Welcome to today's TCA webinar, A Framework for Success Using Spikes in Difficult Conversations. I'm Kim Berry and I'm going to be the moderator for today's webinar. This is such an interesting topic and I anticipate that there are going to be many questions. So if you have a question, please place them in the chat. We will be addressing questions at the end of the presentation today. So let's get started. It is my privilege to introduce the team sharing their knowledge and expertise with us today. Michael Pellegrino is a member of Inova's patient experience team, working with teams to foster a more seamless experience for patients and team members alike. Michael also serves as chair of Inova PRIDE team member resource group, promoting a welcoming and inclusive environment for the LGBTQ plus community at Inova. Michael joined Inova last year, following a decade of clinical work as a music therapist. He supports Inova's communications training as a simulated patient and jumps at opportunities to work with committed, caring individuals as they grow their skills. Mackenzie Rowe is a third year general surgery resident at Inova Fairfax medical camp. Dr. Rowe has been interested in surgical education and effective communication that enhances teamwork and relationships and results in improving patient care and experience. Dr. Rowe has been involved in projects that improve and steady residency feedback practices and has been supporting communication training efforts for the program. Anna Newcomb is the education director for Inova Health Systems Surgical Simulation Center. Dr. Newcomb focuses on communication, leadership and professionalism research, development and training. Her most recent efforts have included the development, dissemination and evaluation of relationship focused feedback, training for the clinical staff, engaging former patients and current staff as actors and trainers. So without further ado, I will turn today's presentation over to them, so Anna, take it away. I am going to just, before she gets started, sorry, I set her up and then I stopped her. This is our disclosure for today's live webinar. It is worth one CME and there are no disclosures. So now Anna, take it away. Thank you, Kim, really appreciate it. And we're so excited to be invited by TCAA to be able to share these skills that really run across all forms of medicine, but actually in the home too. Today, what we really wanna talk about is recognizing the communication challenges that most folks are experiencing in some way or another in trauma care, and we'll be presenting or maybe re-presenting to you this model of approaching difficult conversations. Most folks in medical school have heard of spikes. The rest of us, if we haven't been in medical school in the last six years, it's new to us. And then we're gonna do a little bit of a demonstration of how that model might be effective in breaking bad news and with engaging with a challenging staff member, which is really our more recent interest in this approach to difficult or crucial conversations. So we, actually, Mackenzie, are you ready to, yes, or Michael, sorry, sorry. Yes. Let me hand this over to Michael to think about together about what would you consider or what do we all consider a difficult conversation? Yeah, so a poll has popped up here inviting our participants today to share, what counts as a difficult conversation for you? Of course, as we're having this conversation, we wanna start out by defining what a difficult conversation will really look like. And so some of the criteria we have listed, right? A conversation that maybe evokes strong emotions. So understanding that people's feelings are gonna be at play. Looking at the stakes or how much a conversation really matters. If we're talking about a healthcare environment, many of our conversations have high stakes. And then the sense that a conversation may be contentious. Is it going to be difficult to predict how someone's gonna respond? Or is the person you're hoping to talk to maybe gonna get defensive about the topic? So these are some of the things that we wanna kind of keep in mind as we're talking about difficult conversations broadly. Seeing the results of our poll here, we have a wide majority of our participants today highlighting that confronting a colleague regarding their clinical practice is something that is one of the more difficult conversations you may have to have. So that's good insight for us as we're gonna be moving into the conversation later today. And thinking about that difficult conversation with a colleague or with patients, it sounds like the patients and the families are less of a challenge, but still those difficult conversations bring up a lot of stuff. And I'm wondering Mackenzie, in your practice as a surgeon, what do you notice kind of gets in the way of choosing to have a crucial conversation? Right, so there are really a lot of things that can kind of step in the way and make you a little bit hesitant or maybe it'd just be easier to not do it, but overall when you know it's the right thing to do. And so it being a stressful situation in general, whether it's family stressful situation between themselves or with the staff or between having your own emotions about the situation. So it could be, you get really invested in these families and so, and having to deal with all of that or when it's a colleague, you know you're gonna be seeing them again and having to deal with all of that stress can be a lot for people not knowing how to have the conversation. And so that's why we're here today. So we could talk, give some people some tools, but when you don't have those, it can be really intimidating. A lot of us too just don't wanna do it wrong. I feel like a lot of people in medicine are a bit of perfectionist, right? And so I don't wanna try and then mess it up and then it's just even worse. And so that's the fear there. And then having bad experiences in the past, whether they were the one leading the conversation or they were the one receiving the conversation that can make it really difficult to try and do it again when you know it went poorly before. And