Crew Resource Management Assertive Statements Susie, I’m concerned that … Let’s ……

Crew Resource Management

Assertive Statements

Susie, I’m concerned that … Let’s …….

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Components of an Assertive Statement

• Get Attention - Call the person by name

• Express Concern - “I am concerned . . . .”

• State the Problem - Brief, clear, objective• State in 10 seconds or less• Goal is to get immediate attention

• Propose a Solution - “We or Let’s . . .”• Don’t ask a Yes/No question!• Use of “we” or “let’s” indicates it’s a team problem.• If you don’t know the solution, restate the problem, using

team words• Within scope of your clinical role

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To get immediate attention . . .

Remember

Delta

Use it if you have to!

4

Notes on Statements

• There are no absolute right or wrong answers• This is a brief 7-10 second statement – it can be

followed up by a longer conversation• Key issues:

– All 4 parts of the statement used?– Problem statement is brief, factual, non-provocative– Solution is NOT a yes/no question– Is the focus on solving the problem and/or turning

attention back to the patient?– NO sarcasm

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Situation # 1

The CRNA, Sally, brought a patient to PACU and began giving a verbal report before the PACU RN could place the patient on the monitor. When the RN informed Sally that there should be a mandatory pause prior to report, Sally kept talking.

Draft an Assertive Statement from the PACU RN to Sally:

Get Attention

Express Concern

State the problem

Propose Solution

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Potential Statement - #1

Sally, I’m concerned that I will miss important information while I am focusing on getting the patient monitored. Let’s do report in just a minute.

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Situation # 2

The tech and the RN are setting up for the case, but the vendor has not yet arrived with the implant. The anesthesia provider, Dr. Rush, is in a hurry to start the case, so he brings the patient to the room. Dr. Rush wants to proceed with induction to avoid further delay.

Draft an Assertive Statement from the RN and/or Tech to Dr. Rush:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Rush, I’m concerned that we may not have all the needed supplies. Let’s wait to anesthetize the patient until we have confirmed the implant is here.

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Situation # 3

When the circulating RN pulls back the sheet to prep the patient, she discovers that the clip prep done by Mary, the holding area RN is incomplete and poorly done. This is not the first time this has happened.

Draft an Assertive Statement from the Circulating RN to Mary:

Get Attention

Express Concern

State the problem

Propose Solution

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Mary, I’m concerned that the clip preps are incomplete and may predispose the patient to infection. Let’s talk about the type of prep needed for this procedure.

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Situation # 4

Your co-worker, Steve, does not change gloves between taking off an old dressing and applying the new one to the patient’s wound. You hand Steve a new set of gloves – he takes them, but glares at you and refuses to speak to you later.

Draft an Assertive Statement to Steve:

Get Attention

Express Concern

State the problem

Propose Solution

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Steve, I’m concerned that not changing gloves as needed may predispose the patient to infection. Let’s talk about our dressing change process.

ORSteve, I’m concerned. I believe you are upset with me, and we need to be able to work together for safety’s sake. Let’s talk about this.

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Situation # 5

A patient is crying, clearly upset and uncomfortable. The patient’s caregiver, Queen Bee, is talking and laughing on the phone, clearly on a personal call, and you believe she is ignoring the patient.

Draft an Assertive Statement to Queen:

Get Attention

Express Concern

State the problem

Propose Solution

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Queen, I’m concerned. Your patient is upset and needs some attention. Let’s see what we can do for her.

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Situation # 6

You are relieving another RN, Anita Break, for lunch in the middle of a procedure. There are specimens on the field that have not yet been identified or labeled. Anita gives report, states she is “very hungry” and that you should be able to handle the specimens.

Draft an Assertive Statement to Anita:

Get Attention

Express Concern

State the problem

Propose Solution

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Anita, I’m concerned that there’s a big potential for error here. Let’s label and verify the specimens together before you go.

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Situation # 7

The patient was brought into the room and positioned by team members. At the last minute, you are asked to substitute for one of the members. Finishing your current task takes a few minutes, so the team proceeds with the Pause for the Cause without you – they do not want to repeat it on your arrival to the room.

Draft an Assertive Statement to your team:

Get Attention

Express Concern

State the problem

Propose Solution

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Team, I’m concerned that I may not have all the information I need to help keep the patient safe. Let’s repeat the PreProcedure Briefing so that we are all on the same page.

