Ask anyone about a memorable experience they had as a patient and they will invariably describe an interpersonal one:
“The team was nasty. They rolled their eyes when I asked for anything, talked about their vacations while putting in my IV as if I wasn’t there and in pain, and chatted loudly near my room at all hours of the night.”
“My nurses were the best. They always gave a report to each other in front of me, including me in the plan, they checked on me often, and patiently answered my questions.”
In both of these examples, the concern of the patient is less about the skill level with which the injury or disease was managed, but rather the care team’s ability to communicate effectively and considerately with the patient. Furthermore, evidence suggests patients who have a good rapport with clinicians do better overall. And it doesn’t end with the patient. Effective communication among members of the care team is just as essential to the patient’s well-being as direct interaction with the patient themselves.
Communication and Outcomes
A fundamental feature of quality patient care is bedside manner. Although this implies the inpatient setting, it includes all interpersonal engagement with patients. Practicing empathy and establishing trust are two benefits of effective communication that not only makes the experience more pleasant for the patient and the team, but also it improves clinical outcomes.
It’s not difficult to understand why. A patient with less stress is physiologically better off. A patient who trusts their providers may be more candid about sensitive and pertinent health history information, such as recreational drug use and sexual behaviors. Similarly, a transparent interprofessional care team may be more willing to admit mistakes or ask questions without fear of ridicule.
Guidelines for Effective Communication
Although the specialized skills of all clinical professionals are essential, the importance of effective communication with and about the patient cannot be overlooked. Consider the following guidelines for effective communication:
Greet patients and colleagues.
Inform the patient before touching them or undertaking tasks.
When in doubt, ask.
Reserve casual conversation for breaks and non-clinical areas.
Act with integrity: treat patients as if their loved ones are around.
Such simple considerations can have a tremendous impact on the patient encounter, in addition to making it a more pleasant and fulfilling experience for everyone.
Our health care system today has made tremendous progress in providing care to individuals and families. Change is good, but as the health care industry rapidly responds to emerging trends, markets, and opportunities, how staff nurses respond to different kinds of work culture is important, particularly when work culture highly impacts a nurse’s job function.
Work culture is made up of the norms, values, and beliefs that characterize an organization. Several factors, including management, workplace practices, policies and philosophies, employees and their interactions, leadership, expectations, rewards or recognitions, communications, transparency, and support within an organization, can influence work culture. Work culture,which can make or break a workplace, is powerful. It can inspire health care employees to be more productive and positive at work, or it can make them feel undervalued and frustrated. Thus, it plays a crucial role in shaping behaviors in organizations.
Your Work Culture
Ask yourself the following:
What is the culture like in your workplace?
Do staff naturally unite and collaborate?
Are the leadership and executive teams available and transparent?
What values and principles does your organization express?
Sometimes, you might say “it’s challenging.” Defining work culture can be difficult; nevertheless, it is fundamental to good (or poor) practice. Work culture is not often discussed, but clearly, nurses can be negatively or positively influenced by their work culture.
Work culture in nursing is critical to job satisfaction, nurse retention, and patient outcomes. A toxic work culture can lead to increased sick days, stress-related symptoms, and nurse turnover. It also plays a large role in the ability to provide quality nursing care. Work culture can impact everything from the safety of patients to job satisfaction. If yours is negative and discouraging, you cannot just wait for it to change. The first thing you must realize is that it might not change at all without you taking some kind of action.
Understanding your work culture is key to developing practice that aims to improve care. Although a positive work culture is mostly created from the top down, it often happens from the bottom up. Nurses should not undervalue the power of their work culture. Understanding work culture as a learning environment is related to how nurses choose to engage in their workplace and how the workplace normalizes their involvement in activities and interpersonal relations. Nurses can take inspired action, engage in networks, and initiate work culture change. This is not a simple task, but nurses can utilize their own personal power and create cultural transformation in their workplace. Keep in mind that work culture can—and will—change and evolve over time. The first approach is to define and evaluate your work culture—both what it is now and what it should be in the future.