so if anyone else has any thoughts of what has been made it difficult for them to have difficult conversations, that would be a good time to throw them in there. Yeah, go ahead and put stuff in the chat so that we can make sure that as we progress, we can think about ways that we might overcome some of those barriers. Give us an idea, and we've got our chat open here about what might be getting in the way of being brave enough to approach some of these conversations. And while you're thinking about what it is that gets in the way, we're going to be thinking together about how to use the spikes protocol. And I'm not sure if you guys have had a lot of exposure to it, but it gives us a way of thinking. It's not linear. It's just a way to think about the different approaches you might use to having this conversation. So it has to do with your setting and perspective, and we're going to go through each one of these at a time. I see that we've got a few comments here that having the repeat conversations with the same colleague. Actually, we're going to go over that at the end of the webinar, we're going to demonstrate one of those repeat conversations, physical size of the person. So Mackenzie, you can't tell Mackenzie is not a very large person. She may end up at some point dealing with some patients who are a little bigger than she is. And that may be intimidating. So we could talk about that. And for me, conversations with patients and families are short term having one, okay. We hear this all the time when we're doing how to give feedback to a peer and Mackenzie, I'll get you in on this in a second. But we do these trainings where we're asking people to not confront a peer, but have a meaningful conversation around their practice. And they tell us, you know what, it's just easier to fix the problem, because the patient I'm going to see one time, and my peer, it's super important that I maintain that relationship. So what we wish to do is have relationship focused kind of conversations, conversations that actually enhance our relationship rather than impale them, while we are also addressing some maybe clinical concerns. I don't know, Mackenzie, do you find that that is something with your team, that maybe gets in the way of having feedback conversations? The worry about the relationship long term? Yeah, absolutely. That's known as like one of the top barriers to feedback in general. And so we actually were just doing a study on we set up a structured peer feedback time. And I asked the question at the end, I said, Do you feel like this changed any of your relationships? And so far, all the responses have actually been no. So that's actually really reassuring. I think we give each other more grace than we think we do. So thinking about the spikes protocol, the first, the S, it has to do with setting and I always think of setting initially, I thought of setting is like being in a private space, don't be having these conversations in front of other people. Certainly not in the trauma bay, telling somebody how they did badly in front of everyone. So part of the setting is taking it out of an audience. But the big part of the setting is really where headspace is and, and how you are getting yourself prepared to have that conversation without being as, or as being as free from your anxiety as possible. Not always possible. But Mackenzie, how is it that you manage the setting when you're having these kinds of conversations? I think it's really important not to have a conversation when you're upset. When you're really angry, that's a really bad time to tell someone that they did something wrong because you're probably going to say something that you don't mean or in a way that you don't mean it. And almost always, if you just wait, even if it's a few hours, you, you think a lot more reasonably, right? Like trying to have a productive conversation is different than just telling someone that you're mad and not being able to talk about how we can make it better. So I think the main thing for me is waiting until the time has, that immediate time has passed, but it's still pertinent to them and talking about it later. So Brooke Wilson is mentioning that the time, having that conversation quickly, but respectfully is important to have it be relevant to what you were talking about. Not have it be like three weeks later and you're been harboring this thing, but also as Mackenzie mentions, not having it in a hot state. We really want to be cognitively engaged rather than just emotionally engaged in the topic. Thinking about the perspective, this is something that physicians who are, or clinicians who are very comfortable having clinical conversations with patients, they're very good at this. They often start with, let me just find out where you are so that I'm not over explaining something that you have heard a bunch of times and just assessing what's going on. So this works both with patients and with your staff, getting a sense for what is their understanding of the situation. Mackenzie, how do you lean on this? Like you said, that's any difficult conversation I'm about to have with a patient, I introduce myself and I immediately ask them what's going on. Like what do you think, what do you know is happening right now? Because you don't want to be talking at someone, you want to be talking with someone and the level that they're at. And then when it's a peer, it's kind of asking, I think it's really important to start with questions. If I noticed that Michael did something wrong, I don't want to go to Michael and say, hey, you did this thing wrong, because I have no idea what the context of that situation is unless I asked him and he's like, well, actually, like someone told me to do this because of this reason. And then I look like a jerk if I'm the one who was like, oh, well, okay, my bad. Right? Like just start with questions is how I always approach it. So thinking about the invitation, this is getting a sense, this is after you have figured out what is their perspective on it. So you're kind of gathering data about what is the situation that you're about to deal with. But then you also want to