When she first met her husband, Patty Loeffler was thin, active, and the picture of good health. But nine years into her marriage, Patty found herself 100 pounds overweight and a perpetual yo-yo dieter. She had joined and left Weight Watchers so many times that she was embarrassed to even consider going back. And yet, she knew she needed to make a big change. That’s why in 2012, she made the resolution to simply “get healthy”—and the timing couldn’t have been better.

In March 2012, Patty enlisted in Influencer Training by VitalSmarts. Already a Crucial Conversations certified trainer, she was excited to learn the Six Sources of Influence model for changing behavior. When prompted to identify a change challenge to which she could apply the model and principles, she selected her “get healthy” initiative. Shortly after, she received the newest book from VitalSmarts, Change Anything, which helped her further apply the Six Sources of Influence to her personal goals.

Patty started her “get healthy” change plan by identifying two vital behaviors that proved to be instrumental to her success:

1. Make a plan. Patty found planning to be essential. She not only planned her healthy meals, but also where she would go if and when she ate out. She learned where all the healthy restaurants and meals were in the city so she would never have to make a last-minute unhealthy choice.

2. Weigh daily. By weighing herself daily, she found that she could stay on top of her weight loss and most importantly, quickly get back on track if she started slipping.

Patty used all six sources of influence to help keep her vital behaviors, but she attributes the majority of her success to social motivation and ability. She says the social influence that was missing from her past diet attempts meant the difference between her success and the years of failure.

Patty recruited her husband and son to join her in her goal to get healthy. Like Patty, her husband also had a history of failed weight loss, and as a result, was pretty reticent to participate. But after Patty begged him, he agreed and they made a very serious commitment to each other that they would see the plan through to the end.

When Patty’s son came home from college that summer, she also recruited him to participate, and together the three found success in applying the model from Influencer and Change Anything. The Six Sources of Influence Patty identified to help keep her behaviors included:

Personal Motivation – Patty hung her skinniest jeans on her closet door which served as a daily reminder of what she looked like and how good she felt when she first met her husband. The jeans also reminded her that at the age of 53, her window of opportunity to change was closing as she may only face more health issues in the future.

Personal Ability – A key part of Patty’s plan included a nutrition program called Ideal You sponsored by her employer. At first, Patty was skeptical this would be just another failed diet plan, but this program taught her skills to control her diet with higher protein and lower carbohydrates and fats—skills she never learned before. There was also a phased approach which began by limiting her diet in the beginning and slowly adding in healthy foods as she learned to get her intake under control. The program also taught her effective strategies to maintain her weight loss.

Social Motivation and Ability – Patty and her husband faced every part of their weight loss journey together. They started by publicly announcing their diet at her daughter-in-law’s birthday party. This public proclamation lead to support from her entire extended family. Her husband also did most of the shopping under their approved dietary guidelines and they began exercising together and spent less of their time together watching TV or eating out at unhealthy restaurants.

Patty also garnered support at work. She teamed up with a few coworkers who also had a goal to get healthy and they spearheaded a transformation of their entire team. For example, they stopped bringing in unhealthy food to celebrate events and when they ate out together, they went to healthy restaurants. Patty’s family and friends never made her feel bad for wanting to choose healthy meal options. On the contrary, many actually thanked Patty for her example and motivating them to make their own healthy choices.

Patty also attributes much of her success in beginning an exercise regimen to the help of personal trainers who reintroduced her to exercise and how to do it effectively.

Structural Motivation – Instead of falling into old habits of rewarding herself with her favorite foods, Patty started going to the spa and treating herself to massages, manicures, and pedicures when she hit her weight loss goals. She was also really motivated to change by shopping for cute clothes she couldn’t fit into previously and the money she saved from giving up expensive and fattening fast food meals helped to offset the expense of a new wardrobe. Patty was also motivated to stick to her new diet because it was a plan she paid to be part of and she didn’t want to see that money go to waste.

Structural Ability – Early on, Patty decided to chart her weight loss. This strategy helped her to see her long-term success—which was a tremendous motivator during the weeks of plateau. She also changed her surroundings. She brought exercise equipment out of storage and placed it in her family room. She also got rid of all the junk food in the house. She even made changes at work. For the first time in her career, she began to use the on-site personal trainer and fitness center provided by her employer.

