Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Good afternoon, this is Sergio Cianotti, Chief Medical Officer for Sound Critical Care.
Speaker: I want to welcome you to our clinical webinar as part of our Critical Care Leadership Week for March 2024.
Speaker: And today we're going to talk about conflict resolution and healthcare.
Speaker: So I want to thank you for everything you do at the bedside, first and foremost, but also thank you for taking time today in your busy agenda to join me and to hear a little bit of my thoughts on what I consider to be a very important topic
Speaker: for us in sound critical care in healthcare in general, but also outside of healthcare.
Speaker: So the plan for today is to start with an introduction, some basic concepts on conflict.
Speaker: I wanna dive a little bit deeper into conflict in the ICU and talk about potential sources of conflict and also ways of deescalating conflict in the ICU.
Speaker: And finally, I wanna take a look at the
Speaker: a broader approach and learn from experts who have negotiated and mediated in conflicts around the world of great magnitude and try to find a framework that we can apply to conflicts of tremendous size, but also conflicts maybe that are a little bit smaller.
Speaker: And that is really focusing on what is possible if we work together.
Speaker: So we'll talk about moving to possible.
Speaker: As an introduction, why are we talking about conflict today?
Speaker: Well, when you look at data on conflict, 85% of employees at all levels experience conflict to some degree.
Speaker: It's a daily occurrence, either disagreements at the workplace, in transferring patients, in dealing with patients, with families.
Speaker: It could take other forms that are more toxic.
Speaker: But certainly as a clinician, I encounter conflict on a regular basis.
Speaker: But also when I wear my hat as CMO, I am often consulted for different types of conflicts in our programs.
Speaker: And what I realized is that the majority of people, this is data that showed that 53% or more of employees are handling toxic situations by ignoring them.
Speaker: So the majority of healthcare workers, the majority of people in general,
Speaker: Don't have good tools to deal with conflict and one of the arguments i'll make today, and I hope I convinced you is that.
Speaker: This should be a core competency of every ICU clinician having better tools to deal with conflict, I think, is a must.
Speaker: And there's data and there's science and there are frameworks that I think can be applied and can help us significantly when trying to move the needle towards what is possible and creating better outcomes for our patients, but also better careers and better days for ourselves.
Speaker: So what is conflict?
Speaker: I think a definition from the Merriam-Webster dictionary says conflict is a competitive or opposing action of incompatibles.
Speaker: antagonistic state or action as a divergent ideas, interest or persons.
Speaker: So in general, I think when we think of conflict, it has a negative connotation.
Speaker: And I think that is one of the reasons why so many people deal with conflict by avoiding it.
Speaker: Now, is conflict always bad?
Speaker: Or can it be good?
Speaker: And the reality is that we need conflict.
Speaker: We need conflict in the workplace to make our ICU safer.
Speaker: We need conflict in the workplace to advance our understanding of critical care.
Speaker: And we need conflict in the world to move things forward.
Speaker: The problem is not that we don't want to avoid all conflict.
Speaker: The problem is how do we handle conflict and how can we make it more productive and focus on making negative consequences less and trying to increase the positive consequences.
Speaker: So what are some of the negative consequences of conflict?
Speaker: It obviously diverts a lot of energy from work.
Speaker: I mean, I experienced that today.
Speaker: Threatens psychological well-being.
Speaker: I think it's a contributor to people being burned out.
Speaker: It wastes resources in many ways, creates a negative climate, breaks down group cohesion, and is really a destroyer of good psychological safety when it's not handled correctly, and can increase hostility and aggressive behavior at the workplace, but also throughout the world.
Speaker: But there's also positive consequences of conflict that is held, that is managed appropriately.
Speaker: It definitely leads to new ideas.
Speaker: Without a conflict of ideas, new ideas and new theories, new frameworks, new plans of treatment will not emerge.
Speaker: It stimulates creativity.
Speaker: Creative people are constantly in conflict with ideas.
Speaker: It motivates change.
Speaker: And I think as leaders, we've talked about this before, what we produce is change and hopefully change
Speaker: for a better situation for our patients and for our teams.
Speaker: It promotes fatality within a team or organization.
Speaker: It helps individuals and groups establish identities, and it serves as a safety valve to indicate problems.
Speaker: So if we can't bring up conflict in the ICU, it is very likely that patient safety will suffer because we're not identifying problems that need to be addressed.
Speaker: So my message here is conflict is common.
Speaker: We don't have good tools to manage it.
Speaker: And instead of avoiding it, what we should learn is to conquer it so that we can benefit from positive consequences of conflict and mitigate the negative consequences of conflict when it's poorly managed.
Speaker: As we move into what we need to do to manage conflict and learn these skills, I think like everything in life, it starts with knowing ourselves.
Speaker: And there are two basic,
Speaker: personalities or approaches to conflict.
Speaker: There's avoiders and there's seekers.
Speaker: And one is not better than the other.
Speaker: And we are programmed to be one or the other and recognizing that and understanding also what the other side of the equation is in the conflict helps us a lot.
Speaker: So avoiders usually are shy or shy away from conflict.
Speaker: Their values are high on harmony and positive reactions.
Speaker: They will try to placate people or maybe change the topic and avoid conflict.
Speaker: They don't want to disrupt team dynamics.
Speaker: And that's what really they value the most is a harmonious team.
Speaker: I'm an avoider.
Speaker: It's the way I'm built.
Speaker: And I think a lot of people I've encountered have that same tendency.
Speaker: So recognizing and being self-aware of how you are programmed, let's say from birth,
Speaker: to deal with conflict, I think is very important because it's an emotional intelligence tool that will allow you to put yourself in better positions.
