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By Beth Boynton
The Paradox of Interruptions I want to share some thoughts about interruptions in healthcare. We face a paradox regarding interruptions in healthcare because sometimes they prevent errors and sometimes they cause them. If we can discern differences, we’ll stand a better chance of fostering the former and eliminating the latter. As explained in the first few minutes of the YouTube, “Interruption Awareness: A Nursing Minute for Patient Safety”, interruptions can alert us to problems and stop us from making a mistakes. They can also be examples of less than perfect behavior and an opportunity for personal growth. Interruptions can also be a form of bullying and are hugely dysfunctional. They interfere with our ability to think clearly in the moment. And when tolerated become entrenched in an organizational culture and threaten staff’s psychological safety. In healthcare, interruptions lead to mistakes, (sometimes catastrophic ones), loss of creative problem-solving capacity, and burnout. When are interruptions Bullying? Communication is an art and most of us, including myself, have room for improvement. Yet imperfection is vastly different from persistent poor behavior. With that in mind, here are several ways to distinguish intentional i.e. helpful interruptions and the imperfect behavioral ones from those that should be characterized as aggressive. These three signs will help you determine whether someone is bullying or not. 1. An apology. I’m sorry, I just interrupted you. Please continue. This suggests that the person has awareness of his/her behavior, how it might impact you, and a willingness to work on it. Additional ownership might be nice, but not necessarily essential. 2. The interruptions stop. While an apology shows signs that another person is considering your needs, persistent interruptions show s/he does not. Sometimes, an inability to listen well involves impulsivity and a learning curve. So interruptions may not stop completely, forever, or all at once. However, the trend should be in that direction if the relationships and culture are going to be healthy. 3. There is a clear intention to prevent a perceived problem. Speaking up to stop a wrong-site, wrong-person, wrong-procedure incident in the operating room is one good example. STOP! That is the wrong kidney! Another would be interrupting a gossiping colleague: "stop talking about me behind my back." Summary Bullying interruptions undermine cultures of safety for patients and the workforce. And there are no excuses for it in healthcare. It is up to us to raise awareness about it, speak up against it, and do our own work to become better listeners. Learning to listen well is a complex and important soft skill to cultivate. It requires clear expectations from leaders, practice opportunities that are safe, room for learning curves with feedback loops and forgiveness, and ultimately disciplinary action. Planning your next event? Get in touch with us at the Capitol City Speakers Bureau today to schedule your ideal speaker and make your event a success!
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By Beth Boynton
The butterfly effect is a property of Complex Adaptive Systems and refers to a small thing happening in one place, like a butterfly flapping it’s wings, contributing to a large thing happening someplace far away, like a hurricane on the opposite side of the world. There are all sorts of communication-related skills that contribute to positive or adverse events in healthcare that can be explained at least in part by this property. How We Interact Matters Human Factors, Leadership, and Communication involve human interactions. They are also long-standing root causes of sentinel events. As these examples illustrate, respectful and effective communication contribute to desirable or adverse outcomes.
The concept can be elusive, yet understanding the connection between soft skills and outcomes is an important aspect of leadership in complex human systems such as healthcare. In short, leaders who build trust and promote positive communication and respectful behavior will be empowering staff to be their best selves. Individuals then bring their best selves into therapeutic and inter-professional relationships including teamwork and leadership. All of which who in turn will influence the culture in the most positive ways. Everyday healthcare professionals are presented with opportunities speak up, listen, lead, follow, delegate, set limits, honor others’ boundaries, give and receive constructive feedback. All of which, for better or worse are influencing outcomes such as patient safety, patient experience, and workforce health. As a leader, influencing the butterfly effect in a direction of positive outcomes requires providing effective communication training, clear expectations and modeling of behavior, and ensuring a supportive culture where these skills can be practiced. Planning your next event? Get in touch with us at the Capitol City Speakers Bureau today to schedule your ideal speaker and make your event a success! By Beth Boynton
