Managing Conflict & Negotiation Skills

Drs. Ramesh Mehay & Nick Price

Programme Directors (Bradford VTS)

Aims

1. the causal factors leading to conflict

2. systems and strategies that may prevent it

3. skills in managing conflict positively

Scenario

• John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you.

• One day, on a home visit to someone else, you see him working in his garden.

• You’ve asked him to come in.• Call him in…….

What's all the Fuss?

"An exhausting consultation

between a doctor and a patient which

often triggers off some powerful emotions either

in the doctor dealing with them, in the patient or both!”

And it can affect the next consultation

AND

• You might carry those feelings back home

stress, fear, anger, low morale, helplessness• The patient might feel and take them home too

……and that’s not fair nor good for either of you

Can you relate to any of this

Are you hooked?

So, What are we after?

• A (patient) lose – lose (doctor) aproach ?

• A (patient) win – lose (doctor) aproach ?

• A (patient) lose – win (doctor) aproach ?

• A (patient) win – win (doctor) aproach ?

The Session Plan from here

1. Causation

2. Strategies & Skills to Prevent It

3. Strategies & Skills to Halt Escalation

4. Recovery strategies when things go really belly up

Causation

• Individually: take the next 5 minutes to reflect on a emotionally dysfunctional consultation and the factors you think led to it

• In trios, pool together your thoughts and discuss new items (flip chart)

• Team up with another trio and pool together your thoughts and discuss new items (flipchart)

Buckets of Shit: Causation

patient doctor

Unidirectional Consultations

Failing to• ICE

• illness vs disease

•Missing cues• empathise

•Personalities•Language•Egotism

Patient behaviour that annoys the doctor – Christie & Hofmaster (1986) “Pull Yourself Together” report (2000), Mental Health Foundation)

Certain Medical Illnessses - Christie & Hofmaster (1986

ORGANISATION

Before the consultation:• accessibility

• conflict with others (other patients, reception)•Doctor running late

Doesn’t all this remind you of JoHari’s Window?

Unknown

Things the patient knows

Things the patient don’t

know

Things I know about the patient

Things I don’t know about the

patient

Arena

Facade

Blind spot

In trios, think about…….

1. Things you can do to prevent consultations from going bad

2. How you can recognise things are going bad

3. What can you now do to try and stop things getting worse

(15 minutes)

CONFLICT PREVENTION

REDUCING THE CHANCES OF CONFLICT

The Calgary Cambridge model

You can’t go wrong!

Look…….

INITIATION

• Read the patient’s notes • Acknowledge and apologise

– for running late etc– “you told me to come in”– Any others?

• Establish Rapport – and attend to patient’s comfort (physical, emotional)

• Figure out their agenda• Neutralise YOUR feelings• Be aware of your own negative verbal/non verbal cues

GATHERING INFORMATION

1. Explore ICE properly

2. Figure out the ILLNESS vs disease

3. Really show EMPATHY 4. Figure out the patient’s agenda, Identify your agenda,

and BLEND the two….(SHARED AGENDA SETTING)

EXPLANATION & PLANNING

• AVOID PREMATURE REASSURANCE• PITCHING explanation• SHARED planning WITH the patient• CHECK understanding and acceptability (seeking

agreement before moving on)

Paying attention to your language

• Prefacing your remarks“Sounds like…", "So,…", "In other Words…", "You’re saying…"

• Avoiding absolute words such as "always" and "never"• Replacing "loaded" words with neutral words.

