Conflict resolution in the setting of professional medicine

The definition of "conflict"

Saltman et al (2006) define conflict as "a disagreement within oneself or between people that causes harm or has the potential to cause harm". This, of course, is madness. Not all conflict causes harm. Conflict is present in the course of all human interaction, and the objective of good leadership in a health organisation is not to end all conflict. Avoidance of conflict will also lead to dysfunction. Thus, a better definition might be as follows:

Conflict is a complex behaviour where one party perceives that its interests are being opposed or negatively affected by another party". Dysfunctional conflict hinders individual and organisational performance.

This is a fusion of some Kreitner and Kinicki (2003) with some Patton (2014). In general, as far as literature goes, the best reference to start would probably have to be Patton's 2014 review. That has served as the jump-off point for the rest of this summary. The objective here is not to add to the (massive, overwhelming) ocean of published literature on this subject, or to offer any novel insight into the process (which the author can not claim to have). Instead, this chapter prepares the ICU exam candidate in near-final stages of their training to answer viva and interview questions about conflict resolution.

Sources of conflict in the medical workplace

Ambiguity in communication

• Communication skills are often lacking
• Ambiguity and lack of clarity in communication are to blame for much of medical conflict.
• Misunderstanding of another's actions and processes is the major cause for conflict in the healthcare setting
• This can take many forms:
  • Inaquate information: "I was not told that patient was a bedbound nursing home resident, otherwise I would not have asked ICU to see them!"
  • Incorrect information: "They told me the family agreed with laparotomy! Now you tell me the consent was signed by a neighbour?"
  • Different interpretation of the same information: "When you said "patient lives alone", I thought you meant the patient was functionally independent."
  • Misunderstanding of role expectations: "I thought it was your job to talk to the family about the end of life care"
  • Misunderstanding of clinical situation: "When I said I'd talk to the family in the morning, I did not understand what the lactate of 10 meant"

Problem with the personnel:

• Physicians often have highly task-oriented "type A" personalities.
• There is usually little training in interpersonal skills.
• There is often a lack of emotional intelligence

Problems with the environment:

• Massive amounts of information competing for the attention of individuals
• Unreasonable work expectations
• Unreasonable externally imposed limitations on work capacity, eg. bureaucratic restrictions on the role of the clinician

Consequences of dysfunctional conflict in the medical workplace

• Increased workplace stress decreases efficiency of the workplace
• Morale and staff satisfaction suffers, and the resulting increase in staff turnover has the effect of decreasing efficiency and increasing senior workload ("How many more orientation sessions do I need to do this year?")
• The clinician who is the source of conflict loses staff support and may become isolated
• Dysfunctional behaviour breeds retaliation and more dysfunctional behaviour from other similarly insightless people

Psychological models of conflict resolution

Morton Deutch: Cooperative model

• Two basic orientations of the parties involved in the conflict: cooperative and competitive
• The competitive approach leads to win-lose outcomes

Roger Fisher and William Ury: Principled Negotiation

• Separate people from their problem. This helps parties to get a clearer picture of the substantive problem.
• Focus on interest rather than position.
• Generate a variety of options before settling on an agreement.
• Insist that the agreement be based on objective criteria

John Burton: Human Needs Model

• When  somebody is denied something fundamental (identity, security, recognition or equal participation) conflict is inevitable.
• To resolve such conflict, threatened needs must be identified and the situation restructured to ensure they are no longer threatened.

Bush, Folger And Lederach : Conflict Transformation

• Conflict transformation aims at a fundamental change in attitude and/or behavior of the involved individuals.
• For building peace destructive or negative communication patterns need to be transformed or replaced by constructive or positive interaction patterns
• Lederach stresses the need to transform the disputing parties by empowering them to understand their own situation and needs

Responses to conflict

I hesitate to call these "techniques", because little technique or skill is involved in these largely instinctual responses to conflict. If analysed in detail, the origin of many of these can be traced to the kindergarten playground, and observing individuals engaging in some of these behaviours can result in a deep depression. We should be able to do better. As my former director has been heard to remark, "these are adults with university degrees". In short, responses to conflict range in their demands for investment of energy, long-term effects and short-term outcome. The following breakdown is based on the Rahim and Bohoma definitions (1983), themselves derived from experience in business management literature.

Avoidance 

• Avoidance is not failure to acknowledge the problem - it is the conscious choice to exchange nothing between the two parties in conflict. Cooperation is also not sought.
• This works in the short term, especially if there is no time to address the problem in greater detail (eg. in the middle of a cardiac arrest).
• However, the conflict will not go away.
• Conflict-producing behaviours will be reinforced by the lack of challenge

Accomodation

• Accomodation sets up a dominant-submissive relationship in the conflict, with emphasis placed on achieving the outcome desired by the dominant party.
• This is also a conscious choice, made to make the conflict resolve faster, to achieve some other goals seen as more important.
• Again, the conflict will end quickly but it will not go away.
• The needs of the accomodator will not be met; the focus will be on the needs of the more dominant player. 

Domination and intimidation

• This refers to the use of authority to impose one group's will over another. "I am the ICU specialist. The patient will not come to my ICU." 
• It may bring the conflict to an end quickly.
• This requires the greatest amount of assertiveness, and may backfire as some negotiators are by nature submissive individuals who may sound inauthentic when trying to dominate another.
• Even if successful, this technique gives rise to power struggles and degrades relationships.