“I-Statements” can be time-consuming and emotionally challenging. We have to check in with ourselves about how we feel and why. We also have to be willing to have ownership about our part in a conflict and possible solutions. Are they too wishy washy for us in healthcare? Do they take too much time? Don’t we need to focus on the next urgent issue and not tip toe around people’s feelings. The answer is sometimes yes and sometimes no! Communication-related or ‘soft’ skills are essential for best outcomes in healthcare and sometimes require more time than we have or think we have. Here is an example and checklist you can use to determine when an “I-Statement” makes the most sense. The Situation Three nurses are at the nurses’ station. Two are talking about the new policy on discharge planning. The third nurse, Donna, is documenting a new order she just received on one of her patients. Donna is finding it difficult to concentrate and the order involves setting up a Patient Controlled Anesthesia pump w/ complex medication orders. Here are two possible approaches Donna could take: A) “Shhhhh, stop talking so loudly!” B) “I’m frustrated with your loud conversation. It is hard for me to concentrate on writing these orders correctly. I’d appreciate it if you would lower your voices or find another place to have your conversation.” Which do you think she should take? The Answer: It depends on what the relationships are and what Donna would like them to be! For instance, if Donna has a positive history of working with these two colleagues, and they have established a pattern of mutual respect and collaboration, then they are likely to take a quick “Shhhhh”, apologize, lower their voices, and move on. They may also discuss other options such as a quiet place for Donna to go. If, on the other hand, Donna doesn’t know these two nurses, or there is tension in their relationship and Donna would like to help all involved get to a more collaborative place, then Donna would be wise to use an “I” Statement. “I-Statements” can be very effective in many conflicts because they show ownership and respect for other perspectives. Problem solving involves all stakeholders and commitment to outcomes is inherently increased with a collaborative process. Since communication and collaboration issues are persistently showing up as root cause factors in safety statistics, doesn’t it make sense to incorporate communication strategies that will build positive relationships at times? Try using this “I- Statement” checklist with your next conflict to determine whether you should take the time and energy involved to use an one. The more more checks, the more valuable an “I-Statement will be. “I” Statement Checklist
Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Beth Boynton
In applied or medical improv activities, we are always practicing communication skills and building positive relationships in a trusting environment. With proper facilitation participants practice taking a little more risk, in a safe way to share ideas and build on the ideas of others. Intellectually, these growing edges seem simple. They are not. Both sides of the communication coin, listening and speaking up involve sharing power and that can be very challenging. Being more assertive means showing ownership , being accountable, and maybe even wrong. Listening more respectfully requires a letting go of control to make room for other people’s ideas and concerns. If our communication is limited then so too are our relationships. Our collaborative problem-solving will be stunted, we may hold resentments about not feeling heard, we’ll have trouble managing conflict, and ultimately will not be bringing our best selves into our team and leadership roles. Another way to explore how the roots of our communication can impact the system and is to look at three of the principles of complex adaptive i.e. human systems; adaptability, the butterfly effect, and flexibility. Adaptability Adaptability refers to the ability of the participants to adapt and learn from changes in their environment. In a high-stakes, high-stress health care environment, we could not be adaptible without consistent, effective and respectful communication. For example, inviting input on an issue and listening to it is key for engaging staff. Leaders sometimes avoid such engagement, because they assume that staff will expect them to follow all recommendations, which could lead to conflict if they don’t. Instead of validating, considering input and setting limits, they simply avoid asking. Staff who don’t feel heard may become disengaged or use resistance to solutions (consciously or subconsciously) as a passive-aggressive way of being heard. Whereas, many people will accept reasonable limits if they feel heard. Leaders can also embrace this idea to increase staff accountability for stubborn problems like, for instance, hospital-acquired infections. By asking staff, “What do you need to comply with hand-washing protocols?” and then listening carefully to the responses, they create the conditions for learning new information that might help, and they relay the message that input is valued. The butterfly effect The butterfly effect refers to a small event happening in one place, like a butterfly flapping its wings contributing to a large event happening someplace far away, such as a hurricane on the opposite side of the world. The butterfly effect of disrespectful versus respectful communication can be seen in these two health care-related examples:
Emergent behavior Emergent behavior refers to how we behave in the moment and in relationship to others. To gossip or not, to offer or take in constructive feedback versus avoiding conflict, or to speak up or remain silent about a concern are soft skills that are intrinsic in each of these behaviors:
Conclusion These communication-related skills and how they relate to outcomes in healthcare may be hard to see, but now that you know how to look for them, you’ll spot them more easily. As you do, you may see or suspect their impact in the workplace. Did the nurse who hurt her back ask for help? Was the surgeon receptive to challenges during the wrong-site surgery? Would the resident have fallen if the nurse assistant sat with her for a few minutes and listened to her concerns? Without getting at the roots of assertiveness and listening we will not have, cannot have the healthiest system we owe our patients and providers. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Beth Boynton
