Keep lines of communication open between managers and staff
While many departments are focusing on enhanced communication with patients, what ED personnel say to each other is equally important
The quality of communication between staff members in the ED can heavily influence staff morale, patient care, and overall efficiency. The often stressful and hectic environment in the ED makes good communication especially challenging. Still, managers must do everything possible to keep the lines of communication open.
ED staff look to managers to convey what’s expected. "People will model their leaders, so you can set a tone for the communication style in the ED," says Liz Jazwiec, a consultant who works with EDs on communication issues, and former Acting Vice President of Nursing at Holy Cross Hospital in Chicago.
Good communication shouldn’t be confined to formal staff meetings but should be a day-to-day habit. "Seventy percent of your communication should be informalwalking around the department or chatting at the nurse’s station," says Jazwiec. "You need to let every single person in the department know you’re accessible."
When all personnel communicate freely, everyone is better off. "Nurses, clerks, and aides are a tremendous source of information and assistance to a physician," says Vicken Y. Totten, MD, MS, FACEP, FAAFP, director for emergency medicine research at the Catholic Medical Center of Brooklyn and Queens in Jamaica, NY. "When staff are comfortable voicing their suspicions, questions, and ideas, the physician is in a much safer position."
If staff members aren’t comfortable communicating with one another, risks increase. "Everybody misspeaks themselves, everyone forgets a dose," says Totten. "If you write the wrong thing, but staff are comfortable calling you on it, you’ve got a fail-safe mechanism in place."
ED staff often focus on communicating effectively with patients, but those habits don’t always extend to colleagues. "The principles of good communication, which are so important regarding patients, are just as important in day-to-day interactions among health care providers," says Steven Rosenzweig, MD, FACEP, an attending emergency physician at Thomas Jefferson University Hospital in Philadelphia and Clinical Assistant Professor of Emergency Medicine at Thomas Jefferson Medical College.
Ironically, good communication is often more difficult with colleagues you see every day, he says. "We share the same goals, but that can be obscured in the moment through the distraction and chaos in the ED," explains Rosenzweig. "You have no long-term relationships with your patients, and, also, the power distribution is a little bit more complex when you’re dealing with staff members."
Open door policy is a must
Having an open-door policy is a necessity for ED leaders. But, for the policy to be effective, managers must be approachableto everyone. "You need to be consistent. You can’t all of a sudden have a shut-door policy or share information with some staff members and not others," says Jazwiec.
When Jazwiec discovered that some of her staff members were going to other sources for information, she confronted the problem head-on by calling a meeting and giving each staff member an anonymous two-question survey. "I asked them, do you find me approachable, yes or no, and if not, what can I do to change that?" she says.
The majority of ED staff responded positively, while the others expressed a perception that Jazwiec seemed constantly busy. At the next meeting, the survey results were announced. "I told everyone, 90% of you found me approachable and I’m delighted because that’s one of my main goals. But to others who didn’t, I want you to know if you need me, I’m there for you," she says. Jazwiec provided her home, car, pager, and office numbers and encouraged all staff members to call if they needed anything.
As a result, she conveyed a strong message that communication is a two-way streetthat if they made the effort to find their manager, she in turn would always be willing to listen. "If the whole department hears you give out all your numbers, then when Susie the troublemaker says, Liz doesn’t care what we’re thinking,’ the others won’t be likely to buy into that," she says.
ED experts agree that the best way to communicate an open-door policy to staff is to come out from behind your door. "People who work with you should see you in the same environment they’re in," says Katherine Heilpern, MD, assistant professor of the division of emergency medicine, and director of medical student education at Emory University School of Medicine in Atlanta. "If you’re a leader of an ED, you need to work in the ED. You need to cross the threshold of the door and get out and walk and talk with people and listen."
It’s important for leaders to be part of the day-to-day operations of the ED. "The higher your status, the lower you have to stoop to show you’re part of the team," says Totten. "An administrator should be somebody who can pick up litter. The head doctor should work weekends and nights, and the head nurse should be seen bringing bedpans."
