Difficult Conversations Within Healthcare: a Pilot Study

Difficult Conversations Within Healthcare: a Pilot Study

Brett Williams, Bronwyn Beovich, Tanya Edlington, Geoff Flemming & Grant Donovan Medical Science Educator e-ISSN 2156-8650 Med.Sci.Educ. DOI 10.1007/s40670-017-0378-4

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Author's personal copy Med.Sci.Educ. DOI 10.1007/s40670-017-0378-4

SHORT COMMUNICATION

Difficult Conversations Within Healthcare: a Pilot Study Brett Williams 1 & Bronwyn Beovich 1 & Tanya Edlington 1 & Geoff Flemming 2 & Grant Donovan 2

# International Association of Medical Science Educators 2017

Abstract Adverse effects resulting from medical care such as patient injury, disability, or death are believed to be preventable in many cases. Communication failures have been shown to contribute substantially to these adverse healthcare outcomes. Many healthcare professionals witness colleagues demonstrating a lack of skill, mistakes, or unwillingness to follow safety procedures, but most are unwilling to discuss their concerns. This pilot study is the first to explore experiences of these issues in an Australian health service. Findings suggest that healthcare professionals find such conversations enormously difficult and that this may have subsequent deleterious effects on patients. Keywords Difficult conversations . Medical errors . Healthcare professionals . Healthcare service

Background Patient harm from medical care resulting in significant patient mortality and morbidity is well documented and has been described as a common phenomenon [1], with an * Brett Williams [email protected]

1

Department of Community Emergency Health and Paramedic Practice, Monash University, McMahons Rd, Frankston, VIC 3199, Australia

2

Vitalsmarts, Level 1, 363 Camberwell Road, Camberwell, VIC 3124, Australia

estimated 10% of patients experiencing an adverse event related to their treatment during their hospital stay [2]. An adverse event (AE) is an ‘unintended injury or complication resulting in prolonged hospital stay, disability at the time of discharge or death and caused by healthcare management rather than the patient’s underlying disease process’ [2], and it is believed that approximately half of these events are preventable [2]. A crucial signpost to this problem was published in 1999 when it was estimated that between 44,000 and 98,000 people died each year in hospitals in the USA from preventable medical errors [3]. It has been argued that since this time, there has not been satisfactory improvement in the quality and safety of patient care [4]. A major factor identified to contribute to medical errors is communication failures between healthcare professionals [5–8]. Data from a 2016 report indicates that almost 80% of sentinel events in hospitals were related to problems of communication [9]. Decisions to avoid difficult conversations with colleagues may compromise patient safety [10] and as such can have serious consequences. The ‘Silence Kills’ Study [6] collected data from more than 1700 nurses, physicians, clinical staff, and administrators in the USA and identified various types of conversations that are perceived to be difficult. The difficult conversations identified concerned broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement [6]. The ability to have these conversations correlated with improved patient outcomes, staff commitment, discretionary effort, and employee satisfaction. A further study in 2010 demonstrated that communication breakdowns can harm patients. This study found more than

Author's personal copy Med.Sci.Educ.

80% of 3403 nurses surveyed had concerns about dangerous shortcuts, incompetence, or disrespect; however, less than half of these nurses had spoken to their managers about their concerns, and less than a third of these nurses had spoken about all their concerns with the person demonstrating the behaviour [7]. The aim of this pilot study was to study the workplace experiences of difficult conversations in staff employed by a regional healthcare service in Victoria, Australia. This study was informed by the US studies, ‘Silence Kills’ and ‘The Silent Treatment’ [6, 7]. To the best of our knowledge, such a study has not previously been undertaken within the Australian healthcare setting.

