Clear is Kind, part 2

Last time, I wrote about Brene Brown and how she stresses that clear is kind. I related it to my own experiences surrounding death and dying and, while using language like passed on to a better place may feel more comfortable, it isn’t clear. And it isn’t kind.

Thinking about all that reminded me of another incident in which being clear would have been much kinder.

I was working at a smaller community hospital, not a large trauma or academic medical center, when a patient who’d had multiple cardiac arrests on the floor was moved to the Intensive Care Unit with a significant decrease in brain function. The family was understandably upset and wanted answers about how this happened. 

We needed to have a family conference but there were no conference rooms available at that moment. We did the next best thing and gathered in the empty patient room next to his while the team of physicians and nurses spoke with the family about what had happened and what the plan was, moving forward.  

In hindsight, it’s easy now to see where we went wrong. We allowed to family to remain in that empty patient room after the conference. We thought we were being sensitive and accommodating, but over the next several days, they had multiple family members round the clock, sleeping in sleeping bags on the floor of that room. They brought in coolers filled with water and juice and even plugged in a crock pot for pulled pork sandwiches. 

We thought that by not setting any boundaries, we were being nice but it was the worst thing we could have done. By not telling them at 9pm that it was time to go home, we gave them the message that they shouldn’t leave. They stayed and didn’t get the rest they needed. They even asked if they could use the patient showers so they could clean up. 

It also put an undue burden on the staff. There was a window between the two rooms so anytime a nurse went into his room to provide care, the family was watching. It was very hard for the nurses to focus  and concentrate, knowing that there were people looking at them. People who, quite frankly, didn’t really know what they were looking at. 

This went on for over a week before the patient was transferred to a hospital that could offer a higher level of care. That place, I knew, had very clear boundaries about how many visitors could be there at any given time, very clear visiting hours, and a very strict no crock pot policy. 

It’s important to remember that the things we say or do when we try to be sensitive or accommodating aren’t always the kindest. Families need to know it’s okay to go home. To sleep in their own bed. To shower in their own bathroom. Or if they live out of town, at least at a hotel. Somewhere that isn’t the hospital so they can recharge, refresh, and be ready to support the patient and each other. 

This is where being a patient experience professional can get a little tricky. For those of us who have a hard time saying no, saying yes to every request seems like the kind thing to do. It isn’t. Not always. We have to stress the importance of downtime, of rest, and we have to be sure we’ve earned their trust, so they know they can leave the room and their loved one will still be safe. 
I wish we’d done things differently for that family. I wish I’d known of Brene Brown and her clear is kind message at that point in my career. It would have been a much kinder situation for everyone.

Clear is Kind

I read a lot of Brene Brown’s work. Her book, The Gifts of Imperfection, made a huge impact on me and I’ve been a fan of hers ever since it came out in 2010. I’ve started reading her most recent work, Dare to Lead, and in it, she talks about how being clear is kind.

It made me think back to when I was working in organ donation and transplantation. I was not on the recipient side, where the person who has been sick for so long finally gets that life-saving transplant. I was on the donor side, where a family who has just suffered a sudden tragedy is asked to make the ultimate selfless decision and donate their loved one’s organs. 

Since most Americans hate to think of death, we tend to use phrases like ‘passed on,’ ‘is no longer with us,’ or ‘is in a better place.’ They told us on day one of orientation NOT to use euphemisms. Say ‘dead’ or ‘died.’ It may be uncomfortable for you as the bearer of bad news, but it’s the kindest thing you can do. Families will appreciate it.

I said it a lot. I got used to saying it and I got used to hearing it.

Fast-forward a few years to when my husband and I were throwing a party at my house around the 4th of July. All of our friends and family were there, including my very best friend. It was well into the evening and many of us had had a few too many drinks, so when her phone rang and I saw all the color drain from her face, I didn’t know what had happened. 

I’d heard her say her brother’s name. I’d heard hospital. I thought I’d heard accident, but I wasn’t sure. I looked to my other friend in the room. “Wait… what happened? Is he okay?”

“He’s fine now,” she said. 

“Oh, thank God,” I answered. “Something happened but he’s okay?”

“He’s much better now. He’s out of pain.”

“Wait. Is he okay or is he not okay?” I struggled to read her face and make some sense of the situation. My friend had run out of the room crying and saying she had to get to the hospital, but my other friend was calmly telling me he was better. I had no idea what to think and those moments of uncertainty were horrible.

