Book Review: Crucial Conversations by Patterson, Grenny, Mcmillan & Switzler

This book has the subtitle "Tools for talking when the stakes are high" and I found there was not a single page that disappointed me. Part way reading through the book I thought this is all common sense, and of course a lot of it is. However, the authors are showing and telling in an extremely compelling manner that you just can't help going "aha", oh-yes", "of course" every few minutes. My copy is full of notes, highlighter marks and pages turned over.

So what's the meat in the book?

At its heart is a dialogue model which is about me and the other and how we each act, feel, tell a story and see/hear. In our dialgue we are aiming to create a pool of shared meaning and there are a number of factors that impact this, such as safety, and silence (withdrawing, avoiding, masking) and violence (controlling, attacking, labelling). All this sounds cold in this description, what brings this book alive is the way the authors develop the model with the use of various tools and stories. It's impossible to read it anot feel connected yet at the same time feel empowered to do something about your next high stakes conversation.


You can download book chapters and sample MP3 audio from http://www.vitalsmarts.com/books_more.aspx . There is also the stress test to discover your style under stress.

Difficult Conversations 4: Fierce Conversations - practical tips

The practical advice in this slideshow is very helpful. I particularly like the "Sixty second" technique for starting off the conversation.

Fierce Conversations

View more presentations from Evan Wood

Difficult Conversations 3: Tips from the psychology viewpoint

There's no one way to approach a difficult conversation. The short slideshow below covers some useful hints and tips - if the psychological viewpoint is interesting and useful to you.

Making Difficult Conversations Less Difficult

View more presentations from John Deely

Difficult Conversations 1: The DED Technique

Dealing with the difficult situation is difficult - usually because emotions are running high and emtoional responses tend to send all good planning straight out the window. One technique I've found useful is simple enough to remember when the flak hits the fan and tends to work well - the DED technique.

D = Describe 

E = Example

D - Discussion

Describe the behaviour you're finding difficult, how it makes you feel and explain the wider impacts of the behaviour. Without any description the other person probably has no idea why you are upset.

Then provide an example of what it is you've just described. Without an example the other person may think you're making it up and may not be able to ground the descriptions in reality.

Discussion - or I prefer the term dialogue as that presumes it is a two-way thing - is the obvious important and final step. If the first D and the E have gone well then the discussion should be fairly straightforward - though posisbly still emotive.

Do you have a favourite technique you'd like to share?

eLearning 3: 5 Resources for effective online conferences

With the bans of travel and other cost reductions in place, eConferencing is on the up. Unfortunatley, this is iften paralled with a signficiant reduction in value for the participants. eConferencing is more than ticking the box that you've "run an event".

Let's look at what not to do in a video conference:



Other resources

• 19 tips for effective online conferences; from eLearning Technology
• http://onlinelibrary.wiley.com/doi/10.1002/stvr.411/pdf (I liked the lessons learned and tips for the future) PDF
• Guidelines for running online seminars
•  Online conference - a participant's perspective

eLearning 1: 5 Resources for supporting online discussions

Creating and moderating an online discussion group requires more than sending out an email inviting people to join. In some cases it is not the cheap, quick fix you may be after. It's work. Treat it like a project - from strategy, planning, resource allocation through to evaluation.

Here are a few of my favourite resources on the topic:

1. Designing and Managing online discussions from Oxford Brookes University (PDF paper, with references - my favourite)
2. Teaching with online discussion forums - good introduction 
3. Online discussions: Tips for Instructors from the Centre of Teaching Excellence at the University of Waterloo. Web page with bullet hints
4. Using discussion boards to engage students 
5. How to avoid problems with online discussions - student guide. Short web page with more links on it. USeful because it is from the student/user perspective

5 checks to test whether your conference call is productive

Conference calling is often touted as the more productive way to have a meeting. In many cases it is, however, some calls are so badly organised, chaired and processed, that it may have been better to meet face to face - or not meet at all.

1. Don't start on time.
"We'll wait another couple of minutes for Dean and Tam."
silence
"Is Mike on the line?"
silence
"Janet can you call Mike on his mobile to check he is dialling in"
Silence

If 20 people wait 3 minutes past the start time for the people who have not joined the meeting it means 1 hour has been wasted. If 100 people wait 3 minutes it is the equivalent of 5 hours wasted by the organisation.

A good way round this problem is to predictably open the line 5 minutes before the session starts and then predictably start on time - every time. You wouldn't keep the meeting room door locked until the advertised start of the meeting.




2. Use slides
"For those of you with Internet connections, you'll see the agenda. What? Oh Mary, yes, I'm sorry, the agenda is so up to date it couldn't be circulated beforehand."
...
"Can everyone see the slides?"
"Next slide please. No, go back one. Yes, that's it."
...

Slides are used mostly as personal notes for the person speaking. As some people don't have access to the computers when they dial in, any necessary slides should be circulated before the call (rather than afterwards). Some learning styles work better when they have had time to read and then contribute.

