UW Health,Ambulatory Education,Educational Opportunities,Grand Rounds,Nursing Grand Round Presentation Video Archive 2012,Leading and Managing in a Clinical Practice Discipline 2012,02/08/2012 - Healthy Work Environments and Positive Outcomes: Make the Connection!,Resources


Handout - UW Health, Ambulatory Education, Educational Opportunities, Grand Rounds, Nursing Grand Round Presentation Video Archive 2012, Leading and Managing in a Clinical Practice Discipline 2012, 02/08/2012 - Healthy Work Environments and Positive Outcomes: Make the Connection!, Resources

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Healthy Work Environments
and Positive Outcomes:
Make the Connection!
Ann Malec MS, RN, ACNP
Leading and Managing in a Clinical Practice
Discipline Grand Rounds
February 8, 2012

 Connection to Outcomes
 Review of Supporting Literature
 Causes of Communication Breakdown
 Effective Communication Strategies
 Interactive Case Scenario

Healthy Work Environments

Establishing and Sustaining Healthy Work
Environments: A Journey to Excellence

American Association of Critical-Care Nurses (AACN), 2005

AACN, 2005

Focus on Skilled Communication
“We cannot be truly human apart
from communication…..To impede
communication is to reduce people
to the status of things”
Paulo Freire
International educator, Community activist

Skilled Communication
Nurses must be as proficient in communication skills as they are in clinical skills
 Promote interdisciplinary collaborative relationships
 Encourage open and direct dialogue
 Show goodwill and mutual respect to reach consensus
 Demonstrate congruence between words and action
 Establish zero tolerance for abuse/disrespectful
behavior in work place

AACN, 2005

Supporting Literature
 Nearly 3 in 4 errors are linked to interpersonal
Schaefer HG, et al., 1994

 Breakdown in communication is a top contributor to
sentinel events

Joint Commission , 2011

*Slide is not inclusive of all top root causes

Supporting Literature
 Intimidation: Practitioners Speak Up About This
Unresolved Problem
 2,095 health care providers from various hospitals
responded to Institute for Safe Medication Practices
(ISMP) survey
 Convenience Sample
 1,565 nurses
 354 pharmacists
 176 others

ISMP, 2004

Survey Findings
 88% experienced condescending language last year
 87% experienced impatience with questions
 79% encountered refusal to answer
questions/phone calls
 48% experienced strong verbal abuse
 43% experienced threatening body language
 4% reported physical abuse
ISMP, 2004

Who’s Intimidating Who?
 Physicians and other prescribers: At least twice as
intimidating than other professionals
 Condescending
 Reluctant to answer questions
 Impatient with questions – “Just give what I ordered”
 Threatening body language

ISMP, 2004

Not Just Physicians
 Nearly 40% indicated that other health care
providers had threatened to “report them” as a way
to intimidate
 Intimidating behaviors did not just come from one
 Findings support that health care providers, not
just MDs, have conformed to unhealthy behaviors
ISMP, 2004

A Threat to Patient Safety
 49% reported intimidation hindered willingness to
clarify confusing orders
 75% asked a colleague instead of intimidating
 34% reported that a prescriber’s stellar reputation
prevented them from clarifying a concern
 49% felt pressured to accept an order, administer
or dispense a medication
 7% reported involvement in medical error where
intimidation played a role
ISMP, 2004

Silence Kills: The Seven Crucial
Conversations for Healthcare

 VitalSmarts and AACN co-sponsors
 Revealed this concerning culture of silence
 Less than 10% of individuals speak up!

Maxfield, D. et al., 2005

Crucial Conversations:
Seven Common Categories
Survey linked seven categories of conversations that
are especially difficult; yet, crucial to master:

1. Broken rules
2. Mistakes
3. Lack of support
4. Incompetence
5. Poor teamwork
6. Disrespect
7. Micromanagement

Maxfield, D. et al., 2005

Why Don’t We Speak Up?
 Fear of………….
 Losing respect
 Being Patronized
 Having ideas dismissed
 Not having enough time/too busy
 Not having positive results/no luck in past
 Retaliation
Maxfield & Sears, 2007

What Happens Next?
 Creates vicious cycle
 use defense mechanisms as driving force in decisions
and interactions
 Blame others
 Refuse to take healthy risk
 Results = organizational stagnation
Maxfield & Sears, 2007

Maxfield & Sears, 2007

How This Affects Practice
Workarounds or shortcuts may be seen as acceptable
or common practice
 Conscientious Nurses who do follow policy may
become targets and perceived to disrupt “the norm”
 New nurses may be criticized for having “bright shiny
new ideas”
McGrath, 2010

