Teamwork is essential in the surgical arena and trust is the foundation from which any high-performance team must operate. When a team member breaks a promise, violates expectations or exhibits bad behavior, managers must prepare for a face-to-face confrontation to hold that person accountable. Anyone in the OR can learn strong confrontation skills. As you'll see, those efforts will be rewarded with increased productivity, a higher performance quality and greater job satisfaction.

Damaged trust
All too often within the high-stress surgical environment, staff's trust in each other can be damaged. Trust-damaging behaviors carry a high cost in decreased productivity, employee dissatisfaction and low morale, wasted supplies, cancelled cases and, in the worst case, threats to patient safety. Because of the potential for patient harm and the demoralizing effect they have on the surgical team, these trust-damaging behaviors must never be tolerated:

• Failure to communicate critical information (intentionally or inadvertently). The admitting nurse withholds information about a patient to make a circulating nurse appear incompetent.
• Broken promises. A nurse who promises to open the room while her co-worker takes a break fails to do so, delaying the case's start time.
• Bad behavior. A surgeon shouts profanities at a scrub tech loud enough for patients and families in the admitting area to overhear.
• Violated expectations. A scheduler forgets to schedule the pathologist for a frozen section; the case must be rescheduled after the patient arrives and the error is discovered.
• Gossip. A nurse shares a difficult personal issue with a co-worker in confidence, then hears about it a few days later from a mutual acquaintance.

It is the responsibility of not only the surgical leader but also each team member to guard against these behaviors. The response to any of these behaviors is clear, respectful and timely communication. Sounds easy, doesn't it? But in reality many people have a tough time effectively confronting the person who has disappointed them or violated their trust. It's much easier to remain silent, to bottle the anger or hurt feelings, to plot retaliation or even to turn to verbal or physical violence. Comments about OR bullies reported in Outpatient Surgery Magazine's May 2006 issue are clear evidence that lateral violence - abusive behavior toward one's co-workers - is all too common. But the silent treatment and lateral violence are far from effective in eliminating trust-damaging behaviors.

In the book Crucial Confrontations, Patterson et al. define "confront" as "holding someone accountable, face-to-face." Lack of accountability for one's own actions and for the overall success of the surgical team is one of five issues Patrick M. Lencioni cites in his book The Five Dysfunctions of a Team as most damaging to a team's effectiveness. One reason many have so much trouble effectively confronting a person who disappoints them with team-damaging behavior is that the first response for most people is an immediate surge of emotion that triggers a self-protection reflex known as the fight-or-flight response. Whether fueled by anger, hurt, resentment, fear or frustration, the body reacts with a surge of adrenaline that increases blood flow to the muscles while decreasing blood flow to the brain to prepare the body to flee or fight. This is the reason people often feel tongue-tied and have difficulty thinking clearly in the moment they first find themselves in a confrontation.

For healthcare workers, several additional factors may contribute to ineffective responses to crucial confrontations. Here are a few.

• Pecking order. Medicine is a historically hierarchical profession with years of education and seniority as the primary factors in determining staff pecking orders. For centuries, doctors (especially surgeons) have ruled the roost. Right or wrong, nurses, techs and other allied health professionals have occupied lower rungs of the healthcare ladder. Even though some institutions are working hard to change this rigid view by embracing teamwork, many physicians still resent being corrected by a nurse or, heaven forbid, a scrub tech. Given that the dirty stuff flows downhill, it's not uncommon for nurses to take out their frustrations on colleagues of lower seniority, who in turn unload on those still lower. It's a never-ending waterfall of frustration. Many nurses and scrub techs are too fearful of repercussions, real or perceived, to step up to advocate for themselves, their co-workers or even a patient.
• Caring profession. Health care tends to draw people who truly care about others. This caring attitude can backfire if you're too afraid of hurting another's feelings to speak up when you see another doing wrong, either intentionally or inadvertently.
• John or Jane Wayne in the wilderness. Medicine draws more than its fair share of overachievers whose behaviors are reinforced by competition throughout the educational process. This can lead to a style of rugged individualism characterized by thoughts like, "I figured it out on my own. Why should I say anything? Let her figure it out herself. If she gets burned, she gets burned."
• Hero or martyr syndrome. When someone fails to follow through on a commitment, overachievers jump to the rescue and often get a sense of satisfaction from saving the day. The difference between a hero and a martyr is that the hero may brag about it after the fact while the martyr most likely complains. Both the hero and the martyr are seeking recognition. Instead of dealing effectively with the issue, they'll often let team-damaging behaviors slide. They may even encourage them with their own ineffective behaviors.
• So much to do, so little time. You might be uncomfortable confronting a person in the moment. Although you have the best intentions and think you'll get around to it later, life intrudes and you forget. Or perhaps in retrospect you decide the behavior isn't something worth rocking the boat about.

