.

Keywords: conflict, crucial conversations,

difficult conversations, healthy work envi-

ronments, skilled communication

A B S T R A C T

Denise Thornby is Director, Education and Professional

Development, Virginia Commonwealth University Health

System, PO Box 980073, Richmond, VA 23298-0073 (e-mail:

[email protected]).

VOLUME 17 • NUMBER 3 • JULY–SEPTEMBER 2006 BEGINNING THE JOURNEY TO SKILLED COMMUNICATION

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breakdown in team communications and an inability to collaborate and achieve high- quality outcomes. The Joint Commission on Accreditation of Healthcare Organization’s publication, Health Care at the Crossroads: Strategies for Addressing the Evolving Nurs- ing Crisis, reported findings that more than one half of nurses have been subject to verbal abuse and over 90% have witnessed disruptive behavior.1

Skilled Communication Standard In 2005, the American Association of Critical- Care Nurses (AACN) published the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence.2 They articulated 6 standards based on the interwoven concepts and rela- tionships of the quality of work environment, excellent nursing practice, and patient care outcomes. The standards are evidence-based and founded on relationship-centered princi- ples of professional performance, such as how healthcare professionals communicate, make decisions, and collaborate. Each standard is considered essential to the creation of a truly healthy work environment.

The first standard, skilled communication, states, “Nurses must be as proficient in com- munication skills as they are in clinical skills.”2

Clinical knowledge, skills, and judgment are not enough to achieve excellent outcomes. Critical care nurses must demonstrate the abil- ity to be skilled communicators in all aspects of their professional work in order to achieve safe care and quality outcomes. The skilled communication standard articulated by AACN also describes a work environment where these skills are fostered and supported (Table 1). Without supportive, healthy envi- ronments, nurses will be unable to achieve the desired behaviors of skilled communication and care will continue to suffer.3

Silence Kills It is critical to understand that the skills of communication may be as, if not more, impor- tant than the ability to interpret an electrocra- diogram strip or detect a heart murmur. This was clearly illustrated by the results from the landmark study, Silence Kills.4 AACN and VitalSmarts, a company specializing in leadership training and organizational per- formance, studied more than 1,700 nurses,

Table 1: Critical Elements for Standard One—Skilled Communication

• The healthcare organization provides team

members with support for and access to

education programs that develop critical

communication skills including self-awareness,

inquiry/dialogue, conflict management,

negotiation, advocacy and listening.

• Skilled communicators focus on finding solutions

and achieving desirable outcomes.

• Skilled communicators seek to protect and

advance collaborative relationships among

colleagues.

• Skilled communicators invite and hear all

relevant perspectives.

• Skilled communicators call upon goodwill and

mutual respect to build consensus and arrive at

common understanding.

• Skilled communicators demonstrate congruence

between words and actions, holding others

accountable for doing the same.

• The healthcare organization establishes zero-

tolerance policies and enforces them to address

and eliminate abuse and disrespectful behavior

in the workplace.

• The healthcare organization establishes formal

structures and processes that ensure effective

information sharing among patients, families,

and the healthcare team.

• Skilled communicators have access to

appropriate communication technologies and

are proficient in their use.

• The healthcare organization establishes systems

that require individuals and teams to formally

evaluate the impact of communication on clinical,

financial, and work environment outcomes.

• The healthcare organization includes

communication as a criterion in its formal

performance appraisal system and team

members demonstrate skilled communication to

qualify for professional advancement.

Reprinted with permission from the American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence; 2005:17–18. Available at: http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWEStandards/$file/ HWEStandards.pdf. Accessed March 18, 2006.

THORNBY AACN Advanced Cri t ical Care

268

physicians, clinical staff, and administrators. They found that less than 10% of healthcare professionals confronted behaviors in others, such as trouble following directions, poor clin- ical judgment, or taking harmful shortcuts. They further illustrated the role of a culture that accepts poor communication and collabo- ration among the healthcare team in leading to communication gaps that can cause harm to patients.

The study authors described 7 “crucial con- versations” healthcare professionals struggle with that contribute to patient harm and unac- ceptable error rates (Table 2). It is important to note that the study found that the majority of healthcare professionals surveyed do not exhibit problematic behaviors, but many of them have witnessed individuals who have sig- nificant performance issues and find them dif- ficult to confront. They suggest that improve- ment in the ability to effectively confront and hold difficult conversations can contribute to significant reductions in errors, as well as improve the quality of care, reduce nursing turnover, and achieve healthier work environ-

ments. This evidence should compel all health- care professionals to self-examine communica- tion and collaboration skills, as well as the willingness to confront those with problematic behaviors.

First Steps in Skill Development Once it is accepted that being competent in skilled communication is essential to excellent patient care, it then takes skill development and added courage to hold crucial conversations and address difficult situations. Communica- tion, including the skill of confrontation, is like any other skill professionals need to master.