get an idea of how much they're into this conversation right now. You might have done the setting well, where you create a psychologically safe space. You have each other's attention, but then you do want to know, is this really the time that they are prepared for this kind of conversation? And there's a couple of comments that are actually relevant to this. One was Melanie mentions dealing with a colleague who doesn't see their shortcomings as an issue. Mackenzie would have or we might have understood that when we say, tell me what you think what we're dealing with. And when that colleague says, I don't really know what the problem is, but my Bob over here is really always in my face. You may be able to get an idea of, are they prepared? If Bob is really in their mind, the person that's really the problem, you might say, I wonder if it would be okay if we have a conversation about that. And they know right away that you're not agreeing that Bob's the problem. This is one of the ways that you might do an invitation to have a conversation that might be slightly different than their perspective. Mackenzie, is this something that you find is useful with patients or mostly colleagues? I admittedly, I don't always do this one. And I think that's something for me to work on. And sometimes the situation makes it a little bit more difficult, but the way like you put it here as an example, right, like finding your, asking the perspective really gives you the intro into asking the invitation, if that makes sense. And so once you hear their perspective, like, oh, let's, can we talk more about that? And I feel like that's kind of the easiest way to move forward. Bentley Morgan here says that, how do we approach this to prevent the defensiveness? And what do we do when the receiver becomes defensive, despite our delivery? We are sort of trying to set it up prior to giving our observations and our opinion. We're trying to get a sense. We're trying to communicate that we are actually open to learning something. We're open to hearing a little bit more about what their perspective is. And that may support they're not feeling quite as defensive. If we come in right away and say, let me tell you what I see, rather than starting with, let me hear what's going on for you. Is this an okay time for us to talk about this? They can get a sense that you're going to give your observations. That may, it may not, Bentley, but it may help them get a sense that you're not here to yell at them. You're here to have an actual back-to-back conversation with them. Then this is the part that the providing knowledge or giving your observations of what you see regarding their practice or regarding the information that you want to share with the patient. The most important thing that we try to give, we try to ask our learners to practice is to speak slowly. So when we are giving crucial information, the person who's receiving that information is likely in a heightened state of anxiety. It's more likely to be in the heightened state of anxiety than if you're just having a regular conversation about what you did last weekend. So they may be having a harder time absorbing the information that you're offering. So this is a good time to not throw a whole lot of information in all at once. Medical information is going to get lost if you are hammering away with medical details and information about your feedback to them may get scrambled in the anxiety of receiving it. This is when it's a really good time to talk in short bursts, stop, give it some space, see if that space gets filled with a comment of theirs, or if it's an okay time for them to, for you to continue. Really giving time to process. Now, Mackenzie, of all three of us, you're probably the main person who has provided the, say, bad news or information about a diagnosis. We'll get to the whole peer thing in a little bit, but tell me how you find giving information has been most effective and when you found that it's not landing at all. I think, again, asking perspective guides this a lot because if someone knows nothing, you shouldn't give them all of the details on what their drip doses are and like this and this and this, right? You want to keep it more basic to start, and then if they want more, they'll ask more questions. And so I've run into this problem before where I went to go talk to a family in the ICU and had to give some really bad news about somebody's spouse, and I think I was nervous and I gave a little bit too much information, and I was like, he didn't, I left and I was like, he didn't absorb anything I just said. There was nothing I said that landed, except this is really bad. And so I didn't need to say all of that, right? Like you can, if they want more, they'll ask you later. And so really just starting with the headline and the base, and then seeing what happens from there, I think has really been the most effective when I've been able to do that. Michael, give us some idea of how we, how we use the acknowledging or addressing emotions to really ensure that the conversation is a conversation and not a yelling at. Yeah. One of the things that I find myself saying a lot to our team members is that we are very solution oriented people in healthcare, oftentimes because of the time constraints on our day and the expertise that we carry, there are many times where we really jump to solutions very quickly when we want to put empathy first. So in our conversations, the, the ways that we can do that, and there's some of the, some quotes here, I can see that you're caught off guard by this. It sounds, it sounds like you're frustrated by this. I can imagine this is difficult news to hear where you are reflecting the emotional experience you expect the individuals having, or that they have expressed they're having demonstrates that you're listening. And it, once again, it puts their feelings at the forefront. So you can build a partnership in terms of, you know, what their experience is like, and they feel that they can trust you a little bit more in conversation. So it, it, it again, comes from that place of, of learning and connecting with the person that