Conflict Resolution (Transcript)

October 12, 2010

Operator: Good evening, ladies and gentlemen, and welcome to your CUSP content call. At this time all participants are in a listen-only mode. Later, we will conduct a question-and-answer session, and instructions will follow at that time. If anyone should require operator assistance during the program, please press star then zero on your touchtone telephone. As a reminder, today’s conference is being recorded. I would now like to introduce your host for today’s conference call, Dr. Jill Marshall. You may begin, Ma’am.

Jill Marshall: Thank you. Hi, everybody, and welcome. We are very excited to talk to you today about conflict resolution. Conflict resolution, of course, is something that exists -- well, conflict exists in all of our lives -- and we do a variable job of dealing with it in any given situation. So David and I are going to give you some tools today to try to work on your own personal conflict resolution and also so you can model behaviors to the rest of your quality improvement team that’s working on the On the CUSP Stop BSI program, and possibly do some coaching with your people, especially the ones who are conflict-resolution challenged.

So let’s start on our first slide with “What is conflict?” It is essentially the perception of mutual interference, and let me emphasize the word “mutual.” So here what we’re saying is that there needs to be obviously some kind of interaction and interdependence, otherwise conflict wouldn’t exist. Those who move about their day essentially handling their own work without interacting with others are typically not going to have a lot of conflict because they are the master of their full scope. But that’s not true for most of us, and it’s certainly not true in patient care because all the different roles have to interact with each other. So it’s a process that begins when the goals of one party are frustrated by the goals of another party.

There are different views of conflict in terms of the literature about how to deal with conflict and so on. I like to call the first one “conflict good.” And conflict good represents what we might call the interactionist view. It suggests there are benefits to conflict, and that they are eventually that you improve any given solution via having a conflict or a discussion about that solution. So first I say to David, “You know, I really think that we should plant flowers.” And David says, “No, I hate flowers. Let’s plant tomatoes.” And I say, “I don’t really care for tomatoes. Let’s go for green peppers.” And in the end, we choose the right plant for both of us because we had this conflict. It wasn’t necessarily an ugly conflict; nevertheless, it was a disagreement. However, at the end, we’ve come up with the best solution that pleases the largest number of people and, were this a patient care situation, would be the best outcome for the patient, who maybe is tomato and flower intolerant. So it’s good that we came up with the best solution.

Another view is that conflict is just plain natural. It’s not really good. It’s not really bad. It just exists. And that’s what we would call the human relations view. The more predominant view, I think, in most people’s experience, is that conflict is bad. This is traditional, that people view conflict as bad. In the workplace, when we’re not getting along, it’s uncomfortable. People tend to avoid conflict like the plague. We try to find ways around direct conflict and, oftentimes, that leads us to doing things that are done covertly or behind someone’s back in order to avoid an outright conflict. For example, if I was expecting someone to have completed a task and they did not complete that task, it’s much more likely for me to avoid mentioning it or to wait a very long time before inquiring about the status of that task because I’m trying to avoid that conflict. Whereas to get the task done, the most direct mechanism would be for me to ask, “Where are we on this task? Is there anything I can do to assist you in completion of it?” So, in any case, whether you look at conflict as good or natural or bad, conflict must be managed, or it can really slow down your processes.

So the sources of conflict are essentially arising typically from resource scarcity. And what I mean by that is that oftentimes, you have to make one choice, and making one choice is making a choice not to do something else. So if you are having to choose whether you’re going to approach a patient problem with Method A as opposed to Method B, then by collecting Method A, you have foregone Method B. So there just aren’t enough resources for us typically to be doing absolutely everything. And that’s one of the reasons why conflict arises. Sometimes the goals of the parties are incompatible. We hope that in our patient care situations, the goal is always taking the best possible care of the patient. But there may be differing opinions about what’s the right path to get that done, and so the near-term goals of the parties may be incompatible. There could be other structural factors. For example, the larger a group is, the more likely it is to have conflict. Where things are very routine, then you typically have a lot of standardization, and that may minimize conflict. But where things become specialized and each person has one piece of the role or one small role in the process or one piece of the process, that might lead to more conflict because it’s introducing a larger number of actors into the process. In addition, conflicting perceptions or ideas or beliefs, down to the very values that we come to work with, these can lead to conflict. Differences between people and conflicting thoughts or needs within an individual can lead them to behave in a very inconsistent way, which then can cause conflict with other people. And of course, our old favorite, lack of communication. How many times do we have a conflict or a seeming conflict that is actually the result of result of not understanding what the person was trying to say or perhaps missing a piece of information, and we make assumptions to fill in the information that we don’t have, and sometimes that leads to conflict. So that lack of communication can be a problem.

