NUR 600 Discussion 11.1: Utilizing the Greeny article (in the Learning Materials for this module), select two of the four given “crucial conversations” healthcare professionals struggle with that contribute to patient harm and unacceptable error rates. Describe how you have witnessed/observed these in practice and what you can do to stop/deter them/Bradley University
NUR 600 Discussion 11.1: Utilizing the Greeny article (in the Learning Materials for this module), select two of the four given “crucial conversations” healthcare professionals struggle with that contribute to patient harm and unacceptable error rates. Describe how you have witnessed/observed these in practice and what you can do to stop/deter them/Bradley University
Discussion Guidelines
Initial Post
Utilizing the Greeny article (in the Learning Materials for this module), select two of the four given “crucial conversations” healthcare professionals struggle with that contribute to patient harm and unacceptable error rates. Describe how you have witnessed/observed these in practice and what you can do to stop/deter them.
ORDER A CUSTOMIZED, PLAGIARISM-FREE NUR 600 Discussion 11.1: Utilizing the Greeny article (in the Learning Materials for this module), select two of the four given “crucial conversations” healthcare professionals struggle with that contribute to patient harm and unacceptable error rates. Describe how you have witnessed/observed these in practice and what you can do to stop/deter them/Bradley University HERE
Response Post
Reply to the initial posts of at least two classmates.
Submission
Post your initial and follow up responses and review full grading criteria on the Discussion 11.1: Crucial Conversations page.
Week 11: The Comprehensive Physical Exam (cont.)—Behavior and Mental Health
Welcome to the eleventh week of Advanced Physical Assessment. During this lesson, you will continue to coordinate the comprehensive physical exam. The focus of this week is the behavior and mental status assessment. Please keep in mind that because there is a psychiatric nurse practitioner specialty degree, this unit will provide only a brief overview of the psychiatric assessment, as family nurse practitioners do not typically perform this focused exam in detail. You will look different exam techniques and then practice your exam assessment. You will review proper terminology for identifying and then appropriately documenting those subjective and objective findings. You will also focus on the seven crucial conversations that healthcare providers struggle with.
Review a list of all items due this week in your course syllabus.
Lesson 1: Behavior and Mental Health Status
During this lesson, you will continue to coordinate the comprehensive exam, focus on the behavior and mental status, look at different exam techniques, and review proper terminology for objective findings. Please note that this is just a brief summary of mental and behavioral health. These topics require far more attention from specialists and will only be covered in a general sense in this course.
Learning Outcomes
At the end of this lesson, you will be able to:
Begin the practice of sequencing and coordinating the comprehensive physical exam of the adult patient regarding mental and behavioral health status.
Identify the anatomical landmarks of the human body of mental and behavioral health.
Correlate examination techniques of the patient’s mental and behavioral status using the correct sequence and anatomical landmarks in an adult patient.
Use correct terminology to record objective components of the physical examination findings.
Before attempting to complete your learning activities for this week, review the following learning materials:
Learning Materials
Read the following in your Bates’ Guide to Physical Examination and History Taking textbook:
Chapter 9, “Cognition, Behavior, and Mental Status”
Additional Required Resources:
Also read the following article:
Grenny, J. (2009). Crucial conversations: The most potent force for eliminating disruptive behavior. Critical Care Nursing Quarterly, 32(1), 58–67.
This reading will help you perform a mental status assessment, recognize pertinent positives and negatives related to that system, and also document appropriately.
A sample of This Assignment Written by One of Our Top Writers
Crit Care Nurs Q
Vol. 32, No. 1, pp. 58–61
Copyright Ⓧc 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Crucial Conversations
The Most Potent Force for Eliminating Disruptive Behavior
Joseph Grenny, BS
The Joint Commission announced this year that rude language and hostile behavior pose serious threats to patient safety and quality of care. And, for good reason. The Silence Kills study, conducted by VitalSmarts and the American Association of Critical-Care Nurses, reveals that more than three fourths of caregivers regularly work with doctors or nurses who are condescending, insulting, or rude.
But while these disruptive and disrespectful behaviors can be hurtful, what prompted The Joint Commission to address them as a condition of accreditation is the mounting evidence that these behaviors are also harmful. The Silence Kills study found that more than 20% of healthcare pro- fessionals have seen actual harm come to patients as a result of such behavior.
The most powerful force over human behavior is social influence. People will do almost anything to gain acceptance or avoid rejection. If healthcare leaders want to not only secure the well-being of patients but also increase employee retention and engagement, the most immediate and effec- tive thing they can do is to change this culture of silence.