Results Demographics Forty individuals completed the online survey, of which 75% were female. Overall, 73% percent worked in a clinical health field, 20% were from non-clinical areas such as administration, while the remainder did not reveal their work area. The majority (58%) were aged between 31 and 50 years of age, with 43% of respondents having over 7 years of experience in their role. In contrast, a similar number (38%) was relatively new to their role with 1 to 3 years of experience. Survey Results

Method Design This pilot project was designed as a cross-sectional study where participants completed an online questionnaire (18 items). This questionnaire was based on that used in the aforementioned two studies [6, 7] with modifications made to the wording to increase relevance to the target cohort, as well as the addition of questions concerned with the frequency of difficult conversations in which the person had observed or were involved. The questionnaire examined workplace experiences regarding observations and perceptions of colleagues and willingness to speak up if potentially harmful behaviour was witnessed. Participants and Procedures A convenience sample involving clinicians, managers, and administrators employed in a Victorian regional health service were eligible to participate. The study was promoted to staff via flyers and staff intranet and consent was implied by completion and return of the questionnaire. The questionnaire was accessible via the Qualtrics online survey tool. As several questions allowed for more than one response, some response percentages may total to greater than 100%. Ethics Ethics approval from the relevant agencies was granted prior to the commencement of the study. Respondents were informed of the purpose of the study, the voluntary nature of their participation, and of the procedures to protect confidentiality and anonymity in all published outputs.

Sixty-five percent of participants believe that they work with people who are not as skilled as they should be, for example, colleagues who are not up to date on a procedure, policy, protocol, medication, or practice, or are lacking basic skills. Sixty-five percent of participants also believe that some colleagues demonstrate behaviours which could be dangerous for clients. One section of the survey asked the participants to reflect on colleagues who they felt were under-performing in their professional duties. ‘Underperformance’ was not explicitly defined; however, it is generally taken to mean to perform less well than expected. In the context of this study, the appraisal of this quality, along with the other included professional qualities, is subjective in nature. Colleague underperformance was seen to have many impacts. Fortyeight percent of the respondents reported that a client had been affected due to the poor performance of someone in their healthcare team, nearly a quarter (23%) indicated that errors had occurred but had been caught prior to having an impact on the client, and approximately half (53%) suggested that an error had not actually been made yet but there was a genuine potential for a mistake to occur. Over one third (35%) said that they would feel uncomfortable to have that person look after a family member. Participants were also asked to reflect on the person whose underperformance created the most danger for clients, and to whom they had spoken about the situation. Only 23% had spoken to the person and expressed their complete concerns, 13% had spoken with friends and family, 23% had spoken with some of their co-workers, over half (57.5%) had spoken with their manager, while 23% of participants had not spoken to anybody about the concerning behaviour. The survey also asked for feedback on difficult conversations in their workplace. Sixty-three percent reported that they


had witnessed one or more difficult conversation and approximately the same number (65%) had participated in one or more within the last month. Forty-five percent reported avoiding at least one difficult conversation within the same timeframe.

Discussion The present study describes a cross-sectional survey of a health service cohort regarding perceived colleague performance and resultant ‘difficult conversation’ issues. To the best of our knowledge, this is the first study of this type to be performed in Australia and was informed by previous US studies [6, 7]. The majority of respondents were women which is reflective of gender employment statistics in the healthcare industry [11]. In the present study, 65% of people had concerns about the competence of one or more of their colleagues who demonstrated behaviours that could be dangerous for clients. In comparison, ‘The Silent Treatment’ study found 82% of participants stated they had co-workers that were under-skilled or incompetent. Furthermore, 84% worked with people who demonstrated behaviours that may be dangerous to clients [7]. The 2005 study showed similar results [6]. It may be that the lower level of concerns expressed by our cohort can be partially explained by the sampling of cohorts from different medical environments. In the present study, the population was from a health service consisting of both hospital and community components, whereas both US studies surveyed people working in acute care hospitals, where errors may have a greater possibility of a deleterious outcome. It has been suggested that speaking up about safety concerns in healthcare is more likely to occur in cases which are perceived to carry a higher potential for patient harm [12, 13]. It may be that this is the case in higher acuity settings such as acute care hospitals from which the US cohorts were sampled. However, further investigation is required to resolve this discrepancy. Unfortunately, it is common not to voice a concern regarding the behaviour of a healthcare colleague. In the present study, participants only shared their full concerns with the involved colleague in 23% of cases. Previous studies have shown that nurses report approaching the person with their full concerns in 12–21% of cases [6, 7]. The disparate results between studies will require further larger scale enquiry. This results of this study indicated that 65% of people had participated in at least one difficult conversation with a colleague within the preceding month. However, at least one difficult conversation had been avoided by 45% of participants. Furthermore,

