Crucial Conversations


Crucial conversations remain one of the variables capable of positively influencing the quality of healthcare and reducing the number of deaths caused by errors in the process of treatment. Opposing opinions, high-stakes, and strong emotions have been identified as primary characteristics of crucial conversations that differentiate such engagement from other vanilla conversations. The goal of engaging in such robust conversation must always be to improve the quality of healthcare and increase the safety of patients. Besides, the small number of professionals involved in crucial systematic discussion contributes to reduced mistakes, improve respect, and deal with the critical level of incompetence. The purpose of the essay is to evaluate an example of a crucial conversation in the healthcare environment. Working on self, asking questions, confronting with safety, and moving in action have been identified as primary tools to the effective crucial conversation. The author concludes that although learning of various communications skills necessary for effective communication can help increase the number of people engaging in crucial conversations, hospitals need to cultivate a conversational culture.

Keywords: crucial conversation, tools, healthcare, high-stakes, strong emotions, opposing opinions



Crucial Conversations

All too often, well-intentioned nurses and other healthcare professionals refrain from speaking up when they are concerned with health of a patient and behavior, decisions, inaction, or actions of a colleague. Such mistakes in interpersonal communication account for more than half of all medication errors recorded in healthcare facilities. As a matter of fact, a majority of healthcare workers witness their coworkers make mistakes, break rules, demonstrate incompetence, fail to offer support, show disrespect to patients and colleagues, demonstrate poor teamwork, and tend to micromanage others, yet say nothing about it. Healthcare workers avoid such crucial conversations because they are characterized by high emotions, opposing opinions, and high stakes. Despite an obvious need to engage in crucial conversation, individuals often back away instead of confronting their fears when it matters most. Lack of necessary tools for crucial conversations significantly contributes to avoidance of tough conversations, leaving health and sometimes life of patients at stake. The essay presents an example of a high-stakes conversation with the aim of analyzing and identifying various elements of crucial conversations and presenting a viable conversational tools plan to make such engagements efficient.

Numerous studies have been conducted with the intention of identifying specific concerns that make communicating hard for some people, hence contributing to the high number of errors and other chronic healthcare problems. People’s ability to discuss emotional, debatable, and risky topics in a healthcare setting with major results like the quality of care, nursing turnover, and patient safety among others remain critical (Shrader & Zaudke, 2015). A pharmacist will fill in an apparently wrong prescription without raising a question simply because the doctor has a history of showing hostility when challenged. Similarly, a nurse will quit reminding coworkers to wash their hands, put on gloves, or put up the child’s bed safety rails because of an unfavorable response in the past. An administrator will reluctantly push for quality improvement in a health facility because some physicians have been predictably incorporative with previous similar initiatives (Lamba, Offin, & Nagurka, 2013). These are examples of professional healthcare refraining from crucial conversations despite the fact that candid discussion on these issues could be a key variable in the process of saving lives and improving results in the healthcare.    

Case Example of a High-Stakes Conversation

One should consider a scenario when a patient has been admitted to the Trauma/Surgical Intensive care unit being very sick and in need of immediate surgery. During the surgery, the nurse noticed that the patient had developed a severe reaction to one of the medications, leading to sustained raised body temperatures to about 104 degrees Fahrenheit. As a result, the patient experienced chain reactions that made it difficult for the kidney to operate at optimum level, increasing risks and eventually leading to acute renal failure. Moreover, kidney functions had already revealed signs of deterioration based on the patient’s laboratory indicators outcomes. Being an experienced expert in continuous renal replacement therapy (CRRT), the nurse knew that the only way to spare the patient kidney from any further damage was through immediate commencement of therapy (Major, Abderrahman, & Sweeney, 2013). After ascertaining that the patient qualified for the treatment, the nurse had to consult with the nephrologist, being the only person who could order the treatment. Unfortunately, the nephrologist dismissed the nurse’s opinion with an abusive and condescending “we will not start the dialysis; period!” statement without even reevaluating the patient’s medical records. The nurse felt emotionally violated, hence refraining from pursuing the issue further even with a clear understanding of the inevitable fatal outcome caused by the nephrologist’s decision.

