‘Crucial Conversations’ in the Workplace

Abstract

Offering nurses a framework for discussing-and resolving- incidents of lateral violence.

This is the second article in a series on leadership, coordinated by the American Organization of Nurse Executives (AONE), highlighting how nurses are leading change efforts in hospitals. It describes work done in conjunction with the AONE's Care Innovation and Transformation initiative, which provides leadership development and educational opportunities to nurse managers and staff aimed at supporting nurses at the point of care in making changes to improve the quality and safety of patient care.

"Lateral violence." "Horizontal hostility." Aggression. Incivility. Whichever term is used to describe a nurse's behavior, the meaning is the same: an RN acting toward another staff member in a verbally, emotionally, or physically abusive way. The most common forms of this behavior include nonverbal innuendo, verbal affront, undermining activities, withholding information, and sabotage.1 Lateral violence may be overt-when one shouts at or blames a coworker, or makes faces or raises eyebrows in response to a colleague's communication-or more subtle, such as when one fails to assist a colleague or makes up information.2

Figure. Mary Cashman... - Click to enlarge in new window

Figure. Mary Cashman, BSN, RN, engages in a "crucial conversation" with a coworker at the Hospital of the University of Pennsylvania in Philadelphia. Photo by Katherine Major.

A study of new nurses revealed that as many as 90% had experienced some form of "coworker incivility."3 Stanley and colleagues, who sought to assess nurses' perceptions about lateral violence in an online survey, reported that 65% of respondents had frequently seen incidents of lateral violence occur among coworkers and 46% described lateral violence as being a "very serious" or "somewhat serious" problem.4 The American Nurses Association notes that lateral violence and bullying have been issues of concern for decades and have a negative effect on individual nurses, the workplace, and the profession.5 Embree and White conclude that lateral violence adversely impacts the work environment, staff retention rates, and patient outcomes.6

CRUCIAL CONVERSATIONS

It's critical that nurse leaders refuse to tolerate lateral hostility. They can best do so by addressing any incidents as soon as they occur. When a staff RN approaches the nurse manager for assistance in dealing with collegial conflict, the manager might first direct the nurse to engage the other staff member in conversation about the offensive behavior, and it may ultimately be necessary for the nurse manager to do the same. These discussions typically take on the characteristics of what Patterson and colleagues have described as "crucial conversations,"7 those in which the participants feel strong emotions, the stakes are high, and there are differences of opinion-factors that preclude many people from being able to converse effectively and clearly. Patterson and colleagues have also described a framework, outlined below, in which these conversations can most effectively proceed so that all parties can find a satisfactory resolution to the incident.

Start with heart. Stay focused on what you really want. Ask yourself: "What is the outcome I'm looking for in this conversation?" Are you simply trying to win the argument, seek revenge, or keep yourself safe? Your motivation is not to simply watch someone squirm-it's to encourage the free flow of information that is at the core of every successful conversation.

Learn to look. Be conscious of when a crucial conversation is needed. It's best to plan for these discussions, rather than suddenly discover you're in one. During the discussion, constantly assess your behavior: "Am I becoming silent or violent? Are others?"

Make it safe. State your mutual purpose and establish respect by making it clear to the other person that you value her or his perspective and experience. Avoid ambiguity, which sometimes leads people to assume the worst, at which point they may become scared, defensive, or both. Feeling defensive can prevent a person from listening to important information.

Master your story. Take charge of your emotions by "telling your story"; for example, think about and rationalize what you're feeling and why. Retrace your path to action for the listener-explaining how and why you've come to these conclusions-so she or he can better understand your point of view. Be sure to separate the known facts (the charge nurse has yelled at you in front of colleagues, for instance) from your story (she doesn't respect you), and remember to ask yourself how you've contributed to the problem.

State your path. Share the facts as you see them and tell your story, while also asking others how they've reached their conclusions and about their feelings and stories. Ask yourself, "Am I clearly communicating why this conversation is taking place?"

Explore others' paths. To learn about other people's perspectives, use four "power listening skills": (1) ask questions to encourage others to share their views; (2) mirror how others look or are acting to confirm that you understand how they feel; (3) paraphrase what they've said to acknowledge that you understand their story; (4) prime, or encourage, them to share details they may not otherwise reveal. Ask yourself, "Am I actively exploring others' views?"

Move to action. Decide together how you will make decisions about the issue being discussed, document these decisions, and follow up.