Model for change
While acquiring crucial confrontation skills requires dedicated practice, the payoff is high. After studying dozens of organizations in various industries, Patterson et al. discovered that the most influential people were those who, regardless of title, technical skills or role, were most skillful at confronting co-workers, including bosses, to hold them accountable for trust-damaging behaviors. They also demonstrate in numerous case studies that teaching people to use crucial confrontation skills yields impressive results. "When an IT group improved crucial confrontations practices by 22 percent, quality improved over 30 percent, productivity climbed almost 40 percent and costs plummeted by almost 50 percent, all while employee satisfaction swelled by 20 percent," they write.

Even the most skilled communicators don't effectively confront all the problems they face all the time, but using a model for thinking through and planning difficult communications ahead of time will increase the likelihood of success. When confrontation is done skillfully, it sets the stage for involved parties to be open, honest and respectful. Problems are solved, relationships are enhanced and, most importantly for the health of the surgical team, accountability is restored and trust is preserved.

But what about when you have to confront someone in the moment and you don't have time to plan or think through the issue? Patterson et al. break the process down into three stages.

1. Before the confrontation: Work on me first.
Thinking through and planning a crucial confrontation before you undertake it increases the likelihood of its success. This is especially true when you're first learning how to respond to confrontations.

First, choose which issue needs to be confronted, such as chronic lateness, unauthorized use of overtime, not wearing safety goggles or a violation of other regulations. When making a crucial confrontation, don't dump all of your frustrations on the targeted individual. You'll be much more effective if you choose the most important issue, distill it into one clear problem statement and address that issue first. If you need to address several issues, set an expectation that you'll address them later, either during the same conversation after the first issue has been resolved or at a later date.

Choosing the most important issue may seem obvious at first, but when multiple issues present simultaneously it's easy to get sidetracked and lose sight of the underlying issue that's most serious. Let's say you're addressing tardiness and you catch the employee in a lie. Put the tardiness issue on hold and immediately address the lying, which tops the list of employee trust-damaging behaviors.

When an issue arises concerning patient safety, you should always speak up, although this might not be quite as easy for a scrub tech dealing with a hotheaded surgeon. When faced with this kind of dilemma, use the "Headline Test." Imagine yourself picking up the paper to see a front page headline that reads, "Scrub Tech Joe Smith Could Have Prevented Loss of Healthy Foot." If you would not enjoy seeing your name in that headline, that's a pretty good indication that you'd better speak up, no matter who you're confronting.

But when the issue is unclear, ambiguous or might result in some harm to you (a damaged relationship or lost job, for example) things can be trickier. Most people err on the side of silence. A good rule of thumb to help you decide if issues should be addressed is: do they get in the way of fully engaging with your clinical team? In a high performance team, full participation of all team members is critical. When you notice yourself holding back because of some unspoken emotion, it's time to say something.

Once you've decided to speak up and you've chosen your issue, it's time to do a bit of self-reflection, which Patterson et al. call "mastering my stories." The first sentence or two of a crucial confrontation will set the tone for the rest of the interaction and may well determine its success or failure. It's difficult to turn the conversation around once you've started down the wrong path. Most of us have had that experience in the heat of the moment, when we've operated the mouth before engaging the brain and said something we later regret.

You're much more likely to create a sense of safety for the person you're confronting if you come from a place of curiosity; but it's hard to be curious when you're fuming. Try starting a confrontation by giving the other person the benefit of the doubt. This is usually easier to do if you're part of a great team because you most likely already have high regard for the other person involved. However, if that's not the case and your first inclination is to think, "She just ruined my day by double-booking cases because she was probably talking to her boyfriend, who always calls during work," it's especially important to rein in your imagination. We are so good at crafting stories that when someone does something to disappoint or harm us, we act as judge, jury and executioner within a split-second - all while refusing to consider the facts.

Because we have a natural tendency to make snap judgments, giving others the benefit of the doubt is one of the toughest steps for some to master. Most people don't come to work each day thinking of how they can mess up or make your life miserable. Most people are conscientious and want to do well. Patterson et al. suggest that you ask yourself, "Why would a reasonable, rational and decent person do this? Are there other versions of the story that could account for this person's behavior?" These are powerful questions that can open your mind to other possibilities while helping to calm you when you're faced with confrontation.

Doing a little story management before beginning the confrontation's conversation will help you calm down and start from a place of curiosity. That will feel much safer to the person you're confronting than if you instead decide to go on the attack. When people feel attacked, they immediately go on the defensive. Curiosity, however, will set the stage for problem solving and you'll be in a much better position to work through the issue to get to the result you want - ensuring the behavior doesn't happen again.

2. During the confrontation: Confront with safety.
The first few words you speak may determine whether you succeed or fail. As Patterson et al. say, "If you can create a sense of safety, you can talk with almost anyone about almost anything - even about failed promises." To ensure that you're not setting yourself up to fail, avoid these behaviors.