Healthcare leaders who want to engage social influence to eliminate disruptive behavior will have to break the code of silence in 4 crucial conversations. Key words: crucial conversations, disruptive behavior, social influence, sanctions, verbal abuse
ORA is a trauma nurse. One Friday morning her patient had an adverse reaction to a medication that caused his temperature to stabilize at 104◦F. She was convinced he was headed toward acute re- nal failure. The chief resident agreed that con- tinuous renal replacement therapy should be started immediately but asked her to first con-
sult a nephrologist—which she did.
The nephrologist was dismissive and curt. He rolled his eyes as she pressed her point. When she asked if she could share some re- search indicating the best treatment option for the patient, he cut her off midsentence, pointed his finger in her face, and yelled, “We
Author Affiliation: Research and Intellectual Property, VitalSmarts, Provo, Utah.
Corresponding Author: Joseph Grenny, BS, Research and Intellectual Property, VitalSmarts, 282 River Bend Lane Ste 100, Provo, UT 84604 (awalston @vitalsmarts.com).
58
will not be starting dialysis. Period.” And with that, he walked away.
The Joint Commission announced this year that Cora and her fellow nurses should not have to face situations like this again. And for good reason.
The Silence Kills study, conducted by VitalSmarts and the American Association of Critical-Care Nurses, reveals that more than three fourths of caregivers regularly work with physicians or nurses who are conde- scending, insulting, or rude. A full third of study participants say the behavior is even worse and includes name-calling, yelling, and swearing.
But while these disruptive and disrespect- ful behaviors can be hurtful, what prompted The Joint Commission to address them as a condition of accreditation is the mounting ev- idence that these behaviors are also harmful. The Silence Kills study found that more than 20% of healthcare professionals have seen ac- tual harm come to patients as a result of such behavior.
For example, one nurse tearfully told us of a diabetic patient who had a colon re- section with a large surgical wound. He was complaining of nausea and his stitches were coming loose. The surgeon on call had a reputation for being rude and hostile when awakened, but when the patient continued to deteriorate she made the call. The surgeon refused to come and check the patient and demanded that she simply reinforce the dress- ing on the wound. Ultimately, the patient vom- ited, popped his stitches, and died from com- plications of his open wound.
The study found countless examples of care- givers who delayed action, withheld feed- back, or went along with erroneous diagnoses rather than face potential abuse from a col- league. Even more startling is that more than half of participants reported that the bad be- havior in question had persisted for a year or longer. A surprising 20% said the problems had continued for 5 years or more.
IT IS NOT THE CONDUCT BUT THE SILENCE
The Joint Commission has taken an impor- tant step by requiring hospitals to create a clear code of conduct demonstrating the un- acceptability of disruptive behavior and lay- ing the groundwork for holding caregivers ac- countable for their behavior. Although this is an important element of influencing behavior change, the research shows that there is some- thing far more immediate and powerful indi- viduals and leaders can do to drive change: They need to break the code of silence. Un- til they do so, they will fail to mobilize social pressure to drive change.
The most powerful force over human be- havior is social influence. People will do al- most anything to gain acceptance or avoid rejection. Unfortunately, the vast majority of healthcare workers fail to exercise the enor- mous social influence they have in the face of disruptive behavior. The study showed that when physicians or nurses see disrespectful or abusive behavior, there is a less than 7%
ORDER A CUSTOMIZED, PLAGIARISM-FREE NUR 600 Discussion 11.1: Utilizing the Greeny article (in the Learning Materials for this module), select two of the four given “crucial conversations” healthcare professionals struggle with that contribute to patient harm and unacceptable error rates. Describe how you have witnessed/observed these in practice and what you can do to stop/deter them/Bradley University HERE
Crucial Conversations 59
chance they or anyone will effectively con- front the person who has behaved badly.
As a result, disruptive behavior has lingered for years awaiting social disapproval, yet re- ceiving none. So if healthcare leaders want to not only secure the well-being of patients but also increase employee retention and engage- ment, the most immediate and effective thing they can do is change this culture of silence. They need to substantially increase caregivers’ skill and will to step up to crucial conversa- tions immediately and directly when inappro- priate behavior emerges.
CORA SPEAKS
Cora was an exception to the rule of silence. She was one of the rare caregivers we found who was capable of confronting disrespectful behavior head on.
As the nephrologist walked away, she po- litely asked for another moment of his time. Although he was clearly aggravated, she calmed things by explaining, “I am not trying to challenge your expertise. I know you are well trained for this decision. I apologize if it sounded as though I was being insubordinate. I know we both want to do the right thing for this patient. May I please explain why I have additional concerns in this case?” And with that small change in approach the entire con- versation shifted. The nephrologist listened to her concerns and ultimately agreed to order dialysis—saving the patient’s life.