No one should be above tending to the needs of patients. "From the administrator to the janitor, all staff members make an impression on patients. It’s not my job’ should not be heard from anyone," says Totten. "Otherwise, the attitudes of superiors will be reflected down the line, and patient care will get fragmented. As a result, things will not improve and will most likely deteriorate."
Leaders should send a message that all ED staff are there to serve the needs of the patient. "First, middle, and last, everything we do is to achieve that end," says Totten. "It’s a problem when any staff member is more wrapped up in ego than in the reason that brought them to medicine in the first place."
Make it a group effort
Ideally, staff meetings should include both nurses and physicians so the different perspectives are shared. "Physicians tend to meet regularly for their faculty meetings, and nurses tend to meet individually," says Heilpern. "Getting together on a regular basis gives people an understanding of where everybody’s coming from."
The meeting’s leader should invite uncensored comments. "Tell people you really want their open, unchecked feedback," says Heilpern. "You want them to feel they can state their opinions without fear of retribution."
Staff are often relieved after they voice their complaints. "Sometimes you’ll find that the same thing has been bothering eight or 10 people in the room," says Heilpern. Allow staff members to vent, and encourage the group to give additional input. At the end of the meeting, give a statement that summarizes the group’s feelings.
Leaders should resist the temptation to respond immediately to comments or complaints. "One of the most important things to do is keep your mouth shut and let people say what they want to say," says Heilpern. "It’s human nature to become defensive, but we need to remind ourselves to just be quiet and listen. If you take a defensive stance, people will be concerned that their comments are being misconstrued."
It’s not enough to allow staff members to vent. Leaders need to take appropriate action. "At the end of the next staff meeting, summarize what was done about the problem, such as a task force being formed or administrators who were contacted," says Heilpern.
Meetings are an ideal time to discuss the kind of communication you expect from staff. "Let them know what you’ll do and what you’ll expect from them," says Jazwiec. "Ask them to set expectations for you, and find out what they expect from you as a leader."
Different individuals prefer to get information in different ways, so provide a variety of communication methods. "You have to remember that not everyone learns the same way. Some people like to talk, while others would rather have something they can read," says Jazwiec. "I’m more of a talker, which might frustrate staff who like to see things in writing, so I make an effort to provide handouts for them."
Instead of having a formal structure to staff meetings, it helps to present information creatively, with group discussions, role playing, or quizzes. "We wanted everybody to know our weekly score for patient satisfaction, so I’d carry around a bunch of meal tickets in my pocket, and ask, What’s our score?’ or I’d start a meeting by saying, OK, what’s our average waiting time this week?’" says Jazwiec. Staff members who knew the answer were given a free meal at the cafeteria.
Whatever the format, meetings should be well-mediated and collegial, says Totten. "They shouldn’t be dominated by one party or the other, so that all the different representatives or any individual staff member can make their opinions heard. Meetings should not be allowed to degenerate into name-calling or finger-pointing," she says.
It’s an ED leader’s job to make sure that each and every staff member feels comfortable bringing up concerns, either publicly or privately. "In addition to meetings, there should also be channels for anonymous suggestions to the nursing and physician directors, who should both be very approachable people," says Totten.
Conflict will inevitably arise between staff members working under stressful circumstances. The hectic pace of the ED may make it necessary to put differences aside for the time being, but don’t let things fester. "There’s often too little time to process events as they occur," says Rosenzweig. "The challenge of the ED environment is to refrain from reacting very strongly at a moment of confrontation, but you need to make the effort at a more quiet moment to approach a colleague and review what happened."
Encourage individual solutions
The potential for conflict is amplified in the ED, where tensions often run high. "Conflict is natural, so don’t be thrown by it," says Rosenzweig. "If one can understand that we can’t read each other’s minds and that we all basically share the same goals, it can help you face the painful but necessary process of approaching a colleague and working something through."