• Don't play games. Avoid using the sandwich technique to soften the blow - starting with a compliment, slapping in the criticism and then finishing it off with another compliment. This diffuses the message and dilutes the compliments along with your credibility.
• Don't hint around. Many people who are afraid to come right out and directly confront issues will try to get the message across with hints like snide comments, a raised eyebrow, the cold shoulder or a disapproving look. This is confusing at best, may be completely missed or even ignored out of spite and definitely undermines teamwork.
• Don't pass the buck. You'll undermine your authority and credibility if you start the confrontation by blaming someone or something else. Don't say, "I really don't care whether you wear safety goggles, but OSHA will ding us if you don't."
• Don't set a trap. One of the quickest ways to destroy a sense of safety is to make a person feel trapped by starting with a vague question like, "Why do you think I called you in here today?" Another version of a trapping technique is to lure them into denying a problem only to surprise them with damning information you already have.

A good start to a crucial confrontation includes:

• Describing the gap. This is the difference between what you expected and what actually happened. Keep it simple, stick to the facts. For example, "Dr. Smith, each member of our staff deserves to be treated with respect. When Susan asked you for the patient's consent form this morning, you accused her of being incompetent and used profanity in a loud enough voice that patients sitting in the waiting room overheard."
• Establishing mutual purpose. This helps the person see that you have a common goal and sets the stage for problem solving. For example, "Dr. Smith, I know that you want to bring your patients to a facility that maintains high standards of professionalism where each person is treated with respect. Our goal is to be that kind of facility."
• Anticipating and preempting. If you suspect the other person might get defensive, feel disrespected or try to place the blame on others, address it right at the start, and then get right back to the point. For example, "I understand you were frustrated that the paperwork was missing and that is an issue we will address later, but right now I want to talk about how you spoke to Susan this morning."
• Finishing with a diagnostic question. How can the issue be avoided in the future? For example, "Was there something besides the missing paperwork that got you so upset?"

Once you have the person talking, you're in a position to start working toward a solution. But first you'll need to do some further diagnosis, such as whether the person violated your expectations because of a lack of motivation or a lack of ability. Each of these reasons requires a different approach. If the individual didn't meet your expectations because of a lack of motivation, the best approach is to clearly explain the consequences of the trust-damaging behavior. Emphasize consequences that matter to the person. Don't exaggerate; stick to the truth and don't present the consequences as a threat. Let the person know how the desired behavior would result in more desirable consequences.

If the offending behavior is instead an ability issue, determine whether the person needs more training or additional resources, or whether there are obstacles that can be removed. If you're the manager talking with an employee, this is a good opportunity to use your coaching skills to explore options together rather than just telling the person what to do. As you listen to the other person's ideas and ask probing questions, you'll learn more about what they really know and you'll give them the opportunity to learn from the situation as they work with you to come up with a better solution. This is a great way to build capability within the team.

When people are motivated and able, they're much more likely to meet your expectations and be accountable for their actions. But there's one final step Patterson et al. recommend: "pop the question." If you've determined that the issue was related to motivation and you've come to an agreement about the course of action, check for the individual's ability for change. Ask, "Now that you understand the consequences of forgetting to start the autoclave at the end of the day, is there anything you need to know about how to start it or what sets should be run?" If the damaging issue was about ability, check the employee's motivation to change. Ask, "You've agreed to take an online course on sterilization techniques that should give you all the information you need to know. Are you willing to commit to finishing that course by the end of the month?"

3. After the confrontation: Move to action.
Once you've had the initial discussion, resolved the issue and checked for motivation or ability, it's time to move to a plan of action. Detail and clarity are keys to an effective plan of action. Many otherwise effective crucial confrontations go to waste because the ball is dropped with conversation-closers like, "I expect you to do better next time," or "Don't be late again." Patterson et al. suggest that you establish who does what by when. Then follow up on that action plan.

An effective closing statement might be: "Dr. Smith, I'm glad we agree that shouting profanities isn't the way to demonstrate professionalism to our patients and our staff. I will investigate why the consent form was missing and let you know by the end of business tomorrow. You have agreed to apologize to Susan before you leave today and the next time you feel angry enough to shout at a staff member, regardless of the issue, you have agreed that you will bring the issue to me in private so that we can address it together. I'll check back with you in one month to see whether you have had any problems with our staff or with missing paperwork. Is there anything I have left out?"

Only as good as your word
One of the fastest ways to kill your credibility and damage trust is to not follow-up when you said you would. Often you're confronting the other person because he violated your trust. So if you say that you'll do something, then don't keep your word, you'll now be the one in the wrong. Why would a person take you seriously when he's thinking, "It couldn't have been that big of a deal if she's already forgotten about it." If you want your staff to keep their commitments, start by keeping yours.