Results
By using the change plan found in Change Anything, Patty shattered a long history of failure to lose weight. In just nine months, she lost an impressive 102 pounds. And, as it turns out, her weight loss impacted her life in even more immediate ways. After discovering a life-threatening illness months into her get healthy initiative, doctors told her that losing the weight was the best thing she could have done and possibly even slowed the progression of the disease thus allowing it to be discovered and treated at an early stage.

Patty wasn’t the only one who experienced such dramatic success. The social influences she learned about in Change Anything really made a difference not only for her but also for her husband and son. In the end, Patty’s husband lost 80 pounds and her son lost 100 pounds, proving that with the right plan, you really can change for good.

The Challenge
J. Lynn Jones is a VitalSmarts veteran. An elementary school principal for sixteen years, he became a certified trainer in Crucial Conversations and used those tools to help his school boost achievement. When he was promoted to director at the Nebo School District in central Utah, he added a certification in Crucial Confrontations. He taught both courses to most of his 600-person staff and also offered them to other administrators, teachers, and support staff in his district.

But his biggest challenge in his expanded role was a persistent one. He was responsible for special education in the district and focused particularly on the special education teachers in its twenty-seven elementary schools. These are the instructors who give extra help to mainstreamed students with learning disabilities. And they didn’t have a history or culture of being accountable to progress their students.

“We had a number of veteran teachers who never had high expectations, and the kids never performed well. The teachers used the excuse that ‘these kids have disabilities’,” he said. “In the end, we weren’t seeing good instruction and we weren’t seeing good results.”

Of about sixty teachers, Jones was comfortable with only five or six of their results. But because he was not a career special educator, he lacked immediate credibility to shake things up by himself.

About the same time he came to this realization, he added another VitalSmarts certification to his credentials: Influencer Training.

The Results: Read our case study to learn how J. Lynn used Influencer Training to boost literacy rates and double the number of special education students released into the regular school system.

This letter was received in response to a question Joseph Grenny answered in the February 29, 2012 Crucial Skills Newsletter titled, “Influencing Unprofessional Dress.”

Dear Joseph,

I am the “CEO” of this company—that is, I am the superintendent of schools of a 5,000-student K-12 district and my challenge was to get the building principals to agree that impressions do matter to our “customers.”

In public schools, we have a rather unique situation in that one never knows where the parents are on the “dress for success” spectrum. Some (like Joseph and some who responded to his column) do not like ties and suits (very few of us do!) and argued for a relaxed, personal approach to dress. But that doesn’t work when it comes to interacting with parents who are more likely (given that they’re taking the time to actually visit you rather than call or e-mail) to have an issue and are quite possibly mad and ready to draw conclusions of one sort or another. The impression we create for those parents matters, so we have to dress the part.

However, my building leaders were often not setting a good example for the teachers in their school, and as a result, the entire building’s level of dress was unacceptable by most peoples’ standards. The occasional spirit day or casual Friday is totally fine and welcome in a school, but this was becoming the norm.

So I decided to engage the leaders in a conversation. At our leadership council meetings we first talked about our impressions of the teachers’ dress and then about how we could be role models for them. Addressing the teachers’ dress was a secondary objective—they are unionized and for such “initiatives” we need to get union leadership on board. I decided to first discuss and then decree that leaders start wearing a jacket and tie (or the equivalent for women). Now, school leaders definitely look more professional. I’m not saying they wear three-piece suits, or even a suit, but the norm is now to wear a tie, and that has raised the general level of dress quite appropriately.

In fact, I’ve started a conversation with union leadership about teacher dress. We’ll need to define terms such as “business casual” which means different things to different people, but there is consensus that such a term, once better defined, can and will help us get away from the ragged jeans and flip flops. I just cannot help but think how that type of dress harms our profession’s reputation and union leadership agrees, so perhaps we have some mutual purpose and common ground from which to operate when we begin step two of the dress for success campaign in our school district.

Thank you once again for the advice and for the ensuing comments from your readers. Very helpful to me indeed!

