Appropriate Assertion Call (Transcript)

December 14, 2010

Operator: Good day, ladies and gentleman and welcome to the CUSP Content Call. At this time, all participants are in a listen only mode. Later, we will conduct a question-and-answer session, and instructions will follow at that time. If anyone should require audio assistance during the conference, please press “star” then “zero” to reach an operator. I would now like to turn the call over to Dr. Jill Marstellar. You may begin.

Jill Marstellar: Hi, everybody. Welcome to our call about appropriate assertion today, and I would like to thank Dr. David Thompson for the slides that he put together. He is not going to be able to join us today, so I’m going to handle the call. But David, of course, has been working on assertion for a number of years. And I benefit from all of his experience on his topic.

To get us started I thought I would start with a description of why we care. Why is it important for us to even be talking about appropriate assertion? Everybody has it in their head, they know at some level that it’s important to be assertive in some situations, right? Well, an interesting quote from Northcote Parkinson is that, “The void created by the failure to communicate is soon filled with poison, dribble, and misrepresentation.” I love that quote primarily because I think that people don’t even think about the fact that when we opt to be passive or not say anything in a given situation, we assume that people will think, “Wow, Jill is being so big about this; she’s really such a congenial type that she’s not upset by this situation.” That’s what I assume, of course, but, in fact, sometimes people may be thinking, “Well, I don’t know why she’s not saying anything. She certainly seems angry about this situation. I can’t believe the way that she is being so passive-aggressive.” Right?

We need to be concerned that in any situation, our choices to stay silent or our choices to speak out in a very emotional way and potentially aggressive way can both look pretty bad for us. And what’s more important is they could ultimately be very bad for the patient. So, if you go to the second slide on communication styles, you see there that we have arrayed four of the communication styles. On one side you have assertive communication then, of course, there’s aggressive communication, and at the bottom passive or passive-aggressive communication. And I’m going to talk about each one of those a little bit.

Clearly, all of us use these different communication styles in different circumstances. So, for example, if my grandmother and I are having a disagreement, as we have on occasion, I opt for the passive style with her. And I would not typically even assert my opinion particularly strongly because she’s 95 years old, and she’s come to her opinions through a long, hard process, and I’m not going to change her mind. It’s not worth the family disharmony for me to make a big deal out of something. So you may choose to have a passive style in some situations.

You might be an old-school person. You might say, “Well, you know, I believe there’s a certain way that you are supposed to communicate.” Nurses might say, “Well, there is a certain way that you have to treat doctors; there is a certain way that you would speak to them.” There’s the old school; there’s the new school: I think all of the schools are great. But, what they all can agree upon is that it’s important to stand up for the patient when the patient needs you to.

It’s important to be assertive and share what you know in order to provide the best care, the safest care for each patient. So we have to accept that, fundamentally, there is an issue of self-worth here in assertive communication. You may prefer to not be overly assertive in most situations. But, if there is a question about how to care for a patient, and you have an opinion, it is essentially your duty to share that opinion in a way that is not aggressive and yet ensures that you are heard in your manner.

When I say that it is fundamentally about self-worth, it goes back to this notion that your opinion is important. And that you have every right to express your opinion and, in fact, a duty to express your opinion from your collective experience. All of the background that you have is different than someone else’s so, in some cases, there may be no one representing your point of view, your experience, or your background, and so on. Unless you do it, that information won’t be added to the process. It’s very important for you to feel not only that you should share your point of view, but that you are not expected to know absolutely everything. And, in fact, everyone knows you don’t know everything. And you would have to decide is it more embarrassing to have everyone think that I think I know everything or is it more embarrassing to actually have to speak my mind? I think you will conclude that the second one is obviously a better way to go.

So on the third slide; let’s talk a minute about passivity. In the passive communication style, the goal is essentially to appease and kind of avoid conflict at all costs. So, in that case, you would fail to express your thoughts and opinions or you might take sort of a sarcastic approach, “Well we’ve all got time to listen to that…  again.” Or “Certainly, I can do more. It’s not like I have anything else to do” and so on. So these are somewhat passive-aggressive stances to take when you are being a little bit sarcastic. Another passive communication strategy is giving in but, in fact, harboring some resentment about it, which we know is not healthy and ultimately will come out in some other way somewhere down the pike.

You may remain silent, and you may take what David calls the “victim” stance with your body language. So you are essentially looking down. You may be holding your arms across your chest. You are essentially having your shoulders sort of rolled forward, which is kind of a submissive kind of posture but hiding your eyes so no one could really see what might really be going on in there. So all of these kinds of passive body language and the notion or the desire to actually kind of accept whatever is going on around you in order to avoid having to disagree with anybody or to avoid a potential conflict, of course, is not good for the patient.

