DTD 166
[00:00:00] Hey guys. Welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today we have a special topic by Laura. Take it away. So a few years ago, I became aware of the concept of nonviolent communication, and I will tell you, there was a time in my life if I had heard somebody probably during my medical training, if I heard somebody say nonviolent communication, I would've thought they were an oversensitive hippie or something.
Like I would not have given credence to this concept. However, I. I really have come to, I don't know if testimony is the word, but I have come to really understand the importance of our words and that sometimes when we're mystified by people taking things we say in a way that we didn't mean, it's because we're using language in a way that.
Well, basically we're just not [00:01:00] realizing how we come across and what nonviolent communication does is it teaches us a framework to communicate with other people where that is less likely to happen. Now, ultimately, the way people receive things is also gonna be on them. However, this is a great framework so that we can communicate with our spouses, our patients, our children, our friends.
Colleagues in a way that is gonna be the most beneficial. And we know that old saying, sticks and stones may break my bones, but words will never hurt me, is like, there's nothing like seeing what happens on social media and what happens to people who are victims of cyberbullying to show us that that is absolutely not the case.
Our words are possibly one of the most harmful things that we can use to hurt people. So I believe it's super important to learn how to use them well and do, as Hippocrates said, [00:02:00] first do no harm. So that's what we're gonna talk about today. Nonviolent communication. This is a great topic I think, because so many of the people that we talk to are like.
I don't know. Everyone in my office is just really sensitive. And that may be, I do find when I'm talking to different groups of people, if you're talking to a bunch of ER docs, like a lot of it's gonna bounce off of us. If you're talking to certain other populations, it's not, it's not the same humor.
I was teaching A-A-C-L-S class and like joking around that the patient didn't make it and like. Some people were horrified. And I was like, are you serious? It's a fake patient, you know? You know what I mean? It's like your handshake meme. Yeah. But anyway, it was like okay. So we do need to like take into account who we're talking to and then this, I love this Laura, that you're giving us the skills for what to do when you read the room and maybe your usual way of communication isn't appropriate.
So we'll start by defining what is nonviolent [00:03:00] communication. It was developed by psychologist Marshall Rosenberg. Nonviolent communication is a framework for communication that centers empathy, clarity, and connection instead of blame, criticism, or control. Why does it matter in healthcare?
Well, we've talked about this before. Medicine is hierarchical, emotionally charged, and communication-intensive. We all, whether you're in the ER or not, work on a team. This is not a standalone profession. We rely on teams no matter where you are. And so that relies on effective communication and sometimes we're in super stressful environments.
No matter where you are, things get out of hand or completely go awry, you know, unexpected things happen all the time and so that can really charge emotions and people when they get supercharged. It's very difficult to pause and introspect for a moment. Doctors are trained to diagnose and fix, [00:04:00] but often not taught how to listen with empathy or connect authentically which we are big fans of authentic people showing up every day.
Harmful communication erodes team culture, increases burnout and impacts patient care. So some common pain points in medical settings, miscommunication during handoffs, which there have been several articles written that state this is a high liability area is handoffs. We hand off at the end of our shift.
We hand off, you know, when we're going from ed to inpatient, when we're whatever. This is a delicate situation and miscommunication can happen. Chronic tension between departments or staff. Sometimes in the ed, we think it's us versus the world. It's always us versus them in the ed. It's like everybody else in the hospital and then the ed and we kind of band together, but we tend to have a grouping mentality.
It's like, everybody else is hater aid for the ed, but that's not always the case. Physician burnout from [00:05:00] unspoken or unacknowledged emotional burden. So this can be stuff that you're dealing with at home that you don't realize that you're bringing to work with you every day. The cost of poor communication.
70% of sentinel events in hospitals are linked to communication breakdowns. This is from the Joint Commission in 2015, and that's what I was talking about. It's a very delicate situation when you're handing off the patient in any, going from or PACU to the floor or or. To home or ed to inpatient.
Like that is a very delicate situation and I think sometimes we don't respect it as much as we should because of the amount of effective communication that goes into it. Miscommunication increases emotional exhaustion and compassion fatigue. That kind of goes without saying, I. I love this quote from Brene Brown and Dare to Lead.
