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Pat Conway-Morana, BSN, MAd, RN, C, NEA-BC, CENP, CPHQ, FACHE

National Content Call. Understanding the Power of Structured Guidelines for Effective Communication and Assertion March 13, 2012 4:00pm ET. Pat Conway-Morana, BSN, MAd, RN, C, NEA-BC, CENP, CPHQ, FACHE Consultant, Joint Commission Resources. Objectives.

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Pat Conway-Morana, BSN, MAd, RN, C, NEA-BC, CENP, CPHQ, FACHE

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  1. National Content Call Understanding the Power of Structured Guidelines for Effective Communication and AssertionMarch 13, 20124:00pm ET Pat Conway-Morana, BSN, MAd, RN, C, NEA-BC, CENP, CPHQ, FACHE Consultant, Joint Commission Resources

  2. Objectives • Discuss the importance of involving physicians in the CUSP project • Identify conflict preferences • Recognize conflict management skills • Discuss structured communication

  3. Avoid Being Put in Situations Requiring Conflict Management • Before the CUSP project kicks off, find a physician champion • A high admitting physician who is a patient advocate • Believes in collaborative teamwork • Well respected by his/her physician colleagues • Identify why physicians do not remove catheters • They forget! • They succumb to staff requests for convenience • They succumb to family requests • They fear patients will fall while getting up to the bathroom • They fear skin breakdown if bed linens get wet. • They think catheters are the only way to get accurate I&Os

  4. Avoid Being Put in Situations Requiring Conflict Management • Include key physicians in developing criteria for catheter use. Physicians usually respond to the evidence. • Have criteria approved by medical staff mechanisms. • Include key physicians in designing processes to prompt removal of catheters. • EDUCATE the medical staff! • Before, during and after implementation • Include your medical staff champions/leaders in education • Hold nursing accountable for following the process. • Develop an agreed upon conflict resolution process (Medical Staff chain of command).

  5. Scope of Care Discontinuation of foley catheters requires a physician order May be included in protocols and standing orders, but you need an order to implement protocol/standing orders Some organizations are having physicians write catheter continuation orders every 24 hours with reason, just like restraints

  6. “Policing” Physicians Nursing is sometimes put in the position to “police” other disciplines in the best interest of the patient. It is our role as patient advocate. It is our role as hospital employees. It is our role as partners of care.

  7. What is Conflict? • The internal or external discord that occurs as a result of differences in ideas, values, or beliefs of two or more people • Conflict is natural, neither positive nor negative. • Some level of conflict in an organization appears desirable, although the optimum level for a specific person or unit at a given time is difficult to determine. Marquis & Huston, 2012

  8. Common Causes of Organizational Conflict Marquis & Huston, 2012 Poor communication Inadequately defined organizational structure Individual behavior Unclear expectations Individual or group conflicts of interest Operational or staffing changes Diversity in gender, culture, or age

  9. Communication Process Internal Climate External Climate Sender Written Nonverbal Verbal Message Receiver Internal External Climate Climate Marquis & Huston, 2012

  10. Types of Conflict • Types of conflict • Communication problems • Organizational structure • Individual behavior • Categories of conflict • Interpersonal – horizontal violence • Intrapersonal – occurs within the person • Intergroup – occurs between two or more groups of people Marquis & Huston, 2012

  11. Stages of Conflict Latent Conflict Felt Conflict Perceived Conflict Manifest Conflict Conflict Resolution Conflict Management Conflict Aftermath • Latent conflict • Existence of antecedent conditions • Perceived conflict • Intellectualized • Involves issues and roles • Felt conflict • Emotions (hostility, fear, mistrusted, anger) • Manifest (overt) conflict • Action (withdraw, compete, debate, resolve) • Conflict aftermath (positive or negative) • Move on and feel positions were heard • Issues remain and may return Marquis & Huston, 2012

  12. Conflict Resolution Outcomes Win–Win—optimal goal in conflict resolution Win–Lose Lose–Lose

  13. Barriers to Effective Nurse-PhysicianCommunication Traditional hierarchical relationships Increasing workload Mobile workforce Differing perceptions and language Prior experience Curtis, Tzannes, & Rudge, 2011

