Susie, I’m concerned that …
Let’s …….
Crew Resource Management
Assertive Statements
Components of an Assertive Statement
•
•
•
Get Attention Call the person by name
Express Concern - “I am concerned . . . .”
State the Problem - Brief, clear, objective
•
•
•
State in 10 seconds or less
Goal is to get immediate attention
Propose a Solution •
•
•
•
“We or Let’s . . .”
Don’t ask a Yes/No question!
Use of “we” or “let’s” indicates it’s a team problem.
If you don’t know the solution, restate the problem, using
team words
Within scope of your clinical role
2
To get immediate attention . . .
Remember
Delta
Use it if you have to!
3
Notes on Statements
• There are no absolute right or wrong answers
• This is a brief 7-10 second statement – it can be
followed up by a longer conversation
• Key issues:
–
–
–
–
All 4 parts of the statement used?
Problem statement is brief, factual, non-provocative
Solution is NOT a yes/no question
Is the focus on solving the problem and/or turning
attention back to the patient?
– NO sarcasm
4
Situation # 1
The CRNA, Sally, brought a patient to PACU and began giving a
verbal report before the PACU RN could place the patient on the
monitor. When the RN informed Sally that there should be a
mandatory pause prior to report, Sally kept talking.
Draft an Assertive Statement from the PACU RN to Sally:
Get Attention
Express Concern
State the problem
Propose Solution
5
Potential Statement - #1
Sally, I’m concerned that I will miss
important information while I am
focusing on getting the patient
monitored. Let’s do report in just a
minute.
6
Situation # 2
The tech and the RN are setting up for the case, but the vendor has
not yet arrived with the implant. The anesthesia provider, Dr. Rush,
is in a hurry to start the case, so he brings the patient to the room.
Dr. Rush wants to proceed with induction to avoid further delay.
Draft an Assertive Statement from the RN and/or Tech to Dr. Rush:
Get Attention
Express Concern
State the problem
Propose Solution
7
Potential Statement - #2
Dr. Rush, I’m concerned that we may
not have all the needed supplies. Let’s
wait to anesthetize the patient until we
have confirmed the implant is here.
8
Situation # 3
When the circulating RN pulls back the sheet to prep the patient,
she discovers that the clip prep done by Mary, the holding area RN
is incomplete and poorly done. This is not the first time this has
happened.
Draft an Assertive Statement from the Circulating RN to Mary:
Get Attention
Express Concern
State the problem
Propose Solution
9
Potential Statement - #3
Mary, I’m concerned that the clip preps
are incomplete and may predispose the
patient to infection. Let’s talk about the
type of prep needed for this procedure.
10
Situation # 4
Your co-worker, Steve, does not change gloves between taking off
an old dressing and applying the new one to the patient’s wound.
You hand Steve a new set of gloves – he takes them, but glares at
you and refuses to speak to you later.
Draft an Assertive Statement to Steve:
Get Attention
Express Concern
State the problem
Propose Solution
11
Potential Statement - #4
Steve, I’m concerned that not changing gloves as
needed may predispose the patient to infection.
Let’s talk about our dressing change process.
OR
Steve, I’m concerned. I believe you are upset with
me, and we need to be able to work together for
safety’s sake. Let’s talk about this.
12
Situation # 5
A patient is crying, clearly upset and uncomfortable. The patient’s
caregiver, Queen Bee, is talking and laughing on the phone, clearly
on a personal call, and you believe she is ignoring the patient.
Draft an Assertive Statement to Queen:
Get Attention
Express Concern
State the problem
Propose Solution
13
Potential Statement - #5
Queen, I’m concerned. Your patient is
upset and needs some attention. Let’s
see what we can do for her.
14
Situation # 6
You are relieving another RN, Anita Break, for lunch in the middle of
a procedure. There are specimens on the field that have not yet
been identified or labeled. Anita gives report, states she is “very
hungry” and that you should be able to handle the specimens.
Draft an Assertive Statement to Anita:
Get Attention
Express Concern
State the problem
Propose Solution
15
Potential Statement - #6
Anita, I’m concerned that there’s a
big potential for error here. Let’s
label and verify the specimens
together before you go.
16
Situation # 7
The patient was brought into the room and positioned by team
members. At the last minute, you are asked to substitute for one of
the members. Finishing your current task takes a few minutes, so
the team proceeds with the Pause for the Cause without you – they
do not want to repeat it on your arrival to the room.
Draft an Assertive Statement to your team:
Get Attention
Express Concern
State the problem
Propose Solution
17
Potential Statement - #7
Team, I’m concerned that I may not have
all the information I need to help keep the
patient safe. Let’s repeat the
PreProcedure Briefing so that we are all
on the same page.
