Better Communication Needed to Reduce Medical Errors

Cathy Tokarski

January 27, 2005

Jan. 27, 2005 — Healthcare organizations trying to reduce the rate of medical errors frequently overlook a common but important variable — candid communication between physicians, nurses, and clinical care staff. Too often, medical professionals avoid having "crucial conversations" when they observe problems that can lead to unacceptable error rates, according to a new study.

"It's fairly common for people to see problems and do nothing," said Joseph Grenny, president of Vital Smarts, a communications and leadership training company that conducted the study with the American Association of Critical-Care Nurses (AACN). The findings, based on data from more than 1,700 respondents, including 1,143 nurses, 106 physicians, 266 clinical care staff, and 175 administrators, were released yesterday at a Washington, D.C., press briefing.

Although the "problem group" was a "fairly small subset" of individuals whose poor habits or incompetence could cause medical mistakes, many respondents said that a number of their colleagues created problems that were frequent, persistent, and dangerous, Mr. Grenny noted. What's more, those problems were rarely addressed by healthcare organizations, despite the emphasis that many have put on improving overall patient safety.

When the idea of developing standards to create better communication in the healthcare workplace was first proposed by the AACN to help reduce the incidence of medical errors, it was dismissed as "soft," recalled Connie Barden, RN, MN, editor of the AACN's new standards that were released yesterday. "My belief is nothing could be further from the truth," she said. "Addressing the issue is key to halting the epidemic of medical errors."

The first phase of the joint study outlined seven "crucial conversations," or categories of concern, based on colleagues' behavior identified by respondents, ranging from clinical judgment to poor teamwork to a lack of respect.

Breaking rules and making mistakes emerged as significant concerns. However, according to the study methodology, respondents had to indicate that at least 10% of their coworkers were in violation in order for their response to be categorized as "seeing the concern."

Most of the physicians (84%) and 62% of nurses and other clinical care providers saw some number of their coworkers taking shortcuts that they believed were dangerous to patients, according to the study. Eighty-eight percent of physicians and 48% of nurses saw some colleagues showing poor clinical judgment, and 92% of physicians and 65% of nurses said they work with "some people who have trouble following directions," the study found.

Incompetence among physicians and nurses was another troublesome area identified by respondents. Eighty-one percent of physicians and 53% of nurses and other clinical care providers have some concerns about the competency of "some nurse or clinical care providers they work with," while 68% of physicians and 34% of nurses expressed the same concern about physicians.

"A big surprise," said Mr. Grenny, is that physicians are equally or less likely to confront a nurse whom they deem to be incompetent. Instead, "they'll sideline, marginalize, or set aside nurses they have problems with," he said.

Lack of support, poor teamwork, disrespect, and micromanagement were also identified by nurses and clinical care providers as problem-causing behaviors by some colleagues.

More than half of nurses and clinical care providers (53%) reported that 10% or more of their colleagues were reluctant to help, were impatient, or refused to help. And 88% of nurses and clinical care providers have one or more teammates who gossips or is part of a clique that divides the team.

More than three quarters of nurses and clinical care providers (77%) work with some colleagues who they perceive as condescending, insulting, or rude, according to the study. And more than half of nurses and clinical care providers (52%) said they worked with someone who abused their authority — through bullying or threatening — to force their point of view on them.

The second phase of the study examined what happened when physicians, nurses, and other healthcare providers who were "confident in their ability" to confront individuals who display problematic behaviors, especially incompetence, poor teamwork, or disrespect and abuse.

Overall, the study found that people who were confident in their ability to have "crucial conversations" about problem-causing behaviors achieve positive outcomes for patients, for the hospital, and for themselves. For example, nurses who spoke up when the concern was over incompetence observed better patient outcomes (-.336 correlation), were more satisfied with their workplace (-.267 correlation), exhibited more discretionary effort beyond the minimum required (-.240 correlation), and intended to stay in their unit or hospital (-.335 correlation). "These are people who are more productive, and they want to stick around," said Mr. Grenny.

The AACN's new standards, developed by an expert panel, identified six areas considered necessary to create a healthy work environment, according to Ms. Barton. They call for skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership. The standards are "interdependent," she said, and organizations must have all of them in place if they expect to create a healthy work environment.

Reviewed by Gary D. Vogin, MD

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