This is a CE-accredited article. Earn 1.0 contact hour. A downloadable PDF of instructions and post-test are available
by Susan M. Gallagher, RN, MSN, PhD, CBN, HCRM; Anna K. Steadman, MA, OTR, CHSP; and Shannon Michael Gallagher, BA
Dr. Gallagher is a certified bariatric nurse, licensed healthcare risk manager, and wound ostomy continence nurse. She is Clinical Advisor at Celebration Institute, Inc., Houston, Texas. She is author of the continuing education-accredited textbook,The Challenges of Caring for the Obese Patient, which is published by Matrix Medical Communications and is available at www.bariatrictimes.com. Ms. Steadman is from Essential Ergonomics, LLC, Austin, Texas.
Bariatric Times. 2010;7(6):24–28
In an environment where every team member must have the authority to question each step in the delivery process, few staff members have mastered skills to engage in difficult conversations. Further, complex societal biases serve as barriers to crucial conversations. A case study approach is used to explore strategies for successful frontline conversations acknowledging the fact that in most cases crucial conversations are difficult and few want them to happen for reasons described herein.
Crucial conversations, by definition, are discussions between two or more people where stakes are high, opinions vary, and emotions are strong. The fathers of the crucial conversation theory, Patterson, Grenny, McMillan, and Switzler, studied human interaction for more than 25 years, seeking to identify specific strategies for conversation with promises of a predictable outcome.
Crucial confrontation, a next-step approach developed by the authors, is designed to address broken promises, violated expectations, and what the authors refer to as bad behavior, and provides further theory from which to engage in more confrontational dialogue. Although this is a good start in addressing confidence in conversation, neither theory specifically addresses healthcare or the bias that transcends either United States culture or the healthcare setting in which we work. A case study approach is used to illustrate the difference between fact and story, along with a recipe for dialogue when dealing with challenging size-specific topics. A set of communication and assessment skills, based on crucial conversation theory and others, is described. Readers are challenged to acknowledge the societal biases that impact power dynamics across the diverse settings wherein we work, which ultimately interfere with accountability in patient care.
Few would argue the fact that communication is at the heart of bariatric care. The question that deserves debate is what this conversation ought to look like. In today’s fast-paced environment every member of the patient care team is asked to work closely on a daily basis to make decisions and address real-life conflicts and concerns, often in an urgent fashion. The challenging paradox here is that being assertive is often perceived by the individual as socially dangerous, even though that same assertion is essential to general safety. Certainly, experience has proven that not speaking up leads to medical mistakes. In such an environment, every team member must have the authority to question every step, and at any step, in the delivery process. Therefore, each individual must have mastered skills to engage in a difficult conversation during very stressful conditions so that critical information is passed in a candid, yet respectful manner. To be considered as one who has mastered the skills necessary, the ability to assess and self-assess the autonomic responses and adapt mid-stream one must observe “silent or violent” indicators identified by Patterson, Grenny, McMillan, and Switzler. Traditionally, leaders have had conversations with staff members about patterns of behavior that impact teamwork and quality of care. Few staff members have the confidence and skill to engage in these interactions successfully. Yet, until all staff members can transcend the power dynamics inherent in groups and organizations, it becomes impossible to create a meaningful culture of accountability. Fortunately, tools are available to help us move beyond what is holding us back in this otherwise stressful but essential dialogue.
Recognizing societal bias as barriers to success
A number of barriers serve to interfere with successful communication in a country as richly diverse as the United States. Consider the power dynamics outside of the patient care experience itself. Oftentimes the ‘story we tell ourselves about someone before we ever interact with them’ is constructed from power structures permeating the larger society. (See: The Story of Sara and Jill) Because the patient care setting is inextricably tied to society itself, the ability to separate the ills of one from the ills of the other is an impossibility. Additionally, expressions of societal racism, sexism, classism, and size-ism often manifest themselves through individuals. This complicates the crucial conversation for the assertive caregiver because the immediate problem is individual behavior, but the real issue is the larger social trend that encourages or fails to discourage discriminatory or other forms of inappropriate behavior. In light of this, it is essential that the person initiating a crucial conversation does not label the person in question as incorrigibly discriminatory or place blame solely on them. Before beginning a crucial conversation, the person initiating the conversation must plan a dignified egress for the subject of the conversation. For example, in the case study presented in this article, this means Taylor must ensure the opportunity for Dr. Alan to recognize the problem, decide to improve, and apologize.
