Elements of a productive conversation & the advocacy-inquiry framework

Fostering a productive conversation requires attention to delivery and content, recognizing that a successful “difficult” conversation still produces a positive learning experience. First, the conversation must be non-confrontational to avoid triggering defensiveness. Second, the conversation must be direct and concise to maintain the colleague’s focus and attention—especially given that these conversations often occur in busy clinical settings. Third, the steward must accurately identify and teach to a colleague’s specific knowledge gap to avoid appearing condescending or patronizing by sharing concepts that are already known. Finally, a productive conversation creates a sense of shared ownership of a patient, with emphasis on the function of both individuals as members of one team with collective responsibility.

The advocacy-inquiry framework serves as one approach to cultivate a constructive conversation. This methodology originated in the business and organizational behavior literature and was later adopted in the medical simulation sphere as part of “debriefing with good judgment”—an approach designed to encourage open dialogue, reflective thinking, and accurate assessment of a learner’s thought process. ^{Reference Senge4–Reference Sawyer, Eppich, Brett-Fleegler, Grant and Cheng6} In this framework, an advocacy statement is utilized to make an objective observation and is followed by an inquiry designed to reveal a learner’s assumptions and identify the “invisible frames” that inform their actions. ^{Reference Rudolph, Simon, Dufresne and Raemer5}

Psychological safety—defined as “a shared belief that the team is safe for interpersonal risk taking” and a sense of “confidence that the team will not embarrass, reject, or punish someone for speaking up”—is of particular importance in highly functioning clinical teams. ^{Reference Edmondson7,Reference Rotman Devaraj, Cooper and Simpkin Begin8} Notably, the objective and candid nature of advocacy–inquiry statements promotes a culture of psychological safety by encouraging strategies that are associated with safe learning environments—including normalizing discussion of mistakes, fostering curiosity, seeking new perspectives, and recognizing the valuable contributions of all team members. ^{Reference Rotman Devaraj, Cooper and Simpkin Begin8}

Steps 1 and 2: Advocacy-inquiry

A paired advocacy-inquiry statement is a powerful way to open a conversation. It is concise and direct, highlighting a specific issue in two sentences. Despite its brevity, it is also impartial—effectively calling attention to this discrepancy without making assumptions about what occurred, why it happened, or who is responsible for a decision. Finally, it rapidly opens the door for bidirectional conversation, promoting a sense of collegiality and shared decision-making regarding a patient’s care.

Additionally, an advocacy-inquiry statement allows stewards to open the conversation with a posture of humility. Antimicrobial stewards are often not at the bedside and therefore make recommendations based on chart review alone; as such, the open-ended inquiry creates space for stewards to glean new information from the provider that may influence their recommendations (eg, undocumented symptoms).

The juxtaposition of a clinical situation with a perceived incompatible clinical action through a paired advocacy-inquiry statement may be sufficient for a colleague to self-identify an opportunity for improvement. Thus, pausing after the advocacy-inquiry statement allows a colleague to spontaneously correct their error; in these cases, stewards may simply affirm the colleague’s revised action, and the subsequent identify-teach intervention may not be required.

Steps 3 and 4: Identify-teach

The open-ended and unbiased approach of the advocacy-inquiry statement sets the stage for a non-confrontational and targeted identify-teach dialogue, as illustrated in Table 1. By correctly identifying the framework error, the steward creates a concise and high-yield teaching opportunity—and avoids the pitfall of inadvertently teaching content that is already known. Most importantly, the identify-teach framework allows the steward to correct an underlying misunderstanding and behavioral habit—thus improving both the care of the individual patient and avoiding future errors related to the same issue.

Table 1.

Hypothetical scenario incorporating the advocacy-inquiry and listen-teach approach in antimicrobial stewardship

Though this framework is designed to create open dialogue and minimize defensiveness, clinical disagreement may remain even after targeted teaching. It is important to acknowledge that not every conversation will lead to success the first time, nor should that be a realistic expectation. The act of initiating a collegial conversation creates an opportunity for a thoughtful pause and may reiterate concepts that can carry momentum for the next conversation.