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Crucial Conversations Take Practice

Applying the principles to healthcare.

To view the Course Outline and take the exam online, click here.

For a printer-friendly version of the exam you can print out, complete and mail to ADVANCEclick here.

Learning Scope #413
1 contact hour
Expires Dec. 20, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. 

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide information to nurses about "crucial conversations" they can apply to their professional and personal lives. After reading this article, you will be able to:

1. Identify the components of a crucial conversation.

2. Discuss how to master the dialogue of a crucial conversation.

3. Identify the seven crucial conversations for healthcare.

4. Describe a teaching plan to present crucial conversations.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Nurses and allied healthcare professionals likely make up a relatively large portion of the two million readers who purchased Crucial Conversations: Tools for Talking When Stakes Are High when it was first published in 2002.1

If you read the book, you may have already successfully applied the concepts to your work and personal relationships. Perhaps many readers pull the book out to prepare for "special occasions" like prior to delivering or receiving a performance review, before going to budget meetings, or when planning an intervention for a teen abusing substances.

Authors Kerry Patterson, Joseph Grenny, Ron McMillan and Al Switzler have conducted 2,200 research projects and interviewed more than 100,000 individuals in workplaces and other venues for more than 25 years. Their work defining, refining and applying the concepts of crucial conversations has been validated by leadership and organizational experts and is presented with concrete examples that improve workplace and personal relationships.

The authors, who are experienced international corporate trainers, admit their initial intent was not to write a book about communication skills. In their training and consulting activities, they were frequently hired by diverse companies to determine if there were "crucial moments" when specific actions disproportionately affected key performance indicators.

The trainers found "at the heart of almost all chronic problems in organizations, teams and personal relationships lie crucial conversations -- ones that never happen, ones that are handled well and ones that are not handled well." The latter approach usually results in irreparable relationships and raises the high stakes even higher.

In this discussion, we will define crucial conversations and briefly review the steps to follow when implementing the process, with the end result being to master the dialogue that leads to positive outcomes. The final portion of this offering will highlight the results of Silence Kills: The Seven Crucial Conversations in Healthcare, a study conducted by Vital Smarts Inc. and commissioned by the American Association of Critical-Care Nurses in 2005.

Perfect Storm

A crucial conversation is a discussion between two or more people where stakes are high, opinions vary and emotions run strong. The authors note the term crucial conversations initially may connote the book is intended for high-level executives or administrators. However, no one is immune to high-stakes interactions. When individuals can apply the tools associated with crucial conversations and become comfortable in face-to-face conversations with work colleagues, team members and managers, as well as spouses, children, friends and acquaintances, positive results can be qualified and quantified.

Examples of crucial conversations are many and varied. They range from ending relationships and addressing disagreements with co-workers to asking in-laws to quit interfering. However, frequently what one person considers a low-level disagreement can escalate quickly and meet the criteria for a crucial conversation.

However, when a conversation moves from casual to crucial, individuals may not be able to physiologically make the transition smoothly and bring about a rational resolution. The stress response takes over and those involved either automatically withdraw and become silent or fight -- physically or verbally.

The odds are stacked against individuals coming to a favorable resolution when the stakes are high and emotions spiral downward, according to the authors. At this point, most people aren't prepared to take a break, regroup, pull out their Crucial Conversations book and confront the situation. Also, few individuals have formal training, mentors or role models who demonstrate effective behaviors or dialogue.

Human Causes

As mentioned, the authors of Crucial Conversations initially set out to identify essential processes in industry and business that CEOs and managers requested. For example, leaders wanted to identify the root causes of decreased productivity, high costs and poor employee performance. This type of research is always a high priority for leaders -- to save their companies and their jobs.

However, the authors explain the research methodology they used with clients was not standard.2 Based on interviews they conducted with employees, the researchers learned poor employee performance and productivity were not at all related to causes such as deficient policies, processes, structures or systems. Instead, the source of problems was directly related to employee behavior. Employees were not prepared or accountable for confronting the actions or non-actions of their peers or managers -- or spouses and children -- when problems arose.

The researchers concluded employees need to be skilled in "crucial conversations," specifically in face-to-face conversations to improve company operations and relationships. If employees or family members/friends were to buy into this process, open dialogue had to be the cornerstone of the process. Otherwise, constructive and mutually satisfying outcomes would never be achieved or included in the culture of the organization or family/friends units.