Without this type of structured conversation, a discussion among coworkers can turn into a battle, and the free flow of information has the potential to stop, at which point the stakeholders will protect themselves and not share ideas or actively listen.7

A report cosponsored by the American Association of Critical-Care Nurses, Silence Kills: The Seven Crucial Conversations for Healthcare, found that many preventable medical errors are likely attributed to health care professionals failing to communicate properly.8 Specifically, it revealed that an improvement in the way health care professionals communicate in seven types of crucial conversations could lead to a reduction in errors and nursing turnover rates and to improved quality of care and productivity.8 These conclusions build on the findings of the Institute of Medicine's report, To Err Is Human: Building a Safer Health System, which found that each year as many as 98,000 patients die because of medical errors-frequently owing to communication failures among health care professionals.9

EXAMPLES ON THE UNIT

The following case studies highlight how the crucial conversation framework can be used to navigate and resolve incidents of lateral violence among nurses. (These cases are composites based on our experience.)

A confrontational attitude. Sylvia Stevens has worked at the hospital for four years. In the last few months, several of her coworkers have provided the nurse manager of their unit with negative feedback about her behavior. All have described confrontational and unprofessional interactions with Sylvia. Sylvia is often seen rolling her eyes during the "shift huddle," when the nurses gather to discuss each patient, and has yelled at coworkers on the unit.

After each incident, the nurse manager asked Sylvia's coworkers to speak to her about the offensive behavior. In each case, when the coworker told Sylvia she didn't appreciate her behavior, Sylvia denied it had occurred and ended the conversation. The nurse manager has also spoken with Sylvia three times in the past year about her behavior, and this has led to temporary improvements. A few months after these discussions, however, the negative, abrasive, and aggressive behavior that Sylvia's peers have described resurfaced.

In the last four weeks, Sylvia's colleagues have reported several negative interactions.

* A physician's assistant complained that Sylvia made a comment about a patient's "disgusting" body odor within earshot of the patient.

* A nurse coworker described how Sylvia yelled at her for asking too many questions during report.

* An ancillary nutritional aide told the nurse manager she doesn't want to interact with Sylvia after hearing her say on numerous occasions that the hospital's food is "horrible" and she "wouldn't feed it to a dog."

Recognizing that emotions and stakes are high-the nurse manager risks losing a tenured employee and Sylvia could lose her job-and that there will be differences of opinion, the nurse manager decides to follow the framework for crucial conversations to try to resolve the conflict.

The nurse manager "starts with heart,"7 expressing her sincere desire for Sylvia to be happy and successful at work and explaining that she cares about Sylvia's feelings and thoughts. She points out that they share the common goals of all employees at their facility-to deliver quality care in an environment that features collaboration among patients, the clinical team, and management. The nurse manager then informs Sylvia that this collaborative environment has been compromised and that a resolution including all team members is required. She shares with Sylvia the concerns of her colleagues, while explaining that her goal in sharing this feedback is not to assign blame but to maintain the collaborative effort of the team in establishing a high-quality and safe environment for patients. In establishing a mutual purpose and maintaining a respectful tone throughout the conversation, the nurse manager has made the environment "safe" for Sylvia to express herself in an equally honest manner.

"Everything I do is for the patients," Sylvia asserts.

"I understand that you want to give the best care possible to your patients, and I appreciate your hard work on the unit," responds the nurse manager. "You've said you don't feel supported in your practice. Tell me more about what you mean by that."

To encourage Sylvia to express her feelings, the nurse manager is using a device described by Patterson and colleagues as "contrasting."7 The nurse manager doesn't minimize her concern about Sylvia's unprofessional behavior, but she makes a point of identifying the positive efforts Sylvia makes for her patients. For example, Sylvia has been a leader on the unit in diabetes education, teaching patients and family members about the disease. When discussing Sylvia's behavior, the nurse manager uses the phrasing, "It was reported to me that this incident happened[horizontal ellipsis] " She anticipates that Sylvia will use excuses as a defense mechanism and continues to use the contrasting technique to refocus the conversation on their mutual purpose and to encourage respectful dialogue.

When they each "tell their stories," the nurse manager is aware of the temptation to tell "clever stories," which are a way to justify one's actions.7 For example, Sylvia describes how she believed the unit was unsafe and thus was too busy to take the time to communicate professionally with the nutritional aide. The nurse manager redirects Sylvia by saying, "We aren't here to discuss the unit's safety; we're here to talk about your interaction with the nutritional aide."

Throughout their discussion, the nurse manager utilizes her power listening skills, frequently asking questions.7 She also employs a mirroring technique to assist Sylvia in giving more detailed responses. For example, she says, "You say you aren't upset, but I see that your arms are crossed, making you appear to be upset." She then paraphrases Sylvia's words to confirm she has understood her perspective. Finally, the nurse manager uses the priming technique when she believes the dialogue is not advancing, saying, "I think you may be overwhelmed by working and going to school full time while caring for your family. Can you tell me if I am right?"

