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L10: Beyond Fight or Flight:

Managing Conflict on Health

Care TeamsNan Cochran*, MD, Associate Professor of Medicine,

The Dartmouth Institute

Calvin Chou*, MD, PhD, Professor of Medicine,

San Francisco VA Medical Center

Neil Baker*, MD, Principal, Neil Baker Consulting and Coaching

IHI Summit

March 10th, 2014*The presenters have nothing to disclose

Session Objectives

By the end of this workshop, participants will be able to:

1. Explain how to build relationships while negotiating

2. Identify ways to separate facts from assumptions and stories

3. Practice identifying and using emotions during conflict

4. Define the difference between interests and positions

5. Demonstrate how to negotiate in the face of differences in

authority

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Definition Conflict

“real or apparent incompatibility of

parties’ needs or interests...”

Bush RA, Folger JP. The Promise of Mediation. San Francisco: Jossey-Bass; 1994:56.

Kinds of ConflictTask - disagreement among team about content and

outcomes of the task, eg which strategy to pursue

Relational – with peers, supervisees, authority figures –

workloads/schedules, difference in values, personality

differences, salary, low performers, volume and quality

of work, expectations for performance

Process – logistics of how to accomplish a task, eg

delegation of roles, distribution of resources

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Downstream Effects of Unresolved

Conflict

• Decreased safety – more adverse events

• Poor teamwork

• Lower quality of care

• Higher costs of care

• Poor job satisfaction

• Increased staff turnover

• Patient dissatisfaction

• Higher dissatisfaction among trainees

Resolving relational conflict to

build collaboration

• Relational conflict is inevitable -we negotiate our differences every day

• If poorly managed or consistently avoided, it reduces productivity, undermines trust

• If viewed as opportunity, encourages constructive expression of differences so they can be acknowledged, addressed and resolved

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Relational conflict stimulates

many emotions• The physiological

response to conflict is “fight or flight”

• Goal - to avoid accusations, emotional reactivity and defensiveness

There is a third way!

We translate our feelings into:

1. Judgments - “If you were a good coach, you would

have backed me up.”

2. Attributions - “Why were you attacking me?”

3. Characterizations - “You are so inconsiderate!” “You

never…”

4. Problem-solving - “The answer is for us to meet more

often.”

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We translate our feelings into:

1. Judgments - “If you were a good coach, you would have backed me up.”

2. Attributions - “Why were you attacking me?”

3. Characterizations - “You are so inconsiderate!”“You never…”

4. Problem-solving - “The answer is for us to meet more often.”

1.Stay Balanced: successful negotiators are calm, patient, observant.

Be patient, creative and stay grounded. This is as important as

preparing for the substance of the negotiation.

2.Be attuned to your counterpart: if they are feeling defensive and

hostile, everyone will be dragged down.

3.Influence your counterparts’ emotions: emotions are contagious –

if we bring anxiety to the negotiation, others sense it. Conveying

optimism is in our interest.

4.Resilient: self-awareness is key: we need to know our own hot

buttons and how to recover when others push them!

Goal: emotional self-awareness and

self-management

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The Importance of Perspective

Assumptions

can

wreak

havoc!

The Importance of Perspective

Cone in the box

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Selective Inattention Video

http://www.youtube.com/watch?v=vJG698U2Mvo

Role Play

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Table icebreaker

• Introductions

• Reactions to the role play

• Share the first word which comes to mind

when you hear the word “conflict.”

Traditional views of authority

• Expert, professional, academic

• Socio-cultural

• Positional, hierarchical

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Sources of influence• Relationship• Active listening• Openness• Empathy• Appeal to principle – eg

legitimacy, fairness• Experience• Reputation• Humor• Courage – not risk averse• Respecting core emotional

interests• Resources

• Preparation• Process leadership• Mindfulness• Emotional intelligence• Curiosity• Humility – asking for help• Mindfulness – self-

awareness• Understanding process• Creativity• BATNA – having a strong

one• and more…

Impact of authority

Tendencies for “followers”•Amplifies emotional responses, especially anxiety

•Amplifies concerns about loss of influence, control, etc.—increases tendency to interpret what is heard negatively

•Increases tendencies to reactivity (e.g. defensiveness or, more commonly, withdrawal into silence)

Tendencies for those with authority•Increases tendency to talk more and listen less

•In general, makes it harder to walk in others’ shoes

•Overcompensation e.g. too authoritarian vs. too deferential, too controlling vs.not directive enough

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Corrective actions

• Remember different sources of power and

influence

• Assume good intentions

• Authority needs to insure “equal” air time

• “Followers” summon courage to speak up

• All use the techniques we will introduce

Introduction to the Ladder of Inference

6. I take actions based on my beliefs

5. I formulate beliefs

4. I draw conclusions

3. I interpret the data

2. I select “data” - my observations

1. Observable “data”

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Ladder of Inference• I can’t work with Chris; he is totally unmotivated; it’s time to get rid of him.

• He is totally disengaged

• He is focusing on his email rather than the meeting

• He always comes in late

• He knows exactly when our meeting starts; he was deliberately late

• Chris came in 20 minutes late to staff meeting again and didn’t explain why

Ladder of InferenceMy View My Colleague’s View

Conclusion

He will finish the poster I am done with that poster!

Reasoning

My colleague agrees with me. She knows that I don’t agree.

Assumptions

When people disagree, they tell you. When people agree, they tell you.

Directly Observable Data

He was silent as I explained why he

needed to work on the IHI poster

I was silent as she explained the need

to work on the IHI poster.

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Check your assumptions

• Make your thinking process visible to others - explain your assumptions, interpretations, and conclusions.

