Armstrong Institute for Patient Safety and Quality Empowering staff to use Appropriate Assertion Presented by: Jill Marsteller PhD, MPP David Thompson DNSc MS, RN The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
What characteristics do you believe indicate an ineffective/effective communicator? Ineffective Effective Armstrong Institute for Patient Safety and Quality 2
Communication Styles Assertive Aggressive Passive or Passive Aggressive 2009 JHU Quality and Safety Research Group
Passivity- the goal is to appease and avoid conflict at all costs! Fail to express your thoughts/opinions Sarcastic Give in with resentment Remain silent Body language- The Victim Stance
Aggressive- the goal is to g dominate and win! This is what I think, what you think does not matter-you are uninformed Often expression of feeli lings, thoughts in a way that is not wholly truthful, Usually done in an inappropriate and unprofessional manner Body language-clenched g fists, crossed, arms, glaring eyes, intrusive on personal space
Assertiveness Assertiveness is an attitude and a way of positively relating to those around you; a skill set for effective communication. See yourself as having worth You value others equally, respecting their right to an opinion. Engage in communication respectfully, while also respecting your own opinions. i 2004 JHU Quality and Safety Research Group
Being appropriately assertive means: Being organized in thought and communication May require you to think about what needs to be said or how to approach the situation! Speaking clearly, and audibly Disavowing perfection while looking for clarification / common understanding di (This could be a learning or teaching opportunity) Should be owned by the entire e team (not just a subordinate skill-set, and it must be valued by the receiver to work) 2012 Armstrong Institute
Assertion Includes: Saying yes when indicated, but no when you mean no. don t be passive aggressive. Using I when not speaking for the team. Respectively defending your position, even if it provokes conflict.- you re an advocate. Body language- Secure upright position in a relaxed manner, making eye contact, standing with open hands
Someone who is Assertive Is Not Aggressive Hostile Uncomfortably Confrontational Ambiguous Demeaning Condescending Selfish 2012 Armstrong Institute
Assertion Model: A Continuous Process of 4 steps Agree on Course of Action Get Attention NAMES First Propose Action State the issue Quality and Safety Research Group
Helpful Hints in Applying The Assertion Model Focus on the common goal: quality care, the welfare of the patient, safety it s hard to disagree with safe, high quality care Avoid the issue of who s right and who s wrong Patient Centered care It is not who is right or who is wrong. It is what is best for the patient. De-personalize the conversation. Actively avoid being perceived as judgmental Be hard on the problem, not the people 2012 Armstrong Institute
Improving Assertion Names First- get their attention Make eye contact Express you concern-feelings State the issue (clear, concise) Propose action(s) Re-assert as necessary Agree on course of action Escalate if no resolution 2012 AI Agree on Course of Action Propose Action Get Attention NAMES First State the issue
It is easy for personnel here to ask questions when they don t understand. Pascal Metrics SAQ 2011
In this setting it is difficult to speak up. Pascal Metrics SAQ 2011
Disagreements in this work setting are resolved appropriately. Pascal Metrics SAQ 2011
In this work setting it is difficult to discuss errors. Pascal Metrics SAQ Keystone: Surgery 2011
Discussion 1.Why is it difficult to always be assertive? 2.What can you do to assure that your concerns are heard? 3.What can we do at the organizational level that will help you succeed at providing safe patient centered care?
Case Example 1 Central is placed in the PACU. The RN suggests an x-ray before the patient is transferred (that is policy). Physician Assistant states, Get the x-ray on the inpatient floor (violation of policy). The attending is paged but he does not return the page. RN is unsuccessful in getting x-ray taken in PACU and the inpatient floor delays. Meanwhile the patient suffers a pneumothorax requiring a chest tube.
What next? We will build on our assertive training to effectively master conflict resolution strategies. What are some skill sets we should work on before we begin to address personal and work related conflict.
Jill Marsteller, PhD, MPP David Thompson, DNSc, MS RN Conflict Resolution The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011
What is Conflict? Perception of mutual interference A process that begins when goals of one party are frustrated by another Requires interdependence/ interaction
Views of Conflict Conflict Good Conflict Natural Conflict Bad Conflict must be managed
Sources of Conflict Conflict arises from resource scarcity Goals of parties are incompatible Other structural factors (size, routinization, specialization, reward systems) Conflicting perceptions, ideas or beliefs Differences between people p Conflicting thoughts/needs within an individual Lack of communication ca o (maybe)
Types of Conflict Task Content conflict (differing opinions related to the task) G Emotional or Relationship conflict (interpersonal conflict--dislike, negative emotions) B Administrative or Process conflict (disagreement on how to get the task completed e.g., e.g., duties, decision-making technique) B to N
Goal of Conflict Resolution Confront problems, communicate openly and respectfully with someone of opposing opinion to provide optimal patient t care.
