Dr. Meinhardt is an obstetric anesthesiologist at MGH, an assistant professor of anesthesia at Harvard Medical School, the program director for the MGH OB anesthesia fellowship, the MGH learning laboratory operating room simulation officer, and the course director for the anesthesia crisis course at the Center for Medical Stimulation in Charleston, Mass. Is that all? No. Oh my gosh. Great. So I know Dr. Meinhardt as a safety scientist. She's an amazing speaker. She has spoken internationally about her work in team-based communication research, including grant funding research, and speaking up and giving feedback. Thank you. Thank you so much. Can everybody hear me okay with this? Thank you. I'll stand over here. I'm a little bit of a roamer, so I might be running around the front of the room here a little bit. It is such an honor to be here today. I'm humbled by being one of the speakers. Thank you so much to Dr. Van Pelt for inviting me. I feel like I've learned so much from all of you, from the discussions that we've had from the other presenters. So this is just an incredible opportunity to talk about this stuff, which is really, really important. And the reason I'm so passionate about this topic of speaking up is because I really believe that if we can bring more of ourselves to our work, if we can bring all of our exciting, our creativity, all our ideas, all our concerns, we can help affect better change for our patients. We have more joy in our environments, and it's overall make it more meaningful. And as you heard, maybe even decrease burnout and increase engagement, those kinds of things that are really important to us. I have no relevant financial disclosures. I'm on an advisory board for a device company I'm not going to talk about. I'm one of the editors for the ASA Simstat. I'm not going to talk about that. But I do receive money for them, and I really want to express gratitude to the AANA for funding this program. So I also am using Poll Everywhere, and unfortunately, they kind of compete with each other. So I'm going to have to ask you, sadly, I'm going to have to ask you to leave Josh Lee's program, and we're going to join mine, if that's okay, so that we can all collect responses on this one. So what you need to do first is I just use the texting method, so you can just pull up a text box, and in the 22333 number, I want you to first type in leave. And that will disengage you from Josh's polls. And then the next thing that you type is our Meinhart. Does that make sense? Okay. So tell me how this is working, because this part is actually really critical. To be able to hear from you on a communication topic is super important to me, and I think it just enriches the discussion. Are people seeing the right things? Okay. Okay. Anyone having trouble? I'm happy to come over. Going okay? Who here has been able to join, and it says you've joined my session, who's gotten the answer? Okay. Okay. Well, that's good. And, you know, try your best, and we'll see where we get. So I just want to test this out for the people who are able to join, just to make sure that this text message works. So what you'll do is you'll text just an answer to the 22333 number. Okay. Perfect. So you're seeing this is a nice, okay, lovely coffee, my favorite thing. Okay. Oh, sad face. Oh, I'm sorry. Cake. Okay. That's so great. Okay. So this works well. I'm going to move along and just focus us on some of the important things that we hope to cover, that I hope to cover with you today. First I'm going to tell you a story, though, which is the story of how I got started in this speaking up work, and it dates back over a decade to when I was a newly minted Obie Anesthesia Fellow. I was coming from the Midwest, actually Michigan, so not too far away, and I was coming into the Harvard system, and I was so excited. I couldn't even believe my luck that I had a fellowship within the Harvard institutions, and I was so terrified. I was super intimidated. I was worried that they would find out that they made a mistake getting me there, you know, and that I would mess up, and I would be embarrassing myself, and I would feel shame, all of the things. And so I was approached as a new fellow in like the first or second month I was there to take part in a study that helped me to learn how to manage Obie Anesthesia crises. Okay. So I thought, oh my gosh, that's exactly what I want to do. I want to keep moms and babies safe. I want to do that. So I was invited to the simulation center. I was going to take part in the simulation, and then I was told I was going to get a debriefing afterwards where I would get some feedback, and we would talk about things, and then I'd do another simulation session and that kind of thing. So I showed up. I was really excited. I went into the OR. It was a fake OR with a mannequin and everything and actors there, but quickly I got into it, and all of that fell away, and it was just me taking care of a patient within a team. And so I went through, and we went and took care of this patient. Lots of stuff was going on, and I felt at the end when I was walking to the debriefing room, I was feeling like, oh my gosh, I'm going to get great feedback. I was doing all the things. I was really fast. It was great. And then I came into the room, and my mentor who had asked me to do this, Dr. May P. N. Smith, who's also an Obie anesthesiologist at Mass General, revealed to me that it was actually a study on speaking up. And so, you know what's coming next. She showed me the video of when the actor anesthesiologist asked me to do something for the patient that wasn't necessarily in the patient's best interest and definitely deserved a conversation. And I saw myself. I paused. I blinked, and I just did it. And I was horrified, of course, like, oh my gosh, like looking back, oh my gosh. But I remember what was going through my head, and that was, oh my gosh, that doesn't sound right, but this guy's from Harvard. He must know, and I must just be really confused about my knowledge base. I need to hit the books. He knows the study out there that showed that this was okay in this