you're trying to have a difficult conversation with. It does seem like so much of that is really building trust. We are, it is hard for anyone to listen to us if they don't trust us. They're going to be having a lot of thoughts against us if they don't sense that we are really attending to their state. And what we ask of, of our learners is to attend to the emotions. That doesn't mean, oh, this looks so bad. It doesn't mean having a support group right there. It just means helping them know that you, you are interpreting, you recognize the situation that they're in and you are still with them. You're still going to be able to support them in one way or another. So we will be talking a little bit more about attending to emotions in a little bit, finally. And this whole thing doesn't have to take 35 minutes. It can actually all happen in a one to two minute conversation. You can attend to emotions. You can make sure that you are personally in the right space, not in a hot state. You can make sure that they are ready to hear what you have to say, or if they're not, that you make a plan for another time. And sometimes the setting is, and the perspective and the invitation ends up with setting a date for having this conversation at another time. Michael, just a heads up, when you and I do our first, our first role play, we might say, no, this isn't a good time. So it just may be that we are not going through these things all in the same order, but at some point we're going to get to this. And finally, we will end up with some kind of, what's the plan for the next thing? And summarizing so that we both recognize that we've said that we are on the same page. And thinking about the impact of this stressful environment of trauma on patients and families, we know that everyone here on this webinar is in the field of trauma. So we recognize, we've seen the families who are experiencing catastrophic emotional distress. We've seen what that looks like. We have experienced, but maybe not fully understood, that when they are under that intensity of stress, they're cognitively impaired. They are not able to absorb the information that you are giving as easily. They will say, and I'm confident Mackenzie has heard this a bunch of times, no one has told me anything yet. And you have been present and telling them that every day. And when they say, no one has told me anything about what's going on yet, and you are the one who has done that, you translate into that, I have not been able to absorb and process what's been told to me so far. So you don't say, no, I was there yesterday. You might respond with, if someone says, no one's told me anything yet. You might say, again, start from the beginning, tell me what you do understand. And I want to make sure that I'm able to help you understand what's going on. And I am happy to share this with you again. And then I often, personally, I often say, one of the things about trauma is that it really messes with our ability to understand and process stuff. I just want you to know that. And so that if you have to ask me again, that is perfectly fine with me. I am happy to review this again. It is a small price for us to pay to say it again. It is a big price for them to hear you say, I did tell you that. And you should have known this. I don't know, Mackenzie, tell me about your experience with people, their responses, your patients' and families' responses to this high-stress environment in terms of their capacity to understand what you're saying. I mean, just like you said, it's really often that patients ask the same questions over and over again, or their family does, or one family member tried to tell another family member, but then they come in and they don't know what's going on. I feel like that just happens all the time. And I really liked the way that you said that. I think I'm going to steal that one for the future, right? Like, oh, trauma, you know, this is really normal to, you know, let me, I'm happy to explain this to you again. That's really good. Because they can sense that you're judging them for their cognitive impairment. It's like judging somebody with a TBI for having a TBI. So we need to just help them understand we have seen this. We are not freaked out by the fact that you don't remember anything. And they're also just not in the environment that is comfortable for them. I throw this slide up because we did a study in our ICU where we asked a whole bunch of family members what it is that seems to impact their understanding of the situation that's happening. You can't even see all these things. What is their understanding of the situation for their family member, for the patient compared to what the surgeon is saying? And we looked at all the different factors that they were experiencing at that time. And what I put this up so that Mackenzie and others can recognize that even though you may have said that a hundred times, that it is not always your skillset of communicating with them that impacts their capacity to fully understand what's going on. There are so many other things that are happening that have to do with what they're worried about financially, what they're worried about with their child who might have seen something, whether they don't understand what somebody else has said because it's incongruent with what you're saying. There are so many other things besides the way that we are engaging. The best that we can do is continually understand where they are so that when we start providing information, we're not just pouring more information on them that is not so much of value. Yeah, and understanding all of these factors that are playing into the dynamics of communication with our patients and our teams, it's helpful to bring it back to this human-centered perspective. And that's why we have this Maya Angelou quote up here. I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. So that's gonna be central in the way that we're working through the rest of our presentation today. So in that vein, I would like Mackenzie, I would love it if you would provide Michael with a little bit of information in the ICU. He has had a fairly