- 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!)
- 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
- 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.
- 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”
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”
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
- 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?”
- 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?
- 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
- 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