1. Having Difficult Conversations
Sonya Kupka
Regional Executive Director, BC
September 30, 2013

2. Outline Review survey results for some insights to context
Present a framework to identify and tools to respond to crucial conversations
Apply the tools to actual scenarios from interns and preceptors

3. UBC Dietetics Alumni Survey 2007/201:1 Overall Satisfaction with Internship

4. UBC Dietetics Alumni Survey 2007/2011 Satisfaction with Internship Components

5. Preceptor Challenges Literature Review & Key Informant Survey Findings
Logistical issues (part-time preceptors, lack of space)
Lack of time
Negative feelings (burn out)
Student-related concerns
Lack of recognition
Lack of training
Cristina Cicco (Ryerson), Monica Liefhebber (Interior Health), Marlene Wyatt (DC), Shaping a New Preceptor Paradigm. DC Conference (2014) .

6. Thank You Preceptors!
You are doing a great job (only 5% dissatisfied).
Preceptorship is a national and a local matter.
DC is committed to work with you, employers and educators to find creative solutions.

7. Thank you to all who responded! Survey Says…
4 out of 5 interns had a difficult conversation
13 out of 22 preceptors had a difficult conversation
Why didn’t all respondents experience “difficult” conversations?
Is it possible to go through a rotation without a difficult conversation?

8. What is a difficult conversation and when does it becomes crucial?
Opposing Opinions
High Stakes
Strong Emotions
I've had a few situations where there have been issues with performance and I think that talking about "issues" is always challenging.
Casual conversations transform into crucial ones. The more crucial the conversation, the less likely we are to handle it well.
So why only 75% of interns and 59% of preceptors? Are we recognizing when we are having a difficult conversation?
Patterson, Grenny, McMillan, Switzler Crucial Conversations (2012)

9. Possible responses to crucial conversations
We can avoid them
Result: I tried to avoid upsetting the intern, but in the end there were no improvements made
We can face them and handle them poorly
Result: I think there have been times where maybe I have not been as clear as I would have liked, and the intern did not seem to fully understand/appreciate my concerns.
We can face them and handle them well
Result: The outcome was good I think as it was done in a respectful way, with examples to indicate why the conclusion was reached.
Don’t aim for perfection. Aim for progress: I had difficult conversations throughout the rotation when an intern was not doing well. It turned out fine, I had support from my practice lead
When the topic turns from things to people, it’s always more difficult, and to nobody’s surprise, some people are better at it than others.

10. Tools for Crucial Conversations
Principle
Skill
Start with Heart
Work on Me first.
Focus on what you really want. Believe you can have it all.
Learn to Look
Identify safety problems.
Pay attention to conditions.
Make it Safe
Apologize.
Contrast.
Establish mutual purpose.
Explore Others’ Paths
Start with listening.
When you talk: Agree-Build-Compare

11. Start with Heart Work on Me first Stay focused on what you really want
The only person you can directly control is yourself
Resist devolving from correcting mistakes to winning
Challenge the illusion that what you’re feeling is the only right emotion
Stay focused on what you really want
What do I really want for myself?
What do I really want for others?
What do I really want for the relationship?
Commit to having it all
candour and kindness; peace and honesty; high performance and balance

12. A Preceptor starts with heart
I had to advise a student they were not going to pass the internship because they had repeated a clinical rotation twice and were struggling with workload expectations and their knowledge was weak. (High Stakes, Strong Emotions, Opposing Opinions)
After listening to all the reasons why they were struggling (usually the fault of others) we then delved deeper into what they thought was the reason they were struggling and what their real interests were relating to the food and nutrition field. The 'chat' took about a hour. The intern eventually acknowledged they really didn't like clinical but their passion was research.
At this point we were able to discuss various options, employers, etc where this person could pursue that passion. What started on a low point concluded with the person feeling good about themselves, recognizing their true passion and that they were not in fact 'a failure’.
What do I really want:
for myself? (e.g. to be proud of my profession)
for the intern? (e.g. for them to be successful in the workforce)
for the relationship? (e.g. trust and respect)