Speaker: The other side of this equation are seekers, people who almost thrive when there's conflict or they seek conflict.
Speaker: These people usually value honesty and directness.
Speaker: That's what they value the most.
Speaker: And they're very impatient when they feel that you're not being direct or that you're not being honest with them.
Speaker: they will strongly advocate for their own interests and their positions, and they have no issues or qualms ruffling feathers.
Speaker: So I think it's very important to also recognize
Speaker: that some of our colleagues are programmed to be seekers.
Speaker: And like I said before, the key here is understanding and being self-aware.
Speaker: You don't have to try to be something you're not, because at the end of the day, what I'll show you today are skills that both avoiders and seekers can utilize to make conflict much more productive.
Speaker: So in the workplace and in general, there's four types of conflicts.
Speaker: They are task conflicts, which is a conflict over what needs to be done.
Speaker: There are process conflicts, which are conflicts over how we should do something.
Speaker: There are status conflicts, which are usually over who is responsible or who gets to make the final decision.
Speaker: And then there are relationship conflicts, which are usually personal conflicts.
Speaker: And what's important about relationship conflicts is that all the conflicts eventually end up being a relationship conflict, right?
Speaker: But a lot of them might start as a task conflict, a process conflict,
Speaker: or a status conflict, but very quickly if we are unable to resolve or de-escalate the situation, it will escalate to a relationship or personal conflict.
Speaker: Understanding this is important because you can see that the different types of conflict, right, are different things.
Speaker: So in relationship, it's a clash of personalities.
Speaker: An example would be your counterpart interrupts and talks over you in meetings.
Speaker: The outcome, if you get it right, is better understanding of your counterpart and improved relationship.
Speaker: When we talk about process, a disagreement over how to carry out a project, an example would be you think it's important to rule out a new initiative quickly, even if it means sacrificing some quality, while your counterpart believes it needs to be perfect before it hits the market.
Speaker: If you get this conflict right, you will have better process for innovation,
Speaker: and there's more potential solutions to any problems that arise.
Speaker: So as you can see, in each one of these, there are examples, but also what's important is that they will occur.
Speaker: That's guaranteed.
Speaker: So the key here is if we learn to recognize them and work with them, we will be able to have a positive outcome and benefit from the conflict.
Speaker: And that is ultimately what we want.
Speaker: Thomas Kilman h ave a
Speaker: proposed a very commonly quoted modes of conflict responses.
Speaker: So basically the idea being this is what these are the ways that we can actually improve, deal with conflict.
Speaker: So you can avoid conflict and that is usually a lose-lose.
Speaker: And you can compete
Speaker: which usually is I'm right, you're wrong, and that's a win-lose.
Speaker: You can accommodate, that is I lose, you win, you're right, I'm wrong.
Speaker: Or you can collaborate, which is a win-win, let's work together.
Speaker: And sometimes in between collaboration is compromising, which is a win-win, we find the middle ground.
Speaker: What is interesting is that these are plotted against two axes, one of assertiveness or the concern for your own needs,
Speaker: and when on cooperatives or your concerns for the relationship or the other person needs.
Speaker: So at the end of the day, obviously sometimes if the conflict is very minimal, you might choose to avoid it.
Speaker: Sometimes, I mean, in situations, competing might be the way to go and sometimes you have to accommodate.
Speaker: But ultimately I think the goal is to as much as we can is to create shared meaning and collaborate so that we can increase the size of the pie, right?
Speaker: and not a zero sum game, and both sides can win and benefit from the conflict.
Speaker: So the second part of this presentation is going to focus on conflict in the ICU.
Speaker: Obviously, this is, I think, a very highly charged place for many reasons, but it is very common to encounter conflict in the ICU.
Speaker: Now, conflict in the ICU can occur between the ICU clinician and the family.
Speaker: Sometimes it might be between the ICU clinician and the patient.
Speaker: Sometimes it might be between the family members themselves, and we are part of that or dragged into that.
Speaker: It also occurs in between ICU team members.
Speaker: So it can be the physicians with the nurses, the APP with the nurse, APP with the physicians, physicians amongst themselves, APPs amongst themselves with RT.
Speaker: And it's not uncommon, especially in situations like COVID where inter-team conflict might increase.
Speaker: Another common source of conflict is with other healthcare teams.
Speaker: So with a surgical consultant, with a surgical team, with the oncology team, and these are all sources of conflict that we encounter almost on a daily basis.
Speaker: Now, not all the disagreements generate conflict, and we'll talk about that, but I do think it's important to recognize that conflict in the ICU is not only common, but it can also
Speaker: it can also increase significantly when we have situations of crisis such as COVID.
Speaker: This is a recent review that really quite expansive that identified pre-COVID, during COVID papers that talked about conflict.
Speaker: And what you can see here, obviously, is that there's a whole bunch of groups within the ICU or the hospital.
Speaker: And ultimately, there are
Speaker: and blue mitigating methods for conflict like training, which we're doing today, and for managing stress, reinforcement of personnel, identifying opposing parties and backgrounds of the conflicts, calling out what the conflict is, and collaborative decision making.
Speaker: On the other hand, there are factors during the crisis that escalate the likelihood of conflict, and those include scarcity of resources,
Speaker: overwhelmingness of workload, inadequacy of compensation as perceived by some people, shortage of staff, discrepancies in opinions when we don't have a clear path of how to do things.
Speaker: And all of these are present, I think, on a regular basis, but they're much more obvious or much more preponderant during crisis like the one we suffered during COVID-19.
Speaker: Ultimately, why is this important?
Speaker: is because this has an impact that's very negative or can have a negative impact on our patient care, on our satisfaction with our job and burnout, on our well-being, and also has been, I think, one of the reasons why we have increased turnover.
