TeamSTEPPS has a pocket guide with all sorts of communication, team, and patient safety info you can access. One effort to standardize communication by promoting assertiveness 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 makes sense 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, excessive noise, 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 staff able to sustain good relationships despite peaks of stress!

However, in a culture, where blaming, bullying, or other disrespectful conduct is present, this rule reinforces poor behavior by condoning a lack of listening. In other words, ignoring an initial assertive statement is inappropriate and disrespectful! Now, there may be reasons for such behavior that are not intentionally disrespectful as with the above examples, but with no mechanism to address it in a toxic culture, it would be business as usual.

One way to address this problem would be to add a third step to the rule that prompts an investigative effort to determine who ignored the initial assertive statement and why. This can lead to a conversation among stakeholders after the crisis is over and may involve an apology and explanation as well as new understanding between clinicians.

Another method for promoting respectful listening is to use a standardized model, like this one I developed.

GRRRR for Great Listening

■ Greeting: Set the tone for a professional dialogue with a kind hello and by using the other party’s name: “Hi Beth, this is Mary, the nursing supervisor. How can I help”? This is a simple and respectful way to begin a conversation that may be stressful.

■ Respectful listening: Let the other party finish sentences without interruption, but do make occasional acknowledgments, such as “okay” or “hmm.” Allowing for brief pauses can ease anxiety and give the other party a chance to think and transmit critical information.

If the communication takes place in person, make eye contact, nod, and use other receptive body language to promote rapport, even in the middle of an emergency.

■ Reviewing: Summarize the information the speaker has conveyed to ensure that you understand the message correctly and to give the speaker a chance to correct or add any information. Inherent in validating, reviewing allows you to clarify your concerns and express additional thoughts without being intimidating or humiliating the other person. A few seconds spent doing so can help the speaker feel heard, respected, and ultimately understood.

■ Recommending or Requesting (more information): Once the speaker is finished conveying his or her report and has been validated, and the message has been clarified, it is time to either make recommendations or request more information. Even if the recommendation differs from one suggested by the sender, it is important to maintain a collaborative approach and avoid put-downs: “A chest tube is a reasonable suggestion, and the objective information you’ve provided is great. However, this patient has some heart failure and that could be part of the problem. Let’s do a chest x-ray and ABGs.”

■ Rewarding: Rewarding the speaker for the information helps the person feel like a respected team player and is easily done with a simple acknowledgement, “Thanks for your call and attention to our patient’s needs”.

Ultimately, communication is a two-way street and ensuring respectful listening is an ongoing practice in healthcare organizations will contribute to safer care, better patient experience, and more rewarding work.