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Managing Conflict in Health Care: Maximizing Meaningful Relationship

2/20/16

Property of Davis AL, Smith AR, Grandeo JE not to be distributed without permission. 1

Managing Conflict in Healthcare: Maximizing

Combined Sections Meeting 2016Anaheim, California, February 17 -20, 2016

Anissa DavisA. Russell Smith, Jr.Jason GrandeoLynchburg College

Disclosure Statement

No relevant financial relationship exists for any of the presenters.

Case ScenarioWhat is your initial response to this scenario?If you were in this scenario, how would you respond?

Pre Test

I believe that conflict is a negative process.My preferred conflict management style is: ______________________.I believe that conflict has a negative impact on patient outcomes.

Learning Objectives

Upon completion of this course the participant will be able to:

1. Describe the impact of conflict on healthcare outcomes. 2. Identify traditional and preferred techniques of conflict management. 3. Compare the positive and negative elements of conflict. 4. Integrate the principles of conflict management into clinical case scenarios.

Defining Conflict and Impact on Practice


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Conflict: The Basics

• Definition of conflict• What causes conflict?• Characteristics of conflict?• What are the benefits of raising conflict in the workplace?• Individual• Organization

• What are the costs of ignoring conflict in the workplace? • Individual• Organization

www.merriam-‐webster.com/dictionary/conflict

8

Conflict SituationsThe concerns of two or more parties

appear to be incompatible.

9

Get Unstuck

When routine conversations turn into conflictwe can respond in one of three ways:

1. We can avoid them.2. We can handle them poorly.

or3. We can handle them well.

10Patterson et al Crucial Conversations 2012

Health Care Stakeholders

Patient

Third Party Pay ers

Admin is tra tion

Other Heal th Care Prov iders

Phy s ic a l Therapist

Fami ly FriendsEmploy er

“Although our data cannot establish these causal relationships, we do not feel that this is necessary in order for the observed patterns to have importance in better understanding the complex factors involved in both conflict and medical errors.”


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• Disagreement did not lead to delay in return to work

• Disagreement did not lead to higher perceived disability or psychological distress

• Disagreement did lead to more catastrophizing about pain

Conflict Management Approaches

Healthy vs. Damaging ConflictHealthy Conflict• Disagreements communicated in supportive environment.

• Fosters generation of new idea/options.

• Tension increasing awareness.

• Shedding light on a growing concern.

Unhealthy Conflict• Name calling• Personal Attacks• Silent & Withdrawn• Cliques, gossip, and rumors

• Lack of mutual Respect

Addressing Avoiding17

Beliefs about conflict…• Conflict is generally negative and destructive• It is better to ignore small problems• Recognizing conflict can make it increase• Problems will work themselves out• Conflict is the result of bad management• There are usually single, simple causes of conflict

What are your associations with the word “conflict ” ?

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Traditional Techniques for Conflict Resolution

Conquest

Avoidance

Bargaining

Quick-fix

Role-playing19

Thomas-Kilmann Conflict Mode Instrument• Kenneth Thomas and Ralph Kilmann- 1970s

• 5 main styles of dealing with conflict • Vary in degrees of cooperativeness and assertiveness

• “Preferred conflict resolution style”• Different styles most useful in different situations.

• TKI identifies style tendency/preference

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Thomas Kilman Conflict Mode Instrument

Personal preferred conflict resolution style?

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Preferred Conflict Management Style (20) Rusty

Your Styles

Two basic dimensions

-Assertiveness - satisfy self

-Cooperativeness - satisfy others

All styles can be useful!!!

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Thomas-Kilmann Conflict Mode Instrument (TKI)

Competition Collaboration

Avoidance Accommodation

Compromise

LOW HIGHCOOPERATIVE

LOW

HIGH

ASSERTIVE


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AVOIDANCE• PURPOSE: Delay• APPROACH: Non-confrontational • MOTTO: “Ignore and it will go away!”• ADVANTAGE: Buys time;; allows for a “cooling off” period • DISADVANTAGE: May allow resentment to build;; perceived as weak

ACCOMMODATION• PURPOSE: Yield• APPROACH: Non-assertive &

cooperative – possibly at expense of own goals • MOTTO: “Smooth things over!”• ADVANTAGE: Defer to expertise;; preserve relationships;; IOU• DISADVANTAGE: Meet other’s needs at own expense