Every workplace has its own work culture. Most of this is unspoken, but a lot can be learned from an employee handbook or company policy. Observation, assessment, and communication are key approaches to help you uncover your work culture. These key approaches can also be utilized by someone who has unique developmental and socialization needs, such as new graduate nurses, international nurses, student nurses, and nurses who are undergoing role status changes or transitioning to a new area. No matter what your status is, here are five ways to help you thrive in your work culture.
Watch and learn. Give yourself some time to understand the reasons behind workplace behavior and you will be much more successful in understanding the causes. Observe how things are done. Take notes. Keep track. Building relationships with people in your workplace and connecting with someone on your team who has a good understanding of how the workplace culture works can help you better understand and avoid making a mistake.
Don’t be afraid to ask questions. You don’t need to know everything. Questions are a great way to clear up differences and get to know people. Also, be sure to ask for help whenever you need it. Asking for assistance or an explanation should not be considered a sign of weakness.
Remain motivated at work. Nurse burnout is real, so it is important to recognize the impacts you make on your patients and workplace every day. Focus on yourself and how you can be a positive influence.
Be transparent. Let your coworkers know about your background and your career goals. Don’t hesitate to share your ideas and let your team and supervisor know what other skills you have to offer.
Acknowledge your mistakes. Apologize and laugh it off. Keep your sense of humor and learn from every mistake you make.
Developing the skills and ability to understand and communicate effectively with all your coworkers (including your supervisor) is critical to your success in your own career, as well as the success of your organization. These skills are not innate; they require practice, but anyone can develop these skills. Adapting to a new work culture is an ongoing process. Once you have the skills, you can work more effectively with different groups of people and adjust easily to working in different cultures throughout your career.
Nursing is a stressful job. So when you think that a patient may have been misdiagnosed by another health care worker, it’s important to know exactly what to do—especially if the misdiagnosis could cause permanent harm or death. It’s important to protect your patients as well as yourself.
Jennifer Flynn, CPHRM, risk manager for Nurses Service Organization (NSO), took time to answer in detail what nurses need to do when they suspect a patient is not receiving the care they need.
What should a nurse do if s/he thinks that a patient is not receiving the care they need from another health care worker? What are the specific steps that s/he needs to take? Are these steps different depending on the procedures of the facility?
Every day, nurses are challenged to provide patients with the safest and most effective care possible. Many factors can affect clinical performance. For example, being sleep deprived, running late, being assigned to more patients than usual, or experiencing a breakdown in communication with other providers can influence a nurse’s ability to provide safe patient care.
According to the 2015 NSO/CNA Nurse Professional Liability Exposures Claim Report, failure to invoke the chain of command was identified as a common allegation. Nurses are responsible for invoking the medical chain of command when necessary, in order to trigger a practitioner’s intervention for the patient. Closed claims involving the failure to invoke or utilize the chain of command accounted for 7.5% of the treatment and care closed claims, and reflect a higher average payment as compared to all claims in the report.
Nurses must be comfortable with utilizing the medical chain of command whenever a practitioner does not respond to calls for assistance, fails to appreciate the seriousness of a situation, or neglects to initiate an appropriate intervention.
Consider this scenario: a nurse failed to initiate the chain of command when the practitioner would not respond to her concerns of identified non-reassuring fetal distress. The nurse called the practitioner several times to give an update on the patient’s condition, which continued to deteriorate. Each time the nurse requested that the practitioner come see the patient, the practitioner said it didn’t seem necessary. As a result, the infant suffered birth-related brain injury, requiring lifelong care. The nurse was named in the malpractice lawsuit alleging failure to invoke the chain of command and failure to report changes in the patient’s medical condition. While the nurse had documented making the phone calls to the practitioner, the nurse neglected to include what was told to the practitioner and the practitioner’s response.
Nurses know that treatment and care of every patient starts with timely attention to their needs and persisting to the point of resolution. However, nurses may feel apprehensive about chain of command issues. Fear of disciplinary actions, loss of their jobs, or being labeled as a “troublemaker” are other concerns.