Speaker: Whenever there's a toxic environment, there's a lot of conflict in an ICU that's not resolved, the turnover will increase.
Speaker: So obviously this is a problem for any practice that has that issue.
Speaker: This is a wonderful review article published in Critical Care Medicine a couple years ago.
Speaker: A good friend, Joshua Kaiser from University of Pennsylvania and Louis Kaplan of Surgery who passed president of SCCM wrote this.
Speaker: And just, I mean, to bring from, you can look at the reference when we send the slides, but clearly there are different triggers that are very frequent in the ICU, such as communication breakdowns, lack of information for families, high emotions, empathy,
Speaker: family dynamics, who gets to decide, biases and stereotypes that sometimes we have in terms of what we think should be done or how we perceive certain people, health disparities.
Speaker: We talked about that in a recent clinical webinar.
Speaker: There is good evidence of health disparities and end-of-life discussions, which are a frequent source of conflict in the ICU, cultural differences and end-of-life disputes, goals, values, there's a distrust to the medical system,
Speaker: We saw that delta wave and beyond in COVID, significant turns in how people were thinking of the medical system.
Speaker: Chronic illness can also be a trigger, caregiver disagreements.
Speaker: And then there's policies that we might question, the family might question, and all these are triggers.
Speaker: But what I wanted to share also from this particular paper, and I'm not going to talk about that too much, but we do have resources outside of conflict management techniques.
Speaker: So I'm going to focus on the things that we can do, which are conflict management techniques.
Speaker: But I do think it's important to recognize that when there are end-of-life issues, we can consult supportive medicine, palliative care with ethical issues.
Speaker: Most of our ICUs or hospitals have clinical ethics consultation.
Speaker: So getting those third parties involved early, I think, can be very, very helpful in helping resolve conflict.
Speaker: And then even for conflict mediation, sometimes we might involve
Speaker: a supportive care or palliative care consultation because they do have a lot of skills in really navigating these issues.
Speaker: When conflict arises in the ICU, there's a cycle that starts looming.
Speaker: And that cycle, as it accelerates, can really lead, I think, to a very difficult position for everybody involved.
Speaker: So conflict originates.
Speaker: The first thing that happens is we have a communication breakdown.
Speaker: people are entrenched in their positions.
Speaker: That creates a lot of moral distress on all sides.
Speaker: And ultimately that leads to disengagement.
Speaker: And that will only accelerate or feed into the conflict.
Speaker: And we really get into a vicious cycle that needs to be broken as soon as possible.
Speaker: So how do we break the conflict cycle in the ICU?
Speaker: I think there's three steps that we need to take.
Speaker: The first step is develop situational awareness.
Speaker: The second step is separate positions from interest.
Speaker: And this is perhaps one of the most important take home messages that you can take from this talk today.
Speaker: And we'll talk about that in a second.
Speaker: And finally, deescalate conflict with relational communication skills.
Speaker: I think that one of the biggest problems we have in hospital is that as conflict erupts, people escalate very quickly.
Speaker: as opposed to trying to put a pause and de-escalate so that we can get to a position where we can have a better conversation.
Speaker: In terms of developing situational awareness, I think it's important to recognize that conflict involves emotions.
Speaker: If there's no emotions, it's not usually conflict, it's just a disagreement.
Speaker: And they're two separate things.
Speaker: right, because we can agree to disagree on things that are not emotionally charged.
Speaker: But when emotions are present, we are probably in the realm of conflict.
Speaker: So recognizing that early, I think, is very important.
Speaker: We talked about some of the triggers for conflict, and we should be aware of those when they occur.
Speaker: Other things like sleep deprivation, fatigue, right, bad issues at home, all can also trigger somebody to be more predisposed
Speaker: to get into an escalating conflict situation.
Speaker: And what we wanna do is hopefully diagnose impending conflict and deescalate before it becomes too complicated.
Speaker: But sometimes we're already in the midst of conflict and recognizing that is gonna be a problem.
Speaker: The other thing that might happen with situational awareness is that you walk into a situation
Speaker: and very quickly realized that there's a lot of conflict going on and now you're part of that, right?
Speaker: That might be you picked up the service and the family is very angry, very, very upset with the team.
Speaker: So definitely the first step in de-escalating conflict in the ICU is developing situational awareness.
Speaker: You have to recognize conflict as soon as possible.
Speaker: The second, and which I said is one of the things that I really want you to take home today,
Speaker: is being able to differentiate between positions and interest.
Speaker: Positions is what I want.
Speaker: Interest is why I want that.
Speaker: So when the family says, we want our father to receive dialysis, that's a position.
Speaker: But if you dig a little bit deeper, the interest is we're trying to do everything we can to save him, right?
Speaker: We want him to live.
Speaker: we have a lot of things we need to resolve before he dies.
Speaker: So people usually fight over positions, but what we find is that we dig a little bit deeper, we have a lot of common interests and we can find common interests.
Speaker: And that is usually what is most important.
Speaker: So being able to differentiate positions from interest, I think is also a great way to start de-escalating conflict.
Speaker: Finally, we talked about utilizing what we call relational communication.
Speaker: And these are some of the skills.
Speaker: And like many of the skills that we talked about in previous webinars, emotional intelligence, and many others, these are skills that can be acquired.
Speaker: These are skills that we can all learn.
Speaker: And I do believe that it's part of developing that competency and being better at dealing with conflict in the ICU.
Speaker: So skill number one and the most important is active listening.
Speaker: Reframing or restatements to demonstrate you have heard what they are saying and are engaged.
Speaker: Doctors in particular are very bad in listening.
Speaker: There is abundant evidence that suggests that they usually I think it takes 20 seconds before they interrupt a patient or a patient's family.
