ICU Nurse, Attorney, Conflict Resolver - Meet Debra Gerardi

How long have you been a nurse and what areas of nursing did you or do you currently work in? I have worked with healthcare organizations 1979 when I started as an ER admitting clerk when I was 19. After graduating from Creighton University in 1987, I worked as a critical care nurse until 2003.

What led you to pursue law and mediation? I became interested in health policy in nursing school and became involved in Bob Kerry's first senate campaign in 1988. My interest in working in the public health arena, particularly health policy as a means of improving patient care delivery led me to law school in 1989. During law school, I learned about a program in Preventive Law, fashioned after the public health model, and began to learn about mediation as a means of resolving disputes rather than litigation. At that time, mediation was not as widely used and it was just touched on in law school. That is not the case now where law students are routinely exposed to mediation and other alternatives to litigation. I moved to Los Angeles after graduation in 1992 and I did 40-hour mediation training through the LA County Bar Ass. in 1994.

Tell me your biggest concerns about nursing. In my work now as a conflict specialist and executive coach, I am most bothered by the difficulty of the work environments that nurses are working within and how depleted nurses are trying to provide care to patients within a compliance and cost driven system. The need for nurses to make intentional choices for their own self-care and to develop reflective practices to maintain their own resilience and stay grounded in the values that underlie the practice of nursing is growing. I love helping nurses develop practices to help them restore their own well-being so that they can better do the work they were called to do.

What throws you off balance and how do you know you are out of balance? What throws me off balance is when I have not paid attention to my own resilience and I find myself taking in too much of other people's energy into my own body. This depletes me and it makes it easier for me to be "hooked" by my own triggers or habits. This imbalance can lead me to move to far into a "rescue" mode and take on work that belongs to others. To rebalance myself I do a number of practices including: Journaling almost daily, working out (my goal is 5 times per week), regular sleep when I am not traveling, being in nature (I need a lot of this), reading poetry and authors who inspire me and give me a larger perspective, good nutrition and hydration (this works like magic!), and spending time with people who bring me joy and love to play! As you can see, rebalancing is a full time job for me!

What is the role of nurses, physicians, nurse managers and administrators in creating a healthy workplace? So often we adapt to the culture because "it's always been that way". Managers or administrators often are swamped with meetings to address what seems to be petty behavior or bullying. The role of all health professionals, and particularly those in leadership positions, in creating a healthy work environment is to first become aware of how they are personally contributing to an unhealthy work environment and to set an intention for how they might shift their own habits that may make things worse or at a minimum maintain unhealthy patterns. For example, interrupting the tendency to talk about someone rather than directly to them or remaining silent when there are behaviors that are compromising care are two habits that most of us have adopted as part of "the way we do things here." Understanding that I have choices in how I respond and intentionally choosing to respond in ways that align with my values and promote connection with others in healthy ways and then trying on better behaviors is the main way that cultures shift over time.  Leaders who do this can have a much larger impact because everyone is watching them to see how they behave in order to know what is acceptable.

Additionally, the emphasis on bullying and unprofessional conduct has taken on in many places a punitive approach or a compliance-based approach rather than a relational approach. By reframing how we engage, we have a broader range of options for responding in ways that are less about discipline and more about confronting individuals and groups with a mirror to help them appreciate the impact their behaviors are having on patient care and colleagues and then providing them with the choice to change their approach or choose another place to do their work. Often people who are behaving unprofessionally are unaware of the impact of their behavior, they are having trouble coping with the stressors in the environment, and they have poorly developed emotional intelligence. Providing support for development of these skills early in training is essential. For the small percentage of folks for whom this approach will not work, the more traditional disciplinary action can be used to further protect the work environment and the quality of patient care. Of course, this particularly applies to those in leadership positions who are doing the bullying or who are having difficulty coping with the stressors of their jobs due to their own diminished resilience.

What advice do you have for healthcare providers that avoid conflict or difficult conversations? Are there ways to start getting comfortable?  We all avoid conflict! No one likes stepping into an unpredictable situation in which there are strong emotions and if we are worried about retaliation, making things worse, or not seeing any benefits from taking the risk, then we are even less likely to take it on. Knowing when and how to engage are core competencies for engaging in conflict. Becoming more comfortable with engaging in hard conversations comes with practice and development of our intrapersonal capacity (knowing myself and my own triggers) and interpersonal capacity (knowing how I interact with others and how they respond to me). This requires self reflection and self awareness so that I can try on things and see what works. Learning how to listen openly, acknowledge what matters to the other person, reframing the situation into something we can work on together, looking for common interests, and using empathy are all tools that nurses have some exposure to and using them intentionally with colleagues and others helps us get better at engaging, just like practicing other nursing skills helps us develop mastery. Another important point is to appreciate that when we are fatigued or under resourced personally, we are less likely to choose to engage and if we do, we may not be our best self when we do.

You worked with JCAHO on sentinel events. What relationship does a healthy workplace have on patient outcomes?  The Joint Commission started tracking sentinel events around 1997. The data consistently points to the importance of teamwork and communication as essential for safe care. This has led to a number of standards and sentinel event alerts that highlight the need for conflict management and team training. What is missing is attention to how the work environments with the excessive attention to productivity and quantification of patient care are contributing to fragmented approaches to care and removing the time and connection necessary for health professionals to form relationships with patients and with colleagues. It is these relationships that are the source of quality care and that provide a feeling of having done meaningful work.

What advice would you give to new grads starting out? Be compassionate with yourself and others. Nursing is noble work and hard work, and it is one of the most sacred spaces you will ever inhabit. Make friends with your colleagues and support one another- no one does this work alone. Become a life long learner- things will change and there is always more to know- about nursing, the health system, your community and about yourself. Have fun! The work is serious and sometimes overwhelming but you have to find ways to have fun and enjoy what you do so that you can keep doing it for as long as it feeds your soul.