Integrating improv activities into your day to day work can be part of an organizational development effort to boost to morale, improve communication skills, build positive relationships and cultures. Today we're exploring an incredibly simple activity called “I am”. If you are willing to take 10 minutes out of a staff meeting, clinical inservice, orientation process or other, you will build positive relationships and promote assertiveness and listening skills! Don’t be fooled by the simplicity of this activity as the results can be profound! Discovering “I am” This exercise is simple and promotes trust, self-awareness, empathy, and communication skills. By making time for “I am” in your meeting, you will help staff practice assertiveness and listening while inviting people to get to know each other a little better. How to Teach “I am” On a piece of paper, have staff complete the sentence, “I am _____________” three times. Tell them they will be sharing with 2-3 others in the group. Give them examples: “I am excited about this meeting.” “I am stressed about our new EMR.” “I am hungry.” Give the group 5 minutes or so to complete and then instruct them to share with 2-3 others over the next few minutes. Facilitation Tips
There is a lot more to applied improv than meets the eye! Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Beth Boynton
When I teach Medical Improv, what I’m really teaching are ‘soft’ skills! The improv is basically an effective strategy for teaching them. Sometimes I get asked, “What are they?" It is a great question! Emotional intelligence, interactive, people, relationship, and social skills all come under the umbrella of ‘soft skills’. Some of these factors involve skills, like listening and assertiveness, yet many involve human awareness, feelings and behaviors. And when we start getting into these areas, things get a little more tricky, right? They are inter-related, vary among us, and are influenced by almost infinite variables i.e. the weather, being tired, other people’s behavior, and the cultures we work in. Anything that impacts how we feel and behave, individually and organizationally is likely to influence our ‘soft’ skills. This is why they are challenging to teach. It is also why Medical Improv is such an exciting teaching tool. Different people learn different things at the same time playing the same activity! In the activity Same Time Story, for example, one person is practicing speaking up while the other is practicing listening. And it is no small thing that they are having fun and building their relationship too. What are some examples of ‘Soft’ Skills? Here is a list that I’ve developed over the years and am often updating with input from participants:
What would you add to this list now that you get the general idea? Are there any ‘soft’ skills you are working on? Do you have any thoughts on how these skills are related to patient safety, patient experience, or workforce health? Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Beth Boynton
Doctors, nurses, patient advocates, and administrators want to prevent medical errors! Yet communication, collaboration, and workplace culture pose ongoing problems. Problems with ‘soft’ skills that make patient safety a stubborn challenge. “Everyone agrees we haven’t made as much progress as we’d like to make [with reducing medical errors], and the improvements have been uneven,” -Linda Aiken, PhD, RN – Healthcare Still Misses the Mark on Patient Safety. Our approaches so far To date, we have focused on safety engineering ideas and new communication strategies. They come from a scientific and intellectual mindset. Science of safety interventions and structured communication techniques arise from this way of thinking. Safety Science For instance, the science of safety recognizes that humans are imperfect. Researchers that look at patient safety from this perspective design solutions that attempt to make it impossible to make a mistake. They force or try to force patient safe behavior. Pre-op checklists and color-coded IV tubing are examples. Structured communication Standardized communication protocols like SBAR and the two challenge rule have been implemented and assertiveness training programs such as Vital Smarts have been administered to thousands of nurses and doctors. They are trying to regulate human behavior. While these efforts are valuable, they missing important elements of communication and behavior. Communication is gray and messy and human beings want to have choices in how they think and what they do. Communication and Behavior are complex If we are going to make healthcare safe, we need to take a deeper dive into understanding communication and behavior. Listening and speaking up require ‘soft’ skills like trust, courage, and confidence. The ability to work in teams, honor other points of view, manage conflict, and lead collaboratively and authoritatively are also part of this skill set. While not easy in general, these ‘soft’ skills are almost impossible to develop and practice when bullying, blaming or a code of silence permeates the culture. What’s more, the way we behave influences the culture and the culture influences the way we behave. Forcing behavior will keep a nurse from using the wrong IV tubing in a rush, but it won’t help her address a conflict with bullying peer or eliminate worries about her student loans. The consequences of using the wrong tubing may be obvious. Whereas, the bullying behavior or late payments may not be so clear. For instance, will the bullied nurse ask for advice from the bullying person? Will