Nursing Leadership Summary

Patient X walked into the ER, dressed himself in a hospital gown, and became suddenly unresponsive. After regaining consciousness, he was admitted to the intensive care unit. Nurse A noticed that patient X’s temporal artery was in a rapid spasm, presented with right sided weakness, poor muscle control, and was bradycardic. Nurse A notified Nurse B of the symptoms, concerned that this was an acute, high stakes situation indicating neurological involvement. The physician began an assessment and asked Nurse A what she witnessed. Nurse A presented the patient’s symptoms and stated a concern with the neurological presentation of patient X. The physician turned to the patient care assistant (PCA) and stated he did not see anything wrong and asked
the PCA if she could see anything wrong. The physician then turned to Nurse A and indicated strong emotions by rolling his eyes, slumping his shoulders, and stating that he guessed a CT scan of the head could be ordered. When the physician left the room, Nurse B asked the physician if an immediate MRI could be performed and the physician presented an opposing opinion, stating that it could wait until the morning and to start an insulin drip before the patient went to the CT scan. Nurse A and Nurse B both voiced their concerns again to the physician who shrugged his shoulders and said the MRI could wait and there was nothing wrong with the patient. Again, the physician demonstrated an opposing opinion and strong emotions in what had become a high stakes situation. This conversation was never successfully resolved and resulted in a great deal of emotional discord between the physician and unit staff. The patient was eventually intubated and transferred to a larger facility for a massive cerebral vascular accident that was then unable to be treated pharmacologically.
AMPP Strategy for a Successful Crucial Conversation Safety and listening are critical components to engaging in successful, high stakes dialogue. Patterson, Grenny, McMillan, and Switzler (2012) employ a listening strategy to aid in the successful resolution of conversations that involves asking with interest, mirroring the other person’s behaviors when clues and words do not match, paraphrasing the story, and priming the conversation to further engage dialogue (AMPP). Asking questions with interest was the first interaction between Nurse A and the physician. However, there was a breakdown in communication when the physician asked the PCA an assessment question. This action undermined respect for Nurse A since this was not in the assistant’s scope of practice and therefore, did not exhibit genuine interest. The physician could have asked Nurse A more in depth questions about her assessment and asked for clarification. When the physician rolled his eyes and slumped his shoulders, Nurse A could have mirrored his clues by stating his actions seemed to reflect he was not concerned about the symptoms. In turn, the physician could have indicated that Nurse A was overly concerned based on her clues. Nurse A and Nurse B did paraphrase the story once the physician left the room to clarify he did not want an immediate MRI of the brain and also primed the conversation by attempting to obtain an order for the test again. Nurse A spoke to the Nurse Practitioner for the physician once again, voicing her concerns over the high stakes of the situation. While the Patterson et al. (2012) text cautions against priming too hard, Nurse A could have primed the conversation with greater intensity considering the possible outcomes of the situation. Nurse A could have made the conversation safer by stepping back and allowing the physician to find his own objective evidence, paraphrasing his statements to provide clarity of his intentions, and cautiously alerting the physician to the clues he was presenting of his indifference to the situation. The physician could have engaged in conversation with those whose scope was assessment, apologized for his disrespectful clues, and could have explained his rationale for treatment more clearly (Patterson et al., 2012).
Leadership and Communication Authentic leadership is dependent upon the effective handling of critical dialogue so that staff may be inspired to act in the best interest of the patient and organization (Korniewicz, 2015).
Unresolved communication conflicts lead to resentment and an unwillingness to follow leadership. It is especially important for leadership to communicate changes immediately. Korth (2016) recommends that nurse leaders make more time to mentor their staff and engage in unit conversations often, especially when changes are imminent. The ability to foster confidence and safety through leadership communication is a vital component in advanced practice nursing and helps ease transitions which can involve all the aspects of crucial conversations (Portoghese, Galletta, Battistelli, Saiani, Penna, & Allegrini, 2012). Mastering stories is a technique that helps communicate change by staying in dialogue when one or both parties are emotional so that resolution is achieved. Maintaining dialogue, even with strong emotions, improves the quality of the healthcare environment (Polito, 2013). Recognizing signals when a conversation turns crucial is another technique to help maintain safety and respect during critical moments (Patterson et al.,
2012). The practice of nursing is based on objective evidence while the art of nursing is mediated through communication. Creating a safe and honest environment to express opinions deepens mutual knowledge and is an important insight into leadership. Another important insight is that difficult conversations should be explored until a resolution is agreed upon. It is the responsibility of an effective leader to persist and be the catalyst for positive change using these effective communication techniques (Patterson et al., 2012).