traumatic experience finding his friend at the base of the stairs and his friend came in with a TBI. This friend was found unresponsive at the bottom of the stairs by Michael, came into the ED with an ambulance, stable vital signs, but it looks like he's got this bilateral subarachnoid hemorrhage, diffuse axonal injury. So there's not, when we've done this in the past, the surgeons have gone with, there's not a lot of hope, TBI protocols begun, and you are, and Michael hasn't met with anyone yet. He's in the waiting room for you in the ICU. And we'll just go for like a couple of minutes. Hello, hello. Hi, are you the friend of patient Mr. White? Yes, yeah, I'm Michael. How's he doing? Hi, my name's Dr. Rowe. I'm one of the residents on the ICU team. I just wanted to come and kind of give you an update. So what do you know so far? Honestly, not much. I, you know, we got him here as fast as we could. I found him this morning at the bottom of the stairs and called the ambulance right away, but I really don't have many updates in terms of how he's doing after the fall. Wow, yeah, I'm sorry. That must've been really scary. And so I'll tell you that since he has come to the hospital, we found that he has a pretty severe brain injury with some bleeding into the brain. And so we're monitoring him really closely and doing all of the things to try and help with that swelling right now. Is he gonna be okay? You know, it's really hard to say what exactly is gonna happen with brain injuries. They are pretty unpredictable, but right now he's not really able to do very much. Oh my God. You know, we like go for a walk together like every day and that's, and I like texted him last night, but he didn't respond. And I'm just like sitting here wondering like how long was he laying there? Like how long had he been that he'd fallen? I just, I should have done something sooner. You know, this isn't your fault at all. And he's on a blood thinner. And so this can happen when people fall, they can get these really bad brain bleeds, but it was nothing that you did and there was nothing that you could have done. Is there anything you can do for him? Is there anything that your team is doing? Yeah, absolutely. So we're doing everything we can right now. We've got him on different medicines and different really close monitoring systems to try and help with the swelling and do everything we can. And the rest of it will just be time. So we'll be adjusting things as needed and as we can, but right now we just kind of need to see what's going to happen. You mentioned time. Is there a sense of when we'll know or how long we'll have to wait to see where things go? I don't really have an exact time for you, but we're going kind of hour to hour, day to day at this moment monitoring and seeing what our progress is going to be. But we're here at any time. If you want to have more, if you have more questions, if we have any updates, I'll absolutely come and find you and let you know what's going on. We'll touch base again tomorrow, okay? I'd really appreciate that. Thank you. All right. Thank you guys. We didn't even practice that and I knew Mackenzie would do Mackenzie. I'm wanting people to put into the chat. What did you notice among that spikes protocol or anything that she was able to use to allow Michael time to understand what she was saying and sense that she was on his side? Michael, I'm going to start with you while the comments might be coming in to give me or to give Mackenzie, Dr. Rowe, an idea of how you experienced that. So I think first, Dr. Rowe, you did an amazing job starting with what I knew. And that gave me a chance to just kind of share my part of the story. And I hope that you up to kind of tell me the details that I needed to be filled in. A few of the things, we mentioned the space and I think you did a really fabulous job leaving space for me in the times where I felt really emotional or guilty or scared about what was going on. I think in the same way you named emotions in a way that was really beneficial for me to hear. And then one of the things that is your tone of voice too. I think you delivering the bad news and in a way that felt honest about the negative outcome that I could probably expect. I think it felt very human and I appreciated that. So the folks on the webinar are picking up on everything that Michael was saying as well. A couple of the things that you did immediately, you acknowledged the emotions immediately in the McKenzie way. And you didn't kind of land there, you kept going to find out what else he was wanting to know. The big thing that I noticed about your delivery there was the pausing, the quiet and which I'm hearing, I'm seeing a lot of their comments and the slow speaking and the not giving a whole lot of medical information. Cause it didn't sound like, or you were assessing that Michael didn't need to know all about what the scans said. You have seen the scans, you have a lot of information. If he asked about it, sounds like you would have answered that. But mostly there was a pace that made Michael sense that you were really able to listen to him. So yes, pausing to give the brain time to catch up so that he can actually know what questions to ask. A lot of active listening, allowing for the opportunity for a flow of conversation compared to feeling rushed or dismissed. Definitely no rushed or dismissedness. And that was like a three minute conversation and you still were able to communicate all of the, I'm here, I'm listening, this is hard. I'm not going to, I'm going to be honest with you and I'm also going to be here. So thank you, Michael. And I will say the pause was very difficult. So I was like, okay, wait, wait, wait, here we go. Are you counting? What are you doing? Cause I don't know, I was just watching his face and I was like, okay, now I think it's a good time. So yeah, I will acknowledge that that was difficult but thank you guys for saying that it was a good one. I didn't explain why we have this picture of these grade schoolers. When we do these scenarios, we want to make sure people, when we do them in practice, we want to make sure people recognize