• Ask: “What story am I telling myself?”

…might there be other possible stories?

• Use open and nonjudgmental questions

“Help me understand…”

• Assume good intent

• Explore different perspectives

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Analyze Demo using LOI – 10”

• Using the LOI worksheet, analyze the demo

done by Calvin and Neil

• What assumptions were they making

• Where were they on the LOI?

• If time, have one person at each table choose

a work conflict, tell the story briefly, focusing

on assumptions you made about “the other”.

How did your stories differ?

Relationship affects conflict and vice versa

• Conflict in medical teams and in patient care often involve interpersonal incompatibilities

• Detracts from effective functioning

Greer et al, 2012; Kalishman et al, 2012

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Relationship as a conflict transformation tool

PEARLS:

• Partnership

• Emotions

• Acknowledgement (or Apology)

• Respect

• Legitimization

• Support

Marvel et al, JAMA 1999; Langewitz et al, BMJ 2002

PEARLS statements

Partnership: “I’d like to work with you, not against you.”

Empathy: “You seem pretty frustrated.”

Acknowledgement/apology: “What I’m hearing is that you are finding it difficult to interact well with the physicians on the team.”

Respect: “I see how much thought and work you have put into this.”

Legitimation: “Most people I know would also feel troubled after an event like that.”

Support: “What can I do in the next team meeting to support you?”

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Convey empathy nonverbally

Use:

• Pause

• Touch

• Facial expression

• Tone of voice

• SpaceAmbady et al, Surgery 2002

Be aware of your own reactions

Requires self-awareness &

non-judgmental attitude

• How am I feeling?

• Separate the behavior

from the person

• Speak as an equal partner

• Focus on strengths

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Attending to Relationship:

Skills Practice

Skills

1. Make at least one empathic statement

2. Convey empathy nonverbally

3. Be aware of your own reactions

Reflective Listening

• Listen, express interest, and understand the

meaning of what the speaker is saying – with a

minimum of preconceived agenda

• Reflect the speaker’s words:

- repeat what you heard, including NV messages

- short summaries

• Non-verbally remain attentive, open, non-

judgmental

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Skills Practice 6 minute exercise, then 6 minute debrief

• Work in pairs

• You will be in two different roles for 3 min each

1. Storyteller: Describe a challenge in a working relationship – with a patient, colleague, supervisor, etc.

2. Interviewer: Do NOT ask questions, offer stories, or problem-solve. Use only reflection and empathic statements.

“Mm hmm … Sounds like you were angry … That’s really

tough …”

Debrief with your partner – 6”

• For the storyteller roles: What was it like

to talk about your challenges and to

experience reflective listening?

• For the listener roles: How was it listening

using statements and reflections? How

hard was it not to ask questions?

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Focus on Interests, Not Positions

Positions

• What we want, need, think,

or feel

• “Drawing a line in the

sand”

• Basis for debate

“I refuse to work late!”

Interests

• The motivations underlying

our positions: our needs,

desires, concerns, fears,

aspirations

• Basis for dialogue

“I have to pick up my 6 y o

daughter from the bus, no

one else is at home”

Interests

Positions

Demo

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Focus on interests

There are all kinds of interests:

•Tangible and intangible

•Competing and shared

•Yours and theirs

Goal:

•Prioritize each person’s interests

•Find shared interests

•Find options that satisfy each interest

Invent options that will meet your

shared interests

• Brainstorm before deciding

• Don’t rule anything out at beginning

• Develop objective criteria – what are we

basing this on?

• Arrive at option that best meets everyone’s

interestsFisher, Ury, Patton, Getting to Yes, 1991

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Two Common Errors in Negotiation

1. No need to prepare – just get in there and

improvise, go with the flow

2. Prepare for the substance only

Three major tips: prepare, prepare, prepare!

“If I had 9 hours to cut down a tree, I would spend 6 hours

sharpening my axe.” Abraham Lincoln

Dimensions of Preparation

• Relationship – how can you prepare to develop

rapport with the other side?

• Process – what process issues should you think

about?

• Substance – think about every element from

your perspective AND their perspective

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Negotiating Differences:

ARTS of Communication

• Ask OEQ to elicit the other’s perspective and to uncover their interests“Can you help me understand how you see…?”

“I understand that the added work of Saturday clinic is a concern, and what else is important to you?”

• Respond with empathy and use reflective listening“ It is difficult when you don’t get any appreciation for your work.”

• Tell your perspective and your interests“Would it be ok for me to share how I see things? I care most about maintaining team cohesion and improving efficiency.”

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ARTS, cont.

• Summarize your understanding of the other’s perspective, their interests and focus on shared interests

“So you feel that introducing this new measure now will have a negative impact on morale…”

“So our shared interests are… and what matters most to you is….and my greatest concern is …

• Seek solutions, generate optionsWork together to generate alternative solutions which can satisfy

both of your interests

“Let’s take some time to brainstorm options before we evaluate them.”

“Is there a solution here that would meet both of our needs?”

Skills practice –with a partner (10” each)

• Use the conflict scenario you discussed in the

PEARLS exercise, or a scenario on the handout

• Begin with positions and practice identifying

interests underlying positions

• Switch roles – repeat for another 10” - your

partner will choose a conflict

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PEARLS

Partnership

Empathy

Apology/

Acknowledgement

Respect

Legitimation

Support

Potential Skills to practice

Negotiation Skills

• Focus on interests, not positions

• Separate the person from the

problem

• Active listening – be curious

• Check your assumptions

Any Questions?

Please fill out evaluation forms

For further training – go to Dartmouth

Microsystems Academy:

Tools to Relationships Course