  14. Common Conflict Resolution Strategies Avoiding - Parties are aware of a conflict but choose not to acknowledge it or attempt to resolve it. Compromising - Each party gives up something it wants. Competing - One party pursues what it wants, regardless of the cost to others. Accommodating - One party sacrifices his or her beliefs and wants to allow the other party to win. Smoothing - An individual attempts to reduce the emotional component of the conflict. Collaborating - An assertive and cooperative means of conflict resolution whereby all parties set aside their original goals and work together to establish a supraordinate or common priority goal Thomas-Kilmann Conflict Management Preferences Marquis & Huston, 2012

  15. Common Conflict Resolution Strategies Confrontation Third Party Consultation Behavior Change Responsibility Charting Structure Change Soothing One Party Marquis & Huston, 2012

  16. Helpful Hints • Focus on the causes of the disagreement and not on personalities. • Try to arrive at solutions acceptable to everyone concerned. • Get all the information possible. Differentiate between facts and opinions. • Listen carefully and don’t prejudge. • Don’t belabor how the conflict occurred. Instead, concentrate on what should be done to keep it from recurring. • Concentrate on understanding and not on agreement. Marquis & Huston, 2012

  17. Effective Communication Guide Personal considerations Preparation Structure Graded assertiveness – escalates concern through a stepped process Curtis, Tzannes, & Rudge, 2011

  18. Graded Assertiveness • Level 1 – Express initial concern • I am concerned that Ms. Smith still has a catheter even though she no longer meets criteria • Level 2 – Make an inquiry or offer a solution • Would you like me to remove her catheter today? • Level 3 – Ask for an explanation • It would help me to understand why you would like her catheter to be continued. • Level 4 – A definitive challenge demanding a response • In order for her not to get a CAUTI, we must remove it unless there is a medical reason to continue it. Curtis, Tzannes, & Rudge, 2011

  19. SBAR • Situation • Dr. Jones, our unit has been striving to reduce our CAUTI rate. I’m calling you about Ms. Smith. • Background • We have medical staff approved criteria for post operative catheter use. • Assessment • I just completed my assessment on Ms. Smith, and she no longer meets the criteria. • Recommendation • I am calling to request an order to discontinue her catheter, please.

  20. CUSS I am Concerned that…. I am Uncomfortable with… I think we have a Safety Situation

  21. GRRRRListening Tool • Greeting – Offer greeting and establish positive environment. • Respectful Listening – Listen without interrupting and pause to allow others to think. • Review – Summarize message to make sure it was heard accurately. • Recommend or Request More Information – Seek additional information as necessary. • Reward – Recognize that a collaborative exchange has occurred by offering thanks. Marquis & Huston, 2012

  22. Assertion vs. Aggression Assertion – self respect and expressing your validly held opinions Aggression – disrespecting the other person and denying them their opportunity to express their opinions Marquis & Huston, 2012

  23. Assertive Communication Not rude or insensitive behavior Having an informed voice that insists on being heard Reflect the speakers message back to him/her Repeat the assertive message Point out the implicit assumptions – let the aggressor know you have heard him/her. Restate the message, using “I”, not “you” Restate the message by using assertive language Question Curtis, Tzannes, & Rudge, 2011

  24. Don’t Give Up You must measure what you expect Give feedback to staff Give feedback to physicians If one attempt fails, don’t give up. Keep trying. Persistence and consistency is key.

  25. References • Marquis, B. L., & Huston, C. J. (2012). Leadership Roles and Management Functions in Nursing (7th Ed.). Philadelphia, PA: Wolters Kluwer Health. • Curtis, K., Tzannes, A., Rudge, T. (2011). How to talk to doctors – a guide for effective communication. International Nursing Review, 58, 13-20.

  26. Your Feedback is Important! https://www.surveymonkey.com/s/C4CallEvaluation

  27. Questions?

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