Among the types of conflict we have, it’s important to categorize the types of conflict because they have what we would call different roles in our interaction. And some of them are things that we would consider good, and some of them are things that we would consider bad. So task-content conflict is conflict that’s really about differing opinions that are related to a specific task. And I have put a little red “G” there, because I want you to know that is actually good conflict. Again, a little bit of back and forth can usually result in a better outcome because there’s been some kind of discussion. There’s been more thought given to a given course of action or attack. So we think of that as good, and that’s conflict that you want to encourage at sort of a low level. It also keeps people engaged. It’s more challenging. It’s more exciting to work in an environment where people are interacting with each other and sharing ideas and coming back at each other with, “Well, I don’t know if that’s good.” Not in a confrontational way but rather to say, “Let’s both think harder about this. Let’s move both of our intellectual capacities outside of the box. Let’s see where we can go with this.” That can be very exciting. Emotional or relationship conflict is interpersonal conflict. So this is about sort of negative emotions or dislike: “So and so cut me off when I was telling them a story.” It develops into this sort of, “I just feel this person doesn’t value me.” And that sort of negative emotion or dislike, lack of affinity with a person, is what we would refer to as “B” for bad conflict. That’s the kind of conflict that we don’t need in our workplace. And that’s predominantly the kind of conflict that we have to avoid. And in both cases, the task conflict and emotional or relationship conflict, we have to know how to manage those two kinds of conflict so that task conflict achieves its promise without turning into a mire of people being completely unable to agree on, for example, a treatment plan.

The final kind is administrative or process conflict. This is disagreement about how to get the task completed, duties, who’s to do what, what decision mechanism are we going to use, is there a hierarchy in this case, or is there no hierarchy in this case, and so on. So this we would probably call this predominantly bad to neutral. And in the case of being bad, we want to make sure that the group has as much agreement as possible on what processes are, on what the decisionmaking process is, so that you don’t spend a lot of time deciding, “Well, how are we going to decide about what kind of communication plan we’re going to use for talking about preventing blood stream infections?” If we think that we’re going to have to have a vote at every full meeting in order to decide whether or not we like the color red or the color blue in the newsletter that we’re using, then that kind of process conflict is probably negative. It’s slowing things down.

The goal of conflict resolution, then, is clearly to confront problems, not to allow them to fester continually, to communicate openly and respectfully with someone who has an opposing opinion to yours, and to turn the situation around to provide that optimal patient care. So share ideas that may be conflicting, and together, work towards a congruent plan. Go through a divergent period of idea generation and then move into developing the plan that we will use in order to provide optimal care to our patients.

So why should you think hard about conflict resolution and address it explicitly instead of assuming that it’s going to happen? Because it’s inevitable that in these dynamic environments where people are rushed, people are tired, people are highly specialized, that there’s going to be a lot of conflict in our patient care situations. Conflict, where it is unresolved, can again slow processes and defeat the effort that you are undertaking, but it can also lead to feelings of powerlessness on the parts of the people who can’t get a decision made. And powerlessness then leads to problems with how you feel about yourself, with your own assessment of your skills and your effectiveness, and that ultimately could lead to people leaving the institution because they feel like, “There’s so much conflict here, I can never get anything done. And I’m not really sure that I’m that good at being a doctor. I’m not sure that I’m that good at being a nurse. Because it doesn’t seem like we can ever get anything done around here.” So, especially subordinates may feel that administrators and attending physicians, for example, are adversaries and actually people with whom there is so much conflict that we can’t resolve the issues at hand. So I think that’s enough motivation for you to think about how to resolve conflict in your group, and I’m going to turn it over now to Dr. Thompson, who’s going to talk to us about assertion and conflict resolution.