18
Situation # 8
The RN is preparing the label for the specimen. When the
physician, Dr. Sar Castic, is asked what to call the specimen, he
answers, “Call it Fred”.
Draft an Assertive Statement to Dr. Castic:
Get Attention
Express Concern
State the problem
Propose Solution
19
Potential Statement - #8
Dr. Castic, I’m concerned I do not have the
information to accurately label your patient’s
specimen. Let’s repeat the information for safety.
OR
Dr. Castic, I’m concerned that those comments
detract from our teamwork. Let’s work together
to keep your patient safe.
20
Situation # 9
The policy states that 2 staff members are to be in the treatment
area at all times during setup and patient treatment. This morning,
due to a sick call, one staff member, Ima Loner, is working alone.
You walk by and observe Ima treating patients, she states “to avoid
any delays”.
Draft an Assertive Statement to Ima:
Get Attention
Express Concern
State the problem
Propose Solution
21
Potential Statement - #9
Ima, I’m concerned that you are working
alone without our required crosschecks. Let’s talk to the supervisor
about this situation before anyone else
is treated.
22
Situation # 10
The procedure requires that a vendor be present to support the
equipment. During the PreProcedure Briefing, the vendor, Mike,
takes a call on his cell phone. Because the connection is bad, the
vendor is speaking somewhat loudly.
Draft an Assertive Statement to Mike:
Get Attention
Express Concern
State the problem
Propose Solution
23
Potential Statement - #10
Mike, I’m concerned that your phone call
is distracting us from our PreProcedure
Briefing and that you will not hear
important information. Please hang up
and let’s all focus on the discussion.
24
Situation # 11
Anesthesia for the patient will be provided by a CRNA student,
monitored by the CRNA, Joe. During the PreProcedure Briefing, the
student is participating, but Joe is having a personal conversation on
his phone. When prompted to hang up and join the team, Joe
replies that “she is the provider of record”, referring to the student.
Draft an Assertive Statement to Joe:
Get Attention
Express Concern
State the problem
Propose Solution
25
Potential Statement - #11
Joe, I’m concerned that the conversation
is distracting, and everyone in the room
needs to participate in the Briefing. Let’s
stop our other activities and focus on the
discussion about the patient.
26
Situation # 12
The physician, Dr. Imalittle Young, follows the format for the
PreProcedure Briefing, but neglects to make the Safety Statement.
When prompted by the RN, Dr. Young states, “If anybody knows of
anything that sucks more than me having to do this, please speak
up.”
Draft an Assertive Statement from any team member to Dr. Young:
Get Attention
Express Concern
State the problem
Propose Solution
27
Potential Statement - #12
Dr. Young, I’m concerned that those
comments detract from positive teamwork.
Let’s all work together to focus on
providing safe care to our patient.
28
Situation # 13
This case has generated several specimens, with different
processing, i.e. pathology, microbiology. The physician, Dr. I. M.
Impatient, tells the RN, “listen up, because I’m only going to say this
once”, then proceeds to give a detailed, lengthy description of the
tissue.
Draft an Assertive Statement from the RN to Dr. Impatient:
Get Attention
Express Concern
State the problem
Propose Solution
29
Potential Statement - #13
Dr. Impatient, I’m concerned that I don’t have the
necessary information to safely label the specimens.
Let’s verify the information.
OR
Dr. Impatient, I’m concerned that those comments
detract from teamwork. Let’s work together to focus
on caring safely for our patient.
30
Situation # 14
You are the tech on the case. During the procedure, the surgeon,
Dr. Goyo, and the assistant converse in Spanish. At first, it appears
to be casual and un-related to the case, but then the surgeon says
something to the RN, and she brings over additional equipment.
You are the only caregiver in the room who does not speak Spanish.
Draft an Assertive Statement to Dr. Goyo:
Get Attention
Express Concern
State the problem
Propose Solution
31
Potential Statement - #14
Dr. Goyo, I’m concerned that I will
not respond to your needs during
the case. Let’s all communicate in
English for safety’s sake.
32
Situation # 15
During a C-section, the RN and tech discover a lap sponge is
missing. The RN announces this to the team, but gets no response,
and the surgeon, Dr. Good Cutter, and assistant continue to close
the uterus. They are nearly done.
Draft an Assertive Statement from the RN to Dr. Good Cutter:
Get Attention
Express Concern
State the problem
Propose Solution
33
Potential Statement - #15
DELTA! Dr. Cutter, I’m concerned. I’m
missing a lap sponge. Let’s stop
closing and look for the sponge.
34
Situation # 16
Prior to beginning a procedure, the physician, Dr. Ree Sistant, does not
wish to conduct the entire PreProcedure Briefing, since there’s no laterality
involved and it’s a simple procedure (PEG tube insertion). He ultimately
does so, but states “thank goodness we did that, or we would have
mistakenly stuck this tube in the patient’s ear”.