She actually taught this to her kids. I love it. Clear is kind, unclear, is unkind and she says it to her team all the time [00:06:00] too. Being clear or having a moment to clear the room before they leave a meeting. If she even notices that someone in one of her leader meetings and. Department meetings, whatever she calls them is starting to like she can feel tension entering or anything.
She just pauses the agenda and is like, okay, are we all on the same page? Is everybody with us? And then they've developed a culture where I. Whoever is feeling uncomfortable or maybe has a little bit of emotional reactance at the time clarifies. Okay, so what I'm hearing is, and they just take a minute and if it derails the meeting, she's okay with that because it is very clear in the culture of her business that she has created, that clear is kind and unclear, is unkind.
She doesn't want anyone leaving the meeting without. Clarifying either what's going on in them personally or maybe in a certain part of the team that's involved in the project. Maybe misconstrued something. So she harps on that a lot and I think that could very [00:07:00] well impact that statistic I just talked about where 70% of sentinel events in hospitals are linked to communication.
Imagine if we all had that mantra. Clear is kind, unclear, is unkind. It would probably go a long way. Yeah. Well, and with the lack of vulnerability that a lot of us carry in there, not just physicians, I feel like also nurses I feel like are scared to ask us clarification questions sometimes. Oh gosh.
And that's especially dangerous. Especially have nonviolent, right? Like so I think that this is a great topic to help us. I, I wanna add that, you know, we're talking about authenticity, we're talking about clarity. This is not the same as unbridled expression. So this is, remember that losing strategy from a few podcasts ago that we talked about of unbridled expression?
That's where we just dump everything we think on people. That's not what we're talking about. We do want to say what's important. What's true, kind and necessary to be [00:08:00] said, and this framework helps. But this is not carte blanche to go tell, you know, tell your partner that you think they're completely incompetent or to go tell, you know, your nurse manager that you think she's doing a horrible job.
And in those terms, this is a way of being able to communicate non-judgmentally to help them improve outcomes. So here we go. Here's the non-violent communication framework. Okay, firstly, there's four components of it. Observation, feeling. Need and request. Okay. And it's interesting, you know, we talk a lot about facts and story, that this nonviolent communication framework correlates with a book by the same name.
Marshall Rosenberg wrote a book, nonviolent Communication. So check that out. Also Crucial Conversations, if you are not familiar with that book. Slash Training System. That's a great resource for learning [00:09:00] nonviolent communication as well. And it's a similar framework that they use. So that first component observation is stating facts or things that you observe without any judgment.
So an example I use sometimes is, the socks on the floor I have this one child who is the kindest, most, like, he's just a brilliant, wonderful child and he takes his socks off and leaves them everywhere. And so I. What I might, you know, if I were communicating violently, I might say, what the heck is wrong with you?
That you leave your socks everywhere? Which I would never do. Like it hurts my heart even to say something like that about this kid. But I could say it about other people Certainly have said things like that about other people, but I could say instead, when I see your socks on the floor. So that's the observation.
And then we go onto the feeling. When I see this, I [00:10:00] feel, so we're pulling the responsibility for our feelings back onto ourselves, which is where the responsibility lies. We are not accusing the other person of being something. And that's where the verbal violence comes in is when we name call, basically.
And we don't always see it as name calling, but when we're saying you're thoughtless, you're, you know, you're lazy, you're whatever it is, you're incompetent. Things that you know, hopefully we haven't heard in our lives, but coming through medical training, we've probably heard something like that. If we're saying you statements, we need to reflect and say, is this, is this how I wanna frame it?
Is this a nonviolent way of communicating? So when we say, when I see the socks on the floor, I feel frustrated and a little bit sad because number three is the need because I know we've talked about this and it's my hope that I can feel like you hear me and my [00:11:00] request is that when you take your socks off within 15 minutes, you get them to a hamper or you put them inside your shoes.
What do you think about that? Would you be willing to do that? So you're going through your observation, you're feeling the need that you have, that you feel like is not being met. A value or universal human need underneath. And then I'm making a request. So here are a couple examples to, you know, that may apply more to work.
