Nurses are only too aware of the importance of communication and the impact that ineffective communication can have on workplace culture, psychological wellbeing and, ultimately, patient safety and the patient experience.
Patterson et al (2012) argued that the root cause of many of the issues we encounter is how we communicate when there is disagreement. The quality of our relationships at work, specifically with our managers, has a significant impact on our overall wellbeing (Griffeth et al, 2000). The Nursing and Midwifery Council (NMC) (2018)Code has effective communication interweaved within each of the four domains:
Nurses have a professional obligation to communicate effectively with colleagues to ensure that we work cooperatively to preserve the safety of patients and to do this using the principles of honesty, accuracy and the promotion of an environment where we share feedback constructively (NMC, 2018). The key to an effective encounter in any aspect of our lives is empathy and respect. If we are able to apply key, effective principles when dealing with issues, significant improvements in relationships and, ultimately, patient safety and organisational performance is possible.
Creating communication practices that are conducive to empathy and respect is an important challenge for healthcare leaders. On a daily basis, we are witness to incidents that could potentially be avoided through clear, concise, honest and respectful communication. Poor performance is a sensitive issue to tackle but has far-reaching consequences in relation to the credibility of the manager and the morale of the individual and the team. It can also breed negative patterns of behaviour such as gossip or passive-aggressiveness that ultimately can lead to a negative culture and higher staff turnover (Patterson et al, 2012).
Fostering a culture that promotes a whole-team approach to effective performance management can go a long way in enhancing quality as well as individual and organisational wellbeing. According to Maslow (1971), psychological safety is a fundamental human need; demonstrating appreciation, value and respect in our daily interactions begins to establish trust between managers and teams and is a key skill for leaders at all levels. But how do we do this? How do we ensure that our communication is not misunderstood or perceived as contrived or manipulative? How do we avoid the pitfalls associated with addressing disagreements and being met with anger and defensiveness? These are skills that require practice over time but there are key principles that can be adopted with relative ease that will have an immediate impact on our relationships and the way in which we manage difficult conversations and areas of disagreement whatever our role or area of practice.
An easy way to remember these principles is using the TALKS mnemonic (Box 1):
Timely
Addressing issues as soon as they are recognised as problematic is the first step in managing them effectively. In a team that functions optimally, any issues will be addressed first by a peer so when it comes to a management discussion, the individual is not taken by surprise and does not feel betrayed and alienated by the rest of the team. An effective leader will encourage this type of open, non-threatening communication as a matter of course, leading to a more ‘emotionally intelligent’ (Goleman, 1995) way of working. Ideally, only when individuals fail to respond to issues addressed by their peers will the leader need to step in.
These conversations are difficult and a manager or team member who is not equipped with the appropriate tools to hold such dialogues will generally ignore poor performance in the hope that it improves or, use passive-aggressive behaviour or silent treatment in the hope that it will ‘magically’ solve the issue (Patterson et al, 2012).
Most problems develop slowly over time and, if left unchecked, not only does the behaviour become entrenched, but the frustration of the team and the manager grows and when it reaches the point where it is finally addressed, emotions are high and the discussion can be one of conflict (Goleman, 1995).
Performance management is a continuum and leaders should always be performance managing themselves and others at every opportunity, creating a more effective culture. As such, any issues should be dealt with as early as possible to avoid greater difficulty further down the line. Being clear on ground rules and setting clear boundaries for teams is a good way of being proactive about performance management. This way, leaders and team members can be held to account where their behaviour has fallen short. It is also important that managers offer consistent and continuous feedback on both positive and negative aspects of an individual's performance.
Accurate
Begin the discussion by relaying the facts. Pick a significant example to illustrate the problem and ensure that this is an accurate, objective representation of what might be a more generalised pattern of behaviour. Always discuss behaviours rather than aspects of a person's character and ensure that you have all the facts to hand before you begin the discussion. Stating something that is not accurate will reduce your credibility and breakdown trust. If you have heard something through another team member, make sure that this is a statement of fact, rather than an exaggeration or speculation, before you introduce this into the discussion.
For example, rather than saying ‘You're always late’ you might say: ‘Last week you arrived late for three out of four of your shifts and this has been a pattern over the past few weeks. This puts additional pressure on the team, who have to cover the work until you arrive.’
Let go of ego
Interactions become ineffective as soon as we seek to ‘win’ or to ‘punish’ the other person. Let go of the desire to be right or to assert power and authority and aim for a discussion that truly seeks to address the area of disagreement or the undesirable behaviour. ‘Leadership is not domination but the art of persuading people to work towards a common goal’ (Goleman, 1995: 149). The most effective interactions will come from the heart not the ego. We can disagree and remain kind and respectful.
Aiming for a discussion that equally values both sides of the issue, is crucial in ensuring that relationships don't break down. Generally speaking, most of us do not want to feel like we are being ‘managed’ and ensuring that the discussion doesn't turn into a battle over who is right and who is wrong will ensure that the aim of the conversation is met.
Keep focused
Staying focused on the issue in question is as important when giving praise as when offering criticism. By staying with the point you not only offer clarity but you also avoid the pitfall of using this as an opportunity to open a dialogue about every fault you find in the individual. Keeping focused also ensures that the interaction is empathetic, taking into account the impact that your feedback will inevitably have. Be straight to the point as beating around the bush may cause confusion. State what the grievance is and what is wrong with it or how it makes you and/or others feel (Goleman, 1995). You do not want the individual to walk away feeling confused, embittered or defensive and staying focused on the key issue will enable you to contain the discussion around specific behaviours rather than aspects of their character. Consider illustrating expected behaviours using current practice and/or accepted policies or procedures.
For example: ‘Last week you arrived late for three out of four of your shifts and this has been a pattern over the past few weeks. This puts additional pressure on the team, who have to cover the work until you arrive. The practice on this ward, in line with trust policy, is to arrive 5 minutes before the start of the shift and I would like you to do the same.’
Seek to understand before being understood
This is the essence of any effective interaction and practising empathic listening is a key skill that will enhance communication in every context. Giving people the space and the time to truly express themselves and to feel that they have been listened to will build a relationship of trust more quickly than any other practice. With the interplay of a variety of factors relating to power and status, many areas of the NHS, and other healthcare environments, may not have a culture that is conducive to staff being truly listened to. When we listen empathically with the intent to understand we are not waiting to reply, we avoid probing, judging or advising and we are quiet while we truly listen to what the other person has to say and how they feel. This is particularly effective when the person is upset or emotional and while we may ask open, clarifying questions, our intent is to truly understand the issue from their perspective. This is very powerful because it gives you an accurate frame of reference from which to work towards a desirable outcome.
Learning how to listen and demonstrating that we have understood gives us permission to then respectfully seek to be understood (Covey, 2013) and to expand on the facts outlined earlier on in the conversation.
Starting with this very simple mnemonic, we can all begin to ensure that we practise in teams where disagreement is managed effectively. Not only will this save time later down the line by avoiding a bigger problem, but providing teams with these key tools for communication can also enhance working relationships, creating a safe organisational culture for patients and staff alike.