over 60% of people had witnessed at least one of these conversations. These results indicate that many find it difficult to raise the issue of incompetence or potentially dangerous behaviour to their colleagues. This is supported by previous research which contends that many healthcare professionals find speaking up enormously difficult [12–14]. These difficult yet crucial conversations in healthcare have received growing attention in the literature [13–18]; however, further research is necessary to increase understanding of this issue. Due to the pilot nature of this study, there are limitations which need to be taken into consideration. Firstly, the low number of participants and the non-homogenous cohort make comparison with the other studies difficult. The cohort for the present study was derived large range of professions. More than a quarter of participants worked in non-clinical positions within the healthcare service. It is possible that results may differ if only those involved in patient care were surveyed. Also, the use of self-reporting questionnaires may encourage the use of socially acceptable responses rather than actual responses. It appears that many healthcare professionals witness colleagues demonstrating concerning and potentially dangerous behaviour; however, the minority addresses these issues with the person involved or a manager. Given the existing evidence that the inability of health professionals to engage in difficult conversations is associated with higher rates of medical errors and poorer patient outcomes, further investigation in this area is warranted. However, there appears to be a need to develop strategies, processes, and tools that can be used by clinicians to engage in these conversations with their colleagues. The incorporation of educational content to enable this skill in medical and other health science curricula would be valuable at both undergraduate and postgraduate levels. This novel pilot study will inform a further, larger study planned by the authors.

Acknowledgements The authors would like to thank the staff who completed the questionnaire in this study.

Compliance with Ethical Standards Ethics approval from the relevant agencies was granted prior to the commencement of the study. Respondents were informed of the purpose of the study, the voluntary nature of their participation, and of the procedures to protect confidentiality and anonymity in all published outputs. Conflict of Interest The authors declare that they have no conflict of interests.


Appendix 1: Questionnaire

Overcoming Difficult Conversations in Clinical Supervision 1. What percentage of the people who work in your team or program demonstrate behaviours that could be dangerous for clients (for example not respecng confidenality, checking on exisng client informaon, forgeng to perform a risk assessment, ensuring professional development is current and relevant)?

ƶ None ƶ 10% ƶ 25% ƶ 50% ƶ 75% ƶ 100% 2. Think of the person whose underperformance creates the most danger for clients. Who have you spoken with about the problem? (Check each box that applies)

ƶ Have not spoken with anyone. ƶ Have spoken with friends and family. ƶ Have spoken with some of my co-workers. ƶ Have spoken with my manager. ƶ Have spoken to the person but probably didn’t completely express my concerns. ƶ Have spoken to the person and completely expressed my concerns. 3. Describe the impacts underperformance of that person have had in your team or program. Check each box that applies:

ƶ No actual error, but potenal for error. ƶ An error, but caught before any harm came to a client. ƶ A client was affected--but no harm. ƶ A client was harmed--was at greater risk, had to spend more me in the health service, required more attenon from staff or required referral, or required a test--but no medicaon or treatment was required to counter the harm.

ƶ I would feel uncomfortable having a family member under this person's care. 4. What percentage of the people who work in your team or program are not as skilled as they should be (for example, they aren’t up-to-date on a procedure, policy, protocol, medicaon, or pracce or are lacking basic skills)?