she remind this person to wash their hands? Will she pass along a message from a patient’s brother about a concern in a timely manner? And what about worries about paying back loans? Will they be a distraction? Will an important detail be missed? If we are going to move the needle on patient safety, we have to address the roots of communication and behavior that influence relationships. So what do we do? We need a radical shift in thinking! In addition to structuring patient safe communication and behavior, we must also engage, inspire, and empower others to be their best! In other words, we need to help motivate nurses, doctors, and others to communicate effectively and behave respectfully. It is an intrinsic approach to behavior change that is aligned with complexity leadership. This analogy will help explain what I mean: Let’s say our goal is to get our children to eat healthy lunches at school. Our first tendency might be to look for ways to control their eating options. We could:
These ideas will probably have a positive impact too. What we're not doing is engaging, inspiring, & empowering healthcare professionals to be more effective communicators! An intrinsic approach Improv activities offer playful opportunities for nurses, doctors, and other healthcare professionals to feel heard, practice listening, share ideas, and develop trusting relationships. When facilitated properly, the emotional risk in listening and assertiveness is minimized. Think about how powerful it might be for a nurse to experience what it is like to be heard in the course of teaching him or her how to listen. Or how memorable a lesson it might be for a surgeon to accept an idea from a nurse and build on it. And how healing it might be for a nurse who tends to be aggressive and one who tends to be passive to share power in a playful way. The principle of “Yes, and…” Many of you are familiar with the principle of “Yes, and”. Maybe you’ve been to an improv comedy show? Or maybe you’ve been to a workshop where improv techniques were used for team-building? Well, the same concept can be adapted for nurses, doctors, and other healthcare professionals. To do this we take the focus off of performance, use facilitation skills to create a safe environment, and frame the learning in goals that involve patient safety and ‘soft’ skill development. “Yes and…” Improves Communication The “Yes” part of improv activities nudges nurses and doctors to accept what others are saying. Translated into communication learning, it is about listening. And listening will improve patient safety. The “…and” part of improv nudges healthcare professionals to share ideas. In terms of communication, it is about speaking up! And speaking up will prevent medical errors. And there are hundreds of activities that naturally engage participants in practicing communication! It is like a fitness program for ‘soft’ skill development. Moving the needle on patient safety requires a radical shift in thinking! Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Beth Boynton
Do you ever wonder why passive-aggressive, passive, and even aggressive behaviors are so common in healthcare or politics? Assertiveness involves relationships, cultures, and communication skills. Trying to be assertive in a culture where aggression is dominant or with a person who is aggressive is very tricky. Since assertiveness means you respect and take care of your own needs as well as others, when it isn’t mutual it doesn’t work so well. A parable that helps to explore this concept What do you do if you knock on a door and no one answers? (Assume you can hear voices behind the door.) Knocking louder seems like a natural response. But what if still, no one answers? Then what do you do?
Takeaways
Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Beth Boynton
Are you on the fence about going back to school or not? Maybe you have a list of pros and cons going on in your head or like some nurses, even have one on paper. Maybe you are worried about the time and money involved in going back to school or are afraid that you might not be successful. On the other hand, maybe you wonder if the best time to go for your BSN is right now, even with nagging questions in the back of your mind. And maybe, not deciding - sitting on the fence - is the most comfortable place for you. Here you can keep the option open while not making a commitment either way. How can emotional intelligence help your decision-making? Daniel Goleman is the psychologist well-known for bringing the term emotional intelligence (EI) into mainstream culture with his ground-breaking book, Emotional Intelligence: Why It Can Matter More than IQ. His model, which continues to evolve, involves personal and social competencies, each of which include a variety of traits that can be helpful in decision-making. For instance, we can take a deeper dive into the concept of personal competence in an effort to decide about going back to school. Personal Competence and the School Decision There are three areas of personal competence; self-awareness, self-regulation, and motivation. Self-awareness means that you know how you feel at any given moment and have a sense about both present and past causes of your feelings. Try sitting quietly for a few moments and ask yourself what feelings you have about going back to school and not going back to school. Don’t try to change or judge what you are feeling just notice. Once you have a sense on what you are feeling, you can be curious about where the feelings are coming from. Are there old messages that encourage or discourage you from taking a risk? This may be trickier than it seems because sometimes what we feel about a current decision may have more to do with past experiences than