Competition

• Accommodation and domination are the two potential outcomes which competitors achieve when they compete for the resolution of a conflict.
• Competition minimises empathy and emphasises the goals of one party as being the only valid goals. There is typically no acceptable win-win outcome scenario for competitive parties (only "win-crush"). 

Negotiation

• This is a consiliatory style, whereby the parties attempt to strike some sort of a bargain.
• The aim is to minimise losses and maximise gains
• Greatest emphasis is placed on "fairness"; both parties state their positions and try to reach a compromise that disadvantages each party to the least overall degree.
• This requires much more maturity than the competitive or avoidant strategies, and usually requires both parties to have some sort of insight into the fact that they are in conflict and that mature solutions are desirable.
• The approach demands some flexibility. By accepting some of the other party's demands, the negotiator hopes that they will be encouraged to do the same (to "meet half-way"). This relies on the other party being reasonable, and does not work when they are a completely inflexible domination-fixated sociopath.

Collaboration

• This is probably the only response which can be described as a "style" or "technique" of conflict resolution, as it requires the greatest amount of skill to execute. It still falls into a category of instinct-driven responses, particularly for empathetic individuals who are naturally prone to looking for amicable solutions.
• Each participant must be ready to discuss what would satisfy them.
• Common grounds for agreement and common interests are pursued. This resembles the "walk in the woods" model (Marcus et al, 2012)
• Conflict is seen as an opportunity, and effort is invested in finding a creative win-win solution.
• This response to conflict benefits most from timing: it is easiest to resolve conflict through a collaborative approach before attitudes have hardened and the only thing left is mediation

Mediation

• This is a form of avoidance which does not ignore the conflict, but rather displaces the responsibility for finding a solution from the people involved in the conflict.
• In a number of ways, this represents a reversion to primitive kindergarten-level conflict resolution processes. You can't agree, so you run to tell the teacher.
•  A mediator in the healthcare setting (eg. the ICU) would be either the head of department, the CEO of the hospital, some high-level administrator, etc.
• The mediator then may take a number of steps. They may mandate from above: having heard the details, the mediator imposes some solution with might be equally unpopular with each party (lose-lose). Alternatively, they may offer arbitration: having allowed each side to make their arguments, the mediator incorporates their needs into the solution according to the mediator's idea of what "fairness" looks like. This is a variant of negotiation. 

Practical approach to conflict resolution in ICU

There is no such thing as a "best" model here. Interest-based negotiation (also referred to as "principled negotiation") is probably the most effective for the broadest range of situations.  Interest-based negotiation is a form of collaborative response to conflict, and has a high likelihood of achieving the desired "win-win" result. It does not guarantee such an outcome, but it establishes a structure in which such an outcome has the greatest chance of developing.

Advantages of interest-based negotiation:

• This is a detour from the typical progress of a conflict, where each party rapidly identify how their interests are being challenged, and engage one another in argument before either has had a chance to appreciate what the other's interests and needs are.
• The process offers a structure for sharing information which will be critical to both negotiators.
• Through the process, interests, options, and consequences are made explicit.
• This more complete picture then guides the negotiation. It helps the negotiators separate what is important from what is not.

Disadvantages of interest-based negotiation:

• In a conflict, each party is not naturally inclined towards the process of discovering what the other party's interests might be. There is usually a "reservoir of suspicion and mistrust" (Marcus et al, 2012). 

Process of interest-based negotiation:

Exploration of shared interests

• First, each party shares with the other what they hope to achieve from the negotiation.
• This should be conducted in a nonadversarial manner
• The parties are encouraged to listen carefully to what is being expressed.
• Each party must be asked whether all the relevant issues are laid on the table, and whether they feel that the other party has acknowledged these issues.
• This first step concludes when the differences between the parties are no longer a source of automatic hostility. "Stop trying to make each other wrong" is a good way to describe the main objective of this first step.

Enlarging of shared interests

• The parties are asked to identify and list their points of agreement and disagreement
• Often, the points of agreement outweigh the points of disagreement. 
• The points of disagreement need to be reframed as points of lesser value. By this process, "the parties are more likely to walk away from interests that are simply symbolic bargaining chips or attempts to penalize the other party".
• This also encourages each party to see the other side as a potential ally to be recruited rather than an enemy to be defeated.
• This stage concludes when the parties are ready to share the investment of energy in finding solutions to the remaining problems.

Enlightened interests

• This is essentially a brainstorming session where the parties are encouraged to come up with creative solutions to the remaining points of disagreement.
• A zone of "no obligation" is set up, and creativity can flourish without either side needing to commit to anything.

Aligned interests

• With multiple solutions available, each party can now debate what combination of solutions results in maximal recognisable gain for the parties.
• Whatever disagreement remains after this process can be deferred until a future round of negotiations, thus separating persistent points of argument from the agreement which has already been reached.
• The negotiation over solutions will require each party to make some concessions.

Rules for making concessions:

• Be clear about your demands.
• Establish a minimum acceptable outcome in the negotiated agreement.
• Make concessions late. And make them smaller as time goes on. Shrinking concessions suggest to the other party that the point of impasse is approaching.
• Make concessions which do not cost you. Present these concessions as if they are precious.
• Ensure a concession from your side is matched by a concession from their side ("give and take").