At the conclusion of their discussion, the nurse manager restates their mutual purpose and notes that they've agreed that inappropriate interactions with the staff detract from their shared goal. She continues to work with Sylvia for the next six weeks, meeting weekly to discuss situations in which Sylvia has felt frustrated. They talk about the ways Sylvia communicated during these situations, and Sylvia states that she's now more aware of her behavior and its effect on her coworkers. The nurse manager notices that Sylvia has become more mindful of her nonverbal cues and of the way she speaks to her coworkers, and there have been no complaints about her behavior since their discussion.

Undesirable behavior. Christine McDaniels has been working on the unit for the last 10 years and appears to have a good working relationship with her peers. During the last six months, the unit has changed from a medical to a surgical unit, leading to significant changes in nursing practice and the patient population. In addition, many new staff members have joined the team.

During these months of transition, several new staff members have reported feeling intimidated by Christine and describe her as rude. The behavior they've complained about includes the provision of unfair assignments, an insistence on working with certain people, snide comments, and shouting. The nurse manager is perplexed by these complaints, which are the first in Christine's file. But when she informally surveys the staff, she learns that all of Christine's peers are aware of Christine's tendency to behave this way and have tolerated it because they're fearful of her retaliation-she is chair of the scheduling committee and has been known to "punish" coworkers who disagree with her by manipulating the schedule.

The nurse manager reflects on her personal goals for her upcoming discussion with Christine. She hopes Christine will acknowledge that her behavior has been counterproductive to the team and has alienated her coworkers. She knows the stakes are high, opinions may vary, and emotions are likely to be strong. In addition, as a new manager, she recognizes that she is most comfortable shutting down and simply agreeing with the other person's point of view. Thus, the nurse manager takes a moment to reflect on her own communication shortcomings and vows to stay focused during the discussion.

Their conversation begins with the nurse manager acknowledging Christine's passion for nursing and her willingness to go beyond her expected duties. She commends Christine, for example, for her work with the hospital's dietary department to ensure that boxed lunches are available to patients admitted overnight. The nurse manager explains that she wants Christine to retain her passion for nursing and to be successful as a nurse. She reinforces that their mutual purpose is to deliver exceptional care to patients.

The nurse manager then tells Christine that several complaints have been brought to her attention regarding Christine's behavior. Christine becomes upset and says, "I'm doing this because I care about my patients."

The nurse manager asks priming questions designed to encourage Christine to expand upon her answers, including, "What is happening that causes you to want to shout or put down an employee in front of others?"

Christine apparently feels threatened by this statement and stops communicating. The nurse manager recognizes that Christine doesn't feel safe in their conversation and redirects the discussion by reminding Christine of their mutual purpose: "I know we both agree that we must provide exceptional care on this unit, but the care we provide suffers when we aren't able to communicate effectively with our coworkers."

The nurse manager then begins again to address Christine's behavior, describing it and stating that it constitutes lateral violence in the workplace. Feeling safer in their conversation, Christine is better able to hear what the nurse manager is saying, and she says she understands how her behavior has alienated her peers. The nurse manager allows Christine to explain her actions. Christine states that she has been so passionate about patient care she hasn't noticed how her behavior and actions have affected her coworkers.

In their discussion, the nurse manager has encouraged the free flow of information and has discussed with Christine alternative ways to address the lateral violence that has resulted from her behavior-by encouraging greater self-awareness, for example. Christine, in turn, says that their discussion has made her feel supported and important rather than humiliated and reprimanded. By the end of the conversation, the nurse manager and Christine have developed a new mutual goal: that of respect and open dialogue between each other and among all team members. Christine states that she is appreciative of the feedback and appears to be truly distraught about the negative environment on the unit that she has helped to create.

Christine and the nurse manager schedule follow-up meetings over the next few months to discuss her continued progress. Their crucial conversation has been the catalyst to end a cycle of lateral violence, ultimately helping to promote an environment on the unit of exceptional patient outcomes and care.

An aggressive nurse. Tamara Neville is a seasoned RN working on a unit with a new charge nurse, Dana Rubino. Dana has a conversational style that can be described as aggressive-she frequently leans forward and speaks in a loud tone when discussing sensitive information, such as assignments and schedules. This style makes Tamara feel intimidated and flustered. It's not uncommon for Dana to make comments such as, "You're getting the next three admissions in a row, so I can see if you can handle it." Dana often calls her coworkers stupid and lazy.