1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Empowering staff to use Appropriate Assertion Armstrong Institute for Patient Safety and Quality Presented by: David Thompson DNSc MS, RN

2. Communication Styles Assertive Aggressive Passive or Passive Aggressive © 2009 JHU Quality and Safety Research Group

3. Passivity- the goal is to appease and avoid conflict at all costs! Fail to express your thoughts/opinions Sarcastic Give in with resentment Remain silent Body language- “The Victim Stance”

4. Aggressive- the goal is to dominate and win! “This is what I think, what you think does not matter-you are uninformed” Often expression of feelings, thoughts in a way that is not wholly truthful, Usually done in an inappropriate and unprofessional manner Body language-clenched fists, crossed arms, glaring eyes, intrusive on personal space

5. Assertiveness Assertiveness is an attitude and a way of positively relating to those around you; a skill set for effective communication. See yourself as having “worth” You value others equally, respecting their right to an opinion. Engage in communication respectfully, while also respecting your own opinions. © 2004 JHU Quality and Safety Research Group

6. Being appropriately assertive means: Being organized in thought and communication May require you to think about what needs to be said or how to approach the situation! Speaking clearly, and audibly Disavowing perfection while looking for clarification / common understanding (This could be a learning or teaching opportunity) Should be owned by the entire team (not just a “subordinate” skill-set, and it must be valued by the receiver to work) © 2012 Armstrong Institute

7. Assertion Includes : Saying “yes” when indicated, but “no” when you mean “no”. – don’t be passive aggressive. Using “I” when not speaking for the team. Respectively defending your position, even if it provokes conflict.- you’re an advocate. Body language- Secure upright position in a relaxed manner, making eye contact, standing with open hands Making an assertive statement.

8. Aggressive Hostile Uncomfortably Confrontational Ambiguous Demeaning Condescending Selfish Someone who is Assertive – Is Not © 2012 Armstrong Institute

9. Assertion Model: A Continuous Process of 4 steps Get Attention “NAMES First” State the issue Propose Action Agree on Course of Action

10. Focus on the common goal: quality care, the welfare of the patient, safety – it’s hard to disagree with safe, high quality care Avoid the issue of who’s right and who’s wrong “Patient Centered care”– It is not who is right or who is wrong. It is what is best for the patient. De-personalize the conversation. Actively avoid being perceived as judgmental Be hard on the problem, not the people Helpful Hints in Applying The Assertion Model © 2012 Armstrong Institute

11. Improving Assertion Names First- get their attention Make eye contact Express you concern-feelings State the issue (clear, concise) Propose action(s) Re-assert as necessary Agree on course of action Escalate if no resolution © 2012 AI Get Attention “NAMES First” State the issue Propose Action Agree on Course of Action

12. It is easy for personnel here to ask questions when they don’t understand. Pascal Metrics SAQ 2011

13. In this setting it is difficult to speak up. Pascal Metrics SAQ 2011

14. Disagreements in this work setting are resolved appropriately. Pascal Metrics SAQ 2011

15. In this work setting it is difficult to discuss errors. Pascal Metrics SAQ Keystone: Surgery 2011

16. Discussion 1.Why is it difficult to always be assertive? 2.What can you do to assure that your concerns are heard? 3.What can we do at the organizational level that will help you succeed at providing safe patient centered care?

17. Case Example 1 Central is placed in the PACU. The RN suggests an x-ray before the patient is transferred (that is policy). Physician Assistant states, “Get the x-ray on the inpatient floor” (violation of policy). The attending is paged but he does not return the page. RN is unsuccessful in getting x-ray taken in PACU and the inpatient floor delays. Meanwhile the patient suffers a pneumothorax requiring a chest tube.

18. Conflict-Handling Strategies Avoiding (or Withdrawal) Lose--lose Trivial issues; low power; potential dysfunction not worth the effort; low information Accommodating- Conciliation Lose--win Emphasize commonalities; emotional or personality conflict; build relationships Pressing/ competition (or Forcing) Win--lose Quick action; unpopular actions; top-down fiats Borkowski 2009

19. Conflict-Handling Strategies Positive confrontation Compromising Win with some loss--win with some loss Goals are mutually exclusive; deadlock; conflict style differences Collaborating Win--win Complex, long-term issues; high interdependence Borkowski 2009

20. Discussion How will you implement a structured communication technique? Is the an opportunity to include multiple disciplines? What support do you need at the –unit level? –Hospital level? Armstrong Institute for Patient Safety and Quality 20

21. Questions? dthomps1@jhmi.edu Armstrong Institute for Patient Safety and Quality 21