David Thompson: Hi, everybody. So I’ve taught assertiveness training and conflict resolution training now for years, and what I always find is very interesting is, no matter who I ask, everybody already thinks that they are appropriately assertive and that they already can deal with conflict. And I had to teach a class of international nurses, so these are nurses that we hired from all over the place. We had people from the Middle East, the Philippines, etc., and not necessarily a very aggressive or assertive group of people, and yet when I asked them, of course, their hands went up, “Yes, we’re appropriately assertive when we have to be.” And then when I did observations on the inpatient ward, I noticed that, indeed, they were not assertive. So there’s the cultural link, too. So when I say appropriately assertive, I want you to think about that person that we all admire. Their posture: They’re standing straight up. Their hands are not clenched; they’re down at their side. They look very calm. They’re doing something that we call active listening in that they’re looking at you, they’re making eye contact, and they’re ready to have a communication that is going to be not only succinct but it’s going to be beneficial for both parties. That means that we both respect each other. So they’re coming into the discussion already expecting to have a really great conversation and there’s mutual respect between the team. You’ve thought about, usually the person that’s assertive, you’ve thought about what you’re going to say. And there are many of us, and I thought of this because of my own clinical practice in the ICU, about thinking what I was going to say, especially when I had to deal with a difficult resident or fellow or somebody that just absolutely petrified me because they either were always grumpy or they didn’t like to be second-guessed. So I thought about what I was going to say. And that’s a really good thing to think about. Let them know that you’re technically and socially competent. So to do that, you have to have some background. You also have to be willing to say something like, “I’ve never done this before” or “I’ve not seen this in the literature. Can you please explain to me the rationale why we would be doing this?” And then explain why you believe it may be the wrong method of doing something. You know, sometimes it actually ends up being a learning experience because you both learn. You might have the resident or fellow or attending saying, “I didn’t really know that, didn’t anticipate that.” Or they’ll say, “Oh, this just came out last week in JAMA. Excellent results, power high enough, it’s a randomized controlled trial. This is something that we’re going to be doing within the unit.” So it’s an opportunity to educate, to teach. We’ve talked about the subordinate, the scope of how we view people in management as adversaries, that we really begin to feel powerless. But to be appropriately assertive and to deal with conflict, this is not necessarily a subordinate skill set. In fact, I have seen many attending physicians and administrators walk away when a situation has become too intense, and they didn’t prepare well, and they really didn’t feel like they were making any progress. When I talk to you about some of the methods that we use for conflict resolution, I want you always to keep in the back of your mind, if the situation escalates and you’re not going to have the support to manage it in the patient’s best interests, there are ways that we can do it without causing escalation and ending up in fisticuffs, which I actually have seen, not directly in my ICU, but I have had physicians threaten to take each other outside. In fact, a couple of them did take each other outside. Luckily, security got there in time, and nothing bad happened. Not here, but it’s always amazing to see what people’s breaking points are. And so, as Jill said, that emotional component, that bad component or negative, is something that we all have because I think a lot of us worry as we’re being assertive, “Is this person judging me for what I’m presenting to him or are they judging me for me, and we’re making it personal?” And really, as we approach assertion, this should have nothing to do with being a personal problem. This has to do with the issue at hand. So we know what it is. So assertion is not, we’re not aggressive. We’re not passive-aggressive. We’re not hostile. We’re not the person who’s going to come in and demean somebody or to tease them in front of other people in order to gain power over them. The last thing you want is to seem aggressive because usually people withdraw. And in health care settings, if people withdraw, we know that we’re not providing the best care because we don’t have the input, we don’t have that mutual respect that is really necessary for two people of conflicting viewpoints. Confrontational: It’s odd how we look at this because the verbiage is we don’t want to be confrontational, and yet we want to confront the conflict. And so confrontational really means that aggressive component where we go in, we’re loud, we’re inappropriate, and we may be saying things that we really don’t and shouldn’t in any professional environment be saying, and yet we’re still doing it. So we’re making people feel bad, and that’s the farthest thing that you need to do when you really want to have mutual satisfaction and address conflict effectively.

Ambiguous: This has to do more with the passive-aggressive behavior that we see. Instead of being assertive, “Well, I’ll do this” or they’ll write an order. So you go to the resident, and I’ve got tons of experience working in a teaching hospital, every hospital I’ve ever worked in has been academic affiliated, and they write me an order, but it’s not quite the order I wanted. So, yes, they did it, but they didn’t give me what I wanted. So I had to go back and readdress the issue and finally say, “Well, what is it going forward? Why can’t I have both? If I’m going to give the unit of blood, why can’t I give the Lasix that I think they need to have because of their history of congestive failure?” So you have to really try to finish things from the beginning. You have to recognize your passive-aggressive behavior. You want to go in there. And you really want to do it. And if you really are skeptical, and you don’t think it’s going to work, then the last thing is to be ambiguous or passive-aggressive.

The demeaning and condescending: We’ve all seen this. I’ve seen this a lot with nurses addressing other nurses, especially new or younger nurses. I’ve also seen this with senior residents addressing junior residents or fellows and even attendings to other attendings. I’ve heard a surgeon say to an anesthesiologist -- our SICU and cardiovascular SICU here are both managed by both -- and I’ve had a surgeon say to me, “Well, I’m the one that saved their life” and I’ve had the anesthesiologist say to me, “Well, I keep them alive during the case,” kind of gleaning that I’m better than you are; my profession is stronger than you are. So trying to demean and condescend so that they have power and, really, I could care less which anesthesiologist or which surgeon thinks they’re more important. I just want them to take care of my patient. So they don’t need to have the argument with me. And certainly having them put you in the middle is not an appropriate way to be assertive or to address conflict resolution. And that happens a lot.