population. And so I discounted all of my knowledge, my intuition, all of my thoughts about this, and I didn't even say anything because of this hierarchy that I had created in my mind. Because it turns out that wasn't even an anesthesiologist. That was a bioengineer playing an anesthesiologist, so it made me, yeah. So it was the power of that moment of a pause afterwards where I thought, oh my gosh, this feels really bad. Of course, I had to think for a moment and think, well, if they're studying it, it's not just about me. Other people have this problem, so let me turn this around. And so then I became a co-investigator and got on the paper and started to make it part of my life's work to help understand and promote how do we make this better for people that they feel like they can speak up even when they feel like they may not have the right answer. And so this is why I came to this day to you today. We're going to touch, these are the things that I'd like to go over. We're going to start by just briefly touching on what is speaking up because I feel like the elements of that are really important to define for ourselves as we're trying to target interventions to promote it. We're going to talk a little bit also about the reasons people might stay silent. And they might be different for different groups, and so I'm opening it up for you to invite you to share some of your reasons to stay silent. And again, this is all anonymous, so when you text something, it'll come up just as your answer, not with your name on it. And then we're going to quickly move into all kinds of conversational strategies, evidence-based techniques that can actually help this problem of not speaking up, staying silent when perhaps you should really consider voicing. Okay, so first we're going to start with understanding speaking up. So this is going to be a little bit of a think-pair-share for those of you educators here. So what I'd like you to do is I'd like you to consider how you would define speaking up and how it's different from speaking. And I want you to think about it for 30 seconds, turn to your tables, turn to a buddy, talk about it for about a minute, and then at the end of that time period, we're going to gather back around and you're going to share with me, we'll share together what are the things that come up in the definition of speaking up. So think for a couple seconds, and then whenever you're ready, go ahead and turn to the next person beside you and just start chatting. Okay, so I'm going to pause our conversations, if that's okay, I'm going to invite you to pause our conversations. And I'd love to hear some of the things that sounded like there was a lot of discussion and who feels free to share a little bit about what you talked about. What were the elements involved? Oh, sorry. Oh, yeah, sorry. Oh, yeah, microphone. Thank you. We're going to have a much worse situation than the microphone. Who has an idea? So my colleague and I, who just stepped out for a minute, we were talking about all kinds of situations that impacted, and the actual definition for us would be to speak your own particular truth at that moment and feel safe to do so. Okay, so speaking your own truth, which could be your perspective at the moment, so it's time bound, and you said, what was the last one, I'm sorry? Just having the freedom to be open. Having the freedom, so feeling safe to do so. That's right. What else? Oh, sorry. I was just going to combine what we said together. To bring something up, to make it known, that could possibly be confrontational, but could eventually lead to better decision making or increased safety. Okay, so it's something that could, it's challenging the status quo. It's not going business as usual, but for a good reason. It's because it could make things safer, better. It impacts the narrative not exactly in, you know, it's a power difference, basically. So tell me, say it again, sorry. So when there's a power difference, it's harder to speak up and speak the truth. Yeah, so hierarchy influences this. Okay, one more, and then we'll move on. What have we missed? Yeah. Oftentimes it's urgency, like you don't have the time to sit and think about it, it has to be done in the moment. Yeah, yeah, yeah, yeah. Could be. So speaking up feels like it's time pressured. Okay, so what you all described were things that were very relevant to the definition published in 2009. Basically that it's an upward directed voice, which we can talk about, so that's the influence of hierarchy, within or across teams, which I think is an interesting concept, because if we think about how does it feel to speak up to somebody of our own tribe versus somebody in a different tribe, you know, healthcare has been described as very tribal, so how does that impact our ability to speak up? It challenges the status quo, which is what many of you said, and it's because of a good reason to avert or mitigate harm, errors, stop that from happening to a patient, and it comes at interpersonal risk, right? So this is the part that makes it, I think, speaking up the most, is that you have to make a calculation, you go through an equation about whether this is going to come back to me or not. And so I'd like to kind of move along to a little bit, thinking about, well, how often is it a problem? Okay, so, you know, we live in a very speak up culture, see something, say something now, so how often does it come up that this is actually an issue? And so I'd like to just ask you to answer this question. I have disagreed with someone and found it difficult to speak up. A is yes, and B is no. So you just text the A or the B to the same text message, okay? Okay, yeah. It's remarkable to me. I have given this talk, I can't tell you how many times in how many different settings. Senior leadership, international groups, this is the split that we see every single time, 90-10, it's the same. Yeah, it's remarkable. And so what I see here is that for the vast majority of people, this is something that we're going to, it's going to be very relevant. And for the small proportion who says, no, no, I don't have any