So a nurse questions your discharge plan. Okay. Instead of getting defensive, you say. Something in that nonviolent communication framework. So she says, you know, I really think that this patient needs to leave now. There's really nothing wrong with them. And then your plan is to admit them. You say
when I hear you say that you disagree with my plan, I feel concerned, and I wanna [00:12:00] understand where you're coming from. I also wanna make sure that I'm not undermined in front of the patient and in front of the other staff. Would you be willing to keep these concerns between you and me and let's talk it out?
And, because I know we both have the patient's best interest at heart. We both do.
Again, it's forming things in terms of , what the facts actually are, what you're seeing, what you're hearing. Not like you're talking to me so mean. No. It's like when I hear you say You're an idiot, I feel angry. Can you see the difference? And so maybe, you know, maybe they are talking mean, however, they're not gonna receive it well.
When we're accusing, if we keep things coming from our perspective, the conversation's gonna go better. So like say you get home from work and you flop down on the couch 'cause you're exhausted and your partner [00:13:00] says. Well, it must be nice to just be able to come home and lie on the couch while I've got all this other work to do.
Sarcastic. It would be very easy to be reactive and defensive in that moment, and that's going to cause more unpleasantness. So a different way to approach That would be, when I hear you say, it must be nice. I feel sad, I feel unsupported, and I feel like you don't understand how I feel. And what I need is to feel supported and I need to feel like I have a partner who cares about my wellbeing.
I'm open if there's something that I'm doing that's affecting you negatively, I'm open to hearing that. I'm just curious if you'd be willing to pay attention to what you say to me after work. 'cause I am really tired , and your words, you know they affect me and I. I want us to have a good, strong, healthy relationship.
So is that something that you'd be willing to work on with me? So [00:14:00] when we're coming into any of these conversations, it's important to kind of have a little pre-check where we're making sure that we have a good intention for both ourselves and the other person. If we go into a conversation with the intention to prove someone else wrong or.
To be right or to retaliate in some way guess what, it's not gonna go well. So if we go in using, like the nurse at work as an example, if we go in with the intention to have the best outcome for the patient and have a great working relationship with this nurse, that is gonna come through in our communication.
If we're coming into it just wanting to prove them wrong and saying, Well, you know, you clearly don't understand this condition. You know, I have had so much more training than you, and this is my license and I'm the one who's liable the tone is just different and.
It's not gonna be received, it's gonna be received with defensiveness and the [00:15:00] communication breaks down. So go in with a good intention for the whole situation, including the other person, including yourself. And make sure you feel connected to yourself in a kind way that you're not just defending because you feel insecure somewhere.
Make sure you feel solid and. Who you are and how you feel about yourself before trying to communicate with someone in this way.
So here we're gonna have a couple more examples .
So here's an example of maybe a doctor to patient. And for those of you that dispense pain medication, you may connect with this a little bit. So, a violent or reactive response to asking about a pain medication to be prescribed would be you're just here for drugs.
Again, I already told you I won't prescribe anything stronger. Okay, that might work, but something that might work a little better that is more based in empathy and allows you to accept responsibility for where you're coming [00:16:00] from is when I hear that you're still in pain despite the current plan.
I feel concerned because I want to make sure we're treating the root cause, not just masking symptoms. Would you be willing to talk about other options we can explore together? Why does this work? Well, the second response expresses care and holds boundaries without shaming the patient or assuming intent.
It takes practice, guys. I mean, this is, this is not intuitive, especially if this is the 18th out of 20 patient for the day. Yeah, this is gonna take a lot of intentionality. So we're just offering up suggestions here. But know that this will take a lot of intentionality and practice. Yeah. And the other piece is a let go of the outcome because what you're in control of is how you show up so you can know that you're not making that drug seeking patient worse by being a jerk.
When you frame your communication this way, they may not respond well. It doesn't matter. What matters is how we show up and that we're showing up in a kind, [00:17:00] clear way that holds our own boundaries without being rude, and without, you know, without communicating in a way that can make the situation worse, if that makes sense.
So again, whether it works or not. It's more about how you feel about how you show up and how you feel about how you communicated. It's really not as much about how the other person receives it, although this will increase the likelihood they receive it well. So here's another example, which for shift workers comes into play waiting on that doctor to come in.