Speaker: So that is not active listening.
Speaker: Waiting for your turn to reply why somebody is wrong is not active listening.
Speaker: But really to be engaged in trying to understand.
Speaker: So listening to understand is active listening.
Speaker: Being inquisitive.
Speaker: Right, being curious, asking questions to probe the individual's concern and better delineate positions and interest.
Speaker: I think we're always fast to give a solution or our opinion, but perhaps we should be a little bit more curious and try to understand a little bit of the interest for the positions that they're holding and where they're coming from.
Speaker: Empathizing, acknowledging and validating and respecting the individual's struggle, right?
Speaker: I can validate you without necessarily agreeing
Speaker: right, with everything you're saying.
Speaker: But if you're having a hard time, validating that, I think, is very important.
Speaker: And I think in terms of empathy, one of the things that comes most frequently to my mind is when I get a sign out or somebody refers to a difficult family, I try to reframe that in my own mind as this is probably not a difficult family.
Speaker: This is probably a family in a very difficult position.
Speaker: And they're very different things.
Speaker: And I think it really changes the tone of how I approach them.
Speaker: Acknowledging perspectives, right?
Speaker: Messaging the plurality of moral positions around decision making.
Speaker: So there is something known as a moral position, which is what you think morally is right.
Speaker: But there's also something called moral aporia.
Speaker: Moral aporia is when there is not a clear moral stance that everybody agrees on.
Speaker: So morality, I think, sometimes can have different perspectives.
Speaker: And what you think is the right thing to do might not be what the other side thinks is the right thing to do.
Speaker: And understanding that and acknowledging that, I think, is a great way to deescalate conflict.
Speaker: Naming emotions, and we'll talk about that a little bit more in the next slide.
Speaker: So we said that conflict is charged with emotions.
Speaker: So being able to identify what you're feeling, but also what other people are feeling and respecting that primary emotion driving the conflict, I think, is very important.
Speaker: Abandoning the moral high ground, which goes back to that moral aporia recognition, right?
Speaker: Even if you're right, telling them you are right will further inflame and alienate the dispute.
Speaker: Plus, you might be wrong.
Speaker: So I think that, again, moving from a position to an interest, I think that can be commonly is very important.
Speaker: Righting wrongs, I think that if something happened to the family that is wrong, we should acknowledge that.
Speaker: And we should tell them how we're going to fix it.
Speaker: And then compromising is trying to find common ground as we try to find a win-win moving forward.
Speaker: So when we talk about emotions, this is a vital talk, is a phenomenal organization.
Speaker: They have a tremendous amount of education and you can go to the website, very useful during COVID also, but it's all about how do we communicate and how do we talk with people in the healthcare environment when we're talking about very crucial conversations such as end of life,
Speaker: giving bad prognostic information, telling somebody their loved one died.
Speaker: And this is a great acronym, NURSE, for responding to intense emotions.
Speaker: So naming the emotion being expressed.
Speaker: So for example, you would say, it seems to me that you are very angry.
Speaker: Is that how you're feeling?
Speaker: Or many people in your situation would be devastated.
Speaker: Is that how you feel?
Speaker: So really trying to name and give a name to that emotion.
Speaker: Use for understanding.
Speaker: Demonstrate appreciation of the emotion.
Speaker: And I think normalizing what they're feeling.
Speaker: You're not alone in feeling this way.
Speaker: This is a very common way people feel in this situation, right?
Speaker: We've seen maybe this story play a thousand times.
Speaker: But for them, it might be the first time.
Speaker: And in the ICU, what I always tell people is we meet people often on the worst day of their lives.
Speaker: So remember that.
Speaker: Respecting, right?
Speaker: Express praise for how they are handling the emotions.
Speaker: I recognize how hard this must be for you, but you're doing a phenomenal job advocating for your husband, right?
Speaker: I mean, respecting and praising how they're handling their emotions.
Speaker: Supporting, making sure that patients and families know that we are there with them, that we'll get through this together, and that we'll help them.
Speaker: And then exploring, which is explore the emotional state at the time.
Speaker: I imagine this has been tremendously difficult.
Speaker: How are you doing?
Speaker: Tell me a little bit more.
Speaker: And I think it's just a way of deescalating highly charged emotional situations.
Speaker: And it's connecting with another human being, right?
Speaker: And I think that, like I said, if we really think of the interest, often they overlap and are very similar.
Speaker: So once you're in a better position and deescalated the
Speaker: the emotion and the state of the conflict, I think it's a lot better to try to move to collaboration or a compromise, right, and trying to move forward and really creating a path forward.
Speaker: And we'll talk about that a little bit more at the end in the last portion of our talk.
Speaker: So one of the most common conflicts we encounter in the ICU is with families.
Speaker: And I think that this, that I just covered includes families, includes obviously when we have maybe disagreements with our teams and within our team, but there's another type of conflict that unfortunately is all too common in the hospital and in many other work areas.
Speaker: And like they say, there is an I in team and it's in the A-hole, right?
Speaker: So dealing with disruptive behavior.
Speaker: And that is a great source of stress for many healthcare providers.
Speaker: It is something that I get involved with on a regular basis.
Speaker: And it's something that I've been thinking a lot about lately.
Speaker: And the reality is that at the end of the day, we could do a whole different talk of that.
Speaker: But I did feel that it would be
Speaker: disingenuous to talk about conflict in healthcare without addressing this particular problem, which is very toxic in a lot of situations.
Speaker: So disruptive behavior or A-holes is behavior that interferes with work or creates a hostile environment.
Speaker: And we do know that not only that creates problems for the individuals who are in that environment, but it is a clear marker of a place that is not psychologically safe and it's associated with worst patient outcomes.
