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Conflict Resolution in Healthcare
24 Plays2 years ago
In this episode, Dr. Zanotti discusses the delicate balance of conflict resolution in healthcare. Conflict is common in our daily work in the ICU. Many clinicians avoid conflict and have negative feelings towards it. However, conflict, when managed appropriately, can lead to significant benefits for our patients and teams. Dr. Zanotti's discussion is based on a webinar he presented earlier this month as part of Sound Critical Care Leadership Week.
Additional Resources:
Watch the full webinar: https://youtu.be/R3wz29W3C4g
Conflict Management in the ICU. Previous Critical Matters podcast episode with Dr. Joshua Kayser. https://soundphysicians.com/podcast-episode/?podcast_id=342&track_id=1378454077
Books Mentioned in this Episode:
Nonviolent Communication. By Marshal B. Rosenberg: https://bit.ly/4a8h0fp
Getting to YES: Negotiating Agreement Without Giving In. By Roger Fisher and William Ury: https://bit.ly/3TSD5J3
Possible: How We Survive (and Thrive) in an Age of Conflict. By William Ury: https://bit.ly/4aauFCK
Crucial Conversations: Tools For Talking When Stakes are High. By Joseph Grenny, et al: https://bit.ly/43AU6La
The Anatomy of Peace: Resolving the Heart of Conflict. By the Arbinger Institute: https://bit.ly/4a1v0HL
Recommended
Transcript
Introduction to the Podcast
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Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
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Sound provides comprehensive critical care programs to hospitals across the country.
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To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Welcome by Dr. Sergio Zanotti
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And now your host, Dr. Sergio Zanotti.
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Good afternoon, this is Sergio Cianotti, Chief Medical Officer for Sound Critical Care.
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I want to welcome you to our clinical webinar as part of our Critical Care Leadership Week for March
Importance of Conflict Resolution in Healthcare
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2024.
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And today we're going to talk about conflict resolution and healthcare.
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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
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for us in sound critical care in healthcare in general, but also outside of healthcare.
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So the plan for today is to start with an introduction, some basic concepts on conflict.
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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.
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And finally, I wanna take a look at the
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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.
Nature and Necessity of Conflict
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And that is really focusing on what is possible if we work together.
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So we'll talk about moving to possible.
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As an introduction, why are we talking about conflict today?
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Well, when you look at data on conflict, 85% of employees at all levels experience conflict to some degree.
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It's a daily occurrence, either disagreements at the workplace, in transferring patients, in dealing with patients, with families.
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It could take other forms that are more toxic.
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But certainly as a clinician, I encounter conflict on a regular basis.
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But also when I wear my hat as CMO, I am often consulted for different types of conflicts in our programs.
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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.
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So the majority of healthcare workers, the majority of people in general,
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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.
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This should be a core competency of every ICU clinician having better tools to deal with conflict, I think, is a must.
Impact of Conflict in Healthcare
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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.
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So what is conflict?
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I think a definition from the Merriam-Webster dictionary says conflict is a competitive or opposing action of incompatibles.
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antagonistic state or action as a divergent ideas, interest or persons.
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So in general, I think when we think of conflict, it has a negative connotation.
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And I think that is one of the reasons why so many people deal with conflict by avoiding it.
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Now, is conflict always bad?
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Or can it be good?
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And the reality is that we need conflict.
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We need conflict in the workplace to make our ICU safer.
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We need conflict in the workplace to advance our understanding of critical care.
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And we need conflict in the world to move things forward.
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The problem is not that we don't want to avoid all conflict.
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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.
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So what are some of the negative consequences of conflict?
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It obviously diverts a lot of energy from work.
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I mean, I experienced that today.
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Threatens psychological well-being.
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I think it's a contributor to people being burned out.
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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.
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But there's also positive consequences of conflict that is held, that is managed appropriately.
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It definitely leads to new ideas.
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Without a conflict of ideas, new ideas and new theories, new frameworks, new plans of treatment will not emerge.
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It stimulates creativity.
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Creative people are constantly in conflict with ideas.
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It motivates change.
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And I think as leaders, we've talked about this before, what we produce is change and hopefully change
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for a better situation for our patients and for our teams.
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It promotes fatality within a team or organization.
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It helps individuals and groups establish identities, and it serves as a safety valve to indicate problems.
Managing Conflict Effectively
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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.
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So my message here is conflict is common.
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We don't have good tools to manage it.
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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.
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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.
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And there are two basic,
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personalities or approaches to conflict.
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There's avoiders and there's seekers.
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And one is not better than the other.
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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.
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So avoiders usually are shy or shy away from conflict.