Editor’s Note: If you would like to share similar feedback about how the authors’ advice has helped you, please e-mail us at editor@vitalsmarts.com.

Bad behavior runs rampant in the workplace. The healthcare industry is no exception. The American Medical Association’s Council on Ethical and Judicial Affairs defines disruptive behavior as behavior that “tends to cause distress among other staff and affect overall morale within the work environment, undermining productivity and possibly leading to high staff turnover or even resulting in ineffective or substandard care.”

Research among healthcare providers found widespread incidence of disruptive behaviors such as verbal abuse, sexual harassment, racial slurs, physical threats, and profanity. Specifically:

• 91 percent of perioperative nurses reported at least one incident of verbal abuse in the previous year
• 67 percent of staff nurses reported between one and five disruptive incidents in the previous month

One of the most common manifestations of bad behavior occurs between nurses and physicians in the form of power struggles and clashes over roles and personality. One study found that 95.7 percent of physician executives reported knowledge of disruptive physician behavior within their organization.

Not only is verbal abuse pervasive, it is also destructive. Research shows disruptive behavior leads to communication breakdowns that affect outcomes like patient safety and employee morale. Specifically, a study of twenty-six medical residents found that failures of communication between physicians and nurses were associated with 91 percent of the medical errors.

Verbal abuse also leads to medication errors which harm 1.5 million patients each year. A study by the Institute for Safe Medication Practices found that 93 percent of nurses and pharmacists experience condescending language and impatience from bully physicians when they ask clarifying questions about medical orders, and 87 percent encountered physicians who outright refused to answer their questions. As a result, 75 percent of nurses and pharmacists admitted to having a peer interpret a medication order rather than calling an intimidating physician.

Rebecca Saxton, PhD, RN, CNOR, and associate professor at the Research College of Nursing in Kansas City, Missouri, set out to uncover ways to reverse this divisive trend of abusive physician behavior and communication breakdowns. She collaborated with VitalSmarts to create an educational intervention tailored to the nursing experience that included the two-day Crucial Conversations Training course.

The Solution: Read our case study to learn how Rebecca used Crucial Conversations Training to improve perioperative nurses’ confidence and ability to address disruptive physician behavior.

Attending Crucial Conversations and Crucial Confrontations Training has been of great benefit to me both personally and professionally. I am diligent about sharing the books, audio companions, and the Crucial Skills Newsletter with my staff.

I work in a non-clinical department within a trauma center staffed by very experienced nurses in emergency and/or critical care—which contributes to the amazing and thorough work they do in their current roles. I shared your recent Q&A article, “Coping with the Loss of a Loved One” with my staff and received the following e-mail, titled “I felt like a nurse again,” in response:

“Last Wednesday as I was leaving the ICU, I did something I have often wanted to do but didn’t feel comfortable doing. A woman was walking down the hall toward the waiting room, and she was crying—not an uncommon sight. I slowed down, walked along side her, and said I was so sorry for whatever she was going through. I thought it was probably related to one of my patients, but I wasn’t positive. She seemed relieved and said, “It is so hard.” I kept walking with her and asked if she was alone and if I could get her a drink of water. She said family was in the waiting room and that she had a bottle of water in her bag. Just before we got to the ICU waiting room, she stopped and leaned toward me for a hug, then stood for a few minutes before going into the waiting room. At that point, I left.

“If it hadn’t been for the Crucial Skills Newsletter you sent and a recent experience with another coworker who recently lost her husband, I don’t think I would have had the courage to actually approach this woman. I am very thankful that I did so.

“Years ago, I read a book written by a man whose young wife died in the ICU and he says the longest walk of your life is from the hospital to your car after your loved one has died. I have often wondered if there is any way someone can walk out with those folks who stand alone at the bedside when their family member dies. This is just another example of how a small gesture can make a large impact.”

So, I want to thank you for making these resources available to me and my staff. We still contribute to the profession we love and demonstrate this commitment to our patients, families, and associates.

Recently, as my six-year-old daughter asked me for yet another Barbie, I said, “You don’t always get what you want, you need to earn it.”