Within this decision to improve lies the difficult process for both parties involved, as recognition and apology are unilateral and instantaneous. However, the improvement process requires bilateral personal strength as well as a working knowledge of the deeper issues at hand. For example, the complicated issues of race or class in America may intersect with the complicated issue of size in America to create an experience altogether different from that which would result from these statuses individually. The process of recognizing issues and creating meaningful, sensitive dialogue requires much effort, but this can be defined as an ex officio obligation in the larger process of providing quality patient care. In this, understanding people and culture is second only to understanding medical procedures in the field of healthcare. This is complicated by the nature of humanity and culture themselves, which are constantly being reinvented by ever-changing forces. For example, defining race today means grappling with an acknowledgment of race as a social construction, an artifact of human invention, while at the same time recognizing its formidable power. Even in this enlightened understanding, we see the forces of change pulling on each other; as one person calmly says race is merely an ‘invention,’ another asserts the very real consequences race inflicts upon his or her life, and neither are wrong. This is the kind of complication that is destined to surface in crucial conversations. One way to avoid the possible ‘dead end’ created by this type of ambiguity is to appeal to confirmation bias (See Sidebar: What is Confirmation Bias?)
It is important to remember that the crucial conversation is difficult because no one involved wants it to happen. That is, they do not want it to have to happen; patients do not want to be slighted, and caregivers do not want to bear the weight of confrontation or misconduct. More powerful than this is the idea that no one wants to feel negative about the friction between what they are and what meaning society assigns to that, and this despair is precisely what the crucial conversation has the power to prevent. Consider the following case scenario:
William, a 27-year-old, 320-pound architect, had appendectomy surgery yesterday. Sitting in the standard-sized chair he is quiet and tense. Taylor is assigned to care for William. Taylor is a physical therapy assistant who had metabolic surgery 24 months ago and lost 75 percent of her excess weight. Few people know that she was once morbidly obese. She sits down with William and asks if there is anything she can do to help him feel better. As they begin talking, Taylor learns that William overheard the general surgeon saying, “You should have seen that guy…I felt like I was performing surgery on a whale.”
Tackling a tough conversation is challenging for a number of reasons. Experiencing the dual biases of both the individual as a symptom of societal norms and the society itself that condones this individual behavior undermines Taylor’s confidence while simultaneously discouraging her benevolence. According to Taylor, the only word to describe the mixed emotion she felt was furious; she was experiencing an autonomic response to the event William shared, which is a predictable human response to stressful situations. In early evolutionary times, fight was observed as aggressive, combative behavior and flight was manifested by literally racing away from dangerous situations. Today, these responses persist, but fight and flight responses have assumed a wider range of behaviors. For example, the fight response is more often demonstrated in angry, aggressive, or confrontational conduct, and the flight is seen as simple withdrawal. In most situations, we are unaware of the workings of the autonomic nervous system because it functions in an involuntary, reflexive manner. For example, we do not notice vasoconstriction or tachycardia, especially when we focus on external stimuli in the work setting. However, depending on the amount of anxiety created by the situation, Taylor may experience physical signs, such as flushing of the skin, pupil dilation, hearing loss, or impaired peripheral vision. The autonomic nervous system equips us with the fight or flight reaction, which may have served us well centuries ago, but it does not help Taylor today in this situation. Part of Taylor wanted to avoid the discussion she knew she needed to have with the surgeon. However, in a culture of accountability, she knew she needed to confront the issue. Still, another part of Taylor wanted to storm into the Chief of Surgery’s office and demand recourse for William without having to have the direct conversation with the surgeon in question. The natural human response does not serve us very well in most of our work settings today where we are faced with the same “threat” day after day. A different kind of response to the threat must be designed in order to ensure a meaningful, trusting relationship with our colleagues on a day-to-day basis.