For checkout, who's late once again. So a violent way of communicating would be, well, first of all, I think also like subversively, I think I would just stew and say nothing, which also is not, that's violent against myself. Yeah. Yeah. So, but violent externally would be, you're always late and clearly don't respect anyone else's time.
Or go say that sort of thing to all your other colleagues to get everybody riled up [00:18:00] at that person. Nonviolent, which would be clear and connected would be, Hey, when you arrive after our agreed handoff time, I feel frustrated because I need reliability so I can get home on time too. Would you be open to talking about what might help stick to a better schedule or.
Would you be open to texting me when you know you're gonna be five minutes late so that I can make other arrangements or something like that? When Laura and I used to work in a single coverage place, it's terrifying when your relief didn't show up. Like, is he in a car crash and you're gonna be up for another eight hours?
Or like, you know, there's all kinds of stuff. With single coverage, things that start popping up when people are late. Even not single coverage. It's easy to catastrophize and be like, oh god. Yeah. And it's amazing how quickly my shifts over how quickly you go into fight or flight. As soon as like one minute pass the time they're supposed to be there.
You're like, oh crap. Oh, a hundred percent. I've been counting down the hours to that minute. I know, I know. All of a sudden it's not [00:19:00] up. Yeah, no. But you see how like non accusatory, but you're also not being steamrolled. You are saying, Hey, this matters to me because I've got kids I gotta go pick up.
Right? I need to figure out another plan. Like the reason why I get so activated is because of really good reasons. Right. Plus my time matters too, you know, so. Yes, yes. Um, I like that we're not just putting up with it, but we're also not violent. Right. Right. So why this works? Yeah. The second version shifts from accusation to collaboration, naming the need, which was reliability.
It's a very common need. I think that's not unreasonable. And opening the door for a solution. Yep. All right. Dr. Depo, after a long shift. Dun, dun, dun dun. Nobody listening to this would ever talk to their spouse like this. I'm sure, however, you know, it has happened. So imagine this very self-important doctor coming home, being sarcastic and dismissive.
Wow. Must be nice to sit at home all day while I've been running around saving [00:20:00] lives. Ha ha ha. Mm-hmm. And then the nonviolent way, which would require vulnerability and clarity. I'm feeling exhausted and a little overwhelmed after today. I'd really appreciate some help unwinding tonight, or even just a few minutes to myself.
Would that be okay? Because I'm imagining in this scenario, spouses coming home to a bunch of young children going crazy. The doctor is, and then the spouse is at home. We're just waiting, waiting for help to arrive also, please. Yes, please, please. We've been on both sides and Yes, absolutely. And so, coming home from work and if we're really, truly feeling overwhelmed, just making that request, Hey, I'm just so, I'm just so overwhelmed.
Can I just have a few minutes and I promise I'll reengage after I get myself a little more regulated. Why does this work? The second response invites support without [00:21:00] resentment and without sarcasm. Like sarcasm works well in some scenarios, generally not at home with the people you love. Unless you have special circumstances, which some of us do.
Generally in a situation like the sarcasm, iss not gonna land well. So this response invites support without resentment, honors both people's needs. I recognize that you have needs and I have needs, and let's try to get 'em both. Get both sets of needs met.
Yeah, I think that's crucial to understand. Just even holding space or acknowledging that both of you have needs. I think especially in a relationship like a marriage, and especially in a two physician household, you know, you start to like, say well my job is this, or I am crazy busy.
Or, I mean, I know early on once my husband and I became attendings, I felt myself getting resentful because he had, then go to work at the same time come home at the same time. [00:22:00] He would have long days, but in ER shift work, I was like, one day at a 8:00 AM shift and then I'm going in at two and then I'm getting home at two or 6:00 AM or something all over the place.
And so I think one of the things that in therapy that helped us was just. Holding space too, to recognize they both have needs. We both have, you know, stressful jobs that have different things, but just asking for what I needed, like, Hey, I am gonna get home at 2:00 AM tonight, would you be available to take, you know, the kid to school, at six 30 so I don't have to get up or whatever the request is.
It's just understanding that, both jobs are demanding and I think also just asking for what you need was a big thing that, I don't know, some point just clicked in my brain that like I have permission to ask for what I need too and go about it that way instead of like, my job's crazy 'cause I go to work, you know, all the different times of the day.