She then said, “That’s not fair, you always get what you want. How do I get what I want?”

The Crucial Conversations book happened to be sitting on my desk, so I handed it to her, and laughing I said, “Read this, it gets you what you want.”

Now she refuses to put down the book. It goes in the car with us everywhere—to school, you name it. When someone asks why she is reading the book, she says, “Dad said from now on I’m going to get what I want.”

As many conversations are with my six-year-old, the full conversation was actually quite a crucial conversation about how to earn what you need and communicate that need. For the record, she “earned” the Barbie a few days later from her grandmother through some effective communication.

Like many of us, Maureen Winningham didn’t grow up in a home where family members practiced crucial conversations regularly and well. Rather, she grew up in one of those households where he who yells the loudest gets his point across. The worst culprit of all was her father whom she labeled “Mr. Blow-and-Go” for his explosive temper and anger-filled communication style.

Many years later, after one particularly dreadful Christmas dinner, Maureen used her skills to hold a long overdue crucial conversation with her father in which she recognized her role in the problem, explained the damage her father’s communication style had caused in her life, and asked him for a way to repair their relationship to a healthy level of love and respect.

Watch as Maureen describes how that one conversation literally changed her life and helped her build a special relationship with her father before it was too late.

The Context
When the economy took a turn for the worse in 2009, the U.S. government enacted an economic stimulus package to save and create jobs, as well as invest in infrastructures, education, health, and energy.

Part of that stimulus included the Health Information Technology for Economic and Clinical Health Act that offered incentives through Medicare and Medicaid to physicians who adopted a certified Electronic Health Records (EHR) system and demonstrated a meaningful use of this new technology. Further, physicians who refuse to adopt an EHR by 2015 will face financial penalties.

The Challenge
Eager to comply with the stimulus act and incur the benefits of an EHR system, McKenzie Medical Center located in McKenzie, Tennessee, set a goal in September 2010 to achieve 100 percent EHR adoption by January 1, 2011 and collect the full stimulus payment.

The EHR adoption team, lead by physician and managing partner Volker Winkler, M.D., recognized that EHR adoption is a behavior challenge rather than simply a software implementation process—a realization many clinics and healthcare IT providers overlook.

With that understanding, Dr. Winkler knew his system faced an uphill battle in changing three hundred employees. His workforce had used paper records for decades and wasn’t technologically savvy. For example, their urologist didn’t own a cell phone or have an e-mail address.

Dr. Winkler knew they needed help to overcome resistance to EHR adoption and change long-standing behaviors.

The Training
Prior to their September launch, Dr. Winkler and his team attended a conference hosted by their EHR provider. In one session, they heard a VitalSmarts speaker teach the Influencer model for changing behavior.

Intrigued by the prospects the Influencer model offered for their initiative, Dr. Winkler brought VitalSmarts in to train fourteen managers in Influencer Training. The management team consisted of clinical nurse leaders, lab directors, satellite clinic managers, one physician, and one managing partner.

The Solution: Read our case study to learn how McKenzie Medical Center used the Influencer model to achieve their ambitious goal of 100 percent EHR adoption in less than four months.

Over the years, I’ve canoed the Brazos River near Brenham, Texas. It is usually a relaxing way to get back to nature and away from everyday stress. It is an old, slow, and sometimes shallow river, so you never see jet skis or large motorboats. Many days, you may never see another human being!

The most stressful things I have encountered were the occasional alligator, miscalculations of time, and getting the canoe out of the water on steep and narrow footpaths. One Saturday, however, all of that changed.

That day, the river was high and flowing fast. It was a cool seventy degrees with beautiful fluffy clouds in a perfect blue sky. We heard someone shooting off in the distance.

As we got closer, the shooting became louder. Since we couldn’t see over the steep bank, we figured it was someone target practicing. Then suddenly, we heard another shot followed by the plinking of buckshot hitting the water beside me. Another quick shot and more plinking—this time a few pellets hit the side of the canoe.

We started screaming “Quit it!” as loudly as possible. In the country, sound carries and surely this careless shooter would hear us and stop. But then a third shot and more plinking. We were now fifteen feet downstream from the first blast and the story I told myself was that the gunman was deliberately shooting at us.