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Their values are high on harmony and positive reactions.
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They will try to placate people or maybe change the topic and avoid conflict.
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They don't want to disrupt team dynamics.
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And that's what really they value the most is a harmonious team.
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I'm an avoider.
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It's the way I'm built.
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And I think a lot of people I've encountered have that same tendency.
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So recognizing and being self-aware of how you are programmed, let's say from birth,
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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.
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The other side of this equation are seekers, people who almost thrive when there's conflict or they seek conflict.
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These people usually value honesty and directness.
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That's what they value the most.
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And they're very impatient when they feel that you're not being direct or that you're not being honest with them.
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they will strongly advocate for their own interests and their positions, and they have no issues or qualms ruffling feathers.
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So I think it's very important to also recognize
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that some of our colleagues are programmed to be seekers.
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And like I said before, the key here is understanding and being self-aware.
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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.
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So in the workplace and in general, there's four types of conflicts.
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They are task conflicts, which is a conflict over what needs to be done.
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There are process conflicts, which are conflicts over how we should do something.
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There are status conflicts, which are usually over who is responsible or who gets to make the final decision.
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And then there are relationship conflicts, which are usually personal conflicts.
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And what's important about relationship conflicts is that all the conflicts eventually end up being a relationship conflict, right?
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But a lot of them might start as a task conflict, a process conflict,
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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.
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Understanding this is important because you can see that the different types of conflict, right, are different things.
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So in relationship, it's a clash of personalities.
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An example would be your counterpart interrupts and talks over you in meetings.
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The outcome, if you get it right, is better understanding of your counterpart and improved relationship.
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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.
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If you get this conflict right, you will have better process for innovation,
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and there's more potential solutions to any problems that arise.
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So as you can see, in each one of these, there are examples, but also what's important is that they will occur.
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That's guaranteed.
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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.
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And that is ultimately what we want.
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Thomas Kilman have a
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proposed a very commonly quoted modes of conflict responses.
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So basically the idea being this is what these are the ways that we can actually improve, deal with conflict.
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So you can avoid conflict and that is usually a lose-lose.
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And you can compete
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which usually is I'm right, you're wrong, and that's a win-lose.
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You can accommodate, that is I lose, you win, you're right, I'm wrong.
00:11:00
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Or you can collaborate, which is a win-win, let's work together.
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And sometimes in between collaboration is compromising, which is a win-win, we find the middle ground.
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What is interesting is that these are plotted against two axes, one of assertiveness or the concern for your own needs,
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and when on cooperatives or your concerns for the relationship or the other person needs.
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So at the end of the day, obviously sometimes if the conflict is very minimal, you might choose to avoid it.
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Sometimes, I mean, in situations, competing might be the way to go and sometimes you have to accommodate.
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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?
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and not a zero sum game, and both sides can win and benefit from the conflict.
Sources and Impact of ICU Conflict
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So the second part of this presentation is going to focus on conflict in the ICU.
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Obviously, this is, I think, a very highly charged place for many reasons, but it is very common to encounter conflict in the ICU.
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Now, conflict in the ICU can occur between the ICU clinician and the family.
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Sometimes it might be between the ICU clinician and the patient.
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Sometimes it might be between the family members themselves, and we are part of that or dragged into that.
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It also occurs in between ICU team members.
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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.
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And it's not uncommon, especially in situations like COVID where inter-team conflict might increase.
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Another common source of conflict is with other healthcare teams.
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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.
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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
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it can also increase significantly when we have situations of crisis such as COVID.
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This is a recent review that really quite expansive that identified pre-COVID, during COVID papers that talked about conflict.
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And what you can see here, obviously, is that there's a whole bunch of groups within the ICU or the hospital.
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And ultimately, there are
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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.
00:14:09
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On the other hand, there are factors during the crisis that escalate the likelihood of conflict, and those include scarcity of resources,
00:14:18
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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.
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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.
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Ultimately, why is this important?
00:14:45
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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.
00:15:00
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Whenever there's a toxic environment, there's a lot of conflict in an ICU that's not resolved, the turnover will increase.
00:15:06
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So obviously this is a problem for any practice that has that issue.
00:15:12
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This is a wonderful review article published in Critical Care Medicine a couple years ago.
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A good friend, Joshua Kaiser from University of Pennsylvania and Louis Kaplan of Surgery who passed president of SCCM wrote this.
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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,
00:15:40
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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.
00:15:52
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We talked about that in a recent clinical webinar.
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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,
00:16:10
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We saw that delta wave and beyond in COVID, significant turns in how people were thinking of the medical system.
00:16:20
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Chronic illness can also be a trigger, caregiver disagreements.
