What are two specific concepts that are most beneficial in this article? I will copy and paste the article Crucial Conversations: The Most Potent Force for Eliminating Disruptive Behavior By Joseph Grenny In this article… Examine techniques to encourage healthcare workers to speak up and address a problem with patient care rather than cowering from a possible disruptive confrontation. Candace is a trauma nurse. On Friday morning her patient had an adverse reaction to a medication that caused his temperature to stabilize at 104 degrees and put great distress on his kidneys. A specialist for continuous renal replacement therapy (CRRT), Candace was convinced her patient was headed toward acute renal failure and believed they needed to begin therapy on him as soon as possible. The chief resident agreed that CRRT should be started immediately but asked Candace to first consult a nephrologist—which she did. The nephrologist was dismissive and curt. He rolled his eyes as she pressed her point. When she asked if she could share some research indicating the best treatment option for the patient, he cut her off midsentence, pointed his finger in her face, and yelled, “We will not be starting dialysis. Period.” And with that, he walked away. In July of 2008, The Joint Commission issued a Sentinel Event Alert that Candace and her fellow nurses should not have to face abusive situations like this again. And for good reason. The Silence Kills study, conducted by VitalSmarts and the American Association of Critical-Care Nurses, reveals that more than three-fourths of caregivers regularly work with doctors or nurses who are condescending, insulting or rude. A full third of study participants say the behavior is even worse and includes name-calling, yelling and swearing. While these disruptive and disrespectful behaviors can be hurtful, what prompted The Joint Commission to address them as a condition of accreditation is the mounting evidence that these behaviors are also harmful. Their warning stated explicit- 30 PEJ NOVEMBER•DECEMBER/2009 itly that “rude language and hostile behavior among health care professionals goes beyond being unpleasant and poses a serious threat to patient safety and the overall quality of care.” The Joint Commission’s warning echoes the seriousness of this threat as uncovered in the Silence Kills study. According to the study, more than 20 percent of health care professionals have seen actual harm come to patients as a result of disrespectful and abusive behavior between physicians, doctors and staff. Each year, one in 20 in-patients at hospitals will be given a wrong medication, 3.5 million will get an infection from someone who didn’t wash his or her hands or take other appropriate precautions, and thousands will die because of mistakes made while they’re in the hospital. In a devastating example, one nurse tearfully told us of a diabetic patient who had a colon resection with a large surgical wound. He was complaining of nausea and his stitches were coming loose. The surgeon on call had a reputation for being rude and hostile when awakened, but when the patient continued to deteriorate late into the night she made the call. The surgeon refused to come and check the patient and demanded that she simply reinforce the dressing on the wound until he could examine him the next morning. Ultimately the patient vomited, popped his stitches, and died from complications of his open wound. Pervasive disrespect The Silence Kills study found countless examples of caregivers who delayed action, withheld feedback or went along with erroneous diagnoses rather than face potential abuse from a colleague. The data in the table shows that three-quarters of the health care workers surveyed experience some level of disrespect. For many, the treatment is frequent and longstanding. The correlations show that the more frequent the behavior and the longer it has gone on, the greater the workers’ intent to quit their jobs. In fact, these correlations are so strong (correlations where r > .1 are meaningful, here we find r = .424, which is impressive) that disrespectful behavior is suggested to be a primary cause of people’s desire to quit their jobs. Discussing their concerns with the person who is responsible for the abuse is almost out of the question. Even more startling than the pervasiveness of disrespect is that more than half of participants reported that the disrespectful behavior had persisted for a year or longer. A surprising 20 percent said the problems had continued for five years or more. It’s not the conduct but the silence The Joint Commission has taken an important step by requiring more than 15,000 accredited health care organizations to create clear code of conduct demonstrating the unacceptability of disruptive behavior and laying the groundwork for holding caregivers accountable for their behavior. While this is an important element of influencing behavior change, the research shows that there is something far more immediate and powerful individuals and leaders can do to drive change: They need to break the code of silence. Until they do so, they’ll fail to mobilize social pressure to drive change. The most powerful force over human behavior is social influence. No matter how motivated and able people are to behave appropriately, they encounter enormous social influences that will either catalyze their efforts to succeed or completely impede progress. For example, when senior physicians don’t wash up before treating patients, the likelihood that their residents will wash is less than 10 percent. In short, people will do anything to avoid rejection and to gain acceptance in their cultural environment. Unfortunately, when it comes to confronting bad and abusive behavior, the vast majority of health ACPE.ORG 31 care workers fall victim to negative peer pressure. In the face of disruptive behavior, they fail to exercise the enormous social influence they have. The study showed that when doctors or nurses see disrespectful or abusive behavior there is a less than seven percent chance they or anyone will effectively confront the person who has behaved badly. The obvious reason is that confronting people is difficult. In fact, the majority of respondents indicated it is between difficult and impossible to confront people in these crucial situations. People’s lack of ability, belief that it is “not their job,” and low confidence that it will do good to have the conversation, are the three primary obstacles to direct communication. As a result of people’s decision to choose silence over speaking up, disruptive behavior has lingered for years awaiting social disapproval, yet receiving none. So if health care leaders want to not only secure the well-being of patients, but also increase employee retention and engagement, the most immediate and effective thing they can do is change this culture of silence. They need to substantially increase caregivers’ skill and will to step