that this is just practice and it's totally fine to do whatever comes out because then we can talk about it and we can process it and think about how to update it. So this is the nurse mnemonic, which we live by. We're not going to go in great detail, but actually Mackenzie, you did, you named his emotion or you acknowledge that this is really tough and you respected and supported him by saying, this is not your fault. Now he will need to hear that many, many times over, but hearing it from a physician is very different from hearing it from a neighbor. So you helping him understand that even if he had gotten there earlier, that might not have changed the outcome of his friend. You did the respect and support, you did, you explored and exploring doesn't always mean tell me more, which is a word that we love to, or a phrase we love to use, but it often exploring looks like silence. So you did, your capacity to explore was giving the space for him to say more. A lot of times folks are afraid to do that because they're afraid they're never going to get out of the room, but you notice that Michael was able to kind of absorb and know that you need to go back and see what you can do for him. So now we want to think a little bit about how we use those same skills when we're thinking about peer conversation and in the trauma environment, the same high intensity is happening between all of us in the ICU and the trauma bay on our, we call it tax, but on the trauma unit, there's still a lot at stake between us. And we have a capacity to miscommunicate when our emotions are the main thing that we're communicating and the emotions are the main thing we're not absorbing from somebody else. So if somehow we can figure out how to acknowledge others experience while acknowledging our own of being frustrated, somehow that allows us to move forward to have a more productive conversation with our team members. So the impact of our communication during these crucial conversations, it really does affect how our team members are experiencing us, how they understand what they should be doing better. It will impact their processing of their own clinical skills and where they land with regards to how well they're doing compared to their peers or other standards. And this spikes protocol really works well with working with peers. You in your setting, just like with patients, you wanna be able to create a space where they're not feeling shamed. You wanna be curious about what's happening for them. You may not know everything about what's causing them to behave in this way or to make those clinical decisions. It's best to just see if you can figure out, assume positive intent and understand where the missing link might be. Figuring out when is it a good time to have that conversation determining how much feedback they're interested in is gonna work in your favor because giving them more than they are ready to absorb is meaning it's gonna be not absorbed. Again, not acknowledging emotions, attending to emotions, pretty important. So we're gonna do a quick demo, Michael and I. So Michael is one of my team members. He is an emergency department nurse and he's actually worked with us for a good five years. He's been a fantastic team member, but over the last month, he's been very frustrating to me as his manager because, and everyone is complaining to me about him. I don't know if you've ever had one of these team members, but everyone is coming to me and complaining, you need to do something about him. He mostly shows up, I mean, he shows up when he's on a schedule, but recently he's been coming in late and oopsie, and he's flustered and he's not ready to work when he gets there. And so the handoff is a little bit complicated. He used to be awesome, something's going on. You do know, you heard something about there's a divorce at home or something, you're not really sure, but from your manager perspective, staffing is tight and you can't really afford to have somebody like that messing up in this way. You heard that he came in late for his shift last night. So it's morning and he came in and somebody else had to be called and he did get there eventually, but you've had enough time to call him into your office. Now you hear in my voice, I am very frustrated with him and I can't, he's not clearly getting how much this matters to me. So I'm gonna help him understand. Michael, do you have a second? Can you come into my office? Yeah, sure. What's up? So what's happening? You were late again last night. What's going on? I can't afford to have this happening all the time. Actually, I'm not interested. You know what? You have been, I mean, you used to be great and lately everybody is complaining about you. Everybody has been coming to me. It's really not gonna work for me. What's it gonna take to have you step up? Okay, I have been late like a handful of times at most. Michael, I have the- And you think everyone is coming to talk to you? Like the whole team has been complaining about me? Like I worked with them last night. You wanna see the data? They didn't seem to have a problem. Would you like to see how many times in the last month I've had to cover for you or get someone to cover for you? Would you like to see that? So you've been like keeping count of like every time I have a little mistake? Absolutely, I'm keeping count. You know what, Michael? Is this the way that you've been leading this whole team? You just, you keep- Michael, this is not about me. This is not about me. This is about your performance. And I think you need to go home and we're gonna talk about this tomorrow. Okay, so Mackenzie, how'd it go? Wowza. Yeah, I got the setting. I got, we were in my office. You gave us- I asked him what's going on. Pretty clearly, so. I asked him- You invited him to come back tomorrow. I did invite him to come back. Okay, so yeah. Michael, how'd that go? I felt like I was on the back foot immediately. Your, hold on, I don't even need to hear what you have to say. I was like, I felt so small in that moment. And then it was like a compressed star just like exploding out of me. Okay, so I am going, let's do this again. And