So the assertion model is very simple: Get the person’s attention. And what I would have to say here, and we did this here at Hopkins and many other places that I’ve talked to, when we do this, we want to use names. And we had a campaign, “Names First.” So, the attending physicians that like to be called Dr. So and So, we went through a period of making sure they were okay being called their first name. And it was very important for all areas. And there are numerous cases. We work with a surgeon, Marty. And Marty would say, “I need a chest tube” or “I need this new piece of equipment.” And he said, “So here I am in the OR asking for this information because they haven’t set up the trays that I need to do the case. And I’m just yelling for somebody to get it for me”. You know, if you don’t use a name, chances are nobody’s going to bring it to you. So that name component. And if not, introduce yourself, because in a teaching hospital, chances are, if you’ve missed a couple days at work, you’ve had a couple of great days off, you’ve got a new resident who’s managing your patient, and you kind of go in and say, “Hi, my name is David, and I’m taking care of Mr. So and So today,” and let them know that you need to know who they are and what their role is: Are they a surgeon or an anesthesiologist? And express your concern.

So I’m going back to some of the old fashioned things that I learned a couple of years ago. When you’re expressing your concern, begin to use some of the CUSP words. I’m sure some of you that have done team training or cockpit resource management know the CUSP words: “I’m concerned,” “I’m uncomfortable,” “This is a safety issue.” Use those words to let them know that, indeed, not only do you feel that this is not the right mode of action, but you’re actually emotionally involved and that you recognize that you fear for your patient. And then after you express your concern, state your problem. There’s a lot of research, and we had an organizational psychologist. and one of the things that we have as nurses is that we learn to tell stories. So we give them everything. “This is Mrs. So and So. She’s 70 years old, has a history of congestive failure, she’s had a right vent bypass,” and we go into all this detail before we get it out and just say, “I think Mrs. So and So is desaturating. I think she’s in congestive failure.” “I think we’re going to need” then go to the next point and propose your action. “I think we’re going to need to give some Lasix; we should probably get an X-ray.” So we told this whole story but when it’s a physician, they’re used to talking in bullet points. And one of the things out of the research study that was studied that was sponsored by Daimler-Benz was that physicians need to listen and talk more like nurses, but nurses need to present their information much more like physicians. So in a bullet point, you don’t have to review the entire history. You’re talking about the problem. “She’s in congestive failure. I’m proposing that we give her some Lasix. You’re the doctor. I’m going to let you decide, maybe or not.” Say “20 milligrams has worked before, or 40 milligrams, or we’ve been alternating Newmax and Lasix.” And then reach a decision. And really, it’s a very simple concept, just five steps. And when you do them, this can all take place in less than 2 minutes. It’s more effective for the patient.

And I think the next thing I’ll let you know about trying the assertion model is how we move this away from being personally taken aback or feeling that we’re judged if somebody doesn’t like our perception of the situation or how we want to manage it. We’re focusing on the common goal of quality of care. It’s not about who is right or who is wrong, who’s had education. Yes, in my career, I’ve had people tell me, “Well, I’m the doctor here today” or “What medical school did you go to yesterday, David? Because yesterday I knew that you were a nurse.” And I’ve had really rude things said to me over time. And if you take it upon yourself to address that later and just deal with the patient, I’ve got a couple of methods that we work on that personal problem that is negative that Jill has identified. So we’re really not worrying about ourselves as much here in applying the assertiveness model in order to be confrontational. We’re worried about our patient. It’s hard to disagree with safe and high-quality care. And I think everybody can agree with that.

Patient-centered care is a little bit different. Usually that means that we involve the patient. Most of us in the ICU are used to working with patients that don’t have a voice for themselves. They’re either intubated or unconscious. So we’re really concentrated on doing the right thing. We’re going by their wishes, their family’s wishes. And we’re depersonalizing the conversation. We’re not going to be saying, “You know, every time this happens, you do or you don’t do this.” We’re going to state and we’re going to be objective in what we’re saying. And we’re going to go back to, “I think she’s in congestive failure. I’ve just (indiscernible). She’s got (indiscernible) halfway up on the right. She’s desaturating down to 88 percent. Her SAP had been running in the mid-90s today. I noticed that we discontinued her Lasix strip about 5 hours ago, and I think maybe we need to resume her PRN Lasix schedule.”