00:16:24
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And then there's policies that we might question, the family might question, and all these are triggers.
00:16:30
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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.
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So I'm going to focus on the things that we can do, which are conflict management techniques.
00:16:44
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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.
Strategies for Deescalating Conflict
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Most of our ICUs or hospitals have clinical ethics consultation.
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So getting those third parties involved early, I think, can be very, very helpful in helping resolve conflict.
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And then even for conflict mediation, sometimes we might involve
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a supportive care or palliative care consultation because they do have a lot of skills in really navigating these issues.
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When conflict arises in the ICU, there's a cycle that starts looming.
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And that cycle, as it accelerates, can really lead, I think, to a very difficult position for everybody involved.
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So conflict originates.
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The first thing that happens is we have a communication breakdown.
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people are entrenched in their positions.
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That creates a lot of moral distress on all sides.
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And ultimately that leads to disengagement.
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And that will only accelerate or feed into the conflict.
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And we really get into a vicious cycle that needs to be broken as soon as possible.
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So how do we break the conflict cycle in the ICU?
00:18:00
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I think there's three steps that we need to take.
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The first step is develop situational awareness.
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The second step is separate positions from interest.
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And this is perhaps one of the most important take home messages that you can take from this talk today.
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And we'll talk about that in a second.
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And finally, deescalate conflict with relational communication skills.
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I think that one of the biggest problems we have in hospital is that as conflict erupts, people escalate very quickly.
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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.
00:18:45
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In terms of developing situational awareness, I think it's important to recognize that conflict involves emotions.
00:18:57
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If there's no emotions, it's not usually conflict, it's just a disagreement.
00:19:01
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And they're two separate things.
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right, because we can agree to disagree on things that are not emotionally charged.
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But when emotions are present, we are probably in the realm of conflict.
00:19:13
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So recognizing that early, I think, is very important.
00:19:16
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We talked about some of the triggers for conflict, and we should be aware of those when they occur.
00:19:21
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Other things like sleep deprivation, fatigue, right, bad issues at home, all can also trigger somebody to be more predisposed
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to get into an escalating conflict situation.
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And what we wanna do is hopefully diagnose impending conflict and deescalate before it becomes too complicated.
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But sometimes we're already in the midst of conflict and recognizing that is gonna be a problem.
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The other thing that might happen with situational awareness is that you walk into a situation
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and very quickly realized that there's a lot of conflict going on and now you're part of that, right?
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That might be you picked up the service and the family is very angry, very, very upset with the team.
00:20:05
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So definitely the first step in de-escalating conflict in the ICU is developing situational awareness.
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You have to recognize conflict as soon as possible.
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The second, and which I said is one of the things that I really want you to take home today,
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is being able to differentiate between positions and interest.
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Positions is what I want.
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Interest is why I want that.
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So when the family says, we want our father to receive dialysis, that's a position.
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But if you dig a little bit deeper, the interest is we're trying to do everything we can to save him, right?
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We want him to live.
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we have a lot of things we need to resolve before he dies.
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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.
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And that is usually what is most important.
00:21:08
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So being able to differentiate positions from interest, I think is also a great way to start de-escalating conflict.
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Finally, we talked about utilizing what we call relational communication.
00:21:21
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And these are some of the skills.
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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.
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These are skills that we can all learn.
00:21:35
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And I do believe that it's part of developing that competency and being better at dealing with conflict in the ICU.
00:21:42
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So skill number one and the most important is active listening.
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Reframing or restatements to demonstrate you have heard what they are saying and are engaged.
00:21:51
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Doctors in particular are very bad in listening.
00:21:55
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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.
00:22:03
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So that is not active listening.
00:22:05
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Waiting for your turn to reply why somebody is wrong is not active listening.
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But really to be engaged in trying to understand.
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So listening to understand is active listening.
00:22:15
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Being inquisitive.
00:22:16
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Right, being curious, asking questions to probe the individual's concern and better delineate positions and interest.
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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.
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Empathizing, acknowledging and validating and respecting the individual's struggle, right?
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I can validate you without necessarily agreeing
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right, with everything you're saying.
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But if you're having a hard time, validating that, I think, is very important.
00:22:52
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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.
00:23:11
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This is probably a family in a very difficult position.
00:23:15
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And they're very different things.
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And I think it really changes the tone of how I approach them.
00:23:21
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Acknowledging perspectives, right?
00:23:23
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Messaging the plurality of moral positions around decision making.
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So there is something known as a moral position, which is what you think morally is right.
00:23:31
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But there's also something called moral aporia.
00:23:34
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Moral aporia is when there is not a clear moral stance that everybody agrees on.
