How should health care workers, especially infection preventionists, give constructive criticism in their positions?
I remember being the primary nurse for a patient who was critically injured in a car accident. I had never worked so relentlessly to save someone’s life. Surprisingly, we were able to successfully transfer him to the intensive care unit from the emergency department. A week later, I received an email from the facility’s quality department. They stated that we had failed to place an orogastric (OG) tube prior to transferring the patient to the intensive care unit.
I read the word “failed” multiple times that afternoon.
Education was attached to the email that reviewed the importance of placing an OG tube to prevent health care–acquired pneumonia. I felt crushed, insulted, angry, and defensive. How dare they point out the one thing that we did wrong when we had worked so hard to save this man’s life?
Now, obviously, insulting our efforts and putting us on the defensive were not at all the intention of that email. I know now that our quality department was trying to help us improve practices to better prevent infections, but in the heat of the moment, that goal was not obvious to those of us on the front lines. Instead of their email being a helpful reminder of best practices, our team was distraught that no one appreciated our efforts. What the quality department had attempted to accomplish—improving practice—was not fulfilled that day simply due to its incorrect formula for providing constructive criticism.
This memory has stuck with me throughout my years as a nurse and an infection preventionist (IP). As IPs, we are charged with improving the prevention and control of infections in health care settings. This is no easy task. For us to improve prevention, we must first identify opportunities for improvement. Then we need to present those opportunities to frontline teams and work with them to implement new workflows. Often this goes hand in hand with needing to provide constructive criticism, such as when lapses in best practice lead to poor outcomes. And no one likes to hear bad news or criticism.
However, it not the receipt of constructive criticism alone that determines whether an individual will be receptive to implementing positive change and improved workflows. As with so many things in life, it is not so much what we say to someone but how we say it that matters most. Over time, I’ve realized that 3 key ingredients are necessary to successfully provide constructive criticism so that the message is heard, people feel empowered, and steps are taken toward positive change. Those ingredients are transparency, humility, and empathy.
When giving constructive criticism, I always start conversations with transparency—transparency about myself and my intentions for the interaction. Transparency means being seen through, readily understood, or visible. Before providing constructive criticism, I present myself so that the other individual can feel relaxed around me and understand my goal for the conversation. Obviously, this task is much easier to do when constructive criticism is provided in person rather than via email.
One example of how I present with transparency would be how I generally open a meeting to discuss new infections. I am always the first to introduce myself in a meeting that I’ve called together. I say who I am and why I’ve brought all of us to the table. It is as simple as letting the audience know my name, my role at the facility, the intention of the conversation, and that my favorite color is purple. My favorite color? Yes, when appropriate, I tell people random facts about myself when providing my introductions. I find that doing so humanizes me and puts others at ease. It allows participants in the room to see that I am, like they are, just another individual.
My introduction usually sounds something like this, “Hi. My name is Heather. I am a nurse and one of the infection preventionists here. I chose to be an IP because I’m very passionate about keeping you and our patients safe by preventing and controlling infections. I’m looking forward to working with all of you to find ways to improve infection prevention in [insert area.] And, in case you were wondering, my favorite color is purple, I have 1 cat, and 2 sons.”
Usually, following my introduction, the those in the room will laugh at the personal random facts that I’ve chosen to provide, and I can palpably feel the tension dissipate in the room. And usually as these introductions continue, everyone else will begin to share their favorite color, how many pets they have, or if their kids like tomato sauce or pumpkin squash. The air is always lighter when those individuals in the room are better acquainted with everyone’s favorite color. It’s amazing, but a little bit of transparency about yourself, your job, and your intentions can go a long way in preventing people from becoming defensive when providing constructive criticism.
This brings me to our second ingredient, humility. We must approach individuals with humility, acknowledging that we don’t know everything about their world, their experiences, their successes, or their challenges. We should always be a learner before we’re a teacher and compliment those we seek to influence when warranted. People will always be more likely to accept constructive criticism after you’ve first provided a compliment.
You never want to stroll into a health care area and immediately tell staff what they’re doing wrong. If you do, they will whisper to one another, “Can you believe the arrogance of this guy who told us what we should be doing when he doesn’t even know a thing about the challenges of our job?!” I know that this is what they whisper because it’s how my colleagues and I responded to poorly delivered constructive criticism. We were offended and defensive. Although the perceived goal was for the constructive criticism to be accepted and lead to change, what we wanted was for our perspectives to be appreciated, our efforts to be acknowledged, and our opinions to be considered.
It was, again, not what was being done (providing constructive criticism) that was the issue, but how it was delivered. Assumptions were made and solutions were created without any input from our team. In turn, as IPs, when providing constructive criticism, we must seek to listen and understand, with humility, recognizing that we do not know everything about the problem or the solution. And when we do, staff will be more accepting of implementing our suggested changes.
Finally, we should approach the delivery of constructive criticism with empathy. I once had the opportunity to work with a group of surgeons to reduce the rate of surgical site infections. These were horrific infections with often poor outcomes. After a meeting one day, one of the surgeons pulled me aside and shared with me something that I will never forget. She said, “You know, I remember every one of them. I know their names, and I can see their faces.”
As IPs, we could easily forget that these patients are not just infections or numbers calculated as rates. They are individuals. But our health care workers don’t forget that. They see their patients’ faces; they remember their names. We would do well to remember that health care workers also often take these infections personally. Therefore, we should never present news of new infections in an accusatory or flippant manner or without regard for the impact it has on the health care staff.
Rather, we should always discuss infections and provide constructive criticism with empathy. We should enter conversations with compliments before discussing opportunities for improvement. We should acknowledge how difficult it is to prevent these infections and invite collaboration around ways to improve prevention. We will connect with people more effectively if we come alongside them to celebrate their wins while we empathize with their losses.
Multiple times while responding to COVID-19 outbreaks, I had health care workers say to me “Heather, it’s so refreshing to talk with you because you’re the only one to acknowledge what we’ve done right instead of simply listing everything that we’ve done wrong.” Recognize everything your health care teams have done right. See their hard work and all they’ve accomplished. Take a moment to acknowledge the humanity in all of us and understand that it hurts to know that something we did or didn’t do might have resulted in an infection. That news should be delivered with grace and empathy and preferably from someone with whom you have formed a connection.
As IPs, we give people constructive criticism for a living. If we truly want to make an impact in the prevention and control of infections, we must be careful about how we approach the delivery of constructive criticism. Bad news ought to be delivered with transparency, humility, and empathy.
I would hope that this is how someone would approach you with constructive criticism. Let’s do better and approach our health care workers with the same courtesy.