Actively avoid being perceived as judgmental. You know, sometimes, and we’re all human and humans are capable of failure. So I think the thing is if something that you’ve tried and it didn’t work out well, rather than say, “Well, we did it your way and, look, it didn’t turn out too well,” we don’t want to be judgmental. We can say, “Well, as you know, we’ve given this, so let’s try something else.” We want to take that judgment out of there or anything that is going to be perceived as a character flaw. To be hard on the problem and not the people, I think, is the definitive way to deal with it.

So strategies for conflict resolution: There are many and, depending on where you look for these, you’re going to see them addressed in several different ways. So the ones that come up most in health care are withdrawal: little or no significance to either party, kind of a lose-lose situation for both parties. But as we go through these five methods, I want you to think about the other person. So it’s not just you and the other nurse or you and the other doctor, or whoever, you and the respiratory therapist. It is you, the other person and then, ultimately, the patient. So that’s why we’re paying attention. So withdrawal: No one really cares about the outcome or deny they care about it to protect the relationship and avoid hostility. And, really, I’ve seen this a lot when you have new residents in training, and they’re questioning each other, and they’re making suggestions, but nobody’s willing to make the final decision. So they’ll both pull away when there’s conflict, and we won’t address the situation, so I’ll say, “We address this” or “We try to address this on daily goals, but nothing really happened with it.” So we walked away from the problem. Definitely not effective.

Forcing: People of influence positions force an outcome regardless of its effect on the other party. Leads to resentment and hostility. So I always think when I say forcing, this is again that aggressive resident who I can still see to this day who said, “Oh, David, I want to extubate.” And I said, “Oh, we can’t extubate because that’s the apnea alarm you’re hearing. We’ve already reversed their anesthesia.” And he said, “You know what, I’m the ENT resident, and I don’t see any swelling and I want to extubate.” And they’re going to force. And they’re going to say -- and that was one of the persons that ever said to me, “Hi, what medical school did you go to last night because yesterday you were a nurse?” It’s a win for him and kind of a lose for me. It was a lose for our patient. And lucky for me that I learned one of the methods for effective conflict resolution, and I was kind of able to bring a third party in and get them to recognize that it’s more than just not having any edema around the vocal cords. It has more to do with whether they can maintain their airway. So having the apnea alarm going off was definitely not a way. So forcing that function. And we want to try to stay away from forcing. Because if we force, chances are we haven’t heard all the information, and we definitely haven’t respected the person that we’re having our disagreement with. I don’t want to call them an adversary.

And then, conciliation can also lead to resentment over time. It’s giving in to perceived relationships with the other party. It may not benefit the patient or reach a desired outcome. This really has to do, you know, some people, and I’ve seen this a lot, you know they always step away. “Well, whatever you want to do first,” or “I have this suggestion.” But we’re always giving into the same person. Eventually over time, we’re going to recognize that our viewpoint is not recognized as important, that having technical competence and social competence is being completely ignored. That “Yes, I’ve got this many years of education and I have 15 years experience in this ICU, I understand what I’m doing.” I can’t give in. Not only to protect myself but to protect the patient.

And then compromise and concern for both the outcome and the relationship. And this can be a win-win, and we call this a conservative response as we address conflict. This is where you might say, “Well, yes, they’re having their O2 saturations drop.” And the resident that you’re working with says, “Well, you know what, David, I really want to go up to 70 percent of Fio2 and turn their (indiscernible) up to 12.” And you say, “Okay, but you know, their hematocrit is tending down. They’re 2 days post-op, and their hematocrit is now 24. You know our transfusion guidelines for this patient or this patient group is 27. Certainly one unit of blood cells, I think, would improve both their volume and their oxygen carrying capacity. So I’m going to let you do it your way, and then if that’s not enough, then I think I should have my blood transfusion.” I’m going to get what I want, and hopefully if the patient’s not critical, I haven’t done any damage.

And then lastly confrontation. Meet the problem head on. This has to go back to respectful negotiation. You recognize that both of you are health care professionals. You have specific training to the situation, and you both come to it with different life experience. But you’re willing to listen to each other and hear each other out. Now when you confront and prepare for your conflict resolution, one of the things that’s really important to do is ask your questions. Both parties should ask all of their questions and have full understanding before that decision is made. If not, you haven’t really confronted the issue. You really want to go through and say, “Well, my concerns are…,” have each one of them addressed, let them ask what their concerns are, and talk about what’s going to happen as far as the patient benefit and how you want to proceed from there. So when I say “We’re confronting the conflict,” it’s great, but we’re not doing it in an aggressive or overtly aggressive fashion.