00:23:40
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So morality, I think, sometimes can have different perspectives.
00:23:44
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And what you think is the right thing to do might not be what the other side thinks is the right thing to do.
00:23:49
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And understanding that and acknowledging that, I think, is a great way to deescalate conflict.
00:23:54
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Naming emotions, and we'll talk about that a little bit more in the next slide.
00:23:58
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So we said that conflict is charged with emotions.
00:24:01
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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.
00:24:11
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Abandoning the moral high ground, which goes back to that moral aporia recognition, right?
00:24:18
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Even if you're right, telling them you are right will further inflame and alienate the dispute.
00:24:23
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Plus, you might be wrong.
00:24:25
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So I think that, again, moving from a position to an interest, I think that can be commonly is very important.
00:24:32
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Righting wrongs, I think that if something happened to the family that is wrong, we should acknowledge that.
00:24:37
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And we should tell them how we're going to fix it.
00:24:39
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And then compromising is trying to find common ground as we try to find a win-win moving forward.
00:24:45
Speaker
So when we talk about emotions, this is a vital talk, is a phenomenal organization.
00:24:51
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,
00:25:08
Speaker
giving bad prognostic information, telling somebody their loved one died.
00:25:12
Speaker
And this is a great acronym, NURSE, for responding to intense emotions.
00:25:19
Speaker
So naming the emotion being expressed.
00:25:23
Speaker
So for example, you would say, it seems to me that you are very angry.
00:25:28
Speaker
Is that how you're feeling?
00:25:30
Speaker
Or many people in your situation would be devastated.
00:25:33
Speaker
Is that how you feel?
00:25:35
Speaker
So really trying to name and give a name to that emotion.
00:25:39
Speaker
Use for understanding.
00:25:41
Speaker
Demonstrate appreciation of the emotion.
00:25:44
Speaker
And I think normalizing what they're feeling.
00:25:47
Speaker
You're not alone in feeling this way.
00:25:52
Speaker
This is a very common way people feel in this situation, right?
00:25:57
Speaker
We've seen maybe this story play a thousand times.
00:26:01
Speaker
But for them, it might be the first time.
00:26:04
Speaker
And in the ICU, what I always tell people is we meet people often on the worst day of their lives.
00:26:09
Speaker
So remember that.
00:26:11
Speaker
Respecting, right?
00:26:11
Speaker
Express praise for how they are handling the emotions.
00:26:16
Speaker
I recognize how hard this must be for you, but you're doing a phenomenal job advocating for your husband, right?
00:26:21
Speaker
I mean, respecting and praising how they're handling their emotions.
00:26:25
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.
00:26:32
Speaker
And then exploring, which is explore the emotional state at the time.
00:26:36
Speaker
I imagine this has been tremendously difficult.
00:26:38
Speaker
How are you doing?
00:26:39
Speaker
Tell me a little bit
Addressing Disruptive Behavior
00:26:40
Speaker
more.
00:26:40
Speaker
And I think it's just a way of deescalating highly charged emotional situations.
00:26:45
Speaker
And it's connecting with another human being, right?
00:26:48
Speaker
And I think that, like I said, if we really think of the interest, often they overlap and are very similar.
00:26:57
Speaker
So once you're in a better position and deescalated the
00:27:02
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.
00:27:12
Speaker
And we'll talk about that a little bit more at the end in the last portion of our talk.
00:27:19
Speaker
So one of the most common conflicts we encounter in the ICU is with families.
00:27:25
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.
00:27:44
Speaker
And like they say, there is an I in team and it's in the A-hole, right?
00:27:49
Speaker
So dealing with disruptive behavior.
00:27:52
Speaker
And that is a great source of stress for many healthcare providers.
00:27:58
Speaker
It is something that I get involved with on a regular basis.
00:28:02
Speaker
And it's something that I've been thinking a lot about lately.
00:28:05
Speaker
And the reality is that at the end of the day, we could do a whole different talk of that.
00:28:10
Speaker
But I did feel that it would be
00:28:12
Speaker
disingenuous to talk about conflict in healthcare without addressing this particular problem, which is very toxic in a lot of situations.
00:28:21
Speaker
So disruptive behavior or A-holes is behavior that interferes with work or creates a hostile environment.
00:28:28
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.
00:28:41
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.
00:28:54
Speaker
So examples would be verbal abuse, sexual harassment, yelling, profanity, vulgarity, threatening words or actions.
00:29:02
Speaker
Those usually, I mean, require immediate action and intervention.
00:29:07
Speaker
unwelcome physical contact, threats of harm, behavior, reasonably interpreted as intimidating, same thing.
