Communication in a Crisis

OVERVIEW

• Communication is a key non-technical skill for effective crisis resource management (CRM)
• Communication may fail in a crisis for many reasons
• Physicians often fail to communicate what they are doing, and why, in a crisis — and when they do they often only do so with other physicians
• With nurses there is often a delay between identifying problem and communicating it to the rest of the team
• Closed loop communication is a simple and effective way of avoiding communication failure, but there are many other useful strategies
• Team members must feel empowered to question and/or correct the decisions of the team leader and other team members if it in the patient’s interest
• Safety tools such are checklists are only effective if people speak up when they identify concerns
• Nurses have to have license to say “I’m am worried, please see this patient now.” and expect doctors to do so, rather than demand objective reasons (being able to label a concern doesn’t make it more or less valid!)

IMPORTANCE

• In 2004 The Joint Health Care Commission found that in 70% of 2455 sentinel events the primary root cause was communication failure — and in 75% of these the patient died.

USE OF COMMUNICATION IN A CRISIS

“Keep everyone on the same page and ensure there are no surprises”

• Maintain situational awreness
• Establish a shared mental model (so that everyone knows what is happening and can contribute)
• Establish a safe envirnoment so that others can speak up
• coordinating tasks
• centralizing the flow of information
• stabilizing emotions

REASONS FOR COMMUNICATION FAILURE

• Physical constraints, e.g. noise
• Linguistic differences
• Differing communication styles
  • nurses tend to be trained ‘not to diagnose’ and broad and narrative in descriptions (“paint the big picture”)
  • critical care physicians tend to want focussed information and get to the question
• Authority gradient/ hierarchy/ power distance
• Use of jargon
• Cognitive biases and emotional disturbance leading to misinterpretation
• Cognitive load/ focus on other tasks

THE 3 Cs OF COMMUNICATION

• cite names
• clear instruction
• close the loop

COMMUNICATION STRATEGIES IN A CRISIS

• Avoid mitigating language – “let’s intubate now” not “perhaps we should think about intubating”
• Call out – team members state their actions, observations and concerns out loud
• Fly by voice – verbalise thoughts and observations
• Graded assertiveness
• Focus on advocacy
• Closed loop communication
• SBAR
• Below 10
• Step back method – “let’s stop and reassess”
• Repeat back method

CLOSED LOOP COMMUNICATION

• Sender communicates a message
• Receiver interprets the message, then acknowledges it’s receipt and communicates it back to the sender
• Sender confirms that the intended message is received.
• Receiver reports back when the message has been acted upon.

For example:

• Sender: “John, give 1mg adrenaline IV followed by a 20 mL normal saline push”
• Receiver: “OK Mike, I am going to give 1mg adrenaline IV followed by a 20 mL normal saline push”
• Sender: “That’s correct John”
• Receiver: “ Mike, 1mg adrenaline IV with a 20 mL normal saline fluch has been given”

COMMAND TYPES

Six basic command types:

• Hint – “should things look like this”
• Preference – “I think it would be wise”
• Query – “what do you think we should do”
• Shared suggestion –“ you and I should do the following”
• Statement – “I think we need to do the following”
• Command – “do this now”

GRADED ASSERTIVENESS

e.g. PACE approach

• Probe – “do you know that…?”
• Alert – “Can we re-assess the situation…?”
• Challenge – “Please stop what you are doing while..”
• Emergency – “STOP what you are doing!”

Graded assertiveness is described in more detail in Speaking Up

5-STEP ADVOCACY

• Attention getter – “Excuse me, Doctor”
• State your concern – “The patient is hypotensive”
• State the problem as you see it – “I think we need to get help now”
• State a solution – “I’ll phone ICU to arrange transfer”
• Obtain an agreement – “does that sound good to you?”

SBAR

• Situation – what is going on with the patient?
• Background – what is the clinical background, or context?
• Assessment – what do I think the problem is?
• Recommendation – what would I do to correct it?

BELOW 10

• aka below 10,000 feet communication
• means the ‘sterile cockpit rule’ is in effect, ie. no unnecessary communication during a critical procedure
• others should ask “I want your opinion on X, can we talk now or later?”
• proceduralist states: “later”

References and Links

Journal articles

• Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care. 2011 Apr;26(2):155-9. doi: 10.1016/j.jcrc.2011.03.004. PubMed PMID: 21482347.
• Brindley PG. Patient safety and acute care medicine: lessons for the future, insights from the past. Crit Care. 2010;14(2):217. doi: 10.1186/cc8858. Epub 2010 Mar 9. Review. PubMed PMID: 20236461; PubMed Central PMCID: PMC2887110.
• Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85-90. PubMed PMID: 15465961; PubMed Central PMCID: PMC1765783.

FOAM and web resources

• The Nurse Path — Graded assertiveness (2013)
• American Association of Critical-Care Nurses. The silent treatment: why safety tools and checklists aren’t enough to save lives. Aliso Viejo (CA): The Association. Available from :http://www.silenttreatmentstudy.com