You just arrived for the start of your shift at the inpatient pharmacy when you answer the phone for the first time for the day.  On the other end of the call is a very upset nurse, calling about a patient’s missing antibiotic dose.  She berates the pharmacy department for a lack of competency during the call and you start to get upset as well because of the interaction.  Or, consider another scenario. Today is the first day you are participating as a vaccinator in a COVID-19 vaccine clinic at your hospital.  The institution’s vaccinator training emphasized the importance of reviewing an identification prior to administering the vaccine.  Your first patient for the day unfortunately arrived without identification and was extremely angry when you turned them away.  The challenging part of the interaction was that this patient is also a physician at your hospital!

Healthcare is a high stakes environment by its very nature; the health and well-being of our patients hang in the balance with every interaction.  This can create a highly emotional environment due to the stakes - healthcare providers understand the importance of their actions and decisions and as a result, want to ensure the best care possible for their patients.  However, healthcare providers have different backgrounds and training, which inevitably results in different opinions on the best course of action.  The outcome of this environment is a major safety challenge, as unintended task-conflict can exist among providers, patients, and service lines.  Conflicts such as these can become relationship-conflict, causing stakeholders to withdraw from conversations or lash out at co-workers.  Ultimately, the team suffers as “being on the same page” becomes harder without an open dialogue.  This may not be your experience and I’m not suggesting that conflict cannot be productive.  In fact I suggest the opposite – that how conflict is managed can affect relationships among all stakeholders as well as institutional culture.  Here I present several free and low-cost resources available to help navigate and overcome conflict in the healthcare workspace. 

Crucial Conversations is a book with years of research behind it that I highly recommend for having “safe” high stakes conversations in healthcare.¹ According to the book, crucial conversations are discussions when stakes are high, emotions are strong, or participants have opposing views.  Therefore, many conversations in healthcare could be considered crucial conversations.  Knowing this definition, recall the last time (it doesn’t have to be work related) that you had a crucial conversation when you were emotional.  How did you react?  Did you quietly seethe in your rage, or did you go on the attack to prove your point?  Either reaction is counter-productive to finding an outcome amenable to all parties.  This book presents tools and philosophies for ensuring a more productive crucial conversation.  I encourage you to read the book on your own, but here are three key processes/philosophies I want to highlight:

1. Focus on yourself first.  You are the only person that you can fully control.  How you present yourself, approach the conversation, and react to the other party’s reaction to conflict are the only things you can control.  Other parties in the discussion may not have the reaction you wish for, but that is okay.   Focus on yourself.
   
   
2. Make conversations safe.  Dialogue can only happen when people contribute to the conversation and that can only happen when people feel safe to express their concerns and ideas.  Restore safety when you sense the conversation taking a turn for the worse.  Safety can be restored by finding mutual purpose, ensuring mutual respect, and apologizing when appropriate.
   
   
3. Use STATE.  

• Share your facts – Leading with facts ensures all parties understands the origin of your view. Facts are not controversial or insulting, and they can be persuasive.
• Tell your story – This can be a bit scary, but is also the moment when you present your conclusion from the facts you have gathered.
• Ask for others' paths – Gain an understanding of what others' viewpoints are.
• Talk tentatively – This means not presenting your story as a hard conclusion.
• Encourage testing – Invite opposing views, it’s important to hear everything, identify controversy, and build consensus.

The second resource you should consider exploring is the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program.² It is an evidence-based system developed by the Agency for Healthcare Research and Quality (AHRQ) and Department of Defense (DoD) to optimize patient care and teamwork among healthcare professionals.  The resource is a 7-course core module that can be taken without additional guidance (ie. classroom slides are available online along with a pocket guide).  However, if a more formal roll-out is desired, an instructor’s guide, implementation guide, and practice scenarios are also available.  Additionally, there are TeamSTEPPS practice-focused courses that may be of better use to you and include long-term care, rapid response, and office-based care. The most streamlined version of the TeamSTEPPS content is their Essentials course.³

There is A LOT to the TeamSTEPPS program; some concepts are briefly described here.  Four teachable/learnable skills are the foundation for team-based care – communication, leadership, situation monitoring, and mutual support.² The program emphasizes several high-yield safety communication strategies.  These include Situation-Background-Assessment-Recommendation/Request (SBAR) reports which convey critical information in a structured way; call-outs which are announcements that inform all team members simultaneously; check-backs which close the communication loop by providing feedback on the information received; and hand-offs which transfer information and responsibility.  TeamSTEPPS also identifies three “CUS” words/phrases, which should be used when in a safety situation – “I am CONCERNED,” “I am UNCOMFORTABLE,” and “this is a SAFETY issue.”  The program also recommends using briefs, huddles, and debriefs to ensure mutual understanding of the plan, responsibilities, and expected outcomes.  Lastly, a high-functioning team has mutual support, which is a climate where assistance is actively sought and offered.  A provider can implement TeamSTEPPS practices without an institutional roll-out, so please consider utilizing these strategies.  

This short commentary cannot replace any kind of safety related training.  However, some of the presented processes can be immediately implemented.  Self-exploration, reflection, self-awareness, and coordinated institutional implementation are necessary to cultivate a safety culture at your workplace.  Overall, there are many available safety systems and programs, and there is significant overlap among them.  The goal is the same for each, so determine which is best for you and work towards safety every day at work.  Safety starts with you.