Sarah Lavonne: Hi, I'm Sarah Lavonne, and I'm so glad you're here. Here at Bundle Birth, we believe that your life has the potential to make a deep, meaningful impact on the world around you. You, as a nurse, have the ability to add value to every person and patient you touch. We want to inspire you with the resources, education, and stories to support you to live your absolute best life, both in and outside of work, but don't expect perfection over here. We're just here to have some conversations about anything birth, work, and life, trying to add some happy to your hour as we all grow together. By nurses, for nurses, this is Happy Hour with Bundle Birth Nurses.
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Sarah: I'm not going to lie. I'm nervous about this episode because I'm opening the can of worms of the world, but I also know that this is one of the biggest challenges that we have in our profession. It's also where, as I've been prepping for our MOVE Learning Retreat, by the way, we are having an in-person event at a five-star resort in Mexico coming up in the beginning of May this year. It is our last one, for sure, at this resort. We will see what we do in the future.
Of course, we want to see you in person, but we are pivoting and re-evaluating the future of Bundle Birth and where we're investing our time and efforts. It's literally the coolest thing that we do. The theme of that is centering the patient experience, the creative art of nursing. Everything is all about living colorfully. One of the ways that we have a little bit more of a black-and-white existence, one of the challenges, one of the darker areas of our lives. Sometimes, not always, is our provider communications.
This is the biggest challenge I hear from you. This is constant. It's so incredibly nuanced. It is not a concrete skill that I can be like, "The baseline is this. Are there accelerations or not? This is a late decel because of whatever." It's so not concrete. These are the things that you hear about in nursing school, but also are like, you don't. You don't really know how it all works in the hospital and how to be that nurse and how to have those relationships, how to work with providers, then you throw in some system dynamics. You throw in the unique dynamics of your unit, and things get really challenging.
I will not be able to answer everything today. I want to set realistic expectations that I want to give you some tips for working with your providers and specifically responding to this audio note from one of you that sent it in. By the way, we'll drop the link down below. If you have other questions for us, you have other episodes that you want to write in about, we'll drop that link down below. You can send us a little voice note, and it may end up on a future episode. I'm going to play you this clip, and then I'm going to respond. Where we're going today is I want to talk about having those hard conversations and what to do in scenarios like this.
Voicemail: Hi. I am a new grad labor and delivery nurse. I have attended a few of your guys' classes, like the physiological birth class and the Pushing Class. I've absolutely been loving it. I've been really struggling, though, recently with communication with providers. Just learning their communication styles, and sometimes it feels like based off of their mood, like what they want. I do work night shift, and it's really hard when you're calling in a provider. They're already cranky because you're calling them, and it's nighttime or 3:00 AM, and it's really hard.
However, I've had them cut me off. I've had them yell at me over the phone, which is fine. However, when they come in for delivery or to evaluate a patient, they try to correct me and give feedback to me at bedside. I've had some rude interactions with providers, I would say. Not so positive ones at bedside, trying to talk to me about my phone call with them while in front of the patient, which I feel like, in my opinion, is a little unprofessional. What is your advice on how I can navigate this, if that makes sense? Because it's just really frustrating.
Sarah: Yes, it is very frustrating. I'm running through the list of the many times that I have been in that scenario. I know those of us listening, we've all been there. If you're a provider and you're listening, just hold some space for this conversation because, again, I'm nervous because I don't know how to do it right. I can't teach all of the things, but I hope that you'll get some little nuggets for us as we all continue to build out our communication with our providers.
Two resources I want to start with. Actually, there's three. One book, I'll link down below. That's one of my favorite books. It's very woo-woo. It's very spiritual. If you have a religious practice, it may be very uncomfortable for you. I grew up Christian, and I think me 10 years ago would have had a hard time with it, but me now just eats it up because I fully believe in it. It's been really life-changing for me. It's called The Four Agreements.
