Strained conversations ranging from a lack of clear communication to outright incivility occur in perioperative settings every day in the U.S.  As a result, critical patient safety processes may be lost in the heat of less-than-civil words and non-verbal communications.

Educators play a critical role in helping nurses to disarm this hostility by teaching standardized communication methods, according to Gerry Altmiller, EdD, APRN, ACNS-BC, FAAN, professor of nursing at The College of New Jersey School of Nursing, Health & Exercise Science in Ewing, N.J.

In her work to advance shared understanding of education tools that can improve surgical patient safety, she says educators, nurse leaders and frontline nurses across the country voice incivility as a chief concern. “It’s a challenge to talk to people who are being disrespectful and find a way to de-escalate the strain in the conversation—but it is possible.”

Changing the Conversation

Cognitively rehearsed phrases that all team members can learn are useful tools to signal attention to situations that create potential patient harm, or to combat incivility in a civil manner, Altmiller suggests.

Such standardized communication techniques have been developed through programs like the Agency for Healthcare Research and Quality’s (AHRQ) TeamSTEPPS®. But, she stresses, all team members including surgeons and anesthesia partners must understand and practice them to be successful.

Here are three communication techniques Altmiller says educators need to be teaching on the frontline:

1. CUS—Concerned, Uncomfortable, Safety.

   This is a valuable tool when a safety concern needs to be immediately voiced to halt an action. For example, if a nurse is concerned that vancomycin is about to be given to a patient with an elevated creatinine level, the nurse can say:

   I am concerned with giving vancomycin. I am uncomfortable because this patient’s creatinine level is 1.5. I don’t think this is safe.

   “If you lay out a concern using the CUS strategy, it can make for a clearer statement of your position,” Altmiller says.



2. Two-Challenge Rule

   This involves the obligation health care workers have in voicing a concern and following up if the concern is not acknowledged. For example, if a nurse is working with a colleague who breaks sterile technique, the nurse can say:

   I noticed you have broken sterile technique and I suggest you change out your gloves.

   If the colleague doesn’t respond or denies breaking sterile technique, the nurse has an obligation to voice the concern again, perhaps saying:

   I feel strongly that your sterile technique is compromised, and I think it is in the best interest of patient safety to change out your gloves.



3. Ask for Clarity

   Specific phrasing can serve to clearly signal the team about a concern. For example, if a nurse has a patient safety concern that a senior member of the team is about to make an error but is hesitant to speak up due to past negative interactions, the nurse can bring attention to the concern by stating:

   I need some clarity.

   This statement should stop everyone for the moment so that the work of the team can be identified, and any potential error can be stopped before it occurs.

   Clarifying questions also can de-escalate a tense moment of incivility. For example, if a nurse is reporting off to another nurse who is rolling her eyes and sighing, instead of reacting with anger or ignoring the situation, the nurse can maintain civility in the face of incivility by stating:

   I sense there is something that you want to say to me, and I learn best when people are direct, so please be direct with me.

Teaching Tips for Educators

Small groups can be a good setting to demonstrate and rehearse phrasing for more effective and civil practice conversations, Altmiller suggests, “The key to improving communication among team members is to teach communication tools and help members practice them together.”

An interdisciplinary approach is valuable, she adds, so that teams learn civil ways to communicate with each other and act based on specific phrases.

Altmiller directs educators to use the TeamSTEPPS® video training about these and other strategies for team communication. “Use video examples to help staff increase awareness and competence in these communication strategies and use cues to combat incivility in a civil way.”

Additional Resources

Find information on TeamSTEPPS® and use these video training tools to augment training for healthier and more effective team communication.

Free Resources for Members Only

Guideline Essentials: Educate your team to communicate effectively with ready-to-use and customizable PowerPoint templates, competency tools, step-by-step instructions and videos, case studies, and more for the guideline on Team Communication.