anything else. We may fear failure or even success and the fears are keeping us on the fence. The more you are aware of your feelings, the more you use them to guide your decision. Even if you have strong fears that are keeping you from taking action, now you’ll have a sense about what those fears are and use the awareness to take steps to separate the past from the present and the ‘shoulds’ from the ‘coulds’. Self-regulation refers to our ability to manage our feelings and how we respond to various situations. If we are having trouble making a decision, there is a chance that our fears are paralyzing. There may be very good reason for going or not going to school right now and either decision could be best. Yet, if old voices or fears are dictating inaction, that could be a red flag that your self-regulation is hung up on the past and you might miss an opportunity to grow your career. The truth is, if you made it through an Associate Degree or Diploma program, you are one smart dude. With support and encouragement, a BSN could open up many doors for you in your nursing career. However, honoring fears about time and money may give you a sense of relief in knowing this isn’t the best time to go back to school. A psychotherapist or nurse career coach could be very helpful in discerning your next best steps and then taking action. Motivation is the driving force behind our behavior and absolutely essential for successful return to school. This is the part of EI that speaks to your needs and desires. So often, nurses are grounded in meeting needs of patients and families. Even meeting the needs and desires of your own family may take precedence over your own. While sometimes this makes perfect sense such as with your children or at times with your life partner. But, if you are not getting your needs and desires attended to also, this can lead to burnout or even the kind of apathy that contributes to errors. If the idea of going back to school is an exciting one to you, then there is a good chance you have the motivation for you need to be successful. This will be extremely important in participating in career development of any sort. If you can make the connection between your desire and an action step, you’ll be using your emotional intelligence in a healthy way. Conclusion Going back to school is a big decision and the more you understand your feelings, responses and desires, the more you’ll be able to move forward in the best direction for you at this time. Keep in mind that lifelong learning is a given in nursing regardless of your degree and try to stay open to all ways of learning and growing. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! By Beth Boynton
Daniel Goleman, the psychologist well-known for bringing the term emotional intelligence into mainstream culture with his ground-breaking book, Emotional Intelligence: Why It Can Matter More than IQ, describes empathy as an important component of social competence. In a more recent article, he describes empathy as a component of effective leadership stating the importance of understanding others’ feelings and points of view. Empathy and relationships Ultimately, empathy is important for building healthy relationships of all kinds, including professional ones with colleagues and therapeutic ones with patients. It is closely tied to attentive listening where the focus is on the other person. Remember only 10-20% of our communication is attributed to the actual words we exchange! An empathic person is taking in all sorts of the other 80-90% of information in any given relationship. A nurse with a high degree of empathy has an invisible radar that interprets facial expressions, body language, and tone of voice. She may be the one on the unit who notes the early signs of a patient’s escalating anger or a colleague’s signs of irritability. This nurse can be a real asset to the team because he may help prevent a workplace violence incident or get help for a peer who is developing burnout. Nurses vary with their ability to start an IV in an elderly dehydrated patient or accurately assess subtle lung sounds before a fluid overload crisis, right? We also vary in our ability to show and feel empathy. That’s Okay because just like practicing clinical skills, empathy can be developed too! Many exercises come from the emerging field of Medical Improv where theater activities are used to build emotional intelligence and communication skills. For instance, one activity involves synchronized storytelling aka same-time-story, where two people try to tell the same story at the same time. How to play synchronized storytelling This activity requires working in pairs, where one person tells a story while the other acts as a mirror and tries to tell it at the same time. So if I say, ‘Once upon a time,’ the idea is that my partner is going to say that at the same time that I am. It’s a little slow at first, and what happens is the person following the storyteller becomes intently focused on that person. Because the activity requires almost 100% attention on another person in a safe and fun way, there is a natural opportunity to develop empathy. If you decide to try it with a colleague, make sure you both have a chance to play both roles and notice:
While this activity and these concepts may seem outside the scope of clinical communication, they open the door to developing awareness and skills associated with empathy. They also create opportunities to discuss the value of the skillset and when and where it can help in your work as a nurse. Looking for your next healthcare speaker? Get in touch with us at the Capitol City Speakers Bureau today to make your healthcare event a success! |
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