problems with this, this is important for you too, because this means that somebody else who's in your environment is having trouble with it. So there are some techniques that I'm going to share that even those of you who feel super brave and super sure that you'll speak up every time, that you can help somebody else. So it's relevant for everyone here. So there was a study done, it's about 14 years old now, 2005, and I think it's really relevant to this group, basically surveying hundreds of nurses and physicians to say, what are these vignettes? They had a series of vignettes, and they had to rank them as far as their willingness to speak up about the problem. One in particular generated this response, that 84 to 99% of physicians and nurses surveyed thought it would be hard or near impossible to speak up, and the vignette was about an impaired provider who was impaired at the point of care. And so just as we talked about all today, this is incredibly hard. All of the conversations that we've had, Rigo and Claudia, I mean, this is real, right? And so this is why this is a critical thing to talk about. This is more than just people struggling with their people they know. This is so ingrained in human behavior that I think this study is pretty impactful and represents it well. So there was a study done where they took 48 seasoned nurses, and they were randomized to have a pre-op discussion with either a real surgeon, like a person, or a computer screen with an avatar who looked kind of like a surgeon, kind of like a person, but it was kind of a crude drawing of a person, okay? And the surgeons were suggesting something dangerous. So the surgeons were saying, we need to go with this case, we need to start this case, EBL is probably estimated to be 500 cc's or so, I know the patient has had a positive antibody screen before and we don't have a type in screen that's active, but we just need to go. Okay, so these nurses were all told this situation. Only 20% of nurses in each group stopped the line and said, no, we cannot go forward, even when they were talking to the cartoon character. It's so ingrained. This is not, it's not like they didn't know, they knew. It's just patterned human behavior. So this is stuff that goes really deep for us. And so now I'm going to move to why would those nurses not speak up? What sort of challenges do you feel when you're having struggles speaking up, or what do you think that other people experience when they struggle speaking up? So I just want you to feel free to text anything here. What are your hurdles to speaking up? Intimidation, fear of ridicule, oh yeah. Hierarchy, retaliation. I've been put down. I have a history of this. It doesn't work. Ridicule and fear, I feel embarrassed. Hierarchy, yeah. Potential knowledge gap, I might be exposed. I just didn't know, and then I'm stopping everything. All of this hierarchy. Fatigue, yeah, just too tired. Confrontation, superiority, humiliation, lack of confidence. I don't really know. Hierarchy, so these are all things. I mean, these are all not getting along with the team. Ah, it hurts the relationships. Yeah, being shot down. Student nurse versus attending physician, again. Hierarchy, sounding stupid. Perfect. So these are all things. Losing job. These are all things that are represented in other spheres that other people say makes it hard for them to speak up. So these are papers that we've done with attending anesthesiologists, and I'll talk a little bit more about that in a minute. But a lot of these are driven by the reasons that people stay silent are really driven by fear. So fears of maybe not looking like you have the answer. Fears of harming relationships, fears of retaliation come up again and again. Totally again and again. And this is, the influence of hierarchy is interesting. to me. So this is studies done, this is a study done by Gutele Grote and Nadine Biedenfeld, who are organizational psychologists in Switzerland. And they basically looked at, they looked at cockpit crews. So cockpit crews consist of a captain, a first officer, so that's like the captain and the co-pilot, and then the flight attendants, and then somebody called a purser. And the purser is in sort of the liaison between the captain and the flight attendants. So in the order of hierarchy, it kind of goes, captain, purser, first officer, and then the flight attendants. So they asked all these people, it was like over a thousand cockpit crews via survey, to rank order, to share with them why they didn't speak up. So for the first officers, pursers, flight attendants, all the people below the captain, they basically were worried about punishment. They were worried that they were gonna, you know, be ridiculed, like loss of career, there'd be some retribution. For the people at the lowest rungs, the first officers and flight attendant, they felt it would be futile. They've tried it before, it didn't lead to anything, it's just not even worth it. For the captains, there was a real fear of damaging relationships. So this is where the hierarchy is a little interesting, because you would think, captains, they shouldn't answer, they should answer, I'm never afraid to speak up, I always speak up. But in fact, hierarchy is sort of relative, and so in the social structure, with social relationships, they knew that the flight attendants sort of listened to them, or gossiped about them, based on how their relationships were. And so this is a really influential thing, for even the leaders in the area, in this audience, to think about, that even those are some considerations about speaking up. From our own research, we looked at 70 anesthesiologists from the Harvard medical system, and basically found that certain things came up for them as well. One of the biggest ones was that it was just unclear. They were uncertain about the issue, couldn't really tell what was happening. There were stereotypes that came into play, all nurses do this, all surgeons do this, all colleagues do this, and so they would then silence themselves. Familiarity worked both ways, whether they were really familiar with the person, and they