FierceHealthcare recently got the opportunity to talk with Beth Boynton, RN, MS, and author of "Confident Voices: The Nurses' Guide to Improving Communication & Creating Positive Workplaces" about the state of nursing today, and where she sees the profession going. Her consulting work includes training, coaching and speaking. She is an adjunct faculty member with New England College, and publishes the free e-newsletter Confident Voices for Nurses.
FierceHealthcare: What are your thoughts on the state of nursing today, in general?
Beth Boynton: I think that we have a huge potential to impact healthcare systems for the better, yet, I think based on major challenges and having our voices heard and respected, also impact things in a way that would be helpful for us professionally while promoting safe, quality care. I see us as a huge work force. We're, generally speaking, very smart people, very passionate people; we juggle stressful work dynamics. It's a job that calls upon physical, intellectual and emotional demands almost constantly and almost always urgently. And yet, I also see that we are not always the most effective communicators.
We also often work in environments that aren't healthy; workplace dynamics that aren't positive. So, I think that if we can become better communicators, and have better, healthier work places, that we can change the landscape of healthcare.
FH: How and why would you say that that's the case as far as not being good communicators?
BB: Well, I think there's a variety of reasons for that. Part of it is that there is a very old, traditional dynamic--a power dynamic--that exists in healthcare that kind of says that doctors are the bosses and managers and nurses are subservient. That's a very old pattern that hasn't changed, even though much around healthcare has changed and needs to change. I think there's also elements, like the profession is made up of mostly women and, speaking for myself, it took me a long time to learn how to be assertive. And the profession itself is based on--the very nature of our work is based on--understanding what other people need.
So if you take all of those things, it's very easy for us to not necessarily take care of ourselves as best we should. So, what we have is like this totem pole of aggression at the top, down to passive aggressive and then passive behaviors, and those kinds of behaviors are governing or informing a lot of our communication. And they impact staffing, job morale, workplace violence, medical error, just about everything. I mean, medical mistakes are the fifth leading cause of death in our country, and this is according to the Joint Commission. The leading root cause, year after year after year, is a communication failure.
SBAR (Situation, Background, Assessment and Recommendation) is a new model of communication that came into place to address some of the communication issues. Basically it's a format of how to report a problem and it's not meant just for nurses, it's meant for anybody in healthcare as a standard way to report problems. But, what we fail to do is say how are we going to receive those reports. It's like we only look at that "speak-up" part of it. We do that with patients, too; we have the "speak-up" campaign, but if we don't also say 'not only do we need to be good, assertive participants, we also need to have an environment where there's respectful listening and healthy dynamics.' We need assertiveness, we need respectful listening and we need an organizational culture that will support both of those. If you take away one of those, it's not going to work.
FH: What do you think are some big issues that aren't being talked about that should be talked about more?
BB: What we're not doing is we're not getting at the underlying causes. If we don't get at the underlying issues, then any model we have is not going to be as effective as it could be. And I think--and this is where my thinking may be different and new--is that there are three fundamental problems in healthcare. The first is that we don't have optimal collaboration among professionals; No. 2 is that we have excessive moneymaking in some sector; and No. 3, we don't have individual or social supports that promote healthy lifestyle choices.
We spend so much money in healthcare today on chronic illnesses that are basically prevented with simple stuff, but our treatments are looking at it from a medical perspective when people are getting diabetes and obesity and heart attacks; we're not going back far enough and looking at 'what are the emotional intelligence issues?' or 'why are we using food as a coping mechanism?' That kind of stuff. I think if we focus on those foundational problems, then we will begin to solve, much more effectively, all of the symptoms that are showing up--all of the stuff that we read about every day.
FH: Pennsylvania recently banned mandatory overtime for nurses. What are your thoughts on that?
BB: I would applaud it and I would say it's too bad we had to get to the point where we banned something because it's so unsafe. You would think that we could look at what is a realistic workload for a smart human being in the world and have a system that supports it in a healthy way, rather than have a law that says 'no, you're not going to do overtime.' Instead of creating a healthy place to begin with, we have to do something like that; I wish we didn't have to. I wish we didn't have to have unions, too, but quite frankly, in some places that's the only way to have an effective, fair playing field.
I don't think it's ideal. I'm much more idealistic in that I think we could get along more adult-like together and create thriving places where the quality of care is high and consistent and people are happy to go to work and they're also happy to go home, and patients are getting decent care and we're not wasting billions of dollars on mistakes. I applaud it, but it wouldn't have been an avenue I would have preferred to see things take place.
FH: You said earlier that some of the problems in nursing today have stemmed from dangerous environments. Aside from working too many hours, what else contributes to a dangerous environment for nurses?
BB: Well, there's a lot of workplace violence, both covert abuse and overt abuse. Staffing shortages. I think that--this is a little bit more of a vague comment--there are different agendas. We have to make money and save money on the one hand versus provide quality of care on the other, so that can create some fragmentation of care, being pulled in different directions. Those are the basic ones to come up with, but they're all big. And sometimes nurses--when I talk about communication skills--some of it comes from us not being able to say 'no' effectively. Some of it also comes from saying 'no' and not being heard. That's why I always go back to basic, respectful communication.