And when we get to the next slide, we are looking at aggressive behavior. In aggressive behavior, the goal is to dominate and to win, so it is very competitive and would tend to be accompanied by statements like, “This is essentially what I think, and you are uninformed; therefore, whatever your contribution is is not important in this particular situation or doesn’t matter in general.” There tends to be an expression of feelings or thoughts in a way that is not really truthful. So the aggressive person is feeling very emotional about something, and they essentially are putting forth a case they feel is persuasive or forceful and so it may involve taking liberties with the facts in order to make the case stronger. It’s usually done in kind of an unprofessional way. It’s very hard to imagine being aggressive and being professional at the same time, right? It’s about domination and winning. The words tend to be accompanied by the body language of clenched fists, sometimes crossed arms, glaring looks. Sometimes people actually become intrusive on personal space; they get a little too close. They are “up in your face or your grill,” as some people say. They might, for that matter, stand up at an inappropriate time while everyone is sitting around the table. And, in order to make their point, they kind of stand up and use their height to their advantage. So these are all somewhat aggressive postures that you might see.

There’s a good description of the distinction between aggression and assertion that comes to us from the author Dixon. She suggests that aggressive behavior is competitive, overriding, always lacking in the regard of the other. It means winning at someone else’s expense. On the other hand, assertion is based on equality, not superiority; cooperation, not competition; honest and appropriate expression of feelings, instead kind of ruthless expression of them.

On slide 5, let’s look at assertiveness. Assertiveness is an attitude and a way of positively relating to those around you. It is a skill set for effective communication. There is nothing bad about appropriate assertion. Assertion is the way that you are able to show that you have self-worth and that you are confident in what you are saying. It does not mean that you have to know all the answers. It actually means that you are appropriately aware of your own limitations and appropriately aware of your own expertise. And that you are offering your expertise to the situation, accepting the fact that there might be some piece of information that you are lacking. That’s why you are seeking out other people’s input. You value others in an equal way; you respect their right to an opinion; you also respect your own right to have an opinion in assertive communication. It’s about respect for absolutely everybody in the situation. And as you enter into a situation where you need to be assertive, a communication where you need to be assertive, you are opening that conversation with the knowledge that the purpose of the conversation is to reveal all relevant information, whether you have it or whether others have it. When you think of it that way, again, it becomes a duty to express yourself fully but to also listen to what others have to bring to the conversation.

On slide 6, you see that assertion is organized in thought and communication. It can be structured if that’s helpful to you. You can actually use one of the rules that we taught you in our last call, which was about conflict resolution, or one of our previous calls about teamwork. You could use a structured communication tool like the SBAR format in order to communicate what you need to communicate. You have given it some thought before being assertive or, if you are a naturally articulate person, then you essentially allow your confidence to help you structure your communication and be sure that the other person is following where you are going. But you are also waiting for them to answer back to you. It’s an interaction that is equal. Speak very clearly and audibly. I know a person who, whenever she is talking, she always swallows the end of her last sentence. I don’t know why she does this, but it gives the impression that she is not confident in herself. She will often be describing something and finish it off by saying, “Well, I don’t really know if anybody really cares about that” or something along those lines, which tends to completely discredit whatever she said before that because she is essentially saying “I don’t think what I just said is very important. Why should anyone else?”

Part of assertion is also disavowing perfection -- knowing that you are not fully aware of the full situation -- asking for clarification, trying to create a shared pool of meaning as they would say in the crucial conversations material. Creating a common understanding among everyone about what the situation is. And appropriate assertion needs to be owned by the entire team. So this is not as David would call it a “subordinate skill set” where only the people in the supportive roles should know how to be assertive. In fact, whoever the receiver of their assertion is needs to be a person who values the opinions of others or at least needs to listen and have the ears open for assertion to actually be effective.

On slide 7, you’ll note that assertion also includes kind of saying yes when yes is the right answer but saying no when you actually mean no. How many of us have trouble saying no to something when we’ve been asked to take on yet another task? We say, “Well, okay, I’ll try to get to it.” What we are really hoping is that they say, “Oh, you mean you are busy? You don’t have to do that.” But nobody ever says that so we have to learn how to say, “No I really can’t help this time. You know that I’m usually available to you, but today I’m afraid I can’t” or whatever you need to say. But you need to say no when the answer is actually no. You should go ahead and use “I” when you are not speaking for the team and make it clear that you are expressing your own opinion and your own thoughts. You should be defending your position, if necessary, even if it provokes conflict. The point is that you are bringing your information to the table and you wish it to be heard, and if there are those who don’t want to hear it, they should be prepared for you to assert again and to be strong in your position. Even if it means that you are going to have a little bit of conflict with somebody, it’s better to have gotten that information out on the table and made your point.