up to crucial conversations immediately and directly when inappropriate behavior emerges. Candace speaks Candace was an exception to the rule of silence. She was one of the rare caregivers we found who was capable of confronting disrespectful behavior head on. As the nephrologist walked away, she politely asked for another moment of his time. Though he was clearly aggravated, she calmed things by explaining, “I am not trying to challenge your expertise. I know you are well-trained for this decision. I apologize if it sounded as though I was being insubordinate. I know we 32 PEJ NOVEMBER•DECEMBER/2009 both want to do the right thing for this patient. May I please explain why I have additional concerns in this case?” And with that small change in approach the entire conversation shifted. The nephrologist listened to her concerns and ultimately agreed to order dialysis—saving the patient’s life. But Candace’s conversation didn’t stop there. Had she walked away at that point, she would have done right by the patient, but would have failed to exercise social influence on the nephrologist’s bad behavior. Having reached agreement, she asked him for two more minutes. “Doctor, I suspect you found my approach to you a moment ago disrespectful. If so, I apologize. I recognize your expertise and will work harder in the future to address you as you deserve.” The nephrologist’s eyes widened. She continued, “And doctor, I must ask the same of you. When I shared my concerns about the patient, you raised your voice, you rolled your eyes, and you spoke to me harshly. That doesn’t work for me, either. May I have your word that you will not address me that way again, either?” He whispered an apology and never addressed Candace disrespectfully again. Social influence—if wielded skillfully—is incredibly potent. The problem is it is rarely used. What shapes and sustains the behavioral norms of an organization are lots of small interactions. Unless and until social actions are positively aligned, the chance of influencing real change in the organization is slim. So while the code of conduct may be an essential element to changing cultural norms in disruptive behavior, the conversations around it will ultimately determine the pace and pervasiveness of change in any hospital. Can you teach people to talk? Not surprisingly, the Silence Kills study found that the small number of “Candaces” who speak up produce far better outcomes for their patients, their colleagues and themselves. These skillful seven percent enjoy their jobs more, intend to stay in their positions longer, are far more productive and see better patient outcomes. So we’ve studied what it takes to clone the Candaces of the world. We’ve found that there are recognizable, repeatable and learnable skills for dealing with crucial conversations. One hospital, Maine General Health, spent two years teaching these skills to its employees. The caregivers learned to speak up about issues and concerns they had formerly ignored. For example, those who acquired greater skills were: • 88 percent more likely to speak up when they saw someone take a dangerous shortcut. • 83 percent more likely to speak up when they had concerns about someone’s competence. • 167 percent more likely to speak up when they saw someone demonstrate poor teamwork. • 167 percent more likely to speak up when they saw someone be disrespectful. A poignant example came from the heart of the operating room. In one OR, some of the staff had felt unappreciated by a feisty surgeon for a long time. After participating in Crucial Conversations Training, two members of the staff independently approached the surgeon and shared their concerns. Humbled, the surgeon started to make small but significant changes in his approach—including, for the first time in a decade, thanking staff when they did a good job. The result was a more unified and potentially safer team. Four crucial conversations for leaders Health care leaders who want to engage social influence to eliminate disruptive behavior will have to break the code of silence in four specific conversations: Administrations must go public about the pervasiveness of concerns. Most hospitals attempt to put a good face on disruptive behavior by dismissing it as a problem with “a few bad apples.” The truth, according to the Silence Kills study, is that it happens every day in most hospitals. The problem is much more pervasive than just a few bad apples. In order to influence change, leaders need to begin by acknowledging the frequency of concerns. Caregivers must directly confront disruptive behavior. Next, leaders need to invest substantially in increasing the will and skill of every employee to speak up when they see problems. The focus needs to be not just on confronting disruptive behavior, but on speaking up when people see mistakes, incompetence, violations of safety standards and more. The Silence Kills study identifies seven kinds of problems; fewer than one in ten people address these problems effectively, which can lead to burnout, disengagement, errors and worse. tion to address concerns if their leaders don’t lead the way. Administration must back up sanctions when they occur. The most common reason people fail to speak up in hospitals is because they adopt the attitude of “It’s not my job.” The second most common reason is the belief that The real change will occur when we substantially increase skills in conversation—especially the emotionally and politically risky conversations we so consistently avoid. When this vast potential of social pressure is finally tapped, our hospitals will become healthier for patients and caregivers alike. Medical directors and nurse managers must respond appropriately to escalations. The research also shows that the problem is not just upward, it’s sideways and downward. Nurses fail to speak up to their peers when they have concerns. Managers fail to confront direct reports. Medical directors give their underlings a “pass” rather than make waves. The silence is deafening in every direction—and lower level employees will not feel the expecta”Others won’t back me up if I do.” For example, nurse managers worry that if References they confront a disruptive doctor who brings a lot of money into a hospital, no one in administration will back them up. Administration must make it clear that if code-of-conduct violations occur, they will back up those who take appropriate action. As the saying goes, “Silence betokens consent.” The pervasive and risky 1. 2. The Joint Commission News Release, “Joint Commission Alert: Stop Bad Behavior among Health Care Professionals.” http:// www.jointcommission.org/NewsRoom/ NewsReleases/nr_07_09_08.htm Lankford MG and others. “Influence of Role Models and Hospital Design on Hand Hygiene of Health Care Workers,” Emerging Infectious Diseases , 9(2):217-23, February 2003. problems with disruptive behavior in ACPE.ORG 33
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