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Andrea M. Landis, PhD, RN UW LEAH November 30 th, 2012

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Conflict: Introduction Definition Fight, battle, war Antagonistic state or action (as of divergent ideas, interest, or persons) Mental struggle resulting from incompatible or opposing needs, drives, wishes, or external or internal demands Within or between Where can conflict occur?

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Conflict Conflict can arises from: Different goals Differing sets of information Differing perceptions Horizontal violence Perception that levels of appreciation are not equal

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Conflict GOAL: Advance collaborative practice and conflict competence among health professionals and industry leaders who are responsible for the following: Improving patient safety Achieving accountable care Developing healthy work environments Creating a resilient workforce

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Part 1: Perspectives in Conflict

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A Nobodys in Charge World Shared responsibility for the same programs & goals UW Shared Governance Integrated and networked organizations require power sharing Interdependence required to get things done places limits on individual authority Disagreements & conflicts are not uncommon

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How do you view conflict? A battle to be won? A problem to be solved? A danger? An opportunity? Something to be avoided at all costs?

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Perspectives of Conflict BehavioralInevitableControl TraditionalDestructiveEliminate InteractionInevitableManage

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Common Reactions to Conflict FIGHT FLIGHT Confronting Sabotaging Over-reacting Bypassing Avoiding Under-reacting

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Consider your Shadow Side What are your behavioral tendencies when you are Angry? Exasperated? Tired? Stressed? In a bad mood? Can you recognize when you are

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Dealing with your Emotions Take your emotional temperature Resist your first negative reaction Consider a time-out Get the facts Get another perspective Vent to someone else If time permits, plan your approach

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Dealing with their emotions Allow them to vent Use restatement; dont raise your voice Accept their feelings as legitimate Help them save-face work towards a win-win Dont refute their statements yet! Dont be afraid of silence Dont be afraid to say You might be right

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Reduce Tension Through Listening Listen to understand Listen actively (in an involved way) Listen with your eyes Dont tune out messages you think youve heard before Listen first THEN plan your next comment

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Part 2: Strategies for Navigating & Resolving Conflict

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Conflict Management Comprehensive term indicating the range of attitudes and behaviors individuals, groups, and organizations manifest in dealing with conflict. Always present Range from denial, suppression, and retaliation to creative proactive programs

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Alternative Dispute Resolution (ADR) (Gerardi, 2010) Provides an array of processes designed to achieve that goal, negotiation, mediation, and arbitration for health care providers Developed body of literature documenting best practices and empirical findings to guide both students and practitioners of ADR

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ADR continued Came to age in the 1990s Restructuring of health care organizations Reductions in the number of acute care nurses; shortened length of stay that increased patient acuity concurrent with increased emphasis on patient safety. IOM report (1999) To Err is Human: Building a Safer Health Care System Documenting the magnitude and severity of preventable medical errors (adverse events) Further catalyzed the patient safety movement Creation of patient safety organizations that generated substantial data sets Documented that problematic relationships among providers was a primary causal factor in adverse events.

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ADR continued ADR practitioners considered health care the last frontier persistently resistant to self-examination and action that might enhance existing conflict management practices. Reasons for resistance: Health care environments are complex adaptive systems; Widespread inequalities and imbalances in power; Includes numerous subcultures with significant variance; Difficulty determining who should be at the table History of litigation pattern of conflict aversiveness, avoidance, suppression, and blame.

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Thomas-Kilmann Conflict Mode Instrument 5 potential responses to conflict: Avoidance Compromise Accommodation Competition Collaboration* * Both high cooperativeness and assertiveness and provides long-term solution to a conflict

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Conflict Engagement Part of ADR De-emphasizes conflict resolution and shifts the focus to competent engagement Blueprint for collaboration

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Silence Kills AACN (2005) sponsored a landmark study (1,700 nurses, physicians, clinical-care staff, and administrators) identifying conversations especially difficult for health care professionals, at the same time essential for people in healthcare to master including: 1. Broken rules 2. Mistakes 3. Lack of support 4. Incompetence 5. Poor teamwork 6. Disrespect 7. Micromanagement Concurrently developed related standards for health work environments

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Silent Kills Majority of healthcare workers regularly see some of their colleagues break rules, make mistakes, fail to offer support, or appear critically incompetent; < 10% say anything This study explored the frequency with which people experience these kinds of concerns and the consequences of their failure to speak up when they do Online survey of nurses 53% respondents reported that conflict while on the job was common This study suggests that creating a culture where healthcare workers speak up before problems occur is a vital part of the solution.

