“The chemistry between a Quarterback and Receiver is almost like a dance.”

      All-time best Wide Receiver in the US NFL, San Francisco 49ers’ Jerry Rice.

“Speaking up” when one has concerns about clinical management of a patient is often the final barrier to unintended patient harm (Raemer et al., 2016).   We know speaking up is important for patient safety and it has also demonstrated a positive correlation with technical clinical skill (Kolbe et al., 2012) and team performance (Edmondson, 2003). Because speaking up has been framed primarily as a backstop for patient safety, it is usually seen as the end, rather than the beginning of a conversation.  The healthcare community’s collective response has been to develop ways to teach people to speak up (Grenny, 2009; Ceravolo et al., 2012; Johnson and Kimsey, 2012; Brock et al., 2013; Raemer et al., 2016).

Instead of seeing speaking up solely as “calling out” and error-in-the making, we highlight speaking up as the opening lines in a dynamic two-way conversation and collaboration on the clinical management of a patient.  By highlighting speaking up as launching a conversation, we also focus on the importance of the conversation partner, the person who needs to listen up to collaborate with other clinicians, and often the patient, to identify the best course of care.  Clinicians worry a lot about the impact of speaking up.  Uncertainty or inconsistency around how the message is received has been identified as a major barrier to speaking up (Pian-Smith et al., 2009; Eppich, 2015) and often healthcare providers choose silence instead of speaking up when there is unpredictability for speaker about how the message will be received (Garon, 2012; Schwappach and Gehring, 2014). Factors that positively influence the decision to voice concerns include well-received past interactions with an explicit thank you (Szymczak, 2016). Conversely other studies have reported that staff who chose silence over speaking up had greater frequency of exposure to poor receiver behavior, such as rudeness and intimidation (Lyndon et al., 2012). 

The concept of  “Receiver” has been foundational to the development of communication theory over the last 60 years (Shannon, 1948; Schramm, 1954), but teaching and learning to listen-up, manage our emotions and provide a respectful response to colleagues when they speak up to us, has been largely ignored.  

Echoing the work of a handful of communication researchers in feedback (Eva et al., 2012; Stone and Heen, 2015), we turn the conversation about improving speaking up conversations on its head, and change the strategy of the game to focus on the Receiver through the example of the ‘Wide Receiver’.   

As many in the United States will know, the Quarterback is specifically trained to create and look for opportunities on the field.  They are trained to throw accurately, with power and speed spiraling the ball in such a way that their team-mate can catch it. Sometimes these opportunities are predictable, as when a set play works, while others arise in the moment, requiring the courage and know-how to change the game plan when needed.  If the Quarterback throws a wobbly ball, leads the receiver by too much, or throws it short, the ball is more difficult to catch, or results in an ‘incomplete pass’. The star power of Quarterbacks like Tom Brady, Joe Montana and others illustrates what a big impact throwing can have on the game. 

Less well known is another star position in American football, the ‘Wide Receiver’. Players in this position are dedicated and trained to ‘getting open’ by dodging and darting into position.  They reliably catch the ball on the run, standing still, whilst jumping in the air, or with someone charging at them. The game relies on the Receiver catching the ball, just as much as on the Quarterback throwing a good pass. The Receiver also has to make in-the-moment decisions that can shape the course of a game. What if the Receiver doesn’t catch the ball, or decides to run a different route than instructed or expected for that set play? These actions too can have a big impact on the game!

Let’s look at this in the healthcare speaking up context.

The Sender (Quarterback) is the person speaking up. Sometimes the moments we need to speak up are predictable and at other times not; speaking up often requires an instantaneous decision and takes courage. We teach people how and when to speak up and what words and phrases to use. Whether someone in a particular moment decides to speak up or not, can have a big impact on a patient’s care episode and outcome (Okuyama, Wagner and Bijnen, 2014).  

Why is it that we teach people to speak up, yet not the skills to listen and respectfully respond? 

Unlike American football, we don’t train the Receivers how to seek and receive the speaking up message, yet we still have high expectations that they can skillfully catch the message in varying ways and under varying conditions. Indeed, we don’t teach people how to listen with curiosity, how to manage the emotions that can be triggered, and how to respectfully (or at least neutrally) negotiate in the moment. 

When someone speaks up to us, how we choose to respond, is a decision that can redirect action, heat up or cool down hot emotions, escalate or help to regulate anxiety. Regardless of seniority, profession or level of certainty, in that moment we all can demonstrate skills and make decisions that can directly impact patient care. Calmly and empathically hearing other people’s concerns as they speak up takes agentic energy and self-management.

For the football Receiver, having a ball being thrown hard at you can really hurt. In the same way, receiving feedback when someone speaks up in a demanding or challenging way can lead to defensiveness and the internal reaction, ‘OUCH, that hurt’! So how do we make reasonable decisions when faced with receiving a ball thrown really hard at us?  Imagine if we tried as hard as Wide Receivers to get open and to “catch” the message colleagues are throwing at us?  Good Receivers are attuned to the Quarterback; they are eager to catch the ball.   Instead of focusing on defending our current position, we can reimagine listening up as a dedicated interest in “getting open” to catch what the other is throwing us, as mutual adjustment in service of getting over the goal line of good patient care.  

How do we become willing Receivers? To listen up eagerly (or at least grudgingly) when someone speaks up to us, may require a number of adjustments to our internal state.  1) RESET our emotions (Smith, 2011), by regulating our feelings of threat or anger and managing our defensiveness.  To do this a second step is helpful:  2) Cognitively REFRAME the situation; the technique of seeing the same situation in the different ways.  To become an able receiver, these reframes are helpful: 

1. Instead of assuming the other person has bad intentions or is unskilled, give them the benefit of the doubt or hold the ‘Basic Assumption’ (Rudolph, Raemer and Simon, 2014);
2. Instead of dismissing what they are saying, recognize the courage it took to speak up;
3. Instead of assuming “I have the whole picture,” ask yourself, what is it they are seeing that I currently am not? What don’t I know? We all have blind spots, biases (Watson, Jones and Hewett, 2016) and filters that impact how we view the world. Our blind spots will always be blind to us without feedback (Stone and Heen, 2015).

ENGAGE in a curious conversation.  

1. Listen for information or ideas you may be missing;  
2. Ask follow up questions to understand the other person’s perspective gives us then the chance to,
3. Collaborate to decide whether to stick to the current direction/decision (which maybe appropriate), or change direction based on the presented information?

What can you do to start having a direct impact on the outcome of the game? 

It takes both the metaphorical Quarterback to speak up and throw the ball, and the metaphorical Receiver to catch it willingly, to move patient care down the field and across the goal line.  So, let’s position ourselves as ‘Wide Receivers’, colleagues actively trying to catch and understand what others are throwing at us, even when it is scary or difficult to do so.   

Resetting oneself emotionally to ‘catch’ messages that might initially feel unwelcome, reframing to focus on the value of what the other colleague is saying, and engaging in a curiosity-driven conversation can transform conflict into a better understanding of other ‘players’ and the needs of the patient.  Becoming an able and eager Receiver, can change the game of healthcare conversations in that moment and beyond.