If you haven't read this book, I read it probably maybe every year. There's these four lessons, four "agreements that set you up for life success." The four agreements are, I'm going to do them out of order, be impeccable with your word, don't make assumptions, don't write people's story, always do your best, and don't take anything personally. I start there just because, as I'm hearing this audio, I'm like, "Oh, it's so hard." You're saying, "It's okay that they yell at me." No, it's not. It's not okay.
That goes for all of us. I don't care if you're a nurse, you're a doctor, you're a manager. It is never okay that we're yelling at each other. When and in what environment is that ever acceptable behavior? If someone's yelling at you, we're going to talk about boundaries in a second. I think especially when the conversation is heated like that, we've got to learn to set those boundaries of what's acceptable behavior and what's not, because we have tolerated being yelled at.
I was called the C word on the job by a doctor. I took it as a new grad. B word, I have been called on the job. That is unacceptable. When those are happening, the first thing I'm going to say is, "Don't take it personally." When people are going to confront you, are going to have attitudes, we've got to learn to separate their actions from taking on meaning of what it means for us.
The second resource I have for you is Crucial Conversations. This is super cliché. It's been around a long time. I know when I was in the hospital, they had a Crucial Conversations class you could take as a manager. I think I did it. I've also read the book a few times. I think the tenet of Crucial Conversations, I'll link the book down below, is that a conversation is crucial when the conversation is high-stakes with strong emotions and differing opinions.
You think about our job. Our crucial conversations, we're having crucial conversations constantly, right? They're high-stakes. This is potentially life or death. People have strong emotions about how things need to go. They're going to have differing opinions. How do we navigate these conversations? As simple as you called me in the middle of the night. Now, you're pissed.
Also, knowing that, if you've listened to our previous episodes, the relationships that we have with our coworkers make or break our experience, our retention, our ability to sustain, our likelihood of staying at a job, our feelings about the job. In fact, I'm about to do a webinar for our hospital partners. When we look at nurse retention/nurse satisfaction that the number one indication of nurse job satisfaction is a supportive work environment.
Consequently, a supportive work environment actually correlates with better patient safety, better quality ratings, and is the strongest predictor of high-satisfaction scores. If you are an educator, you are in leadership, hello, we need to be paying attention. Under supportive work environments, there's four things that are at the top. There's a lot of things and ways you could describe that, but it's strong nurse leadership, coworker relationships, autonomy, autonomy is the biggest, and a supportive teamwork and collaboration.
That's what a supportive work environment looks like. When we're working with each other, this, like I said, leads to either job satisfaction or job dissatisfaction. We've got to be holding each other accountable. We've got to be watching out for the bully. It's like cancel culture is never okay. Putting each other down is never okay. It's never okay to be mean, violent, et cetera, et cetera. It can be subtle, et cetera.
Those crucial conversations are important that they need to happen. Unfortunately, we haven't been taught communication. We haven't been taught how to go there in a respectful way. Too often, when you're dealing with two different people who have different levels of training, different interpersonal skills, different egos, different opinions about things, different backgrounds on conflict, it gets really, really tricky, okay?
I actually prepped for this episode. Not that I don't prep for the other episodes, but I wrote down a ton of things. I scripted out some things. I put together some frameworks, et cetera. Now, mind you, the other third resource I have for you is something that I made up called the CARE Framework. The person that wrote in, they have actually been to the Pushing Class. I'm going to have you go back to those slides and look at the CARE Framework information, because I was fed up with the lack of our ability to have these conversations, and we need a system.
I created a system because I was frustrated and wanted to give you some resources for that. That comes with our Pushing Class, but we are actually hosting for anyone coming to our MOVE Learning Retreat. It is included with the cost of your ticket. We are doing a prerequisite class to MOVE in March. I'll link it down below. I don't remember the date right now, but it is in March. If you are coming to MOVE, check your email. You are invited.
