Part 5
The Art of Creating a Safe environment
3M Dental is proud to sponsor the Dental Economics year-long "Mastering the Art of Communication" series.
Sandy Roth
Many people are reluctant to raise important and sometimes touchy issues because of concern about unintended repercussions. But communication cannot occur without addressing issues of importance to the relationship. Some people are so timid that they avoid even benign discussions; others are conflict-adverse and prefer not to "rock the boat." But when even confident people are afraid to engage in open discussion, it usually signals that the environment is not safe enough and that communication is not regarded as a natural and essential component of a healthy working association.
In this chapter of Mastering the Art of Communication, I`ll address the importance of creating a safe environment and give you an array of ideas about how to work toward a practice culture which supports full participation by each member of the team. Although I`ll focus most of my thoughts in the context of dentist-staff-team relationships and communication, you will discover that all of the principles apply equally to patient relationships. The primary difference is that it is reasonable to ask team members to observe a set of communications agreements. Patients, however, cannot be held accountable to communications pacts in the same way.
We begin our exploration of this topic by identifying two simple facts:
(1) The only person you can change is yourself.
(2) The only person you can control is yourself.
These facts are important to stress from the beginning. Many of us wish it were otherwise and so we attempt to exert our influence. In fact, we`re often pretty sure that if the other person would change to suit our perspective those things would be hunky-dory. Granted, that other person is probably saying the same about us. We can easily see ourselves as being more right than the other guy and maintain the futile wish that the other person will see the light and change. Assuming the above two facts, you will notice that the focus of this chapter will be on you - your motives, your intentions, your attitudes, your behaviors, and your responses.
Although it is important to focus on positive aspects of any given situation, here we will be looking at problems and negative situations. Of course, we would all prefer to have problem-free relationships, but that isn`t going to happen unless we learn to deal with problems. Indeed, it is paradoxical: the ability to identify, address and work through problems is the best tool to avoid problems. You must be able to develop the skills you wish to avoid having to use. Those skills become important in helping people anticipate potential problems or deal with problems while they remain small. Problems rarely go away; they just get more difficult to handle. Thus, the people who insist on avoiding problems because they don`t like conflict are those who are most likely to be oppressed with problems continuously.
Let`s begin by looking at the elements which comprise a safe environment.
Common purpose - A group of people who are working toward a commonly understood, valued, and agreed-upon purpose is more likely to create a safe environment than those who have competing or controlling agendas. There is a significant difference in the intensity and nature of problems that arise from differences on what to accomplish vs. how to accomplish it.
Clear expectations - I often find that major problems result from the simple failure to clearly communicate expectations. Sadly, dentists are often remiss in their attention to this requirement. Although other team members are not immune from this aspect of the relationship, the dentist`s opinion of team members and their performance can often be the single most important factor in determining the success or failure of an employee. If the dentist fails to identify expectations in advance, team members are left to guess about their performance, creating a constant state of apprehension and worry.
Agreed-upon rules and permissions - When a group of people jointly create a code of conduct outlining the promises they will make to one another and the permission each has to address issues and problems, the safety of each member is virtually assured. Of course, once agreement has been reached, members must hold themselves accountable to the pact.
Honest, mature effort from all - Mature attitudes and behavior are highly important in forming a team. We have all known teenagers who behave maturely as well as adults who never developed grown-up interpersonal skills. Age isn`t the important factor; intention to participate fully with an honest effort is. Discussions which focus on one`s failings can cause embarrassment, and this is when an honest personal assessment and mature effort is essential.
Willingness to risk and make oneself vulnerable - Opening a difficult discussion is a tacit agreement to address all issues, even those you wish were left unexposed. Thus, a safe environment is based on a foundation of risk and vulnerability. You cannot keep yourself safe while threatening others. This is a practical example of one of my introductory facts: you cannot control anyone but yourself. You must give up the futile wish to control the topics others raise. Those who are conflict-adverse hesitate to become involved in difficult discussions because they realize that raising an issue gives others permission to respond in kind. Thus, I believe that the fear of hurting the feelings of others is really a fear of being hurt yourself.
