Managing Difficult Conversations with Practice Staff

Of all the challenges incumbent in a physician's daily practice, one that often stands out as particularly tough, is having those difficult conversations with staff.  These can take the form of performance problems related to errors in clinical care, negative interactions between staff members, inappropriate staff-patient interactions, or unsuitable attire, to name a few.  Addressing these problems can feel like a no-win situation: avoid the conversation because it is uncomfortable and so the problem persists, or engage in the conversation and have it go badly and result in unknown consequences (defensiveness, the employee quitting, the problem persisting, and/or damaging the relationship between the physician and the staff member).

Let's look at how to have the difficult conversation AND have it result in positive outcomes.  It is helpful to recognize that all difficult discussions have at their core 3 common ingredients:

• Differing perspectives between the two individuals

• Emotions get triggered, and

• The stakes are high (either the results or the relationship may suffer).

Knowing that these form the basis of all negative interactions allows us to develop strategies to achieve a positive outcome.  Here are four critical strategies for engaging in the conversations:

1. Ensure that you have positive intentions for having the conversation and that you communicate those positive intentions.  Typically, the positive intention is because you want the person to be successful and that, by having the conversation, you hope they will learn and grow from it.  This starts the discussion off on a positive note and tends to be reassuring to the person. Here's an example of how to kick off the discussion:  "I would like for us to discuss the recent interaction you had with our patient, Mr. Jones, because I want our patients to continue coming to our practice and I want to help you feel more effective when you communicate with them."  Or it could be, "I know it is never easy to hear that there is something you could have done more effectively with patient care, so I am sharing this with you as a way to help you grow your clinical skills."

2. Look for ways to minimize threat for the other person. It is never easy to hear that someone is not happy with your performance or actions, so how you communicate that dissatisfaction is critical.  As stated above, one of the ingredients of difficult conversations is that emotions get triggered.  Strategies to minimize threat include letting the person know why you are having the discussion (communicate your positive intention), you are there to be supportive and help them learn, saying you believe in the person's potential to grow and change, and asking for their perspective on the situation.

3. Helping a person learn and/or change their behaviors should involve less "telling" and more "asking."  If you truly believe in the person's potential and ability to grow, then the use of open-ended questions gives them the opportunity to tap into that potential.  Of course there are times when asking questions is not the most effective strategy for changing behavior - this occurs when the person lacks necessary knowledge and/or skills.  For example, if the person provided inappropriate care, the person may not know that is was not the right action and helping them understand this might involve less asking and more sharing of information.  Whenever possible, it is best to ask more than tell.  When you communicate genuine curiosity in how the person sees the situation, you allow them to begin to explore and examine their own ideas and insights.  Additionally, asking questions helps you to understand what might be "at stake" for the person (as mentioned above, one of the 3 key ingredients of difficult conversations).  An example of this might be that when you express dissatisfaction with how the person provided care, that person might feel afraid of losing his job, or feel that you don't like him.  Understanding this allows you to provide reassurance as appropriate.

4. Focus more on the solution than the problem.  Asking questions and providing feedback that is solution-oriented is much less threatening than focusing on the problem.  Being more solution-focused involves asking questions such as "How might you help Mr. Jones feel that we are being responsive to his concerns?"  or "What ideas do you have for how to improve patient flow in the office?" or "I would like you to prepare the patient in this manner so that we can be more efficient in treating the patient."  Solution-oriented communication can help to foster a positive learning culture in your practice, where people engage in resourceful problem-solving rather than negative complaining or blaming behaviors.

Of course, like any other skill, successfully managing difficult conversations takes practice and a genuine desire to learn effective communication practices.  Put the strategies above into practice and you will find that those conversations are actually not as difficult as you thought they would be.

Catherine Hambley, Ph.D. works with healthcare providers and organizations to facilitate effective leadership, team interactions, and high-performance cultures.