Some of the methods that we’ve learned over time is -- confrontation being an assertive means of conflict -- is respectful negotiation. What is right, not who is right. Never aggressive. Use it as an opportunity to educate, to explain your perspective. And I would say one of the best things that I’ve learned in all these years about working in a teaching hospital is the ability to take a situation where there is conflict and use it as a chance to learn from either new therapies or from proven methodologies. If any of you are informed about evidence-based best practice, then you know that sometimes it can take 16 years to get evidence-based best practice into clinical practice. So you might be telling somebody something for the first time even though there’s literature to support what you’re saying dating back to the 1990s. Use it as an opportunity to educate. And if they still insist on doing it their way, well, there are a couple of methods that we jump to.

So this is the two-attempt or some people call it the two-approach or the two-confrontation rule. We didn’t like the word confront. We like two-attempt because confrontation, I think, scares people off. We want to use the elements of assertion to make two attempts to reach a common goal.

There’s a great story that Peter told me many years ago when I was still in the ICU, and I’m going to kind of use that now. So he was the attending physician for two ORs, and he had a resident that kept calling him into the OR. And the patient had declining saturation, had dropped in blood pressure, and things just weren’t looking really good. And they’d given a little bit of a neobolus. They started a drip. They gave a unit of cells because their hematocrit was also low. And then things seemed to stabilize. He came back, and the resident said, “You know what, no matter what we do, this patient’s blood pressure is not staying up.” And Peter looked around at the situation, made his assessment with his vast number of years of clinical. He recognized this to be a latex allergy. So he said to the attending surgeon, “You know, I think this is the third surgery for this patient this year, I think she’s developed a latex allergy, and we need to change over to a non-latex field.” The surgeon ignored him. Ignored him completely. If you know Peter, he’s sort of gregarious and very cheerful, so that tone changed in his voice. He was a little bit louder, but he said, “Excuse me, but I think the patient is having a latex allergy. We need to change over to a non-latex field.” And the surgeon looked up to him and said, “Well, that’s not my experience. Wouldn’t she have already had the latex allergy?” And for those of you that have experience, you realize the more that you’re exposed to latex, the more likely you are to become allergic to it. The resident said, not a big deal, but the surgeon still insisted, no. And Peter said, “I don’t see why.” And he said, “All we’re talking about is you needing to change your gloves, and we can have this all done in a couple of minutes. And so you’re telling me just on principle you’re not going to change just because you’re right and I’m wrong.” And he said, “Yes. Quite frankly, it’s not worth it, and I’m almost getting to where I want to close. No way.” So Peter said, “Okay.” He went to the phone this time, and the surgeon said, “What are you doing?” and he said, “I’m calling your director of surgery,” who’s been a chairman for quite a while, and he said, “I’m going to tell Dr. So and So that you’re unwilling to change over to a non-latex field.” So with that he escalated the problem. So we’re using the hierarchy. And I know we talk a lot in communication and teamwork about reducing hierarchy, but understanding your hierarchy, if there is one, is equally as important. So for this surgeon, it seemed like the only person he may listen to since he wasn’t listening to his colleague, who is of equal rank, both professors, one a surgeon and one an anesthesiologist. So Peter goes, “Direct me to Dr. So and So.” As he was being connected, the surgeon cussed at him, threw the gloves off, and switched over. And sometimes we have to escalate. But hopefully, not to the point of where we’ve already kind of demeaned the situation so that the patient was less worthy of appropriate focus by both members of the team. So the two-attempt rule has been very effective for conflict in life-threatening situations. What’s important about this is it can be used in any practice domain in understanding your hierarchy and the numbers to call.

One of the things we did here at Hopkins and some other teams I’ve heard from across the United States have also done is set up a safety hotline so we do have a safety officer available at all times, so that when we don’t know the hierarchy we can call the safety officer and have them come to our defense to make sure we’re getting correct care for our patient. So that’s the first one, and this comes to us from the Department of Defense and nuclear naval is a big place, and through cockpit resource management. So Department of Defense and aviation have used this for a long time.

