M7: Managing Conflict on Health Care Teams -...

3/15/2015

1

M7: Managing Conflict on

Health Care TeamsInstitute for Health Care Improvement

March 15, 2015

Nan Cochran, MD

Neil Baker, MD

Calvin Chou, MD, PhD

These presenters have nothing to disclose.

Objectives

1. Explain how to build relationships while negotiating

2. Define differences between interests and positions

3. Identify ways to separate fact from assumptions and

stories

4. Practice identifying and using emotions during conflict

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

authority

3/15/2015

2

Gawande, A. Cowboys and Pit Crews The New Yorker, 2011

Staffing on hospital teams to care for one patient:

1970’s 2.5 FTE

“Medicine’s complexity has exceeded our individual capabilities as doctors.”

Increased complexity in care

1990’s 15 FTE

Conflict

• “Real or apparent

incompatibility of

parties’ needs or

interests”

• How much of health

care workers’ time is

spent in conflict?Rosenstein et al, Am J Nursing 2005;

O’Mara, Emerg Med Clin N Am 1999

3/15/2015

3

Negative consequences of conflict

• Lower job satisfaction

• Decreased well-being

• Higher perceived stress

• Sleep deprivation

• Use of alcohol and

medications as coping

strategies

Conflict affects patient safety

• Dysfunctional team dynamics

lead to more than 70% of

medical errors

• Disruptive behavior leads to

– Poor patient satisfaction

– Increased costs of care

– Decreased staff retention rates

3/15/2015

4

I experienced conflict that I found

difficult in the last month

A. True

B. False

I experienced conflict that could have

compromised patient care in the last

month

A. True

B. False

3/15/2015

5

Exercise – what is most

challenging about conflict?

• Take 2 minutes to think about what is most

challenging about conflict to you

• Share with a partner, 4” each

• Then, share at your table

• Large group debrief

Relational Task

Different kinds of conflict

Process

3/15/2015

6

Conflict Styles

Thomas-

Kilmann

Conflict

Styles

3/15/2015

7

A story

3/15/2015

8

Why is conflict so hard?

Reactivity

Ladder of Inference

CONCLUSIONS, ACTIONS

JUDGMENTS, ASSUMPTIONS, OPINIONS

SELECTION OF DATA

OBSERVABLE DATA AND EXPERIENCE

3/15/2015

9

Ladder of InferenceCONCLUSIONS, ACTIONSI can’t work with Chris; he is totally unmotivated; it’s time to get rid of him.

JUDGMENTS, ASSUMPTIONS, OPINIONSChris is slacking off, totally disengaged and does not care about our team.

SELECTION OF DATAChris is constantly late to our staff meeting and never apologizes or explains.

OBSERVABLE DATA AND EXPERIENCEI have worked with Chris for 2 years. I see he comes to a staff meeting late for the third time in a row. This last week I have worked until about 9 pm every night.

Climb Down the Ladder

Take a step back:

• What was the observable data?

• Do we agree on the data?

• What assumptions did I make?

• What conclusions did I draw?

• How did those conclusions influence my subsequent

observations?

3/15/2015

10

Caution! Flawed assumption:Feelings don’’’’t matter.

Watch for body language

Created by Neil Baker M.D. for AACH

3/15/2015

11

Watch for “I feel that….…you have poor judgment.””””

(judgments)

…it’s your fault!””””(blame)

…you are attacking me!””””(attributions)

…you are passive-aggressive.””””(generalizations)

…the answer is…””””(cognitive)

Bundles of

feelings and

thoughts


Name feelings - modulate your intensity

High intensity

Pissed off

Angry

Shocked

Low intensity

Concerned

Unsettled

Puzzled


3/15/2015

12

Self-reflective practices

• PAUSE to observe within

• Create a habit of using self-reflective questions

• Find ways to relax

• Practice meditation

• Try journaling

• Know your dominant conflict styles

• Consult with colleagues

• Prepare for difficult conversations

Ladder of Inference Exercise

• Choose an interpersonal situation that was difficult for you - perhaps the relationship you have with the other person is challenging or you regret something you said or did

• Choose a situation that felt important, that is likely to recur and that you are willing to learn from

Potential conflicts:• you can't reach agreement with your colleagues or with a patient

• someone is not pulling his or her weight on a team

• you believe you are being treated unfairly by your boss or supervisor

• you believe your point of view is being ignored

3/15/2015

13

Ladder of Inference Exercise

• What assumptions did you make that contributed

to the conflict?

• Seek disconfirming data!