Why Address Conflict Resolution? Inevitable in dynamic environments Conflict can lead to feelings of powerlessness Can cause anyone to view coworkers as adversaries Creates animosity, divided loyalties in the workplace
Conflict-Handling Strategies Avoiding (or Withdrawal) Lose--lose Trivial issues; low power; potential dysfunction not worth the effort; low information Accommodating- Conciliation Lose--win Emphasize commonalities; emotional or personality conflict; build relationships Pressing/ competition (or Forcing) Win--lose Quick action; unpopular actions; top-down fiats Borkowski 2009
Conflict-Handling Strategies Positive confrontation Compromising Win with some loss--win with some loss Goals are mutually exclusive; deadlock; conflict style differences Collaborating Win--win Complex, long-term issues; high interdependence Borkowski 2009
Positive Confrontation is an appropriately p assertive means of y Resolving Conflict Respectful negotiation Effective conflict resolution is about WHAT is right, not WHO is right. Never Aggressive. Use to explain perspectives. If handled app ppropriatelypp may be an opportunity for two-way learning and relationship growth.
Two Attempt Rule: Using the elements of assertion, make 2 attempts to reach a common goal. If your viewpoint is disregarded, bring in a third party to help resolve Continue up the chain of command ( escalate ) Charge nurse, Nurse Manager, Fellow, Attending Third party may act as mediator, consultant, arbiter or inquisitor
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DESC SCRIPT What is it? A structured, assertive, communication approach for managing and resolving conflict D Describe the specific situation E Express your concerns about the action S Suggest other alternatives C Consequences should be stated Ultimately, consensus shall be reached. When to use it? Whenever you have a personal conflict with another health team member that threatens your ability to perform your job well. Key Points 32 Have timely discussion Armstrong Institute for Patient Safety and Quality
DESC Example D- When you scream at me in front of my coworkers about the delay in care, you re making it personal. E- This reduces my credibility with the patients and undermines my authority with staff. I feel you don t respect me. S- If you are upset about delays or other patient care issues, pull me aside and I will address your concerns. C- If your outbursts t continue we won t have a good working relationship and patient care will suffer.
DESC Example 2 D- I understand we need to move this patient out to make room for the next case E- However the pressure to get this done is making us rush S- Placing the central line and the foley catheter sequentially is more consistent with hospital policy C- I am concerned that we will put the patient at risk of infection if we place the line and urinary catheter simultaneously
ALEEN- What is it? A conflict resolution approach to reduce the tension in a confrontatiti on, clarify the problem, and reach a solution. A -Anticipate Anticipate Pause, think of problem, then approach person L Listen Listen without interrupting E Empathi ze Summarize and show empathy E Explain Explain your behavior or action N Negotiate Reach a mutually agreeable N Negotiate Reach a mutually agreeable solution When to use it? In conflict situations where a patient, family member, or colleague is upset and approaches you wi th a complaint or concern ce that you can address. Key Points - Listening to full story of other person without interruption is important to reduce escalating tension and help the upset person realize that they are being heard. - Show genuine empathy - Reaching a mutually agreeable plan would require some flexibility from your 35 end on matters that are within your control. Armstrong Institute for Patient Safety and Quality
ALEEN - Example A- Anticipate perspective L- Can you help me understand how you see the situation, how you are weighing the risks and benefits. E- I can see how you see it that way E- Let me explain how I see things N- Let s put the patient first and agree on a plan
Managing Conflict (Leaders) Focus on eliminating dysfunctional conflict In conflict resolution, solicit all sides & mediate Set the tone for open discussion Emphasize interdependence Encourage functional conflict Build in a devil s advocate process Encourage people to speak up/ confront issues Reward constructive dissenters Help conflict avoiders learn how to deal with conflict
Discussion How will you implement a structured communication? Is the an opportunity to include multiple disciplines? What support do you need at the unit level? Hospital level? Armstrong Institute for Patient Safety and Quality 38
Questions? dthomps1@jhmi.edu jmarstel@jhsph.edu Armstrong Institute for Patient Safety and Quality 39