Role Models Identified

The key method the researchers used when they consulted with organizations was to ask all individuals designated by the company to list the people they considered as "best at getting things done." The researchers tallied the information. Those who were named 20 or 30 times were designated as opinion leaders. Many of those selected were not managers or supervisors. Then a researcher followed each of these individuals in their daily activities for a week or two, recording all of their interactions.

In one of the book's case studies, Kevin, a vice president, hadn't done anything remarkable for a few days. The researchers were beginning to think he had been chosen by popularity rather than merit, until at a high-stakes meeting he masterfully challenged the CEO by telling him he was violating his own policies, and Kevin asked him to reconsider his decision. The group applauded this action; most had remained silent, not asking questions or offering their opinions.

The researchers assessed Kevin's crucial conversation. He didn't have any more insight than the others. But he expressed himself with candor and at the same time showed respect for the CEO.

Mastering the Dialogue

What Kevin did best in this situation, according to the researchers, was to prevent the group from being steamrolled into making a bad decision. They were prevented from making a fool's choice, thinking they had no other alternatives.

Making a fool's choice provides only two options: Either speak up and turn the power person into their enemy or suffer in silence with a decision you don't support and may be detrimental to the organization.

Kevin's actions were not magical, but the primary skill he exhibited was to keep dialogue, the free flow of meaning between two or more people, moving toward an action or goal. Keeping dialogue alive is having all participants contribute to the "pool of shared meaning," a metaphor the authors use to include the collection of ideas, theories, feelings, thoughts and opinions that are shared among the group.

"Anything less than total candor shrinks the pool, while the more information in the pool the better prepared the participants are to resolve issues and make good decisions," the authors offer.

Mastering dialogue for a crucial conversation is a learned experience. Here is an abbreviated list of the techniques or tools to guide individuals when they attempt to have crucial conversations with others. This list can be used as a checklist before engaging in any crucial conversation:3

1. When do I need a crucial conversation? It can happen whenever you are stuck or in a rut or have met an impasse between you and the individual or group. These conversations usually result in a greater understanding of the issue or problem.

2. How do I stay focused during a crucial conversation? As the authors emphasize frequently in the book, the leader must stay on message regarding his goals, rather than the goals of group member or relationship dynamics.

3. How do I catch warning signs of trouble before it's too late? When others move to silence or violence (controlling or verbally attacking), it is a glaring sign others do not feel safe. When these behaviors occur, it's important to reemphasize safety is the main concern in the group.

4. How do I make it safe to talk about anything? Remember: People don't get defensive about the content of the conversation. They get defensive when they are trying to know what your intent is or if you have hidden agendas. Redirect the group back to the purpose of the conversation.

5. How do I control my emotions? Master your emotions by getting to the root of them. Leaders may ignore their role in creating problems related to the discussion, or the leader may attribute the discussion problems to the group members. The leader needs to step back, examine his role and ask why others would want to disrupt the group.

6. How can I be persuasive but not abrasive? When you start with the facts and stay on message, there is a better chance the discussion does not have to regress to an emotional level.

7. How can I explore others' views? The easiest way to reduce defensiveness is by being a responsive listener. Spend as much time exploring others' ideas and positions as sharing your own with the group.

8. How can I end it well? End with clear expectations and an action plan. Don't just be satisfied with a good discussion.

Silence Kills in Healthcare

In 2009, the Consumer's Union, publisher of Consumer Reports, reported it has been a decade since the Institute of Medicine estimated medical errors kill 98,000 Americans annually.

Despite recommendations and edicts from numerous governmental agencies to get these numbers down, it hasn't happened. Since 1998, there have been other studies that have aptly documented poor communication has been a major factor in patient safety errors. For example, the Joint Commission suggests communication has been a major factor in reported sentinel events.

In 2004, VitalSmarts, a company that specializes in organizational leadership, partnered with the American Association of Critical-Care Nurses to examine why nurses and other professionals fail to address seven crucial conversations in healthcare, resulting in medical errors, decreased quality of care, increased nurse turnover and decreased productivity.4

The study documented the seven crucial conversations are difficult to master but should be a priority to identify patient safety indicators. Data were obtained from groups, interviews and workplace observations.