Perspective

3/15/2015

14

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

Negotiating Differences

Ask

Respond

Tell

Summarize

3/15/2015

15

Negotiating Differences

ARTS of Communication

• Ask the other’s perspective – use active listening

• Respond with empathy and reflective listening

• Tell your perspective and your interests

• Summarize your understanding of the other’s perspective, their interests

• Seek solutions--generate options

Negotiating Differences:



Distinguish interests from positions

• Respond with empathy and use reflective listening

• Tell your perspective and your interests– Beware of assumptions

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

• Seek solutions - generate options

3/15/2015

16

Goals of Active

Listening

• Help a speaker feel heard, understood

• Encourage exploration at a deeper level

• Strengthen the relationship

• Understand different perspectives

• Show respect

Listen, don’t reload!

And listen to yourself

• Understand your anger and other feelings beforeengaging in a difficult conversation

• Negotiate with your feelings • What assumptions am I making?

• What story am I telling myself about their intentions?

• Describe your feelings carefully, and gently

• Use “I” statements - “You …” statements often heard as blaming

“I feel angry” vs “ You make me so angry”

3/15/2015

17

Interests

Positions

Relational Task

Different kinds of interests

Interests

Process

3/15/2015

18

Ask about positions and underlying

interestsPositions

• What we want, need, think,

or feel

• Drawing a line in the sand

• Basis for debate

“I can’t let Bobby transition to

the adult team”

“ Why 4 mandatory visits per

year?”

Interests

• The motivations for our

positions: our needs,

desires, concerns, fears,

aspirations

• Basis for dialogue

“I’m afraid the adult team won’t

understand how to work with

Bobby.”

“I worry they won’t provide the same

level of flexibility and care.”

Example

In a clinic process improvement meeting, a ground rule had

been set to "arrive early to start on time." Dr. X consistently

arrives 15-30 minutes late, typically entering the room with

apologies, along with a statement that "patient care comes

first." Even though the group had developed guidelines for

team members, including not scheduling patients for 15

minutes before the meeting and identifying a time that

really worked for everyone, Dr. X enters expecting to have a

recap of what has been discussed. Many times, Dr. X

intervenes to change decisions the group made before he

arrived.

3/15/2015

19

Positions and Interests: group

Positions and Interests: Dr X

3/15/2015

20




• Respond with empathy, reflective listening




3/15/2015

21

Listening

Filters that affect our listening (that we don’t notice)

•Culture

•Language

•Values

•Beliefs

•Expectations

•Intentions

What you

mean to say

What is understood

What you say

What is heard

Reflective Response

Potential Pitfalls in Communication

Adapted from Health Behavior Change by Stephen Rollnick

“The single biggest problem in communication is the illusion that it

has taken place.” George Bernard Shaw

3/15/2015

22

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?”

3/15/2015

23

Convey empathy nonverbally and verbally

Use:

• Pause

• Touch

• Facial expression

• Tone of voice

• SpaceAmbady et al, Surgery 2002

Attending to Relationship:

Skills Practice

Skills

1. Make at least one empathic statement

2. Convey empathy nonverbally

3. Be aware of your own reactions

3/15/2015

24

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 nonverbal

messages

- short summaries

• Non-verbally remain attentive, open, non-

judgmental

Reflective Listening Demo

3/15/2015

25

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, share your stories, or problem-solve. Use only reflection and empathic statements.

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




• Respond with empathy, reflective listening




3/15/2015

26

Identify Shared Interests

• Uncover and highlight shared interests

• Remember that you and colleagues

are allies and have many shared goals

• Incompatible interests do exist…

Practice a conflict scenario in pairs10”

• Identify a current conflict in which you are faced

with a person who is entrenched in a position

• Describe the situation briefly to your partner

• Your goal is to identify their interests and find

shared interests

• Group debrief

3/15/2015

27

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

observant.

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

and hostile, everyone will be dragged down.

1.Influence your counterparts’ emotions

1.Resilient: self-awareness is key

Goal - emotional self-awareness, self

management

What is power?• Power as ““““legitimized”””” authority

– Positional power

– Professional or “expert” power

– Cultural power

• Power as the ability to produce intended effects

– Experience and knowledge

– Ability to build healthy relationships

– Ability to resolve differences

– Ability to influence others

3/15/2015

28

Why is POWER so hard?

