Speaking Up When the Stakes are High

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Speaking Up When the Stakes are High

• Nancy Krafcik-Rousseau, Ph.D.
• Leadership and Organizational Development

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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.

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• Ice Breaker
• Observations in the OR

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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 physician 72 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
Why is it difficult to confront when there is a
concern? What happens to us that keeps us
silence?
Silence Kills The Seven Crucial Conversations for
Healthcare, VitalSmarts 2005, Crucial
Conversations.
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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.

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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)

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Issues to be discussed

• Confront with positive outcomes
• How can I have crucial conversations and confront
  issues I need to address?

• Open Environment
• How do I contribute to creating an open
  environment?

What can I do about this?
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Confront With Positive Outcomes

• We must first reflect on ourselves
• How do I deal with conflict/confrontation?

Violence
Safety
Pool of Shared Meaning
Safety
Silence
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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.

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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.

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What is the story we are telling ourselves?

• Our story becomes our truth.
• Assumptions are made.

EVENT
See/Hear
ACT
Tell a story
Feel
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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

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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)

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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

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Session II Getting what you want Communication
Strategies that help you get what you need

• Nancy Krafcik-Rousseau, Ph.D.

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• ICEBREAKER

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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 Poenaru
• Blackwell Publishing Ltd Medical Education 2004.
• Overview of Findings
• Common set of communication themes that impact OR
  team functioning
• 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.
• The significant dissonance in both role
  perceptions and attributions of motivation speaks
  to a lack of mutual understanding and effective
  communication.

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Key Themes and Tension Patterns

• Roles
• Dispute over technical and professional
  responsibilities. Assumptions about domains of
  responsibility, expertise or authority.
• Situational Control
• Communication that occurred in order to make
  decision about the physical elements room
  temperature/patient positioning.
• Resources
• Communication regarding equipment or personnel
  needs.
• Safety and Sterility
• Nurses were almost always participants in these
  communication exchanges, reflecting professional
  responsibility for aseptic technique.
• 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.

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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.

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Reporting Good Collaboration
Caregiver Position Being Rated
Surgeon Anesthesiologist Nurse CRNA
Surgeon 85 84 88 87
Anesthesiologist 70 96 89 92
Nurse 48 63 81 68
CRNA 58 75 76 93
Caregiver Position Performing Rating
In order to be a team you need everyone that
agrees to be a team member and a leader/coach
to facilitate the process.
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SILENCE Withdrawing Avoiding Masking
Safety
OTHERS
Pool of Shared Meaning
ME
See Hear
Tell a Story
See Hear
Act
Feel
See Hear
Tell a Story
Feel
Act
Safety
Controlling Labeling Attacking VIOLENCE
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Take Away from Session I

• Recognize how you get your ENERGY
• Extraversion vs. Introversion
• Approach to a conflict or conversation that needs
  to happen
• Violence/Silence
• Focus on what your want your message to be

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What Went Wrong In That Conversation?E-I
Differences

• People with Extraversion preferences
• Communication
• Dont 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.
• Feedback
• Prefer 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
• Dont 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
  didnt 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.

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Focusing on What We Have Control Over Circle of
Influence
Circle of Concern
Circle of Concern
Circle of Concern
Circle of Influence
Circle of Influence

• Where 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
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Take Away for Session II

• How is my message being interpreted (perception
  vs. intent)
• Finding strategies that will communicate true
  intent
• What is the story I am telling myself
• Refuse the Suckers Choice
• Recognize the story (Victim, Villain,
  Helplessness)

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The Meaning of the MessagePerception vs. Intent

• Sender of Message Receiver of Message

What people see and hear triggers their
associations, by whichthey make sense of
themessages they receive.
Your method and means of sending messages make up
your interactional style.
Style
Experience
Beliefs
Training
Filters
Non-Verbal
The meaning of the message resides in the
receiver.
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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

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The Power of the StoryWhat 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

Mental Models Ladder of Inferences
Peter Senge
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Recognize your Style Under Stress

• Refuse the Suckers Choice (Violence/Silence)
• Caught between two distasteful options
• 1. Disagree and get in trouble for it.
• 2. Remain quiet.
• Work on me first
• Remember the only person you can control is
  yourself.
• Focus on what you really want.

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Recognize your Style Under Stress

• Master your story separate fact from the story
  and focus on the behavior
• Clever Stories
• Victim Stories Its not my fault
• Villain Stories Its all your fault
• Helpless stories Theres nothing else I can do

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Recognize your Style Under Stress

• Retrace your steps
• Am I in some form of silence/violence.
• Are people understanding my Intent.
• Analyze my story (what are the facts).
• What do I want from this.

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Session III When the Going Gets Tough Achieving
a Positive Outcome
Nancy Krafcik-Rousseau, Ph.D. and Betsy
Lunt Leadership and Organizational Development
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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)

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So what have you learned . . .
10 minutes
35
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

Violence
Safety
Shared Meaning
Safety

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

Silence
36
2. What is the story we are telling ourselves?

• Our story becomes our truth.
• Assumptions are made.

EVENT
See/Hear
ACT
Tell a story
Feel
37
The Power of the StoryWhat 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

Mental Models Ladder of Inferences
Peter Senge
38
3. Recognize Communication Style

• Recognize how you get your ENERGY
• Extraversion vs. Introversion
• Focus on what your want your message to be
• Perception vs. Intent

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4. The Meaning of the Message Perception
vs. Intent

• Sender of Message Receiver of Message

What people see and hear triggers their
associations, by whichthey make sense of
themessages they receive.
Your method and means of sending messages make up
your interactional style.
Style
Experience
Beliefs
Training
Filters
Non-Verbal
The meaning of the message resides in the
receiver.
40
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 others interest in the
  situation.

15 minutes
41
Practicing the Skills

• Role Play

15 minutes
42
Culture Definition of . . .

• Define the culture
• Observations thing we heard
• How do we change the culture

10 minutes
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In Summary . . .

• Next Steps
• Future Training
• Support from Administration
• Create the change you want to see Gandhi