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Every utterance functions on two levels Level 1: Communicates ideas Level 2: Negotiates relationships

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Develop a Negotiation Mindset What is your personal goal in managing conflict more effectively?

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Two Primary Concerns for Every Negotiator Achieving the best outcome and agreement Maintaining and building the relationship

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Diagnosing Disagreement 1. What is the nature of the difference? 1. Facts 2. Goals 3. Methods 4. Values 2. What factors may underlie these differences? 1. Information: differences based on different set of facts 2. Perceptual: parties bring different sets of biases and beliefs 3. Role: position and status of parties can place constraints on the discussion

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Underlying Causal Factors Information Factors Disagreement is based on different facts Do the disagreeing parties have access to the same info? Perceptual Factors Different set of biases and beliefs Do the disagreeing parties perceive the shared information differently? Role Factors Disagreement is influenced by the position or status of the parties in the organization and/or society How much are the disagreeing parties influenced by their position or role in the organization?

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Plan Your Approach Know your goal for resolving the disagreement: what do you want? Define the problem/issue for yourself Consider how the other party defines the problem/issue

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Execute Your Approach State the problem/issue Set a positive tone for the conversation Explore each others needs Start with, How can we. Ask open-ended questions Dont include solutions in your questions Watch your listen/talk radio Observe non-verbal cues Avoid interpreting motives Identify possible options Select the best one Reach agreement

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Handling Disagreements Without Resolving Them Listen but dont argue Agree to disagree Accept their feelings, not points Focus on something else

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Dealing effectively with differences depends on. Desire to resolve the differences Ability to diagnose and understand the differences Awareness and ability to use the appropriate behavioral responses Ability to deal with your own feelings especially those that might limit your effectiveness

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Carefronting (Kupperschmidt,2008) How to manage conflict when individuals have divergent values, beliefs, and attitudes Goal is to guide individuals and/or teams to get past their day to day problems, conflicts, and communication issues Augsburger (1981) refers to the skill of caring enough about oneself, others, and desired goals to confront inappropriate behavior responsibly while offering the opportunity for change.

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Carefronting Act of inviting, not demanding, another to change and a creative way through conflict, a way to unite caring and candor in relationships Key tenets: Truthing it: A simplified speech style Owning anger: Let both your faces show Inviting change: Careful confrontation Giving trust: A two-way venture Ending blame: Forget whose fault the conflict is Getting unstuck: The freedom to change Peacemaking: Getting together again

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TenetDefinitionExamples Truthing itWillingness and ability to listen deeply, empathetically, and accurately to assure understanding of others point of view I want to hear you accurately; I want to share my feelings and attitudes with you; I want to be heard Owning Anger Anger is both a positive, self-affirming emotion and a demand; When one feels ignored/rejected the normal response is anger I am a person of worth, I demand that you recognize and respect me; Each person is responsible for choosing how they respond and react to others when conflict occurs Inviting change Focus on feedback on the behavior, not the person; on observations, not conclusions; on descriptions, not judgments; on ideas and alternatives, not on advice and answers. Think caringly, gently, constructively, and clearly

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TenetDefinitionExample Giving Trust Trust grounded in authentic self- disclosure; Trust confronts openly, frankly, respectfully, and responsibly, trusting that the other person will assume his/her responsibility to be equally honest and frank Release demands and accepts apologies Ending Blame Confrontation that endeavors to place blame inevitably evokes resistance and resentment. Ends the blame game, leading to real questions Where do we go from here? When do we discuss the conflict? If not now, when? Getting unstuck Owning responsibility for ones part in the conflict and refusing to waste time in assigning blame Accepting accountability for behavioral changes that accept responsibility for the present conflict and focusing on what can be shared. Peace- making Truly present in conflict situations, listening, and caring for all stakeholders; care enough to confront and drop the demands of the past Value others; those who have rediscovered that the values that shape their decisions must be lasting values consistent with the values of the profession

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Carefronting Alternative to traditional conflict resolution Useful in healthcare environments where team synergy and interdependence are required for high quality and safe patient care (think interdisciplinary) Development of trust among team members on teams begins with communication in relationships, especially, when there is disagreements Relationships live within the context of conversations that individuals have or do not have with one another

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