Step one begins with a self-assessment to determine current effectiveness as a communi- cator and manager of conflict and to realize opportunities for growth. Self-awareness is a critical skill in developing the ability to be effective, influential, and skilled in dialogue, conflict, and managing change.5 As one begins to learn about effective communication and confrontation and practices these skills, one must also align resources to assist with the journey. Finding a mentor or coach to provide

Table 2: Silence Kills—7 Crucial Concerns Requiring Crucial Conversations

1. Broken Rules—taking shortcuts, not following procedures or standards that can lead to patient harm.

Examples might include failure to check second identifier prior to administering a medication, not using

infection control precautions or bypass “time-out” procedures prior to an invasive procedure at the

bedside.

2. Mistakes—difficulty following directions, demonstrating poor clinical judgment, or inadequate

assessment of patients. Examples might include: inability to effectively triage patients or set priorities of

care, missing the importance of critical symptoms or test results, attempting to manage difficult

situations without the appropriate skill level or competency.

3. Lack of support—Examples might include: unhelpful behaviors, refusing to answer a question or provide

needed patient information, impatient and making it difficult for others to ask for assistance,

complaining when asked to help or refusal to assist others, or nonhelpful critique of others.

4. Incompetence—Examples might include questionable interventions, inability to deliver a standard of

care, lack or critical thinking skills, or lack of knowledge and skill required by one's position.

5. Poor teamwork—nonsupportive team behaviors. Examples might include: cliques that divide the team,

not valuing or acknowledging the contributions of others, unhealthy competition with others, not being

dependable, or looking good at other's expense.

6. Disrespect—Examples might include: disrespectful language such as being condescending, rude,

abrupt, insulting. Using aggressive and angry language. Dismissing behavior such as telling others to

shut up or ask who cares what they think. Dismissive remarks about another’s role on the team,

educational preparation, or years of experience.

7. Micromanagement—Examples include those who abuse their authority (whether by role or by position)

pull rank, bully, threaten, or force their point of view on others.

Adapted from Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Silence Kills: The Seven Crucial Conversations for Healthcare. 2005. Available at: http://www.silencekills.com/PDL/SilenceKills.pdf. Accessed March 18, 2006.

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insights and feedback about progress in skill attainment (as well as encouragement) may be helpful. And, it is important to understand that the skills of effective communication, con- frontation, and managing of differences are at- tainable with education, practice, and commit- ment, but the process will take time. Acquiring competence in complex skills occurs slowly; consequently, practicing with simple con- frontations before tackling truly threatening ones may be a useful approach.

Strategies to Consider Everyone has different issues with their ability to skillfully communicate in difficult situa- tions. Some people are timid, fearful, insecure, or worry about offending others and hurting relationships. Many may have received mes- sages about “being nice” rather than con- fronting others. Others may struggle with con- trolling their emotions, being too aggressive, or being insensitive to how their behaviors af- fect others. Consequently, strategies chosen to develop skills are as unique as the individual. There are hundreds of books, articles, and re- sources available for gaining insight and learn- ing how to improve skills, each offering differ- ent ideas and approaches. Regardless of the resources chosen, each requires actively work- ing to put the skills into action in order to make a difference.

The following 3 concepts may be particu- larly helpful in beginning the journey toward more skillful communication: it’s all about safety, creating our own mental stories, and we can only control ourselves.

It Is All About Safety When the environment feels safe, one can communicate freely. Safety is lost when indi- viduals feel threatened and it seems that others fail to share the same goal or interest (mutual purpose) or do not demonstrate respect (mu- tual respect). In the book, Crucial Conversa- tions: Tools for Talking When the Stakes Are High,6 the issue of creating safety so there can be a dialogue is fully examined. The authors describe the natural reaction to the loss of safety and how that sabotages the ability to effectively communicate and confront. Most importantly, they provide strategies to restore safety so these important discussions can take place.

While in extreme situations, one might feel physically threatened, but the perception of

feeling emotionally threatened can be equally as powerful in inhibiting the ability to success- fully communicate. In either case, the results are often the same: the inability to fully listen, understand, and rationally respond. When threatened, individuals will either flee from the situation or prepare to fight and become more aggressive (flight or fight stress response). Tools, such as the Style under Stress Survey (www.vitalsmarts.com), are particularly useful in providing a self-assessment of one’s own style and strengths in communicating during stressful situations.7

We All Create Our Own Mental Stories In any conversation or situation, things are said and circumstances exist, but how they are interpreted and meaning is perceived depends upon the individual. The mental story one cre- ates then determines one’s reaction by foster- ing feelings that lead to certain actions.6 How this interpretation and development of mental stories occurs is complex, but it is a key ele- ment to mastering emotions and the readiness to take positive action.