The following strategies can help reduce apprehension regarding chain-of-command issues:
Proactively address communication issues between nursing and medical staffs, and identify instances of intimidation, bullying, retaliation, or other deterrents to invoking the chain of command.
Notify leadership of individuals or areas that prevent nursing staff from invoking the chain of command or impose punitive actions for doing so.
If the organization’s current culture does not support invoking the chain of command, explain the risks posed to patients, staff, practitioners, and the organization, and initiate discussions regarding the need for a shift in organizational culture.
Are nurses usually taught this in nursing school? What should they know about speaking up?
Education in this matter is an ongoing effort. It starts in nursing school, but it must be continuously addressed, communicated, and supported for it to become part of practice.
The first step in protecting yourself from legal action is to know and understand your facility’s policy and procedures on invoking the chain of command to resolve concerns about patient care. In many facilities, policy and procedures manuals are readily accessible. If no chain-of-command policy or procedures exist, find out who in your facility is responsible to do so.
Don’t hesitate to call the appropriate practitioner when there’s a change in your patient’s condition. Most facilities have policies that require this. However, some nurses may feel intimidated by appearing to question a practitioner’s management of a patient.
Express clearly what, if any, action you would like the practitioner to take. If you think your patient needs to be seen, say so. After the conversation, document exactly what you told the practitioner about the patient’s condition.
If you believe the practitioner isn’t taking your concerns seriously, go to the next person in the chain. If necessary, go up your facility’s chain of command until the concern has been addressed. As you contact different staff members in the chain of command, be sure to make a note in the patient’s chart.
By invoking the chain of command, not only do nurses fulfill their obligations as patient advocate, but they protect themselves from liability.
What should nurses not do if they think their patients aren’t getting the care they need?
Advocating for a patient may not always be easy, but it is part of a nurse’s responsibility. Advocacy includes the duty to invoke both the nursing and medical staff chains of command to ensure timely attention to the needs of every patient, and persisting to the point of satisfactory resolution. Not following the chain of command puts the patient’s safety at risk and exposes nurses to the potential of a malpractice lawsuit.
Document each of the steps taken, and the reasons they were taken, to advocate for the patient’s care. Refrain from speculative or subjective comments, including ones regarding colleagues and other members of the patient care team.
Can a nurse get in trouble for reporting something like this? How should they approach this so that they do what is most professional?
To be an effective advocate, nurses first need to understand the laws and regulations governing their practice. Nurses who understand their scope of practice, state practice act, and facility policy and procedure are best able to use established processes to advocate effectively for their patients while protecting themselves from retaliation and litigation.
Effective communication is key. One technique available to nurses is SBAR, which is an acronym for Situation, Background, Assessment, Recommendation. This communication style can be used to facilitate prompt and appropriate communication. It is a way for nurses to communicate effectively with one another, and between the health care team. It allows for important information to be transferred accurately.
Allegations of malpractice can result from miscommunication or lack of communication between practitioners and nurses. By carefully documenting the information about the patient shared with other members of the patient’s care team, nurses can significantly reduce communication-related risks.
By enhancing their communication skills, nurses can minimize the risk of claims. Some communication strategies include:
Clearly articulate your concerns so that others are able to respond.
Consider what information to share, when to share it, and with whom it should be shared.
Ensure communication among caregivers is professional and respectful.
Carefully and timely communicate patient assessments and observations to other members of the health care team.
Read back or repeat verbal orders to the practitioner who issued them to verify accuracy and understanding.
Nurses can ask to become more involved in developing and influencing facility policy around advocacy and communication. Nurse leaders, health care administrators, and organizations can change the culture of retaliation and blame, which tends to point fingers instead of recognizing issues and problem solving.
A nurse’s training takes years of school, years of on-the-job experience, and years of adjusting emotionally to a job that can be as draining as it is exhilarating.
But even if you perform your nursing duties above exception, you still might find the toughest part of your job is communicating with your peers and colleagues. In a career as high-stress and fast-paced as nursing, developing a positive and effective communication style is essential.