Draft an Assertive Statement from any team member to Dr. Ree Sistant:
Get Attention
Express Concern
State the problem
Propose Solution
35
Potential Statement - #16
Dr. Sistant, I’m concerned that the
comment detracts from teamwork
aspects of CRM. Let’s focus on positive
comments that help us keep the patient
safe.
36
Situation # 17
The physician is leading a thorough PreProcedure Briefing. About halfway
through, the phone in the room rings, and the RN, Miss Dee Stracted,
walks over and answers the phone
Draft an Assertive Statement from any team member to Nurse Dee
Stracted:
Get Attention
Express Concern
State the problem
Propose Solution
37
Potential Statement - #17
Dee, I’m concerned. Answering the phone
now interrupts the briefing and our teamwork.
Let’s ignore the phone for now and focus on
the Briefing for our patient.
38
Situation # 18
The new work schedule has just been posted. Your co-worker, Mr. Dis
Pleased, is unhappy with his assignments, and proceeds to disparage the
manager and the schedule in front of patient and families
Draft an Assertive Statement to Mr. Dis Pleased:
Get Attention
Express Concern
State the problem
Propose Solution
39
Potential Statement - #18
Dis, I’m concerned that your
comments may send the wrong
message to our patients and families.
Let’s take this discussion to a private
area.
40
Situation # 19
The PACU RN notes a developing hematoma after a carotid procedure, and
informs the physician, Dr. Ima Grouch. Dr. Grouch states “why are you
calling me? The Nurses at their other hospitals never call me for this. I’m
not coming there now.”
Draft an Assertive Statement from the RN to Dr. Grouch:
Get Attention
Express Concern
State the problem
Propose Solution
41
Potential Statement - #19
Dr. Grouch, I’m concerned that this hematoma may
compromise your patient’s airway. Let’s discuss our plan
of action.
OR
Dr. Grouch, I’m concerned that those comments detract
from teamwork. Let’s focus on what we need to do to
keep your patient safe.
42
Situation # 20
The team has been called in for an emergency procedure at 4 a.m. No one
thinks it’s necessary to do the PreProcedure Briefing and Time out, except
for you.
Draft an Assertive Statement to your team:
Get Attention
Express Concern
State the problem
Propose Solution
43
Potential Statement - #20
Team, I’m concerned that not doing
the Preprocedure Briefing will
compromise our patient’s safety.
Let’s do the right thing.
44
Situation # 21
During the Debrief, the discussion centers around a piece of equipment that
was not readily available nor properly prepared. The tech, Dee Fense, gets
very upset and begins to blame other team members for the oversight,
including several people who are not in the room
Draft an Assertive Statement to Dee Fense to help get the discussion back
on track:
Get Attention
Express Concern
State the problem
Propose Solution
45
Potential Statement - #21
Miss Fense, I’m concerned. The
goal of the debrief is to focus on what
we can do better as a team, not to
point fingers. Let’s keep the focus on
performance.
46
Situation # 22
You are assuming care from your Co-worker, Miss Short Cutz, who is going
on a break. The patient does not have an ID bracelet on, although there is
one taped to the chart. Miss Cutz states that the patient came from the
nursing unit that way, and will not leave the bracelet on. Miss Cutz asks you
to proceed with the patient’s care, and she will fix the bracelet later.
Draft an Assertive Statement to Miss Short Cutz:
Get Attention
Express Concern
State the problem
Propose Solution
47
Potential Statement - #22
Short Cutz, I’m concerned. Not
having a bracelet seriously
compromises our ability to provide
safe care. Let’s fix the bracelet now.
48
Situation # 23
On receiving the patient from the nursing unit, you discover that the Blood
Bank has not processed the Type and Screen order because the verbal
order was written with the unapproved abbreviation “u”. The patient’s skin is
broken down at the potential procedure site. When questioned, the nursing
unit RN, Miss Ina Hurry admits she was “rushed” and didn’t adequately
assess the chart or the patient, but “isn’t that your job?”
Draft an Assertive Statement to Miss Ina Hurry:
Get Attention
Express Concern
State the problem
Propose Solution
49
Potential Statement - #23
Ina, I’m concerned. These are major
safety issues for the procedure. We need
to work together to ensure the patient’s
safety. Let’s talk about the steps needed
for pre-procedure preparation.
50
Situation # 24
The patient has undergone MAC anesthesia for an uneventful procedure.
During the debrief, the physician, Dr. Wo Isme, begins to complain about
the CRM process, multiple delays and the competency of the staff. The RN
is concerned that the patient may overhear the comments, even though the
patient is sedated.