Sometimes, the mental stories or interpreta- tions are helpful and enable one to act in a way that is effective and productive. Other times, these stories can immobilize and disable (Figure 1). For example, if past experiences with a coworker have been negative, with episodes of intimidation and belittling, even the change of shift report can become a source of stress. For example, if during report, you are asked if you bathed your patients, you may react with anxiety or irritation. In that mo- ment of anxiety, you don’t feel safe and that feeling influences actions you take. You may choose “flight” to escape, by becoming silent and ignoring their question or “fight” back answering with sarcasm or anger.

In fact, all your colleague did was to ask about the bath, but you interpreted the ques- tion through a filter of judgments and precon- ceived ideas about his or her intent. We judge other’s intentions by how his or her words or actions have had an effect in the past.8 So, in the moment of asking about the bath, if you feel intimidated or at risk, you most likely will judge the intent of the questioner to be critical and designed to embarrass. The problem with writing one’s own stories and determining the intent of others is that frequently these inter- pretations are inaccurate. Human intentions,

THORNBY AACN Advanced Cri t ical Care

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even one’s own, are complex and rarely black and white in nature.

The authors of Difficult Conversations: How to Discuss What Matters Most,8 offer the observation that every conversation has 3 different questions being asked when one lis- tens to another person. The first is the “what happened?” question in which the focus is on the facts or truths of the situation or conver- sation as it is understood. Often 2 individu- als in a situation have totally different under- standings about what actually transpired, which leads to conflict or tension. The sec- ond facet of the conversation involves con- sideration of the feelings involved with the situation or conversation. While listening, in- dividuals experience a range of feelings and think about whether they are valid. They also sense the feelings of the other party and con- sider whether those feelings may be valid as well. While having a conversation, emotions may begin to overwhelm thinking, to the point that one can think of little else. Or, the situation may continue to escalate because feelings are not acknowledged. The last ques- tion one usually asks while listening is the identity question: “what are they saying about me?” One considers whether others are saying, “you are good, bad, competent, or worthy of respect and regard.” This last question often causes the most difficulty for

nurses and healthcare professionals when conversations center around one’s work, be- cause one often interprets that one’s identity as a professional (competent, caring, etc.) is being questioned.

According to the authors, these 3 conversa- tional facets are occurring mentally as individ- uals attempt to listen to others, making it diffi- cult to truly listen and understand. The conversations can be very emotional and cause one to be reactive and even destructive in ef- forts to achieve positive outcomes.

Understanding that one’s own interpreta- tions of conversations and situations may be flawed emphasizes the importance of clarify- ing the situation and the intentions of others. Taking a moment to be reflective about one’s interpretation and considering an array of other possible interpretations can be very in- sightful. The authors of Crucial Conversations6

suggest considering, “Why would a reason- able, rational, and decent person do what this person is doing or saying?” This question is es- pecially helpful when one’s story involves making the other person the “villain.”

We Can Only Control Ourselves It is human nature that in any difficult situa- tion or conversation, the hope is that the other person will simply stop and change his or her behavior. In reality, the only person one can

Figure 1: How we make our own stories.

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control or change is oneself. In doing so, how- ever, others are often influenced profoundly. Understanding how to feel safe in discussing or confronting difficult situations, as well as working to create safety for the other person, makes a significant difference. Understanding that no one knows what others are thinking and what their intentions truly are can reframe one’s own thinking and lead to empowerment. Thoughts and stories about a situation give rise to feelings and those feelings then influ- ence actions and words. By reframing thoughts or stories into those that will create more positive empowering feelings rather than negative, reactive feelings, one can take con- trol and interact more effectively.

In the example above, when the coworker asks about the bath, the first inclination may be to think: “Doesn’t she know I always do my baths on night shift? We have been through this before where she is nit-picking through my shift, looking for things I haven’t done to her liking. Does she think I am lazy and trying to dump work on her? Why is she focused on the bath when this patient has been unstable all night and I have finally managed to stabi- lize his blood pressure?” These mental stories happen at lightening speed and then give rise to feelings about the situation. They can lead to feeling irritated, annoyed, and even unap- preciated, thus making one feel unsafe and de- fensive in the moment. With these emotions, many seek to withdraw and be silent or “fight” back with sarcasm or angry words. This then causes the coworker to feel unsafe and develop his or her own mental stories with resultant feelings and reactive actions. This sit- uation can be reframed by changing one’s thoughts to be more neutral and empowering. Instead of thinking about all the possible nega- tive intentions related to the question: “Have you done the patients bath?” one could think: “I had a busy night, but I was able to get the bath done. Maybe she is asking about the bath because she is trying to get her day planned.” These types of thoughts create less reactive feelings and allow one to simply answer the

question. By creating more neutral or empow- ering thoughts about a situation and with emotions in tow, one feels a sense of safety and chooses actions that are more helpful rather than reactive.