If you think your style could use some work, taking steps to improve your communication skills helps in many different ways. People will understand what you’re trying to say faster, and when there’s less friction with others, your job becomes easier. The positive results reduce stress for everyone.
How can you fine-tune your communication style?
Do you know you have a reputation for being difficult or hard to work with? Do you know why? If you’re in charge of a staff of 15 emergency department nurses, you have to be exacting, precise, and demanding and that might come across as tough on people. But lives depend on it. Problems crop up when colleagues see your expectations as unrealistic or your approach as disrespectful.
Lead with Confidence
Effective leaders trust the people who work for them to do their job as expected. Micromanaging employees who have proved to be skilled, dependable, and excellent nurses should be allowed to do their jobs within the established framework. If your need to get involved is overshadowing others’ abilities to do their jobs, look deeper to see if there’s a valid reason. If there is, bring it up and talk about it openly with the employee.
Would you want to work with you? Some people joke about being difficult and they know part of the reason is they speak impulsively or are quick to accuse because that’s the way they have always done it. Learning how to state expectations clearly, ask for what you need directly, and speak only to the people you are having trouble with is necessary.
Your coworkers are not mind readers. If you are tired of one of your colleagues continually leaving a messy workstation or not being fast enough to respond to a request, your frustrated cold-shoulder treatment isn’t going to help. Communication is a two-way street, so you need to communicate your frustration and give your coworker time to reply. Just because you are unhappy doesn’t mean they know why.
Take Stock of Yourself
When you feel yourself getting defensive or just abrupt or you sense others are reacting negatively to you, take a minute to reassess. What’s your tone like? How is your body positioned? Are your words matching what you’re trying to get across? Taking stock lets you identify triggers. If your voice is getting raised, lower it. Adopt a purposefully neutral physical stance. Listen to what others are saying without interrupting.
It might be embarrassing, but ask a couple of trusted coworkers about your strengths and weaknesses in communicating. By giving them a chance to identify both, they will be more likely to share their honest opinions. And don’t get defensive about the bad stuff or too proud of the good stuff. Take it all and figure out how you can use the information to become a better communicator.
No one can say nursing is a stagnant profession. Even freshly minted grads can feel they are scrambling to keep up with new procedures, technologies, treatments, and processes. If you’re a nurse, you might start to wonder what skills you will need to succeed and stay current in the coming years.
There are a few qualities shared by all successful nurses. Being an excellent multitasker, having empathy, and being nearly obsessed with details never failed a nurse. No matter what your specialty, your location, or your aspirations, experts agree that a few skills in your wheelhouse will not only advance your career, but also help you satisfy your goals of being the best nurse for your patients.
“The first thing you have to have if you want to be the best nurse possible is you have to really want to do it,” says Leigh Goldstein, assistant professor of clinical nursing at the University of Texas at Austin School of Nursing. “You really have to want to be a nurse and not just bring people pills and plump pillows. To get there, you have to put in the hours and put in the study. There’s that little thing in you that tells you, ‘This is it,’” says Goldstein. “It makes learning all the other skills easier.”
LaDonna Northington, DNP, RN, BC, professor of nursing and the director of the traditional nursing program at the University of Mississippi Medical Center, agrees that nurses need a passion for the job. “This is not for the faint of heart,” she says.
Looking ahead, here are some of the essential skills nurses will need to meet job demands at any career juncture.
Develop Critical Thinking/Critical Reasoning
The best nurse thinks outside the box. Adapting to changing situations, unique patient presentations, unusual medication combinations, and a rotating team takes awareness. Assessing and evaluating the whole picture by using the critical thinking developed in school and on the job is essential to success.
“Nursing is not like working in a bank,” says Goldstein. “It’s not 9 to 5. It’s always a unique set of circumstances. You have to tailor and adjust the care you deliver based on the picture the patient is giving you.”
According to Northington, nothing in nursing is static. Nurses can’t usually just treat one patient issue—they have to determine how the patient’s diagnosis or disease has affected them across the lifespan, she says. And nurses have to consider not just the best choice for the patient and the best option for the nurse right now, but they also have to consider those things in light of the city they are in, the timing, and the resources they have at hand or that are available to them.
