A crucial conversation is a discussion between two or more individuals where opinions may differ to influence behavioral change or promote a just culture. In medicine, we have historically tolerated dysfunctional nice cultures, which can appear deceptively polite and harmonious on the surface, and may contain fear, barriers to change and toxic work environment internally.

To foster a just culture, it is important that physicians be able to both recognize the importance of and embrace crucial conversations to address sensitive topics, resolve conflicts and drive positive change. It is time to collectively move beyond "dysfunctional nice" work environments to genuinely caring and communicative communities.

Putting a stop to unacceptable and disruptive behaviors is one of the most important reasons for courageous conversations. Unacceptable behaviors are actions or inactions that are discordant with an organization's norms, values or policies.

On an individual level, this can include physical aggression, passive verbal abuse, passive-aggressive behaviors, or disruptive, disrespectful or distressing interpersonal behaviors. Systemically, unacceptable behaviors can include unachievable work benchmarks and normalizing discourteous behavior in the workplace, such as the commonly performed "Monday morning quarterbacking" of a colleague's decision in public gathering spaces.

Interpersonal disruptive behavior – whether between physicians or between physicians and team members – disrupts normal operations of a team or workplace and may create an uncomfortable or hostile environment that can negatively impact patient care. Addressing such behavior requires a comprehensive approach that includes dedicated leadership focused on monitoring well-being and enforcing institutional policies. It is also beneficial to have a neutral third-party to resolve conflicts and respond to feedback.

Intentional time to educate and train all team members (i.e., more than required online modules) is also useful. Navigating crucial conversations is never easy, but ensuring everyone is on the same page and able to easily recognize and address disruptive behaviors before they escalate benefits everyone involved.

Crucial Conversation Strategies

Start with addressing the issue early, before it involves strong emotions.

Prepare for conversations by gathering facts, writing a script and rehearsing the conversation (as if you are about to give a patient some bad news).

Identify the message you want to communicate and what success looks like.

Choose your setting of delivery effectively – ideally in a location with privacy.

Define your roles using examples like "This is business, not personal," or "I am here as [role] because I am concerned about [issue]." Deliver content using the ACTION acronym (Figure).

Start conversations with observations, ask clarifying questions, and listen actively.

Discuss the intention and impact of the behavior, share your reactions and end by determining next steps.

Follow up with the recipient after the conversation. Some people may respond to crucial conversations with embarrassment, withdrawal, anger or indifference. Following up with the recipient can go a long way to provide closure and resolution to a distressing situation, maintaining relationships and growth.

Keywords: Cardiology Magazine, ACC Publications, Communication, Workplace, Aggression, Patient Care