Culture in health care is a nebulous concept and can be tricky to define, but Patrick P. Kneeland, MD, put it simply.
“Culture is no more than how we behave with each other over time,” he said at the Society of Hospital Medicine's CONVERGE conference, held in late March in Austin, Texas. “And what's cool about that is we can control that, to a great extent,” whether leading a team, being a teammate, or interacting with patients.
People almost universally want certain qualities in their leaders, colleagues, and physicians, mainly trust, listening, and loyalty, said Dr. Kneeland, who is vice president of medical affairs and lead for advanced care and extended care at DispatchHealth, a high-acuity home health care provider based in Denver.
“We all have a sense that we want to be operating in a psychologically safe space, where our voices are listened to and where people care about us as humans,” he said.
Such spaces are environments where clinicians feel comfortable in interpersonal risk-taking, Dr. Kneeland explained. “That's really important when we're thinking about solving the complex problems that all of us have to solve on a daily basis. … Ultimately, most of us desire to get to a point where we're in a learning organization that's continuously striving to improve,” he said.
During the talk, “From Surviving to Thriving in a Changing Healthcare Environment,” Dr. Kneeland and ACP Member Read G. Pierce, MD, offered three high-yield strategies to cultivate a thriving work environment.
1. Ask powerful questions.
As a leader, colleague, or individual, try to ask powerful questions, including during the most stressful moments of your workday, rather than making statements, Dr. Kneeland said. “We like to think of this as turning to wonder,” he said. “Most people experience [being asked] truly open-ended questions that are nonjudgmental as being a positive form of communication, versus a statement.”
Asking a question in this way requires that you don't already have an expected answer in mind, Dr. Kneeland said. Example questions to ask in an annual performance review might be, “Can you tell me something you're really energized about in your work right now?” or “Can you tell me something you're struggling with in your work right now?”
This strategy can also be applied during rounds by leadership. Dr. Kneeland described a system in which a patient-safety leader visits a frontline unit and asks for two things that are going well and one that has room for improvement. In a study published in March 2018 by The BMJ Quality & Safety, health care workers who received more feedback in this way reported significantly better leadership, teamwork, safety, emotional exhaustion, burnout, and work-life balance than those who received less. “This is correlative, for sure, but a pretty interesting breadth of impact from a single behavioral change that's actually pretty simple. And it's really about a powerful question,” he said.
A more common example of a powerful question is to replace asking a colleague “How are you?” with “Hey, it's been a tough six months. How's it going?” said Dr. Kneeland. Asking in this way is “a little step beyond social and normative versions of that question,” he said.
Physicians can also ask themselves powerful questions. “Folks may have heard in the past about a concept called Three Good Things, and this is about asking ourselves a question as we're getting ready to go to bed for the night, for example, what were three good things that happened in my day today?” Dr. Kneeland said. Data show that if done for 14 consecutive days, this practice works as well as or better than a selective serotonin reuptake inhibitor for mild to moderate depression, he noted.
2. Listen reflectively.
Once you're in the habit of asking open-ended questions, try to practice active listening, said Dr. Pierce, who is chief of hospital medicine and associate chair for faculty development and well-being at Dell Medical School at the University of Texas at Austin. “So I'm going to listen to the other person, and I'm going to convey interest,” he said.
But people usually skip a useful next step, reflective listening, Dr. Pierce said. “Before I do anything else—before I solve the problem, make a suggestion, ask a follow-up question, make a comment about the leadership of the organization—I'm going to summarize briefly what I [heard] from the person who's speaking,” he said.
Reflective listening is simple, but it's not easy, especially given time pressures and physicians' role as “fixers,” Dr. Pierce noted. “We want to move the conversation forward because we think we have a handle on the problem or the concern, when the reality is that, particularly for us as humans, our emotional experience of work and life is complex,” he said. “The first thing that may come out of our mouth (and the second and third thing) may not actually be the whole story.”
This is especially true in interactions with patients. “Anybody had that experience where you're interviewing a patient, it's like 10 minutes in, and the real issue comes up?” Dr. Pierce said. “You would've missed it if you cut the interview short.”
Letting people feel heard doesn't just have a powerful impact on culture; it can also affect outcomes, said Dr. Pierce, adding that reflective listening can even help with clinical problems such as low back pain. “Listening is not a passive thing we're doing,” he said.
3. Recognize and respond to emotion.
When in conflict, try to see the emotion in the other person and address that emotion before moving on to solutions, Dr. Kneeland said. That may sound basic, but it's quite difficult to do, he added.
That's because people are wired to respond in the moment, especially when under stress, by getting defensive, throwing somebody under the bus, providing data or a technical solution, or avoiding the situation altogether, he said. “We live in a high-pressure, very complex world most of the time. And in that world, our brains, for biological and evolutionary reasons, like to do one of these things,” Dr. Kneeland said.
Try to buck your evolutionary urges by recognizing what emotion the person is experiencing and responding to it before moving forward, he advised.
Dr. Kneeland shared PEARLS as a helpful acronym for doing this, which comes from the book “Communication Rx”: Partnership (“How could we walk through this together?”), Empathy (“I imagine that has been very difficult for you”), Apology/Acknowledgment (“I am so sorry I don't have better news”), Respect (“You have worked very hard on this project”), Legitimization (“Anyone who has gone through this would be angry”), and Support (“How can I most effectively support next steps?”).
He added that naming the emotion is also useful (“I am sensing quite a bit of anger”).
“This is helpful for me to have in my toolkit, particularly when I'm not showing up at my best,” Dr. Kneeland said. “It's been super helpful just to have some ideas for those moments.”
He called out legitimization as a particularly powerful component. “Just legitimizing what the other person experiences in the world … and you're not agreeing with any of the details; you're just saying that's a normal human reaction,” Dr. Kneeland said.
Adopting these behaviors in difficult conversations can improve your energy levels in addition to your interactions.
“At the end of the day, I've got a container of [limited] energy … so if I can leave that interaction in a better place than if I were to get defensive, throw someone else under the bus, avoid, and then think about it all day, I'm going to have a little bit more energy for the next interaction, because there's going to be other important ones that day,” Dr. Kneeland said. “A little bit of an investment up front actually saves me a lot of backend energy.”