00:29:12
Speaker
But then there's a lot of passive aggressive behaviors, sabotage and bad-mouthing colleagues or organizations.
00:29:18
Speaker
And we see different versions and tones of this.
00:29:21
Speaker
And I think it's very important for us to find out how to deal with it.
00:29:24
Speaker
So Hickson has been, he's from Vanderbilt.
00:29:28
Speaker
He's an internist from Vanderbilt with a lot of experience in disruptive behavior.
00:29:32
Speaker
And this is a very classical, a classic paper in academia.
00:29:37
Speaker
that looks at a framework for approaching the strip of behavior in the clinical setting.
00:29:44
Speaker
And the vast majority of professionals have no issues.
00:29:49
Speaker
The vast majority of people that we work with are fine.
00:29:53
Speaker
They are professional, they try to do their best, and they're trying to build a better environment.
00:30:00
Speaker
The problem is that it takes one bad apple to rot the whole case
00:30:05
Speaker
And we have all probably encountered or seen or heard of truly toxic personalities that create a lot of problems.
00:30:12
Speaker
So the way he has approached this is if there's a single unprofessional incident.
00:30:19
Speaker
So first of all, in red are mandated issues that need discipline immediately.
00:30:23
Speaker
So that's anything that's physical, anything that has sexual harassment.
00:30:27
Speaker
anything that is truly intimidating, that needs to be escalated immediately, right?
00:30:32
Speaker
But most of what we see is lower than that, but it still builds a lot of toxicity over time.
00:30:40
Speaker
So if you see a single unprofessional incident, that really requires an informal cup of coffee intervention.
00:30:46
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.
00:30:51
Speaker
What happened?
00:30:52
Speaker
What were you thinking?
00:30:54
Speaker
How are you feeling?
00:30:55
Speaker
And the truth is that
00:30:57
Speaker
everybody has a bad day once in a while.
00:30:59
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.
00:31:14
Speaker
So that is, I would say, 20% of situations.
00:31:19
Speaker
If after that informal talk, there seems to be an apparent pattern of complaints and things are escalating,
00:31:27
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.
00:31:36
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.
00:31:48
Speaker
Now, people who have a pattern usually don't like when they're confronted.
00:31:56
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?
00:32:07
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
00:32:25
Speaker
And if we were involved, we can describe how we felt.
00:32:28
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.
00:32:38
Speaker
So once there's a pattern, I think the person has to be made aware.
00:32:43
Speaker
You might even put that person on some sort of PIP, which is a performance improvement plan.
00:32:49
Speaker
But if the pattern persists, now you need an authority intervention that needs to be escalated.
00:32:53
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.
00:33:04
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.
00:33:12
Speaker
And ultimately, if the pattern still does not change, then there's discipline intervention that really can escalate to reporting to national
00:33:21
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
00:33:50
Speaker
unaware of the impact they have and it won't repeat itself.
00:33:54
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.
00:34:04
Speaker
They're always blaming others.
00:34:06
Speaker
It's always everybody else is an idiot by themselves, right?
00:34:10
Speaker
And I think that we need to document and we have to document accurately.
00:34:15
Speaker
We have to document without judgment.
00:34:17
Speaker
And we have to document consistently because that's the only way that eventually we will be able to escalate this.
00:34:22
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.
00:34:38
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,
00:34:46
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.
00:34:55
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.
00:35:11
Speaker
We are leaders in the ICU.
00:35:14
Speaker
And we should always, always protect our team.
00:35:17
Speaker
Right.
00:35:17
Speaker
So I think that dealing with these people sometimes is very deflating, very difficult.
00:35:22
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.
00:35:32
Speaker
So this is a great quote from Eli Weasel, a Holocaust survivor.
00:35:38
Speaker
And I think that the silence of the bystander is a problem.
Negotiation Methods in Conflict Resolution
00:35:42
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
00:36:10
Speaker
is nothing more than just bringing an idea from another area to your own.
00:36:14
Speaker
So this is William Ury.
00:36:15
Speaker
He's an American author and academician.
00:36:17
Speaker
He's an anthropologist who is a negotiation expert.
00:36:22
Speaker
And he has written several books on negotiation.
00:36:27
Speaker
He founded the Harvard Program on Negotiation.
00:36:30
Speaker
He helped found the International Negotiation Network with President, former President Jimmy Carter.
00:36:36
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,
00:37:06
Speaker
method or basically the balcony bridge and third side path to possible.
00:37:14
Speaker
And I want to share with you a little bit of this because I think it's a great framework to think about.
00:37:19
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.
