Anatomy of a Difficult Conversation: A Guide for Midwives During Challenging Moments

The Scenario

The midwifery student sat at the computer in the clinic office, looking through her preceptor’s busy schedule and preparing for the day. She got there a little early, and the office was quiet, giving her time to think through plans of care for the clients they would see that day. Suddenly, the office door opened, and one of her preceptor’s CNM colleagues stepped in. Seeing the student alone, the midwife closed the door firmly behind her. “Hey, I’ve wanted to talk to you,” she said with a conspiratorial tone. “What are your plans after graduation?” The student looked up from her notes. “I don’t know,” she said slowly.

She felt suddenly uncomfortable with the closed door. She added, “I would love to work here, but I will be happy to be a midwife anywhere!” The CNM sat down in her office chair. “Well, I haven’t told anyone else yet, but I’m retiring soon,” she said. “They should hire you to replace me.” The student smiled hesitantly. “Well, thanks, but my school won’t be complete for a few months, and I don’t know if the group would agree,” she said. The senior midwife chuckled. “Don’t worry about that,” she said. “This practice needs new blood, and you can always play the race card. That has gotten you pretty far already.” The student glanced towards the office door, willing someone else to enter and derail this painful conversation. What should she say? What could she say?

Real-Life Applications

Have you ever been in a situation where a difficult conversation needed to happen at work? Have you struggled with standing up for yourself or someone else but did not know where to begin? Have you been hesitant to tackle a difficult conversation because of power imbalances, fear of engaging, or people not listening to your ideas? If so, our presentation at the ACNM 2021 Annual Meeting, “the Anatomy of Difficult Conversations in Midwifery,” will give you the tools to engage in difficult conversations, such as in the scenario above.

Clear Communication

Clear communication is essential to success and happiness in our personal and professional lives. In a workplace, the ability to send and receive messages accurately signifies a culture of trust, engagement, and shared purpose. Clear communication is a skill of an effective leader who encourages collaboration, values different perspectives, and empowers others to make decisions. When we don’t communicate, passive-aggressive behavior, backchanneling, gossip, and overcommitting increase.

A communication tool used in many healthcare settings is the SBAR model. The model helps people transfer information accurately by defining the Situation, Background, Assessment, and Recommendation for a patient. Clear communication is central to who we are as nurse-midwives, and we use it with ease with our patients and their families. However, it can be a struggle to implement clear communication within our professional relationships at times. While SBAR is a clear and objective information transfer to improve patient safety, we need a different guide for more difficult conversations about feedback, decision making, delegation, and strategy within the workplace.

 Preparing for a Difficult Conversation

To prepare for a difficult conversation, take time to ask yourself a few questions:

• What outcome do you want to achieve? Why do you want this outcome? What’s important to you about that?
• How willing are you to be flexible?
• What ideas are you offering in this situation?
• What outcome might the other person want to achieve? Why might they want this outcome? What’s important to them about this situation?

It’s also good to be mentally prepared, but drafting a script usually isn’t worth your time because it’s unlikely to go as planned.

Anatomy of a Difficult Conversation

Having a clear, productive, and empathetic conversation means actively listening, staying curious and generous, leaning into vulnerability, owning mistakes, and sticking with the messy work of problem-solving. The table below provides a guide to difficult conversation skills with a midwifery example for each step.

Difficult Conversations: A Step-By-Step Guide for Midwives
ACTION	SUGGESTIONS/QUESTIONS TO ASK	MIDWIFERY EXAMPLE
1) Open with curiosity & willingness to listen.	Try introducing your openness to both talking and listening.	“Thank you for meeting today. I am curious to hear your recommendations for the patient.”
2) Find common ground/purpose.	Reframe your discussion as a partnership by identifying what you are working towards together.	“We both want this patient to have a good outcome. How do we work together to be successful?”
3) Early and often, check-in with yourself.	What emotions are coming up? Name them in your mind or to your conversation partner. If you are getting defensive, how can you calm yourself in the moment? Remember to breathe and take breaks when needed.	“I feel surprised that you are recommending induction of labor for this patient today based on blood pressure. Though elevated, it is not hypertension. I feel frustrated that you are not adhering to our guidelines.”
4) Get curious about differences.	Differences are hairy but stick with them to work through them. Listen, ask open-ended questions (who, what, when, how), and explore each other’s stories. Reality check assumptions about the other person’s situation or intention.	“We do not see this from the same lens. Tell me more about the evidence you are using for this recommendation. I want to hear your point of view.”
5) Stay focused. Use “I” statements to own your parts (feelings & actions).	Advocate for yourself and ask for what you need. Stay focused on behaviors that can change (instead of changing the person).	“If we induce this patient today, we increase the risk of cesarean section. I would like you to offer informed consent to the patient before a decision is made. I need the patient to have consented clearly. Without this information, the patient cannot make the best decision.”
6) Identify the problem.	Get on the same page by exploring questions together. “What is the problem we are trying to solve? What is the bigger picture?” Sometimes we haven’t yet identified the specific issue. Sometimes we resolved the issue by talking through our differences and understanding intentions.	“We are both trying to ensure a safe and healthy outcome for this patient, but we have two schools of thought about how to approach the conversation with the patient.”
7) Problem solve. Remember your common ground.	What questions do we need to ask? What information do we need to solve this problem?	“What happens if we do not induce today? What does the antenatal testing look like moving forward? How will your recommendations change if the patient declines?
8) Create an agreement and commitment to action. Ensure understanding.	Ask yourselves, “What are the next action steps?” Decide who will do what and by when. Clearly define when you will check-in.	“Now that we have an agreed-upon plan, the next step is to discuss with the patient. Would you please come with me for that? I will plan to go talk to the patient at 11:00 today.”

Practice is always worth it.

            After a challenging conversation, pat yourself on the back — no matter what. You showed up to do some hard work, and that’s what matters. Take a minute to reflect on what you learned and how you’ll carry those learnings into your future discussions. Remember that difficult conversations are meaningful and can ultimately bring you to a better working relationship with other midwives, providers, nurses, and staff. You can learn more about clear communication and the anatomy of difficult conversations at the upcoming ACNM 66th Annual Meeting, held virtually May 23 – 25, 2021. We hope you will join us there!

Authors: