© The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011

Conflict Resolution

Armstrong Institute for Patient Safety and Quality

Jill Marsteller, PhD, MPP

A case in conflict resolution

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Cardiology consult reveals aortic stenosis, and recommends pt not go to surgery.

Resident attempts to schedule surgery after receiving cardiology report.

An 89-year-old man was admitted to orthopedic service after sustaining a hip fracture.

Resident comes to the floor, calls the RN ‘stupid’ and claims that the cardiology findings are irrelevant.

The floor RN pages the resident and explains cardiology findings

CMO describes the risk of perioperative death to resident and attendingRN calls the CMO and explains

the situation.

Surgery is cancelled.

What is Conflict?

• Perception of mutual interference• A process that begins when goals of one

party are frustrated by another• Requires interdependence/ interaction

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Views of Conflict

• Conflict Good• Conflict Natural• Conflict Bad

• Conflict must be managed

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Sources of Conflict

• Conflict arises from resource scarcity

• Goals of parties are incompatible

• Other structural factors (size, routinization, specialization, reward systems)

• Conflicting perceptions, ideas or beliefs

• Differences between people

• Conflicting thoughts/needs within an individual

• Lack of communication (maybe)

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Types of Conflict

– Task Content conflict (differing opinions related to the task) G

– Emotional or Relationship conflict (interpersonal conflict--dislike, negative emotions) B

– Administrative or Process conflict (disagreement on how to get the task completed—e.g., duties, decision-making technique) B to N

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Goal of Conflict Resolution

• Confront problems, communicate openly and respectfully with someone of opposing opinion to provide optimal patient care.

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Why Address Conflict Resolution?

• Inevitable in dynamic environments• Conflict can lead to feelings of powerlessness• Can cause anyone to view coworkers as

adversaries• Creates animosity, divided loyalties in the

workplace

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Conflict-Handling Strategies

• Avoiding (or Withdrawal)– Lose--lose– Trivial issues; low power; potential dysfunction not

worth the effort; low information• Accommodating

– Lose--win– Emphasize commonalities; emotional or

personality conflict; build relationships• Pressing/ competition (or Forcing)

– Win--lose– Quick action; unpopular actions; top-down fiats

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Conflict-Handling Strategies

• Positive confrontation• Compromising

– Win with some loss--win with some loss

– Goals are mutually exclusive; deadlock; conflict style differences

• Collaborating– Win--win

– Complex, long-term issues; high interdependence

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Positive Confrontation is an appropriately assertive means ofConflict Resolution

• Respectful negotiation• Effective conflict resolution is about WHAT is

right, not WHO is right.• Never Aggressive. Use to explain

perspectives. If handled appropriately may be an opportunity for two-way learning and relationship growth.

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Two Attempt Rule:

• Using the elements of assertion, make 2 attempts to reach a common goal.

• If your viewpoint is disregarded, bring in a third party to help resolve– Continue up the chain of command (“escalate”)

– Charge nurse, Nurse Manager, Fellow, Attending

• Third party may act as mediator, consultant, arbiter or inquisitor

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DESC ScriptWhat is it?

A structured, assertive, communication approach for managing and resolving conflict.

D Describe the specific situation

E Express your concerns about the action

S Suggest other alternatives

C Consequences should be stated

Ultimately, consensus shall be reached.

When to use it?

Whenever you have a conflict with another health team member that threatens your ability to perform your job well or that poses a safety risk.

Key Points

Have timely discussion

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DESC Example

• D- When you scream at me in front of my co-workers about the delay in care, you’re making it personal.

• E- This reduces my credibility with the patients and undermines my authority with staff. I feel you don’t respect me.

• S- If you are upset about delays or other patient care issues, pull me aside and I will address your concerns.

• C- If this continues we won’t have a good working relationship and patient care will suffer.

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DESC Example 2

• D- I understand we need to move this patient out to make room for the next case

• E- However the pressure to get this done is making us rush

• S- Placing the central line and the foley catheter sequentially is more consistent with hospital policy

• C- I am concerned that we will put the patient at risk of infection if we place the line and urinary catheter simultaneously

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ALEEN

• A – Anticipate• L – Listen• E – Empathize• E – Explain• N – Negotiate

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ALEEN for conflict with patients and families

• Anticipate – Gather all information about what is happening

• Listen – ‘Can you help me understand why you are upset?’

• Empathize – ‘That is understandable.’ ‘You have every right to be upset.’

• Explain – ‘Would it be ok if I explained why things are happening as they are?’

• Negotiate – ‘Let’s try to agree on our path forward.’

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Managing Conflict (Leaders)

– Focus on eliminating dysfunctional conflict• In conflict resolution, solicit all sides & mediate• Set the tone for open discussion• Emphasize interdependence

• Encourage functional conflict– Build in a devil’s advocate process– Encourage people to speak up/ confront issues– Reward constructive dissenters– Help conflict avoiders learn how to deal with

conflict

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