SPEAKING UP WHEN THE STAKES ARE HIGH

Nancy Krafcik-Rousseau, Ph.D.

Leadership and Organizational Development

Presentation Objectives

To understand the impact of silence in a healthcare environment.

Identify individual ways to take a leadership role in making a difference.

Learn effective ways to have effective crucial conversations and confrontations that have meaningful results.

Ice BreakerObservations in the OR

Silence Kills

Categories where conversations are especially difficult: Broken Rules Mistakes Lack of Support Incompetence Poor Teamwork Disrespect Micromanagement

When the concern is

Percentage Saying it is difficult or impossible to confront the person

Incompetence 56% of the physician72% of Nurses and other clinical-care provider

Poor Teamwork 78% of nurses and other clinical-care providers

Disrespect or Abuse

59% of nurses and other clinical-care providers

Silence Kills The Seven Crucial Conversations for Healthcare, VitalSmarts 2005, Crucial Conversations.

Why is it difficult to confront when there is a concern?

What happens to us that keeps us silence?

The Survey Says…(Safety Attitudes Questionnaire 10/10)

I am encouraged by my colleagues to report any patient safety concerns I may have.

I am frequently unable to express disagreement with staff/attending physicians.

My Observations – Barriers to Team Communication(Comprehensive Surgical Checklist)

Language Barriers Shared commitment Assumptions (they should

know) Follow through/Efficiency Interruptions Side conversation

Fatigue and stress Multi-tasking Complacency High-risk Personal Issues

(unknown) Workload/Staff

fluctuation Shared

understanding (roles/terms/purpose)

Issues to be discussed…

Open Environment

How do I contribute to creating an open environment?

Confront with positive outcomes

How can I have crucial conversations and confront issues I need to address?

What can I do about this?

Confront With Positive Outcomes

We must first reflect on ourselves How do I deal with

conflict/confrontation?

Pool of Shared Meaning

Violence

Silence

Safety

Safety

Why do we withdraw or act out?Fight or Flight

When experiencing a threat Hormones help us to run and fight Increase heart rate/blood pressure

increases Mobility of the body to survive (fight/flight)

has a negative consequence (excited, anxious, jumpy, difficult with rational thoughts etc)

Flight/fight response can be experience when frustrated and interrupted.

Watch outs

When you are stuck there is a crucial conversation that needs to happen.

When people start to feel unsafe they move to silence/violence as their approach.

Finding ways to develop a “mutual purpose”.

Creating a way to stay in “dialogue”.

What is the story we are telling ourselves?

Our story becomes our truth. Assumptions are made.

EVENT ACTFeelTell a

story

See/Hear

Getting to a Pool of Shared Meaning

Focus on what the message is Learn to see the signs of

violence/silence in your approach Understand your styles and tendencies

when under stress

Learn to look at the patterns- CPR

Content What just happened (a single event)

Pattern Behavior/events that occurs again

Patterns help to articulate the issue

Relationship What is happening to us (individuals and team)

Open Environment

How do I help to create a sense of team? Commit yourself to being part of the team

success Help your team build a common

understanding of the issues be responsible for what you say and do

Make your best effort to keep commitments Contribute your ideas and suggests to the

discussions Be open to others ideas – concentrate on

understanding their ideas and intentions

SESSION II: GETTING WHAT YOU WANT: COMMUNICATION STRATEGIES THAT HELP YOU GET WHAT YOU NEED

Nancy Krafcik-Rousseau, Ph.D.

ICEBREAKER

Setting the StageArticle Review #1 – Perception vs. Intent

Tension influencing operating room team function: does institutional context make a difference?

Lorelei Lingered, Stacey Garwood & Dan PoenaruBlackwell Publishing Ltd Medical Education 2004.

Overview of Findings:1. Common set of communication themes that impact OR team functioning:2. Role Perception and Attribution to motivation data confirmed the

following• While both parties viewed themselves as patient advocates, their

commitment to the welfare of the patient was perceived very differently in the eyes of the other.