Make Friends with Technology
Nursing moves fast, but technological advances are sometimes even faster. While new nurses might lack years of direct patient experience, they often have essential technological familiarity. “Most nurses are probably aware that the world of electronics has just taken over,” says Barbara Vaughn, RN, BSN, BS, CCM, chief nursing officer of Baylor Medical Center in Carrollton, Texas. “The more senior nurses who didn’t grow up in the technology world tend to struggle more than nurses who grew up with that.”
With apps that allow nurses to determine medication dosages and interactions and websites that allow patients access to electronic health records, technology is an integral part of modern nursing. “Technology is changing how we practice and will change how nurses function in the future,” says Vaughn.The benefits are incredible. Instead of having to make the time-consuming drive into the ER when needed for an emergency, a specialist might now be able to save precious minutes by first examining a patient remotely with the help of monitors and even robotic devices. Nurses will have to adapt to this new way of doing things.
Nurses have to practice with technology to gain a fluent understanding, says Vaughn. Vaughn, who is studying for her PhD, says she didn’t grow up with online training as the norm, so when her new classes required online work, she wasn’t prepared. Realizing this could be a hindrance, Vaughn asked newer nurses about how to do things, and she practiced navigating the system until she became better at it.
Whether you are accessing patient records, navigating online requirements for a class, or learning a new medication scanning program, technology will improve your work day and help you take better care of your patients. In the meantime, Vaughn just recommends playing around with the computer when faced with something new. In her own department, Vaughn recalls some nurses who were especially stressed out about learning the new electronic health records system. With training and practice, they excelled. “They were later identified as superusers for their unit,” says Vaughn with a laugh.
Adapt to the Broader Picture
With all these developments comes new and greater responsibility.
“As an inpatient nurse, you used to worry about the 4 to 6 days when the patient was under your care,” says Vaughn. “Now if you are in a hospital based setting, you are going to be more involved in patient population health.” That means an inpatient nurse not only has to get the whole story of what happened before the patient arrived at the hospital, but also think about working with the care team to give specific instructions for when patients get home that will be practical.
“The more specialized medicine gets, the more fragmented health care becomes,” says Northington. Technology and that broad view can help reign that all in—and nurses need to know how the puzzle pieces fit together and where and how patients are receiving care.
“More patients will be followed in nontraditional health care settings,” says Vaughn. “Our world and the world we know is going to change,” says Vaughn of the health care industry. With more patients being followed by health care centers in easily accessed sites like Walmart and Walgreens, telemedicine is going to become more important to understand and to navigate.
Practice Effective Communication
Thirty years ago, communication about patient care was effective, but certainly not at today’s level, says Northington. “We have to communicate,” she says. “You have to ask, ‘What do you know that I don’t know that can help this patient?’ or ‘Are these therapies contradictory?’ Nurses are in that integral place to facilitate that interprofessional education and communication.”
Good communication isn’t always easy. Beth Boynton, RN, MS, author of Successful Nurse Communication, says the most effective communication is based in speaking up and in listening.
Especially in fast-paced and dynamic health care settings, the underlying interpersonal relationships can have a huge impact on how colleagues communicate and relate to each other. Nurses need to not only recognize the dynamics at play, but also learn how to work within the environment.
“We all think this is easy,” says Boynton, “but we have to recognize this is harder than meets the eye. Be patient with the learning curve.” Nurses might be assertive about speaking up for their patients’ needs, but not for their own, explains Boynton. So, as nurses look to the future, they should be mindful of not only fine-tuning their ability to speak up, but also listening to both patients and colleagues in return without judgment so everyone can work towards the best possible outcome.
“The nurse of the future has to stay committed to learning,” says Northington. “Take what the research is saying and use the best practices. Ask the questions like, ‘Why are we doing it that way?’ and ‘What can I do differently that will produce a better outcome?’”