Encourage staff to resolve most matters on their own. "It’s the exception that you need a third party to mediate," says Rosenzweig. "People work very closely together in the ED and need to function with a high level of understanding, so it’s really necessary for people to address conflicts as they arise and make the attempts to work them out. Usually the resolution is fairly simple and the air clears very quickly."
Often, it’s taking the first step of approaching the other staff member that is the hardest thing to do. "We tend to feel that it’s best to just let things go, but that tends to leave uncomfortable feelings and issues that may arise later on," says Rosenzweig.
ED directors can facilitate this process by sharing strategies on conflict resolution from literature and personal experience. "There are useful guidelines for working through conflict that can be shared with staff members to bring greater awareness to those inevitable situations," says Rosenzweig.
Avoid focusing on which party is right or wrong, he suggests. "Put the emphasis on listening and hearing the other person out and acknowledging their perspective," he says. "When one party feels they’re not being heard, it adds tension to the situation."
Another effective approach is to simply express your feelings, he says. "If you communicate a feeling of anger, resentment, or humiliation, it often enables some release of that emotion and allows the other person to clarify that it wasn’t their intention to make you feel that way."
Conflicts between staff members need to be kept out of the earshot of patients. "Since the patient is the focus, managers need to ensure there is professional behavior at all times," says Robert Knopp, MD, FACEP, residency director at St. Paul Ramsey Medical Center in St. Paul, MN, and professor of clinical emergency medicine at the University of Minnesota Medical School. "With 50 or 100 people working together in the larger hospitals, you’re bound to have some situations in which two people may not have a [good] personal relationship, but you must have a professional relationship."
In some cases, it may be necessary to involve a third party. "When one or both parties feel that tension is persistent, and working together remains painful and awkward, it is important to find the right mediator. That may or may not be the director, says Rosenzweig. "It could be a third colleague or ombudsman within the institution. Sometimes a meeting where each person brings an advocate can also be helpful. For instance, when dealing with conflict between a physician and a nurse."
Resist the temptation to confide’
Keeping confidential information to yourself can be challenging, especially when rumors are flying. Even when inside information will affect employees, it’s best to keep it to yourself until the time is right. "If a staffer comes to you and asks if it’s true they’re going to be laying people off in housekeeping next month, I’ll say, I can’t confirm that for you, but as soon as I have information I will share it with you,’" says Jazwiec.
As a rule, managers should feel free to comment on topics that the staff discusses in public. "I overheard one of my nurses complaining about someone else getting more overtime. I went into the nurses’ station and said, Susie has a concern that Mary is getting all the overtime, so I’d like to explain the reason why,’" says Jazwiec. "Susie came back to me and was furious, saying, I can’t believe you humiliated me like that.’ I pointed out that she didn’t come to me one-on-one, and what’s discussed in the nurses’ station will now be discussed openly."
Misconceptions may need to be corrected in public before they spread privately. "If I’d brought Susie into my office and told her the reason Mary is getting more overtime, she wouldn’t have set it straight with the other nine people she’s talked to," says Jazwiec.
Resist the temptation to confide, even in your most loyal staff members. "There’s no such thing as telling one person, even your best, most loyal employee. It’s a booby trap," says Jazwiec. "There have been times when I knew about a hiring freeze that would take place in a month and wanted to let some registry people know that if they wanted to come on staff full-time, the time was now."
However tempting, it’s unfair to share more information with certain staff members and exclude others. "I can’t communicate only to the two people I want to come on staff," says Jazwiec. "I’d have to call a meeting and say,’ If anyone is considering going to a permanent position, let me know in the next two days because things might be changing a month from now.’ Then I can go up to an individual afterwards and say, I want you to really consider what I just said.’"
Although individual relationships will vary, it’s important to give all staff members equal access to information. "You have to walk that line of treating everyone equal and hoping the best turns out," says Jazwiec.
Trusting a staff member with confidential information is a burden for both parties. "Usually when you’re telling them something really big, they’ll have to talk to at least one person," says Jazwiec. "When I was getting ready to leave my position, I didn’t even tell my secretary, because you can’t spring that kind of information on anybody and not expect them to emotionally react to it. You’re better off not saying anything because some information puts people in very awkward positions."