• Nurses viewed surgeons as self-centered and motivated largely by frustration.

• The surgeons on the other side felt nurses were controlling and record-keeping employees motivated by fear of reprisal.

3. The significant dissonance in both role perceptions and attributions of motivation speaks to a lack of mutual understanding and effective communication.

Key Themes and Tension Patterns1. Roles

Dispute over technical and professional responsibilities. Assumptions about domains of responsibility, expertise or authority.

2. Situational Control Communication that occurred in order to make decision

about the physical elements – room temperature/patient positioning.

3. Resources Communication regarding equipment or personnel needs.

4. Safety and Sterility Nurses were almost always participants in these

communication exchanges, reflecting professional responsibility for aseptic technique.

5. Time Time pressures relating to preparation of a surgical case,

turnover of the room between cases and the treat of cancellation due to unexpected delays.

Setting the StageArticle Review #2 – A word on “Team”

Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the

Beholder ( Makary, M. MD, MPH. et all. 2006 American College of Surgeons)

Teamwork is an important component of patient safety. In fact, communication errors are the most common cause of sentinel events and wrong-site operations in the US.

There is no validated tool to scientifically measure teamwork in the surgical setting.

Good teamwork is also associated with better job satisfaction.

Reporting Good Collaboration

Surgeon

Anesthesiologist

Nurse CRNA

Surgeon 85 84 88 87Anesthesiologist

70 96 89 92

Nurse 48 63 81 68CRNA 58 75 76 93

Caregiver Position Being Rated

Car

egiv

er P

ositi

on

Per

form

ing

Rat

ing

In order to be a “team” you need everyone that agrees to be a “team member” and a leader/coach to facilitate the process.

Pool of Shared Meaning

Safety

Safety

SILENCE

Withdrawing

Avoiding

Masking

Controlling

Labeling

Attacking

VIOLENCE

MEOTHERS

See & Hear

Tell a Story Feel Act

See & HearAct Feel

Tell a Story

See & Hear

Take Away from Session I

1. Recognize how you get your “ENERGY”

Extraversion vs. Introversion

2. Approach to a conflict or conversation that needs to happen

Violence/Silence

3. Focus on what your want your message to be

What Went Wrong In That Conversation?E-I Differences

People with Extraversion preferences:CommunicationDon’t really know what they are thinking until they can talk it through. As they talk, things become clearer to them. They often change direction as they talk.

FeedbackPrefer to give immediate and ongoing verbal feedback “I think that too . . .”Want opportunity to discuss issues that come up for them as the conversation continues.

People with Introversion preferences:Communication•Don’t really know what they want/need to say until they can think in through. •When immediate discussion is necessary, the discussion often interferes with their process.•May leave them feeling confused or feel they didn’t say what they needed to say.Feedback•Want to focus on “the topic” which they have already thought about.•New topics – they want time to give feedback.•May feel shut out or talked over.

Focusing on What We Have Control Over Circle of Influence

Circle of Concern

Circle of Concern

Circle of Influence Circle of Concern

Circle of InfluenceWhere do we focus our time and energy?

• Proactive people focus their efforts on the circle of influence.

•Proactive people work on things they can control.

•The nature of their positive energy enlarges and magnifies causing the circle of influence to grow.

Stephen R. Covey

Take Away for Session II

1. How is my message being interpreted (perception vs. intent)

2. Finding strategies that will communicate true intent

3. What is the story I am telling myself Refuse the Sucker’s Choice Recognize the story (Victim, Villain,

Helplessness)

The Meaning of the MessagePerception vs. Intent

Sender of Message Receiver of Message

Your method and means of sending

messages make up your interactional style.

What people see and hear triggers their associations, by

whichthey make sense of themessages they receive.

The meaning of the message resides in the receiver.