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Situation # 8

The RN is preparing the label for the specimen. When the physician, Dr. Sar Castic, is asked what to call the specimen, he answers, “Call it Fred”.

Draft an Assertive Statement to Dr. Castic:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Castic, I’m concerned I do not have the information to accurately label your patient’s specimen. Let’s repeat the information for safety.

OR

Dr. Castic, I’m concerned that those comments detract from our teamwork. Let’s work together to keep your patient safe.

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Situation # 9

The policy states that 2 staff members are to be in the treatment area at all times during setup and patient treatment. This morning, due to a sick call, one staff member, Ima Loner, is working alone. You walk by and observe Ima treating patients, she states “to avoid any delays”.

Draft an Assertive Statement to Ima:

Get Attention

Express Concern

State the problem

Propose Solution

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Ima, I’m concerned that you are working alone without our required cross-checks. Let’s talk to the supervisor about this situation before anyone else is treated.

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Situation # 10

The procedure requires that a vendor be present to support the equipment. During the PreProcedure Briefing, the vendor, Mike, takes a call on his cell phone. Because the connection is bad, the vendor is speaking somewhat loudly.

Draft an Assertive Statement to Mike:

Get Attention

Express Concern

State the problem

Propose Solution

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Mike, I’m concerned that your phone call is distracting us from our PreProcedure Briefing and that you will not hear important information. Please hang up and let’s all focus on the discussion.

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Situation # 11

Anesthesia for the patient will be provided by a CRNA student, monitored by the CRNA, Joe. During the PreProcedure Briefing, the student is participating, but Joe is having a personal conversation on his phone. When prompted to hang up and join the team, Joe replies that “she is the provider of record”, referring to the student.

Draft an Assertive Statement to Joe:

Get Attention

Express Concern

State the problem

Propose Solution

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Joe, I’m concerned that the conversation is distracting, and everyone in the room needs to participate in the Briefing. Let’s stop our other activities and focus on the discussion about the patient.

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Situation # 12

The physician, Dr. Imalittle Young, follows the format for the PreProcedure Briefing, but neglects to make the Safety Statement. When prompted by the RN, Dr. Young states, “If anybody knows of anything that sucks more than me having to do this, please speak up.”

Draft an Assertive Statement from any team member to Dr. Young:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Young, I’m concerned that those comments detract from positive teamwork. Let’s all work together to focus on providing safe care to our patient.

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Situation # 13

This case has generated several specimens, with different processing, i.e. pathology, microbiology. The physician, Dr. I. M. Impatient, tells the RN, “listen up, because I’m only going to say this once”, then proceeds to give a detailed, lengthy description of the tissue.

Draft an Assertive Statement from the RN to Dr. Impatient:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Impatient, I’m concerned that I don’t have the necessary information to safely label the specimens. Let’s verify the information.

OR

Dr. Impatient, I’m concerned that those comments detract from teamwork. Let’s work together to focus on caring safely for our patient.

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Situation # 14

You are the tech on the case. During the procedure, the surgeon, Dr. Goyo, and the assistant converse in Spanish. At first, it appears to be casual and un-related to the case, but then the surgeon says something to the RN, and she brings over additional equipment. You are the only caregiver in the room who does not speak Spanish.

Draft an Assertive Statement to Dr. Goyo:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Goyo, I’m concerned that I will not respond to your needs during the case. Let’s all communicate in English for safety’s sake.

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Situation # 15

During a C-section, the RN and tech discover a lap sponge is missing. The RN announces this to the team, but gets no response, and the surgeon, Dr. Good Cutter, and assistant continue to close the uterus. They are nearly done.

Draft an Assertive Statement from the RN to Dr. Good Cutter:

Get Attention

Express Concern

State the problem

Propose Solution

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DELTA! Dr. Cutter, I’m concerned. I’m missing a lap sponge. Let’s stop closing and look for the sponge.

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Situation # 16

Prior to beginning a procedure, the physician, Dr. Ree Sistant, does not wish to conduct the entire PreProcedure Briefing, since there’s no laterality involved and it’s a simple procedure (PEG tube insertion). He ultimately does so, but states “thank goodness we did that, or we would have mistakenly stuck this tube in the patient’s ear”.

