Research has proven what common sense already knows: That a positive workplace where nurses knew they could influence outcomes, were able to collaborate with doctors, and had access to conflict resolution skills led to greater nurse retention. Both doctors and nurses’ perception of the quality of the working environment was also positive.
Despite the knowledge that respectful, positive and productive communication will affect patient care what normally happens in communication between professionals in acute care settings? A study over a multi year period by Rosenstein and others(2002, 2005-6, 2008-9) researched how disruptive behavior affected patient outcomes. Disruptive behavior is defined as any inappropriate disrespectful action such as raising one’s voice, verbal abuse, to physical or sexual harassment. These actions impede progress towards a workplace goal.
The ramifications in patient care were very significant. The study showed that these disruptive behaviors were witnessed by more than 50% of respondents: raising one’s voice, disrespectful interaction, abusive language, scolding in front of peers, and condescension. These behaviors were exhibited by both doctors and nurses with doctors showing a slightly higher incidence than nurses, 77% versus 65%. RNs witnessed an even higher percentage. This negative communication was correlated with patient outcomes. 60-70% of negative patient events were a result of communication problems. Negative events included medical errors, increased mortality, decreased patient safety, quality of care, and patient satisfaction.
Among all personnel surveyed 18% were able to link a specific adverse occurrence in patient care to disruptive behavior. A negative clinical outcome could occur for example, if the nurses feel inhibited to contact a certain doctor and therefore did not, or if the doctor ignores the nurses’ observations of the patient.
Disruptive behavior also affects nurse job satisfaction which contributes to staff turnover and retention. One third of nurses leave hospitals because of disruptive behaviors from doctors. It goes without saying that negative communication contributes to stress, frustration and even decreases the probability of future professional collaboration and impacts relationships between all parties involved.
There are many reasons that less than effective communication occurs. Working in a care setting where pressure is constant and decisions must be made quickly is very stressful. Lack of respect is a definite contributor, as are lifelong communication habits, personality, emotional intelligence, among other reasons.
It is quite possible that the traditional hierarchical structure of hospital organization does not maximize the opportunity for effective professional collaboration. Could institutional leadership be more proactive in recognizing how disruptive behavior and poor communication affects the quality of medical care? The study even posed the question of how gender affects communication.
So what is the answer to improving communication between professionals? Various studies have focused on interprofessional education. Collaboration requires competence in one’s own discipline as well as mutual understanding and respect. Professionals must also understand the context and complexity of the health of a given population. Content would include such challenges as continuing quality improvement, patient safety, and staff resource management. Are these challenges ways to improve interprofessional collaboration? Does achieving those mean that collaboration will automatically improve? Or if those are goals in a given care setting that collaboration will take place? If the executive of an acute care setting sets these as goals will they be achieved if there is not a deliberate effort to increase productive communication?
Workplace design can be planned to minimize incidents of negative behavior which can be a result of frustration. Workloads and shifts lengths are factors as well with fatigue contributing to more impulsive communication. Team decisions would mean shared responsibility for a decision which could reduce stress.
Leadership in hospitals must be seriously committed to improving communication and interdisciplinary collaboration. Any program would have to start with the basis that people need to become more aware of the impact of their disruptive behavior on their peers and ultimately the patient. A serious commitment means time and money spent and the implementation on education programs to develop skills in conflict resolution, problem solving strategies, assertiveness training and an understanding of communication styles.
Executive are starting to realize that changing attitudes and behavior takes time and there must be ongoing efforts to make progress, not just maintaining the status quo. Staff input is essential and that input could begin with a survey. Nurse would be able to provide valuable leadership and feedback because of their unique role in the health care system. There must also be structures in place to enforce consequences and discourage disruptive behavior. Compliance results from respect for others and the common goal. Staff must feel free to report incidents of disruptive behavior. These cannot be one time programs but must be a regular part of any continuing search for improvement in patient care.
E Brown, president of the American Nurses Association of California, has stated that acute care could learn from other sectors of health care that have experienced success in interdisciplinary collaboration, such as mental health, long term care, hospice, and palliative care. Again here is another reason to develop a national strategy to enable the sharing of best practices.
In conclusion a goal set with together, plus the understanding that all professionals need to work towards the common good will go a long way towards changing disruptive behavior to productive communication and collaboration. The result will be healthier patients.
Every nurse has an experience to share on this topic. You are invited to respond to this or any article.
A Summary of the October 2009 Forum on the Future of Nursing: Acute Care
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