If you feel the need to inform staff members about major changes for their own protection, it’s possible to send out subtle signals without crossing the line. "If you feel you need to do something to protect people, you need to do it far in advance. When I started thinking about leaving, I dropped some hints to my secretary by saying, Things aren’t permanent around here, so don’t pass up an opportunity if it comes your way,’" says Jazwiec. The message was conveyed so the secretary wouldn’t pass up a job offer, but the information remained confidential.
Here are some tips on improving communication between staff members in the ED:
• Encourage even nonclinical staff to report their observations. Patients will sometimes confide in other ED personnel when they are reluctant to "bother" their physician. For example, a female patient may not feel comfortable telling a male physician about domestic violence or her worries about a vaginal discharge but may confide in a female clerk or technician.
It’s important that all staff members feel comfortable reporting their observations. "If the janitor says, I don’t know much about medicine, but I saw that patient limping when she went to the bathroom and she said she didn’t tell you about it, I thought maybe you should know,’ it may clue you in to a whole different type of problem than the original chief complaint of sore throat," says Totten. "An abusive husband may be very appropriate in front of the physician but may not care as much when the janitor is in the room."
• Enlist the help of staff who speak foreign languages. A technician or clerk may be the only one in the ED who speaks a patient’s native language. "The patient may be relying on a family member for communication or translation or may speak English but not well enough to express some of the emotional overlay that goes with it," says Totten. "The staff members often can add the linguistic notes or observable clues not readily apparent to the physician."
• Videotape resuscitations to improve communication during codes. "This gives us an objective environment to observe communication between various physicians and nursing personnel," says Knopp. After viewing the taped codes, feedback is given to individual staff members about their communication skills. (For more information about videotaping resuscitations, see the October 1996 issue of ED Management.)
• Encourage good communication skills with residents. Residents need to be aware that their communication skills will influence their future success. "Unfortunately, medical school hasn’t always been very good at emphasizing the importance of communication," says Knopp. "At times, the process of medical education may actually work to counter good communication."
Communication is part of residents’ formal evaluation. "We want to train them to be good communicators, because in some instances, the educational process has allowed bad habits to develop," says Knopp.
• Listen to input from paramedics. When critically ill patients are brought to the ED by paramedics, the prehospital personnel often get overlooked in the flurry of activity. "When a patient is very ill, we tend to focus on the patient, which is essential, but we also need to get information from the paramedics," says Knopp. "We all wrestle with the problem of hearing what they’re saying while we’re trying to intervene in a critically ill patient." (For a more in-depth look at improving communication with paramedics, see the June 1997 issue of ED Management.)
• Improve the lines of communication between caregivers. When things get hectic, nurses and physicians may not fully update one another on the status of various patients. "Nurses and physicians should try to round on patients together, so there is no disconnect on what the patient’s status is," says Heilpern. "Sometimes we change shifts at different times and we have somewhat different priorities, but our overall priority is the same, which is excellence of patient care."
It may not always be possible to go on rounds together. "In many busy EDs, the physician, nurse, and clerical personnel may see patients at different points in time," says Knopp. "On a busy Saturday night with several trauma patients coming in, that ideal model of care is just not going to occur."
Good verbal communication is essential in those cases, he says. "The time to catch any problems is before a patient leaves the ED," he says. "You need to ensure there is a clear understanding between caregivers. Ideally, the physician discusses the discharge instructions with input from the nurse, and any misunderstanding or confusion between them needs to be clarified."
Nurses need to feel comfortable discussing any reservations with physicians. "If written orders don’t make sense to the nurse, they may not be the right ones," he says. "It’s important for the physician to recognize that some of the most important information they have comes from the nurses. They may be able to find out certain things about the patient’s condition the physician wasn’t aware of." That discussion is imperative and should be stressed by ED managers, he adds.