Finally, my husband who thankfully doesn’t drink, said, “He died, Kate. We have to get her to the hospital so she can be with the rest of her family. Let’s go. I’m driving.”

And at that moment, I understood. As horrible and unthinkable as that news was, I was almost relieved to know what we were dealing with. The next few days were a terrible blur for all of us, but I kept going back to those first moments when everything was so confusing.

I suppose it’s easier to deal with being mad at the one being unclear than it is to deal with your feelings about a friend dying. But when you’re faced with a sudden, unexpected, and tragic loss, what you need is information. Clarity. 

I know when Brene Brown says “clear is kind” she’s talking about instructions, feedback, expectations, generally between co-workers or bosses and employees. But it’s also true in painful situations like death. While we may want to soften the blow and use those phrases we think are helpful, it really only makes things worse. 

When I’m talking to an angry patient and trying to do some service recovery, the very best thing I can do besides apologize is be very clear about what happened and what we’re going to do about it. Patients want answers and as uncomfortable as it can be for me, it doesn’t pay to use fluffy language to try and soften things up.

Clear is kind. 

Some Positive Thoughts on Positivity

Earlier this morning as I was doing my daily patient rounding, one of the nurses I’d said ‘good morning’ to smiled and told me how much she enjoyed seeing me every day. “You always have such a positive energy around you,” she said. “It really brings the mood up when you come and talk to patients and to us. I really appreciate you.”

Wow. What a lovely thing to hear.

I sort of blushed and said thank you but what I really wanted to tell her was that it was a very deliberate decision every morning to show up with a smile. 

We patient experience directors have to walk a tricky line. On the one hand, we’re trying to dispel the outdated thinking that patient experience is ‘fluff stuff’ led by a bunch of vapid do-gooders who have no clue about real life. And at the same time, we can’t appear jaded and cynical or give in to all the forces that tell us that other things are more important.

I’ve taken a bit of heat in my career trying to be positive. I’ve encountered plenty of eye rolls, arms folded firmly across chests, sarcasm, and open hostility. I’ve been dismissed from meetings with a flick of the wrist, interrupted, had my data challenged in every conceivable way, and told ‘that’s nice, but we have real work to do.’

I’ve even had patients tell me to leave when I’ve come to round on them after learning I wasn’t a physician or a nurse. If I can’t give them pain meds then what good am I?

I have to choose to be positive. But honestly, why would I choose to be anything else? 

I’ve been angry, frustrated, outspoken, sarcastic, and cynical myself and you know where it got me? No further than being positive. Being positive just makes me feel better. Noticing the good, recognizing when something goes well, celebrating people who give a little extra… these things make me happy. And knowing that by doing them I can make someone else happy makes me even more happy. 

Staff perform better when the culture is positive. The world has enough desk pounders, enough cynics, enough people who are eager to rain on your parade. If I expect staff to be supportive and friendly and caring to patients, how can I not be that way to them?

So yes, when I walk in the front door, step off the elevator, and onto a med/surg unit, I am smiling. I am positive. Even if I have to fake it for a few minutes. Fluff stuff? No way. I’m changing healthcare.

More Thoughts on Appreciative Coaching

Last time, I wrote about appreciate coaching and how it’s more effective for people to improve and learn. Well, this past week, quite by accident, I stumbled upon an article from the Harvard Business Review entitled “Why Feedback Fails.” In studying how people learn, thrive, and excel, they point to three core evidence-based learning theory tenets:

1.       Telling people what we think of their performance doesn’t help them thrive and excel, and telling people how we think they should improve actually hinders learning;

2.       Humans are highly unreliable raters of other humans. The feedback you give is more about you than the person receiving feedback;

3.       The only realm in which humans are an unimpeachable source of truth is that of their own feelings and experiences.

People tend to perform better by being given goals and results to achieve, when they receive positive feedback about what they are doing well, and by watching other people excel and receive validation for their excellence. The article went so far as to give examples on how to more effectively communicate with teams to elicit these principles:

Instead of:                                                            Try:

Can I give you some feedback?Here’s my reaction
Good job!Here are three things that really worked for me. What was going through your mind when you did them?
Here’s what you should doHere’s what I would do
Here’s where you need to improveHere’s what worked best for me and why
That didn’t really workWhen you did (x) I felt (y)  -or- That didn’t really work for me
You need to improve your communication skillsHere’s exactly where you started to lose me
You need to be more responsiveWhen I don’t hear from you, I worry we’re not on the same page
You lack strategic thinkingI’m struggling to understand your plan
You should do ____   (in response to being asked for advice)What do you feel you’re struggling with and what have you done in a similar situation? 

