Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Courageous Conversations: Meeting the Challenges of Change Leadership

11/27/2013 10:44:23 PM | 0 comments

As a nurse leader, I once overheard staff talking about a certain nurse who was abrupt with a patient when he tried to give her a lengthy explanation of his condition. In the past, I had observed this same nurse being somewhat curt with colleagues, and several patient surveys had described "rude" behavior by this person.

Though red flags were waving, I was reluctant to act. Rarely does a leader take their role because they excel at or enjoy confronting members of their team. Even those of us with years of experience can think of reasons to postpone a conversation with a team member who is derailing our team's success:


However, I've learned over many years of experience that problem avoidance does not improve the behavior or the situation. Addressing issues requires courageous conversations. What's more, the coming sea change in healthcare demands fundamental shifts in organizational culture. To meet the challenges of reform, physician, nursing and administrative leaders must prepare to confront values, customs and processes that do not serve the goals of the organization.

On the bright side, when managed with empathy and consideration, "courageous conversations" can improve performance for the team at large. Concurrently, in this era of value-based performance, ensuring that everyone is striving toward the same goal can ensure an organization's ongoing success.

Here's the process I teach to leaders of all kinds who are striving to meet the demands of today's healthcare environment:

Know when to act. Issues come to your attention in many ways: from your team, your customers and from your own observation. Anyone can have a bad day, but problems that arise multiple times from multiple sources should be considered red flags.

Decide what action is needed. Are you confident that your reports understand your expectations? If not, a general conversation for everyone should occur. (Hopefully, this clarification will take care of any outliers.)

If that does not work, or if expectations are already clear, it may be time for one of those courageous conversations.

Have the talk. As soon as you're aware of an incident, find the person responsible and ask to talk them. (Make sure to respect their privacy.) Often, the person will not fully realize the impact of their behavior. It's important to share others' perceptions and ask for some self-reflection about how they will act differently in the future.

Write it down. Documenting the conversation can be as simple as sending the individual an email thanking them for the discussion. Tell them you were reassured by the fact that they were not aware of the perception others had of them and appreciate their willingness to work on the issue. Documentation is important because it means that a second occurrence will be real in the eyes of human resources.

Follow up if necessary. In at least one-third of cases, the issue will reoccur. In the second conversation, it is important to ask the individual if they remember your previous conversation. If they say they do not, refresh their memory by sharing the date and your notes.

Ask them, "Why do you think this is continuing to happen?" Listen to what they say, and guide them if they are misdirected. If the person is in denial, remind them that the pattern of behavior is not acceptable, because the two of you have already discussed it.

Formulate a plan of action. At this stage, it's time to make an improvement plan. Offering a mentor, suggesting self-help books and referral to employee assistance are all possible strategies. Share that further recurrences will lead to corrective action.

Hold them accountable. In my experience, the first courageous conversation is not terribly difficult, the second is more difficult and the third is the one I want to avoid.

When the third conversation occurs, it is important to ask the individual about their will to continue in their current role. Compassionately ask them if they have thought of something that might allow them to be more successful or happy in their job. Let the individual know their pattern of behavior is not acceptable and your plan is to hold them accountable — even if that means they need to find a place where they can be more successful.

Commence corrective action. At this point, the process needs to be formal and documented. Whatever your HR process is, initiate it now.

Between meetings with this individual, it is important to treat him or her like anyone else on your team. If they demonstrate improvement, let them know the change is positive and noticeable.

Continue to set high expectations. Good coaching practices are essential to culture change. Use straightforward language to describe issues or needed behavioral changes. Being direct and to the point demonstrates the seriousness and strength of the leader.

In my experience, individuals who require "courageous conversations" make up about 5 percent of the team. Holding those people accountable makes the other 95 percent happier and more responsible.

The position of leadership will never be easy, and being a leader will not make you popular. Leaders need to focus on the organization's vision and mission to sustain a positive culture. Sometimes the only way to achieve that is by the use of courageous conversations.

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