"wastes time" "takes time to…"

• Using words/phrases that have positive connotations"She always wastes time" "You want to work more efficiently.“

• Reflecting the emotional tone of the message as well as the words eg sound like you feel xxx because of yyyy”

Responding to Cues

• Verbal/Non-verbal• Suchman 1997: patients seldom verbalise their

emotions directly and spontaneously, but tend to offer cues instead

• Skills to Consider: Encouragement, Silence, Repetition (echoing), Paraphrasing

Following the helical model

• ie what I say influences what you say in a spiral fashion (ie what you then say influences whay I say next)

• reiteration and repetition• coming back around the spiral of communication at a

little different level each time are essential

RECOGNISING THE PATIENT WHO’S GOING OFF ON ONE

Read the patient continuously

• Verbal (HEAR) – tone, pitch, rate, content• I sense that you're not quite happy with the explanations

you've been given in the past. Is that right?'• Non-Verbal (SEE) – facial expressions, posture,

agitation• 'Am I right in thinking you're quite upset about your

daughter's illness?‘• Check how you are feeling

DE-ESCALATING CONFLICT

BRINGING A STOP TO ESCALATION

Principles

• Take a deep breath, stay calm. Neutralise YOUR feelings• Be aware of you own negative verbal/non verbal cues• Don’t fight anger with anger, Don’t be defensive• Look for the reason for the reaction, remember, it’s

often not personal • Recognise and accept the feelings as natural and

reasonable• Remember that the irrational component of anger may

have it origins from previous experiences and you may need to explore this (with care)

Specific Communication Skills

• Get down physically to the patient’s level• Feedback what you see or hear• Go back and revisit the patient’s framework + other

contributory reasons for the anger (INFO GATHERING)• Listen to the patient’s distress• Express empathy, concern and support• Apologise that they feel upset (and mean it!)• Reformulate the main problems for the patient (INFO

GATHERING)• Move on with the patient re: possible solutions, ways

forward (JOINTLY) = PLANNING• Offer realistic and achievable help (PLANNING)

Try it again………

• John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you.

• One day, on a home visit to someone else, you see him working in his garden.

• You’ve asked him to come in.• Call him in…….

Confrontation with a little C

• Sometimes, a little bit of confrontation can be good• eg challenging an attitude, belief or behaviour, to bring

something to someone’s attention, an uncomfortable truth• Your aims in this case would be to • Allow the pt to hear and acknowledge you without destroying to

Dr-Pt relationship• To address behaviour whilst affirming the patient’s worth as a

person• BUT: our own anxiety gets in the way: our past experiences of

confrontation (personal and professional) and the present situation lead us to either to sledgehammer or pussyfoot or avoid

How DO You Do IT Then?

• Be honest, be supportive

• Feedback what you have seen or heard directly from the patient – it’s hard to argue with the evidence

• BUT

• Do this sympathetically…. Heron shows you how…..

Heron (1975) says…

• Signpost your intent

• State what the problem is & the effect it has

effect on U and patient, use I statements

• State what you would like to happen

and why (eg the benefits for both of you)

• Make a valueing statement about the person

separate the pt’s behaviour from them as a person

• Overtly demonstrate your care/empathy

• Then give plenty of time, ask about feelings, explain difficulty fo u too, negotiate how to move on (planning)

CONFLICT RESOLUTION

HOW TO RECOVER A STITUATION THAT’S GONE

REALLY BAD

Why recover? Let it go???

• It is cost saving • Avoids polarization of parties • It is educative thru understanding• Probes wider issues • It promotes fairness• Gives disputants more control over the dispute process

Principles

• You may need a “cooling off” period before engaging

• Both parties (Dr and Pt) must be willing to participate

• Establish ground rules

• Ensure both you and patient understand win =win aim;

• own volition into engaging, not enforced

• No interrruptions whilst other is talking

How to Do IT

• An agreement to talk about a set agenda

• One party speaks without other interrupting

healthy venting of emotions, what the problem is for them

• Other party paraphrases what they heard

• First party corrects any miscommunication

• Process repeats the other way round

• What does each party need or want to happen…..in light of what’s been said

• Boulle, L (2005) Mediation: Principles Processes Practice, Australia, LexisNexis Butterworths

Key Message

if you resolve conflict positively you can really build upon a foundation of loyalty and trust in the relationship