3. Rely only on audio
Meetings of any sort work best when there is trust. Unless the session is an online seminar when your role is to push out information via some slides to a large group, then video is essential. Even in the seminar option, the speaker needs to use video.  The more participants who use video, the more everyone will pay attention and not do their email at the same time.  Multitasking is proven not to be productive.  A 90 minute conference call with everyone doing two tasks at once is unproductive. It could be replaced by a 30 minutes, focused, video-face-to-face committed time discussing what matters.

When presenters refuse to use the video option they lack the ability to influence using body language. The same goes for listeners. This makes the call ineffective and unproductive as messages have to be repeated.

4. Don't use names
'Thanks for that..um.. sorry, who was that who agreed to review the budget?"
...

Audio, especially without visual, is anonymous - which may account for why some groups enjoy using it - it feels like they are having meetings yet no much happens to move the work forward. Anonymity is not a good name as it means listeners have to work hard to keep connected.

Each time you speak, say your name: '"Sarah here, I like what you're proposing Simon, however, I am not sure about item 3."  Try and say the other person's name as often as possible to let them know you are connecting with what they are saying.

5. Have a call when an email would have done
Holding a meeting is an act of power and control, and one to be used with care.  If the intent of the call is to share information then consider first whether an email or discussion group would be a better and more productive option.  If group discussion is required - then a call is good. If information needs to be shared and not much discussion is expected or required, then another method is far more productive. Many calls can be replaced by the use of efficient and productive discussion groups and document storage systems. Huddle is a great one, though Google groups/documents is a good start.  The real issue here is about power and control; relinquishing the weekly conference call and replacing it with an online discussion group means someone has lose control of the process.

4 kinds of relationships

So much of spreading good, known and evidenced practice is based on social connections and relationships. John Maxwell has four ways in which relationships can be categorised.

1. Some people add things to life (we enjoy them) +
2. Some people subtract something from life (we tolerate them) -
3. Some people multiply something in life (we value them) *
4. Some people divide something in life (we avoid them) /

If a key role of the person who group is trying to influence others to change their behaviour then it might be useful to reflect on the relationship between the "spreader/pusher" and the "adopter/puller".

There are some people I avoid (4) and I am unlikely to even receive the messages they are pushing out, let alone act on them. In a similar vein, those I tolerate (2) I will probably put them low on my priority list and will be fairly sceptical about what they put out. Whether I adopt anything they are pushing will be a matter of personal judgement.

On the other hand, those whose company I enjoy (1) I will probably get to hear a lot about what they are saying, thinking about and pushing in my direction. I will take their information in quite quickly, though may still toss the ideas about before making any changes to my behaviour.

Those I value I will probably not wait for them to send me information. I will be finding ways to connect, listen out carefully and will most likely shift my behaviour quite quickly when they send out behaviour related messages.

So which types of relationships are you creating and endorsing?

Healthcare needs new norms to counter abuse of power

I believe the problem we’re facing in improving the quality and safety of healthcare is about setting new norms rather than the eternal quest to take innovative ideas or set of guidelines and then impose these on the rest of the system. Yes, this “pilot and spread” approach is useful and can be demonstrated to raise standards, though there may be questions about sustainability of results and few organisations review improvement programs three or more years after they were completed to test this.

Obviously new norms can’t be “set” as such. Where does our current norm come from? I think of a norm as the sum of all the behaviours actually at work in a system. A different norm therefore requires a different set of behaviours – not only (if at all) a planning meeting to decide and list these behaviours but an actual change in the behaviour of one, then two, then three, then four and so on people in the way they act and interact with each other.

More about this norm approach in forthcoming posts. In this post I am thinking more about why we end up with the norm we have. For example, what is the norm at work in an organisation where 400 or more patients are harmed or die inappropriately (for a series of reports / investigations on UK health organisations http://www.cqc.org.uk/publications.cfm?widCall1=customDocManager.search_do_2&tcl_id=2&search_string=&top_parent=4513&tax_child=4574 ) or where one nurse is able to harm and kill a number or patients http://www.nytimes.com/2009/04/03/us/03nurse.html?_r=1? No doubt there are many causes involved in each and every event. However, I’ve been asking myself the question “Why is it so difficult to shift the norm?” Allied to this is the question for me of “How can professionals reach the stage where they become part of a norm that seems to go against their stated values, yet do nothing – their behaviour continues “as normal?”

There are procedures for the NHS in England to manage whistleblowing http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4050929 and again, there will be many reasons why people don’t step outside of a norm and take action. So why is this norm “pull” so strong?

One reason I have been dwelling on is the abuse of power. Not so much a conscious step but rather one which is part of our human condition. And when enough people behave in ways where power is being abused, then a norm develops so others, who may not be inclined to do so, end up part of the problem.

