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Here is a Third and Essential Step for the “Two Challenge Rule”

TeamSTEPPS has a pocket guide  with all sorts of communication, team, and patient safety info you can access.  One effort  to standardize communication is called the “Two Challenge Rule” and is described in the pocket guide as follows:

“It is your responsibility to assertively voice concern at least two times to ensure that it has been heard.

When an initial assertive statement is ignored:

The team member being challenged must acknowledge that concern has been heard.

If the safety issue still hasn’t been addressed:

  • Take a stronger course of action.
  • Utilize supervisor or chain of command.”

In a healthy culture, this rule would probably be fine as is as it is a rare event that an assertive statement would be ignored.  Perhaps it is particularly stressful situation, other urgent situations are going on at the same time, noise is unusually excessive, someone has a hearing problem or laryngitis, or some other explanation for a lapse in speaking up or listening skills.  Our environments are likely to be like this from time to time and can be considered WNL sometimes and in a healthy workplace staff can sustain good relationships despite peaks of stress!

However, in an unhealthy culture,  a culture that is in transition from toxic to healthy, or a relentlessly overstressed staff,  there must be a vigilance about promoting assertiveness AND listening.

This is when and why the “Two Challenge Rule” needs a third step to address why an assertive statement was ignored in the first place.  Ignoring someone who is being assertive can be a symptom of a toxic culture,  a behavior that undermines a culture of safety,  an abusive behavior,  poor listening skills, understaffing, an environment that is too noisy, or a hearing problem.  All of which should be addressed, right?

Organizations can make sure there is a genuine mechanism in place to look a little deeper.  Such a process could be framed as a Communication Root Cause Analysis where the clinician fills out a quick form  (after the urgent situation has been addressed) that triggers a review that includes record-keeping, action steps, timeframes and accountability.  This is how we can distinguish an occasional problem in a healthy workplace that saves a life from the same old toxic hierarchies that are so problematic in patient safety efforts.

Some potential outcomes from further investigation and work include:
  • Difficult and productive conversations among nurses and doctors that include apologies for not and commitments to speaking up effectively and listening respectfully.
  • Emergence of patterns of ineffective communication that suggest a particular nurse or doctor might benefit from training or coaching in more effective and respectful communication and subsequent discipline prn.
  • Identification of noisy areas might be paired with patient experience feedback and signal an evaluation of the ‘Environment of Care” for acoustic solutions.
  • Further exploration of staffing issues that might be associated with a high frequency of some clinicians saying things twice or account for why some may not be listening in the first place.
Talk about challenges!  Nevertheless this is the hard and vital work we need to do to make healthcare safer and more rewarding to work in. I think we CAN do it if we put our minds to it!  Your thoughts?



Guest post by Beth Boynton RN, MS

Beth Boynton, RN, MS, is a nurse consultant, author, and teacher specializing in communication and collaboration among healthcare professionals and within organizations. She offers interactive workshops, leadership coaching, a ‘whole systems’ approach for culture change efforts, and a new method for building ‘people skills’ called ‘Medical Improv’. She has recently completed her second book, a core text called: Successful Nurse Communication: Safe Care, Healthy Workplaces, and Rewarding Careers which is scheduled to be published by F.A. Davis Publishing Co. Spring 2015. She writes about related issues at, “Confident Voices in Healthcare” blog. Her video, “Interruption Awareness: A Nursing Minute for Patient Safety,” and blog have drawn audiences from all over the world. She is trained in the Professor Watson Curriculum for Medical Improv through Northwestern University Feinberg School of Medicine. She has one grown son who is works in India, loves improv, Zumba dancing, walking, and swimming, and lives in Portsmouth, NH.

You may view Beth's online continuing education course - 4 Essential Strategies that Promote Patient Safety. This is a 2 contact hour course that features Beth in 10 short video's designed to engage and teach the student.  This instructional continuing education course is designed for nurses who are in direct care or middle management positions in hospitals; long-term care facilities, and other frontline in- and out-patient practice settings.  Despite 15 years of national focus on improving patient safety outcomes, we continue to have staggering statistics involving preventable deaths, illnesses, and injuries that are due to medical errors. And because communication breakdowns and associated problems with inter-professional relationships have long been major contributors to these alarming problems it is imperative for nurses to develop skills and promote positive interpersonal dynamics. Respectful interactions and effective communication seem simple on paper, yet successful efforts to practice them in the field remain elusive.  In this course, students will examine patient safety statistics and root cause analysis data in order to understand the scope of the problem and how persistent issues with communication and human dynamics are interfering with providing safe care.  This foundation will provide the incentive to commit to exploring and practicing communication strategies that will help to solve them. A basic knowledge of assertiveness, listening, and emotional intelligence is required as students take a ‘deeper dive’ with Beth Boynton, RN, MS to develop their abilities to:  set limits, delegate tasks, and give and receive constructive feedback.


Posted: 12/4/2015 2:35:43 PM
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