The Prime Directive: Editorial for Online Journal of Rural Nursing Fall 2009


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Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 

Editorial 

THE PRIME DIRECTIVE 

Angela Collins, RN, DSN, APRN-BC, CCNS 
Editorial Board Member 

 

Skilled communication is one of the most elusive competencies to master. However, 
when the focus is patient safety, it is the prime directive for organizational excellence. The two 
documents that have been personally highly applicable in this author’s clinical practice are the 
research reports called Silence Kills (Maxfield et al., 2004) and Dialogue Heals (Maxfield et al., 
2008). The full reports are available as a pdf download at www.silencekills.com if an email 
address is registered. 

These reports focus on seven categories of conversations that are both challenging and 
perceived by most healthcare professionals as “risky”.  These categories represent the problems 
in communication that lead to poor patient outcomes (Maxfield, et.al. 2004). 
 

• Broken Rules 
• Mistakes 
• Lack of Support 
• Incompetence 
• Poor teamwork 
• Disrespect 
• Micromanagement 

 
Maxfield et al., (2004) call the inability to communicate in these circumstances as a choice not to 
have a crucial confrontation.   Addressing these problems in rural healthcare environments can 
present with an additional level of complexity, due to the financial interconnectivity of only a 
small group of providers.  

Confrontations in communication are paradoxical. Handled correctly there can be 
insights gained, relationships enriched, and problems solved. Incorrectly handled confrontations 
can lead to decrease productivity and job disengagement. The recommendations set forth in the 
report Dialogue Heals and the companion book Crucial Confrontations are to reflect on the 
essence of the problem, make it safe for the conversation to occur, and to consider scripting the 
intervention. This author uses the lens of these resources at a starting point for reflection. The 
suggestions are interventions to improve communication competency based on evidence. 
Recommended interventions include practice, choosing the best timing for a confrontation, 
words to use, and safe persons with whom to rehearse a confrontation. What is the issue that 
needs your deliberate decision to make rural healthcare safer for your community of concern?  
Use these resources to take that decision to communicate about an issue to a higher probability of 
success. 

 

 



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Online Journal of Rural Nursing and Health Care, vol. 9, no.2, Fall 2009 
 

REFERENCES 
 

Maxfield, Grenny, McMillan, Patterson, & Switzler. (2004). Silence kills. Retrieved on 
November 9, 2009, from http://www.silencekills.com/ 

Maxfield, Grenny, McMillan, Patterson, & Switzler. (2008). Dialogue heals. Retrieved on 
November 9, 2009, from http://www.silencekills.com/ 

 
 

http://www.silencekills.com/
http://www.silencekills.com/