Toughness with issues; tenderness with people - Nothing improves the sharpness of a team better than a good old-fashioned debate about the relative merits of an idea. But nothing can destroy a team faster than harshness and aggressive behavior. Separating issues from personalities is a major contributor to a safe environment. Actually, there are only a few personal issues, such as questioning a co-workers integrity, honesty or character. Most problems are differences of opinion about subjects which have to do with non-personal issues in the practice. Baggage - by which I mean unaddressed or unresolved historical issues - can become a serious matter. And thus we discover another reason for addressing problems when they are young and resolving them with finality.
Sponsorship from the dentist - I mentioned earlier that the dentist can have a profound impact on the safety of the organization when he or she fails to identify expectations. The dentist, as practice leader, must be accountable for sponsoring a safe environment. Frankly, if he or she fails to do this, the team is doomed. As the dentist, you are a powerful person and the important question is whether you use that power to enhance the safety of the group or contribute to a hazardous environment. Indeed, Orwell said it best in 1984 when he suggested that all of us are equal but some of us are more equal than the rest.
How to introduce and address an issue
I suspect that many of you might wish to become more comfortable with raising issues that are important to you, but you don`t know how. I`d like to offer a simple yet very effective way to prepare yourself and give you some experience in creating a safe environment for your working partners. The following eight steps can be applied to almost any situation:
1) Determine both your motive and your intention. Your motive is what prompts you to raise the issue in the first place. Why do you really want to bring up the issue? Are you hurt? Are you embarrassed? Are you angry? Are you concerned? If you are bothered, why are you bothered? Next, look at your intention or what you hope to accomplish by raising the issue. Do you want to avoid unpleasantness in the future? Do you want to change the way the practice works or the way patients are served? Do you want to clear the air? Do you want to win? Note that the intention is a broad set of circumstances, not a specific solution. A solution is created through input from all members of the team. If you enter a discussion with a solution to which you are wedded, you deny the group its authority and responsibility.
Motive and intention are very important. They frame the spirit with which you come to the discussion. In many cases, they are more important than the message and can heavily influence how others participate in the discussion. So be serious and honest in your self-assessment before you begin. Thoughtfulness here can make the difference between a successful outcome and a disaster.
2) State your motive and intention as a preamble. It should become immediately apparent that stating your motive and intention forces you to come clean. If exposure of an impure motive or intention would cause you to be embarrassed or ashamed, you will probably want to have a little discussion with yourself. For example, "I`m angry because you get more privileges than I do and I`m raising this to make myself look better in the eyes of the dentist," is a motive and intention you might want to review. If you aren`t willing to state the truth because you would expose an unkind or inappropriate motive and intention, it is time to examine your own heart. Stop. Do not raise the issue. Return to self-discussion, abandon your ugly intent and divest yourself of your ill feelings. You are very likely to hurt feelings when your intention is to do so.
3) Address any reactions you do not intend to provoke and that to which you will hold yourself accountable. Many people tell me they are hesitant to raise an issue when they fear someone might misinterpret their intentions. That`s a simple problem to solve. Just express that concern. If your fear is that someone might adopt a defensive position and not hear you out, state that concern. This is particularly important if there is a shaky history or baggage that hasn`t been cleared. "I`ve been reluctant to raise this with you because we haven`t always seen eye-to-eye and our inclination has been to react negatively to one another rather than look for a healthy, positive outcome. I`m hoping that won`t be the case this time, and I promise that I won`t let myself go there."
