Influences on conversations in healthcare

This month I’m focusing on the subject of conversation. This is a huge subject, so I’m just providing a brief overview.

Having completed reading: Crucial conversations (Grenny et al 2023) and now part way through: Let’s talk (Nihal Arthanayake 2022). These authors use interviews, previous studies and stories, in providing valuable insights into discovering why we react to certain dialogues, and how to have better conversations.  

In his interview with Professor Stokoe, Nihal discusses the difference s between “turn” and “taking” during a conversation, where each individual waits until someone has stopped talking before they take the turn. Some individuals will dominate a conversation so turn-taking goes out of the window, in disallowing or ignoring opportunities for others to join in to have their say.

There may be acceptable overlaps between people in conversation using speech like ‘mm or yeah, to show enthusiasm and support for the speaker, and that you are interested and following the dialogue.

On the other hand, we’ve all been in situations where people talk over us, or interrupt. It demonstrates a lack of interest, and reduces the quality of the exchange. For the person that has been interrupted, it takes on average about 20 mins to fully get back into a conversation, once that has happened. That’s a lot of potential input lost. Whereas, interruptions that are acceptable are those where permission has been gained to interject.

Get to the point!

I am certainly guilty of beating about the bush or going round the houses when it comes to some conversations. Sometimes it’s to protect someone or not hurt their feelings, other times because I am nervous or anticipating a back lash, so I’m protecting myself.

Unfortunately, the longer we take to get to the point, the weaker our message becomes.

It’s important to know your audience. You might be talking to someone who prefers direct communication, focusing on the core message, so decisions can be made quickly and efficiently. You on the other hand might prefer to tell your story. It’s not hard to imagine why someone who prefers direct conversation might lose patience with the story teller. So, get to know the other persons preferences for maximum success.

When you pre-empt that your conversation is going to be hard, because of the historical difficulties that have existed between you both, then you are already putting a barrier in place. Potentially closing off the conversation before you’ve properly got going. Letting go of your internal biases, or prejudices therefore becomes paramount if you are going to change the outcome.

When it comes to having difficult conversations at work, one thing I have learnt is not to focus on the past so much. My experiences of conversations with a particular individual, (and therefore ongoing opinion). Were based purely on previous negative interactions with him, where I felt disrespected, incompetent, and upset. Being naturally fairly introvert, speaking up unprepared was a no, no, so saying nothing was the easiest option.  

I wasn’t on my own in this instance, and guess what? We are far more likely to talk about the bad conversations then we are the good!

By changing my perspective, I am now able to consider that the behaviour I was on the receiving end of, is not the entirety of that individual. It goes back to making the effort to find that common ground with someone to improve your relationship and future dialogues.

Grenny et al, believe that by starting your conversation with good intention, it lays down the foundation for safety. Which hopefully reduces the chances of the other person becoming defensive! Even if that does happen, your good intention can be reiterated when needed.

These authors talk about using a skill called “Contrasting”. It’s a don’t/do statement that serves to avoid misunderstandings at the beginning of the conversation. It also helps create a safe space for communication.

-          The “don’t” part explains what you don’t intend for the conversation. So addresses others’ concerns that might be perceived as disrespectful.

-          The “do” part clarifies what your intention is for the conversation, confirming your respect and explaining your real purpose. (Grenny et al 2023).

Professor Stokoe’s message states that: “The most effective conversation is the one that generates the least misunderstanding, the least friction, and the least need to do the thing again”.

Conversations with patients.

Think about the type of conversations you have with your patients. The quality of which will be dependent on several different factors, and please add to the list as you see fit.

-          How well you have known the patient. (Just met them, known them a few days, or a long- standing relationship).

-          Your own state, and that of the patient (e.g. Upset, in pain, afraid, angry, or unfriendly).

-          The context and setting (e.g. Emergency, or less urgent, hospital or home).  

-          What you need to say or ask, or the information you need.

-          The questions the patient asks.

-          The language spoken, cultural beliefs, gender, age, their ability to understand.

-          People who have a sensory impairment

-          Those with other communication challenges.

As senior nurses and AHP’s you are trained to adapt your conversation accordingly. You’ve honed your skills over many years, and if you need help, you’ll ask for it. (e.g. family member, interpreter, friend or other professional).

You watch for the non-verbal cues, you use simple jargon free language, and you confirm levels of understanding as you go on. You are sensitive in your choice of words, balancing professional with personable.

You work on building trust by implementing all of the above, using all your senses, and it works. You communicate with your colleagues about the patients needs, discussing changes as needed.

Think of an experience you’ve had in your clinical environment when that communication with a patient is tested somewhere along the line. A classic example is where the patient has been given two different plans of care by two different members of the medical team. The conversation ends in with the patient in limbo, and someone back-peddling to rectify the problem or apologising for the misunderstanding. Patient care and trust is potentially compromised and it’s taken a whole lot more time.

Without attempting to find out what is going on for that patient, you are unlikely to make much progress in your conversation.

Returning to your professional relationship challenges, how much of that list above do you apply to encouraging a constructive conversation with your work colleagues?

I get it, you are too busy in your clinical role to try too hard at this. Otherwise you’d have done it by now.

What if you looked at the list again, thought about what you are already doing to try to improve things and what you could do better.

Having a conversation with yourself.

Conversations are likely to start as soon as someone enters a room. Not audible ones, but the ones inside your head. How many times has that dialogue continued even when the other person has started talking? Have you already formed an opinion good or bad? In Covey’s (2004) words, avoid prescribing before you have diagnosed!

I have to admit, if I’m on my own at home, going about usual housey things, I talk to myself. I think it relates to confirmation, and it helps to externalize my thoughts, reinforcing me that I’m doing the right thing.

It helps with problem-solving. If you verbalise your thoughts to yourself it can help you break down complex issues and make them more manageable.

Think of the times you have rehearsed something by speaking out loud, like a speech or presentation. The sound and strength of your own voice seemed to increase your confidence, reinforcing your ideas and making them more real.

Have you ever stood outside an exam room, talking to yourself in last minute revision, in the hope that saying it out loud will help you recall information? (I’ve definitely done that). 👍

Conversely, you are your own worst critic! Telling yourself all sorts of rubbish about not being good enough, or making generalisations about something or someone really won’t work!

I hope you’ve enjoyed reading this and here’s a few key points to take away.

1)      Think about contracting when you enter a conversation with a colleague that might be challenging.

2)      Use all your senses

3)      Seek first to understand – then to be understood. (Covey 2004).

4)      Practice empathetic listening. So, listen with the intent to understand rather than reply.

5)      Be open to change your perception

6)      Remain curious

Good luck!

References:

1.       Covey S (2004) The 7 habits of highly effective people.

2.       Grenny, J. Patterson, K. McMillan, R. Switzler, A. Gregory, E.  (2023) Crucial conversations

3.       Arthanayake, N. (2022) Let’s talk

Influence