00:37:28
Speaker
So the balcony, you go to the balcony, that's a term that a lot of people use.
00:37:33
Speaker
And he talked about that in one of his old books with
00:37:37
Speaker
with Roger Fisher, another famous Harvard academician that studied conflict.
00:37:44
Speaker
And basically the idea is to move away from the dance floor and go to the balcony to see what's happening, right?
00:37:49
Speaker
But the balcony focuses on the I. So it's an intervention for yourself.
00:37:56
Speaker
Building what they call the golden bridge focuses on the you, on the other side of the conflict.
00:38:03
Speaker
And finally, involving the third side,
00:38:06
Speaker
is the us or everybody else who is part of the conflict.
00:38:10
Speaker
So let's use this as an example in the ICU.
00:38:14
Speaker
I have a dispute with a CT surgeon.
00:38:18
Speaker
Going to the balcony works on myself.
00:38:22
Speaker
Building a golden bridge is trying to engage the CT surgeon on a collaborative solution.
00:38:29
Speaker
And going to the search side might include the rest of the ICU team, the nurses, the APPs,
00:38:35
Speaker
the patients, their families, and really looking at how they will respond and how they can be part of that solution as well.
00:38:42
Speaker
So that is the path to possible.
00:38:44
Speaker
This is a famous Latin saying from time of the Romans, Omnitrium perfectum, which says that everything that comes in threes is perfect.
00:38:57
Speaker
And for those of you who know my affection to the number three, you'll understand.
00:39:01
Speaker
But these are three things we need to do.
00:39:04
Speaker
Balcony, bridge, and third side.
00:39:06
Speaker
And each one has three steps.
00:39:08
Speaker
So the balcony is pause, zoom in, and zoom out.
00:39:11
Speaker
The bridge is listen, create, and attract.
00:39:16
Speaker
The third side is host, help, and swarm.
00:39:19
Speaker
And there are phenomenal lessons here.
00:39:21
Speaker
I'm not going to go into detail into each one of these.
00:39:24
Speaker
But I do think that let's start with the balcony.
00:39:28
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.
00:39:37
Speaker
Breathing is a very powerful tool to ease stress.
00:39:39
Speaker
There's different types of breathing.
00:39:41
Speaker
I like to do box breathing, but there's different things.
00:39:44
Speaker
Take a break, walk away for a second, walk.
00:39:48
Speaker
And sometimes, I mean, you even wanna retreat or you wanna take your group for discussion to a separate room.
00:39:55
Speaker
But the pause,
00:39:57
Speaker
is about creating space between input and output, right?
00:40:02
Speaker
Something that Viktor Frankl talked about very eloquently.
00:40:06
Speaker
And I think it allows you to deescalate your own state, right?
00:40:12
Speaker
When adrenaline is high, through our survival instinct, our options are very narrow.
00:40:18
Speaker
When we can lower that and pause, our options become broader.
00:40:23
Speaker
And that is the first step, and this is all about yourself.
00:40:26
Speaker
In every conflict, you are usually the worst enemy for resolution.
00:40:30
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.
00:40:41
Speaker
The second practice is to zoom in.
00:40:44
Speaker
And zooming in is all about understanding positions and interest, right?
00:40:50
Speaker
Asking why five times.
00:40:51
Speaker
Why is this a problem for me?
00:40:53
Speaker
Because of this.
00:40:54
Speaker
Why?
00:40:54
Speaker
Why?
00:40:56
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?
00:41:05
Speaker
Listen to these emotions as signals.
00:41:08
Speaker
And also, this is a good time to think about what does the price look like, right?
00:41:13
Speaker
Write down the top three interests in your negotiation that you think would be the best outcomes from your side.
00:41:22
Speaker
And the third practice of the balcony is now to zoom out.
00:41:26
Speaker
So there is a very famous concept in negotiation that actually Roger Fisher and William Uri created called the BATNA.
00:41:35
Speaker
BATNA is the best alternative to a negotiated agreement.
00:41:40
Speaker
So what happens if you walk away?
00:41:42
Speaker
And whoever holds the best BATNA holds the leverage sometimes in the negotiation.
00:41:47
Speaker
But knowing your alternatives before you start dealing with a conflict, I think will help increase your chances of having a satisfying result.
00:41:56
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
00:42:24
Speaker
we were at the edge of nuclear warfare.
00:42:27
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.
00:42:36
Speaker
A lot of times Kennedy was given advice by his military that could have triggered a war.
00:42:41
Speaker
What did he do?
00:42:42
Speaker
He took time, he went to the balcony, he paused, he zoomed in, understood what was important for him.
00:42:49
Speaker
He zoomed out, understood what was important for the other side,
00:42:53
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.