COMPETITION• PURPOSE: Win• APPROACH: Forceful; power;

position; status; persuasive • MOTTO: “I get what I want!”• ADVANTAGE: Your view

understood quickly; stand-up for what you think is right• DISADVANTAGE: Will cause

resentment

COMPROMISE• PURPOSE: Find middle ground.• APPROACH: Assertive but

cooperative.• MOTTO: “Life’s a trade-off.”• ADVANTAGE: Identify solution

partially satisfying everyone.• DISADVANTAGE: “Lose-lose”;

frustration that you never get your way

COLLABORATION• PURPOSE: Find a win-win• APPROACH: Assertive and

cooperative• MOTTO: “How can everyone win?”• ADVANTAGE: All feel heard;;

create ideal outcome• DISADVANTAGE: Time-

consuming; high-level trust required; impact of weakest link

Preferred Conflict Management Styles• Avoiding: Neglect• Accommodate: Appease• Collaborate: Integrate• Compete: Dominate• Compromise: Share


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Competition

Style Indications Contraindications

COMPETITION

• Emergency

• Low stakes relationally

• Time is an issue

• Black & White – policy

• Self- Protection indicated

• Emotions high

• High paranoia

• Cooperation is needed

Skills Related to Competition

• Argument and debate• Confidence in personal opinions and feelings• Position clearly stated• Influence• Stand firm

33

Collaboration


COLLABORATION

• Team commitment needed

• Expand options/solutions

• New ideas, insights, “better solutions”

• Trust developing

• Time restriction

• Juice not worth the squeeze

• Low trust

• Lack of team commitment

Skills Related to Collaboration

• Actively listen• Identify concerns as arise• Identify personal and others’ interests• Open-minded• Analyze variables

35

Compromise


COMPROMISE

• Temporary fix

• Expedient

• Low stakes

• Other styles ineffective

• Expedient solutions under time pressure

• Strong feelings

• Violates core values

• Great disagreemen t

• Impacts team strategies

Skills Related to Compromise

• Find middle ground• Make concessions • Split the difference• Emotionally “Let it Go”


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37

Avoidance


AVOIDANCE

• Issue of low importance

• Issue not urgent

• Breathing room needed

• Form of delegation

• “Formal procrastination ”

• Benefits outweigh risk of confrontation

• Team feels undervalued

• Frequent/rec ur rin g concern

• Problem stewing

• Appears weak

• Leadership questioned

Skills Related to Avoidance

• Ability to withdraw• Sense of timing• Willing to allow unresolved issues

39

Accommodation


ACCOMMODATION

• Relationship priority

• Better solution

• Low importance

• Deadlines

• Team harmony is priority

• Feel always lose

• Wrong solution with costly consequences

• Role confusion

Skills Related to Accommodation

• Defer personal desires• Yield and keep peace• Apologize gracefully

Thomas-Kilmann Conflict Mode Instrument (TKI)

Competition Collaboration

Avoidance Accommodation

Compromise

LOW HIGHCOOPERATIVE

LOW

HIGH

ASSERTIVE

Break

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Model of Conflict Management

43 44

Approaches to Organizational Conflict

PrescriptionPeriod Philosophy Nature Strategy

1890-1940’s Traditionalists Destructive Eliminate

1950-1980’s Behavioralists Natural Accept

Present Time Interactionalists Necessary Encourage

Walter H. Gmelch , Center for th e S tudy o f Acad emic Lead ership , University of San Francisco .d oc

A New View of ConflictFrom perceiving conflict as always being…

A disruption of order, a negative experience, an error or mistake in a relationship.

To perceiving conflict as often being…

An outgrowth of diversity that might hold possibilities for mutual growth and for improving the relationship.

45

ATTITUDELife is 10% what happens to meand 90% how I react to it!