The body language associated with an assertive stance tends to be you are in a secure and upright position but not locked like a tray table. You have a relaxed manner; you are making eye contact; you are standing, making sure your hands are open and your body language is saying, “I’m ready to talk. I’m open to discussion on this point.” You don’t want your body language, as we talked about before, to be aggressive or passive but rather ready for communication, open to the other person’s point of view, and also open to share yours.

On slide 8, a little bit of discussion about what assertion is not. We’ve talked about what it is: It’s not aggressive, it’s not hostile, it’s not confrontational. Yes, a confrontation may result, and you need to be prepared for that possibility. But it is not in itself confrontational to simply be willing to state your opinion and be assertive in the way that you present your opinion or your information. It’s also not being ambiguous. The worst is to be like the person I mentioned before to essentially discount what it is you just said or to not provide specific details when you are being assertive, allowing things to be too wishy-washy, making statements like, “Well, I don’t know. Do you think we should consider possibly looking into this as a source of the fever?” You need to be a little bit more direct in what you are actually thinking. Assertion is also not demeaning or condescending, so it would never go into the area of suggesting that you feel you know better. It rather is saying, “Based upon the amount of time that I’ve spent with the patient, my impression is this.” It doesn’t say anything about discounting other people’s points of view. “Well, you’ve really only been over here to the bedside twice, so I’m not sure how you could know anything about what is going on with this patient.” It’s not in any way demeaning or condescending. It’s not in any way aggressive or hostile. It is simply stating your point of view and being strong and confident in that statement of your point of view. It’s also not selfish. It’s not about, “I want to win.” It’s about what can we do that is going to be best for the patient in this situation.

Let’s look at the QSRG assertiveness model, which is presented to you on slide 9. Communication to improve patient safety is a continuous process, and David developed this model with Peter’s input. Essentially, it starts there above the darkest arrow. You first start by getting the attention of the person that you are needing to be assertive with and recommend using the name of the person in order to be sure that you are getting their attention. You then state what the issue is – “This is what I think is going on” -- and I’ll provide you with an example in just a moment, and then propose an action, and finally agree on the course of action. And, if for whatever reason you can’t agree on the course of action, you can restate your proposed action or provide a backup plan, a contingency plan, or a secondary course of action and see if you can agree on that one. If that doesn’t work, then you would need to find someone else to help you resolve the conflict, as we discussed on our last content call.

Moving to slide 10, some helpful hints in applying this assertion model. First of all, that you are always, as we said before, focusing on the common goal, which is the highest quality care that you can offer, being sure that you are invoking the need to care for the patient in the best way possible. You are interested in the welfare of the patient. It’s not about me. It’s not about you. It’s about what’s best for the patient. You want to try to avoid the issue of who is right and who is wrong. Once you’ve gotten into a disagreement because you’ve been assertive, and the person is responding also in an assertive way, hopefully appropriately assertive, you are then in a little bit of a conflict. You want to be sure that the whole situation doesn’t spiral down into a struggle of who is stronger or who has more power or who is more inflexible. You are trying to avoid this notion of “I am right and you are wrong” or wherever the disagreement may go. You wish to be sure that you’ve stated your case in an appropriate and assertive way so that the information is on the table and then, together, you should try to focus on what would turn out to be best for the patient. Wherever you can, depersonalize the conversation. Try not to have it be about you and me and we can’t agree. Actively avoid being perceived as judgmental. So this is back to some of the examples I have offered so far. Be hard on the problem, not on the people.

When you move to slide 11, you’ll see in the corner there the assertion model again, and we are going to go through the steps. The first is you say the name of the person and get their attention. An example of this: If we were to think about a central line that has remained in the patient, and the group decided that it was ready to come out a couple of days ago, perhaps the nurse is trying to get someone to pay attention to it so that the line can be actually ordered to be taken out or actually taken out by the appropriate staff. You would start by saying the name, “Bob,” or if you feel more comfortable, “Dr. Maelstrom” or whatever his name may be. And while you say this, make eye contact. Be sure you have the person’s attention by making eye contact. Then express the concern. And if you wish to talk about the feelings you are having related to that concern, you can or you can just say, “I’m concerned” or “I’m worried that Mrs. Smith’s central line is still in and it’s not needed anymore.” Then propose an action after having stated the issue: “The line is still in although we agreed it’s ready to come out.” Propose the action: “I think that we should get that line out today. We need to call the right person to get this line removed.” In our unit, it depends on where you are. Sometimes it’s nursing; sometimes it’s a physician. And then, reassert as necessary. If the person seems not very interested -- “Well I don’t have time to do that today” – then that’s the appropriate time to say, “Well, you realize the risk of infection goes up with every additional day that that line stays in there now that it’s not needed. And I really think we should remove that line today.” Okay, so reassertion. People in assertive communication agree on a course of action, but if there is no agreement on the course of action, then it makes sense to escalate it. Not to say make it more emotional, make it more aggressive but rather escalate it in the sense of going up the chain of command or finding someone else to offer an opinion and act as a mediator in the situation. It’s okay to go cross discipline with that if you need to. So if you are a nurse, it’s okay to ask someone who is in the medical chain of command to offer a point of view on the specific issue.