Speaker: So I think we have an obligation to our patients, but also to ourselves and our coworkers to do everything we can to deal with these disruptive clinicians in the workplace.
Speaker: So examples would be verbal abuse, sexual harassment, yelling, profanity, vulgarity, threatening words or actions.
Speaker: Those usually, I mean, require immediate action and intervention.
Speaker: unwelcome physical contact, threats of harm, behavior, reasonably interpreted as intimidating, same thing.
Speaker: But then there's a lot of passive aggressive behaviors, sabotage and bad-mouthing colleagues or organizations.
Speaker: And we see different versions and tones of this.
Speaker: And I think it's very important for us to find out how to deal with it.
Speaker: So Hickson has been, he's from Vanderbilt.
Speaker: He's an internist from Vanderbilt with a lot of experience in disruptive behavior.
Speaker: And this is a very classical, a classic paper in academia.
Speaker: that looks at a framework for approaching the strip of behavior in the clinical setting.
Speaker: And the vast majority of professionals have no issues.
Speaker: The vast majority of people that we work with are fine.
Speaker: They are professional, they try to do their best, and they're trying to build a better environment.
Speaker: The problem is that it takes one bad apple to rot the whole case
Speaker: And we have all probably encountered or seen or heard of truly toxic personalities that create a lot of problems.
Speaker: So the way he has approached this is if there's a single unprofessional incident.
Speaker: So first of all, in red are mandated issues that need discipline immediately.
Speaker: So that's anything that's physical, anything that has sexual harassment.
Speaker: anything that is truly intimidating, that needs to be escalated immediately, right?
Speaker: But most of what we see is lower than that, but it still builds a lot of toxicity over time.
Speaker: So if you see a single unprofessional incident, that really requires an informal cup of coffee intervention.
Speaker: Somebody should sit down and usually it's going to be the leader of the team to talk with that person and ask them questions.
Speaker: What happened?
Speaker: What were you thinking?
Speaker: How are you feeling?
Speaker: And the truth is that
Speaker: everybody has a bad day once in a while.
Speaker: And the thing that's also true is that most people initially might get defensive, but eventually they realize the impact what they did had on other people and on patient safety, most people will try to behave better and will try to improve.
Speaker: So that is, I would say, 20% of situations.
Speaker: If after that informal talk, there seems to be an apparent pattern of complaints and things are escalating,
Speaker: I think a level one intervention, which is an awareness intervention where you actually show them the complaints and how they compare to their peers is very important.
Speaker: And again, focusing on the facts without judgment, but also on the impact they have on the team, on their patients and what they're trying to approve.
Speaker: Now, people who have a pattern usually don't like when they're confronted.
Speaker: And I think it's very important for us in order to have a pattern for people to be honest when they are reporting disruptive behavior, right?
Speaker: If we observe disruptive behavior or we suffer disruptive behavior, we need to report that in an objective way that does not have any judgment but can always describe what we saw or we observed
Speaker: And if we were involved, we can describe how we felt.
Speaker: But I think that without putting labels on the behavior on the person, we have to document because without documentation, we can't move up this pyramid.
Speaker: So once there's a pattern, I think the person has to be made aware.
Speaker: You might even put that person on some sort of PIP, which is a performance improvement plan.
Speaker: But if the pattern persists, now you need an authority intervention that needs to be escalated.
Speaker: usually can be in an academic setting to the head of a department, to the dean, in a hospital, might be the CMO, the CEO, but really starts escalating in terms of the intervention.
Speaker: And there are some things that the individual might need to do in order to stay in good standing or stay working at that place.
Speaker: And ultimately, if the pattern still does not change, then there's discipline intervention that really can escalate to reporting to national
Speaker: and state boards and others and that might include with removal of license or privileges at a given hospital to removal of their license to practice medicine so as you can see there are these scales that need to go up and we need to be able to be part of that now what i would say is that we have to start with a conversation because i do believe that most bad situations happen despite it because people are
Speaker: unaware of the impact they have and it won't repeat itself.
Speaker: But when there's patterns, if somebody is not willing to change or doesn't have the emotional intelligence and the self-awareness to realize why they have to change, we've all met these people.
Speaker: They're always blaming others.
Speaker: It's always everybody else is an idiot by themselves, right?
Speaker: And I think that we need to document and we have to document accurately.
Speaker: We have to document without judgment.
Speaker: And we have to document consistently because that's the only way that eventually we will be able to escalate this.
Speaker: Now, unfortunately, in medicine, there's been a tradition of tolerating some of this behavior, especially for high revenue subspecialties, right, that bring a lot to the hospital financially.
Speaker: But I think times are changing, and I think that if we document appropriately and we don't escalate, right, we don't get into their games,
Speaker: I think that we definitely over time will be able to either change their behavior or make sure that that person is no longer in that position.
Speaker: So a lot, this is very distressful, but what I would also say is that there is another angle of this and that is when you see unprofessional behavior, focus on the victim.
Speaker: We are leaders in the ICU.
Speaker: And we should always, always protect our team.
Speaker: Right.
Speaker: So I think that dealing with these people sometimes is very deflating, very difficult.
Speaker: But I think if we take it as an obligation to help others and be the first to speak up, the first to bring it up, others will follow suit.
Speaker: So this is a great quote from Eli Weasel, a Holocaust survivor.
Speaker: And I think that the silence of the bystander is a problem.
Speaker: and we should not permit that in our in our icus so finally i think that in the last couple of minutes in the last segment i want to focus on moving to possible right so um there have been all sorts of conflicts around the world and that we can learn from and i think that learning from them and applying that to medicine is the best way to to to grow i always say that innovation
Speaker: is nothing more than just bringing an idea from another area to your own.
