Developing Practical Skills for the

Unavoidable Difficult Conversations

Orlando, FloridaFebruary 11, 2010

• Reminder of 2009 CCPTP Presentation• 2010 Focus: Difficult Conversations• Brief Review on Difficult Conversations– within psychology– other fields

• Role plays focused on skill development for “difficult conversations”

Fouad et al. (2009) Competency Benchmarks:

• “Faculty & supervisors need to…develop the ability to intervene early to help trainees who are falling behind”

• “….faculty & supervisors must shift to discussing concerns with trainees early”

• “Supervisors & faculty members worry that they do not have the basis to have these conversations.”

• CCTC Work Group on Trainees with Competence Problems

• Manuscript in preparation: “Trainees with Competence Problems: Difficult but Necessary Conversations”

• Jacobs, Huprich, Cage, Elman, Forrest, Grus, Schwartz-Mette, Shen Miller, Van Sickle, & Kaslow

• Four of these authors joined while students, three have completed Ph.D. & are still active

• Depend upon the system being adequately prepared• Policies & procedures in place• Known to all

• Skills we know & use, but may ignore in context of competence problems

• Capacity of faculty AND trainees to have “difficult conversations” IS a profession competency

• Avoidance of conflict• Resentment of time/effort required• Fear of negative perceptions of ourselves as

educators• Threat or reality of being sued• Denial of seriousness of problem• Hope the problem:

• Is developmental and will resolve itself over time• Will be dealt with elsewhere in the training system

(e.g., off- campus practicum or internship)

• Grandiosity: If we are nurturing and caring enough, our support will lead the trainee to get message & improve performance

• Tendency to diagnose/treat • Failure to translate “problematic behavior” into a

competence language/professional standards• Lack of faculty competence to address

competence problems• Lack of comfort when competence intersects w/

diversity demographics• Lack of ethical framework to guide conversations• Lack of policies/procedures to utilize/fall back on

•Self-examination, reflection•Management of emotions•Skill development

• Curriculum focuses on skills to provide feedback about competence problems

• Students know ethical responsibilities related to competence problems in peers

• Assessment uses competency framework• Faculty accept gatekeeping role & model

appropriate responses to competence problems

• Prevention focus to resolving faculty disagreements

• Consistency with and shared “working” knowledge of policies (due process)

• Research on strategies for increasing acceptance of feedback

• Addresses self-assessment foundational competency

• Motivational Interviewing procedures enhance likelihood• Trainees will decide to make changes• Helps trainees “give voice” to the need for changes

• Trainees found strategy helpful:• time consuming• required effort• would use this method if providing supervision

themselves.

• Sobell, Manor, Sobell & Dum (2008)

• Formative assessment is opportunity to train students to give & receive developmental feedback

• Opportunity to receive feedback on giving feedback to peers about competence issues

• Students should be instructed & practice how to provide feedback – it is an acquired skill & a competence itself

Kenkel (2009)

• Feedback oriented work settings promote:• employee loyalty• courtesy• cooperation• teamwork

• To be effective, feedback must be: • specific• timely• relevant• provide direction on ways to improve performance

London, 2003

• Embrace both stories by using the “and”• Avoid the “but” conversation• Map the contribution across the system…not the blame• Explore what happened: “learning conversation”• Explore how identity & feelings are involved• Create a problem-solving dialogue• Keep standards in mind• Invent creative options/solutions

Stone, Patton & Heen (1999)

• Keep your goals realistic. You can't eliminate the stress, but you can reduce it. Spend your energy on preparation - your specific script.

• Give bad news upfront. Tough messages should be simply & clearly stated in the first sentence.

• Adopt the "And Stance". Take control of the conversation by pre-empting distractions, objections & blame by using "and". "I know you worked all night, and I know you want to do well, and I know you are new, and I know I could have been clearer..." And, and, and.

• Get out of the "blame frame." Each person involved in the situation has a different objective story. Your goal is not to judge right & wrong, it's to manage better outcomes.

• Paraphrase. Create clarity & let people know you're genuinely listening, summarize what they're telling you.

• Be prepared for bad reactions. Finger-pointing, denial, arguments & tears are all possible outcomes of tough conversations. You cannot control the other person's reactions, but anticipate & be ready.

• Pretend it's 3 months or 10 years from now. Put the conversation in perspective by thinking about the future. Conversations that are hardest right now will seem less daunting.

• Dowling, Harvard Business Review (online 03/09)

• Trainees with Competence Problems: Difficult but Necessary Conversations. Jacobs, Huprich, Cage, Elman, Forrest, Grus, Schwartz-Mette, Shen Miller, Van Sickle, & Kaslow (in preparation)

• Stone, Patton, & Heen. (1999). Difficult conversations: How to discuss what matters most. New York: Penguin.

• Use this review of difficult conversations as a catalyst to:

• Anchor “difficult conversations” in competency framework• Giving feedback about competence problems IS an:

• Ethical responsibility• Professional competence

• Educate about “difficult conversations” prior to actual cases

• Develop curriculum to educate trainees• Educate others in training system about “difficult

conversation” responsibilities & need for competence

• Align policies to support “difficult conversations” competencies

• Prepare to have difficult conversations EARLY!!

• Two types of volunteers:• Scripted responses for student & faculty roles• TD received questions to prepare; roles not scripted• TDs practicing possible responses

• “Tap in, tap out” format• TDs try out possible responses• Run out of ideas, “tap out” by raising hand• TDs in audience with ideas they would like to try can

“tap in” by raising hand

• Role plays provide locations for:• practice/experimentation• opportunity to enact & observe different approaches to same

situation• opportunity to analyze strengths & limitations prior to being

in the REAL situation • not complicated by home program relationships• other TDs understand & have empathy for complexity of

relationships & responsibilities• MOST IMPORTANT: OK to screw up & have fun

• Background for Role Play• Student on remediation during 2nd year• Competencies of concern

• professionalism• self assessment• interpersonal relationships

• Concerns observed across settings • Midway assessment determines NO progress to date• Student continues to be in denial/blames others/believes remediation

is unfair• Training Director schedules meeting w/ student to discuss remediation

• Background for Role Play• Other students express concern about peer via gossip & other

unprofessional behavior• Faculty member observes unprofessional behavior in

classroom/takes concern to faculty meeting• Faculty recognize unhealthy nature of situation & agree action is

needed• Faculty agree that TD will meet with student cohort to discuss

professional & ethical responsibilities, program expectations, & provide opportunity to practice giving feedback & confronting colleagues about competence problems

• Background for Role Play• Faculty member has close working relationship w/ student on

remediation• A faculty member undermines remediation by providing only support,

avoiding negative feedback & communicating to student that all is well

• Faculty member requests discussion of remediation at next faculty meeting

• TD leads discussion at faculty meeting• Diverse opinions/approaches surface among faculty