Gerry Altmiller, EdD, APRN, ACNS-BC
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Learner will be able to identify types of difficult
communications.
Learner will be able to describe manifestations and
consequences of difficult communications
Learner will be able to describe strategies to use
during difficult communications to improve patient
safety.
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Write about a situation/conversation where there was
conflict that impacted patient safety-tell the story.
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Hierarchical relationships
Oppressive communication patterns
◦ Communication is the root cause of 66% of Sentinal Events
1995-2005 The Joint Commission
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Complexity of care/Sophisticated technologies
Heavy workloads-fatigue
Time pressured schedules
Stereotyping
High stakes/high stress environment
Organization’s failure to enforce code of conduct
Concealment due to isolation
 Interdisciplinary
Interactions
◦ Hierarchial relationships
◦ Presence of an authority gradiant
◦ Negative or disruptive behaviors
 Nurse-patient/patient-Nurse
interactions
◦ Angry patients
◦ Angry nurses
 Nurse-Nurse
Interactions
◦ Lateral Violence: an aggressive &
destructive behavior of nurses against
each other.
Woelfle & McCaffrey 2007
◦ Results in injuring the dignity of another
◦ Reduces one’s confidence and self esteem
Oppressed population concept
 Cyclical
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 Exclusion from the power structure
Seen as “Right of Passage”
 “This is how people were to me when I was
learning”
 New-to-practice RNs and new-to-practicearea are at greatest risk
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Talking behind one’s back
Discouragement; humiliation
Blocking chance for promotion
Scapegoating; innuendo
Belittling or criticizing a colleague in front of others
Isolating or freezing a colleague out of group
activities; exclusion
Sabotage; withholding pertinent information
In-fighting
Failure to respect confidences and privacy
Eyebrow raising, snide remarks, turning away, making
faces
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Cyclical repetition
Physical symptoms
Use of sick days
Extreme cases suicide
Nurses leave the profession (1 in 3 internationally)
30% leave 1st new grad position within 1 year
(Bowles & Candela, 2005)
Nurses aren’t at their best so patient care suffers
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Lateral violence violates The Code of Ethics for Nurses
with Interpretive Statements (ANA, 2001)
 http://www.nursingworld.org/codeofethics
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Barriers impede knowledge & skill acquisition
To improve professional practice life
To stress for new to practice nurses
To improve conflict resolution skills
To attrition
To stop new generations of nurses from being
socialized into negative practices
The Joint Commission mandates change for
patient safety in Sentinel Alert 40
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Accept one’s fair share of the
workload.
Respect the privacy of others.
Be cooperative with regard to the
shared
physical working conditions
(noise, temp).
Be willing to help when requested.
Keep confidences.
Work cooperatively despite
feelings of dislike.
Don’t denigrate to superiors
(speak negatively about, have a pet
name for)
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Do address co-workers by their first
name,
ask for help and advice when necessary.
Make eye contact with co-workers when
speaking.
Don’t be overly inquisitive about each
other’s lives.
Repay debts, favors, compliments.
Don’t converse about a co-worker with
another co-worker.
Stand up for the “absent member” in a
conversation when he/she is not present.
Don’t criticize publicly.
Griffin, 2004
Cognition: obtaining, organizing & using
intellectual knowledge
 Self reflection both personal and professional
 Liberate the oppressed by not letting it
continue
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Rehearsed direct responses
◦ I see from your expression there is something…….
◦ I learn most from people who communicate directly..
◦ When things are different from what I learned…..
◦ It is my understanding that there was more information…….
◦ I don’t feel right talking about this….
◦ I don’t feel right talking about him/her….
Griffin, 2004
◦ Stops the automatic process of the event
◦ Consciously not responding or not reacting
◦ Allowing time to process information previously
taught
 The event is not a personal affront
◦ Allows individual to respond differently to
harmful inference of lateral violence
◦ Liberates the oppressed by not letting it continue
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Reframing conversation using safety strategies
◦ Debriefing
 Feedback whether positive or negative should always be an
unbiased reflection of events and open the door to discussion of
evidence-based practice
◦ Two Challenge Rule
◦ CUS
 Concerned, uncomfortable, safety
◦ Check back
◦ Time-out
◦ Critical Language
 “I need some clarification.”
Effective Communication
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SBAR for Safe Patient
Hand-offs
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Situation
Background
Assessment
Recommendation
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De-escalation techniques for aggressive
behaviors
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Take the focus off the power struggle
Refocus discussion back to the patient needs
Enlist the support of those more senior
Identify those receptive to questions
Listen to concerns of others
End conversations where co-workers are being discussed
Reflection
 Challenge yourself to remain civil in the face of
incivility
 Ask yourself what went well? What went poorly?
What could I have done differently?
Clear
Timely
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Familiarize students with The Joint Commission
expectation: Sentinel Event Alert 40: Behaviors that
Undermine a Culture of Safety
Sentinel Event | Joint Commission
 Reframe
situation/conversation using:
◦ Cognitive Rehearsal
◦ Safety Strategies
◦ De-escalation
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Difficult Communication patterns are a patient
safety threat
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Creates fear of ridicule for asking questions
Strategy: Always bring focus back to the patient
Education has a positive effect
◦ Empowers nurses to know that it is not personal
◦ Breaks the cycle; it can be stopped
◦ Contributes to making team members accountable to each
other
◦ Encourages a professional dialogue
Woelfle, C. & McCaffrey, R. (2007). Nurse on nurse. Nursing
Forum, 42(3), 123-31.
Griffin, M. (2004). Teaching cognitive rehearsal as a shield for
lateral violence: An intervention for newly licensed nurses.
The Journal of Continuing Education in Nursing, 35(6), 257263.
Bowles C. & Candela, L. (2005). First job experiences of recent
graduates: Improving the work environment. Nevada
Nurses Association ISSN: 0273-4117