Moving to slide 12, these are all of the units that had submitted safety attitudes questionnaire data up to about the year 2008. You can see there are just tons and tons and tons of units represented in this. When you look at this nice, large and pretty smooth distribution, it’s all responses to the question about, “It is easy for personnel in this ICU to ask questions when there is something they do not understand.” On the y axis there, you can see that this is the percent respondents that agree, and so it’s really pretty good. For the majority of these sites, 80 percent of the people on the unit are agreeing that is easy for them to speak up and ask questions when there is something they don’t understand. Most of us seem pretty good with the idea of accepting that, no, we don’t know everything and we’re not expected to know everything. It’s not too hard to ask a question.

But when we move to slide 13, we see a different question which is, “In this ICU, it is difficult to speak up if I perceive a problem with patient care.” Now it’s become negatively worded and the percent that are agreeing with this, of course, is going to be -- we hope -- low because we don’t want people to say, “Yes, it’s really hard to speak up,” right? It’s important to note, though, that this question has the notion of a problem, and so you are speaking up about something negative that has happened. When you look at the distribution here across all of these different ICUs, you can see that the majority of the sites actually have about 30 percent responding that it is difficult to speak up when they perceive a problem with patient care. That’s saying that it is difficult for a fairly large portion of the people on the unit than if you look at the tail end of that you see that some of the units have as many as 50 percent of the people saying, “Yes, it is really hard for me to speak up when there is a problem.” In fact, we might find that of concern when we think about how many units are saying, “I find it hard to say anything about a problem.”

When you move to slide 14, we’re back with a positively worded question again. “Disagreements in this ICU are resolved appropriately.” That means not who is right, but what is best for the patient. We can see that if we are hoping that about 80 percent of the people respond positively to that question, you can see across this gigantic array of units, there are not a very large proportion of them that actually reach that 80 percent mark of people saying, “Yes, indeed disagreements are resolved appropriately.”

When you think about the last three slides, try to imagine where your unit is in that array of different units. If you are one of them that had answered that question, where would you be across this distribution? And these may be questions that you find effective to ask of your own staff to see how comfortable they are with assertive behaviors of speaking up and asking questions when they don’t know the answer, of speaking up when they perceive a problem with care and how they feel that disagreements are resolved within your unit. Those are three questions that you can ask your own unit and you could ask them on a piece of paper and have them respond anonymously, if you think that would help. It is a great way to gauge how comfortable people are with being assertive in the appropriate situations where assertion is called for.

Then if you go to slide 15, you can see some of the questions that you would have in a group meeting to talk about your assertion questionnaire results. For example, you could open the discussion with people by saying, “Why do you think it’s difficult for us to always be assertive? Tell me what you think are the barriers to you personally being able to assert your expectations for care, your opinions about care.” This is a great way to bring in your middle management. It’s a great idea to have, for example, the ICU director be there when the group is discussing some of these questions about how hard it can be to be assertive. Because, again, you need both the receiver and the sender to understand the principles of assertive communication and be willing to receive that assertion just as they are willing to be assertive in their own self-expression. Another question would be, “What can you do to be sure that your assertions are heard?” So, how can you express yourself in a way that is assertive but not aggressive and be sure that you avoid passivity? What can we do at the organizational level that might help you succeed at providing safe, patient-centered care? When we want to endorse and support your use of assertive communication toward better patient care, what can we do as an organization or as a unit to help you? What kinds of things do you need us to do? Who do you need to model these behaviors to and so on?

