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Silence Kills, Dialogue Heals
August 20, 2007
The reluctance of American workers to confront questionable workplace practices takes an extensive toll on results such as productivity, quality, job satisfaction, and especially safety. Here's how to use crucial conversation skills to address issues, solve problems, and save lives.
By Walter L. Ross, Ph.D.
Why do fatal auto accidents occur when the passengers in the car are fully aware their driver is driving under the influence? Why do commercial airliners crash when members of the cockpit crew have reason to believe the aircraft is unsafe or the conditions are treacherous? Why did the seven crew members of the space shuttle Discovery lose their lives when qualified scientists and technicians had reason to question the safety of the space vehicle before launch?
The propensity to remain silent rather than confront unsafe practices is embedded deeply in our culture. Sometimes it has dire consequences, and sometimes the consequences are fatal. The reluctance of American workers to confront questionable workplace practices takes an extensive toll on results such as productivity, quality, job satisfaction, and especially safety.
Unfortunately, health care is not immune from these same destructive tendencies. Even in an industry where the stakes are especially high and errors can mean the difference between life and death, people are reluctant to speak up about questionable practices.
Indications that people hesitate to confront unsafe practices include: the 3.5 million infections contracted each year in American hospitals, incorrect or suspicious medication prescriptions that go unchallenged, or professionals who choose to quit their job rather than confront a co-worker. Or how about the number of medical errors that occur such as the patient who entered the hospital for a routine tonsillectomy and left with an amputated foot—when no less than seven members of the health-care team had reason to question the procedure that ultimately was performed.
The results of a national study of health-care practices conducted by VitalSmarts and the American Association of Critical-Care Nurses helped to shed some light on these issues. The study called, "Silence Kills: The Seven Crucial Conversations for Health Care," was built on past research that showed more than 60 percent of medication errors are caused by mistakes in interpersonal communication (JCAHO).
The study revealed two most interesting phenomena. On average, 90 percent of health-care practitioners fail to confront their peers about questionable health-care practices: Nurses don't confront nurses, doctors don't confront doctors, and nurses and staff certainly don't confront doctors.
Perhaps the most intriguing finding was that the 10 percent of professionals who do confront their peers about questionable practices hold these crucial conversations in a way that effectively leads to improved performance, increased trust and candor, and stronger relations with the people they confront.
The fact that this select number of individuals can effectively address unsafe or questionable practices isn’t just a matter of courage. An analysis of what these individuals do revealed that they understand and use crucial conversation skills. In short, they skillfully address issues, solve problems, and save lives by the way they communicate. What are these key skills?
1. Dialogue: These effective individuals understand the power of dialogue in holding crucial conversations that result in positive outcomes. Dialogue means a two-way, candid conversation with both parties feeling they hear and understand the other person and, in turn, are heard and understood by the other person.
2. Intent: Crucial conversations begin with clarity about personal intent. The intent of these health-care professionals is to correct unsafe practices and to improve and strengthen communication and relationships—not to punish, embarrass, reprimand or belittle.
3. Safety: The environment for effective dialogue is safety. Both parties have to feel safe to engage candidly in the kind of conversations that result in a win for both parties. Safety is created in three ways. The first is by beginning the conversation with a clear statement of positive intent. The second factor is dialogue and agreement about mutual purpose or jointly shared goals and outcomes. Finally, an open expression of mutual respect—genuine concern for the person being confronted—is the third factor.
4. The Right Conversation: One of the keys to holding a crucial conversation is to talk about the right issues. To do this, the person initiating the conversation first must understand the situation. This includes separating the facts from assumptions. We are all prone to explaining what we observe by interpreting what we experience and filling in the gaps with our own assumptions about "what really happened."
After ensuring we understand the situation we are confronting, we need to hold the right conversation. Discussing the wrong issues will not lead to the desired outcomes. If the issue is something that has just been observed—such as an unsafe practice—then that is the focus of the dialogue. If the issue is a pattern of behavior, the conversation should focus on that pattern of behavior. If the issue is your relationship with the other person—for example, you find yourself not trusting him or her—that would be the topic of conversation.
It is easy to get pulled into discussions that debate the wrong issues. When this happens, the crucial issue is not addressed. This is why it is critical to recognize when the conversation is getting off track and to stay focused on the right conversation and the right outcomes.
5. Move to Action: The final skill is to move beyond dialogue to action. This involves creating desired outcomes, a path to action, mutual commitment, and provisions for follow-up. The question is, how do we break out of this deeply embedded culture of silence? Can these skills be transferred to others? Patrice Putman, director of employee development at MaineGeneral Health, a health-care system in Maine, addressed these issues when she implemented a culture change initiative in her facility, which included Crucial Conversations Training. The results were promising:
• Managers who learned the skills showed a 53 percent improvement over other managers in speaking up about a shortcut that could be dangerous for patients.
• Managers who learned the skills showed a 51 percent improvement over other managers in addressing a mistake in providing patient care.
Health-care professionals, like many in our society, believe it is easier, safer, and less of a hassle to ignore unsafe health practices. Consequently, they compromise lives for personal comfort. As Putman demonstrated, it doesn't have to be this way. With the right skills, anyone can address unsafe and questionable workplace practices to create and maintain healthy working environments.
Walt Ross, Ph.D., is a master trainer for VitalSmarts, an innovator in corporate training and organizational performance. He is certified to train on "Crucial Conversations" and "Crucial Confrontations," programs that help companies improve organizational effectiveness, build teams, and enrich relationships. For more information, visit www.silencekills.com.
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