Healthcare is rich with human interactions and relationships. Whether inter-professional or therapeutic in nature, our relationships influence our communication, teamwork, cultures and systems. When this ‘soft’ skill set is healthy, the influence is more likely to be positive. When it is limited or dysfunctional, the outcomes can be catastrophic.
There are links between such ‘soft’ skills and serious, persistent, and pervasive issues in healthcare such as patient safety, patient experience, and workforce health. The recalcitrant nature of these problems is a compelling reason to look for possible common causes. Understanding these common roots will help explain why our solutions to date are not effective enough and why organizations should consider experiential teaching methods that focus on behavioral rather than more typical intellectual learning.
We can seek common causes of key issues in two ways. First by viewing healthcare as a complex adaptive system (CAS), one that is rich with human interactions. From this vantage point, such problems can be seen as outcomes or emergent properties that are arising from a common foundation, the quality (or dysfunction) of our relationships! Relationships which rely on communication and behavior and are subject to a multitude of individual and organizational variables. The health of the relationships, whether positive or negative, will have a relative effect on teamwork, organizational culture, and the care we provide.
The high incidence of bullying and/or disruptive behavior among healthcare professionals provides a perfect example of troubled relationships with nonlinear or butterfly effects on patient safety, patient experience, and workforce health as shown in the following examples.
- A doctor yells at a nurse on Tuesday. Saturday she hesitates to call him to report a subtle change in a patient’s condition and since it is close to the end of the shift, reports her concern to the oncoming nurse. The oncoming nurse, makes it a priority to check this patient, but the telemetry alarm beats him to it. The patient does not survive.
- A nurse overhears a colleague talking about her in a negative way and interrupts the conversation. “I’d appreciate it if you have concerns about my work that you discuss them with me directly and professionally.” The gossiping nurse apologizes and later offers to help the nurse find an IV pump available for use. This enables the nurse to get her pain medication to her post-op patient quickly and the patient is comfortable. Both he and his wife feel cared for. The patient experience scores increase.
- A nursing assistant is reluctant to ask the other nursing assistant for help because the last time they worked together she teased him about needing too much help. The patient is begging to be repositioned and no other staff is available. He boosts the patient in bed and has acute pain in his low back. The course of his workers’ compensation claim includes evaluation and treatment by emergency and company physicians, medications, physical therapy, case management by the insurance nurse, oversight by the employee health nurse, several days out of work, several weeks of light duty, and a review of ergonomic training. The employee is teased by the same nurses’ assistant during his alternative duty and leaves the organization. Employer turnover problems persist and a new nurses’ assistant is hired.
Notice how the positive or negative ramifications for all of these significant outcomes are linked to invisible and tough-to-measure effects involving human interactions.
Another way to look for commonalities is by examining each of these issues separately to see where communication and behavior are implicated.
A. Patient Safety and the Human Interface
The Joint Commission’s tracking of sentinel events since 2004 reveals much more consistency in the root causes of all events than a particular trend in any type(s) of events. The tracking data shows that human factors and communication are the top two root causes of sentinel events from 2004 through to the most recent summations in 2015.
Meanwhile statistics for types of events bounce around such as the number of wrong-site, wrong-patient, wrong-procedure events reviewed which was 109 in 2013, decreased to 67 in 2014, and increased to 92 by the end of the third quarter of 2015. Although not intended to be an exhaustive analysis of this data, the point can be made that there is a persistent and elusive problem with patient safety! Even fifteen years after the release of the Institute of Medicine’s (IOM) To Err is Human! This same point is fortified by comments regarding medical error reduction and quality improvement by Dr. Ashish Jha, professor of health policy and management at the Harvard School of Public Health. In his testimony before a Senate Subcommittee on Primary Health and Aging in July of 2014, Jha states that, “[w]e have not moved the needle in any meaningful, demonstrable way over all. In certain areas, things are better; in certain areas, things are probably worse, but we are not substantially better off compared to where we were [15 years ago] (More than 1,000 preventable deaths a day, 2014, 33:35).
B. Patient Experience and the Human Interface
The Hospital Consumer Assessment of Healthcare Providers and Systems’ (HCAHPS) surveys that measure patient experience are rich with feedback about interactive behaviors of staff. Of the 32 items surveyed, 18 encompass critical aspects of the hospital experience, including communication with doctors and nurses, the cleanliness of the hospital environment, quietness of the hospital environment, pain management, communication about medicines, discharge information, and overall rating and recommendation of the hospital. Of these 18 items, 14 are directly related to communication and emotional intelligence such as, “During this hospital stay:
- …did nurses treat you with courtesy and respect?
- …did doctors listen carefully to you?
- …did nurses explain things in a way you could understand?”
The feedback from these surveys sheds light on the interactive skills of staff and directly or indirectly reflects the quality of collaboration and culture within the organization.
C. Workforce Health and the Human Interface
In 2013, the Lucien Leape Institute-National Patient Safety Foundation (NPSF) released a roundtable report that focused on the harm experienced by the healthcare workforce.  The report focused on physical and psychological harm and included these statistics:
- Health care workforce injuries 30 times higher than other industries
- More FTE days are lost due to occupational illness and injury in health care each year than in industries such as mining, machinery manufacturing and construction
- 76% of nurses in national survey indicated that unsafe working conditions interfere with the delivery of quality care
- An RN or MD has a 5-6 times higher chance of being assaulted than a cab driver in an urban area
- Lack of respect
- A root cause, if not THE root cause, of dysfunctional cultures
- 95% of nurses report it; 100% of medical students; huge issue for patients
- Lack of support
- Lack of appreciation
- Non-value add work
- Production pressures
The emotional intelligence and interpersonal skills that influence both kinds of harm include the awareness of one’s own and others’ limitations, the ability to ask for, offer, and refuse help, and a dynamic culture where giving and receiving constructive feedback is ongoing, trusting, and respectful. So how do you find a unique and engaging way to combine skills and culture to optimize outcomes? Medical improv could be the path to get you there.
“Soft” skills that inform our behavior are fundamental to quality of care and developing them should be a priority. As with all change, raising awareness is a vital step forward.
Where do you see links between emotional intelligence and interpersonal skills in the work you do?
Beth Boynton, RN, MS, author of Successful Nurse Communication: Safe Care, Healthy Workplaces, & Rewarding Careers, is a speaker and medical improv trainer. More information about her work can be found on her website and she can be contacted at firstname.lastname@example.org.
 The Joint Commission. Retrieved December 2015: http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_2004-3Q_2015.pdf
 The Joint Commission. Retrieved December 2015: http://www.jointcommission.org/assets/1/18/2004-2015_3Q_SE_Stats-Summary.pdf
 More than 1,000 preventable deaths a day is too many: The need to improve patient safety. Hearing before the Subcommittee of the Committee on Health, Education, Labor, and Pensions, Senate, 113th Senate. (2014.) Testimony of Ashish Jha. Retrieved from http://www.help.senate.gov/hearings/more-than-1-000-preventable-deaths-a-day-is-too-many-the-need-to-improve-patient-safety
 Medicare.gov Hospital Compare, Retrieved from https://www.medicare.gov/hospitalcompare/About/Survey-Patients-Experience.html December 2015.