It is free for you, and we've chosen to open it up to the community. It's going to be super-duper cheap. It's not currently live, as I'm recording this right now, but check the link down below. If you want to come to this class, what we're going to do is I'm going to talk you through the CARE Framework, which really is a four-step process where you clarify the goal, ask with curiosity, recommend facts and evidence, and engage afterwards.
It includes all this stuff that I've learned through crucial conversations. It includes patient-centered care. There's some change leadership stuff in there. It's a structured communication way. We learn to negotiate, and we talk about creating psychological safety. It's pulling from all the different resources that I've taken in over my many, many years of leadership training, of being in different roles, and of having these conversations of being a boss, of hiring and firing, all of that, to put it together and smoosh it into a system for you.
It comes with the Pushing Class, but we're doing a special two-hour live online class for anybody interested. We'll link that down below. You're more than welcome to join us. We would love to have you. It'll be super cheap, easy touchpoint. Again, come to our MOVE Learning Retreat because this is a prerequisite for the MOVE Learning Retreat, so that we have that shared conversation, that shared knowledge, that shared language, because we're going to build off of this into our entire MOVE Learning Retreat.
What patients want is to be seen, safe, and soothed. What they want is to have us meet their expectations. They want support. What we're going to do is we're going to break down the nursing profession, remind you of how beautiful it is to be able to be a nurse because, right now, it's pretty black and white. It's not very colorful. We want to infuse color back into your job and give you super simple tools to make your job more colorful and to help support the patient experience.
I'll also link that down below. You're more than welcome to come. You'll get the class with it. Going back to that, when we go through crucial conversations, and my notes of the tips that I want to give you. I have a few ground rules going into this conversation because I think it's easy when you're having a hard conversation, you're not getting along with a provider, whatever it may be, that it's easy to blame the other person and say it's their problem.
Yet, my script from the last year of how I've been trying to take ownership over my life, and that has come up in so many of the talks that I've been doing, both publicly and online, is that we can only own our decisions. If somebody else isn't going to do it, we have the opportunity to set the example of what it looks like to communicate in a respectful way, to listen to one another, and to work things out, okay?
Going forward, my ground rules for this conversation for us to understand is that we all come in with our own stories. The goal is to hold space for and not always try to be right. When you're having these conversations, that's going to be scoped out so quickly. Now, you might be talking to somebody who is trying to be right. We can't control that. If we can approach the conversation saying, "I have my opinions. I have my feelings about it," your feelings are always valid, and they're bringing in their own stuff.
The question for yourself first is, "Am I open to hearing it? Do I want to know their perspective?" Because when we meet fire with fire, we are only going to burn the house down. I wrote that one down, that when they're hot, don't approach fire with being hot. I think about, for somebody who's learned a second language, that may not make sense to some of you. Basically, if you're angry and you meet someone with more anger, it only amplifies the anger, the aggression, the frustration.
We know this from our patients. We get to co-regulate with one another. If they're hot, slow everything down. They're going to start to mirror you in that. Your non-verbals matter a ton. If you meet them with an aggressive [growls] face, they're going to feed off of that, versus you're calm, you're collected. You almost have to think about yourself as the parent in the situation that you see this with children, that they're freaking out.
All of a sudden, my tone is, "Do you want to talk about it? Okay, I see that you're frustrated. Yes, that's hard," versus, "Yes, that's hard. Get up. Suck it up." [chuckles] That energy gets fed with each other, or you feed that energy to each other. Then my other tip is, in just beginning this conversation, I'm going to try to make this not super-duper long, but bear with it, is that you've got to also establish what your ground rules are.
What this means is, what's your non-negotiables in a conversation? We don't think about this ahead of time. I will talk about this in the CARE Framework for us to give some examples of what this looks like. For me, it means no violence, no name-calling, no disrespect, no raising your voice at me, that we are both grown humans who can have a conversation. We can be kind to one another while holding difference in opinion, right?
