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
1
Objectives
• Discuss the importance of involving physicians
in the CUSP project
• Identify conflict preferences
• Recognize conflict management skills
• Discuss structured communication
2
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
3
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).
4
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
5
“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.
6
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
7
Common Causes of Organizational
Conflict
•
•
•
•
•
•
•
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
Marquis & Huston, 2012
8
Communication Process
Internal
Climate
External
Climate
Sender
Written
Nonverbal
Verbal
Message
Receiver
Internal
Climate
Marquis & Huston, 2012
External
Climate
9
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
10
Stages of Conflict
• Latent conflict
– Existence of antecedent conditions
Latent Conflict
• Perceived conflict
– Intellectualized
– Involves issues and roles
Felt Conflict
• Felt conflict
– Emotions (hostility, fear, mistrusted, anger)
Perceived Conflict
Manifest
Conflict
Conflict Resolution
Conflict Management
• Manifest (overt) conflict
– Action (withdraw, compete, debate, resolve)
Conflict
Aftermath
• Conflict aftermath (positive or negative)
– Move on and feel positions were heard
– Issues remain and may return
Marquis & Huston, 2012
11
Conflict Resolution Outcomes
• Win–Win—optimal goal in conflict resolution
• Win–Lose
• Lose–Lose
12
Barriers to Effective Nurse-Physician
Communication
•
•
•
•
•
Traditional hierarchical relationships
Increasing workload
Mobile workforce
Differing perceptions and language
Prior experience
Curtis, Tzannes, & Rudge, 2011
13
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
14
Common Conflict Resolution Strategies
•
•
•
•
•
•
Confrontation
Third Party Consultation
Behavior Change
Responsibility Charting
Structure Change
Soothing One Party
Marquis & Huston, 2012
15
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
16
Effective Communication Guide
•
•
•
•
Personal considerations
Preparation
Structure
Graded assertiveness – escalates concern
through a stepped process
Curtis, Tzannes, & Rudge, 2011
17
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
18
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.
19
CUSS
• I am Concerned that….
• I am Uncomfortable with…
• I think we have a Safety Situation
20
GRRRR Listening 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
21
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
22
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
23
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.
24
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.
25
Your Feedback is Important!
https://www.surveymonkey.com/s/C4CallEvaluation
26
Questions?
27