Reactivity

Power

• Those with formal authority

– Less listening

– More talking

– Harder time getting into

others shoes

• Those with less formal authority

– Withdrawal

– Criticism or attack

3/15/2015

29

Long term influencing strategiesBuild relationships

• Identify opinion leaders and those with formal authority

• Get to know their interests, challenges

• Build allies and stay engaged with opponents

• Help others with their challenges

• Use PEARLS, ARTS, INTERESTS vs. POSITIONS

Power


– Less listening

– More talking

– Harder time getting into

others shoes


– Withdrawal

– Criticism or attack


– Self-management, courage

– More listening, less talking

– ACBD


– Self-management, courage

– Use long term influencing

strategies

– Focus on ARTS

3/15/2015

30

ARTS--up the power gradient

• Ask the other’s perspective – use active listening– Begin by understanding their interests, barriers, and challenges

• Respond with empathy and reflective listening– Assure they know you want and care about their success.

• Tell your perspective and your interests– Explain how your ideas impact their interests.– Check their reactions to your ideas and their concerns.

• Summarize your understanding of the other’s perspective, their interests– and your understanding of their reaction to your position.

• Seek solutions--generate options– Make sure you meet again.

Prepare for conflict

• Be clear about your goals for:

- the relationship

- the substance of conflict

• Distinguish interests vs. positions

• Distinguish feelings from thoughts

• Check your assumptions

3/15/2015

31

Example

In a clinic process improvement meeting, a ground rule had

been set to "arrive early to start on time." Dr. X consistently

arrives 15-30 minutes late, typically entering the room with

apologies, along with a statement that "patient care comes

first." Even though the group had developed guidelines for

team members, including not scheduling patients for 15

minutes before the meeting and identifying a time that

really worked for everyone, Dr. X enters expecting to have a

recap of what has been discussed. Many times, Dr. X

intervenes to change decisions the group made before he

arrived.

3/15/2015

32

3/15/2015

33

Demo

• Team Leader Role

– Has done the preparation and takes the lead with

ARTS

– Goal to find mutual interests

• MD Role

– Not prepared

– Does not know what to expect in the conversation

Consultation groups

• Form triads

• Think of a conflict at work

• 3 rounds: in each round:

– One person shares a question

– Consultants ask clarifying questions

– Client then turns back on consultants

– Consultants discuss ideas, suggestions, 5 min

– Client returns, shares take-homes

3/15/2015

34

Summary

• Seek to understand and demonstrate your

understanding before seeking to be understood

• Make the goal of “understanding” a collaborative

effort

• Develop a strong working relationship

• Embrace differences

Summary

• Explore the data, reveal your reasoning

• Discuss how each of you has interpreted the data

and reached conclusions

• Explore the interests underlying positions to

expand the pie

• Seek to be “unconditionally constructive”

3/15/2015

35

ReferencesBooks:

1. Getting to Yes by Roger Fisher, William Ury and Bruce Patton 3rd edition 2011 Penguin Books

2. Difficult Conversations, How to Discuss What Matters Most by Douglas Stone, Bruce Patton and

Sheila Heen. 2010 Penguin Books

3. Thanks for the Feedback by Douglas Stone and Sheila Heen. 2013 Penguin Books

4. Nonviolent Communication by Marshall Rosenberg, 2008

5. Dialogue: The Art of Thinking Together by William Isaacs, 1999

Articles:

Aschenbrener, CA et al. Managing Low to Mid Intensity Conflict in the Health Care Setting The

Physician Executive, July/Aug 1999; pp 44-50.

Greer, LL et al. Conflict in medical teams: opportunity or danger? Medical Education 2012: 46: 935–

942

Janss, R. et al. What is happening under the surface? Power, conflict and the performance of medical

teams. Medical Education 2012: 46: 838–849

Rosenstein, AH. A Survey of the Impact of Disruptive Behaviors and Communication Defects on

Patient Safety, JCAHO, 8-08

ExercisePreparation for conflict; interests vs. positions

• Case scenario

You have recently been promoted from nurse manager of a primary

care clinic to be the Chief Nursing Officer for a large integrated health

system with 20 primary care clinics and more than 15 specialty clinics.

There is a huge backlog of patients from primary care waiting for

appointments in many specialty clinics. You have been appointed by

the CEO to chair a steering committee to guide an improvement effort.

The CEO has said there is NO additional money for solutions.

3/15/2015

36

Demo

• CNO Role

– Has done the preparation and takes the lead with

ARTS

– Goal to find mutual interests

• MD Role

– Not prepared

– Does not know what to expect in the conversation

M7: Managing Conflict on Health Care Teams -...

Documents

Transcript of M7: Managing Conflict on Health Care Teams -...