To be the best nurse, you must stay current in the newest developments. Take the time to learn new procedures, but also recognize where your skills need updating. For example, if you know you’ll need to deal with chest tubes, don’t just assume you’ll know what to do when the time comes. Make an active effort to gain current experience.
Develop Mentoring Relationships
Every nurse needs a mentor. It doesn’t matter what your role is, how many years of experience you have, or even how many months you have been practicing. If you want to advance and learn the intangible skills needed to excel in nursing, you need to actively cultivate a mentoring relationship. Nurse mentors are often found at work, through networks, or within professional organizations.
Refine Your Personal Compass
A little bit of a thick skin will do wonders for any career nurse. “You have to defend your patient from everyone and take care of them,” says Goldstein. That means when a physician makes a call you disagree with or you overhear an unfriendly comment, you need to speak up when it matters and let it roll when it doesn’t.
And some of the personal work nurses have to do isn’t easy, including reflecting on and adjusting for any personal feelings or prejudices they have about patients in an open and honest manner. “We need to be able to take care of people no matter what their circumstances or color or what they did to get here,” says Goldstein. “You can’t treat patients differently. You need to take care of them and not make a judgment.”
Prepare for the Unexpected
You never know what your day will bring, so lots of personal reflection, discussions with others in your profession, and cultivating skills can help you when you are faced with something you’ve never had to deal with before.
“I think whether you are starting out as a new nurse or you are a seasoned nurse, nursing care is constantly changing, and being flexible to those changes is paramount,” says Princess Holt, BSN, RN, a nurse in the invasive cardiology department at Baylor Medical Center in Carrollton, Texas. It’s not easy, she says, to constantly adapt to new approaches and new practices, but nurses need to sharpen their focus. “When I get frustrated, I always go back to put myself in the mindset of my patient I am caring for or of my physician who is making this order or of the family I am taking care of to find new ways of looking at it. It grounds me and helps me understand.”
Developing all the coping skills to deal with job stress is a personal approach that nurses will cultivate as they go.
“New nurses don’t always take care of themselves and the emotional baggage you take with you,” says Goldstein. “You have to incorporate those experiences into a coping strategy that you have to develop on your own. Every nurse needs to figure out what they need to do to handle that.” And if you aren’t able to really learn how to cope, nurses must have the skills to either recognize that some kind of career shift is necessary (maybe even just moving from the ER to postpartum, suggests Goldstein) or to be open to hearing it when others recognize it.
Recognize Your Private Life Impacts Your Career
Nurses have to realize their career choice is 24/7. And while you have to balance your life and leave the hospital behind, you also have to somehow adapt to always being a nurse first. Family picnics can turn into a mini diagnosis session, neighbors might ask you to look at a child’s rash, and your private life can impact your job very directly in a way that won’t happen in other professions. “Nurses are held to a higher standard than the average citizen,” says Goldstein.
Learn Where to Learn
Yes, nurses in school learn the hands-on nursing skills like hand hygiene and infection control, says Goldstein, but, like any nursing skill, mastering them takes time.
Some hospitals have new nurse orientation programs that help new nurses acclimate to the setting, but if you don’t have that option, rely on your own observations, ask questions, and take classes to help get you up to speed. When you’re on the job, watch others to see how they incorporate things like patient safety into their routine interactions with patients. And Holt, who has worked in departments from ER to interventional radiology, says moving around builds skills. “I have seen it all,” she says, “and there is still more to see.”
Put It All Together
When nurses consider all the skills they need to succeed, some are easier to gain than others. “You need to understand what goes on behind all the mechanics,” says Northington. “It’s the knowledge behind the skills you need. They can teach nurses things. Nurses have the rest of their lives to learn things. We need nurses who know how to think, to problem solve, [and] who know when they are in over their heads to call for help. The most dangerous nurse is one who doesn’t ask a question.”
And nurses must keep moving forward and adapting even when the pace seems relentless. “We’ve come a long way,” says Northington. “And in 20 years, nursing won’t look like it looks now. Nursing is one of the best careers because it’s always evolving.”