just implicitly trusted them so much, versus they had no idea this person, how they would react, that really played a role. Respect for experience, people deferred a lot, and some of these were very senior clinicians who were in here, deferring. And then finally, fear of repercussions. These all came up. So now I'm going to move to, how do we get over this? How do we move forward and make it better for people? So I'm going to ask you first, just to ask, when do you find it easy to speak up? What helps you? What moves it along for you? A true patient safety issue, when it's clear. It's clearly a patient safety issue. Past experiences, okay. Personality, when it's encouraged. Ooh, the encouragement. When I know something is wrong. So certainty, again, I have the right answer. Knowledge, patient safety is involved. When I feel accepted, oh, that's so good, yeah. Patient safety is focused, strong relationships. When I know I'm right. So the certainty really matters, especially in our field of healthcare, where certainty is quite valued. When I trust those who I'm speaking up to, when I feel I'm an expert or approachable person, trust culture, supportive environment. So these are all things that we're gonna talk about next. Yeah, when everyone has asked for their voice. I love that one. Collaborative environments. When you feel part of the team from the very beginning. These are really important things. I'm gonna move along. And just to say that when we asked the attending anesthesiologist, one of the first two things that came up for them is a little bit of the community and a little bit of the how do I do it. So they said that if I had language for speaking up, if I knew the words to say or how to say it so the other person would hear it better, then this would be really helpful. The second thing is, if I had a buddy come in and say, yeah, you're right, you should totally speak up about that, then that would be really helpful. So I think these are the things that we tried to build into an intervention that we did with them, which is we combined a two-challenge rule with the way of speaking that helps people hear you better and share their point of view, and that's called advocacy inquiry. I'm gonna first describe the two-challenge rule, and then I'm gonna talk about advocacy inquiry as a technique. So the two-challenge rule comes from aviation. Who here is familiar with two-challenge rule? Okay, okay, this is cool, okay. So essentially what it is is that the airline industry says that if the first officer and the captain are flying the plane and the first officer thinks that something is wrong, like we're losing altitude, something like that, the first officer is mandated to first question or challenge the captain, initially from a stance of curiosity, so as not to rock the boat too much, and then if there's no answer or a nonsense answer, then that person is supposed to challenge with more ferocity. Okay, so I'm really concerned, and if there's no answer or a nonsense answer, then the first officer is mandated, given the responsibility of flying the plane to safety. As determined by the first officer, but nevertheless taking over the controls of the plane. So as you can imagine, this is hard to import into medicine and healthcare, where we do such different roles, right? It's unusual to have two people who are very much in the same role. So if I disagree with a surgeon, I'm not leaping over the curtain to take the laparoscopic instruments from that person. It's not gonna work. So what we said was, well, we like the idea of the two challenges. We think that's important. So first from curiosity, and then if there's no response or a nonsense answer, like this is the way we always do it, which sounds like an answer, but it's not, then to escalate it and to make your concern more clear. And if there's still no resolution, then the next thing is to call for help. Call for help from a colleague who can just be a second set of eyes, another set of eyes, another set of brains, to see what can we do about the situation. And the language we taught was to use this advocacy inquiry language, which I'm gonna describe later. So this is, we thought, a good idea. And it turns out, actually, in residents, it works really well. They challenge, they challenge again. In attending anesthesiologists, not so much. So they don't really challenge. And in fact, in some work we're doing now that's unpublished, they only challenge once many times. And so that is even more fascinating to me. So it really goes to the team environment and how we're promoting our work environments, how we're seeing the team's contributions. So advocacy inquiry is a really unique way of speaking, and I think it combines a lot of really interesting things. It was developed in business and in organizational behavior, psychology disciplines, to really be efficient and effective at making clear your point of view, and then also asking for the other person's point of view in just a really impactful period of time, a small period of time, with the greatest room for impact, so that they would actually be closer to sharing with you what was on their mind. And so the way it goes is this. The first part is the advocacy, and that's just sharing your point of view. And it combines two things. It combines data. I don't know if you can see this. I saw or I heard. So in the airplane example, it might be, I see we're losing altitude. We were at, whatever, 15,000 now, or we're at 10,000. So that's data that everybody can agree on. And then what you think about it, which is kind of hard for us, I feel like. It's just hard for people in general to share what's on your mind. I'm curious, I'm concerned that that's not actually where we wanna be. I'm concerned it's a safety issue. And then it's paired with an I wonder, an open-ended question. But help me understand why we're doing this. And then if there's an answer that happens, then this is the time when it'll happen, after this open-ended question. And that's when there's listening to the other person, which we'll talk a little bit about. Because listening to other people, I