M7: Managing Conflict on Health Care Teams Institute for Health Care Improvement

Transcription

1 M7: Managing Conflict on Health Care Teams Institute for Health Care Improvement March 15, 2015 Nan Cochran, MD Neil Baker, MD Calvin Chou, MD, PhD These presenters have nothing to disclose. Objectives 1. Explain how to build relationships while negotiating 2. Define differences between interests and positions 3. Identify ways to separate fact from assumptions and stories 4. Practice identifying and using emotions during conflict 5. Demonstrate how to negotiate in the face of differences in authority 1

2 Increased complexity in care Staffing on hospital teams to care for one patient: 1970 s 2.5 FTE 1990 s 15 FTE Medicine s complexity has exceeded our individual capabilities as doctors. Gawande, A. Cowboys and Pit CrewsThe New Yorker, 2011 Real or apparent incompatibility of parties needs or interests How much of health care workers time is spent in conflict? Conflict Rosenstein et al, Am J Nursing 2005; O Mara, Emerg Med Clin N Am

3 Negative consequences of conflict Lower job satisfaction Decreased well-being Higher perceived stress Sleep deprivation Use of alcohol and medications as coping strategies Conflict affects patient safety Dysfunctional team dynamics lead to more than 70% of medical errors Disruptive behavior leads to Poor patient satisfaction Increased costs of care Decreased staff retention rates 3

4 I experienced conflict that I found difficult in the last month A. True B. False I experienced conflict that could have compromised patient care in the last month A. True B. False 4

5 Exercise what is most challenging about conflict? Take 2 minutes to think about what is most challenging about conflict to you Share with a partner, 4 each Then, share at your table Large group debrief Different kinds of conflict Relational Task Process 5

6 Conflict Styles Thomas- Kilmann Conflict Styles 6

7 A story 7

8 Why is conflict so hard? Reactivity Ladder of Inference CONCLUSIONS, ACTIONS JUDGMENTS, ASSUMPTIONS, OPINIONS SELECTION OF DATA OBSERVABLE DATA AND EXPERIENCE 8

9 Ladder of Inference CONCLUSIONS, ACTIONS I can t work with Chris; he is totally unmotivated; it s time to get rid of him. JUDGMENTS, ASSUMPTIONS, OPINIONS Chris is slacking off, totally disengaged and does not care about our team. SELECTION OF DATA Chris is constantly late to our staff meeting and never apologizes or explains. OBSERVABLE DATA AND EXPERIENCE I have worked with Chris for 2 years. I see he comes to a staff meeting late for the third time in a row. This last week I have worked until about 9 pm every night. Climb Down the Ladder Take a step back: What was the observable data? Do we agree on the data? What assumptions did I make? What conclusions did I draw? How did those conclusions influence my subsequent observations? 9

10 Caution! Flawed assumption: Feelings don t matter. Watch for body language Created by Neil Baker M.D. for AACH 10

11 Watch for I feel that. Bundles of feelings and thoughts you have poor judgment. (judgments) it s your fault! (blame) you are attacking me! (attributions) you are passive-aggressive. (generalizations) the answer is (cognitive) Created by Neil Baker M.D. for AACH Name feelings - modulate your intensity Low intensity Concerned Unsettled Puzzled High intensity Pissed off Angry Shocked Created by Neil Baker M.D. for AACH 11

12 Self-reflective practices PAUSE to observe within Create a habit of using self-reflective questions Find ways to relax Practice meditation Try journaling Know your dominant conflict styles Consult with colleagues Prepare for difficult conversations Ladder of Inference Exercise Choose an interpersonal situation that was difficult for you -perhaps the relationship you have with the other person is challenging or you regret something you said or did Choose a situation that felt important, that is likely to recur and that you are willing to learn from Potential conflicts: you can't reach agreement with your colleagues or with a patient someone is not pulling his or her weight on a team you believe you are being treated unfairly by your boss or supervisor you believe your point of view is being ignored 12

13 Ladder of Inference Exercise What assumptions did you make that contributed to the conflict? Seek disconfirming data! Perspective 13

14 Relationship affects conflict and vice versa Conflict in medical teams and in patient care often involve interpersonal incompatibilities Detracts from effective functioning Greer et al, 2012; Kalishmanet al, 2012 Negotiating Differences Summarize Tell Respond Ask 14