On the final slide there, these are essentially your action items: What next? After you talk to people and find out about how they feel on these assertiveness questions and you’ve had some conversations with people about what makes it hard to be assertive, when is it appropriate in their view and when is it very hard to do, what can be done to support them, then you could say you will be happy to bring in some of the conflict resolution strategies that we talked about before. You may want to actually consider more assertiveness training in order to help people be appropriately assertive. You may want to help them practice using the model that we suggested here then talk to them as well about some skill sets that they should work on that will help address personal and work-related conflict. It would be a great time to talk about such interactive, structured communications that they could use in order to better express themselves and diffuse conflict and be able to deal with it.

To end, I wanted to describe the assertive person so you can kind of hear the way that assertion has been described before. This is from a book called Assertiveness in You written in 1988 by Dixon. In the book, she describes a bunch of different people who are either aggressive, passive, manipulative, or assertive. I am going to read you the description of the assertive person. “Selma respects herself and the people she is dealing with. She is able to accept her own positive and negative qualities, and in so doing, is able to be more authentic in her acceptance of others. She does not need to put others down in order to feel comfortable in herself. She does not believe that others are responsible for what happens to her. She acknowledges that she is in charge of her actions, her choices, and her life. She does not need to make others feel guilty for not recognizing her needs. She can recognize her own needs and ask openly and directly even though she risks refusal. If she is refused, she may feel rejected, but she is not totally demolished by rejection. Her self-esteem is anchored deeply within herself. She’s not dependent on the approval of those around her. From this position of strength, she is able to respond sincerely to others, giving herself credit for what she understands and feels.” I’ll close by saying also giving them credit for what they feel and understand.

I’d like to open the lines now for any questions that people might have or comments they’d like to make, and I appreciate your time in listening.

Operator: Ladies and gentlemen, if you have a question at this time please press the “star” key and then “one” key on your touchtone telephone. If your questions have been answered or if you wish to remove yourself from the queue, please press the “pound” key. Again, if you have a question please press “star” “one.” I am going to give everybody a moment to queue up.

Jill Marstellar: As people are thinking about their questions, I am reminded of a story that Peter Pronovost likes to tell about a young physician who had to go to an M&M conference and talk about a situation where a patient hadn’t received the needed care in time. And there were a lot of issues involved, but one of the issues, for example, was they couldn’t get an elevator and they were rushing the patient from one place to another, and they couldn’t get an elevator on time and clear. They asked the physician what he would do next time and his response was, “Well, I guess I will just have to push harder. I’m just going to push harder.” And so Peter’s response to that was that, first of all, it was too bad that this poor person had such a feeling of responsibility and angst over what happened and sort of felt like he was compelled to next time act more aggressively in order to make people listen, make people pay attention. In fact, we don’t need to go that far when we are being assertive. We need to think about how the system is set up and whether it’s allowing us and permitting us and being open to that assertion. And we need to avoid allowing things get in that aggressive territory. But it does raise sort of our awareness of the fact that sometimes when people get aggressive, it’s because they care so much and so appropriate assertion does not cross into aggression but it’s understanding of the person might accidentally allow it to get there and then it tries to help them calm down to the point where they can relate what it is they are really trying to say or get done.

Operator: Our first question comes from Barbara Stockton.

Jill Marstellar: Hi, Barbara.

Barbara Stockton: Hi. Thank you for taking my question. I missed the title of the book that you mentioned. It sounds quite good for our facility, for our management development folks. What was the name of that book and who was it written by?

Jill Marstellar: It was written by Dixon and the full name of the book was, the second half is “Assertiveness in You.” But the first part of it is -- I don’t want to throw people off and the reason I didn’t say it before -- is because it’s “A Woman in Your Own Right: Assertiveness in You.” That’s the full name. It was written in 1988, and Dixon is the author. The reason I didn’t mention the first part of it is that the descriptions of the people that she offers in her book could be a man or a woman. It just so happens that the book was written more targeted toward the female audience who needed to be assertive. I am trying to have everybody understand that. I am coming from a place where I think that both men and women can have trouble with assertion, either not knowing where it is in the continuum between being passive or being aggressive, not being able to find that spot of being assertive without being aggressive or assertive without avoiding passivity.

Barbara Stockton: I know there is a health care situation, and it’s a situation where there’s a nurse who takes care of a patient during 12-hour shifts and then they’ll do a report, and she is very passionate about safety and quality. She is an assertive person, and she’ll share her, “I’ve spent 12 hours with this patient. I’m thinking this is what’s going on.” And the leadership folks often contradict that, and she gets aggressive then because she is trying defend.  She said, “You know, I’ve been with the patient for 12 hours,” she gets to the point where it is so exasperating that they won’t listen because they think she’s being aggressive and assertive. And the more that it happens, the more unhappy she becomes. And I keep trying to coach her and say, “Focus on the patient; just try.” But, oh my goodness, some of these health care arenas are really horrible for this, and then you’ve got so many passive staff because they want to be friends with everybody. But if you get a nurse that will stand up for what’s right, she’s considered aggressive and horrible and isn’t a team player. And it’s horrible for these girls that stand up for what’s right. I’ve seen it over and over, and they end up crying and the managers think they are uncooperative. Do you see this in institutions?

