Crucial Conversations in Health

Vital Smarts

People’s ability to hold crucial conversations emotionally and politically risky discussions is key to creating a culture of safety in healthcare and also relates to significant gains in quality of care, productivity, and staff turnover, among other crucial issues.

Healthcare professionals for example, see a co-worker take a shortcut, make a mistake, demonstrate dangerous incompetence, fail to support a co-worker, undercut the team, treat someone with disrespect, or abuse their authority. According to the Vital Smarts study, fewer than 10% of healthcare professionals speak up when they have these types of concerns.

TIPS FOR DIFFICULT CONVERSATIONS

  • TALK FACE TO FACE AND IN PRIVATE – don’t chicken out by resorting to email or talking on the phone

  • ASSUME THE BEST OF OTHERS – Perhaps they are unaware of what they are doing. Enter the conversation as a curious friend rather than an angry co-worker

  • USE TENTATIVE LANGUAGE – Begin to describe the problem with “I’m not sure you are intending this” or “ I am not even sure you are aware of this”

  • SHARE FACTS, NOT CONCLUSIONS – not only are our conclusions possibly wrong but they also foster defensiveness. Facts are less likely to create anger than interpretation. For example, compare “you are so dismissive” with “ In the last two meetings I noticed you laughing when I made suggestions”

  • ASK FOR INPUT/OTHERS VIEW – Ask people to help you understand the situation or check in on how they see it.

  • USE EQUAL TREATMENT – these skills apply to both bosses and co-workers. Everyone should be treated as reasonable and rational.


SEVEN CONVERSATION TIPS AND EXAMPLES

No matter what the conservation, always remember to ask yourself; why would a reasonable, decent and rational person be acting in this way?

BROKEN RULES

  • Have a ‘content conversation’ at the time to immediately correct the behavior

  • If the behavior reoccurs then have a pattern conversation

Example:

Excuse me you’ve lost the finger off your glove – can you put a new glove on please. Twice in the last month I’ve needed to remind you about infection standards. This is a pattern and I am being placed in a position where I have to escalate to our boss or make the problem worse by ignoring it. How do you see it?

MISTAKES

  • Not confronting mistakes undervalues you, the patient and the person making the mistake

  • A mistake doesn’t mean a bad practitioner …not correcting one does

  • Assume the best of others

  • If the response is aggressive or dismissive then refer to the Disrespect tips

Example:

A nurse was teaching a patient about a medication and had not checked the history property. She was teaching about a condition the patient didn’t have and describing a sound alike medication the patient wasn’t taking. I called her out of the room and helped her see the error. She returned and cleared up the mistake. By acting discretely, I was able to help her and the patient.

LACK OF SUPPORT

  • Check your assumptions – facts don’t make people angry; stories and interpretations do

  • People can hear a hard message if they feel safe with the messenger

  • Start any lack of support conversation by establishing your care and respect for the person

  • This conversation aligns closely with the poor teamwork conversation

Example:

May I talk to you about a concern that I have. [Wait for response] The last two weeks I have noticed that you seem frustrated when you are asked to take on extra workload? Am I on the right track? [Wait for response] Can you help me understand what is happening for you?

POOR TEAMWORK

  • Start with above – check assumptions, establish care and respect

  • Highlight how you experience their behaviour

  • Discuss the natural consequences of their behaviour that they may not have intended and/or considered

  • If the person becomes defensive then return to safety and respect

  • Share the story you have started to tell yourself to allow the person to understand the impact.

Example:

Sometimes I hear through the grapevine that you have a concern with me but I’m uncertain how to approach it because I haven’t heard anything from you. Other times you seem upset with me but I don’t always know what I’ve done. I’m beginning to wonder if you think I’m hard to talk to. I want to be easy to approach but maybe I’m not. Am I on the right track here??

DISRESPECT

  • As ever, begin with the safety of patients – if a person’s behaviour is placing a patient at risk then ask them politely to change it

  • If the response is disrespectful but not intimidating then discuss this behaviour after the initial safety issue is resolved.

  • If you receive an intimidating response and you do not feel able to address this alone then document the exchange and get support immediately from a manager or colleague.

  • If you witness others being treated in a disrespectful way then speak up to support them.

Example:

Doctor Smith could I ask you to replace your gloves before you touch the patient please. Later. Doctor Smith. I noticed earlier when I asked you to replace your gloves that you rolled your eyes and said ‘If I must’. When you were putting your gloves on you told the patient that ‘all the nurses round here are really anal’. My concern is that hearing that may cause the patient to take his treatment instructions less seriously than is safe. Also I’ve noticed that I am responding to this type of behaviour by becoming less likely to raise issues with you. I feel like this makes us less safe as a team. Can you help me understand how we can avoid this behaviour in the future?

MICROMANAGEMENT

  • Give yourself and the other an opportunity to ‘calibrate’ so you both have an accurate understanding of each other’s capabilities

  • Challenge the stories you are telling yourself – does this person really think you are an idiot or do they just not know you?

  • Outline your best intention – then describe the behaviour and its impact

  • Share the stories you are beginning to tell yourself

  • Suggest a testing/teaching cycle approach

Example:

Anne, I really respect you as both my CNM and my colleague. I would like to talk about how I can better support you and improve the way we work as a team. Is that OK? I noticed this morning you gave me instructions on inserting IV and turning patients. At one point you stepped in to access a patient record on my behalf. Even though I am new to the ward, these are fairly routine tasks for me. I’m wondering if I’ve done anything that would make you question my ability or attention to detail. (Listen to the response).Perhaps we could go forward this way. If you feel like you want to explain something to me then maybe you could test me by asking me how to proceed. That way you don’t waste time explaining if I already know and I get to identify what I need to learn. Would that be alright with you?

INCOMPETENCE

  • Don’t assume the person will be devastated by your approach

  • Make sure the other person knows that you care about his or her best interests

  • Highlight impact of the behaviour that would be against the person’s best interests

  • Describe one or two concrete instances but also explain that you are seeing them as a pattern

  • Escalate if need be

Example:

I’d like to talk to you about an important concern. I’m sure you don’t realise it but I think the way you do certain procedures may be putting patients at increased risk. I really value my working relationship with you, and I want to explore the details of this issue. I could be wrong here but I wouldn’t be being a good colleague if I said nothing. Can I explain what I’m seeing and get your point of view?


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