And then the conservative response. Again, this is the opportunity when you have especially a subordinate or if you have somebody at the same level, but you know they don’t like conflict and they’re likely to be screaming at you and being inappropriate. A conservative response is a nice way to handle this because you’re not going to have them end up making the choice. What you’re doing is asking somebody to come in and kind of mediate the two opposing opinions. So what you do is you bring somebody with the appropriate background. So if you’re having disagreement with your ICU fellow, you can bring in your attending. You both explain what you want to do. You both allow each other to ask all the questions that you would like to. And you allow the person mediating to make sure that they have a good understanding so they get to ask you all the questions, your background, your rationale, why you think this is going to work. And then they make a decision. You’re seeking advice from an outside team member, and then this is one of those opportunities where you may go ahead and you say, “We’re going to do this first and then second we may do this.” Or he’s going to say, “No, no, no. I disagree completely. I like what David is saying. The patient definitely is volume-depleted, and he definitely has saturation falling, and I think it’s because of the oxygen-carrying capacity.” So, effective for both me, the other team member, and my patient. So it’s kind of nice, especially when you’re worried, and one of the things we’ve seen consistently is if somebody has been yelled at, and the literature supports, so a nurse being yelled at by another nurse, a surgeon is also most likely, you’re less likely to use the two-attempt rule. So this is one of the ways in which you’re going to get your patient taken care of without putting you in a situation where you’re going to be yelled at to reduce, well, to reduce your power and your skill set. This is for that middle component that Jill said, and we’ve done this in our team training here. And this comes to us from, it’s also from the Department of Defense, but we use this in our TeamSTEPPS program. And we used it here long before we developed our work with TeamSTEPPS here. So it’s called the DESC Script. It’s a structured assertive communication approach for managing personal conflict. And we all say that personal conflict is one of the worst types of conflict to have in the workplace. And we describe a specific situation, so you want to tell them what it is that they do that is bothering you. Express your concerns about their actions and suggest other alternatives. So what they can do to approach you in a way that you feel less threatened and less bothered. And then you’re going to state the consequences. That if they continue this aberrant behavior, and I’ll call it aberrant because it is -- you shouldn’t be screamed at in the workplace -- what’s going to happen to your work relationship? Ultimately, consensus shall be reached. We have another physician who’s doing research here who has two methods for personal conflict. Examples of this are, let’s just say, “When you come to this unit and scream at me in front of my coworkers about the delay in care, you’re making it personal. You’re making it seem like it’s my fault. Expressing your concerns, this reduces my credibility with the patient and undermines my authority with my staff. I feel you don’t respect me. And I think those are important things.” Then telling them what they have done to you that is going to affect your working relationship. And then, “If you’re upset about the delays or other patient care issues, pull me aside, and I’ll address your concerns.” I think what’s important here is when you’re talking and you express your concerns in the situation is to say, how might they effectively do it? Screaming is certainly in front of everybody at the nurses station is never going to lead to a win-win situation. And then after you do that and you explain the alternatives of how you want to be addressed, the consequences. “So if your outbursts continue, we won’t have a working relationship and the patient care will suffer.” It could be something more serious. We have a code of conduct for all of our members of our clinical staff. So sometimes it can mean, “I will be contacting the ethics board” or “I will be contacting, I will be filing a report on you,” or “I will be filing a pink slip.” Or a yellow slip or whatever your hospital has about inappropriate behavior that then will go to the person supervising their behavior.

So I think the last one is something that they’ve been doing in surgery and anesthesia, the LEEN model. Listen, empathize, explain, and negotiate. And this can be used for a workplace with both families and with your colleagues. Conflict with patients and families, and this has really become an issue more and more. We have begun to, within our ICUs here, let the patients have their families in during rounds. In fact, when I first came here, visiting hours were 20 minutes three times a day. And then they moved to all of 30 minutes a day. And then they went to 45 minutes. And I never thought we would get to a point where we didn’t ask people to leave except in the sort of situations where diagnostic equipment couldn’t be in the room if the family was there. But we’re letting them stay there, and we’re inviting them to participate in rounds so that they’re getting an update. This has worked fairly well. However, there are some patients’ families who have really had a hard time with it. So, “Can you help me understand what you’re upset about?” And I think that’s really important. I think that’s one of the things, that when we see somebody that’s upset, one of the things we want to do is get away as quickly as possible, especially if we’re trying to get our rounds done all before 11 o’clock. So we’ve begun to listen. And often what we find is they’re upset, maybe not over the game plan that you have for your patient, they’re upset about everything. And it’s just an opportunity to vent. Or something that they didn’t understand because even though we’ve allowed them to participate in rounds, it doesn’t mean we’ve changed our conversation or that we’ve made it completely laypeople understandable. We’re still using some of the words that they really don’t know what they mean. Or they think they know what they mean and they’re unclear. And then again, empathize. And just say, “That’s understandable. I can see why you are upset.” And you explain why. And this is not -- I don’t want to say that we do this in jest. This is really how we have to approach our families for patient-centered care. We really have to listen to them. If our patients aren’t allowed to give us feedback and tell us what they want, then we are definitely paying attention to our families. And we want to make sure that they’re happy with the way we’re proceeding, that we work this out, because there’s mutual decisionmaking in patient-centered care. And then finally, we’re explaining the reason why we want to do it this way because, you know, sometimes, you find out there are cultural reasons why they don’t want something done, or they’ve had something done before with a poor outcome. And you may explain some of the safeguards that you’re going to use to make sure that you have a better outcome in the future.