Elements of Crucial Conversation Present

As suggested above, critical conversations have three primary elements that differentiate them from other vanilla conversations. A difference in opinion or opposing opinions is one of the fundamental aspects of such conversations (Patterson, Grenny, McMillan, Switzler, & Maxfield, 2013). In the example under consideration, the nurse and the nephrologist had opposing views on the need to start dialysis as soon as possible. Secondly, emotions got in the way of the nurse’s attempt to do the right thing, especially after the nephrologist responded with a harsh and condescending finality statement. Strong emotions resonate with the refrain from the speaking-up tendency associated with healthcare workers (Shrader & Zaudke, 2015). In addition, high-stakes, which form the third fundamental element of crucial conversation, was evidenced in the example considering that life of the patient and reputation of the healthcare facility depended on effectiveness and eventual outcome of the conversation. Due to lack of necessary crucial conversation tools, the nurse backed off from any further engagement with the only person who could help the patient. Lack of respect, incompetence, failure to offer support to nurses, poor teamwork, and mere arrogance of the nephrologist led to the fatal mistake. Such elements of crucial conversation hindered workers from focusing on health of the patient as the central issue.

Tools for Effective Crucial Conversation

To avoid an adverse outcome similar to the one observed above and equip healthcare professionals with necessary interpersonal communication skills used in achieving effective crucial conversations, the following tools are recommended. First, the person who sees the need to initiate the conversation must begin with working on self (Patterson, Grenny, Switzler, & McMillan, 2012). Working on oneself means preparing before confronting the person with the right problem of discussion. In doing this, an individual seeks to identify the purpose of the conversation, the end goal of the engagement, and the expected ideal outcome (Lamba et al., 2013). In the process of working on oneself, a person can identify all assumptions and possibilities of feeling disrespected, intimidated, belittled, and ignored. A clear view of all options helps an individual to avoid being emotionally involved, hence facilitating an objective attitude and perception of the conversation (Patterson et al., 2012). Furthermore, the tool enables an individual to perceive the problem from the eyes of the person with the opposing opinion, thus identifying their source of errors (Major et al., 2013). A comprehensive analysis of the situation before the conversation cultivates an attitude of maximum effectiveness and reframes the opponent as a partner.

After identifying the real problem through the use of questions as a useful conversation tool, the second step involves gathering evidence to support the argument and the ideal expected outcome. Content, Pattern, Relationship (CPR) skills classify the problem into any of the three categories (Shrader & Zaudke, 2015). If it is the first time that the nephrologist is rudely ignoring the nurse’s opinion, the problem can be categorized under content. Nevertheless, a repeated lack of concern with team members’ opinion indicates a pattern. In case such incidences are only identifiable when a particular nurse confronts the nephrologist, it is an indicator of a relationship problem. Proper categorization of the entire problem and evaluation of the whole story determine the outcome of the engagement. Instead of the nurse wondering what the matter was with the nephrologist, they should be concerned with why a rational person would make such a decision. An understanding of what informs the person holding an opposing opinion helps in identifying things that can motivate the individual to change their mind and make the right decision (Shrader & Zaudke, 2015). After objectively weighing the evidence in support of the two opinions, the nurse would have been more ready to engage in a useful crucial conversation.