don't know, I find very challenging, at least when I first started. I was often just listening to, I'm right, I'm right, I'm right, instead of listening to what they were telling me. And so opening your mind up to listen to the other person, to actually hear what they're saying and consider their concerns. And then moving the discussion to a joint plan, something that's a win-win for the patient, a win-win for you, is where you go next. And so this is the verbal component. And as we'll talk about, there's a non-verbal component that's really important. Yes, please. And I was gonna say, this is used in simulation debriefing, too. Yes, it is, thank you, yes. Because that's a beautiful thing to provide safety in a situation. I love that you say that. And it's actually so important to use it in simulation, which is, in those moments when you're sort of, you know, kind of acting in front of, you know, you're performing in front of an audience, often of people you don't know, sometimes people you really know well, then it's really important to kind of hold this idea that we have to be curious about somebody else, and that's the next part of it that I'm gonna talk about, too. No, it's great. And this comes from, also, people that I work with at Center for Medical Simulation, who you might know. Yeah, yeah. So the verbal and the non-verbal is really interesting. So I'm gonna put this slide up, and I'm gonna share with you, what if I told you, what a brilliant idea, glad you're on this team. If you just read that out, you're like, oh, that's nice. Thank you, that's good. And yet, if I said it in this way, like a snotty snide, you know, like smirking, then it completely changes the meaning, and it's not equal. This way overpowers, the non-verbal way overpowers this verbal message. It completely changes it, in fact, right? And so lots of studies have been done on non-verbal and verbal communication, and what percentages really help us understand the message, and it turns out that about 80% of our communication is done non-verbally. This is body language, this is posture, tone of voice. And even in the operating room, the perioperative settings, we're all covered up, have just the eyes, you can tell when somebody's staring you down, versus they're just glancing at you distractedly, like they were lost in thought, and you just happened to be there, that they were in their line of vision. So this is really important. So how do these non-verbal messages come to be? How much are they under our control? It turns out they're not really under our control. Our verbal words are much more under our control, we can choose them very carefully, but our non-verbal messages just come out. And why is that? Well, I'm gonna start with saying that with speaking up, a lot of times people focus on the fact that it's like this. There's a person, so I'm gonna say the sender is like the person who's worried, like the person who feels like they have to speak up. Okay, they see something, they feel like they have to speak up. And the receiver is the person who maybe is needing to be spoken up to. Does that make sense? So what a lot of people will focus on is they'll focus on the speaking up part, where these words, what are the words that we say, and then how does the person respond to it? But it's much more interesting than this, and it's much more nuanced than this. What's actually happening is the sender, the person who's observing and sees something to speak up about, suddenly has this big reaction. Oh my God, there's something. Their tone of voice changes, their facial expression changes, something changes. We are hardwired to see these changes in each other. This happens faster than the speed of thought. And so people who come at, say, if I were to come at somebody with signs of aggression, if you actually saw the speed of that response, the stress response in the other person, it's much faster than the person actually thinking through what is it that's coming at me? And so what happens is if our nonverbal expressions are aggressive or forceful in some way or really exaggerated, which is something that happens in our heads that we can't always control at the moment, if we don't control over those, then they leak out and they basically impact our ability to have productive conversations with the other person. Because the other person is busy responding to the threat that now we are exhibiting. And then there's the speaking up, and then there's the responding, which may or may not be that productive based on the emotional states of the two people involved. Does that make sense? So this is where it gets really tough. Sorry, I'm just gonna have, I had a Sudafed, so I'm like all dry. So if you have to say, I see you're about to do something that I think is dangerous, what's up with that? You don't want to do it this way, or this way, or this way, right? So these are really gonna be not moving you forward, which is where you want to be in that productive conversation, let's make the patient safe together kind of role. So this is a little bit, I'm gonna talk about some techniques that have been tested, and they work to reduce the emotionality of any kind of situation. These are the ways that we can start to get control over our emotions. Then I'm gonna take you through how do we start to form those emotions in the first place about our colleagues or situations at work. So this is an example of when you have a lot of time, when you have some time, it's not so time pressured that you have to speak up. Some things that are helpful are things like just even letting time pass. When you see something that makes you upset, and you have some time to delay addressing it, then it basically can help your cataclysm dissipate from your brain, and you can sort of get more on control, get more in control about the way you think about things and the way you feel. So it's not a reply all right away. The first minute you see the email that makes you angry, it's a let's wait five minutes or 10 minutes and then revisit. The other one that I'm not, I don't know how many people are familiar with this, but it's