Style Experience

Beliefs Training Filters Non-Verbal

It is not what you say but how you say it . . .

Tone, inflection, and facial expression accounts for 93% of your message the actual words account for 7%.

Be aware of (Non-verbal components) Eye Contact Body Posture Distance/physical contact Facial Expression Gestures Vocal Tone, inflection, volume Fluency Timing Clothing

“The Power of the Story”What is the story we tell ourselves?

We live in a world of self-generated beliefs which remain largely untested.

We adopt those beliefs because they are based on conclusions which are inferred from what we observe or past experience

Our ability to achieve the results we truly desire is eroded by our feel that

Our beliefs are the truth The truth is obvious Our beliefs are based on real data The data we select are real data

Peter Senge

Mental Models – Ladder of Inferences

Recognize your Style Under StressRefuse the Sucker’s Choice

(Violence/Silence)Caught between two distasteful options1. Disagree and get in trouble for it.2. Remain quiet.

Work on me first:1. Remember the only person you can

control is yourself.2. Focus on what you really want.

Recognize your Style Under StressMaster your story – separate fact from the

story and focus on the behavior:“Clever Stories” Victim Stories – “It’s not my fault” Villain Stories – “It’s all your fault” Helpless stories – “There’s nothing

else I can do”

Recognize your Style Under StressRetrace your steps:1. Am I in some form of silence/violence.2. Are people understanding my Intent.3. Analyze my story (what are the facts).4. What do I want from this.

Nancy Krafcik-Rousseau, Ph.D. and Betsy LuntLeadership and Organizational Development

SESSION III: WHEN THE GOING GETS TOUGH: ACHIEVING A POSITIVE OUTCOME

Shared Understanding of thePurpose Behind the Training

Focus: Effective team communication Development of individual effective

dialogue skills “Culture” – impact and definition

“Teamwork is an important component of patient safety.”

Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder ( Makary, M. MD, MPH. et all. 2006 American College of Surgeons)

So what have you learned . . .

10 minutes

1. When you are stuck… there is a crucial conversation that needs to happen.

We must first reflect on ourselves Recognize when our approach becomes silent or

violent

Shared Meaning

Violence

Silence

Safety

Safety

• Finding ways to develop a “mutual purpose”• Creating a way to stay in “dialogue”

2. What is the story we are telling ourselves?

Our story becomes our truth. Assumptions are made.

EVENTACTFeelTell a

story

See/Hear

“The Power of the Story”What is the story we tell ourselves?

We live in a world of self-generated beliefs which remain largely untested.

We adopt those beliefs because they are based on conclusions which are inferred from what we observe or past experience

Our ability to achieve the results we truly desire is eroded by our feel that

Our beliefs are the truth The truth is obvious Our beliefs are based on real data The data we select are real data

Peter Senge

Mental Models – Ladder of Inferences

3. Recognize Communication Style

1. Recognize how you get your “ENERGY”

Extraversion vs. Introversion

2. Focus on what your want your message to be

3. Perception vs. Intent

4. The Meaning of the Message Perception vs. Intent

Sender of Message Receiver of Message

Your method and means of sending

messages make up your interactional style.

What people see and hear triggers their associations, by

whichthey make sense of themessages they receive.

The meaning of the message resides in the receiver.

Style Experience

Beliefs Training Filters Non-Verbal

Purpose of Session IIIRebuilding Safety

Fight your natural tendency to silence or violence

Step out of content (if I were watching this on TV what would indicate that the conversation had turned?)

Contrast to fix misunderstandings – clarify intent or real motivation

Establish mutual purpose (what do we both want to happen here?)

Listen for understanding (remove resistance/understand other’s interest in the situation. 15

minutes

Practicing the Skills

Role Play

15 minutes

Culture – Definition of . . .

Define “the culture” Observations – thing we heard How do we change “the culture”

10 minutes

In Summary . . .

Next Steps: Future Training Support from Administration

“Create the change you want to see” Gandhi