Reflect on a recent tough conversation you have had. Consider a conversation that did not go as well as you wanted. Was there a difference of opinion or was emotion involved? Did the interaction produce the desired outcome? Did the conversation leave you feeling unsettled, defensive, or offended? How did you feel during the conversation? What behaviors did you exhibit? What behaviors did the other person exhibit? Consider the path taken in planning the conversation. What pre-judgments became part of the story? Based on the story, how did you feel? How could the story change for a different outcome? There are defining moments in our work lives that make a difference—this was one for Taylor. She knew that, by definition, she needed to prepare for a crucial conversation. After having the lived experience as a person with morbid obesity she felt compelled to have a respectful, meaningful conversation with the surgeon—with the goal of changing behavior. Whether referred to as crucial conversations, tough conversations, fierce conversations, critical conversations, or other variation the objective is the same: use of a behavior-based model of respectful dialogue to reach agreement when stakes are high, opinions vary, and emotions are strong.[1,7,8] The goal of the conversation is to get to a result despite the human factors and emotions that often interfere.
One model for a critical conversation is as follows:
• Observe the situation
• Accentuate the positive by two
• Question of concern (open ended)
• State the consequences
• Solution question (open ended)
• Get the Agreement (clarify)
Let’s listen to some options for a critical conversation:
Observe the situation—Taylor understands that conversations go best when done privately and respectfully, so she speaks with Dr. Alan alone in his office where he likely will be more receptive to the goals of the conversation. Taylor understands the power dynamics inherent in the traditional organizational structure but she also recognizes the meaning of accountability. She is mindful of her goal: move Dr. Alan to acknowledge the insensitivity, and formulate and agree to a plan of action to overcome the behavior.
Accentuate the positive by two—Taylor: “Dr. Alan, I have always enjoyed the opportunity to work with you. You have great outcomes, which make my job easier.”
Question of concern (Open ended)—Taylor: “I am here because we are all responsible for maintaining a culture of accountability. Is that correct?”
Dr. Alan: “Well, of course.” Nods in acknowledgment.
Taylor: “To that extent, can we talk about something a patient said to me today?”
Dr. Alan: “Sure.”
Taylor: “Do you know what I am talking about?”
Dr. Alan: “Not really, Taylor.”
Taylor: “Dr. Alan, William in 17A felt you said some harsh things about his weight while discussing his surgery outside his room. Is this your understanding?”
Dr. Alan: “Well, yes, Taylor. You have to understand how much I hate performing surgery on obese patients.”
Taylor: “This concerns me, coming from anyone, but especially coming from a surgeon, who patients and staff members hold in such high regard.”
State the consequences—Taylor: “Dr. Alan, William is a very intelligent man and leader in the community. He really is pretty upset. You understand probably more than I do the issues here; this impacts his trust in you and in all of us.”
Solution question (Open Ended)—Taylor: “Dr. Alan, how do you think this is best addressed now—with William—and in the future? You really are an important member of our team…we all really like you and respect you as a surgeon. How do you see next steps?”
Dr. Alan: “Honestly, Taylor, I am just frustrated because these big guys never do well so I don’t really like what they do to my statistics.”
Taylor: “We have an interdisciplinary team that is designed specifically to address this issue. I wonder if you feel that you could contribute to the group or at least provide a perspective to move us in a meaningful direction.”
Dr. Alan: “Taylor, I knew there was a team. I do think I could help the team but more importantly, I think if we could work together we might be able to manage some of the problems with these big guys. What else might help me?”
Taylor: “Do you think it was helpful for William to hear the conversation in the hallway?”
Dr. Alan: “No, of course not…I just get so frustrated.”
Taylor: “Dr. Alan, I had weight-loss surgery. Did you know that I once weighed 382 pounds? I can tell you that it would not have helped my recovery to hear that discussion in the hall. But let’s talk about William for a minute. Any ideas?”
Dr. Alan: “Oh, Taylor! I am so sorry. Listen, I need to talk with him about this. He is really a sweet person; I need to let him know how much I respect him. He’s designed some beautiful buildings around town…did you know that? I think there are a number of things we can do to make things better for these big guys…you’ll help me with this, right? ”
Get the agreement (Clarify their words)—Taylor: “Dr. Alan, let’s agree that you will become involved with the size-sensitive interdisciplinary team, and if you have questions or need ideas for mobilizing patients of size any of us in the physical therapy department will be happy to help you. Agreed?