Speaker: So this is William Ury.
Speaker: He's an American author and academician.
Speaker: He's an anthropologist who is a negotiation expert.
Speaker: And he has written several books on negotiation.
Speaker: He founded the Harvard Program on Negotiation.
Speaker: He helped found the International Negotiation Network with President, former President Jimmy Carter.
Speaker: And he's been involved in negotiations in Venezuela, in the Gaza Strip, in South Africa, all over the world, in labor disputes, averting wars, and really has, with Colombia and the FARC, has an enormous, enormous wealth of knowledge and has distilled everything he's learned over his very illustrious career into what he calls the BB3,
Speaker: method or basically the balcony bridge and third side path to possible.
Speaker: And I want to share with you a little bit of this because I think it's a great framework to think about.
Speaker: And again, depending on where your conflict lies, you might apply parts of this, but I think all of them are very, very relevant to healthcare and to the ICU.
Speaker: So the balcony, you go to the balcony, that's a term that a lot of people use.
Speaker: And he talked about that in one of his old books with
Speaker: with Roger Fisher, another famous Harvard academician that studied conflict.
Speaker: And basically the idea is to move away from the dance floor and go to the balcony to see what's happening, right?
Speaker: But the balcony focuses on the I. So it's an intervention for yourself.
Speaker: Building what they call the golden bridge focuses on the you, on the other side of the conflict.
Speaker: And finally, involving the third side,
Speaker: is the us or everybody else who is part of the conflict.
Speaker: So let's use this as an example in the ICU.
Speaker: I have a dispute with a CT surgeon.
Speaker: Going to the balcony works on myself.
Speaker: Building a golden bridge is trying to engage the CT surgeon on a collaborative solution.
Speaker: And going to the search side might include the rest of the ICU team, the nurses, the APPs,
Speaker: the patients, their families, and really looking at how they will respond and how they can be part of that solution as well.
Speaker: So that is the path to possible.
Speaker: This is a famous Latin saying from time of the Romans, Omnitrium perfectum, which says that everything that comes in threes is perfect.
Speaker: And for those of you who know my affection to the number three, you'll understand.
Speaker: But these are three things we need to do.
Speaker: Balcony, bridge, and third side.
Speaker: And each one has three steps.
Speaker: So the balcony is pause, zoom in, and zoom out.
Speaker: The bridge is listen, create, and attract.
Speaker: The third side is host, help, and swarm.
Speaker: And there are phenomenal lessons here.
Speaker: I'm not going to go into detail into each one of these.
Speaker: But I do think that let's start with the balcony.
Speaker: So the first thing you must do when you recognize your emotions are flaring and you're in a situation of conflict is to pause.
Speaker: Breathing is a very powerful tool to ease stress.
Speaker: There's different types of breathing.
Speaker: I like to do box breathing, but there's different things.
Speaker: Take a break, walk away for a second, walk.
Speaker: And sometimes, I mean, you even wanna retreat or you wanna take your group for discussion to a separate room.
Speaker: But the pause,
Speaker: is about creating space between input and output, right?
Speaker: Something that Viktor Frankl talked about very eloquently.
Speaker: And I think it allows you to deescalate your own state, right?
Speaker: When adrenaline is high, through our survival instinct, our options are very narrow.
Speaker: When we can lower that and pause, our options become broader.
Speaker: And that is the first step, and this is all about yourself.
Speaker: In every conflict, you are usually the worst enemy for resolution.
Speaker: So if you can control your own emotions and you can deescalate within yourself, you're going to be in a much better position to lead that conflict to a better place.
Speaker: The second practice is to zoom in.
Speaker: And zooming in is all about understanding positions and interest, right?
Speaker: Asking why five times.
Speaker: Why is this a problem for me?
Speaker: Because of this.
Speaker: Why?
Speaker: Why?
Speaker: And ultimately, you get to deep human emotions and needs like fear, the need to support my family, what I want for my patients, my dad is dying, right?
Speaker: Listen to these emotions as signals.
Speaker: And also, this is a good time to think about what does the price look like, right?
Speaker: Write down the top three interests in your negotiation that you think would be the best outcomes from your side.
Speaker: And the third practice of the balcony is now to zoom out.
Speaker: So there is a very famous concept in negotiation that actually Roger Fisher and William Uri created called the BATNA.
Speaker: BATNA is the best alternative to a negotiated agreement.
Speaker: So what happens if you walk away?
Speaker: And whoever holds the best BATNA holds the leverage sometimes in the negotiation.
Speaker: But knowing your alternatives before you start dealing with a conflict, I think will help increase your chances of having a satisfying result.
Speaker: map all the stakeholders you might be dealing with only one party but there are other stakeholders in that conflict and one also great great exercise to do in the zoom out is to sketch three future scenarios both positive and negative to optimize how you prepare as you move forward great example of going to the balcony the cuban missile and missile crisis many many times
Speaker: we were at the edge of nuclear warfare.
Speaker: The fact is that when the blockade was started, the Cubans did have nuclear missiles in, sorry, the Russians did have nuclear missiles in Cuba.
Speaker: A lot of times Kennedy was given advice by his military that could have triggered a war.
Speaker: What did he do?
Speaker: He took time, he went to the balcony, he paused, he zoomed in, understood what was important for him.
Speaker: He zoomed out, understood what was important for the other side,
Speaker: and really I mean took us down a path of de-escalation that ultimately resulted in an agreement that where both sides could save face and both sides got interest that were of knowledge.
Speaker: So phenomenal example I think in a very critical time in our in our recent history that if he wouldn't have, if people would not gone to the balcony like Kennedy we would have ended probably with millions of people dead.
