22 December 2020

Dr Chris Tiplady, Honorary Senior Clinical Lecturer and Director of Undergraduate Studies for University of Sunderland reflects on the challenges in holding difficult conversations as a manager and clinical lead.

When you think of a difficult conversation, who or what comes to mind? Was it your own dread, was it the content or was it that you just didn’t know what to say? Many of us are trained to give bad news but what we are often not trained in is managing unprofessional behaviour, resolving disputes or having to speak to a colleague about something sensitive. We can find ourselves in these situations because of responsibilities, because you are seen as the sensible one or just by accident.

Conflict between people and teams can be very damaging, just read a little around #civilitysaveslives to understand the clinical impact of bad behaviours. The “civility saves lives” campaign is led by Dr Chris Turner and aims to show us how rudeness is harmful to the quality and delivery of healthcare. Simple measures like being polite are easy to institute and they share lots of positive stories about the difference people see when we are being civil. Disagreements, strong opinions and debates are healthy but rudeness, gossip and violence are just not. How can you stop things escalating? What is your role when you see or hear bad things? What can you do or say when you find yourself stuck in the middle? Why on earth should you bother when it is far easier to just ignore it? And when half of our professional conversations take place online what is it about these conversations that can so easily go wrong?

Be aware that everyone can have a bad day though, a day when it might not be right to have a difficult conversation unless you really have to.

It’s all in the build up

Difficult things are only what you make them. If you expect it to be difficult, it will be. How you think will affect the words you choose, your body language and your tone. It is good to prepare for the hardest conversations but whatever you do, don’t script things. You might be having to tell someone about a mistake they made for example. This is never nice to hear, but pretty much everyone wants to know if they have erred. Make sure you know what you want to cover, stick to the facts and tell them what needs to happen.

Avoid accidentally upsetting people

I think this is what people worry about most. Just acknowledge it if it happens. It is either because you have got the story completely wrong or you have got it completely right and touched a nerve. Be prepared for two versions of any story, keep your mind open to all explanations and don’t worry if you have to pause things for a while. We are talking about adults here. Be aware that everyone can have a bad day though, a day when it might not be right to have a difficult conversation unless you really have to. Ask if they are OK to talk about something, make an appointment with them so they have time to prepare, don’t talk in the corridor, give them that warning shot – it will be appreciated.

Learn to reframe

We had massive road works on the A1 in Newcastle for several years. The traffic signs were proud examples of reframing, “Lanes narrowed for your safety” and “Road improvements ahead”. They were all telling us to expect the bad news of delay but done in a way to help understand why. A simple technique but useful for all sorts of difficult messages.

Know where your own biases lie, consciously eliminate them and the personal reactions from your conversation.

Avoid hooks and triggers

One of the stand out things I remember from my own mediation training was what hooks and triggers are. Important to be aware of so you can be seen to remain impartial in any conversation. If someone is using a 'hook' they are effectively 'fishing' with phrases to see if you are on their side. For example, 'she is just like all doctors, isn’t she?' or 'can you believe they thought that was right?' These are usually unconscious actions for the speaker but if you find yourself nodding along or agreeing then you are instantly revealing whose side you are on. Watch a good interviewer with a good politician to see more overt examples of this.

Triggers are more subtle devices. You need to know what your triggers are, the things that make you see red, get angry, be a bit irrational. It could be sexism, swearing, unfairness or just people wearing sunglasses indoors. Know where your own biases lie, consciously eliminate them and the personal reactions from your conversation.

Listen more than talk

It is a really old adage in medicine but it is the best way to really understand what is going on. Don’t feel you have to fill in every silence. Once someone has the facts they will need time to process them and may even need a day or two to formulate a proper response, so don’t worry if you don’t conclude a difficult conversation in one go. If you have made it clear you are open, are not prejudging or prejudiced, then people will talk to you. Responses to errors are a good example of this. Once a person has understood what happened they might start talking about why it wasn’t their fault. With time, reframing and reflection, they might move onto the things they can do to prevent it happening again – a far more useful conversation to have. Use of the phrases 'what else?' or 'is there anything else you have considered?' will help.

Do not have difficult conversations via text. You miss out on reactions, body language, tone and kindness.

Communicate face to face

Some emails just make you feel angry and there are the emails you write and regret instantly. So much of our communication is text based and instant, it feels like cycling along a road littered with pot holes. One wrong turn or lapse of attention and your front wheel is off. Sometimes the best thing to do is to go and see someone. Do not have difficult conversations via text. You miss out on reactions, body language, tone and kindness. By all means arrange a time to meet and use it as a warning shot, but don’t do the hard stuff on email. I was told off by my daughters once for 'full stopping' a few years ago – a full stop on the end of a text was seen as a final 'do not reply or disagree' message. I realise that is quite an extreme example but it shows how easy it is to misinterpret a message on the receiver’s end.

Similarly, be aware how easy it is for disagreements to start on email. Many folk fail to appreciate how they are perceived on email. Long winded elaborate 'mansplains' or short aggressive denials all convey something to the receiver and might be their 'trigger'.

Maybe we should all be using emojis?

Get trained

We have had a long culture of conflict resolution and management in our Trust and a review of this work was commissioned by ACAS in 2015. Training in conflict resolution, difficult conversations and the implementation of mediation as part of routine dispute management over a ten-year period has contributed to the very high rating in the most recent staff survey. Many staff across the organisation know how to de-escalate, how to manage disputes and how to have difficult conversations. You can be trained in such things, there will be an excellent return in terms of culture and patient care.

In summary

As a clinical haematologist I have often had to give some really awful news to people. As a manager and clinical lead I have had to have difficult conversations with colleagues about mistakes or performance. I think they are both hard in their own ways. You have to maintain a relationship, a working understanding and a trust for the future. You can not avoid either one, you can not shy away from responsibility and you can not ignore things hoping they go away. Learn how to do it properly, go on the course, watch a colleague, sit in, read, reflect and strive to improve.