Jill Marstellar: Yes, I mean it’s definitely a problem, and I do think that you hit the nail on the head that a lot of the difficulty is the assertion where nurses are trying to say something and physicians are not necessarily listening. There also is another group that has a lot of trouble is the residents, if you have any residents. Sometimes residents are actually scared of everybody -- I mean the nursing staff and the physicians -- and they also have a lot of difficulty.

Barbara Stockton: I’ve heard of that, too. The nurses, a lot of the time, know more than the residents do from a patient care perspective, and if you get a real aggressive nurse they can make some of the residents just feel just horrible.

Jill Marstellar: Well, sometimes they don’t feel like they are allowed to not know something, or they are worried about what they don’t know. And that tends to make them less willing to assert what in fact they, in fact, do know.

Barbara Stockton: Sure.

Jill Marstellar: So. I think you are right. It is a big problem, and there is a question of how to get the receivers to be receptive to appropriate assertion.

Barbara Stockton: Yeah, I think that’s probably the bigger issue.

Jill Marstellar: So that’s why I’m really talking about trying to get as many of your middle management and leadership types from the unit to come together and understand the need for appropriate assertion. That it is an integral thing to providing the best care for the patient. And your more traditional types are going to potentially have some problems with that.

I think it’s better to start with a few people who are more open, who are receivers that are a little more open to that, and have them interact with and help your senders figure out how best to send the message in a way that can be received. For example, when you’re looking at the model of assertion and you are looking, that’s back to slide nine, if we look at the model of assertion when you get the attention with names. In a place where there is more hierarchy, you would not need to call them Bob, you could say Dr. Smith to maintain some of that hierarchy. When you are stating the issue, there are different ways you can do that. You could essentially make a statement of what the issue is and propose an action. Another way to do it is to ask a question or ask for clarification in order to then raise the issue. So it would be adding a step where you ask a question, “I’m not clear on whether or not this is appropriate” or “I’m not clear on what the need is for this particular procedure.” Something like that. Then you move to making a request. “Could we instead consider doing this?” Those are ways that you are actually asserting your opinion, inserting your opinion into the situation, but you have sort of camouflaged it, if you will, in a question and then a recommendation.

Barbara Stockton: Yeah, that is a good technique. I have heard people do that. They ask a question which makes the other person feel confident and that they’re valued. I guess that’s what it does. Maybe I’ll take some of these stuff to our leadership committee and see what we can do because I think it’s really, really critical. I see this more and more.

Jill Marstellar: And with the individual that you have who is being appropriately assertive and then she crosses into aggression because she thinks she is not being listened to. It could be that the way she is asserting herself is not sending the message that she values what they are bringing to the table as well. It starts from the beginning with your assertive effort trying to be assertive and, unfortunately, it sounds a little forceful. Or it sounds like I am not seeking your opinion as well.  That’s essentially, if like she’s going to say, “Well I’ve been with the patient for 12 hours,” and that’s how she opens it, it makes it sound like she’s expecting an argument. So it’s something for her to try to consider. Am I seeking a position that I’m engaging in a session of sharing information? I’m gathering right now. We all should as a team be gathering as much information as possible, and then we all together are going to make a decision about what is best for the patient.

Barbara Stockton: Okay, yeah, I can give her some of those tips. I appreciate your advice on that issue because I see that a lot.

Jill Marstellar: I think you are right that it’s a problem. It’s a tough problem to know how to try to address it.

Barbara Stockton: I think, I don’t know how other hospitals feel, but I think there are probably more passive people than aggressive or appropriately assertive because the passive people just learn that if they make waves, it’s not worth it. So they just do it, but they’re resentful. So this is good stuff. Thank you very much.

Jill Marstellar: Okay. So do other people have thoughts and ideas that they would like to share on what Barbara’s raised?

Operator: The next question comes from Denise Lacomb.

Denise Lacomb: Hello.

Jill Marstellar: Hi, Denise.

Denise Lacomb: I’m looking for the PowerPoint that you had for the call today. You mentioned you had a PowerPoint slide presentation. Is that going to be posted on the CUSP website?

Jill Marstellar: Yes, it sure will. You’ll be able to find it on the Web site. I don’t know how long it will take to be posted but it’s usually a matter of a few days.  And they sent them out attached to the Friday update, I think it was 2 weeks ago.