actually for predictable situations, which is a cognitive process called reappraisal or reframing. This one I use a lot, and this one I think is really helpful. So in the moment when I talk to you about I was telling myself I'm not that smart, this guy is from Harvard, this guy knows much more than I do, it's basically saying another, like telling yourself another story. Actually my views are worth saying, worth sharing, worth even calling the question, because the cost is too high to not do that. So sort of going through your mind and thinking about situations that are predictable, like if somebody were to, like oh I'm working with that person today, I always have to speak up to them, I just don't wanna, or they always challenge me about something, thinking of it instead as an opportunity to teach more or to practice your difficult conversation skills. Like thinking of it that way can help reduce the emotionality of the actual thing, the actual thing that you're worried about. Okay, so even when there's no time, we need to take a little bit of time to get under control of our emotions, because even when there's just absolutely no time, to have a non-productive conversation wastes much more time and puts the patient at much more risk than just at least taking a few seconds to get yourself a little bit more centered. So the things that we can do are, it's been studied, if you just kind of focus inward and do this mindfulness exercise, attention to breath, thinking about how the air feels coming into your nose, thinking about how it feels when your lungs expand, those kinds of things can help center you and decrease, and help your brain get back on track, help you decrease your emotional volatility. Another thing that I think takes a lot of practice in the moment, but which is really helpful, is to do, it's another kind of, it works in the same kind of way as mindfulness, but it's called affect labeling. And it's, instead of becoming the emotion, I am angry, it's distancing yourself a little bit. I am feeling angry, and then wondering, ah, I wonder what's driving that, you know? So when I first started doing this, it took a lot of effort. I was really, every time my kids did something, I would, oh, I'm angry, oh no, I mean, I'm feeling angry. And it took a lot of time to kind of make that switch. But just like any skill that we develop and we practice a lot, now it's much easier. So now it just happens almost automatically. It does work. And it is a nice temporizing, because even when I see stuff that's really concerning, I know now it's like, I can just do that automatically, and it helps me be centered to intervene or do whatever I need to do. And then this is one that I actually use with patients to help their emotional control. So I do OB anesthesia, which is quite emotional at times. And so when somebody is just terrified out of her mind or his mind, I basically will help them recall something that they're grateful for. And it confuses the brain a little bit. So it actually helps to not make it as powerful of an emotion, that fear, that anxiety, or whatever. So we can do that in ourselves as well. So overall, changing the message, that when we're talking about this I saw, I think, I wonder, when we're asking the question to kind of have that deeper conversation that's really honest, we're doing it in a way that's curious and respectful and supportive. And we need to get there in order to have productive conversations. This quote, I think, is just one of my favorite quotes. Respect is like air. You don't really notice it until it's not there. And then it's all you notice. So this is something that we all have felt in the past, I'm sure. If you haven't, I'd love to know your secret. But this is something that really gets in the way. And so we need to demonstrate respect for other people to learn what they are thinking when they're doing something that we think is really dangerous. This is really important for them to actually share with us what it is that's going on behind the scenes. So this slide is about how we think about things, so how we put together the data that we see and how we start to assign meaning, what stories do we tell ourselves, and how that all comes to be. So this is done by Chris Argyris of the Harvard Business School. He was a business theorist. He basically just mapped this out, a schematic diagram of this. So down here is all the available data. And it's way too much for our brains to handle. There's too much data out there. All of our senses are constantly bombarded all the time. So we intentionally select data. And it's actually unconscious for most of us. Unconsciously look at data, bring data in, and start to analyze it based on our backgrounds, our preferences, our training, that kind of thing. And then we start to make assumptions about it. So we start to make meaning out of it. We make an assumption about it. Then we start to draw conclusions, have beliefs, and take action. So this is really important, because once we're at the stage of beliefs, like we believe something about another person, that person's always blah, blah, blah, then we look for examples to support that hypothesis. We're looking for the time. We're looking for the time when they screw up again, so we can use it against them again in our heads. So this is the thing that we do automatically. And so I'll give you an example. Somebody came in right now to this lecture. And they had Starbucks coffee in their hand. And they were on the phone. And they were late, because I started a little while ago. I might see them and think, OK, so the data is Starbucks, late, and phone. And I might think, oh my gosh, my assumption is they don't care about this. They don't care about this topic. They don't care about anything related to wellness. Like, oh my gosh, who are these people? Who is this person? I think that they're just a toxic person, so they need to be out of the environment. And I'm going to just go up and try to get them fired from whatever job that they were doing. Like, you can see how far away from reality you can get, right, if you let this go up unchecked. And