• Pay particular attention to shift changes. Literature shows that this time of the day can be a high-risk time for patient care. "People are tired at end of their shift, so sometimes tests that get ordered never get checked, or tests that are desired never get ordered," says Heilpern.
Good communication is essential during changes of shift, including the patient’s status at the time of sign-out. "Preferably, the nurse or physician who is leaving should introduce the oncoming person to the patient," says Heilpern.
At Emory, physicians make rounds as a group during every shift change. "Instead of doing sign-out rounds at the board, we walk around together and see patients face to face," says Heilpern. "Things may have changed since the last time you looked at the person, so it helps to have the perspective of someone who’s been taking care of that person."
• Compliment staff in writing. Although most managers routinely document disciplinary problems, written commendations are equally important. "If you know somebody had a difficult shift and managed it well, a note to their boss with a copy to them is one of the nicest things you can do, because that goes in their file and lets people above them know they’ve done a good job," says Heilpern.
• Spend time on the floor talking to staff informally. Some of the most valuable input can be obtained during casual conversations. When gathering staff feedback, record suggestions in writing for future reference. "Either ask staff members to submit their concerns in writing, or have a pad and pen to make notes so they know you’re listening," says Heilpern.
Avoid putting staff members on the defensive. Leaders can be more effective by using a light humorous tone to address a minor problem. "If a nurse has one bad day, don’t storm in with a big confrontation. Instead, say, Mary, were you purposely boycotting IVs today?’" suggests Jazwiec. "Instead of saying out in the open, Hey, Kerry, the people who you gave me a report on don’t look anything like you described. What’s wrong with you?’ I’ll take her aside in the lounge and say, I don’t know if you were tired, but yesterday when you were giving me a report, you kind of forgot a few things,’" says Jazwiec.
Address problems early and monitor progress. "The worst thing is to blindside somebody and take severe action when they have no idea it’s a problem," says Heilpern. "Also, address it in private, not out at the nurses’ station."
If a problem is a lack of knowledge or skill in a specific area, offer some on-the-job education. "Put them on shifts working with people who are particularly good in an area they’re lacking," says Heilpern.
Make it clear upfront what the problem is and how you expect it to be resolved. "Let them know you’re going to be revisiting the issue. Say, in six weeks we’re going to sit down again and see what your progress is," says Heilpern.
Let staff members vent. On one occasion at Holy Cross Hospital, a physician came in to complain about a nurse. "He told me she was incompetent, and [said] You have to do something about her,’" says Jazwiec. "When I told him I’d write her up, he then did an about-face and said, Well, don’t come down too hard on her.’"
In some cases, the process of complaining will help get the problem off the employee’s chest. "To blow off steam, rant or rave for 10 minutes is not necessarily a bad thing," says Jazwiec. "That may be just what they need to do once in awhile."
Staffers should apologize when it’s appropriate. "One of the best techniques for managing your boss is to fall on your sword,’ says Jazwiec. "Don’t start saying, Well, I had three other patients, and it’s not my fault.’ Instead, try saying, You’re absolutely right. It should have been done.’ Most of the time when people do that, it’s an effective way to defuse a situation."
When deviating from the standard of care, explain why. Keeping staff informed can have a positive effect on patient care. "If you’re going to give high-dose epinephrine for the first time in an institution or for a particular staffer, tell them why," says Totten. "Say, this is 10 times the usual dose, but I’m going to give it intravenously because some of the research suggests this may work when nothing else does in ventricular fibrillation."
In this scenario, it’s important to share your thought process with staff members. "If you’re planning on using something that’s not well-known to your staff, let them know what to expect from it," says Totten. "If you plan to do a conscious sedation, explain what you expect from the staff, what you expect from the drug for this patient, and what complications are expected."
There is a tendency for some physicians to resist communicating in this manner, she notes. "Often, physicians may feel the less they explain, the less likely they are to demonstrate their own ignorance," says Totten. "Most physicians have been socialized to be very insecure about their knowledge, which they may not be able to admit, even to themselves."
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