Draft an Assertive Statement from any team member to Dr. Ree Sistant:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Sistant, I’m concerned that the comment detracts from teamwork aspects of CRM. Let’s focus on positive comments that help us keep the patient safe.

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Situation # 17

The physician is leading a thorough PreProcedure Briefing. About halfway through, the phone in the room rings, and the RN, Miss Dee Stracted, walks over and answers the phone

Draft an Assertive Statement from any team member to Nurse Dee Stracted:

Get Attention

Express Concern

State the problem

Propose Solution

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Dee, I’m concerned. Answering the phone now interrupts the briefing and our teamwork. Let’s ignore the phone for now and focus on the Briefing for our patient.

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Situation # 18

The new work schedule has just been posted. Your co-worker, Mr. Dis Pleased, is unhappy with his assignments, and proceeds to disparage the manager and the schedule in front of patient and families

Draft an Assertive Statement to Mr. Dis Pleased:

Get Attention

Express Concern

State the problem

Propose Solution

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Dis, I’m concerned that your comments may send the wrong message to our patients and families. Let’s take this discussion to a private area.

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Situation # 19

The PACU RN notes a developing hematoma after a carotid procedure, and informs the physician, Dr. Ima Grouch. Dr. Grouch states “why are you calling me? The Nurses at their other hospitals never call me for this. I’m not coming there now.”

Draft an Assertive Statement from the RN to Dr. Grouch:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Grouch, I’m concerned that this hematoma may compromise your patient’s airway. Let’s discuss our plan of action.

OR

Dr. Grouch, I’m concerned that those comments detract from teamwork. Let’s focus on what we need to do to keep your patient safe.

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Situation # 20

The team has been called in for an emergency procedure at 4 a.m. No one thinks it’s necessary to do the PreProcedure Briefing and Time out, except for you.

Draft an Assertive Statement to your team:

Get Attention

Express Concern

State the problem

Propose Solution

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Team, I’m concerned that not doing the Preprocedure Briefing will compromise our patient’s safety. Let’s do the right thing.

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Situation # 21

During the Debrief, the discussion centers around a piece of equipment that was not readily available nor properly prepared. The tech, Dee Fense, gets very upset and begins to blame other team members for the oversight, including several people who are not in the room

Draft an Assertive Statement to Dee Fense to help get the discussion back on track:

Get Attention

Express Concern

State the problem

Propose Solution

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Miss Fense, I’m concerned. The goal of the debrief is to focus on what we can do better as a team, not to point fingers. Let’s keep the focus on performance.

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Situation # 22

You are assuming care from your Co-worker, Miss Short Cutz, who is going on a break. The patient does not have an ID bracelet on, although there is one taped to the chart. Miss Cutz states that the patient came from the nursing unit that way, and will not leave the bracelet on. Miss Cutz asks you to proceed with the patient’s care, and she will fix the bracelet later.

Draft an Assertive Statement to Miss Short Cutz:

Get Attention

Express Concern

State the problem

Propose Solution

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Short Cutz, I’m concerned. Not having a bracelet seriously compromises our ability to provide safe care. Let’s fix the bracelet now.

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Situation # 23

On receiving the patient from the nursing unit, you discover that the Blood Bank has not processed the Type and Screen order because the verbal order was written with the unapproved abbreviation “u”. The patient’s skin is broken down at the potential procedure site. When questioned, the nursing unit RN, Miss Ina Hurry admits she was “rushed” and didn’t adequately assess the chart or the patient, but “isn’t that your job?”

Draft an Assertive Statement to Miss Ina Hurry:

Get Attention

Express Concern

State the problem

Propose Solution

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Ina, I’m concerned. These are major safety issues for the procedure. We need to work together to ensure the patient’s safety. Let’s talk about the steps needed for pre-procedure preparation.

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Situation # 24

The patient has undergone MAC anesthesia for an uneventful procedure. During the debrief, the physician, Dr. Wo Isme, begins to complain about the CRM process, multiple delays and the competency of the staff. The RN is concerned that the patient may overhear the comments, even though the patient is sedated.

Draft an Assertive Statement from the RN to Dr. Wo Isme:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Isme, I’m concerned that those comments do not enhance teamwork, and that the patient may overhear them. We can address your concerns outside the room.

