Dear Crucial Skills,

I am a nursing supervisor in a nursing home. Most of our patients are white and most of our staff is non-white. Our staff is frequently subjected to vile, racist treatment and remarks by our patients. Naturally, this creates a very difficult working situation. Our staff provides quality care day after day to people who show them flagrant disrespect.

As a facility, we have never sufficiently addressed this. Our nursing administrator, to her credit, wants to bring this issue out into the open and hold discussions with the staff to provide support and improve things if possible. I am sure this will be a crucial conversation where emotions will run high. How do you suggest we proceed?

Thank you,
Seeking Safety

Dear Seeking Safety,

Although you asked specifically about the difficult crucial conversations you are facing, it is important to recognize your team must successfully face both crucial conversations and crucial accountability discussions to move forward. Let’s look at both.

Crucial Conversations
First, the entire staff will need to hold one or more crucial conversations to discuss how to create a healthy, productive, and supportive environment. As you work through divergent viewpoints and strong emotions to reach alignment, the key elements will be to refuse to make a sucker’s choice and to use mutual purpose to create safety.

1. Refuse the Sucker’s Choice. Too often, we pull up short in crucial conversations because we make a sucker’s choice: we believe we can either deliver excellent care or we can hold others accountable to a standard of behavior, but we can’t do both. We create win/lose situations in which the residents get away with racist remarks and bad behavior and the staff puts up with it because that is what constitutes good customer service.

This is a classic sucker’s choice, a needless either/or statement. Recognizing that you are making it is the first step to moving forward. Once you have recognized the choice, you can refuse to make it by consciously asking yourself: How can we provide excellent care and avoid alienating or offending our residents when we address their racist remarks?

2. Mutual Purpose. Next, carefully create safety during the dialogue. One of the most powerful tools for doing so is to establish mutual purpose. However, be warned that creating mutual purpose can be used for good or for evil depending on your intent. Allow me to illustrate.

In my work with healthcare professionals, one of the things I enjoy most is the obvious dedication individuals have to patient safety and care. These values are incredibly powerful when creating safety in a crucial conversation through establishing mutual purpose because the mutual purpose to uphold safety already exists. But, the danger comes when this common goal is used to control or direct the conversation. For example, in frustration, an administrator says to a nurse, “No, we have to do it this way because this is a patient safety issue and that is our highest goal.” Suddenly, this administrator is using the mutual purpose of patient safety to control or end the conversation.

In your situation, it may be tempting to say, “We all have the same mutual purpose here, to deliver excellent care to our residents. And, because of that, we must do X, Y, or Z.” This approach, telling others what their mutual purpose is and then linking a specific course of action to that purpose, destroys safety and dooms the conversation to failure. Instead, determine what mutual purpose unites the staff and then recognize individuals’ unique strategies to meet that purpose.

Crucial Accountability Discussions
Once the staff agrees about standards of behavior and the importance of holding others accountable to those standards, expect a series of accountability discussions with the residents as staff members describe the gap between how they expect to be treated and what they observe. These interactions require unique skills.

1. Describe the Gap. Before you can hold people accountable, you must first clearly describe the gap and explicitly set expectations about appropriate behavior. You can’t assume everyone knows and understands expectations. Say something like:

“Mrs. Smith, when I care for you, I expect we will have respectful and considerate interactions. When you use terms like [blank], I sense you may not respect me because of my race. Can you help me understand what your intent is in using that term?”

2. Avoid a Power Trip. Instead Use Natural Consequences. Be careful not to use your power to motivate change in the residents who are in a dependent, vulnerable position. It is tempting to want to say, “Mrs. Smith, if you use that term to describe me again, I am not going to change your linens today.”

This is power masked as a natural consequence. While it is appropriate to share with the residents how their behavior affects you, it is important you do so in a way that assures them your goal is their excellent care. Instead of motivating the residents to change by explaining the affect their behavior has on the staff, explain the natural consequences of their behavior and how it affects the values and privileges they care about.

You certainly have some difficult conversations ahead of you. But, you also have a huge advantage because you are clear on your intent: to provide excellent care in a supportive work environment. Keep that at the forefront and you will be much more likely to succeed.

Best Wishes,
Emily