I want to, let's assume the setting is set. But I wanna start with the P, okay? Let's just do it again. And the main difference in the setting is that I have settled myself so that I'm not working from my frustration. I am very frustrated with Michael, but I'm not going to work from that. So let's go again. Hey, Michael, do you have a second? I know you worked all night last night. I'm wondering if this is an okay time for us to talk. Yeah, yeah, it's okay. What's up? So tell me how things are going. What do you mean? I heard from Melanie last night that we had to call somebody in because you were a little bit late. Tell me about that. Oh, yeah. Well, yeah, I mean, I was like an hour late. And I'm sorry, I know. I know that I haven't been like the most prompt recently. I'm sorry about that. Is there something happening that I can help you with? No, I mean, it's nothing here. It's nothing here with work. It's like, it's home stuff. It's just, it's really like, it's really no secret, but I think people have been, I've like talked to a few people about it, but like. Okay, Michael, I don't, I really don't want you to feel like you need to tell me things that are uncomfortable to tell me. What I mostly want is for you to understand that we want to support you and that you and I have had a long history together. You have been one of my stars in the ED. And I've really noticed in the last few months some changes. And I'm wondering if that's okay for me to mention some of those. Yeah, that's okay. I've noticed that you have been coming in a little late and that when you arrive, you don't quite feel like you're present here. And what makes me worried is that there's something that I could be doing to support you that I'm not, that we're not doing. I also am worried because I'm not, as a manager, I want to support you, but I also, you know, we're really tight on staff. So I've, that's what I'm noticing. So I don't want to dump that on you, but I, this is why we're having this conversation. I want to figure out how you can feel supported by us while feeling like you really, really want to be here. No, I mean, I, well, I get it. Like I have felt too, like I am not where I want to be when I'm coming in. And things that at home, like I said, have been really difficult. And I know I'm, like when I'm walking through the door, I'm just not my best self. I'm sorry that it's been impacting the team and the patients we see. This sounds so hard, so hard to try to match the Michael who is the energetic trauma nurse and the Michael who's struggling, I feel sad for that. What do you think would be a good way to move forward together on this? All right, I'm going to cut. So Mackenzie, tell me or put into the chat, oh, my time, I'm so bad with the time. Yeah, people comment on what they think. Michael, how do you feel this time compared to last time? I felt a lot, a lot better about it. But like, but still, it was it was heavy and hard. Like I felt I felt real sad. And honestly, the the because because in this situation, me being someone who was a strong team member, and then suddenly not being as strong, I'm already aware of that. And so my leader bringing that to me is like a gut punch in a way that's like, okay, yes, other people are noticing. And that's, that's hard to hear. But it wasn't, it didn't put me in a defensive place, it put me in a reflective place. And I think I was able to, to really acknowledge like, okay, this is something that I need to turn around if I can. Right. So we're talking about, you know, what is our goal here, right? Always thinking about what is our goal of this conversation? It's not to make, make him feel bad. It's to help see what we can do to either get him to come to work or plan more accordingly or anything, whatever that is. And so the first example, I mean, you've seen things like that. That's why it's like so cringy. It's like, ah, um, but how is he gonna get better from that? Instead? He's like mad. He's just mad at her because she's being a bad boss. She doesn't understand what's going on. And so whatever, right? Like that, that's not a place of growth. And so this is reflective and it is heavy. It is, it's still sad, but it needed to happen. Like this conversation needed to happen regardless. And now he can really think about what should I do moving forward and what needs to happen. So I think that was a really great and emotional, but like productive. The amazing thing is it's not, it, it's slower. There's more pausing, but it doesn't take that much more time actually. And I felt calmer because I wasn't being such a mean person. And I think after being a mean person, we all feel really bad about how we are as managers, which Michael did man, you know, did mention in the first one, is this how you manage your team? And I would walk away feeling like I'm a terrible manager and he's a terrible person. So I know we're up to time here. I just want to say thank you, Michael and Mackenzie. Our takeaways are that this is an approach that really is, it spans both working with patients and our staff and that it takes a lot of practice and it's not always comfortable. So Kim, I'm sorry for going so long. No, no, that was incredibly valuable. And I actually took a lot away from it. So thank you very much, all of you for, for your time and sharing that with us. Quick question from me, actually, is this is, you know, sort of been a very, I mean, you've given samples, but it's been a very academic discussion. Have you noticed that using these is, I guess this would be especially directed at Mackenzie, but have you noticed that it makes a difference? Have you gotten better feedback? Do you feel more comfortable? Does it help facilitate relationships? Or what's your take on that? I honestly think it does. I mean, the first time I learned this, I was like, okay, this is something and then you forget it and then you learn it again and then you forget it. And now that I, it really does stick. I actually think about these things before I walk into the room and it kind of helps me calm down and like focus my conversation because I think we can all kind of have these conversations and