How This Affects Practice
 Staff who may not typically agree are likely to
become involved
 May even promote workarounds when perceived as
the “the norm”
 Productivity is affected
 Morale is decreased
McGrath, 2010

Are we breaking the cycle?
Silent Treatment 2010
 2010 study builds on 2005 silence kills findings
 Safety tools are very effective
 not enough if we fail to speak up!
 Focus on three (3) specific concerns: dangerous
shortcuts, incompetence and disrespect

Maxfield, D. et al., 2010

Silent Treatment
 Communication breaks down in two different ways:
1. honest mistakes: poor handwriting, confusing
labels, competing tasks etc.
2. undiscussables: risks known, do not speak up,
intentional choice not to discuss

Maxfield, D. et al., 2010

Silent Treatment
 Organizations often focus on honest mistakes
and create checklists etc.

 Undiscussables requires deeper changes to
cultural practices, social norms and personal

Maxfield, D. et al., 2010

Cultural Practices: A Closer Look
 Longstanding cultural practice of accepting
disruptive behaviors
 Powerful revenue generators
 Strong clinical competency - “Specialist”
 Power shift can lead to further disruptive behaviors
 Establishing equal power relationships = valued
interdisciplinary relationships = positive patient
Longo, J. 2010

Silent Treatment: Study Design
 Story Collector – qualitative data
 2,383 RNs of whom 169 were managers
 Traditional Survey – quantitative data
 4,235 RNs of whom 832 were managers
 Convenience sampling
 AACN members
 AORN members
Maxfield, D. et al., 2010

 Results confirm that safety tools work and are
 However, effectiveness of these tools are undercut
by undiscussables
 58% indicated they had been in situations where it was
unsafe to speak or others would not listen.
 17% said they were in this situation at least a few times a

Maxfield, D. et al., 2010

 Nurses were asked to describe undiscussables
 608 incidents described
 8% of these incidents were described as permanent,
pervasive and beyond personal control = TRIPLE
 Triple negatives – high stakes, risk to patient safety
Maxfield, D. et al., 2010

A Closer Look at 3 Undiscussables
 2005 Silence Kills examined 7 concerns that often go
 Linked these to patient safety, quality and turnover
 2010 focuses on 3 of these 7
 Concerns about dangerous shortcuts
 Concerns about incompetence
 Concerns about disrespect

 Findings from non-supervisory nurses who completed
the survey:
Maxfield, D. et al., 2010

Dangerous Shortcuts
 84% work with people who take shortcuts
 34% say shortcuts caused near misses
 27% say shortcuts have affected patients, but
without harm
 26% report shortcuts harmed patients
 41% reported shortcut/individual to their manager
 17% spoke to person directly, but did not share full
 31% spoke to person directly and did share full
Maxfield, D. et al., 2010

Concerns About Incompetence
 82% report they work with individuals who are
“not as skilled as they should be”
 31% say that incompetence led to near misses
 26% report incompetence has affected patients,
but without harm
 19% say incompetence has harmed patients
 48% spoke to manager about concern
 11% spoke to person, but did not share full concern
 21% spoke to person and did share full concern
Maxfield, D. et al., 2010

Concerns About Disrespect
 85% work with individuals who demonstrate
 46% report disrespect undermines respect for their
professional opinion
 19% say that disrespect challenges ability to get
others to listen
 20% report that disrespect is making them
consider leaving
 49% spoke to manager
 16% spoke to person, but did not share full concern
 24% spoke to person and did share full concern
Maxfield, D. et al., 2010

In Summary: Data is Convincing!
 Silence = breakdowns= harm to patient
 4 out of 5 nurses have concerns about dangerous
shortcuts, incompetence and/or disrespect
 1/2 say shortcuts = near misses or harm
 1/3 say incompetence = near misses or harm
 1/2 report disrespect hinders respect of opinions

 1/2 have spoken to their manager
 1/3 have shared their full concern with the individual
who concerns them

* Data also confirms that nurses are more likely to take concern
to manager than speak directly.
Maxfield, D. et al., 2010

Responses From Managers
 Nurse Manager responses (832) reviewed
 41% of managers directly followed up
 28% spoke to person whose missing competencies
caused threat to safety
 35% talked to person whose disrespect had a profound
negative impact

 Study confirms – We ALL need to partner and become
skilled communicators!
Maxfield, D. et al., 2010

Study Differences
 2010
 More nurses have concerns about dangerous shortcuts,
incompetence and disrespect
 More have seen patients harmed
 More speak up
 Setting related?
 2010 – ICU, ED, OR – high acuity
 2005 – random selection from 13 hospitals –
med/surg units