13. Learn to Look
If you make it safe enough, you can talk about almost anything and people will listen without becoming defensive
Believe that the other person had your best interest in mind
Trust the motives and ability of the other person
Watch for signs that your interns are feeling unsafe
Silence: masking, avoiding, withdrawing
Violence: controlling, labeling, attacking
Avoid getting caught up in the content, and becoming blind to the conditions
Your style under stress test:
SK – masking & controlling

14. This is what happens when an intern feels safe
The coordinator made me feel safe, heard and that my best interest was her priority.
Despite the bad situation I trusted it would all work out
(now that it's after the fact the situation didn't really work out, but at the time the preceptor did exactly what I needed - she listened)

15. Understand others’ conditions, then judge their content
The intern came to her rotation inadequately prepared. There were several assigned readings and questions to be completed before beginning the rotation so that concepts from the readings could be discussed as pts were encountered. The intern was asked to complete the readings and questions and the importance of coming prepared was noted (i.e. the intern missed some learning opportunities)
How did you feel coming into this rotation? What would you have liked to do differently?
This happened with two different interns - in both cases there were significant things going on in the interns' personal lives that made it difficult to complete "homework" at home.
Work on Me: How realistic are my expectations of interns who have lives outside of their rotations?

16. Understand your conditions and how they can influence content
Based on how I felt my performance was during part of a rotation and knowing interns had ++difficulties with said preceptor, I felt extremely down and upset with my progress during the rotation. Based on her body language, the way she tested me, and her reactions to some of my answers, I felt like I was going to fail the rotation.
Your interns may not remember all what you taught them (content), but they will remember how you made them feel (condition).
A few days into the rotation at the end of the day when she was more available, I asked her if she had any feedback about how well I was doing, if there were things I could work on, etc.
A crucial conversation handled very well!
After the conversation, I realized I was doing better than I thought and my preceptor/I were able to develop a MUCH more open, comfortable relationship and environment for the rest of the rotation.

17. How? Make it safe
Step out of the conversation to create safety, then return to the issue
Apologize when appropriate
e.g. when you were wrong or slipped into disrespect
Contrast to Fix Misunderstanding
Provides context and proportion – it is not taking back what you’ve said.
Contrasting clarifies what you do and don’t believe - Start with what you don’t intend or mean, then explain what you do mean.
Create a mutual purpose
Suspend our belief that our choice is the absolute best and only one – open our mind

18. An apology can go a long way
During my relief I had two separate preceptors, which made meeting expectations very challenging.
You know what? I was not aware that you were asked to chart differently in the past. I am sorry that you have received mixed messages. We need to talk about this. I’m glad you brought this up. Thank you for taking that risk. I appreciate the trust it shows in me.
The outcome of the conversation allowed me to express why I had made decisions I had made, and for my preceptors to see I was applying feedback I had received from someone else

19. Contrasting as a form of prevention
The most difficult conversations I have had with interns is in the first weeks of acute care rotations. This is the phase when, as the acute care 1 preceptor, I need to encourage them to raise the bar if they are going to tackle the steep learning curve ahead of them.
The outcome always has them working harder but emotionally, I feel that I have deflated them. I struggle with the type A personalities and the ability to not take things personally.
I don’t want you to think that I expect you to have all the answers in your first acute care rotation.
I do want you to know that I recognize that you have a really good knowledge base for clinical nutrition and it will take time and commitment to translate this knowledge into effective nutrition intervention skills.

20. Create mutual purpose
Reviewing the evaluation and explaining how a lack of skill or progress has resulted in failing a placement.
I have found a focus on behaviours and skills particularly beneficial, but often there is defensiveness and resentment from the intern. I provide formative feedback throughout the placement so there are no surprises
I don’t want you to think that I have made this decision lightly. I do need to let you know that you have not met the competencies required to successfully complete this placement (Make it safe - contrasting).
I start the final conversation with a question about how they feel they did/progressed Tell me why you found this challenging (Recognize the purpose behind the strategy).
We all want you to successfully complete your internship. (Invent a Mutual Purpose)
Let’s find ways to meet these competencies and further develop your skills in your next placement (Brainstorm new strategies).