The events don't really cause the emotions. Our interpretation about the events do. When those emotions get heated, it's easy for that, again, to meet fire with fire. We have to be able to examine and challenge our stories so that we can regulate our emotions. What is the story that you are telling in your head? We have to own our own part in the situation. If you approach it in that way, you're going to get a lot farther with the caveat.
My final caveat before I start talking it through is that you're also dealing with another human being who's unreliable, unpredictable, and has their own full autonomy over how they respond to you. That's where your ground rules really do matter that, one, you know them, and then you uphold those. If somebody starts name-calling, somebody starts attacking your character, that's your boundary.
Then you would say something like, "I am not willing to have a conversation in this way. I feel disrespected. I am willing to have this conversation when we can bring the tone down a little bit. For me to continue this conversation, I need you to refrain from calling me names and being disrespectful. Is that something that you're willing to do? Is that something that you're capable of, or do we need to take a break and come back later?"
It sounds so parenty, but also, it's establishing that boundary of no. Somebody throws something and say, "No, I'm done with this conversation. I'm happy to have this conversation when your emotions are at a place where you can be respectful and non-violent. I won't tolerate violence in this conversation," and then you walk away, right? Again, God forbid, a doctor throwing something I've never seen-- Well, that's not true. I have seen that happen. Not at me, where I'm feeling like there's violence or whatever.
Then you remove yourself from the situation. That's something to me that would need to be escalated, especially in a violent situation, right? Having those quick scripts of, like, "I am happy to have this conversation when we can both be respectful, but I feel disrespected right now, and I'm not willing to sit through name-calling and disrespect. We can have a mutual adult conversation, but that is a boundary that I'm not willing to cross."
Whoa. I've actually had to have those conversations in more recent years, and that is hard. This is not easy-peasy, no-big-deal-type skills. These are skills that take a lot of courage, okay? As we're approaching these, know your boundaries. I'm going back to the audio that we heard about the doctor who wants to-- and we'll use this as an example throughout, that wants to have that conversation at the bedside, that they want to talk about the fact that they felt disrespected, or they felt talked down to, or whatever they felt.
I think going into it, knowing what your intention is to the conversation is really important. Now, in this scenario, are you expecting them to want to have that conversation at the bedside? No, because it's fully inappropriate. You might need to set a boundary right away and to stop somebody that, like, "Hey." They start wanting to have that conversation. You can say, "I'm happy to have this conversation outside the room. When this delivery is over, right now, our job is to take care of person by name, of Rachel in her birth, and I would love to have that conversation outside the room."
Just stop them in their tracks. This is a boundary I'm setting, "We are not having this conversation in front of the patient. This is not what it's about. It's embarrassing for us. We are professionals." Don't say that. I would say that, "Hey, I'm going to stop you right there. I think, right now, what we need to focus on is the patient, and I'm happy to have this conversation outside the room when the birth is over," and then put them in their place. Again, are we ever doing this? Holy moly, this is hard. This is really hard.
Now, as you set that boundary and you know that conversation is coming, and mind you, good luck trying to fully focus on the birth and not be like, "Oh, my God. I have to have this conversation with this provider afterwards," but you do. You do actually have to follow up because you've said you're going to follow up. To be a person of your word, then pull them outside the door afterwards, or say, "Hey, I'll come find you after I recover them, and we'll have that conversation." They're also expecting it.
Now, in the meantime, clarify your intention to yourself. What's the goal? What do you want to happen from the conversation? You have a heads-up. Maybe you do, maybe you don't. In your head, "I want to talk about something important." Then tell them that as you start that conversation, "This is important to me, too. My goal isn't to blame or criticize what I care about."
This is where you're leveling, "I care about getting this right together. I want to have a positive working relationship with you. I want to hear your perspective, and I also want to share mine," or "This matters to me, but I want to have this conversation in a way that feels respectful and productive for the both of us," that you're setting that intention from the jump, and then paying attention to when you need to set a boundary.