You might find that you’ve done a few things in the left column. That’s okay. We all have. But now we know better. Modelling and recognizing excellence is more effective in helping teams provide excellent care, everytime.

Reference: Marcus Buckingdall and Ashley Goodall. “The Feedback Fallacy.” Harvard Business Review, March-April 2019 edition. https://hbr.org/2019/03/the-feedback-fallacy

Appreciative Coaching

What’s the best way to help people improve? How do we work with staff members who do a good job and help them get even better?

Many of us came into leadership positions at a time when we focused on the gaps: what our employees needed to work on and where they were weakest. During annual evaluations, we centered the discussion around mistakes and weaknesses.

There’s a better way.

Appreciative coaching focuses on what people are doing well. It allows them to determine where they’d like to improve.

For example, when watching a nurse do hourly rounding, we might say, “I observed your interaction with Mrs. Jones. How do you think it went? I saw you do __ and __ really well, great job! What do you think could have gone better? Okay, how can I help you with that?”

When we use appreciative coaching, four things happen:

  • We build a road to improvement. Employees are more likely to make improvements when they identify the things they want to do better. We tend to follow through on things when they’re our own ideas.
  • We make it ‘safe’ to not be perfect as long as we’re still trying. Employees do better when they’re supported, not criticized. 
  • We foster a culture of recognition and appreciation. When we tell employees what they’re good at and how important those skills are, they do them more often and even better than before.
  • As leaders, we start to see our staff differently. When we look for the good, we tend to see more good. 

Of course, if there are some serious performance issues, that’s an entirely different conversation. But for your high-performing staff, try a little appreciative coaching. 

The Patient Experience Nurse

Earlier this month, we celebrated Nurse’s Week. Our Chief Nurse Executive had a whole week of wonderful things planned for the department including massages, root beer floats, a homemade meatball contest, and an awards ceremony. She had a few different categories but the one that caught my attention was the Patient Experience Award given to the nurse that consistently exemplified excellent patient experience.

The winner was someone I knew. I had spoken with him a time or two when I did patient rounds on his floor and had heard his name a lot as someone patients absolutely loved. The next time I saw him, I pulled him aside to congratulate him and I asked him what it was he did that earned him this award.

“I just talk to them.”

“Come on,” I said. “Lots of nurses talk to patients. What are you doing that’s making such a difference?”

His answer was not what I was expecting. I thought he’d go into some big thing about how he always does AIDET when he’s in a patient room and he always calls them by the name they wish to be called and he always manages up the other staff… Nope.

“I think it’s my job to help them understand their disease so they can better manage it,” he said. “Most of them don’t connect the dots between what they do and how they feel. If I can help them see how doing this thing makes them sick, they’re less likely to do that thing. If they understand that their health is something they can control, they usually do. But, too often, they come in, they get some meds, they go home, and then they’re right back here again in few weeks. I talk to them. I work with them. I encourage them. I help them.”

“Wow,” I answered. “That was not what I thought you were going to say.”

“I can see myself in everyone here. You got your life together? Great, me too. You got problems? Things in your life went sideways? I get it. I was there, too. You can’t judge people. If you judge, you can’t understand. If you understand, you can’t judge. You just talk to them so they know you’re on their side, you’re rooting for them. I think that’s what I do.”

I thanked him and left feeling so good that we had someone like that working at our hospital. Someone who connects with, roots for, and educates patients. Someone who doesn’t judge, but listens, informs, cares.

Maybe that’s the secret sauce.

The No Pass Zone Pitfall

In every hospital I’ve ever worked, we’ve observed something called the No Pass Zone. The No Pass Zone means that when a call light is on outside a patient’s room, whoever is nearby, no matter what their job title, stops and answers the light. We go in, we tell the patient we saw the call light was on, and we ask what we can do to help.

No exceptions. You do not walk past a patient room when a light is on. Ever.

We drill this like crazy at new employee orientation. We tell clinical and non-clinical staff alike, “Do not walk past a room if there’s a light on. It doesn’t matter if that’s not your patient or you’re not an RN, or you’re in a hurry. If a light is on, you go in.” It’s crystal clear.

