Critical Conversations in Nursing

The stakes are high in critical care.

Difficult decisions may lead to difficult discussions, high tension levels, lives on the line, frequently changing treatment plans, and new technologies all add up to excess stress levels in personnel.

How do we as nurses handle stress? How can we communicate effectively under stress?

According to the “Silence Kills” study conducted by the American Association of Critical Care Nurses, the American Organization of Perioperative Nurses and VitalSmarts, “everyday nurses watch colleagues cut corners, make mistakes, demonstrate incompetence, and disagree with one another. Only a small few speak up, which leads to problems such as avoidable errors, high turnover, decreased morale and diminished productivity.”

In warning against bad behavior among nurses, the Joint Commission noted that “communication is a top contributor” to its Sentinel Event Alerts.

Despite the awareness of the need for improved communication skills in healthcare, problems still exist like: wrong information, lack of information, and lack of caring to give information are often reported in patient satisfaction surveys. These communication deficits often cause patients to file complaints, stressing the need for improving nurse’s communication skills.

The nursing process, however, offers a number of ways to communicate more effectively and will allow for the free flow of information, support collaboration with families and increased unity among nursing team members in the ICU and other areas.

The Nursing Process

The nursing process provides a framework for communication, actions and results. All nurses are trained to use efficiently by using it we can improve our communication skills. There are specific steps to follow:

The first step is Assessment. The signs of a critical conversation includes: dry eyes, stomach pains, weakened immune system, feeling unsafe, anger, fear, shouting, pointing fingers, silence, violence, and fight or flight. The stakes are high. What are you saying? Opinions vary, so assess what others are hearing you say. Emotions are running strong, so listen to what others are saying and assess where they are coming from. Each one of us has developed differently so our communication skills are also different. We must pay attention to our self-awareness, personal characteristics, role conflicts and core values. These all affect our ability to verbalize, but it also affects our nonverbal communication skills like eye contact, posture, expressions and tone. Use the skills of listening, asking questions, clarifying, paraphrasing and knowing when silence is best. Identify which communication skills are the most effective to improve your awareness of others and become more empathetic.

Planning how you will handle critical conversations is the next step in the nursing process. First, step back and decide whether to engage or avoid the conversation. What is the best thing to do at this time? Slow yourself down. Step out of the conversation. Take a deep breath and think about what you are saying so that you can handle the conversation optimally. Find safety, i.e., a mutual purpose, a common thread or goal in the conversation; but most importantly, develop and practice mutual respect with patients, families and co-workers. Always take the time to come up with a plan that is best for everyone impacted by the patient’s eventual outcome.

Next in the nursing process is Intervention. Share your facts. Always start critical conversations with the facts. Do not wander from the truth and the facts. Tell your story, explaining from the beginning to the end what you see is needed. Ask for others to give their input. Encourage them to share their opinions. Talk tentatively. Blend confidence, humility and skill to soften the approach. Don’t “bulldoze” others to get what you want. Always keep an open mind. Get ready to listen and be patient.

Goals & Outcomes
The fourth step of the nursing process is Goals and Outcomes. To achieve the desired results, we must learn to communicate effectively and to improve the free flow of information with all stakeholders. It is important to facilitate collaboration and unity amongst co-workers. One of the most critical concepts and outcomes of effective communication is trust. When there is trust between staff outcomes will improve. In the book Crucial Conversations: Tools for Talking When Stakes are High (McGraw-Hill, 2012), Patterson, et al state: “We must make an effort to respect and understand, and appreciate one another and treat all with civility to be the best team we can.”

The last step in the nursing process is the Evaluation phase. Poor communication skills affect the quality of patient care, jeopardize patient safety and disrupt the operation of the team. If we work on improving communication skills we will enhance the work environment and the quality and safety of patient care. Once nurses have taken the time to improve their communication skills we should be able to observe enhanced communications. There should be improved interaction among coworkers, patients, and the patients family members. There should be more acts of kindness and helping others in the workplace. Employee satisfaction will improve along with improved patient satisfaction. The Silence Kills study found those few nurses who spoke up produced far better outcomes for themselves, co-workers and patients. Good communication is critical to get the best patient outcome, create a safe environment and provide a sense of satisfaction to patients and staff.

Keen Observers

Nurses must use assessment, planning, implementation and evaluation effectively in all interactions and communications with co-workers. We all have had conversations that we look back on and say,” I should have said” this or that. The time has come to enhance our communication skills.

Critical conversations in nursing are always about tough issues, with high stakes, varied opinions and high emotions. Nurses usually ignore these issues rather than stepping up and holding a conversation. When a problem festers, morale and productivity suffers and patients are put at risk.

New techniques and tools of effective communication, with practice, will lead to improved interactions among co-workers, which will decrease the level of stress in the ICU and all other nursing areas. A conscious effort to communicate will also build trust and camaraderie, which fosters an environment of teamwork. This is an important part of patient safety, as better communication can lead to better patient care.

Nurses must observe communication to understand and assist the needs of patients, families, and co-workers. It is important to have self-awareness of your communication style, build trust with and among others, and it will lead to better results.

References for this article can be accessed here.

Sharon Hage is a critical care float nurse at Robert Wood Johnson University Hospital, New Brunswick, N.J.

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