If you know this provider is particularly aggressive, particularly mean, particularly rude, then I would set that boundary from the jump and just say, "I am happy to have this conversation. One thing I won't tolerate is disrespect, name-calling, blaming. We can have a productive conversation and grow from it. I want to build our working relationship so that we can continue to serve patients because we have a mutual goal."
Especially if things escalate, but if you can center yourself and ground each other on that mutual purpose or mutual respect that, like, "I'm going to offer you the same respect that I expect you to offer me," right? If it starts to get tense, you could say something like, "I'm noticing that things are getting a little more tense. Could we pause so that we can keep this conversation constructive? What if we took a break? I care about this. I want to make sure that we're both feeling steady and level-headed, and we don't say anything that we might regret."
If they're feeling defensive, you can say something like, "I'm not questioning you. I respect you. I respect the effort you put in. I respect this situation," fill in the blank, "I just want to talk about the impact." One of the keys that my family taught me, and you've probably heard this before, is there's a difference between intent versus impact. What I was taught, and I think I've talked about this in a previous podcast, was that we are always responsible for the impact.
The intent could be pure. Your intent could be not to hurt somebody's feelings or not to piss them off, but the impact was it hurt their feelings, right? Whether you meant it or not, you can say, and I would say it this way, I'd say, "I really care that this impacted you, and I feel terrible that this impacted you in that way. That was never my intention, but I am so sorry that that could ever come across that way because that is not my heart for you."
That's not justifying. It's saying, "I didn't mean to," right? I'm not admitting that I wanted to harm you, but I am saying I'm responsible for the impact. When you're having those conversations, ground yourself on those mutual goals and say, "I know we both want to get to the end of this conversation with our relationship being stronger. I know we want to continue to be able to care for patients together in a productive way. I know that we both want there not to be an elephant in the room and for us to work this out."
It's giving that benefit of the doubt. I teach that in the CARE Framework as well. Then you're going to open it up, and you'll have that conversation and say, "Hey, I noticed," and state the facts. Clarify what's your feeling, but you have to separate facts from feelings that you wanted to talk about. In this case, I would say something like, and again, this isn't perfect, "I noticed that you were upset because I called you in," or I don't actually know what the scenario is in this case, or "Do you want to tell me about that? I'd love to hear. Can you share your perspective? What was going on for you in that?"
Then you listen, and you don't justify, and you say, "Wow, okay, that's super helpful." Then positive communication is like, "This is what I'm hearing." That can feel annoying, but that is proper communication. That's respectful communication. "This is what I'm hearing. Is that what you meant?" You clarify that you fully understood them before you give your perspective. If you've ever done couples therapy, I feel like I'm reaching from the vault of my couples therapy that I've done in the past. [chuckles]
Then you say, "Are you open to hearing my perspective?" They may say no. In that case, you're going to have to navigate that one, and be like, "Okay, all right." Where I would say is, "That's disappointing to me. That doesn't feel like a mutual understanding, but I can respect that. What I will say is that my intent was never to hurt you, and I'm sorry that you felt that way. How can we move forward from this and just move on?" Now, if they are open and willing to hear your side of the story, one of my favorite frameworks you learn about in mentorship is the CUS framework.
I did not make this up. The idea is to use the phrases, "I am concerned," "I'm uncomfortable," or "This is a safety issue." That is specific to medicine. It's really helpful. If there's a safety issue, make it a safety issue, or make it, "I'm concerned about this behavior because it is unsafe," or "I was uncomfortable when you yelled at me in front of the patient. It felt disrespectful. We are both grown adults here, and it was inappropriate."
Here's what I'm noticing. State the facts, but, "The story I'm telling myself is this. Is that true? I want to check in and see if I'm missing something." Let's give a more specific example. This is a very common one, but, like, "I noticed that you ignored the patient's refusal of the episiotomy. I'm wondering if you just didn't hear them or if I missed something." Then, here's the key with crucial conversations is you state the facts, and then you wait. You pause, and you literally say nothing because that awkward silence holds them accountable.