00:43:05
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.
00:43:20
Speaker
The second
00:43:21
Speaker
part of the path to possible is building a golden bridge.
00:43:26
Speaker
And the first step here is to listen.
00:43:29
Speaker
Listen to the other side and listen to convey respect and reflect back what you hear and be inquisitive.
00:43:36
Speaker
The best negotiators are not those who talk a lot, but are those who listen the best.
00:43:42
Speaker
And I think that this is something that we could all utilize at the bedside as well.
00:43:47
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.
00:43:58
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?
00:44:09
Speaker
Start creating that trust.
00:44:11
Speaker
Reframe that we both have, both sides have power
00:44:15
Speaker
to find better solutions for their interest.
00:44:19
Speaker
Not the positions, but for the interest that we're trying to achieve, right?
00:44:23
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.
00:44:31
Speaker
And finally, the third step of building the bridge is to attract.
00:44:35
Speaker
What do we do in negotiations or in conflict?
00:44:38
Speaker
We push.
00:44:39
Speaker
When you push somebody, what do they do?
00:44:41
Speaker
They push back.
00:44:42
Speaker
right?
00:44:43
Speaker
So we have to change that dynamic and we have to attract them.
00:44:46
Speaker
And we do that by building trust on the other side, building on the other side's ideas, right?
00:44:52
Speaker
If they have an idea, how can we build upon that for something that works for us, right?
00:44:56
Speaker
Address perceived fairness.
00:44:59
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.
00:45:05
Speaker
When we look at leaders and conflicts, perhaps one of the
00:45:10
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.
00:45:26
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
00:45:37
Speaker
And ultimately the clerk served on his cabinet as well.
00:45:40
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.
00:45:58
Speaker
Finally, the third side, right?
00:46:01
Speaker
And here it's about listening to each side.
00:46:03
Speaker
People wanna be included, wanna be felt that they are heard,
00:46:07
Speaker
want to be seen, right?
00:46:09
Speaker
And a lot of conflict ultimately is because we don't feel that people see our dignity.
00:46:14
Speaker
And there are some very interesting examples of hosting.
00:46:18
Speaker
So the Kua are a New Guinea tribe that is very famous for using poisonous darts.
00:46:28
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.
00:46:37
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.
00:46:50
Speaker
So really understanding the third side or the bigger picture of a conflict, not only who's at the negotiating table.
00:46:56
Speaker
In terms of practicing help, it's really getting other people involved that can help us that maybe they are
00:47:04
Speaker
There's a third party that is trusted by both sides or somebody that works with both sides.
00:47:10
Speaker
And how do we get them involved?
00:47:12
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.
00:47:22
Speaker
A lot of conflicts have used a technique called the one text where there's one text that starts hammering out
00:47:29
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.
00:47:35
Speaker
And there's different ways that you can really, I mean, elicit help and bring other sides to the third side.
00:47:41
Speaker
And then Swarm is really about making sure that both teams feel that there's groups that have access, credibility, and trust.
00:47:48
Speaker
And you create a Swarm team where everybody's coming up with new ideas to try to solve the problem.
00:47:53
Speaker
There's this idea that Uri talks about, which is the seven touches, which the right idea
00:47:59
Speaker
to the right person at the right time.
00:48:02
Speaker
People often need to hear an idea seven times before they really are ready to move into a yes.
00:48:07
Speaker
So really building that winning coalition with people that may be beyond those that are at the negotiating table.
00:48:17
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.
00:48:29
Speaker
it was becoming very problematic.
00:48:31
Speaker
A group of negotiators was taken.
00:48:33
Speaker
They negotiated an agreement between the mine leadership and the union leaders.
00:48:41
Speaker
They thought they had a perfect agreement.
00:48:42
Speaker
And then when they took it to the miners, they rejected it because they were not part of the conversation.
00:48:48
Speaker
So this is an example of failing to see the third party of who actually the conflict was about.
00:48:54
Speaker
So what they did is,
00:48:56
Speaker
Some of the negotiators stayed for months with the miners and eventually heard their grievances.
00:49:02
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.
00:49:12
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.
00:49:24
Speaker
So,
00:49:25
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.
00:49:32
Speaker
Going to the balcony is about checking yourself.
00:49:35
Speaker
It's about the eye, right?
00:49:37
Speaker
Bringing down the decibels and trying to understand what are you trying to achieve.
00:49:41
Speaker
The bridge is about the other side or the you, right?
00:49:44
Speaker
How do we build a bridge that ultimately creates trust and attracts them towards a collaborative stance?