4) State your message. Now it is time to deliver what you have to say - clearly, distinctly and without window dressing. Don`t hedge or use self-protective language such as, "I don`t know that you will agree with me but..." or "Maybe you think otherwise, but..."or "I might be wrong. This is just a guess I have, but...." Just say it and remember to be tough on the issues and tender with the person. For example, hear the clarity of the following: "Ruth, I am concerned about the level of service we can consistently promise our patients. It seems to me that you are often so tired at the end of the day that it is hard for you to be fully attentive. I observe that at the beginning of the week, you`re full of energy, but by early Thursday afternoon, you run out of steam. Is that something you`re aware of and would you agree with me?" Many of you have studied Thomas Gordon`s work (Parent Effectiveness Training and other classic books). Dr. Gordon has taught us to avoid "you" messages in favor of "I" statements, and his coaching is important to consider. He suggests that "you" messages are basically accusatory, blameful, and inciting, and he is correct. But many people misinterpret Gordon`s messages to wholly emphasize "I feel" statements in place of any "you" concepts. There is, of course, a big difference between the example above and "Ruth, you are flaking off a lot lately and we can`t count on you to do things right toward the end of the day or week." The latter is blameful. The former makes an observation.
5) Be prepared to give specific examples to represent your message. People may not fully understand how you see an issue unless you give them a specific example. Volunteer the example rather than wait for the other person to ask for one. "For example, Ruth, when Mrs. Jones called last Tuesday afternoon, you put her on hold and forgot about her. It seems that this has happened before and I worry about how the patients are reacting and also the accuracy of your data entry at similar times." Timeliness is important in raising issues, so remember that recent examples are important to the recall of situations and specifics and provide a better foundation for discussion.
6) Identify what you are hoping to achieve through the discussion. Are you hoping for a final resolution or only time for thoughtful consideration? Does the problem require immediate attention or are you simply asking for the other person to be made aware of a new perspective? Whatever your position, let the other person know your goal. "Ruth, I`m hoping that by calling this to your attention we can find a way to improve the consistency of our patient services and be certain that we have accurate data as well."
7) Listen to the other person. Remember that your interpretation of the situation may be incomplete or even wrong. Now it is time to fully listen to the other person without interruption, clarification or argument. (If you need help with this, please refer to "The Art of Listening," published in Dental Economics in March 2000.) Listen through to the end. Be prepared for defensiveness or perhaps even anger. Set aside your personal concerns and give the person the space and time to respond. This is another place where tenderness with people is important. Be sensitive enough to understand that people can require a bit of time to assimilate your message and may be embarrassed to admit the truthfulness of your comments. You must give them a safe way to acknowledge your observations and not berate them or hammer home your points.
8) Keep the discussion on the topic at hand. You may find that these types of conversations result in a tit-for-tat response. "Oh yeah, well, you`re always late in the morning!" If that happens, gently and respectfully ask the person to return to the topic you raised. "I`d be happy to discuss your concerns at another time. But for now, I`m asking you to stay focused on what I have raised."
These simple steps will likely help you feel more comfortable addressing difficult issues. I invite you and your team to practice working through the steps on some simple, agreed-upon issues so you can gain some experience and confidence. Then, any member of the team will have basic skills to use when other, perhaps more challenging issues must be addressed.
Why can`t we just get along?
I suspect one reason why we can`t get along is that we don`t know how. There can be no safety when people engage in a serious infraction that can destroy a practice: Triangulation. First, the fancy definition: Triangulation occurs when one person, having an issue with a second person, takes that issue to a third person. Now for the "street" definition: Triangulation is talking about people behind their backs. Triangulation is a serious problem for many teams, and it can often get a group in big trouble. Although triangulation is a behaviorally immature approach to disagreement, many adults engage in it without understanding the full implications of this choice. Often, team members are simply unaware of their actions. They have learned to gripe but not to address problems directly, and simply continue doing what they have always done.
Triangulation solves no problems. The only route to solving inter-team conflict is a full, honest, and open discussion of the issues with every person`s active participation. All problems ultimately belong to the group and not a secret subset of team members. Here`s why. Let`s say Jeanne and Jane have a difference of opinion. When their individual efforts fail to resolve this difference and either party secretly takes her frustration or anger to a third person, that third person is now involved in a clandestine discussion. This unhealthy dynamic now "infects" the entire team. People always know who is mad at whom and who is part of a faction.