And then your negotiation piece. So let’s agree on a path forward. And one of the things that comes out of this that I see is that we have more frequent conversations with our families. So not only do we take an opportunity to address them in rounds, but we’re having more family conferences so that everybody is on the same page and everybody understands. So that that way when we come in and something is completely unexpected, you don’t have to go through that terrible draining moment where somebody says, “You never told me this,” or “I don’t understand why this was necessary.” It happens a lot when patients start to deteriorate. We do things quickly, and we forget to inform the patients’ family. We’ve extubated them the night before, and they left, the patient was talking. They come back in, the patient is intubated and not only are they intubated, they’re on dialysis now because they’re septic, and we haven’t explained it to the family. So “I’ll talk with you in the future. I’ll keep you apprised,” or “Let’s set a time that I can talk with you every day,” to kind of gain their trust. And then with clinicians, again that listen component. “Can you help me understand how you see the situation and how you’re weighing the risks and benefits?” And we say in getting ready for CUSP and CLABSI, as you’re practicing and you’re having people walk the process, “value the dissenter.” And the reason we say that is we really want to understand what is it about the situation or about what you’re doing that they think isn’t going to go well. Chances are, if you know what they’re going to say, you can begin to plan for that so you have better implementation as you’re planning routine care on your average day, “These are the risks and benefits. This is why we decided to go this way.” And then this is also a great time to talk about a contingency plan. “If this doesn’t work well, this is our next step, or we’re going to be moving this or we’re going to get this consult,” so that they really feel they’ve been kept informed. Empathize. “I can see how you see it this way.” Like one of the things that keeps haunting me still to this day, and I have nursing students on the floor, is people still on general inpatient floors don’t stop to tell the nurse the plan for the day. Not for the patient. They don’t have the same daily goals form. Some of them have adopted a daily goals form and these aren’t issues, but you know, when you don’t keep the nurse informed or the resident doesn’t understand, they get a page and say “Hey, I need you to get the patient down to MRI in 15 minutes” and they never knew about it. Well, we can understand why they certainly are upset about it. “Let me explain how I see things”, and again, talk them through each one of the steps. If you’re already been negligent, the worst thing you can do is not explain to them step 1, step 2, and step 3. “First, I think we’re going to get the MRI. We’re going to make sure that they haven’t had this or that. Then we’re going to go back and we’re going to bring them back and we’re going to follow them for 24 more hours. I’d like to implement this protocol and I think we should start them on an antibiotic.” Let them know that you’re keeping them fully informed. And then negotiate. Let’s put the patient first and agree on a plan of care. So when you’re back there explaining what you would like to do, you’re still dealing with the conflict because they still may have questions. And they have an opportunity to express their feelings. And you need to listen to them. Again, this is mutual respect. And you both have an opportunity to explain your rationale. And then come together again, that sort of conservative response or collaboration, and agree on a plan of care as you move forward.

So those were four of the tools that Jill and I have used in the past. And a little bit about conflict resolution. We’re happy to open it up to questions and comments.

Operator: Ladies and gentlemen, if you have a question or comment at this time, please press the star key on your touch-tone. If your question has been answered and you wish to remove yourself from the queue, please press the pound key. Once again, ladies and gentlemen, if you have a question or comment at this time, please press the star and the one key on your touch-tone telephone. I’m not showing any questions at this time.

David Thompson: Gosh, Jill and I are great! No. If anybody does have issues, please feel free to send us an email or send your faculty rep or your research coordinator a question. We’d be happy to answer them. Anything else, Jill?

Jill Marshall: No, but I hope all of you heard something today that you can use. Try to think about how you might be able to use it personally if you’ve had a recent conflict situation, or think about the people that you work with and is there something that they could benefit from in this presentation. What would be an assertive and yet not aggressive and nonconfrontational way for you to let them know that this material is here? Perhaps you could point them to the On the CUSP Stop HAI.org website, so that they can listen to this presentation later. And good luck, everyone, in managing your relationships and your conflicts.

David Thompson: Yeah. We’ll be having another call on assertion a little bit farther down the line, more with appropriate assertion and training. Have a good day, everyone. Thank you.

Operator: Ladies and gentlemen, this does conclude today’s presentation. You may now disconnect.