00:49:50
Speaker
And the third side is about the us and involving
00:49:54
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.
00:50:05
Speaker
So we talked about some basic concepts on conflicts.
00:50:09
Speaker
I
Understanding and Managing Conflict
00:50:10
Speaker
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
00:50:20
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.
00:50:31
Speaker
We talked about conflict in the ICU.
00:50:33
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.
00:50:43
Speaker
And again, I think that figuring out how to collaborate and how to move in the right direction is very important.
00:50:50
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.
00:51:09
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.
00:51:19
Speaker
And finally, I think we took some lessons from very, very seasoned mediators of conflicts and created a path to possible.
00:51:30
Speaker
In the world of conflict, it's not about avoiding it, it's not about resolving, it's about creating more possibilities.
00:51:36
Speaker
If we believe that we're in a zero sum game, the only way I win is if you lose.
00:51:41
Speaker
But if we think that we can actually increase the size of meaning, right, increase the pool of common interest,
00:51:48
Speaker
we both can win.
00:51:49
Speaker
And that is what's possible.
00:51:51
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.
Recommended Reading and Closing Remarks
00:52:03
Speaker
So with that, I really want to thank you for your time.
00:52:06
Speaker
If you want to know more, these are some recommendations of some phenomenal books.
00:52:11
Speaker
Some are old, some are brand new that I think might be of interest.
00:52:16
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.
00:52:33
Speaker
We have a course for our clinicians on Crucial Conversations within Sound, and then the Anatomy of Peace, which is the Arbinger Institute
00:52:41
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.
00:52:58
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.
00:53:10
Speaker
So with that, I just want to thank you for your time.
00:53:13
Speaker
And I have a couple minutes.
00:53:15
Speaker
If there's any questions, I'll monitor the chat box or any comments.
00:53:19
Speaker
And again, really appreciate everything you do at the bedside and hope to see you soon again in one of these conferences.
00:53:28
Speaker
Thank you.
00:53:33
Speaker
So there's a question regarding what happens with toxic personalities when the hospital seems to protect them.
00:53:40
Speaker
And I think that we did mention that at the beginning.
00:53:43
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.
00:54:01
Speaker
I think that the best way is to document very objectively without judgment, describe the facts, to speak up.
00:54:10
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.
00:54:24
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.
00:54:28
Speaker
So I think that it's not an excuse not to raise our voice.
00:54:32
Speaker
It's not an excuse not to share.
00:54:34
Speaker
So there's a question regarding, again, a copy of the PowerPoint.
00:54:37
Speaker
We will send an email with the PowerPoint and with a recording.
00:54:42
Speaker
So you should receive that.
00:54:44
Speaker
Yes, the answer is absolutely you can receive it.
00:54:47
Speaker
And if you put it in show mode, you can click some of the links and it will take you to those places.
00:54:55
Speaker
So another question is why do you think it's so hard to deal with conflict?
00:54:58
Speaker
Well, I think that because people don't feel safe, right?
00:55:01
Speaker
So if you have a psychologically safe team,
00:55:04
Speaker
a lot of times conflict is resolved in a very easy way, right?
00:55:08
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.
00:55:17
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.
00:55:27
Speaker
And ultimately, I think it has a toll on a lot of us, right?
00:55:30
Speaker
A lot of our suffering is in our own minds.
00:55:33
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
00:56:01
Speaker
They might just, I mean, engage because of their values.
00:56:03
Speaker
But again, having the skills to resolve and to move conflict forward, I think is very important.
00:56:08
Speaker
So what is the best way to address APP, MD conflict regarding disrespect from physicians to APPs?
00:56:14
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.
00:56:31
Speaker
focus on the impact that somebody's behavior is having on you or on somebody else.
00:56:38
Speaker
If that doesn't help, I think the next thing is to escalate.
00:56:41
Speaker
There might be a pattern.
00:56:42
Speaker
I think most people respond to that and they don't really see that they're doing that.
00:56:49
Speaker
But I do think that once that's addressed, it doesn't work, you can escalate.
00:56:54
Speaker
And for anything that occurs in any ICU,
00:56:59
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.
00:57:09
Speaker
That is part of my job.
00:57:10
Speaker
Okay.
00:57:12
Speaker
Well, I really appreciate all the questions and the comments.
00:57:16
Speaker
Look forward to talking with you more and definitely there'll be more about this topic as well.
00:57:22
Speaker
So I hope you have a wonderful rest of the afternoon and look forward
00:57:27
Speaker
to talking with you.
00:57:29
Speaker
Take care.
00:57:30
Speaker
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00:57:34
Speaker
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00:57:40
Speaker
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00:57:44
Speaker
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