Friday, August 28, 2009

Better Communication Reduces Hostility in the Workplace

Nurses thrive in environments that support collaboration among physicians, nurses, and allied health professionals, and as a result, patient outcomes are improved. According to the Joint Commission, 60% of the 3000 sentinel events reported were attributed to poor communication. Hierarchy differences, conflicting roles, ambiguity in responsibilities, and power struggles can all lead to communication failures that compromise patient safety and quality of care. Communication is not just about what a person says but how he or she says it. In fact, as much as 60% of your communication is through nonverbal cues including tone of voice, attitude, and body language.

Disruptive and intimidating behaviors, which include rude language and hostile behavior among healthcare professionals, can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified nurses and other clinicians, administrators, and managers to seek new positions in more professional environments. Problems associated with working relationships in the healthcare environment can be attributed to communication breakdowns, lack of courtesy, disrespect for another's knowledge and expertise, or other elements within the culture of the work environment. If we are truly honest with ourselves, each one of us has probably been guilty of these behaviors at one time or another. Certainly other factors that can contribute to a hostile environment include staffing shortages, floating to unfamiliar environments, and emergency situations all of which significantly increase the already stressful roles we play.

Healthcare leaders and caregivers have known for years that disruptive and intimidating behavior is a serious problem. Intimidation, verbal outbursts, condescending attitudes, and refusing to take part in assigned duties all stifle communication and can lead to breakdowns in care processes. One example includes a sentinel event that was directly related to a nurses failure to verify a physician order. This was due to the fact that when attempting to verify the order, the physician's hostility at being called after hours and abruptness at ending the call, intimidated the nurse to the point that a follow up call was not made. The patient received over ten times the normal dose of the medication.

Unfortunately, this hostile behavior is not exclusive to physicians. The old adage that nurses eat their young still holds true. As we become more experienced and knowledgeable, our expectations of our peers (nurses and allied health professionals) increases and we can become intolerant of those with less experience or those not yet fully competent in their role. For these individuals, there is a critical need for the seasoned professional to act in the role of mentor and to guide the novice caregiver successfully into the expert role. It is also important to remember that ours is not the only department/unit within the facility that has challenges. There is a tendency to forget that other allied health departments and other units also may be facing staffing shortages, increased responsibilities, and/or emergency situations.

As part of the new Joint Commission standards and the National Patient Safety Goals surrounding improving communication, accredited organizations are encouraged to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior. The intent is also to create an atmosphere in which nurses and all members of the care team are empowered to speak up if they think something is wrong.

Among the strategies encouraged by the Joint Commission that are particularly relevant to promoting effective communication are the following:

Educate all healthcare team members about professional behavior, including training in basics such as being courteous during telephone interactions, business etiquette, and general people skills.

Hold all team members accountable for modeling desirable behaviors and enforce the code of conduct consistently and equitably.

Establish a comprehensive approach to disruptive and intimidating behavior that includes a zero-tolerance policy, strong involvement and support from physician leadership, reducing fears of retribution against those who report disruptive and intimidating behavior, and determining how and when disciplinary actions should begin.

Develop a system to detect and receive reports of unprofessional, disruptive, and intimidating behavior.
Put very simply, treat others as you would want to be treated. Take accountability when your professionalism falters or you lose your cool (we all do sometimes) and apologize. Seek and be open to feedback regarding your communication. When that feedback is given, don't get defensive; recognize that it is a result of the perception of reality you created for that individual and is not open for debate. Effective communication is a fundamental component of patient safety. As the frontline providers of patient care, nurses and all caregivers have the opportunity to make effective and lasting improvements in communication.

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