21. Explore Others’ Paths
Start with listening: Ask, Mirror, Paraphrase, Prime
Then, when you talk:
Agree – when you share views. Avoid turning subtle differences into a debate.
Build – when others leave something out, agree where you share views, then add additional elements that were left out
“Absolutely. In addition, I noticed that…”
Compare – when you differ (rather than suggesting he or she is wrong). Start with a tentative but candid opening. Share your observations and invite others to test your ideas.

22. Listening
Advising the intern to use more engagement with patients during interviews.
Ask How comfortable are you with patients during interviews?
Mirror I noticed that there was very little eye contact during that last interview. Are you comfortable with this patient?
Paraphrase Let’s see if I’ve got this right. You find it difficult to have eye contact with patients because you want to be sure you cover all the information that you need for a complete assessment.
Prime I used examples of how I have grown over time, and provided some real examples of how this could be improved. Also noted that this would improve over time and with experience. Intern received this fairly well.

23. A preceptor uses her ABC’s
Intern thought they were ready for staff relief while in nutrition care 2 even though they were missing some basic steps.
I hear that you want more independence. (Listening – mirror & paraphrase)
Yes, you had more independence last week. (Agreement!)
These patients are sicker, these nutrition interventions are higher risk. (Building)
(Compare) I think I see things differently. We have 2 goals here: Nutrition care of the patient and your learning. My concerns are that I need to observe x,y,z before I can offer you that level of independence. For the next 2 days you will do the assessments including patient interview (info gathering only), document your thought process and come find me with your plans before implementing them. We will review and then the approved plan will be implemented.
Lets meet Thursday morning to decide how much independence for the remainder. How does that sound? (invite the intern to test your idea)

24. Touchy and Personal Issues
I didn't actually broach the subject as I didn't want to offend the student. She never seemed to brush her hair! How do you bring that up?
I couldn't tell if it was the style or lack of caring. I'd love to hear how someone has addressed issues of professional appearance.
When misapplied compassion rules over honesty, people can go for years without being given information that could be extremely helpful.
Establish Mutual Purpose: Explain that your reluctant to bring up the issue because of its personal nature, but since the problem may be interfering with the intern’s effectiveness, you really must.
Tentatively describe the problem. It is human nature to form some opinions based on first impressions, a big part of that being appearance. Some of our patients and staff maybe more on the conservative side and may see your hairstyle as messy and may then anticipate that your work may be careless. What do you think? Don’t play it up or pile it on. Describe the specific behaviours (and then move to solutions).

25. More specific tips for providing feedback
Choose an appropriate time and place
Be specific and concise
Describe the impact of the action/behaviour
Request further information
Clarify expectations/confirm understanding
Suggest/discuss potential future action
Thank and extend invitation for future dialogue/discussion
Credit: Peter Lam (2014)

26. How would you approach this?
How to encourage interns who seem less engaged with the RD to improve on this (e.g. write things down, ask questions, take more initiative)

27. How would you respond?
Terrible chart notes while doing clinical relief secondary to student having a "less than acceptable "preceptor in clinical II who didn't teach her to do proper charting.
I had the intern in tears AND had to notify my manager about the terrible job the previous preceptor had done with teaching intern's to chart.

28. For more…
Reading: Patterson, Grenny, McMillan & Switzler (2012) Crucial Conversations: Tools for talking when the stakes are high.
Resources to Practice: DC Website (Career>Mentoring & Preceptoring>Preceptoring>Preceptoring Resources)
Whose Problem is it anyway? Responding to Intern Performance Issues (Daphne Lordly) (2004)
Focus on Feedback (2009)
Connect & Influence change: Dietetic Educators Network (Contact: Theresa Cividin, Co-chair)
Anyone involved in dietetics education is welcome to:
share nationally, and
engage in important decisions related to the future of the profession in the area of education and practicum training.