speaking up when the stakes are high nancy krafcik-rousseau, ph.d. leadership and organizational...
TRANSCRIPT
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