ƶ None ƶ10% ƶ 25% ƶ 50% ƶ 75% ƶ 100% 5. What percentage of the people who work in your department or unit demonstrate disrespect (for example, are condescending, insulng, or rude—or yell, shout, swear, or name call)?

ƶ None ƶ 10% ƶ 25% ƶ 50% ƶ 75% ƶ 100% 6. Think of the person whose disrespect has the greatest negave impact. Who have you spoken with about the problem? Check each box that applies.

ƶ Have not spoken with anyone. ƶ Have spoken with friends and family. ƶ Have spoken with some of my co-workers. ƶ Have spoken with my manager. ƶ Have spoken to the person but probably didn’t completely express my concerns. ƶ Have spoken to the person and completely expressed my concerns. 7. Describe the impacts that disrespecul behaviour has had on you and your work. Check each box that applies:

ƶ I have felt frustrated and unsupported. ƶ I have felt that my professional opinion is not respected or valued. I have been unable to get people to listen to my point of view.

ƶ I haven't been able to trust that others in my team/program are providing the right level of care to our clients.

ƶI would feel uncomfortable to have a family member receiving care in this program.


ƶ I am seriously considering leaving this team/ program. ƶ I am seriously considering leaving the profession. 8. Please read the statements below, and check the ones that are true for your workgroup. Check all that apply.

ƶ People here have the skills they need to intervene without being disrespecul. ƶ When someone wants to speak up about a concern, he/she can count on support from the people around them.

ƶ Intervening when you disagree is clearly understood to be a part of your job here. ƶ Voicing your concerns is seen as a moral imperave here.

9. Policies and procedures around safety, risk assessment and best pracce are used rounely here.

ƶ People who are skilled at speaking up and holding others accountable are recognized and rewarded by the organizaon.

ƶ When people here have a concern, they know how to politely get others to stop what they’re doing and listen.

ƶThe norm here is for people to hold each other accountable regardless of role or posion. ƶ People take pride in their ability to speak up to others, regardless of their role or posion. ƶ All staff who work here expect you to speak up when you have a problem with something they are doing.

ƶ The organizaon uses rewards and sancons to encourage people to speak up and take acon when they have a concern.

ƶ There are specific mes, places, and processes that make it easy for people to share their concerns.

10. How many difficult conversaons have you observed in the last month in your workplace? a. b. c. d. e.

None 0-2 3-5 6-10 >10

ƶ ƶ ƶ ƶ ƶ

11. How many difficult conversaons have you parcipated in during the last month in your workplace? a. None

ƶ


b. c. d. e.

0-2 3-5 6-10 >10

ƶ ƶ ƶ ƶ

12. How many difficult conversaons have you avoided in the last month in your workplace? a. b. c. d. e.

None 0-2 3-5 6-10 >10

ƶ ƶ ƶ ƶ ƶ

13. What are some potenal factors that would support you in applying the knowledge or skills in your workplace? a. b. c. d. e.

Opportunity to use the knowledge/skills Access to more students Organisaonal support Addional me allocated to supervision Other, please describe

ƶ Yes ƶ Yes ƶ Yes ƶ Yes ƶ Yes

ƶ No ƶ No ƶ No ƶ No ƶ No

___________________________________________________________________________ ___________________________________________________________________________ 14. What are some potenal factors that would deter you from applying the knowledge or skills in your workplace? a. b. c. d. e.

No opportunity to use the knowledge/skills Lack of confidence in applying the knowledge/skills Lack of support in my organisaon Service delivery pressures Other, please describe

ƶ Yes ƶ Yes ƶ Yes ƶ Yes ƶ Yes

ƶ No ƶ No ƶ No ƶ No ƶ No

___________________________________________________________________________ ___________________________________________________________________________ 15. What professional program/team/ discipline do you supervise? _____________ 16. How many years of experience do you have in this role(s)?

________________

17. What is your age?

________________

18. What is your gender? a. Female b. Male

ƶ ƶ


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