so this is why this is important to kind of slow down and see. So I might see something in the environment that I think is dangerous. And maybe it is, and maybe it isn't. And if I have presence of mind to say, well, what am I missing here? Let me think about this. Learn more. It helps me be more open to a possibility that I could be wrong, even though mostly I think I'm right. And as we can see, assumptions can really get us into tough places. So this is a, I don't know if you can see, parking spot just for you. Two people here, the car driver and then the person with the chalk. And we don't know why this person parked right on the yellow line. What are some other explanations for this? What are some other explanations for this? You have a broken leg and trying to get out. Broken leg, trying to get out. No handicapped accessible spots. What else? Vision problems. Yes, vision problems, although that's a little scary. You never know. Emergency, didn't have time to center the car, just had to get out. So we don't know why this person parked like that. But just entertaining a few ideas actually helps us build a little bit more flexibility cognitively about seeing the other person's point of view. Maybe brings us down a notch off that ladder to really open ourselves up to the explanation that might come back. And if we just, if this person with the chalk were caught in the act by this person in the car coming out back out to the car, that's putting them in a really tough position too. So it can get us in trouble. And so this idea of emotional reactions to things can be harder for us to hear and consider rational facts. This is true, right? And so the more we can promote, like the more we can decrease the emotionality of the conversation, at least to temper it, because we do, again, interact so strongly with our emotions with each other, it can help provide a more productive environment for a conversation. So the thing I ask myself is what else am I missing here? What else are we missing here? How can we come down this ladder and go back to the data? So that's what that first line of your advocacy is. What data do I see? And then the rest is what my assumption is about it, what I think about it, and then it's an open-ended question. So some other things that can be helpful in decreasing your emotionality or your reactiveness, reactivity, is this idea of perspective taking. So perspective taking is not like, how would I see the world from their shoes? Because that just reinforces your own viewpoint. I would see it exactly the same way. I would still be mad about it. That's not actually what this is. This is, how must the other person see things? And if you engage in this, this is a skill like any skill, it takes ATP, it takes your brain power. It's a little fatiguing mentally, but it has a whole bunch of benefits with it. So we can do this in order to start to understand, or at least approximate understanding where other people are coming from when they're making decisions that we feel are dangerous. And so benefits of perspective taking are that it decreases narcissism. So narcissism is rampant, it keeps growing. It's like so many people just all focused on themselves. And our social media streams don't help because they just show us our own point of view. And so this actually stops that process just by introducing another point of view. It increases curiosity, which again, is one of the recipe elements for doing the advocacy inquiry. And if you think about it, curious people are better to be around. People think that they're more interesting. They are happier people, those kinds of things. So this has been studied as well. It enhances creativity because you're actually thinking about more things and more solutions to the problem. So it can help you with that as well. The basic assumption is something that we teach in simulation a lot. This comes from the Center for Medical Simulation. And it's a way to actually, if you could just hold onto this assumption and replace it by any other assumptions on that level, that ladder of inference, just that the person who's just done what they just did that made me really worried or upset is intelligent, they're capable, they care about doing their best and they wanna improve. So why is it that they just made that choice? It helps to center oneself when you see something that you need to speak up about. I use this, it's almost like brainwashing yourself. It's like, sometimes I have to repeat it out loud to myself. When I see somebody in the environment make a decision that I just would not make. It helps, but it does help facilitate the conversation. And then the listening, actually listening to somebody is super important because it basically generates trust, it builds alliances, it leads to better solutions, and you get some useful info in there too. And so practicing listening is really important as well. Focusing on what the other person is saying. So leaders, all of you, can enhance speaking up as well. So just as you reported, it's easier when you've been invited and when you've been made to feel a valuable member of the team at the beginning. These are the techniques to use. So if you're open and accessible as a leader, this really promotes speaking up. There was a study done in medical students where they were paired with an attending surgeon who was a simulated attending surgeon in a simulated setting, and half of them were told, they were randomized, half of them were told, your opinion matters, I'm gonna do this procedure, and if you see something, please say something about it. The other half was told, we just have to get on with things. We don't have, you know, let's just get moving. The ones who said, who heard your opinion matters, spoke up when the person made an intentionally wrong move. 82% of the time they spoke up, versus when they were just told, we gotta hurry up. Only 30% of them spoke up. So this is really important, so this idea that leadership, and leadership doesn't always have to come from the top. It can be generated in the middle and upward. And so thinking about how we invite other people and