Taking Action It is time to take action, to develop skills, and to support others as they develop their skills so that the entire healthcare team can become skilled communicators. The first steps of the journey involve understanding how one’s men- tal stories, a sense of safety, and control of emotions are helpful in responding to difficult situations or conversations in a more effective manner. It will take courage and perseverance to stretch out of comfort zones and hold con- versations that would have been avoided or unsuccessful in the past. Through one conver- sation at a time, skillful communicators can create a significant impact for our teams, our patients, and their families.

References

1. Joint Commission on Accreditation of Healthcare Orga- nizations. Health care at the crossroads: strategies for addressing the evolving nursing crisis. Available at: http://www.aacn.nche.edu/Media/pdf/JCAHO8-02.pdf Accessed March 18, 2006.

2. American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2005. Available at: http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWES- tandards/$file/HWEStandards.pdf. Accessed March 18, 2006.

3. Heath J, Johanson W, Blake N. Healthy Work Environ- ments: A Validation of the Literature. JONA. 2004;34: (11):524–530.

4. Maxfield D, Grenny J, McMillan R, et al. Silence Kills: The Seven Crucial Conversations for Healthcare. 2005. Available at: http://www.silencekills.com/PDL/SilenceKills. pdf. Accessed March 18, 2006.

5. American Association of Critical Care Nurses. It’s All About You: A Blueprint for Influencing Practice. Aliso Viejo, CA: AACN; 2002.

6. Patterson K, Grenny J, McMillian R, et al. Crucial Con- versations: Tools for Talking when the Stakes Are High. Hightstown, NJ: McGraw-Hill; 2002.

7. Vital Smarts: Style Under Stress Test. Available at: http://www.vitalsmarts.com/CrucialSkills/FreeStuff/ Default.aspx#TestYourCrucialSkills. Accesses March 18, 2006.

8. Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. New York, NY: The Pen- quin Group; 1999.

ullying, incivility, intimidation, and other forms of disrespectful behavior have run rampant in healthcare, allowed to exist while

many remain silent or make excuses— “That’s just the way he/she is”—in an attempt to minimize the profound deva- station disrespectful behavior can cause. “Disrespectful behavior” encompasses a broad array of conduct, from aggressive outbursts to subtle patterns of disruptive behavior so embedded in our culture that they seem normal (Table 1, page 2).1,2 Disrespectful behavior causes the recipient to experience fear, vulnerabili- ty, anger, anxiety, humiliation, confusion, job dissatisfaction, professional burnout, uncertainty, isolation, self-doubt, depression, and a whole host of physical ailments such as insomnia, fatigue, nau- sea, and hypertension.1-8 The presence of disrespectful behaviors erodes profes- sional communication and collabora- tion, which is essential to patient safety and quality, and creates an unhealthy or even hostile work environment.4

Prevalence and link to safety In 2003, ISMP conducted a national survey of nurses, pharmacists, physi- cians, and other health professionals re- garding intimidation in the workplace. Results showed that disruptive (disre- spectful) behaviors were not isolated events, they were not limited to just a few difficult practitioners, they involved both lateral (peer-to-peer) and intradis- ciplinary staff (and not just physicians), and they involved both genders equally.9 Back then, 88% of respondents reported that, in the year prior to the survey, they encountered condescending language or voice intonation; 87% encountered impatience with questions; and 79% encountered a reluctance or refusal to answer questions or phone calls. Almost half of the respondents reported more explicit forms of intimidation, such as being subjected to strong verbal abuse

(48%) or threatening body language (43%). Incredibly, 4% even reported physical abuse.

Almost everyone who works in health- care has a story to tell about disrespect- ful behavior. Unfortunately, patients have paid a high price–even with their lives–for our inability to be respectful to each other, as there is a clear link to ad- verse patient outcomes and disrespect- ful behaviors. Almost half of our 2003 survey respondents told us their past ex- periences with disrespectful behavior had altered the way they handled order clarifications or questions about medi- cation orders.9 At least once during the prior year, about 40% of respondents who had concerns about a medication order assumed it was correct or asked another professional to talk to the pre- scriber, rather than interact with the in- timidating prescriber. Almost half felt pressure to accept the order, dispense a product, or administer a medication despite their concerns. As a result, 7% of respondents reported they had been in- volved in a medication error during the prior year in which intimidation clearly played a role.

In 2008, a survey of more than 4,500 nurses, physicians, and other healthcare professionals from 102 hospitals was conducted to assess the significance of disrespectful behavior and its impact on patient safety.5 More than two-thirds (70%) reported a link between these behaviors, medical errors, and poor qual- ity patient care; more than 65% linked the behaviors to an adverse event; more than 50% reported patient safety had been compromised; and more than 25% linked the behavior to patient mortality!

In 2009, the American College of Physi- cian Executives conducted a survey of more than 2,100 physician

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