Denise Lacomb: Really? I looked through all of my emails but couldn’t find it.

Jill Marstellar: Okay. Anyway, you’ll be able to get it off of the Web site. You could maybe ask your State lead whether he or she received them, and then you could get them from that person as well.

Denise Lacomb: Okay. Thank you so much.

Operator: The next question comes from Diane Hassman.

Jill Marstellar: Hi, Diane.

Diane Hassman: Hi, how are you?

Jill Marstellar: Good.

Diane Hassman: We have a question here. You gave a very good example of being assertive and how to be assertive. But, let’s take that to the next level. How do you do that when you are at the patient’s bedside and you are ready to put in a central line and you see something that should be brought up. How would you be assertive, like with hand washing or scrubbing, how do you bring that up without panicking the patient?

Jill Marstellar: Okay. So I think one of the ways that we’ve recommended to people before is to have the person in a calm voice, with a calm manner, catch the eye of the physician or the line inserter, let’s say, whoever is inserting a line. It could be your PICC team or whatever. Look to that person and say, “Excuse me, doctor, did you forget to wash your hands?” And try to say it in a very calm kind of way. Hopefully, this is not going to alarm the patient. It’s more about how it’s presented, I think, in terms of whether or not the patient will be concerned. Now the washing of the hands, the patient is going to be aware of that because they know everybody is supposed to be washing their hands. But most of the other things probably the assistant could raise, I think, without raising too much alarm on the part of the patient. “Doctor, were you aware that your cap is available on the cart?” Something along those lines, positively worded. “You can find your mask within the kit,” for example. So what’s your reaction to that, Diane?

Diane Hassam: I guess what our concern is that we’ve had some physicians actually when the nurse presents an issue in a very calm, non-threatening manner, he’ll say, “Well, what are you talking about? What do you mean wash my hands? I’ve done that already.” How do you handle all of that right at the patient’s bedside?

Jill Marstellar: Sometimes referring to the document can be a way to bring the physician’s attention to what’s on the checklist. You could say, “I missed it” or “We don’t have it noted on the checklist that you’ve washed your hands” or “I did not see you wash your hands” or “Did you wash your hands when you came in the room?” Or something along those lines. I mean I think that you raise a great point, and it’s going to have to be a little situationally dependant. And people will find that they find a phrase that works with certain people, but it doesn’t work with everybody.

Diane Hassam: I think it depends on which physician you are speaking with a lot of times.

Jill Marstellar: Yes, exactly. I think you’ve really hit on the variation that makes it so hard to give people advice because every situation is going to be a little bit different and a little bit about that person’s personality, the physician’s personality and the personality of the person actually trying to address the issue. That’s why, hopefully, giving them some tools like a piece of paper to say, “Well, you’ll note I wasn’t able to check that off on the checklist” or something along those lines, to try to

Diane Hassam: Deflect it?

Jill Marstellar: Right, right. To raise the issue in a non-threatening way but, again, without calling too much attention so the patient becomes concerned or alarmed. If you are really having trouble getting physicians to be compliant, they should all be going into that room knowing what is expected of them when they’re placing a line, right? So if that’s a problem, then someone in their chain of command should really be having a one on one or a heart to heart with specific physicians or line inserters.

Diane Hassam: They are working on that.

Jill Marstellar: Okay. You can’t expect assertive communication to do everything. Somewhere up the chain they have to send a message that this is how we are doing it here and if you are asked to stop the insertion and address something that’s wrong, you need to be open and receptive to that and we expect you to. And I, as your medical superior, expect you to be open. It won’t work for every personality, but everybody needs that back up. It needs to be clear that management is behind this specific intervention and behind assertive communication toward improved patient safety.

Diane Hassam: Okay, thank you.

Jill Marstellar: Sure.

Operator: The next question comes from Debbie Durrand.

Jill Marstellar: Hi, Debbie. Debbie?

Debbie Durrand: This is Debbie Durrand in New Jersey.

Jill Marstellar: Great.

Debbie Durrand: I had a question about the questions that you discussed in the presentation were numbered like number 37, number 26. Is that from a survey? What is the source of those questions?

Jill Marstellar: Yes, indeed. All of those questions come from the safety attitudes questionnaire, which is one of the culture of safety questionnaires that are available. The Johns Hopkins system uses the safety attitudes questionnaire. Examples of other safety questionnaires towards your safety culture and your teamwork climate, are for example, a hospital survey on patient safety which was put together by the Agency for Healthcare Research and Quality, and that’s the one we are using in the National Stop BSI project and another one is called PSCHCO, the patient safety culture in health care organizations. So those are three different instruments that are available, but those questions come specifically from the safety attitudes questionnaire. Our colleague, Brian Sexton, was the originator of that instrument, and he’s now at Duke but he had been here at Hopkins for a number of years. Does that help?