how we stand up for other people speaking up as well is really important. And so this concept of psychological safety was touched upon, I think, in multiple different ways. It's a team concept. It means that everybody in the environment basically feels safe to take risks, and I think you talked about that a lot when you're building your definition. How important that was. And so it's influenced by every member of the team. So this is really the holy grail of what we need to be doing. It was written about by Amy Edmondson et al, so she really has developed this concept. So understanding practices that lead to better psychological safety are really important. Now I'm gonna flip it a little bit and say, how does it feel to be challenged? Because this is the last sort of concept that I wanna think about. So you've all been challenged, I'm sure. Spouse, children, partner, boss. I love it, oh great. Defensive, that's me, okay. Uncomfortable, yeah. Defensive, uncomfortable. Humiliating, oh my gosh, yes, been there. Comfortable, wonderful. Invigorating, I love it. Not good. Uncomfortable, yeah, uncomfortable. I love it, because this is me too. I teach this stuff and I'm always like, oh, I teach this, I can't get defensive. Take a breath, okay, yeah, let's talk about what you just challenged me on. Humbling, depends on delivery. I love this, because that's what, oh, others are paying attention, gives me pause. Uncomfortable, embarrassed, yeah. Unsettling, yeah, so lots of range of emotions, from positive to sort of negative and maybe even more depending, good or bad, depending on who's challenging you. So there was a study done from Michaela Colby, who's a collaborator of ours with the Center for Medical Simulation. It was just published where she basically took people and had them be challenged. She randomized how the person was challenged to, so who was doing the speaking up was different, but the person was the participant who got spoken up to. And the different styles that they used, where they used this very direct, they called it explicit. It was like, what you're doing is wrong, okay? The oblique was, oh, are you sure you wanna do that? Okay, so maybe not really that clear. And the last one was this respectful, which is like, I see you do this, I'm worried about this, tell me what's on your mind. And that was considered the respectful arm, okay? So what they found was, when the people were spoken up to, the people who were most likely to change their behavior were overwhelming the people who were spoken up to respectfully in the advocacy inquiry style. And a little less, fewer times, it was the explicit group was just really direct. The oblique, they didn't change anything. If you were like, are you sure you wanna do that? It didn't change anyone's behavior. The ones that were thought of as rude, I mean, it's a little bit hard because this was, they were hyper-respectful in the advocacy inquiry group, but the explicit was thought to be super rude. So whether it was helpful in the moment, but then they didn't wanna work with that person anymore afterwards, that's a consideration. So even if you're super direct but not respectful, that can have a consequence. And the oblique was actually also thought to be rude because it was like, why aren't you just coming out with it? Why can't you just say what's on your mind? So to summarize, I'm just gonna go through some of the things we talked about. So I think the hurdles will always be there for 90% of the people who find this is challenging occasionally. And so things that I hope you're taking away from this, and I'm gonna ask you your takeaways, are things like how do we get through this process? And considering the two challenge rule, advocacy inquiry. So I think two challenge rule works well for maybe people who are less ingrained in the environment, maybe at the student level. I'm not sure, this is just a hypothesis. And it may empower them for later, being better at speaking up. We haven't studied that, but that's what I'm wondering. Then I think the structure that I saw, I think I wonder is really important, combined with curiosity, respect, support for the answer. And these are some other things that I thought might be takeaways for you. Thinking about how else can we build psychological safety in our teams and help promote speaking up from everybody. So with that, I'd love to hear your feedback, what you might be taking away from this talk. Empowered to speak up. Perspectives and delivery. Yeah. Perspective. Can and should speak up. Yay. Conscious of nonverbal communication. Yeah, that's a big one. Too challenged, real good. OK. Better approaches. More mindful of my feelings. Yeah. Non-confrontational way. Yeah. Confidence. Yeah. Yeah. Yeah. And I think it's even, I even use it in my emails now. You know, if somebody sends an email out that I'm like, oh, then I have to use advocacy inquiry. I see that you wrote x. I'm worried that it could be taken this way. What's on your mind? Tell me more. So it works even on email, especially if you have a relationship with a person, they know you're mostly respectful. Yeah. Remain open. Trying to have the courage to speak up. Yeah. Yeah. And another reframe that I didn't share initially during the talk, but one of the big ones that helped me just in getting my voice and sharing it more, is to think you never know who you're going to be a role model for. So it's my dream to be a role model for somebody. And so just thinking about that somebody in the environment could see me speaking up and then be more empowered themselves to speak up, was a very empowering frame of mind to have for me. So those kinds of things, like thinking about it in a different way, not that it's coming at a high personal cost, but it might benefit somebody else, is also a way to think about these. Oh, thanks. OK, well, thank you so much.

Rebecca Love

nurse innovation

healthcare products

hackathons

SONCiel

failure

Dr. Meinhardt

obstetric anesthesiologist

safety scientist

team-based communication

speaking up

two-challenge rule

advocacy inquiry

psychological safety

perspective-taking