15 Negotiating Differences ARTS of Communication Ask the other s perspective use active listening Respond with empathy and reflective listening Tell your perspective and your interests Summarize your understanding of the other s perspective, their interests Seek solutions--generate options Negotiating Differences: ARTS of Communication Ask the other s perspective use active listening Distinguish interests from positions Respond with empathy and use reflective listening Tell your perspective and your interests Beware of assumptions Summarizeyour understanding of the other s perspective, their interests and focus on shared interests Seek solutions -generate options 15

16 Goals of Active Listening Help a speaker feel heard, understood Encourage exploration at a deeper level Strengthen the relationship Understand different perspectives Show respect Listen, don t reload! And listen to yourself Understand your anger and other feelings before engaging in a difficult conversation Negotiate with your feelings What assumptions am I making? What story am I telling myself about their intentions? Describe your feelings carefully, and gently Use I statements - You statements often heard as blaming I feel angry vs You make me so angry 16

17 Positions Interests Different kinds of interests Relational Task Interests Process 17

18 Ask about positions and underlying interests Positions What we want, need, think, or feel Drawing a line in the sand Basis for debate I can t let Bobby transition to the adult team Why 4 mandatory visits per year? Interests The motivations for our positions: our needs, desires, concerns, fears, aspirations Basis for dialogue I m afraid the adult team won t understand how to work with Bobby. I worry they won t provide the same level of flexibility and care. Example In a clinic process improvement meeting, a ground rule had been set to "arrive early to start on time." Dr. X consistently arrives minutes late, typically entering the room with apologies, along with a statement that "patient care comes first." Even though the group had developed guidelines for team members, including not scheduling patients for 15 minutes before the meeting and identifying a time that really worked for everyone, Dr. X enters expecting to have a recap of what has been discussed. Many times, Dr. X intervenes to change decisions the group made before he arrived. 18

19 Positions and Interests: group Positions and Interests: Dr X 19

20 Negotiating Differences: ARTS of Communication Ask the other s perspective use active listening Respond with empathy, reflective listening Tell your perspective and your interests Summarizeyour understanding of the other s perspective, their interests and focus on shared interests Seek solutions -generate options 20

21 Listening Filters that affect our listening (that we don t notice) Culture Language Values Beliefs Expectations Intentions Potential Pitfalls in Communication The single biggest problem in communication is the illusion that it has taken place. George Bernard Shaw What you mean to say What you say What is heard What is understood Reflective Response Adapted from Health Behavior Change by Stephen Rollnick 21

22 Relationship as a conflict transformation tool PEARLS: Partnership Emotions Acknowledgement (or Apology) Respect Legitimization Support Marvel et al, JAMA 1999; Langewitz et al, BMJ 2002 PEARLS statements Partnership: I d like to work with you, not against you. Empathy: You seem pretty frustrated. Acknowledgement/apology: What I m hearing is that you are finding it difficult to interact well with the physicians on the team. Respect: I see how much thought and work you have put into this. Legitimation: Most people I know would also feel troubled after an event like that. Support: What can I do in the next team meeting to support you? 22

23 Convey empathy nonverbally and verbally Use: Pause Touch Facial expression Tone of voice Space Ambady et al, Surgery 2002 Skills Attending to Relationship: Skills Practice 1. Make at least one empathic statement 2. Convey empathy nonverbally 3. Be aware of your own reactions 23

24 Reflective Listening Listen, express interest, and understand the meaning of what the speaker is saying with a minimum of preconceived agenda Reflect the speaker s words: -repeat what you heard, including nonverbal messages - short summaries Non-verbally remain attentive, open, nonjudgmental Reflective Listening Demo 24

25 Skills Practice 6 minute exercise, then 6 minute debrief Work in pairs You will be in two different roles for 3 min each 1. Storyteller:Describe a challenge in a working relationship with a patient, colleague, supervisor, etc. 2. Interviewer: Do NOT ask questions, share your stories, or problem-solve. Use only reflection and empathic statements. Mm hmm Sounds like you were angry That s really tough Negotiating Differences: ARTS of Communication Ask the other s perspective use active listening Respond with empathy, reflective listening Tell your perspective and your interests Summarizeyour understanding of the other s perspective, their interests and focus on shared interests Seek solutions -generate options 25

26 Identify Shared Interests Uncover and highlight shared interests Remember that you and colleagues are allies and have many shared goals Incompatible interests do exist Practice a conflict scenario in pairs 10 Identify a current conflict in which you are faced with a person who is entrenched in a position Describe the situation briefly to your partner Your goal is to identify their interests and find shared interests Group debrief 26