So I think that's a much better [00:23:00] approach. So if you have littles or a child who you know you wanna spend time with, but maybe you're trying to get some work done at home. And so you're working on the charting in maybe a violent way that's controlling and frustrated comes through is if you say, go away or don't bother me, can't you see I'm working, you're being really annoying right now, which is yes, can definitely come through the frustration has coming through that loud and clear.
Maybe another way to address this or a nonviolent way to address this is. Sweetie, I see you really want my attention, and I love that. Right now I'm finishing some work and I need some time, or I need some quiet for about 10 more minutes. Why don't you set a timer and then we'll play together when it goes off.
And you know this really validates your child's need for connection and need for attention, but it also honors your need to just wrap up whatever you're doing. And I will say that that is, really validating for a child, but also [00:24:00] it honors boundaries. And I think one of the things I heard recently, I follow this child's psychologist. She's amazing, but she just said, you know, kids do well with boundaries. And when you set a boundary and uphold it, you're in self integrity. Like you're holding yourself to the promise that you're finishing this work, but you're also recognizing that boundaries are good and kids do well when they're boundaried.
Um, So this is an example of both of those and we'll go over a lot better than just your annoying go away. Yeah. Yeah. And you're showing that you're being reliable and when it is important. I'm glad that you mentioned boundaries. It is important with kids to show them that we also have needs uh, we don't wanna raise little narcissists.
That's, that's important. You know, definitely we can be violent in terms of being mean or over controlling, but we can also damage them when we falsely empower [00:25:00] them or don't hold boundaries or show them that it's okay to run all over the parent. That's no better for them than being overly controlling.
So. I'm glad you pointed that out. That's a great way to show respect , for them and for us, and that's important for them to see that. Okay, so one more example. This has happened to me. Sadly, the pandemic made it so that a lot of our nurses retired or moved on to do other things, and so we often have inexperienced nurses who might not realize the urgency of particular medical situations.
For instance, I have had patients come in like. A low brewing anaphylaxis, like you can tell it's about to get bad. And so I said, you know, I, I need this patient to get epi right now, and I put the order in and it might not happen. I've learned I'm just gonna follow that nurse around till the epi gets injected into [00:26:00] my patient, because sometimes it doesn't.
But a violent way to communicate with a nurse that way would be like, how could you forget? How could you be like doing all this other stuff, starting two IVs before you give the epi? Why? Why would you do that? Like you are putting this patient's life at risk. That's blaming them.
And as leaders, which as physicians, we are. It's best for us to take responsibility for the whole situation and also invite them to their own piece of accountability by being calm , and we can be corrective too. Hey, I was expecting the epi to go in first before anything else I felt. Very stressed and worried for the patient.
When I saw that 15 minutes after I ordered it had not gone in. You know, I'm just guessing you don't realize how critical the timing is for this, because if anaphylaxis gets away from us, it's very, very hard to treat. So can [00:27:00] we walk through what happened so we can make sure that this goes more smoothly?
Next time and why this works. Number one, if I'm talking to them and saying, how could you forget this? I mean, like I can feel shame. Like I can feel the shame that that person is gonna feel. And guess what? When people feel shame, , they aren't thinking, they aren't in their thinking brain.
They are very much in their limbic system, and it's very hard. To learn. They are learning something. They learn that you're an enemy. They aren't learning the thing you're trying to teach them. So when we can stay anchored in the shared goal of patient safety and be respectful and still express the emotional impact that the situation had on us, in this case, we don't even have to express our own emotional impact.
We can just say, Hey, I don't know if you realize what the implications of delaying the epinephrine are. We're just, we're seeking improvement without shaming people, and that is just [00:28:00] gonna create a better working environment and better, better patient outcomes too, because then. She's not gonna be, or he's not gonna be afraid to ask me clarifying questions another time.
If I have shamed that nurse, if I have been blaming of them, they are not gonna wanna approach me with questions. So I always wanna, make sure that they feel safe to come and talk to me. I think another way to make it even less accusatory is like, Hey , hopefully this has never happened to you, but I have had a patient before that didn't get the epinephrine in time and it turned out that it was way worse than getting it early, you know?