Draft an Assertive Statement from the RN to Dr. Wo Isme:
Get Attention
Express Concern
State the problem
Propose Solution
51
Potential Statement - #24
Dr. Isme, I’m concerned that those
comments do not enhance teamwork, and
that the patient may overhear them. We
can address your concerns outside the
room.
52
Situation # 25
A patient from ICU is brought over for a procedure. The ICU RN, Miss Diz
Respect accompanies the patient, but states she is not comfortable in the
procedure room, and states she should “not have to be here anyway, if the
procedure RN’s were any good.” She then proceeds to sit in the control
room and read a nursing journal so as “not to waste my time”.
Draft an Assertive Statement from the procedure RN to Nurse Diz Respect:
Get Attention
Express Concern
State the problem
Propose Solution
53
Potential Statement - #25
Miss Respect, I’m concerned that we are
not working together to safely care for the
patient. Let’s help you get situated in the
room and work together to get the patient
safely through the procedure.
54
Situation # 26
The CRNA has given the PACU RN a post-procedure report. You, the
procedure RN, try to give the PACU RN, Mr. I. Gotit, some additional
information not covered in the CRNA’s report. He cuts you off and says,
“CRNA already gave me report – I’m good.”
Draft an Assertive Statement to Nurse I. Gotit:
Get Attention
Express Concern
State the problem
Propose Solution
55
Potential Statement - #26
I. Gotit, I’m concerned that you will
not have all the information you need
to take care of the patient. Let’s
review the additional information.
56
Situation # 27
“Use SCIPS protocol” is checked off on the preoperative order sheet, but
there is no protocol for the ordered procedure (Port insertion). When you
ask the doctor, Dr. Risky, what antibiotic she wishes to order, she replies, “I
told you not to ask me that for these cases. Don’t ever ask me that again.”
Draft an Assertive Statement to Dr. Risky:
Get Attention
Express Concern
State the problem
Propose Solution
57
Potential Statement - #27
Dr. Risky, I’m concerned that the
orders for antibiotics are not clear.
Let’s clarify the orders so that your
patient gets what she needs.
58
Situation #28
When called by Preop area to give report on her patient, Newbie, the medsurg RN stated that she had no orders for surgery. The Preop RN insisted
she send the patient – the surgeon, Dr. Rush, later called and insisted she
send the patient, then put the Holding Area RN, Miss Ino Better, on the
phone
Draft an assertive statement from Newbie to Ino:
Get Attention
Express Concern
State the problem
Propose Solution
59
Potential Statement - #28
Ino, I’m concerned that we do not have the right
patient. There are no orders for surgery, and the
patient has eaten. Let’s verify using patient name
and MR #.
60
Situation #29
An interventional room is undergoing construction, so the physician decides
to perform a case in the OR, despite having been asked not to by the
charge RN, due to staffing/equipment availability. The doctor, Dr. Norules,
tells the RN, Suzie, to take the patient to the OR, and the rest of the team
can “catch up”.
Draft an assertive statement from Suzie to Dr. Norules:
Get Attention
Express Concern
State the problem
Propose Solution
61
Potential Statement - #29
Dr. Norules, I’m concerned that we will not have
the things we need to safely care for the patient.
Let’s discuss this further and get everything into
place.
62
Situation #30
Dr. Bull began to remove a patient’s dressing in preparation for a catheter
removal. He was not using gloves, had not yet obtained consent, and the
patient was still on a stretcher outside the procedure area. Mary, the RN
noticed the activity and stepped over to intervene.
Draft an assertive statement from Mary to Dr. Bull
Get Attention
Express Concern
State the problem
Propose Solution
63
Potential Statement - #30
Dr. Bull, I’m concerned that we may not have what
you need in this location. Let’s get the patient into
the room, get our consent, and get the supplies to
do this safely.
64
Components of an Assertive
Statement
•
•
•
Get Attention Call the person by name
Express Concern - “I am concerned . . . .”
State the Problem - Brief, clear, objective
•
•
•
State in 10 seconds or less
Goal is to get immediate attention
Propose a Solution •
•
•
•
“We or Let’s . . .”
Don’t ask a Yes/No question!
Use of “we” or “let’s” indicates it’s a team problem.
If you don’t know the solution, restate the problem, using
team words
Within scope of your clinical role
65
To get immediate attention . . .
Remember
Delta
Use it if you have to!
66
Notes on Statements
• There are no absolute right or wrong answers
• This is a brief 7-10 second statement – it can be
followed up by a longer conversation
• Key issues:
–
–
–
–
All 4 parts of the statement used?
Problem statement is brief, factual, non-provocative
Solution is NOT a yes/no question
Is the focus on solving the problem and/or turning
attention back to the patient?
– NO Sarcasm
67
Assertive Statements
Remember!
You are empowered!
Speak Up!
68