But if we're not good at limit setting--if we feel guilty to say 'no' and we're in an environment that's short staffed--you can see how that can get exploited in a way, maybe not even intentionally.
FH: How do you think that those sorts of issues can be changed without unions, considering what you said earlier about wishing that nurses didn't need unions?
BB: When I'm doing consulting, not everybody agrees with me on this, but I will tell the senior leadership that if you are looking to make a culture change--to go from this old pattern of passive aggressive and aggressive dynamic--if you really want to change that, there's an important step that you can take: to acknowledge that the behavior that has been in place--the dynamic that exists today--has not been OK. It doesn't have to be a big deal, we don't have to have a big investigation into it, but it's like an acknowledgment that the old way is not OK anymore.
Nurses, I think, they often have a reputation of being resistant to change and there's a saying by Peter Senge that says "People don't resist change, they resist being changed"; I think nurses have been chronically unheard, so we have patterns of 'well, I'm gonna not say anything anymore.' Because we haven't been heard, and nurses need to be heard, I think.
FH: What, if anything, do you think shows like Showtime's "Nurse Jackie" and TNT's "HawthoRNe" do for nursing, and what do you think it means as far as acknowledgment is concerned?
BB: I think that they are signs of progress. I think that, the more accurately we can portray the word of nursing, the more healthcare consumers and nurses themselves will be able to see just how amazing and challenging our profession can be. I think that is a good thing. I had a degree in biochemistry before I went to nursing school--I sort of did it backward--but I was dumbfounded as to how challenging it is. I don't think nurses realize how smart they are. I'm all for anything that helps to build respect, and I know that some nurses may see faults in some of the TV shows, and I would probably agree with them. It's not perfect, but we're progressing.
FH: What would you say are some of the major themes of your book "Confident Voices: The Nurses' Guide to Improving Communication & Creating Positive Workplaces"? What messages are you trying to get across?
BB: Well, I'm trying to get across that nurses have tremendous potential to improve healthcare. The way we're going to do that is by becoming better communicators and by improving our workplace dynamics.
There are three parts to the book. The first part is what sets the stage for why we have these problems; understanding what workplace dynamics are right now. I talk about some of the organizational theories, and weave that in with some real-life stories that nurses will relate to from experience. They're anonymous stories, but pretty much all the feedback I've gotten is that most people can relate to the stories. I talk about why we need to change and organizational culture, so I sort of set the stage for the learning.
The middle part of the book is skill building. There's a chapter on assertiveness, and one of the reasons this book is different from other communication books is that my book adds a dimension of what's going on in the nursing world. I teach assertiveness with respect to nursing and physicians and other healthcare providers. I have a chapter on respectful listening. I also have a chapter on how to create a safe environment.
In the final part of the book, I take a couple of stories--one is a passive-aggressive situation with a nurse--and I apply all the skills we've learned throughout the book to these stories. It's pretty engaging, at least that's the feedback I've gotten, and it's my opinion, too. You can go back and say, 'now I know why an 'I' statement can be so important, and how it gets convoluted in all these different ways that ultimately affect patient care.' The last chapter essentially says 'let's be champions for change.'
I'm holding nurses accountable. This isn't just blaming doctors for being aggressive--and that's true, some are--this is also saying to take a hard look at ourselves. Where are we passive, or where are we passive-aggressive? We are pivotal players in just about every healthcare setting. Worldwide, there's about 12 million nurses. So if there's a way to build the confidence of the people that are practicing nursing I think that it can have an enormous impact.
I think also that in healthcare, doctors and nurses are worried that we're draining our sense of creativity, and that loss, I think impacts every problem solving opportunity out there. In other words, we've got all these really smart people out there--nurses and doctors and physical therapists and so on and so forth--and we're all running around so fast that we can't stop and think sometimes. So not only do we have all these problems manifesting, we're losing and have lost a lot of the potential creative power to solve it. It's like a vicious negative cycle.
I sometimes say that we go to work in the morning and we have 100 things to do and they're all urgent; if somebody did research on how much time it would take to do all those things according to protocol, even without interruptions, it's probably humanly impossible [to finish everything]. Then you add to that bells and whistles are going off and people are calling and there are family dynamics that are understandably on edge. So we have 100 things to do, it's only humanly possible to do 80; it's not a healthy situation in terms of us doing a good job and feeling good about the job we do.
FH: How much do you think that simply more numbers would help to solve some of these problems?
BB: I think that the place to start is, we have to speak up and say 'I can't do that blood transfusion and give Mrs. Jones pain medicine in the next 20 minutes, so can you get me some help?' If only one nurse says that, that might kind of reflect back on her as being inadequate somehow. But if 10 nurses say that, then it might be seen as something that needs to be fixed. That's my hope, that by being more assertive and setting healthier limits [we'll make more progress]. Saying no can be a good thing.
FH: What do you think can be done to curb the nursing shortage, if anything?
BB: If we are respecting ourselves, then we are promoting the nursing professions respectfully, and if we're working in respectful environments, then we're going to tell our kids and our friends it's a great job. I really think it has to start with self respect and respect from our peers in workplaces. That's what's gonna do it in the long run. If we're looking for the leading, one root thing to do, I think that's what it is.
To learn more about Beth Boynton, go to www.bethboynton.com.