So what could possibly go wrong?

I was on my way up to the 3rd floor one Thursday morning to do my daily patient rounds. Each of us on the leadership team has an assignment of four patient rooms to round on. We ask questions about their stay, like which staff member can we recognize for doing a great job, what can we be doing differently to make your stay with us a little better, and some focus questions about a specific topic we’re trying to measure, like quiet and restfulness or RN Communication.

I got off the elevator with my rounding questions all ready to go when the very first room down the corridor had its call light on.

My eyes locked in on that soft white glow hanging from the ceiling. I could see nothing else. This was it. This was my moment. I was going to answer a call light. My mother, an RN of nearly 50 years, would be so proud.

I went into the room and saw a face that was familiar to me. He was a patient from a few weeks ago who had been in one of my assigned rooms for several days; I’d gotten to know him a bit. He looked different today.

“Hi!” I said. “I remember you! I saw your light on, how can I help you?”

“I need my nurse,” he cried. “My stomach is in so much pain and I just pooped myself and I called the nurse and I need help!”

“Oh my… okay… I’ll find your nurse… hang on… I’ll get some help.”

I ran out into the hallway and saw the manager of the unit. “Hey,” I said, “I answered the call light in room 301. The patient said he pooped himself and needs his nurse.”

She looked at me and said very calmly, “Okay, Kate, I’ll get his nurse. You know you were just in a room with a patient who has C-diff, right?”

I stopped dead in my tracks. “What?” C.-diff is clostridium difficile, a nasty little bug that wreaks havoc on your colon.

“Kate, go wash your hands with soap and water. Didn’t you see the signs on the door about contact precautions or notice the cart with all the PPE on it?”

Actually, no. I hadn’t.

Right outside the room there was a cart with PPE – personal protective equipment –  gowns, gloves, and masks and a big sign warning that we needed to take precautions before entering. I was so fixated on the call light, I never saw them.   

Thankfully, I hadn’t actually touched anything in the room, but I still felt like I had cooties all over me. I washed my hands for what seemed like an hour.

Here’s the thing: depending on our lens, we tend to fixate on certain things. As the patient experience director and a non-nurse, when I saw a call light, all I could think to do was answer it. Immediately. Someone needs help. Go help.

What we can’t forget to do is pause and take a look around. Notice the big red signs on the door. As you walk around the giant cart of PPE to get to the door, stop for a second and ask yourself why it’s there. Don’t get so caught up in your own forest that you can’t see the other trees.

More About the Checklist

Last time, I wrote about management by checklist. I stressed the importance of relationships and helping your team connect to the ‘why’ behind the directives.

This time I’d like to expand on that and talk about the number of things that are on that checklist.

A few years ago, I was working at a hospital that really wanted to improve their patient experience scores (their words, not mine) so they decided to make a list of all the things that have been shown to do so: AIDET, hourly nurse rounding, bedside shift report, MD-RN rounds, leader rounds, empathy statements, in-the-moment coaching, physician shadowing… the list went on and on. At the end of the exercise, I think there were 28 things they wanted to implement.

I asked them what they wanted to start with. “We’re doing them all!”

“All?” I asked. “We’re starting with all of them?”

“Yep, we’re going to shake things up all across the board,” they answered. “We’ve designed checklists to ensure that everyone is doing these things and we’re going to see an amazing jump in our scores, just you watch.”

The next week our nurse leaders were presented with a list of 28 things they needed to start doing and monitoring. Some of those things were already in place but happening inconsistently, others were new. We didn’t leave a lot of time for training; most of the instructions were given verbally at the time of the rollout.

There was a blitz, with many units trying hard to do everything on the list, but after just a few weeks, they ran out of steam. Too many plates spinning, too many things falling off, and too many opportunities to fail.

Had we just gone with one or two at a time, given them time to become a habit, and let them see some success before adding another, I think we would have had a very different outcome.

When we give our teams too many things to accomplish, they end up accomplishing nothing.

Management by Checklist

In the world of patient experience, we have a lot of evidence-based best practices that we’re constantly measuring: bedside shift report, hourly nurse rounding, MD-RN team rounds, leader rounding, and more. We spend a lot of time checking off boxes on the checklist to be sure all of those things are being done.

It’s important that we do these things. But how do we get people not only to do these things but do them well?

I’ve seen far too many managers send out communications that outline a process and direct people to action but few that have been all that compelling. That may be management but it’s not leadership.