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Situation # 25

A patient from ICU is brought over for a procedure. The ICU RN, Miss Diz Respect accompanies the patient, but states she is not comfortable in the procedure room, and states she should “not have to be here anyway, if the procedure RN’s were any good.” She then proceeds to sit in the control room and read a nursing journal so as “not to waste my time”.

Draft an Assertive Statement from the procedure RN to Nurse Diz Respect:

Get Attention

Express Concern

State the problem

Propose Solution

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Miss Respect, I’m concerned that we are not working together to safely care for the patient. Let’s help you get situated in the room and work together to get the patient safely through the procedure.

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Situation # 26

The CRNA has given the PACU RN a post-procedure report. You, the procedure RN, try to give the PACU RN, Mr. I. Gotit, some additional information not covered in the CRNA’s report. He cuts you off and says, “CRNA already gave me report – I’m good.”

Draft an Assertive Statement to Nurse I. Gotit:

Get Attention

Express Concern

State the problem

Propose Solution

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I. Gotit, I’m concerned that you will not have all the information you need to take care of the patient. Let’s review the additional information.

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Situation # 27

“Use SCIPS protocol” is checked off on the preoperative order sheet, but there is no protocol for the ordered procedure (Port insertion). When you ask the doctor, Dr. Risky, what antibiotic she wishes to order, she replies, “I told you not to ask me that for these cases. Don’t ever ask me that again.”

Draft an Assertive Statement to Dr. Risky:

Get Attention

Express Concern

State the problem

Propose Solution

58


Dr. Risky, I’m concerned that the orders for antibiotics are not clear. Let’s clarify the orders so that your patient gets what she needs.

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Situation #28

When called by Preop area to give report on her patient, Newbie, the med-surg RN stated that she had no orders for surgery. The Preop RN insisted she send the patient – the surgeon, Dr. Rush, later called and insisted she send the patient, then put the Holding Area RN, Miss Ino Better, on the phone

Draft an assertive statement from Newbie to Ino:

Get Attention

Express Concern

State the problem

Propose Solution

60


Ino, I’m concerned that we do not have the right patient. There are no orders for surgery, and the patient has eaten. Let’s verify using patient name and MR #.

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Situation #29

An interventional room is undergoing construction, so the physician decides to perform a case in the OR, despite having been asked not to by the charge RN, due to staffing/equipment availability. The doctor, Dr. Norules, tells the RN, Suzie, to take the patient to the OR, and the rest of the team can “catch up”.

Draft an assertive statement from Suzie to Dr. Norules:

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Norules, I’m concerned that we will not have the things we need to safely care for the patient. Let’s discuss this further and get everything into place.

63

Situation #30

Dr. Bull began to remove a patient’s dressing in preparation for a catheter removal. He was not using gloves, had not yet obtained consent, and the patient was still on a stretcher outside the procedure area. Mary, the RN noticed the activity and stepped over to intervene.

Draft an assertive statement from Mary to Dr. Bull

Get Attention

Express Concern

State the problem

Propose Solution

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Dr. Bull, I’m concerned that we may not have what you need in this location. Let’s get the patient into the room, get our consent, and get the supplies to do this safely.

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Components of an Assertive Statement

• Get Attention - Call the person by name

• Express Concern - “I am concerned . . . .”

• State the Problem - Brief, clear, objective• State in 10 seconds or less• Goal is to get immediate attention

• Propose a Solution - “We or Let’s . . .”• Don’t ask a Yes/No question!• Use of “we” or “let’s” indicates it’s a team problem.• If you don’t know the solution, restate the problem, using

team words• Within scope of your clinical role

66

To get immediate attention . . .

Remember

Delta

Use it if you have to!

67

Notes on Statements

• There are no absolute right or wrong answers• This is a brief 7-10 second statement – it can be

followed up by a longer conversation• Key issues:

– All 4 parts of the statement used?– Problem statement is brief, factual, non-provocative– Solution is NOT a yes/no question– Is the focus on solving the problem and/or turning

attention back to the patient?– NO Sarcasm

68

Assertive Statements

Remember!

You are empowered!

Speak Up!

Documents

Crew Resource Management Assertive Statements Susie, I’m concerned that … Let’s ……