27 Goal -emotional self-awareness, self management 1.StayBalanced: successful negotiators are calm, patient, observant. 2.Beattuned to your counterpart: if they are feeling defensive and hostile, everyone will be dragged down. 1.Influence your counterparts emotions 1.Resilient: self-awareness is key What is power? Power as legitimized authority Positional power Professional or expert power Cultural power Power as the ability to produce intended effects Experience and knowledge Ability to build healthy relationships Ability to resolve differences Ability to influence others 27

28 Why is POWER so hard? Reactivity Those with formal authority Less listening More talking Harder time getting into others shoes Those with less formal authority Withdrawal Criticism or attack Power 28

29 Long term influencing strategies Build relationships Identify opinion leaders and those with formal authority Get to know their interests, challenges Build allies and stay engaged with opponents Help others with their challenges Use PEARLS, ARTS, INTERESTS vs. POSITIONS Power Those with formal authority Those with formal authority Less listening Self-management, courage More talking More listening, less talking Harder time getting into ACBD others shoes Those with less formal authority Those with less formal authority Self-management, courage Withdrawal Use long term influencing Criticism or attack strategies Focus on ARTS 29

30 ARTS--up the power gradient Ask the other s perspective use active listening Begin by understanding their interests, barriers, and challenges Respond with empathy and reflective listening Assure they know you want and care about their success. Tell your perspective and your interests Explain how your ideas impact their interests. Check their reactions to your ideas and their concerns. Summarize your understanding of the other s perspective, their interests and your understanding of their reaction to your position. Seek solutions--generate options Make sure you meet again. Prepare for conflict Be clear about your goals for: - the relationship - the substance of conflict Distinguish interests vs. positions Distinguish feelings from thoughts Check your assumptions 30

31 Example In a clinic process improvement meeting, a ground rule had been set to "arrive early to start on time." Dr. X consistently arrives minutes late, typically entering the room with apologies, along with a statement that "patient care comes first." Even though the group had developed guidelines for team members, including not scheduling patients for 15 minutes before the meeting and identifying a time that really worked for everyone, Dr. X enters expecting to have a recap of what has been discussed. Many times, Dr. X intervenes to change decisions the group made before he arrived. 31

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33 Team Leader Role Demo Has done the preparation and takes the lead with ARTS Goal to find mutual interests MD Role Not prepared Does not know what to expect in the conversation Consultation groups Form triads Think of a conflict at work 3 rounds: in each round: One person shares a question Consultants ask clarifying questions Client then turns back on consultants Consultants discuss ideas, suggestions, 5 min Client returns, shares take-homes 33

34 Summary Seek to understand and demonstrate your understanding before seeking to be understood Make the goal of understanding a collaborative effort Develop a strong working relationship Embrace differences Summary Explore the data, reveal your reasoning Discuss how each of you has interpreted the data and reached conclusions Explore the interests underlying positions to expand the pie Seek to be unconditionally constructive 34

35 References Books: 1. Getting to Yesby Roger Fisher, William Ury and Bruce Patton 3 rd edition 2011 Penguin Books 2. Difficult Conversations, How to Discuss What Matters Mostby Douglas Stone, Bruce Patton and Sheila Heen Penguin Books 3. Thanks for the Feedback by Douglas Stone and Sheila Heen Penguin Books 4. Nonviolent Communication by Marshall Rosenberg, Dialogue: The Art of Thinking Together by William Isaacs, 1999 Articles: Aschenbrener, CA et al. Managing Low to Mid Intensity Conflict in the Health Care Setting The Physician Executive, July/Aug 1999; pp Greer, LL et al. Conflict in medical teams: opportunity or danger? Medical Education 2012: 46: Janss, R. et al. What is happening under the surface? Power, conflict and the performance of medical teams. Medical Education 2012: 46: Rosenstein, AH. A Survey of the Impact of Disruptive Behaviors and Communication Defects on Patient Safety, JCAHO, 8-08 Exercise Preparation for conflict; interests vs. positions Case scenario You have recently been promoted from nurse manager of a primary care clinic to be the Chief Nursing Officer for a large integrated health system with 20 primary care clinics and more than 15 specialty clinics. There is a huge backlog of patients from primary care waiting for appointments in many specialty clinics. You have been appointed by the CEO to chair a steering committee to guide an improvement effort. The CEO has said there is NO additional money for solutions. 35

36 CNO Role Demo Has done the preparation and takes the lead with ARTS Goal to find mutual interests MD Role Not prepared Does not know what to expect in the conversation 36