Speaker: The second
Speaker: part of the path to possible is building a golden bridge.
Speaker: And the first step here is to listen.
Speaker: Listen to the other side and listen to convey respect and reflect back what you hear and be inquisitive.
Speaker: The best negotiators are not those who talk a lot, but are those who listen the best.
Speaker: And I think that this is something that we could all utilize at the bedside as well.
Speaker: If we truly listen to the other side, if we listen to understand, I think we're much more likely to get to a better place and we start building a bridge that might take us to better possibilities.
Speaker: The second example, or the second step in building the bridge is to create, which is to identify some low cost for me but high value for the other side things that we can give them, right?
Speaker: Start creating that trust.
Speaker: Reframe that we both have, both sides have power
Speaker: to find better solutions for their interest.
Speaker: Not the positions, but for the interest that we're trying to achieve, right?
Speaker: And really it's being very creative with our teams and with our side and coming up with potential offerings or solutions for the other side.
Speaker: And finally, the third step of building the bridge is to attract.
Speaker: What do we do in negotiations or in conflict?
Speaker: We push.
Speaker: When you push somebody, what do they do?
Speaker: They push back.
Speaker: right?
Speaker: So we have to change that dynamic and we have to attract them.
Speaker: And we do that by building trust on the other side, building on the other side's ideas, right?
Speaker: If they have an idea, how can we build upon that for something that works for us, right?
Speaker: Address perceived fairness.
Speaker: And I think that it's a great way of building that bridge and making sure that we're moving in the same direction.
Speaker: When we look at leaders and conflicts, perhaps one of the
Speaker: greatest examples of building a golden bridge was Nelson Mandela and the clerk, how Nelson Mandela actually navigated the relationship with the clerk and ending apartheid and moving South Africa forward as a democracy.
Speaker: He listened to the concerns that the Afrikaners had, he created a golden bridge, and ultimately he attracted the other side to a peaceful negotiated solution
Speaker: And ultimately the clerk served on his cabinet as well.
Speaker: So I think a masterful example of how building a bridge ultimately resolved a tremendous injustice, but also put the country on a path for democracy that a lot of people thought was gonna be impossible.
Speaker: Finally, the third side, right?
Speaker: And here it's about listening to each side.
Speaker: People wanna be included, wanna be felt that they are heard,
Speaker: want to be seen, right?
Speaker: And a lot of conflict ultimately is because we don't feel that people see our dignity.
Speaker: And there are some very interesting examples of hosting.
Speaker: So the Kua are a New Guinea tribe that is very famous for using poisonous darts.
Speaker: When there's a dispute among two members, the families get involved, they hide all the poisonous darts, and the whole tribe gets together.
Speaker: and puts the two people in conflict in the middle and basically they create a community, right, that listens and tries to foster an environment where they can resolve their differences.
Speaker: So really understanding the third side or the bigger picture of a conflict, not only who's at the negotiating table.
Speaker: In terms of practicing help, it's really getting other people involved that can help us that maybe they are
Speaker: There's a third party that is trusted by both sides or somebody that works with both sides.
Speaker: And how do we get them involved?
Speaker: In an example with a family, we might be involving a third party such as like the supportive medicine team or the ethics team.
Speaker: A lot of conflicts have used a technique called the one text where there's one text that starts hammering out
Speaker: what the agreement will look like and people edit back and forth, back and forth, but you always work on one document on both sides.
Speaker: And there's different ways that you can really, I mean, elicit help and bring other sides to the third side.
Speaker: And then Swarm is really about making sure that both teams feel that there's groups that have access, credibility, and trust.
Speaker: And you create a Swarm team where everybody's coming up with new ideas to try to solve the problem.
Speaker: There's this idea that Uri talks about, which is the seven touches, which the right idea
Speaker: to the right person at the right time.
Speaker: People often need to hear an idea seven times before they really are ready to move into a yes.
Speaker: So really building that winning coalition with people that may be beyond those that are at the negotiating table.
Speaker: A great example of bringing in the third party in the 1980s, there were a series of basically strikes in coal mines in West Virginia.
Speaker: it was becoming very problematic.
Speaker: A group of negotiators was taken.
Speaker: They negotiated an agreement between the mine leadership and the union leaders.
Speaker: They thought they had a perfect agreement.
Speaker: And then when they took it to the miners, they rejected it because they were not part of the conversation.
Speaker: So this is an example of failing to see the third party of who actually the conflict was about.
Speaker: So what they did is,
Speaker: Some of the negotiators stayed for months with the miners and eventually heard their grievances.
Speaker: They slowly built trust and at the end implemented the items on that agreement one by one as they were ideas by the third party, which was in this case, the miner.
Speaker: So a lot of times the people at the table are not the only stakeholders and making sure that the whole community is involved in participating is also very, very important.
Speaker: So,
Speaker: I think this is a great framework and there's lessons here that you can apply to any conflict that you encounter in the ICU.
Speaker: Going to the balcony is about checking yourself.
Speaker: It's about the eye, right?
Speaker: Bringing down the decibels and trying to understand what are you trying to achieve.
Speaker: The bridge is about the other side or the you, right?
Speaker: How do we build a bridge that ultimately creates trust and attracts them towards a collaborative stance?
Speaker: And the third side is about the us and involving
Speaker: more than just the people at the table, but all of those who are involved in the conflict or who might benefit from solutions or who might be hurt if the conflict persists.
Speaker: So we talked about some basic concepts on conflicts.
Speaker: I think what we can say is that conflict is very common, that we're not very good at dealing with it, yet we want to improve our skills and make it a competency
Speaker: because there are benefits to resolving conflict and avoiding negative outcomes, but also there are positive outcomes that result from conflict that is well managed and well handled.
