Here’s a 3rd & Essential Step for the “Two Challenge Rule”!

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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... Click To TweetThis 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? 

doc nurse handshakeOrganizations 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?



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6 Responses to Here’s a 3rd & Essential Step for the “Two Challenge Rule”!

  1. Pingback: AHQR IS Listening!

  2. allewellyn says:

    Interesting article Beth. I have not been working in the hospital setting for quite a few years. I am continually amazed at the conflict that occurs. Glad there are some positive steps being taken to address these issues.

  3. Gregmercer601 says:

    Great work, Beth, and thanks for your important work: healht care badly needs improves communication and intrastaff rapport, both within and between professional groups. One thng: I’d not offer any paperwork, however trivial, as it seems apt to risk alienating staff members from the entire project. Plus, adding extra work, however trivially, adds to the very pressures that worsen staff communication and morale. In this way, it can worsen communication more than it helps. I strive to find ways to improve things wihout any paperwork for that reason. Again, thanks for what you do – Greg

    • Beth_Boynton_RN_MS says:

      Thanks, Greg. An important point and perhaps there are some creative ways to use technology? Maybe a quick voicemail or text to a designated person. Trouble is someone will need to follow up and it will take time initially. Perhaps an explanation from senior leader about why it is important would help get buy in and in the long run we’ll save time, patient lives, and nurse/doctor relationships. In any case, discussing this concern in the course of creating a process seems very wise.

      • Gregmercer601 says:

        It’s a tough nut: how to convince busy nurses to change. I’ve found that the more experienced, the less willingness to change r/t greater confidence/pride. Docs, same. Perhaps focus on the young? In any case, it seems to me essential that you find a way for folks to clearly come out ahead up front: if it takes time/energy, find a way to save them more and show them how they’re saving more. Perhaps highlight all the pain and lost time/energy poor communicaiton costs them. Otherwise, every worthy add-on becomes part of a legion of worthy add-ons, each one demanding that much more from the overwhelmed.

        • Beth_Boynton_RN_MS says:

          Although I agree that newer nurses might be more receptive, worry that excluding seasoned nurses will translate into a huge loss of experience and judgement.
          It all depends on whether we really want to provide safe and compassionate care and I mean ‘we’ in the the largest sense. Because a commitment to this means a commitment to healthy communication, collaboration, and culture. ALL of these take more time and therefore money when people are learning new behaviors. Often trust must be repaired and nurses, including busy or resistant ones must be engaged. This ‘stuff’ requires visionary and collaborative and at times authoritative leadership as well as more resources. In the long run we’ll be more efficient, but in the process leaders must help ensure nurses have time and this means enough staff. This too is a tough nut and even more difficult when people aren’t functioning well in teams. It is a vicious cycle that we can fix or as you mention continue creating a pile of worthy add-ons that won’t work b/c we’re avoiding the underlying problems.

What are your thoughts?