Abstract & Commentary
Critical Care Clinicians Require Critical Communication Skills
By Linda L. Chlan, RN, PhD, School of Nursing, University of Minnesota, is Associate Editor for Critical Care Alert.
Synopsis: This article provides many excellent suggestions and strategies for improving communication among the members of the critical care team to reduce medical errors.
Source: Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care 2011;26:155-159.
The purpose of this article was to apply aviation communication principles and strategies to the field of critical care medicine, particularly crisis communication situations. Given the number of medical errors that contribute to patient mortality, most stemming from poor communication, this paper offers several excellent suggestions and simple strategies for improving communication among the critical care team, and includes both speaking as well as listening skills.
Effective communication is at the core of leadership, teamwork, and crisis management. Functioning as a good team or effective leader parallels good communication. The authors describe several effective leadership and communication goals that include the ability to establish a shared mental model, to coordinate tasks, to centralize the flow of information, to establish a structure, and to stabilize emotions. The authors note that medical teams rarely achieve a shared mental model, which they refer to as an understanding of the situation, task, and resources.
One manner in which to achieve a shared mental model is by addressing the culture of a unit/group in order to improve communication. Commercial airlines are one example of an effectively communicating team that functions well in a crisis to avert error or disaster by promoting a culture of horizontal authority, whereby subordinates are empowered to speak up and senior members listen. In the medical arena, nurses usually delay in sharing identified problems with the team because they are viewed as subordinate to physicians in most organizations. Physicians, on the other hand, tend not to communicate what they are doing and why, and usually only communicate with other physicians rather than the entire health care team.
Fortunately, the authors offer several practical strategies from the literature to promote verbal communication, improve assertiveness, improve understanding, and improve task completion. Promoting verbal communication involves using speech best suited for a situation and communicating clearly and assertively, particularly in a crisis. Improving assertiveness includes graded strategies that range from least direct to most direct — hint, preference, query, shared suggestion, statement, command. For subordinates, if hints are ignored they rarely will escalate their assertiveness. Another example to improve assertiveness is the Situation, Background, Assessment, and Recommendation (SBAR) communication, which originated in the military. The SBAR approach allows all members of the ICU team to speak clearly and comprehensively. For improving understanding, the authors note that overly aggressive or passive speech is not appropriate in any situation as this style shifts the focus to power rather than the task at hand. "Heard is not understood" strategies to improve in this area include "call out" and "speaking up," so colleagues know not to interrupt an individual while completing complex, and many times, concurrent tasks. Lastly, strategies to improve task completion include the 3 Cs of communication: clear instructions, citing names, and closing the loop, which is similar to the repeat-back method for confirm understanding of the delivered message.
COMMENTARY
Much has been written over the past years with regard to patient safety and the need to improve it. The "Silence Kills" study (2005), conducted by VitalSmarts, the Association of periOperative Registered Nurses, and the American Association of Critical-Care Nurses,1 revealed that 84% of health care professionals have observed colleagues take dangerous shortcuts when working with patients, and yet fewer than 10% spoke up about their concerns. While checklists and safety tools are important, the crux of the matter lies with respectful and effective communication to prevent errors and promote patient safety. In general, health care professionals are not taught how to communicate in their basic education or training programs. Further, role models are needed in all organizations where a culture that contains a horizontal hierarchy is modeled among leadership.
To promote optimal patient safety in the ICU, all members of the ICU care team need to acquire and practice effective communication skills. Sending and receiving accurate messages can be a matter of life and death, particularly in highly stressful situations such as during patient resuscitation. Educators, preceptors, fellowship directors, and managers are all challenged to model, inform, and promote excellent communication skills, as these skills are just as important as technical skills and knowledge in caring for critically ill patients.
REFERENCE
- VitalSmarts, Association of periOperative Registered Nurses, and American Association of Critical-Care Nurses. The Silent Treatment. Why Safety Tools and Checklists Aren't Enough to Save Lives. www.silenttreatmentstudy.com. Accessed Feb. 8, 2012.
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