Speaker: We talked about conflict in the ICU.
Speaker: And as we saw, a lot of the conflict revolves around families and ICU team, but there's plenty of conflict within the ICU team, ICU teams with other teams.
Speaker: And again, I think that figuring out how to collaborate and how to move in the right direction is very important.
Speaker: A very unique form of conflict in the workplace and in healthcare is toxic behavior or disruptive behavior, which we need to stop because it impacts well-being of our colleagues, but also perhaps, I don't know, more importantly, but as importantly, impacts patient outcomes.
Speaker: And we talked about some models to use of that and why, even though it's hard, we have the obligation as leaders to step up and help move in the right direction.
Speaker: And finally, I think we took some lessons from very, very seasoned mediators of conflicts and created a path to possible.
Speaker: In the world of conflict, it's not about avoiding it, it's not about resolving, it's about creating more possibilities.
Speaker: If we believe that we're in a zero sum game, the only way I win is if you lose.
Speaker: But if we think that we can actually increase the size of meaning, right, increase the pool of common interest,
Speaker: we both can win.
Speaker: And that is what's possible.
Speaker: And if it's possible in some very protracted and very big conflicts, I'm sure it could be possible in our day-to-day, in our ICUs, in our clinical practice.
Speaker: So with that, I really want to thank you for your time.
Speaker: If you want to know more, these are some recommendations of some phenomenal books.
Speaker: Some are old, some are brand new that I think might be of interest.
Speaker: Nonviolent Communication from Marshall Rosenberg, Getting to Guess, that is Roger Fisher and William Ury, Possible that came out last week, phenomenal book by William Ury, that's where he really outlined all his experience in this BB3 method, Crucial Conversations.
Speaker: We have a course for our clinicians on Crucial Conversations within Sound, and then the Anatomy of Peace, which is the Arbinger Institute
Speaker: And again, these have stories of highly charged conflicts, but the basic elements of the conflict, the type of conflict, the issues that evolve and how people behave are the same in the ICU or in a situation that leads in war.
Speaker: And I think understanding that human part is a skill and utilizing some of these techniques to move things forward, I think can be a very useful competency for all of us.
Speaker: So with that, I just want to thank you for your time.
Speaker: And I have a couple minutes.
Speaker: If there's any questions, I'll monitor the chat box or any comments.
Speaker: And again, really appreciate everything you do at the bedside and hope to see you soon again in one of these conferences.
Speaker: Thank you.
Speaker: So there's a question regarding what happens with toxic personalities when the hospital seems to protect them.
Speaker: And I think that we did mention that at the beginning.
Speaker: There are some perhaps clinicians that because of the investment the hospital has made in that program or in that person and the expectations they have of what they can generate or the value they can bring, people are going to have a harder time seeing maybe when there's problems.
Speaker: I think that the best way is to document very objectively without judgment, describe the facts, to speak up.
Speaker: to make sure that we bring it to the attention of the right people, especially when there's a pattern that we also address the issue with the person.
Speaker: A lot of times that I think would be the first step or bring it up to people who can address it with that person.
Speaker: So I think that it's not an excuse not to raise our voice.
Speaker: It's not an excuse not to share.
Speaker: So there's a question regarding, again, a copy of the PowerPoint.
Speaker: We will send an email with the PowerPoint and with a recording.
Speaker: So you should receive that.
Speaker: Yes, the answer is absolutely you can receive it.
Speaker: And if you put it in show mode, you can click some of the links and it will take you to those places.
Speaker: So another question is why do you think it's so hard to deal with conflict?
Speaker: Well, I think that because people don't feel safe, right?
Speaker: So if you have a psychologically safe team,
Speaker: a lot of times conflict is resolved in a very easy way, right?
Speaker: But when people don't feel safe either to speak up or they feel that they're going to be recriminated, I think it's a lot more difficult and we try to avoid it.
Speaker: But the problem is that we avoid conflict on a regular basis and the same situation occurs and occurs, it becomes very difficult to move forward.
Speaker: And ultimately, I think it has a toll on a lot of us, right?
Speaker: A lot of our suffering is in our own minds.
Speaker: it's the stories we tell ourselves so we shouldn't believe everything we think but i do think that uh that uh that that is one of the reasons why it's so hard to deal with this and i think that even people who who um even people who uh who bring up uh who are seekers right that doesn't mean that they have the skills to resolve conflict
Speaker: They might just, I mean, engage because of their values.
Speaker: But again, having the skills to resolve and to move conflict forward, I think is very important.
Speaker: So what is the best way to address APP, MD conflict regarding disrespect from physicians to APPs?
Speaker: I think the best way, in my opinion, or the first step I would take is to address it individually with the person, if you observe it or if you're part of it, and focus on interest and positions.
Speaker: focus on the impact that somebody's behavior is having on you or on somebody else.
Speaker: If that doesn't help, I think the next thing is to escalate.
Speaker: There might be a pattern.
Speaker: I think most people respond to that and they don't really see that they're doing that.
Speaker: But I do think that once that's addressed, it doesn't work, you can escalate.
Speaker: And for anything that occurs in any ICU,
Speaker: that we are in, whether it involves some people or not, as CMO, you can always escalate to me and I will help, I mean, navigate that and try to figure out a way forward.
Speaker: That is part of my job.
Speaker: Okay.
Speaker: Well, I really appreciate all the questions and the comments.
Speaker: Look forward to talking with you more and definitely there'll be more about this topic as well.
Speaker: So I hope you have a wonderful rest of the afternoon and look forward
Speaker: to talking with you.
Speaker: Take care.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sounds transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