My adrenaline started pumping and my first thought was to make this person realize he or she was very much in the wrong by yelling “Stop it you IDIOT!”

I quickly realized I needed to examine my motives and start from my heart. I asked myself what I didn’t want to happen. I didn’t want to get shot. I then asked what I did want. I wanted to get out of there safely. Calling this stranger an idiot might make me feel better for a second, but it wasn’t going to help me achieve my goal.

I then asked myself, “What can I do right now if I really want these results?” The answer was obvious. I quit yelling and dug my oar in hard and fast. My companion heard my paddle, stopped shouting, and quickly joined in getting us to safety.

Before attending Crucial Conversations Training, I would have lost my cool and perhaps angered someone who clearly had the upper hand. And no matter what training we have, we all know who wins when you bring a canoe to a gun fight!

If you have a Before and After story you’d like to share, please send your story to beforeandafter@vitalsmarts.com.

In 1996, I was asked to promote the fitness center at the nonprofit hospital where I worked. Fifty pounds overweight and anything but the picture of fitness, I wondered how I would convince clients to join the fitness center.

I wanted to promote the fitness center based on first-hand experience, so I worked with the director of physical therapy to develop a fitness program and started using the facility several times a week. With her advice and my research, I created and implemented the following change plan.

Personal Motivation: Love What You Hate — I needed to change the way I thought about weight loss and realize I was the only person who could change my life. I visited my default future to stay motivated and avoid giving in to easier behaviors such as sitting on the sofa and eating junk food. I knew if I continued on my current path, I could develop heart disease, high cholesterol, and other health problems many of my family members dealt with. Watching my relatives struggle helped me stay motivated in weak moments.

Personal Ability: Do What You Can’t — To learn the skills I needed to lose weight, I worked with the director of physical therapy and developed a fitness program. The first time I tried to use the cross-country training machine, I fell off. With the director’s help and through deliberate practice, I quickly learned how to use the machine and started working out three or four times a week during lunch.

I also realized I didn’t have the skills I needed to cook healthy meals, so I subscribed to a healthy cooking magazine. I now only buy recipe books that provide nutritional information and have learned to substitute healthy ingredients for high-fat and high-calorie ingredients.

Social Motivation and Ability: Turn Accomplices into Friends — I talked to my family about becoming my friends instead of my accomplices, and their support helped me stick to my plan. Instead of making a separate meal for myself, we agreed to eat the same healthy meals. When I started exercising at home, my children and husband exercised with me.

I also added a new friend when one of my best friends decided she also wanted to lose weight and told me I was her role model. This was a turning point in my life as I realized I could influence others—even those I admire—to change for good.

Structural Motivation: Invert the Economy — I saw pictures of myself in pants with an elastic waistband and didn’t like what I saw. I wanted my kids to be proud of me and my husband to be attracted to me. To stay on track, I created a star chart. Every time I lost a pound, I added a star and rewarded these small wins by buying new clothes when I earned ten stars. I was so pleased when I bought my first pair of size twelve jeans. I’m even happier now that I wear a size six.

Structural Ability: Control Your Space — I knew that to make a complete change, I needed to restructure my space in a way that supported my new habits. I knew if I didn’t work out in the morning I’d be too tired after work, so I prepared in advance. To get myself out of bed, I put my workout clothes in the bathroom, my shoes at the back door, and my radio on the counter. I also built fences to help me stick to my diet. If I knew unhealthy food would be on the menu, I ate in advance. I brought my breakfast and lunch to work every day. If I had a business lunch, I ate a salad with dressing on the side.

We managed distance by moving from our rural community where it was unsafe to walk on the road, to a community where walking became part of our daily routine. I also monitored my progress by weighing myself every morning. I didn’t want a 1-2 pound weight gain to become a 5-10 gain.

Through my change plan, I lost sixty pounds in one year and have kept it off for more than ten years. Quick fixes and fad diets don’t work. Hard work in several areas of your life, coupled with the desire to be something different, is what makes true change happen.

If you have a Before and After story you’d like to share, please send your story to beforeandafter@vitalsmarts.com.