The categories of the crucial conversations and the prevalence of each, as reported by the study subjects, are listed below.

• Broken Rules: Sixty-two percent of nurses and 82 percent of physicians reported they had observed co-workers breaking rules, specifically taking shortcuts that could be unsafe for patients.

• Mistakes: Sixty-five percent of nurses and 92 percent of physicians reported they worked with individuals who couldn't follow directions. This was reflected in these individuals showing poor clinical judgment in triage, assessment, diagnosis and suggestion of treatment or getting help.

• Lack of Support: Fifty-three percent of nurses reported 10 percent or more of their colleagues are reluctant to help, impatient or refuse to answer questions; 83 percent have a colleague who complains when asked to help others. Positive findings included 76 percent of nurses who said their colleagues provide emotional support when needed; 64 percent said half of their colleagues provide help when asked to do so.

• Incompetence: Fifty-three percent of nurses and 81 percent of physicians had concerns about the competence of "some" nurses, and 68 percent of physicians and 34 percent of nurses had concerns about the competence of at least one physician they worked with.

• Poor Teamwork: Eighty-eight percent of nurses had one or more teammate who gossips and is part of a clique that divides the team. Fifty-five percent reported having a teammate who tries to look good at others' expense.

• Disrespect: Seventy-seven percent of nurses worked with some colleagues who are condescending, insulting or rude. Thirty-three percent work with a few who are verbally abusive - yelling, shouting, swearing or name calling.

• Micromanagement: Fifty-two percent of nurses worked with people who abused their authority by pulling rank, bullying, threatening or forcing their point of view.

Study Conclusions

Here are conclusions from Silence Kills: The Seven Crucial Conversations for Healthcare:• The majority of those in the study reported serious concerns about their co-workers related to the identified categories. Few said they shared their concerns with co-workers or managers; most said they rarely spoke directly to the person about their concerns. As a result, the problems are not addressed and continue with high frequency over an extended period of time.

• For hospitals to reduce medical errors, increase productivity, decrease employee turnover and improve physician cooperation, hospital leaders need to create a culture of safety where managers and administrators model crucial conversations that will over time become the standard in the institution for every employee.

• The study reported a small minority -- 5-15 percent of all respondents -- reported they speak up when they have concerns and have not been chastised for their outspokenness. This small group correlates with those in the study who are most committed, effective and satisfied in the organization.

• Hospital administrators and managers need to make crucial conversations a top priority for at a least a year. Because the reluctance to confront colleagues in healthcare is so high, it will take at least a year to see lasting results.

• After the hospital has completed its development program to implement crucial conversations, the baseline for the seven crucial conversations must be measured. This data are then used to create the targets for improvement. Conducting focus group interviews with the staff will then begin, with organization leaders conducting the interviews.

• Leaders/managers in the hospital, not external trainers, should teach crucial communication strategies. The quality of the teaching materials is important. Generic communication tools will not deal with specifics such as risky topics learners are expected to master. Learning should be spaced in small modules and presented over time, not like racing to a finish line. Most importantly, the content must be relevant to the participants, who need to be supported and rewarded throughout the process.

Bridging the Gap

As the Affordable Care Act is phased into healthcare in coming years, transparency of information will become a top priority. Healthcare professionals must be leaders in bridging the gap in improving communication within their own profession and with allied professionals.

Collaboration in interdisciplinary teams in hospitals as well as community agencies is essential if the goals of healthcare reform are to be met as seamlessly as possible. Nurses need to become crucial conversation experts and teach others how to learn these vital skills.

1. Patterson, K., Grenny, J., McMillan, R., et al. (2012). Crucial conversations: Tools for talking when stakes are high. New York: McGraw-Hill.
2. Bensing, K. (2003) Tackling the tough ones. Retrieved Oct. 20, 2012 from the World Wide Web:
3. 8 easy steps for crucial conversations. (2008). Retrieved Oct. 25, 2012 from the World Wide Web:
4. Maxfield, D., Grenny, J., McMillan, R., et al. (2005). Silence kills: The seven crucial conversations in healthcare. Retrieved Oct. 25, 2012 from the World Wide Web:

Kay Bensing is a frequent contributor to ADVANCE.

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