Yeah. Like, just from experience then it's like, oh yeah, I don't want that to happen. Yeah. Yeah. That's a great way to phrase it. So this is such an important topic, but just hoping that we have relayed in a way that's able to be received, that this can really [00:29:00] change your relationships because it can strengthen all types of human connections and. Doctors have very emotionally complex lives, so this can help all sorts of places. With staff, it can improve morale, it can foster respect and teamwork. With patients, you can build trust easier.
It reduces conflicts and increases adherence to your recommendations and with your colleagues. It encourages collaborative problem solving instead of silent resentment. Or brawls, either way. Think the throwdown, the throwdown is on. I think. I think usually we have silent resentment with each other, but occasionally you will meet a character that is not silent, so this can help with that too.
How it helps at home with your partners is to reduce reactive conversation and. Incessant shame cycles. That's just not that helpful for good relationships and with your kids. It models emotional intelligence and invites openness. The thing that we say over and over is that [00:30:00] you have to show people, not tell them.
Unfortunately, with your kids, you might like. Say, oh, you're so great and you should be so confident. But if you're not modeling that yourself, it's just a much more effective way with your kids to model this emotional intelligence. And so for you to be able to practice this learn this for yourself.
It is a gift for your children. Not just immediately, but it'll show them how to be with their own families. A real life example would be like a team member says, this place is a mess. No one cares. And without nonviolent communication, you might say, what are you talking about? You're being so dramatic.
It's not even true with nonviolent communication, you could say, when I hear you say that, I feel concerned because I want everyone to feel valued here. Can you help me understand what's going on for you? That is coming from a place of curiosity rather than judgment. The big shift when you start using nonviolent communication is that it moves us from reacting to responding.
[00:31:00] It moves you from disconnection to mutual understanding. It moves you from defensiveness to curiosity, and so here's a quote that can help drive it home. Empathy is a respectful understanding of what others are experiencing. Instead of offering empathy, we often have a strong urge to give advice or reassurance, but empathy requires us to stay present.
That's from Marshall Rosenberg.
So thank you for joining us. We hope that you are able to get some pearls from this. It might be a little touchy at first.
I understand. Like it's gonna trigger a few things and that's okay. Just be aware of what it does trigger in the certain situations, in the examples. Laura provided some great examples today and just know that we are for you. We see you. We know that this is gonna take intentionality. And it'll take a little practice. So you might have to listen to this episode a few times. We invite you to, we invite you to just see and reflect on what your communication [00:32:00] patterns are like, even if you just notice them the next time you work and just see like, oh yeah, I might have been able to do that a little differently.
Maybe just inviting you to try on one of the phrases that we used, one of the nonviolent communication examples especially, you know, maybe try it on in a not so emotionally charged space first. So you get a little practice because then when it is stressful or very emotionally charged, you'll have that, mental muscle to stay upfront and your prefrontal cortex and make the decision to.
Communicate nonviolently. There will be a little cheat sheet, a nonviolent communication cheat sheet in the show notes, and it'll be downloadable as well as the links to the books that Laura mentioned today, the one about nonviolent communication, self-titled, and also crucial conversations.
Can I add something about crucial conversations? Just like I recommended this to a [00:33:00] client who had to talk to a staff member in his office, and he was also blown away by it. This is a life-changing book. To help you with hard conversations, so if you're like, dreading some kind of conversation, check that book out.
It is awesome. Right, and we can always learn, right? This is not about winning or losing or failing what you've done in the past. It's just about being aware and learning and just, you know, starting small. Even just noticing your own feelings and needs. I. Really can give you that, that personal or that internal validation and really empower you to move forward in adopting this nonviolent communication.
Nonviolent communication isn't about being nice. It's about being real. It's about saying the truth in a way that invites others to meet you right where you're at. So we hope you have enjoyed this. Leave us a review comment, also, if you have any experience with this or further questions about this, or wanna schedule a session and practice, click the link in the show notes or send us an email at [00:34:00] [[email protected]](mailto:[email protected]).
We also want you to check out our new free video, how to Crush Physician Burnout for Good without cutting back hours, quitting Medicine, or sucking it up in silence. All of these links are in the show notes. Scroll down and check it out today. Until next time you are whole. You are a gift to medicine and the work you do matters.