Dr. Alan: “Absolutely. Thank you. We have a deal!”
This conversation was successful, in part because Taylor recognized that a special communication skill was necessary to address a situation when stakes were high, opinions varied, and emotions ran deep. Despite the partial success in this conversation, it is important to recognize the meaning of Bernard Shaw’s words when he said that the single biggest problem with communication is the illusion that it has taken place. Because this is a behavior-based activity, Taylor may want to continue to work with Dr. Alan around issues of size-sensitive behavior. A crucial conversation is goal-based, and the goal in this conversation was to move Dr. Alan to acknowledge the insensitivity and formulate and agree to a plan of action to overcome the behavior. Dr. Alan continued to refer to patients of size as “big guys.” This is a conversation for another day. Keep in mind, several conversations may be necessary. Focus on a specific goal each time, taking care not to deviate, if possible, and then re-establish a goal for subsequent conversations. Taylor recognized Dr. Alan’s reasons for disliking larger patients and redefined them as results of structural failures, not the failures of Dr. Alan or William, thus recognizing a larger problem to be addressed by the larger healthcare community, while still maintaining that personal discrimination is unacceptable.
Taylor may want to reach out proactively and establish when Dr. Alan is admitting a patient whose size would interfere with care or ultimately outcomes, and determine that a size-appropriate plan of action is in place. Most experts agreed that behavioral change require a pattern of change over time.
The conversation between Dr. Alan and Taylor could have gone many directions. It is essential to recognize the distractions, sometimes referred to as the three distracting stories: victim stories, villain stories, and helpless stories. Consider victim stories: Anytime we hear or say, “It’s not my fault,” we are in the midst of a victim story. The real question in this story is, “What is my role in the problem?” Dr. Alan started with this story by indicating that he made the disparaging statement because of his level of frustration due to the associated size-related outcomes, but then quickly took responsibility for his behavior. The second distraction is the villain story, which is usually displayed by phrases such as: “It’s all your fault.” Again, Dr. Alan began by placing blame on patients of size in a general sense—in his mind it was their fault he held his opinion. But, a problem seldom belongs exclusively to one individual or group. This villain story frequently leads to the third distraction, the helpless story, which often springs from, “There’s nothing I can do!” When this emotion surfaces the real response ought to square more closely to: “What should I do right now to move toward a reasonable goal?” Taylor could have used this ineffective story by stating, “How could I make a difference in a surgeon’s behavior?” Then, she could have used the flight response each time she worked with or around Dr. Alan. Consider the tension this could create, in the work setting, especially if one feels slighted as a result of his or her high standard of professional ethics. The purpose of behavior-based conversation that allows for respectful, meaningful dialog between all staff members regardless of role, education, or discipline is that it controls for this tension. Often it is this ongoing tension that leads to misunderstanding and, therefore, risk of medical error. Some suggest it is more than simply mastering crucial conversation skills that lend the confidence to engage in these essential conversations. Recognizing the power dynamics inherent in the patient care team may be just as important.
Behavior-based conversations are designed to transform anger, stress, and fear into positive, powerful, and trusting relationships. In a fast-paced environment that lends itself to insensitivities or misunderstandings it makes sense for members of the patient care team to develop such skills as one strategy to overcome these ongoing conflicts. Consider these skills next time an explosive and difficult conversation presents itself. Consider a recent situation you have encountered, where this skill could change behaviors and move relationships to a new level of understanding and creative synergy. Imagine an environment where patient care team members are emotionally connected to the agreement in such a way that team members are emotionally willing and committed to effectively implementing the agreed upon behaviors, as were Dr. Alan and Taylor. In short, the team recognizes their respective places in the American power dynamic and how this changes the meanings of their actions, which moves them from creating the right mind-set and heart-set to committing to the right skill-set. Take an opportunity to frame the conversation differently with different priorities, concerns, and consequences, reaching an agreement to safe patient care where accountability transcends the power structure and belongs to everyone.
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