CLIENT: AORN
The Association of periOperative Registered Nurses (AORN) represents the interests of more than 160,000 perioperative nurses. It provides nursing education, standards, and services that enable optimal outcomes for patients undergoing operative and other invasive procedures. The Greater Kansas City Chapter serves 331 members in the greater Kansas City, Missouri, and Kansas metropolitan area. This case study has been adapted with permission from the research article “Communication Skills Training to Address Disruptive Physician Behaviour” published in the May 2012 AORN Journal, Volume 95, Issue 5, written by Rebecca Saxton, PhD, RN, CNOR.
THE CHALLENGE
Bad behaviour runs rampant in the workplace. The healthcare industry is no exception. The American Medical Association’s Council on Ethical and Judicial Affairs defines disruptive behaviour as behavior that “tends to cause distress among other staff and affect overall morale within the work environment, undermining productivity and possibly leading to high staff turnover or even resulting in ineffective or substandard care.”
Research among healthcare providers found widespread incidence of disruptive behaviours such as verbal abuse, sexual harassment, racial slurs, physical threats, and profanity. Specifically:
- 91 percent of perioperative nurses reported at least one incident of verbal abuse in the previous year
- 67 percent of staff nurses reported between one and five disruptive incidents in the previous month
One of the most common manifestations of bad behaviour occurs between nurses and physicians in the form of power struggles and clashes over roles and personality. One study found that 95.7 percent of physician executives reported knowledge of disruptive physician behaviour within their organisation.
Not only is verbal abuse pervasive, it is also destructive. Research shows disruptive behaviour leads to communication breakdowns that affect outcomes like patient safety and employee morale. Specifically, a study of 26 medical residents found that failures of communication between physicians and nurses were associated with 91 percent of the medical errors.
Verbal abuse also leads to medication errors which harm 1.5 million patients each year. A study by the Institute for Safe Medication Practices found that 93 percent of nurses and pharmacists experience condescending language and impatience from bully physicians when they ask clarifying questions about medical orders, and 87 percent encountered physicians who outright refused to answer their questions. As a result, 75 percent of nurses and pharmacists admitted to having a peer interpret a medication order rather than calling an intimidating physician.
Rebecca Saxton, PhD, RN, CNOR, and associate professor at the Research College of Nursing in Kansas City, Missouri, set out to uncover ways to reverse this divisive trend of abusive physician behaviour and communication breakdowns. She collaborated with Crucial Learning to create an educational intervention tailored to the nursing experience that included the two-day Crucial Conversations for Mastering Dialogue course.
THE COURSE
While many studies have documented the positive effects of communication training on nurse physician communication, Saxton selected Crucial Conversations as her educational instrument because of its theoretical framework and use of Albert Bandura’s social cognitive theory to ensure skill transference. Bandura’s theory states that people learn by observing others within the context of social interactions, personal experiences, and outside media influences. Crucial Conversations uses video examples, role plays, and personal application exercises to help participants learn new skills.
Saxton partnered with the Greater Kansas City Chapter of the Association of Perioperative Registered Nurses (AORN) to rollout the two-day Crucial Conversations class. She recruited seventeen members of AORN to participate in the training. The participants were female perioperative RNs who provided direct patient care and who routinely had direct contact with physicians. Three-fourths of the participants had more than twenty years of both nursing and perioperative experience.
Saxton invited a Crucial Conversations certified trainer to train the course over two days with instruction tailored to the healthcare setting. Each participant received 14.5 continuing education credit hours for attending Crucial Conversations—a standard CEU benefit that has been approved by the American Association of Critical-Care Nurses.
THE RESULTS
Saxton developed a ten-item Likert-type scale to measure disruptive behaviour. She administered this scale before, immediately after, and four weeks after the course.
The scale measured training participants’ degree of confidence in addressing disruptive behaviour in ten situations, from zero (not confident) to ten (highly confident). Participants’ scores were totaled and high scores indicated a high degree of confidence in addressing disruptive physician behaviour.
By comparing the pre- and post-test scores, Saxton found a statistically significant increase in participants’ confidence and ability to address bad behaviour both immediately after and four weeks after the training.
In the post-test administered four weeks after the course, the nurses reported 123 episodes in which they encountered disruptive physician behaviour. However, using their newly learned Crucial Conversations skills, they also reported that they spoke up and addressed the bad behavior in 87 of those episodes—or 71 percent of the time.
The results of Saxton’s study indicate that Crucial Conversations directly improved perioperative nurses’ confidence and ability to address disruptive physician behaviour.
In her study published in the May 2012 AORN Journal, Saxton indicates that the statistically significant results she uncovered after training nurses in Crucial Conversations point to this course as a solution to overcoming disruptive physician behaviour.
She concludes, “Analysis of this data suggests that one possible intervention strategy to address the threat of disruptive physician behaviour to patient safety is to educate nurses in communications skills that focus on identifying Crucial Conversations and then skillfully holding the conversation.”
RESULTS AT A GLANCE
- Immediate and significant increase in nurses’ confidence and ability to address disruptive physician behaviour
- Nurses spoke up and addressed disruptive physician behaviour 71% of the time