The third tool to promotion of an effective crucial engagement involves confronting with safety. Evidentially, the first thirty seconds of the conversation set the tone and attitude of the entire endeavor (Patterson et al., 2012). To set the right tone and ensure safety, an attitude of discovery and curiosity should be cultivated (Patterson et al., 2012). For instance, if the nurse approached the nephrologist out of concern and an intention to get a deeper understanding of the patient’s condition and implication of various symptoms, the response would probably have been entirely different. It is critical to help the other person appreciate the patient’s best interests without sounding vindictive (Patterson et al., 2013). After setting the right tone, the next step should describe the gap between what was expected in such situation and what happened. Besides, pointing out that the temperature of the patient rose to unexpected levels would have been healthier than presenting the conclusion. If the person appreciates the goal that is to keep the patient safe, but remains defensive, it would be best to retreat and recreate safety. This step should be followed by a confrontation motivated by significant consequences that matter to the other person (Patterson et al., 2012). For example, the nephrologist should be made to understand possible outcomes of the patient’s condition if no actions are taken.

Regardless of effectiveness or ineffectiveness of the above tools, the final tool to effective crucial conversation involves moving in action (Patterson et al., 2012). In case the two parties come to an understanding, they should agree on a plan and a follow-up method in resolving the problem (Patterson et al., 2012). The plan should indicate who does what and by when. Both parties must stay focused and flexible in addressing any issues that might come up in the process of implementing the plan.

When armed with the necessary tools for an effective crucial conversation, the nurse's first step would have been to contact the chief resident with a suggestion of starting CRRT supported by reasons why the patient qualified for this treatment. The chief resident would probably have directed the nurse to consult with the nephrologist. In case the nephrology resident ignored all the data supporting the argument with a similar finality statement, the nurse should have avoided allowing emotions to get in the way of a productive engagement and pursued the issue further. Most importantly, maintaining honesty and respect while citing the research and suggesting the best treatment for this patient throughout the conversation would have played a critical role in reaching the desired outcome (Lamba et al., 2013). If the two fail to come to an agreement in the first meeting, the nurse should have retreated and confronted the nephrology attending physician with more facts, especially when seeing the patient. By this moment, the nephrologist would see the validity of the points suggested by the nurse and order the treatment. However, if the standoff continues, the nurse should get ready to move into action, but without breaking medical practitioners’ rules.

One way of taking action could involve notifying the primary service chief resident of the deteriorating health of the patient. The supervisor would then utilize authority to explain to nephrologists why CRRT must be started immediately and in case they still refuse to approve the treatment, the hospital would be at liberty to seek approval from other nephrologists. Alternatively, the administrator would ask all attending nurses and physicians to come together and discuss the best treatment for the patient based on the available evidence. Objective consideration of all facts out of a mutual purpose of giving the patient the best treatment would result in approval and immediate commencement of dialysis (Lamba et al., 2013). Eventually, the patient would get stable after a week of therapy and receive an improved mental status. In the end, the nurse will experience fulfillment as a result of confronting fear and not allowing emotions to get in the way of delivering quality service to the patient. In any case, healthcare workers must always be ready to confront professionally any unhealthy work practices, disrespect, and other obstacles with the potential of undermining the quality of health services through crucial conversations.


Crucial conversations are communication engagement characterized by strong emotions, high-stakes, and opposing opinions. Fear and lack of necessary tools for crucial conversation contribute to the high number of individuals who refrain from speaking up even when things are about to get fatal. Through evaluation of the example of a patient with an immediate need for dialysis, the author suggested ways in which various tools for crucial conversations can be utilized to arrive at the desired outcome. However, even with successful application of the tools coworkers can still retain their reservations towards an issue, but that should not get in the way of taking the right action.

In sum, healthcare workers should always be prepared to engage in crucial conversations, especially in situations when stakes are extremely high in order to ensure quality services and avoid the loss of life. The above example must act as a clarion call for all nurses to vow to speak and not shy away from crucial conversations with the aim of creating a healthier environment for both the patient and coworkers. If more healthcare workers could learn the tools for crucial conversations and become able to do it systematically, the country would record a significant reduction in errors, lower turnover, and higher productivity. Hospitals have a responsibility of creating cultures of safety where employees can candidly engage each other about their concerns. However, the culture of silence shall not be broken by passing fear policies that protect individuals who speak up. Hence, leaders should intentionally and actively make use of the above recommendations to improve employees’ ability to engage in crucial conversations.

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