Debbie Durrand: Yes, thanks. We were trying to find them in HSOPS, but obviously they are not there and we were just curious about that. Thanks.

Jill Marstellar: Okay, sure. No, those specific questions weren’t in the HSOPS, but they are in the safety attitudes questionnaire. There are similar questions in the HSOPS, and I don’t have a copy of that instrument with me to be able to point them out, but I think if you look through the questions and you wanted to use those data to judge assertiveness, there should be a couple that would be handy in that particular task. Alternatively, you could take the questions that we presented here, you could write your own questions and ask people and to try to assess how assertiveness is going on your unit.

Operator: The next question comes from Bonnie Coalt.

Jill Marstellar: Hi, Bonnie.

Bonnie Coalt: Hi. We just wondered if you had the published schedules for these sessions for 2011.

Jill Marstellar: You mean for the content call and what they are going to be and so on?

Bonnie Coalt: Yes.

Jill Marstellar: The schedule is planned to be the same. It will still happen at 2 p.m. Eastern time, and it’s going to be the second Tuesday of the month.

Bonnie Coalt: Okay.

Jill Marstellar: I believe the schedule is going to be the same in the New Year. What calls are scheduled, I believe they are going to go back to the very beginning of the content calls that were offered in the very first cohort in this project. And they are going to re-offer the same topics again. But the official schedule and who is going to speak when has not been all hammered out as far as I know. I will ask the folks at HRET when that might be available.

Bonnie Coalt: Thank you.

Jill Marstellar: Uh-huh.

Operator: The final question comes from Barbara Edson.

Jill Marstellar: Hi, Barb. How are you?

Barbara Edson: I’m good. How are you?

Jill Marstellar: Good.

Barbara Edson: It’s not really a question, and when I went to go put in the question I lost connection so I don’t know if you talked about this or not. To the person who was asking how do you do it in front of a patient?

Jill Marstellar: Yeah, great.

Barbara Edson: The tool that we have down here is used at Duke, and I don’t know if anyone from Duke is on the line but they use, “I need clarity” and that is the “stop the line” phrase. That means that they stop the line and, literally, we walk away from the patient if they need to. It’s what’s been reported to us from the quality center, and that’s been very effective.

Jill Marstellar: That’s great. I like that. It’s in right in keeping with the use of a safety phrase, “I need clarity.” Everyone needs to know, of course, you have to educate everyone all of your staff, your physicians, nurses, and everybody that this is going to be a cue that you should move a little bit away from the patient or that you need to have a discussion.

Barbara Edson: Yeah, it’s your cue that it’s a safety concern that needs to be addressed immediately, and it’s been approved. Actually, physicians were telling us about it and through their senior leadership, so it’s been effective and reported to us.

Jill Marstellar: That’s great. I like that. That’s another series that people have used, they call them the CUS words so some of you may have heard of this, its C-U-S. If you are not getting attention and you are trying to get someone’s attention, you would start by saying, “I’m concerned,” then you would move to “This is an urgent need,” and then you go to “It’s a safety issue.” So you would actually move through a couple of different words. Some people, instead of saying urgent, sometimes people would say, “I’m uncomfortable.” In any case, what you do is you have a couple of cue words that everybody knows to listen for so if they actually hear one of the cue words, it’s supposed to catch their attention and make them stop what they are doing. That sounds very similar to what you are saying when you say, “I need clarity.”

Barbara Edson: Yes, I think it was adapted because they weren’t comfortable with some of the CUSP stuff coming out of TeamSTEPPS so they just tweaked it a little bit.

Jill Marstellar: Yes, sometimes people don’t like to use another use of the words: Scared. People don’t like to say, “I’m scared.” That would certainly upset a patient if the nurse said “I’m scared.” Yeah. Okay, well thanks, Barb, that’s really good stuff.

Barbara Edson: Yep.

Jill Marstellar:  So does anybody else have a last question? We are pretty much on top of the hour here.

Operator: There do not appear to be further questions at this time.

Jill Marstellar: Okay, well thanks, everybody. I really appreciate your participation. And if you have further questions, you can feel free to ask either your State lead or if you have a question by email you can send it to either me or Dr. Thompso. And I really appreciate your time. So everyone I hope you go off and have a happy holiday season.

Operator: Ladies and gentlemen, that does conclude the conference for today. Again, thank you for your participation. You may all disconnect. Have a good day.