NUR5123 Module 3 difficult conversation plan example

Coffee With Dr. R.: Planning a Conversation With a Senior Interventional Radiologist About a Skipped Order Set and a Nurse Silenced at the Time-Out

Student Name

American College of Education

NUR5123: Relationships Through Communication

Module 3 Assignment

Instructor Name

July 20, 2027

Why the Conversation Must Happen

The structured handoff piloted in Module 2 depends on an order set filed before the patient leaves interventional radiology. In the first three weeks of the pilot, the order set was filed for 91% of patients whose procedures were done by four of the department's five interventional radiologists and for 22% of those done by Dr. R., the department's most senior and most admired physician. Dr. R. has said in the reading room that the procedure note contains everything a floor nurse needs. In the same week, a nurse in the procedure room asked for the time-out after Dr. R. had begun preparing the skin, and Dr. R. told her, in front of the patient and the technologist, that the time-out was being done and she should stop interrupting. The nurse completed the time-out and reported the exchange to the author, the department's nurse manager, the next morning.

Neither behavior is catastrophic on its own, and both are common. That is why they matter. In a survey of more than 4,500 hospital staff, 77% reported witnessing disruptive behavior by physicians, and most respondents linked such behavior with adverse events and medical errors (Rosenstein & O'Daniel, 2008). In a study of more than 13,000 surgical patients, those whose surgeons had more coworker reports of unprofessional behavior had higher rates of both surgical and medical complications (Cooper et al., 2019). A nurse who is corrected publicly for asking for a time-out learns not to ask, and the next time the question matters she will already have stopped.

Preparing the Facts and the Interests

The author gathered facts before planning a word. The order set figures come from the pilot audit and are exact. The time-out exchange has two witnesses besides the nurse, and both confirmed the words used. The author also looked for Dr. R.'s side: the physician's procedure notes are detailed and accurate, Dr. R. was not present at the design sessions for the new handoff, and the order set adds about three minutes per patient on a schedule that often runs late.

The author's interests are safe handoffs and a procedure room where any team member can speak up. Dr. R.'s likely interests include running the schedule on time, being trusted as a careful physician and not being managed by a nurse in front of peers. None of these interests is in real conflict with the others; the conflict is between positions.

Mapping the Conversation

Stone et al. (2010) argue that a hard conversation carries three layered conversations. One, about what happened, concerns facts, intentions and blame; a second concerns feelings that usually go unspoken; a third, about identity, concerns what the situation means for how each person sees themselves.

In the what-happened conversation, the author will describe the order set rates and the time-out exchange as observed facts, will not claim to know Dr. R.'s intentions and will separate contribution from blame by acknowledging that the department introduced the order set without Dr. R. in the room. In the feelings conversation, the author expects Dr. R. to feel irritation at being questioned and possibly embarrassment about the time-out, and expects to feel anxious about confronting a senior physician; the plan is to name the discomfort briefly rather than pretend it is absent. In the identity conversation, Dr. R.'s identity as a careful physician is at stake, and the author's identity as a leader who protects staff is at stake too. The plan protects both by stating early that the conversation assumes Dr. R. cares about patient safety.

Setting and Opening

Hickson et al. (2007) describe a graduated approach to unprofessional behavior in which a single incident or an early pattern is first addressed by an informal, nonjudgmental conversation with a respected colleague, often called a cup of coffee conversation, before any formal process. The author will ask Dr. R. for 20 minutes over coffee in the department's small conference room at the end of a procedure day, not in the reading room and not with anyone else present.

The opening is scripted: "Thank you for making the time. I want to talk about two things from the past few weeks, the new post-procedure order set and something that happened at a time-out on Tuesday. I am raising them because I know how much you care about how patients do after they leave us, and I think we want the same thing here. Can I tell you what I have seen, and then hear how it looks from your side?"

Likely Replies and Planned Responses

Reply one: "My procedure note has everything. The floor nurses should read it." Response: agree that the note is thorough, then explain that the Module 1 event showed floor nurses do not open procedure notes before a patient arrives, and that the order set puts the same information where the receiving nurse will see it. Offer to have the order set prefilled from a template so it takes under a minute.

Reply two: "The schedule is already impossible. I do not have three more minutes per patient." Response: acknowledge the schedule pressure as real, and propose that the procedure nurse drafts the order set during closure for Dr. R. to review and sign, which the other physicians already do.

Reply three: "She interrupted me while I was prepping. The time-out was going to happen." Response: accept that Dr. R. intended to do the time-out, then describe the effect separately from the intent: the nurse was corrected in front of the patient for doing what hospital policy requires of her, and others in the room saw it. Ask what Dr. R. would want a nurse to do if a time-out were in fact being skipped.

Reply four: "Are you writing me up?" Response: say plainly that this conversation is not a formal process and is not being documented as a complaint, that the author hopes it will be the only conversation needed, and that the order set rates will continue to be shared with all physicians, as they are now.

Reply five, silence or a curt agreement to end the conversation. Response: do not fill the silence with arguments. Summarize what the author heard, state the two specific requests and ask directly whether Dr. R. can agree to them.

Agreement, Follow-Up and Escalation

Success means two agreements: that Dr. R. will sign an order set for every inpatient, with the procedure nurse drafting it, and that Dr. R. will speak privately with the nurse from Tuesday or allow the author to tell her that the matter has been discussed. The author will thank Dr. R. in writing the next day, restating only the agreements. The order set rate will be reviewed after four weeks. If it has not risen above 85%, or if another nurse reports being silenced, the author will follow the next level of the graduated approach and ask the chief of interventional radiology to hold an awareness conversation with Dr. R., sharing the data. Only a pattern that persists after that would move to a formal process.

References

Cooper, W. O., Spain, D. A., Guillamondegui, O., Kelz, R. R., Domenico, H. J., Hopkins, J., Sullivan, P., Moore, I. N., Pichert, J. W., Catron, T. F., Webb, L. E., Dmochowski, R. R., & Hickson, G. B. (2019). Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surgery, 154(9), 828-834. https://doi.org/10.1001/jamasurg.2019.1738

Hickson, G. B., Pichert, J. W., Webb, L. E., & Gabbe, S. G. (2007). A complementary approach to promoting professionalism: Identifying, measuring, and addressing unprofessional behaviors. Academic Medicine, 82(11), 1040-1048. https://doi.org/10.1097/ACM.0b013e31815761ee

Rosenstein, A. H., & O'Daniel, M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. The Joint Commission Journal on Quality and Patient Safety, 34(8), 464-471. https://doi.org/10.1016/S1553-7250(08)34058-6

Stone, D., Patton, B., & Heen, S. (2010). Difficult conversations: How to discuss what matters most (10th anniversary ed.). Penguin Books.