Promoting communication and feedback: an essential leadership skill.

Open and honest communication and feedback are at the heart of nursing practice. Today's nurse leaders face significant challenges and opportunities in sharing information and giving feedback in a culturally sensitive way in an effort to move their team and the mission forward. With so much depending on the skills, attitudes and behaviors modeled by nurse leaders, providing culturally sensitive feedback is essential. When poorly done, feedback can be disrespectful, reduce self-esteem, and destroy motivation.

Does any of this sound familiar?

* You're upset when a staff member gives you a report that indicates he didn't understand your directions, even though you thought you clearly explained what was needed.

* You quietly correct an employee, but she blushes and turns away in embarrassment.

* One of your employees is overlooking an important step in a procedure. Each suggestion you make is met with defensiveness and a closed mind.

In each case, it is clear you need to give feedback both to help the employee improve performance and to get the results you need for optimum productivity. Yet how do you give it so that it produces the desired results? While the potential risk of hurt feelings, bruised egos, and defensive reactions is always present in feedback situations, the risks are even greater in a diverse healthcare environment. Miscommunication has a greater chance of occurring when differences in background, education, values, communication styles, and perceptions cause misunderstandings on both the giving and receiving ends.

A first step in giving effective feedback is to understand the impact differences in areas such as age, gender, and culture can have on how we send and receive feedback. Finding out how the values and norms of various cultures influence the transmission of the message is a good beginning. Looking at the following variables may give you clues about why some of your feedback takes while some does not.

DIVERSITY VARIABLES INFLUENCING FEEDBACK

* Avoidance of loss of face

Employees from some cultural backgrounds will interpret negative feedback as a shameful event that causes loss of face. When this occurs, they may attempt to avoid or deflect the information. Embarrassment may be shown by inappropriate smiling and laughter or by blushing. Avoidance may be attempted by failure to make eye contact, missed appointments for feedback sessions, or unwillingness to participate in discussions about any criticism.

* Emphasis on harmony

Employees preferring smooth interpersonal interactions often see feedback as disruptive to harmony and good feelings between the giver and receiver. In order to preserve harmony, individuals may agree even when they don't understand or continue to nod in agreement and say, "Yes, I understand," then proceed to ignore the feedback or make the same mistake again.

* Respect for authority

Employees from hierarchical cultures or upbringings that are more traditional may prefer operating according to a clear "chain of command" and may feel that feedback is an order to be followed without question rather than something to be discussed or debated. In such cases, the employee may be unwilling to ask for clarification, disagree, or even suggest a different approach.

* External locus of control 

Some cultures place more emphasis on external factors such as fate and chance when attributing the cause of success or failure. On the other hand, the culture operating in most healthcare organizations in the United States places a greater emphasis on internal factors such as ability, perseverance, and hard work. Employees who have more of an external locus of control may have difficulty in seeing the consequences of their behavior and in connecting the feedback to their own improved performance, evaluation, or compensation.

* Emphasis on relationship over task

"Get to the point." "Don't beat around the bush." "What's the bottom line?" These common expressions heard in American companies are indicators of the task-over-relationship preference that has little patience for small talk and sees relationship building as a waste of time. Yet some employees may have a different priority, viewing people as taking precedence over the task. Employees with this view may feel that their relationship with the boss, seniority, or their status in the group is more critical to success than following the task-centered direction given in the feedback.

* Difficulty in separating self from performance

Some individuals see their performance as an inextricable part of themselves, so a criticism of behavior is taken as a personal affront rather than as helpful information. When employees have this "I am my performance" view, they may feel betrayed, hurt, and embarrassed, or respond with defensiveness when given corrective feedback.

* Emphasis on group over individual

Employees from more group-oriented cultures may find it awkward and embarrassing to have their individual performance singled out for comment. Whether negative or positive, the individual focus causes discomfort and may be viewed as disloyalty to coworkers on the team.

"So what is a manager supposed to do?" you might ask when you look at all of these variables. The following ten tips may help.

1. Position the feedback as a benefit to the receiver.

Feedback has a better chance of being used positively when the receiver sees its benefit in personally relevant terms. Emphasizing these benefits will "hook" the receiver into being open to and utilizing the information given.

2. Build a relationship first.

Spending time building a human-to-human connection with employees will pay off when you need to give constructive criticism. Taking a coffee break or having lunch with different employees each week is a start. Not only will you get to understand your staff members better, but you will have built a foundation that you can rely on at feedback time.

3. Go from direct to more subtle communication.

Less direct communication can avoid the hurt and loss of face often felt. Making more implicit rather than explicit statements ("The introduction and conclusion of this report are excellent," rather than, "The body of the report needs work,") is one method you can use to be less direct.

4. Make observations about behaviors and conditions, not judgments about the person.

The risk of defensiveness is lowered when the focus is on specific behaviors and situations rather than judgments about the person. "Your patient's room needs to be tidied up" rather than, "Your work is sloppy."

5. Use passive rather than active voice.

Passive language can convey your message in a less confrontational manner. Saying, "Your charting was left unfinished," is softer and a more face-saving way to deliver your message than, "You didn't finish your charting yesterday."

6. Be positive, telling what you do want, not what you don't.

Giving positive directions not only takes the sting out of what might feel like a reprimand, it also gives the recipient of the feedback a clearer idea of what to do. You might say, "Please follow the new format this time," rather than, "Don't do it that way again."

7. Give feedback to the group rather than individuals.

This suggestion is particularly useful when giving feedback to individuals who come from more group-oriented cultures. Talking to the team as a whole avoids the personal blame that might be felt if the feedback were given to one individual. It also may rally the group to help some members "get with the program."

8. Make it low key.

Because of the heightened sensitivity and nervousness that often surround feedback interactions, it is helpful to make the discussions as low key as possible. Speaking in a soft tone of voice and meeting privately are two ways to avoid embarrassment and defensiveness.

9. Use an intermediary.

Intermediaries are often used when face-saving is valued as well as when difficult negotiations are stalemated. Informal leaders and cultural interpreters can be useful go-betweens who can help gain acceptance of the feedback and avoid embarrassment. Ask a third person for advice ("I'd like to help Anthony, but I don't want to offend him. What do you suggest?") alternatively, request them to pass the message on ("Susan, would you work with Joanna on finding a way to deal with patient complaints about the long waiting time for answering call lights?").

10. Assure the individual of your respect

Communicating your respect for the individual is critical in getting your feedback listened to. When people feel valued and accepted, they are less defensive and more open to what you have to say. This respect and acceptance can be communicated in many ways. Telling people directly how much you value their contributions, spending time with them, and asking their opinions are just a few ways. The most powerful communicator of all, however, is your attitude. As Emerson said so aptly, "I can't hear what you are saying, because who you are rings so loudly in my ears."

Once a nurse leader models culturally sensitive feedback, the staff will feel comfortable in providing feedback to the leader. Feedback should be viewed as a gift, and if staff offers this gift to a leader, they should thank them. Leaders need to have reflected back to them how their actions are received and how they affect others. Only when leaders can see how others see them, can they improve in ways that are responsive.

Priscilla Smith-Trudeau RN MSM BSN CRRN CCM is a healthcare management consultant specializing in workforce diversity leadership, team development and conflict resolution. She is the President of Wealth in Diversity Consulting and author of Peaceful Warrior Nurse. The web is www.wealthindiversity.com.