Triangulation creates new problems. Triangulation fractures the group by putting a greater emphasis on differences than on understandings. It almost forces people to focus on the negative aspects of their culture. Moreover, this strategy creates an environment of distrust and disrespect, which undermines healthy aspects of relationships. Attention must then be shifted away from patient care to team dynamics. What a waste!
Triangulation creates false alliances. Jane is angry with Maggie and goes to Susie to dump. "Have you noticed Maggie doing such-and-such?" Jane asks Susie. Now, Susie hasn`t noticed this, and initially she has no beef with Maggie herself. "No," she answers. "Well, I have," adds Jane. At this very point, Susie will most likely make a choice between aligning herself with Jane or standing in defense of Maggie. Susie will find it difficult to disagree with Jane. After all, Jane has come to confide in her - an act of "friendship." And just because Susie hasn`t seen something doesn`t mean it hasn`t really happened.
Human nature will more often result in a secret alliance between Jane and Susie against Maggie that is based on incomplete information and a pact to tell no one else. If she tells Maggie, she has violated Jane`s "confidence." The confidential information Jane has shared is now almost impossible to ignore. (Don`t think of an elephant.) Even if Jane drops the conversation at this point, Susie is now predisposed to seeing Maggie in the negative light of Jane`s characterization. She is now more likely to see those things that confirm Jane`s picture of Maggie, and selectively ignore information to the contrary.
Triangulation encourages factions. Under the guise of "checking it out," a team member triangulates with a third party (sometimes this person is the dentist). First, let`s agree that this is tattling. If the initiator really wants to check things out, he or she should go to only the person who can answer the questions. The real purpose of this behavior is to gain allies. The more people agree that you are right and the other is wrong, the stronger you feel and the more righteous you become. Once the number of allies begins to grow, the opposition is forced to counter. Before you know it, the practice is split and there is full-scale civil war.
So what are the alternatives?
* Go directly to the source. The cleanest way to handle any problem is to go to the source. Yes, this can be tough, but eventually the problem must be aired. Delay only increases the unhealthy circumstances triangulation creates. Forget about rehearsing, making sure you are "right" before you raise an issue, or gaining evidence. None of these excuses justifies triangulation.
* Don`t agree to keep triangulation confidential. If someone asks you to enter into an unhealthy alliance by sharing secret information with you, simply refuse to keep it secret. The proper answer to "If I tell you something, will you promise not to tell anyone else?" is "No." For what honorable reason would someone call your attention to a problem if she didn`t want some help actually solving it? If the real reason is to get your support in the civil war, refuse to be drafted. You can agree to help the person raise an issue, but you must never agree to be a secret agent. Mature behavior is essential!
o Ask for facilitation if you need help. If a co-worker tells you about an issue she has with a team member ask the following: "How did you raise that issue and what happened as a result of your discussion?" Almost always, you will hear that there was no discussion. At this point, encourage your friend to raise the issue immediately and offer to facilitate the process. Facilitate does not mean gang up. Facilitate means to ensure that each party is heard and understood.
o Return the problem to the group if necessary. Of course, the team needn`t handle every issue. But when reasonable attempts to resolve disputes prove unsuccessful, it is time to ask the support of the entire team before the relationship deteriorates needlessly. Be sure to ask team members to listen to the issues and avoid taking sides. The only side that matters is the one that honors the best interests of the practice and the patients whom you serve. Principles, core values and promises to patients matter. Egos must get out of the way.
There is a lot to consider when creating a safe environment. You can see that most of what I have suggested requires you to be fully responsible for yourself and simultaneously involved and responsible for the success of the group process. I encourage you and your team members to spend some thoughtful time with the contents of this chapter before you begin working on the "Guided Team Meeting" Terry Goss and I have prepared for you. Next month, I`ll be serving up a chapter titled "The Art of Addressing Conflict." This month`s work will form a proper foundation for this next, important step.