"I noticed this. I saw this happen. I was uncomfortable by it," and then you wait. It's so awkward, right? What you're doing is, is that you're allowing them to think about it and go, "Ugh," and then let them share. Then, if they're getting defensive, "I really want to understand your perspective. How are you seeing this? What was that like for you? I'm sure you had a different experience," while giving them the benefit of the doubt, and, obviously, setting a boundary when needed to set.
Maybe this is more than you wanted, but this is where I'm going with it. Then you've both shared your perspective, and then you would say, "Okay, so how can we move forward? I want to make sure we're aligned. This is what I'm hearing from you. This is how I felt. What's it going to take for us to own our part and move forward? What do you need from me in this relationship? How can I support you in the future so that this doesn't happen again?" or even what feels like a reasonable follow-up.
"If this doesn't get resolved or if this still feels okay, would you mind if I followed up with you after the next birth? I'd love to talk it through and really work on this with you." What you're showing is rapport. You're showing maturity. You're showing incredible communication. You're never going to do this right. [chuckles] This is real hard, right? The more that you practice this and actually follow through and do the hard thing, what ends up happening is that the brave thing, I think, for us feels shameful, feels potentially like, "Oh, my gosh," and insecure. How it comes across to the rest of the world is so much courage.
I think if I were to summarize this, it's like, "How do you have these conversations? This is my intention. What I'm noticing is this." Give them the opportunity to share their perspective. "This is what I know." Share your perspective. "The story I'm telling is this. This is how it was interpreted by me." Whether that's true or not, I'm going to own that that was my interpretation. Apologizing for the impact, even if the intention was pure, and then, "I want to hear about your perspective. How can we move forward?"
That's basic back-and-forth communication, which maybe feels elementary, but I hope you find really helpful because, again, these are the things we're not taught. These are nursing skills. These are the skills that are going to take you in your job, in your profession, in your work-life relationships to the next level. You can do this not only with a provider, but with a coworker, with a manager. State the facts. Own your own emotions. Apologize for your part. This is our "check our ego." [chuckles]
Often, I hear things, and I'm like, "I am so sorry that that came across that way. I am so sorry. That was never my intent." People are always going to write our stories as well. In knowing that, if we can remember those four agreements as well on not taking anything personally, to be impeccable with our word, not make assumptions, and just do our best, it's going to potentially set us free from the constraints and the challenges of some of these relationships because so often, where it goes so wrong is that we take it personal, right?
Whew, that's all I got for you for now. I invite you to the CARE Framework Class. Join us. It'll be likely a one-time thing, but who knows? If you want just a teaser of this, you can come to our Pushing Class. I give you a little snippet and, really, I give you the whole CARE Framework in the Pushing Class. It's Pushing: Evidence, Empowerment & Practice Change. It really builds off of our Physiologic Birth Class.
If you haven't taken Physiologic Birth, that really is the foundation, and then pushing builds off of that. Then I do have our new Speedy Inductions Class that is going to build off of the physiologic birth content to, how do we apply physiologic birth to our induction clients? We're really going to get into positioning and all the nuances of what happens with an induction, really, the opportunity it is when we get to be in the room with them for so much longer and have more time with our clients than before, especially active labor hits.
You're invited to all of our classes this year. Please join us at MOVE Learning Retreat. We'd be so excited to see you in person. It's going to be incredible. We planned our parties, our welcome parties, our colorful parties. If you're coming, wear the color that best represents you. We have a lot of fun stuff planned for that. Then our closing party is a pink carpet sparkle party, so come in your best dress. Think adult prom. Come, and we get to dress up and be together and grow and learn and enjoy the resort and get some sun and rest your bodies and do something for you. You give so incredibly much. You deserve to feel refreshed and really build your cup because when you get better, everyone benefits.
Thanks, everyone, for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com, subscribe to our newsletter down below, or follow us on Instagram. Now, it's your turn to take what you learned today, apply it to your life, and go practice having one important, challenging, and courageous conversation. We'll see you next time.