If your OR physicians are frustrated and your nurses aren’t speaking up, there is a solution: get them to talk. It’s been said that healthcare is an illustration of the cutting edge of human knowledge. But a problem sweeping the nation’s ORs points to an issue more reminiscent of a high school social drama than a hospital: fear of speaking up. 

David Maxfield, vice president of research at VitalSmarts, said communication breakdowns generally happen in one of two ways. One way is accidental, such as hand-off errors where someone forgets to communicate, has a tough time understanding, or uses abbreviations others on the OR team don’t understand. 

“You see healthcare investing in preventing these accidental slips and errors, but we were interested in a different kind of breakdown, one that’s more intentional, and we didn’t see anyone addressing it,” he said.

Intentional breakdowns, those where someone knows there is a problem or suspects something is wrong and fails to speak up, are generally not the result of a vindictive employee but rather the unintentional development of an unhealthy work environment. “If there is a challenge with people not speaking up, when you talk to them, they’ll often say they saw someone speak up once and it was like catching a landmine—it blew up in the person’s face,” Maxfield said. “Now it’s become an ‘undiscussable,’ the classic elephant in the room.”

Before getting discouraged, it’s important for organizations to understand there are good and bad parts to those pesky pachyderms. The bad news is we’re all familiar with them, they can destroy patient safety, and they often destroy an OR team’s effectiveness. 

The good news is that in most cases, there aren’t 1,000 elephants in the room; there are usually only a few. And once a team figures out how to address and resolve the most challenging issues, the result is a high-leverage way to improve communication channels overall. 

Line in the sand

Those findings came from “Silence Kills: The Seven Crucial Conversations for Healthcare.” The study was co-sponsored by the American Association of Critical-Care Nurses and VitalSmarts and included focus groups, interviews, workplace observations, and survey data from more than 1,700 nurses, physicians, administrators, and clinical-care staff members.

The seven crucial conversations include broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. According to findings released in January 2005, “fewer than 10% [of those surveyed] address behavior by colleagues that routinely includes trouble following directions, poor clinical judgment, or taking dangerous shortcuts.” 

Other findings include: 

  • 84% of physicians and 62% of nurses and other clinical-care providers have seen coworkers taking shortcuts that could be dangerous to patients.
  • 88% of physicians and 48% of nurses and other provi-ders work with people who show poor clinical judgment.
  • Fewer than 10% of physicians, nurses, and other clinical staff directly confront their colleagues about their concerns, and one in five physicians said they have seen harm come to patients as a result.
  • The 10% of healthcare workers who raise these crucial concerns observe better patient outcomes, work harder, are more satisfied, and are more committed to staying in their jobs.

Although “Silence Kills” isn’t only targeted at operating rooms, when looking for answers to improve communication and boost respect in their ORs, Dr. David Feldman, vice president for perioperative services and vice chair of the surgery department at Maimonides Medical Center in Brooklyn, and Kathryn Kaplan, chief learning officer at the center, found problems they were familiar with and potential solutions they were looking for. 

Kaplan found the study spoke to what she experienced, both as a practicing therapist and as an organizational developmental specialist. For example, at Maimonides, while surgeons yelled about getting the wrong equipment and slow response times, nurses felt the brunt of surgeon frustrations and were intimidated to speak up if they saw a problem. 

Maxfield describes Crucial Conversations as speaking truth to power. “When you have a concern, and everyone else is sitting on his or her hands out of fear, you speak up. That’s Crucial Conversations.”

Kaplan and Feldman, along with Pamela Mestel, executive director of perioperative services at Maimonides, went through Crucial Conversations training and gained the certification necessary to roll out the program at their center. Maxfield said what impressed him about the Maimonides rollout were the insights Feldman and Kaplan had about the challenges physicians had in communicating their issues.

“Physicians often feel that in today’s environment, everyone—from government to legal advisors to insurance companies and hospitals—is putting a line in the sand and saying ‘Don’t step across this line,’” Maxfield said. “When they approached their physicians and started talking about implementing a code of mutual respect, the physicians saw it as one more line in the sand they’re not allowed to cross.”

Difference between life and death

Rather than giving up, Kaplan and Feldman looked at how to approach the situation and make it beneficial to both nurses and physicians. They approached the physicians, explaining they were going to track the issues as they came up and then do debriefs to discuss what happened and why.

“They told their physicians that whenever they find themselves frustrated and angry to view those feelings as a symptom of a problem needing to be solved,” Maxfield said. “They put together an almost Toyota pull-chain methodology where when in surgery, whether a physician or nurse, and you experience the kind of frustration that turns your eyeballs red, there’s a code of conduct, and you’re not allowed to blow up and be intimidating or abusive.”

After putting together a pilot program comprising 250 OR physicians, nurses, and staff from the center and taking them through Crucial Conversations training session, Kaplan and Feldman selected 20 individuals to be code leaders. These leaders attended a four-day certification training class and were appointed to be leaders in other training sessions across the organization, helping the staff at Maimonides comply with what was termed the Code of Mutual Respect. 

Along with the code leaders, a group of code advocates was developed. After attending a two-day training course, these informal leaders were asked to act as a support system for physicians, nurses, or staff needing advice on how to deal with certain situations by using what they’d learned through Crucial Conversations. 

“To make this work, we want a core of opinion leaders who can be supportive,” Maxfield said. “Whenever possible, we try to have a physician leader, as well as an OR manager or OR leader, co-train when we’re training people in communication skills. It gives them a chance to see the people they view as leaders saying this process is okay.”

After going through the training sessions at Maimonides, the team compared staff evaluations from before and after. In addition to improvements in employee morale and patient safety, the team found:

  • 54% improvement in how leaders handle disrespectful behavior
  • 39% improvement of how many people speak up when they see someone violating the Code of Mutual Respect

“Respect is at the core of having a safe healthcare environment,” Feldman said in the Maimonides case study. “It’s not surprising that the first change we see as we train Crucial Conversations is people’s willingness to speak up—a skill that in healthcare can mean the difference between life and death.”

Tools over time 

According to Maxfield, another important piece in successfully improving OR communications is not relying on one tool to maintain positive change. He’s found that when companies try to change entrenched habits, they rely on a training program, a change of performance review, or motivational talks individually rather than collectively. 

“The secret is you have to rely on all of them,” he said. “You have to overwhelm the problem because most don’t have a single root cause. You might address one root cause and see improvement, only to see it backslide as the other root causes continue.”

In the same fashion, organizations should spread out their training rather than putting all eggs in one basket. “I would much rather have bite-size chunks over a sustained period of time,” said Maxfield. “You can overdo those things, but, initially, you should have cues and reminders close at hand.”

And as simple as it sounds, small rewards for voicing concerns are also positive reinforcers. During the initial phases of training, Maxfield said coupons for Starbucks coffee or other extrinsic incentives are used but, again, there is no one solution to sustain the message. 

“I once heard a person describe what happens in the OR as bystander apathy; the nurse knew something was wrong but didn’t speak up. But it’s not bystander apathy; it’s bystander agony. Give them a skill—any skill—and they will speak up. That’s Crucial Conversations.”

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