Maxfield, D. et al., 2010

There is Hope!
 Further comparison of critical care nurses from
both studies
 A higher proportion of critical care nurses spoke up in
the 2010 study
 2005 – 10-12 %
 2010 – 21-31%
 Still a lot of work to be done, but improving
Maxfield, D. et al., 2010

Learning From The Best
 Triple Positives: permanent, pervasive and
 Reported actions of top performers:
 Assume the best and speak up
 Explain positive intent
 Make it safe to avoid defensiveness
 Use facts verses personal stories
 Avoid accusations
 Deflect anger and emotion
Maxfield, D. et al., 2010

Top Performers: Take Home Message
 Top performers AVOIDED……
 Utilizing threats to influence others
 Showing frustration or anger

 The top performers always kept their emotions
and feelings in check!
Maxfield, D. et al., 2010

Leaders Play a Key Role:
Comprehensive Review of Evidence
 Total 48 papers – experimental, qualitative and textual
were included
 Leadership styles and characteristics were found to
contribute to HWE
 Specific Qualities and Behaviors identified:
 Motivator, supporter, honest, listener, provider of
information, knowledgeable

Pearson, A., et. al., 2007

Comprehensive Review of Evidence
 Communication: A recurrent theme among all papers
 Leaders involved in creating a Healthy Work
 Communicated effectively
 Involved staff in decisions

Pearson, A., et. al., 2007

Additional Studies: Center for Patient and
Professional Advocacy & Studer Group
 2009 Study
 Voluntary – blog & email invites
 1521 respondents – health care professionals
 84% female
 16% male
 75% - target of unprofessional behavior
 42% on daily, weekly or monthly basis

Studer Group & Center for patient and Professional Advocacy, 2009

Impact of Unprofessional Behaviors
 68% considered leaving current job
 41% transferred or left a previous job
 66% had short term effects – day to week
 37% still effected a week to months
 79% reported incident to supervisor or HR

Center for patient and Professional Advocacy & Studer Group, 2009

Are you ready to help fix the problem?
 ANA Code of Ethics:
 Nonnegotiable ethical standards that require nurses to
be skilled communicators and to speak up on any
questionable practice
American Nurses Association, 2001

 Nurses must focus on what they may do, not what
others should do!
Kupperschmidt, B., et al. , 2010

AACN Takes a Stand!
Nurses must be as proficient in
communication skills as they are in
clinical skills

AACN, 2005

AONE Guiding Principals for Excellence in
Nurse/Physician Relationships
 Require Practitioners to be proficient in
communication skills
 Utilize emotional intelligence and function within
team culture

 Lead work at the unit level

American Organization of Nurse Executives, 2011

IOM: The Future of Nursing
 Report Recommendations
 Expand opportunities for nurses to lead and diffuse
collaborative improvement efforts
Institute of Medicine, 2011

 Implications for Nurses
 “Step it up, participate and lead the change”
Buerhaus, P., 2011

 Communication will be measured!
 Nurse communication
 Doctor communication
 Communication about medicines
 Discharge information
 Responsiveness
 Expectation = we will ALWAYS communicate

Owens, K., 2011

What Can You Do?

 Awareness is the first step
 Help to create a “Zero Jerk Tolerance”
 Become fully engaged in improving systems
 “Become the culture YOU want to create”

McGrath, J., 2010

Commit to Professionalism

 Professionals are fully engaged and committed to:

 Technical and cognitive excellence

 Clear and effective communication

 Modeling respect

 Being available

 Self Regulation

Hickson, G., 2011

Start with a “Cup of Coffee”
 Single event
 Informal conversation or “cup of coffee”
 Vast majority will change behavior
 If not addressed = missed opportunity
 Pattern Persists
May require additional intervention

Hickson, G., 2011

A Cup of Coffee?
 Dialogue between a concerned professional and a
 regardless of rank or title
 Purpose: Make colleague aware of observed behavior
 No judgment or proving who’s right/wrong
 No blame
 No prescriptive solutions
Hickson, 2011

A Cup of Coffee
 Select appropriate location
 Remain objective; yet, empathetic
 “You are a valued leader of the team. That’s why I have
come to you.”
 “I saw something I don’t understand (state behavior).
This is not typical of my experience in working with you.
Help me understand what was happening.
Hickson, 2011

Cup of Coffee
 Reactions may vary– be prepared!
 Stick to message and repeat observations
 Reinforce agreement to respond professionally
 repeat what you observed
 reinforce commitment to professional behavior
 focus on the patient

Hickson, 2011

“A Day in the ICU”
 Interactive Case Scenario

“Our lives begin to end the
day we become silent
about things that matter ”

Martin Luther King