we get through it. But like, this makes me feel more calm, which I think makes the conversation go better. So I really have noticed it's been nice. I see that, you know, just based on the initial poll from the group that confronting colleagues is more complicated. In that same vein, do you feel like this is something you could use or do use in your personal life at home? That's a trick question. Because what we were, yesterday we were talking and Kim said she was going to ask me. And what happens is that when we're at work, we bring, as we say, our grownup self to work. We bring our most evolved self to work and we are able to go through this protocol. We're able to more, you know, more often than not, we're able to bring our educated self to a conversation, which is really our front brains. We are cognitively intact. When we get home, we bring our toddler self to the table and we need to just be our basis self. And so sometimes when we're engaging with our family members, we are not always our most awesome Dr. Ro. We are the first Anna that you saw that just is saying whatever's happening in their coming out at the moment. But there are moments when I think, oh, oh, oh, I know the answer to this. Let me see how my husband is feeling about this rather than me telling him how he is feeling about it. Because I'm pretty darn good at telling him what he should be feeling about it. So sometimes I am able to pull it off once in a while. I don't know, Michael, Mackenzie? Oh, I, well, I want to highlight something that Mackenzie said earlier, but just approaching any difficult conversation from a place of curiosity is just such a big, like it's an easy victory a lot of the times to just, even if, you know, in my patient experience work, I think there are times where I know either based on patient experience data that we receive or something I've observed firsthand, that there's something that maybe someone needs a little coaching on, but instead of going up to them and saying, hey, I think you should, it's like, I'm curious about this practice or this part of what you do in your day-to-day. Can you tell me a little bit more? And then they talk a little bit and say, you know, I'm curious, have you ever thought about, you know, then the coaching, right? And if they say, no, I haven't, or I don't think that would help, then we were having a conversation versus me just coming in and delivering something. So that curiosity piece is big. I'd say go with that in all your conversations. The other thing that I wanna say that I mostly use more than anything else is space, like not saying something, because sometimes I'm not really sure what to say. And I'll say, could you tell me more about that? That's my favorite one is tell me a little bit more about that. Cause I'm like, I don't understand what you just said. So tell me a little bit more. And my, you know, this sounds really hard and then stopping talking and then see what happens next. So I just have these, we all over our careers develop these things that we can fall back on. If we're happen to be tuned out at the moment and we don't really know what they're saying, tell me a little bit more almost always works. Very good. Thank you so much. Just because we just had a performance improvement meeting this morning as the trauma program manager, it just triggered a question because documentation is such a big deal, especially when you're having these kinds of conversations. Do you use this framework? I guess this would be mostly for Mackenzie. I'm sorry, I put you on the hotspot here. Do you use that framework when you're documenting as well just to track the conversations that you've had with families and patients? I've never even thought about it, honestly. I can just try and summarize essentially the end part of the conversation. So people know like what the strategy summary is moving forward, but that's a good idea. I think they document the perspective part from time to time, right? What they understand. I don't talk about the setting or the invitation. The setting is like my internal part of the invitation. I definitely, I'm sure Mackenzie will talk about what they've said, what they've told them. So that's the knowledge part. I, as a social worker, am always documenting about their emotions and not like my empathy, but their emotions, emotional state and strategy and summary. So a lot of it, you are documenting Mackenzie. You're documenting what they knew, what you told them and what the plan is. Yeah, updated family about situation. They were upset. Discussed plan moving forward. We'll just basically, it's longer than that. But yeah, so that's right. I mean, you do kind of walk through a lot of the steps. It was just like the social context for when they have the conversation, if you're not the one who's there again, so. Right, right. No, I just, the reason it came up is because we were talking about the quality of documentation. Because when you're doing PI efforts, it always is like a retrospective look in your charts. And so having that framework is incredibly helpful. So I just wanted to, I wanted to ask if you were being sort of aware of it. That's true because I find it really helpful when the nurses document that stuff, when they've had like a lengthy conversation with patients. And I see that they're like, okay, this person came from this place. And then this family member was here and they said this. I'm like, oh, that's so helpful. Because like, you don't, you're not always there when the family members are there. And it gives a lot of context for everything, so. All right. Well, if nobody else has any questions, I want to thank you again on behalf of myself, the audience and TCAA for taking the time today to share this. This has been amazing. And it will be available on our learning management system. So I'm excited that people will be able to see this even if they were unable to attend today. So on behalf of TCAA, I want to thank everybody and have a great day.

Spikes framework

difficult conversations

Kim Berry

medical settings

personal settings

empathy

communication skills

traumatic brain injury

effective conversations