Communication 101: Shedding power imbalances to protect patients

Katie Fiebelkorn Westman is a registered nurse at an acute care hospital in the Minnesota Twin Cities. She is working toward a clinical nurse specialist degree, focusing on improving patient care quality.

The Joint Commission’s recent sentinel event alert on the detrimental affects of ineffective communication between caregivers prompted me to examine the communication I see daily in the hospital.

The dearth of effective communication skills is not limited to the health care profession — we just have bigger consequences when we get things wrong. Someone in another profession may run a report incorrectly and be annoyed to have to redo it, but in health care, we can take off the wrong body part, give the wrong medicine, or send someone home with the wrong discharge instructions.

These mistakes are big deals. We need, as healthcare providers, to respect each other, our different points of view, and learn how to talk. 

“Health care is a high-stakes, pressure-packed environment that can test the limits of civility in the workplace,” the first line of the Joint Commission article states. When the stakes are high, and stress is running rampant, that’s especially when you want clear, respectful communication. Ingrained power structures, embedded cultures of distrust, and lack of communication skills instead have created environments where silence is the norm and the open exchanges of ideas is rare. 

Philosopher Paulo Freire has a theory of oppression that says when one group oppresses another, the latter becomes silent and insecure of its own value. The oppressed also tend to believe what the dominating group says about them. For example, my knowledge counts more than yours; I hold all the power and there is nothing you can do about.

This boils down to a mixture of resentment, passive-aggressive behavior, and ineffective communication. This puts the oppressed group, be it nurses, new residents, new graduate nurses, nurse practitioners, etc., in the age-old dilemma of challenging authority.

How do you find the courage to speak up to someone who may or may not take you seriously, but also holds more political power than you? In other words, if I question this order, will I have a job tomorrow? If I ask a question about this procedure I’ve never done before, will my colleagues make a joke about stupid new nurses and shatter what little confidence I have?

Nurse-to-nurse communication is not beyond these pitfalls. Have you heard the phrase “eating your young?” Nurses, young and old, munch on each other all the time. Fellow nurses, have you ever pretended to be busy so you didn’t have to help a new trainee with 50,000 questions? Have you ever said or affirmed a statements criticizing nurses working a different shift or gossip behind your fellow nurses’ backs? These seemingly small actions all set up a culture where honest, clear communication doesn’t happen! A nurse has a slim chance of preventing an error in this kind of culture. 

Skillful communication is not a “soft” skill or something only nurses must do. Communicating clearly and creating an open environment requires hard work, consistency and developing new habits and behaviors. The oppression has to stop first, and this poisonous embedded culture has to be remedied.

Everyone has something to contribute to the care of patients, and that contribution needs to be valued. It also requires daily maintenance, and commitment. We have to be brave, and let others take the responsibility for what they say. In other words, if someone speaks to you disrespectfully, call him or her on it. We all also have to be responsible for our own behaviors. In the end, patient care comes first — that’s why we’re here. The inability to communicate effectively should not get in the way.

2 replies »

  1. I’ve been a patient many times in a few different teaching hospitals and the lack of communication caused by hospital hierarchy is completely obvious and its scary. Noone wants to challenge anything and noone wants to appear uninformed. So, Patients: pay attention, and have a family member always present if possible to advocate for you, if you are unable to advocate for yourself. You may end up being the last one in the chain of command to question whats going on, before a potential mistake is made.

  2. I would love to be assertive but find myself penalized at every turn. If you are not supported by the hierarchy your work day can be a long one and any validation of your work other than your own will be shortcoming. case in point: I was spoken to very rudely and aggresively by a m.d. The administrative response was twofold. Did i do anything to provoke him and was i respecting his culture where women are more subservient? This was not even a medical situation..this had to with halloween and his religious distate for it. When you work in hospital where doctors work at will the common thread is whatever it takes to keep them happy. I have lost a job by going to human resources about a work complaint. Since i work in a work at will state there is absolutely no legal protection for me. I am 56 years old and have bills to pay and retirement to think about…I will continue to be proactive for my patients but i will tread those waters carefully.