46

The HEART of Conflict Management Attitude Aptitude


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“Whenever you're in conflict with someone, there is one factor that can

make the difference between damaging your relationship and

deepening it. That factor is attitude.”–William James

49

Attitude• Attitude precedes aptitude• Competition versus Collaboration• “Me” versus “We”• “Me” leads to withdrawal and/or violence

• “We” leads to shared meaning

Aptitude• Conflict content & trigger• Lived experience • “Stories”

• Preferred conflict resolution styles • Right style • Right time

Conflict Content & Trigger• Perceived incompatibility• Lived experiences• “Stories”

Make it Safe

Addressing Perceived Incompatibility

Establish Mutual Purpose: Must Have Common Objectives

• Dialogue begins with mutual purpose• Mutual purpose is foundation of trust• Trust facilitates openness

Without mutual purpose people withhold meaning.53

Lived ExperiencesPositive and negative experiences people bring to the interaction

• Emotional triggers• Diversity in interpretation• What is heard is often NOT what is said.

Seek to understand other’s lived experiences.


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Stories: The Pool of Shared Meaning

• All have a story• Hear the Story• Share your Story

Conflict Management means safely moving forward with shared stories.

Seek To Understand Others’ Lived Experience

Pool ofSharedMeaning

Get Unstuck


Safety is Key!!!!


Safety

Safety


Get Unstuck

Silence

Violence

WithdrawingAvoiding Masking

ControllingLabeling Attacking

Safety

Safety


Possible Responses


Start With Heart

Dialogue Model

59

Crucial Conversations

Patterson et al Crucial Conversations 2012

Patterson et al Crucial Conversations 2012

Start With Heart

Three Problems of the Heart

1. Blind to our Own Role in the Problem2. Motives Degrade3. Limit Our Choices

When we take responsibility for our own heart, we take control of our lives.



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Start With Heart - Heart GoalsUnhealthy Goals Healthy Goals

Be rightLook good/save faceAvoid conflictWinPunish, blame

Create safetyLearn other’s storyShare your storyFocus on future resultsStrengthen relationships


Make it SafeCreating Safety

• Monitor other’s response• Step away from content• Share

• You care about their interests and goals• You care about them

• Then step back in

Remember to establish mutual purpose62Patterson et al Crucial Conversations 2012

“You can observe a lot by watching.”

63

Master My StoriesEmotions Don’t Just Happen

• Others don’t make you mad, YOU make you mad!

• You and only you create your emotions.

• When it comes to strong emotions, you either find a way to master them or fall hostage to them.

64

When the conversation becomes a challenge, slow down.

Stop. Look. Listen.65

Attitude• Attitude precedes aptitude• Competition versus Collaboration• “Me” versus “We”• “Me” leads to withdrawal and/or violence• “We” leads to shared meaning

Aptitude• Conflict content & trigger• Lived experience • “Stories”

• Preferred conflict resolution styles • Right style • Right time


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Application to Clinical and Personal Scenarios

67

Case ApplicationBreak Out Groups

Creating Reliability in Collaboration

Avoid hierarchical beliefs

The person with the least rank has the most impact if the information is critical.

A policy of saying the words "safety check" as a signal…to stop talking and listen.

Shared Perspectives

“Physical therapist and the patient both engage in a shared decision making process. And this is founded on a movement between, and a learning of, each other’s perspectives. There is no doubt that this is a very skilled activity and the physical therapist has a responsibility to create the environment for this mutual learning to occur.”

Creating a safe environment

Respecting the lived experience

Shared Decision Making

• “…in the processes of shared decision making and wide reflective equilibrium, the perspectives of protagonists on both sides of the dilemma are made more permeable with a capacity for change.

“…a deeper understanding of the communicative complexity and the demanding negotiations of the collaboration between physiotherapists and patients…The patients’ and the physiotherapists’ capacity to bear and come through appropriated demanding situations created new ways of interaction.”


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Health Care Stakeholders

Patient

Third Party Pay ers

Admin is tra tion

Other Heal th Care Prov iders

Phy s ic a l Therapist

Fami ly FriendsEmploy er

Conflict in Patient Care

“…demanding situations may generate a potential of development and improvement of treatment outcomes. Understanding such episodes as open and dynamic, in contrast to defining the patient as demanding, suggests a useful perspective for treatment.”

Oien AM, Steihaug S, Iversen S, Raheim M. 2011

75

Post Test

I believe that conflict is a negative process.My preferred conflict management style is: ______________________.I believe that conflict has a negative impact on patient outcomes. Open Discussion, Q&A (15)

78


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