But Cora’s conversation did not stop there. Had she walked away at that point, she would have done right by the patient but would have failed to exercise social influence on the nephrologist’s bad behavior. Having reached agreement, she asked him for 2 more minutes. “Doctor, I suspect you found my approach to you a moment ago disrespectful. If so, I apolo- gize. I recognize your expertise and will work harder in the future to address you as you de- serve.” The nephrologist’s eyes widened. She continued, “And doctor, I must ask the same of you. When I shared my concerns about the patient, you raised your voice, you rolled your eyes, and you spoke to me harshly. That
60 CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2008
doesn’t work for me, either. May I have your word that you will not address me that way again, either?” He whispered an apology and never addressed Cora disrespectfully again.
Social influence—if wielded skillfully—is incredibly potent. The problem is it is rarely used. So while the code of conduct may be an essential element to influence change in dis- ruptive behavior, the conversations around it will ultimately determine the pace and perva- siveness of change in any hospital.
CAN YOU TEACH PEOPLE TO TALK?
Not surprisingly, the Silence Kills study found that the small number of “Coras” who speak up produce far better outcomes for their patients, colleagues, and themselves. These skillful 7% enjoy their jobs more, intend to stay longer, are far more productive, and see better patient outcomes.
So we have studied what it takes to clone the Coras of the world. We have found that there are recognizable, repeatable, and learnable skills for dealing with crucial conversations. One hospital, MaineGeneral Health, spent 2 years teaching these skills to their employees. The caregivers learned to speak up about issues and concerns they had formerly ignored. For example, those who ac- quired greater skills were
- 88% more likely to speak up when they saw someone take a dangerous
- 83% more likely to speak up when they had concerns about someone’s
- 167% more likely to speak up when they saw someone demonstrate poor
- 167% more likely to speak up when they saw someone be
A poignant example came from the heart of the operating room. In one operating room, some of the staff had felt unappre- ciated by a feisty surgeon for a long time. After participating in Crucial Conversations Training, 2 members of the staff indepen- dently approached the surgeon and shared their concerns. Humbled, the surgeon started
to make small but significant changes in his approach—including, for the first time in a decade, thanking staff when they did a good job. The result was a more unified, and poten- tially safer, team.
FOUR CRUCIAL CONVERSATIONS
Healthcare leaders who want to engage so- cial influence to eliminate disruptive behavior will have to break the code of silence in four crucial conversations:
- Administrations must go public about the pervasiveness of con- cerns: Most hospitals attempt to put a good face on disruptive behavior by dismissing it as a problem with “a few bad ” The truth, according to the Silence Kills study, is that it hap- pens every day in most hospitals. It is not just a few bad apples. To in- fluence change, leaders need to be- gin by acknowledging the frequency of concerns.
- Caregivers must directly confront disruptive behavior: Next, leaders need to invest substantially in increas- ing the will and skill of every em- ployee to speak up when they see The focus needs to be not just on confronting disruptive behavior but on speaking up when people see mistakes, incompetence, violations of safety standards, and more. The Silence Kills study identifies 7 kinds of prob- lems; fewer than 1 in 10 people address these problems effectively, which can lead to burnout, disengagement, errors, and worse.
- Medical directors and nurse man- agers must respond appropriately to escalations: The research also shows that the problem is not just up- ward, it is sideways and downward. Nurses fail to speak up to their peers when they have concerns. Managers fail to confront direct Medical directors give their underlings a “pass” rather than make waves. The silence
is deafening in every direction—and lower level employees will not feel the expectation to address concerns if their leaders do not lead the way.
- Administration must back up sanc- tions when they occur: The most common reason people fail to speak up in hospitals is because they adopt the attitude of “It’s not my ” The second most common reason is the belief that “Others won’t back me up if I do.” For example, nurse managers worry that if they confront a disruptive doctor who brings a lot of money into a hospital, no one in administration will back them up. Administration must make it clear that if code-of-conduct violations occur, they will back up those who take ap- propriate action.
As the saying goes, “Silence betokens con- sent.” The pervasive and risky problems with disruptive behavior in hospitals today will
Crucial Conversations 61
not be eradicated by codes of conduct— although these are a worthwhile step in the right direction. The real change will oc- cur when we substantially increase skills in conversation—especially the emotionally and politically risky conversations we so consis- tently avoid. When this vast potential of social pressure is finally tapped, our hospitals will become healthier for patients and caregivers alike.
Joseph Grenny is the coauthor of the New York Times bestsellers Influencer, Cru- cial Conversations, and Crucial Confronta- tions. He is a cofounder of VitalSmarts, where he leads a series of consulting and research projects on the role crucial con- versations play in medical errors, employee retention, and patient satisfaction. He has also consulted with more than 300 of the Fortune 500 on corporate change initiatives over the past 30 years. www.vitalsmarts. com.