How is abuse of power part of our human conditions? We know from a number of experiments that stated values, professional promises and personal beliefs can go out the window if the circumstances are right. For example, the Stanford Prison Experiment in 1971 (http://www.prisonexp.org/ for a slideshow / discussion guide on the whole process) demonstrated in laboratory conditions that when put in a position of power (the guards) about a third of the “guards” showed sadistic tendencies, meting out punishments and inventing ways to humiliate their “prisoners”. The famous Stanley Milgram experiment http://en.wikipedia.org/wiki/Milgram_experiment in 1961 showed how when participants are morally distanced from the consequence of their actions and when they believe in the power of the authority demanding action, they will continue behaviour even when they can see it is physically harming another person. Around two-thirds of participants showed this behaviour. There are many other examples as well, not least of which come from politics and wars.

So what does this mean for raising the standards of healthcare? Imagine working in an organisation where a critical mass of people (clinical professionals as well as managers and administrators) feel distanced from their actions, feel the need to respond to authority figures, are in a stressful context and feel they can act in ways that are driven by their own very personal demons. The sum of the behaviours exhibited become the norm culture.

So when I encounter really good examples of clinical or administrative practice and I am asked to help with spreading this to other places, then one of the key things I am thinking about is the underpinning behavioural dynamic. What is it about the team and the behaviour of the individuals in the team, that contribute to their identified quality / safety improvement performance? What is their norm? To what extent is this about how they manage the power dynamics? And if others are to adopt their work, what will this do to their use and abuse of power within their own systems? How will they break free of their current norm? Whose behaviour will be critical in this shift of norms?

I’ve been through the process of listing, rather objectively, the behaviours required for good practice to be adopted. Maybe this is helpful in working out just what needs to be done to effect the change. What I know now is a list of behaviours is not the same as the behaviour itself. I am also a great deal more aware of the context in which behaviours are played out and I am open as to the impact of power dynamics in a system.

This is messy stuff that doesn’t lend itself to the predominant method of change in healthcare, namely the issuing of a “how-to” guide. I think it requires conversation, dialogue, self-awareness and attentiveness. There’s no quick fix.

Blogging best practice policy checklists

Over the last few months I am meeting up with groups and organisations who want to dip their toe into the social media soup yet are concerned they have no policy or ground rules for staff to do this. Why do they want to blog - well, various groups and different answers. However, a continuing theme amongst all of them is in finding a way to reach out to others to share their experiences, news, views and opinions - often about products or services they are working with. They are seeking new ways to enable others to learn about and adopt their prodycts and services.

A good place to start when developing your own strategy is

a) avoid reinventing the wheel

b) use existing checklists and guidleines such as those provided by the blogcouncil http://blogcouncil.org/disclosure/

c) be brave and know the genie is already out of the bottle and know that success is in how much you let go rather than how much you control

Watching conversations; the impact of social media

Normally we'd hear conversations, but now we can also watch them. How? With the growth in social media use, such as Facebook, LinkedIn and Twitter, we are able to hold conversations out in the open, for anyone to read or interact. So what used to happen in relative private between a few people is now something that can be available to many others.

There is obviously a good side and a not-so-good side to this. For the paranoid / those who like to control what is said, then this is a very scary notion. Do you know who is saying what about you / your organisation / your product? There are a variety of systems around that search the online conversations and let you know when someone does speak up on your topic (New Stuff for Change Agents for some links to these sites).

On the good side, think just how rapidly information can pass from one person to another. The first photo available from the plane that landed on the Hudson river was posted on Twitter - within minutes of it happening. The online network then spread it about very quickly.

How will you be tapping into social media in 2009 in order to enable the spread of good practice and large scale change?

No time to chat? How will you influence others?

The irony of middle and senior managers sitting alone in their offices and quietly developing communication plans on how messages and information was going to be spread around their organisation was not lost on me when I visited an organisation recently. It seemed everyone worked in isolation and apart from a few meetings where no-one really listened to each other and true dialogue was missing, the organisation appeared to have a dearth of conversation.

Yes, there was a lot of open plan office space, yet this was lunch time and most people sat at their desks, on their own, eating their sandwiches while pressing keys and watching screens. It was very quiet. The kitchens where you can make a coffee are stand around places with no seats, nowhere for sitting down and talking over a coffee. This is an organisation where chat, conversation and informal discussions seem not to happen very much. So I'm not really that hopeful about their "spread" plans. We know from the evidence in researching the impact of planning methods versus informal conversatioons and we know that the informal conversations and peer to peer discussions have a high degree of influence over another's behaviour.

In contrast, I have a client in the Netherlnads that when they redesigned their offices and moved from the rabbit hutch corridors of offices to open plan did so with conversation in mind. Their kitchen areas have seating arrangements and tables around them to encourage eating and talking together. They report that this works well and keeps the flow of information informally moving around the various teams in the organisation.

Design can play a large part but so can culture. If your office is a "no-speak-lunchtime" one, then try sharing your lunchtime with someone else in the coming week. You may even like the break it gives you.