The thing that moves people to action isn’t always a directive. And even if they do start moving, there’s no guarantee they’ll be moving effectively.

We make lasting change through relationships. People are far more likely to make a change when they understand the reason behind it and trust the person leading the change.

When we spend time with staff, understand what drives them, recognize the challenges they face, and get to know them as people, we begin to earn their trust. I’m far more likely to get behind a leader who knows me than one I’ve never even seen.

The checklists aren’t enough. Help your team connect to the why. When leaders lead with trust, mutual respect and connection, they create teams who not only make the change but do it well, with intention and purpose.

The Doctor-Patient Relationship

The relationship you have with your primary care physician can mean the difference between life and death.

How’s that for an opening statement?

My parents had my eldest brother, Chris, in 1959, then 14 months later had my other brother, Andrew, and 18 months later had my sister, Mary. It was just the three of them in this tight cluster until 7 years later when I came along. Those two were full of energy, into everything, and had non-stop energy. She, on the other hand, was an introverted sensitive soul.

She also had a weight problem. For as long as I could remember she was extremely self-conscious about it. My brothers were skinny, especially Chris, and poor Mary got picked on. A lot.

It didn’t help that our primary care physician was a scary looking old man who spoke in a thick German accent and used to tease her about her weight every year at her annual school physical. She dreaded those visits and even as an adult hated going to the doctor for fear that they’d say something unkind.

Those early pediatrician visits made a big impression on her. She thought every doctor was an old man who said things like, “Vell younk lady, you ah putting on some veight, again, yah? You haff to shtop eating so many cookies.” And always in front of my brothers, giving them plenty of ammunition for teasing.

She never got over it. This was a woman who, in her late 30s, refused to go to a doctor when she clearly and unmistakably had gallstones. Incredibly painful gallstones which she insisted on treating with over the counter tylenol. They either resolved on their own or she just adjusted her pain tolerance, I’m not sure which. But it infuriated my mom who was a nurse and me who worked at a hospital. We begged her to go to a doctor but she absolutely refused. She told us didn’t want to go because she was sure they’d get on her case about her weight. Exasperated, Mom and I finally gave up.

Fast forward to the fall of 2012. Mary was suffering from some insanely horrible back pain. Nothing over the counter could touch it. She’d gone to a chiropractor, a massage therapist, and an acupuncturist, but got no relief at all. I remember her telling me that driving over railroad tracks made her see stars.

Finally, I said, “That’s it. I’m getting you an appointment to see a doctor. We have GOT to get this looked at.” A few days later, I was able to get her in to an internal medicine physician with the medical group I worked with. Although I turned my head when he asked her to take her shirt off, there was no way not to notice the giant lump she had on her breast. It was huge. Softball size huge. I couldn’t believe my eyes.

A few imaging tests later and it was confirmed. The pain in her back wasn’t a bulging disc or muscle spasms. It was stage 4 breast cancer with compression fractures in her spine. The cancer had spread from her breast, through her rib cage and into her back. There was nothing they could do. They gave her six months.

I was as supportive as I knew how to be but I had to ask why she didn’t go see a doctor as soon as she found the lump. It all came down to her fear of ridicule. She truly thought that her doctor would spend more time chastising her about her weight than addressing the lump in her breast.

Now I’m not going to blame my sister’s death on her childhood physician; at some point, we all have to grow up and do the right thing. But she was truly traumatized as little kid and those scars stayed with her well into adulthood.

Sometimes we say things and we don’t mean anything by it. We’re joking, we’re trying to inject humor in an uncomfortable situation, or we’re just not thinking about how the other person is hearing it. Whatever the reason – it matters. Doctors, believe me, we listen to what our physicians say to us. It may be a throwaway comment to you, but it’s gospel to us. Venn you vant to make a shatement about your patient’s veight, pause. Think about how that may impact their relationship to the medical field.

I loved my old PCP. There was nothing he could have advised me to do that I wouldn’t have done. And not because it was good advice; other doctors gave me the same advice, it was because I liked him. Liking him made me much more inclined to do what he asked. When he addressed issues about my weight, it was always with compassion and sensitivity

Doctors, you’re more than just the treating physician. Inspiring behavioral change doesn’t really happen without relationship. Get to know your patients. Be kind when you have to deliver some unpopular or sensitive news like needing to lose weight. The words you choose can make all the difference.