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Previously Published in: ACResolution, The Quarterly Magazine of the Association for Conflict Resolution, Spring 2003.
The health care professional’s typical day involves a frenetic race to coordinate resources, provide care, perform procedures, gather data, integrate information, respond to emergencies, solve problems and interact with diverse groups of people. Regardless of the role of the professional; physician, nurse, administrator, manager, social worker or technician, as a group, health care professionals face more conflict and greater complexity than any other profession. Despite the challenges of balancing competing interests, philosophies, training backgrounds, the endless quest for adequate resources, and the emotional quality of the work that they do, very few health care professionals have had the opportunity to learn the skills and processes necessary for negotiating their environments. There is little formal training available to them in this area and role models for collaboration and good negotiation are far and few between. As a result, the clinical environment is one of competition, quick fixes, hot tempers, avoidance tactics and at times, hopelessness.
The field of dispute resolution has a unique opportunity to inject hope into our hospitals and clinics. By providing education, professional development, and strategies for conflict management and dispute resolution, the ADR field can create synergy by merging solid conflict resolution processes with an environment rife with complex problems and motivated problem solvers. By creating shared meaning between ADR and health care, clinicians can begin to integrate interest-based processes into their existing activities. Through development of conflict management skills of experienced clinicians and administrators, health care organizations can begin to raise the level of dialogue from that of survival-of -the-fittest to that of collaboration and synergy.
Where to Provide Training/ Professional Development
Providing training and education for health care professionals can take various forms. For licensed providers, creating continuing education courses can provide an educational forum that takes advantage of their licensure requirements and creates an opportunity for more intense learning outside of the clinical environment. Continuing education can take place at conferences and workshops, or through CE centers. Additionally, education can take place within the clinical setting through grand rounds, staff meetings, retreats, HR development programs, brown bag discussions, leadership development courses, and internal newsletters, websites and journals. From within the health care organization, education in conflict management can occur through integration of facilitation and mediation techniques into patient safety processes such as root cause analysis, process reviews, failure modes and effects analysis, disclosure conversations with patients, and team care conferences. Finding multiple ways to integrate skill development and process understanding into currently existing health care activities is essential to the successful development of the field of health care alternative dispute resolution.
Training Strategies That Work
To provide a framework for teaching conflict resolution to health care professionals, it helps to tie the principles of dispute resolution to their clinical experience. Simple analogies during a facilitated session can help them see how something they are doing to resolve the conflict is similar to something they do clinically. For example, a group of obstetrical physicians who are developing an important guidelines document and who are having difficulty understanding the importance of the process necessary for the creation of the document, by focusing on content alone, can be given insight with an analogy to the birth of a baby. As obstetricians, their focus for 42 weeks is on the process for development of a healthy baby. Analogizing how lack of attention to the process can affect the health of the "baby" (the document) helps them understand the collaboration and process issues and recognize the need to work together at a different level.
Health care professionals are excellent problem solvers. They are expert at analyzing a problem, developing a strategy, locating resources and implementing the plan. This is how they are trained to care for patients. Using the analogy to patient care enables clinicians to grasp quickly the concepts associated with conflict management. The skills used to take care of patients can be honed to resolve conflicts and negotiate effectively. A useful strategy for integrating skill development into a training session is to identify the steps in caring for a patient. The first step is assessment, then diagnosis of the disease or illness, then creation of a treatment plan, followed by evaluation of the treatment and modification of the plan if necessary. Given a clinical scenario, health care providers easily identify these steps in the process. They have difficulty applying the same process to conflict situations. If given a conflict scenario, for example a dispute regarding visiting hours on the unit, most of the clinicians will jump straight to diagnosis or treatment. They will describe the problem as, “inconsistency in the enforcement of visiting hours” and therefore there must be a stricter policy and re-education about the policy. Diagnosis- Inconsistent practice. Treatment- Tighter policy and re-education. Assessment of what is leading to the inconsistent practice is not done. Analogizing the situation to one of treating a patient without taking vital signs, listening to their lungs or looking at their lab work helps clinicians grasp the importance of assessing the interests and needs at stake in a conflict situation. ADR professionals are expert at assessing needs and interests and can provide skill development for clinicians in this regard.
Conflict Resolution Skill Development
Despite an abundance of years in schools, most physicians and nurses are lacking in basic skills necessary for resolving conflicts. Some of the skills that must be developed for effective conflict management in the clinical setting include, being present in the moment, listening for understanding, mutuality, openness, and reflection. Due to the chaos and complexity that exists in most health care environments, a majority of health care professionals are busy thinking about the next patient, how to get the next resource, when to fit in a test or procedure, when to eat or sleep, and responding to multiple distractions and interruptions. It is difficult to truly be present in the environment and listen to what others are saying at a deeper level. Listening is typically restricted to information needed to move through the day and is rarely done at a level that enables understanding of a situation where there may be collaboration barriers resulting from fear, need for control, fatigue, a need to be right, or shame. Creating the ability to listen at a deeper level within a chaotic clinical environment is an essential skill for developing conflict resolution abilities in clinicians.
Despite the descriptor, “health care team”, there are relatively few times throughout the day when members of the interdisciplinary team function as a team. Most often, they are working as individual advocates for the patient through their role and only in rare instances, such as clinical emergencies, do they step out of the role and truly work together as a synergistic team. Turf battles, differences of knowledge level and experience, and rare opportunities for group conversation lead to a competitive atmosphere where everyone is struggling to do the right thing. Development of the skill of mutuality is essential for managing disputes and for preventing the shame/blame game that so frequently arises in the clinical setting. Fear of doing harm to the patient creates a great need for control of the patient and the environment and can cause harm to the development of true teams. Demonstrating ways for developing mutuality through exercises and role-playing is a great method for advancing the professional development of skilled clinicians.
Openness to alternative solutions is key to resolving complex problems. Developing this skill in clinicians enables them to consider creative alternatives to a conflict situation. It is what enables them to think beyond “a policy”, “a guideline”, or “re-education” as the solution to their current conflict. Openness is necessitated by a trusting and supportive environment. ADR professionals may be required to come into a toxic environment to recreate trust and establish support structures before openness can be fostered. In a competitive environment where mistakes can be lethal, it is difficult for health care professionals to be open to the fact that their idea or answer could be wrong. There is a need to be right so as not to hurt the patient. This trait carries over into conflict situations where everyone has the right answer to the problem and has difficulty hearing conflicting solutions. On a broader level, with varied levels of training, there is a built in tendency to believe that you know more than someone else because of specialty training, certification, more experience or position within the organization. Developing openness across professions and across hierarchical levels is difficult but necessary to foster just agreements and lasting solutions.
Training in methods of reflection is also key for health care professionals. As a result of the need to be right, there is a difficulty managing situations where it appears that the wrong choice was made or a system design flaw lead to a bad outcome for the patient. Many conflicts in health care flare up around adverse outcomes or near misses with a patient’s care. The quick jump to diagnosis usually results in a search for who to blame for the bad outcome. The blame environment exacerbates the conflict by creating secrecy and shame. Individual reflection is a necessary skill for resolving these types of conflicts by enabling clinicians to learn from the event and identify what they would do differently the next time. Organizationally, hospitals and health care organizations must also find a way to reflect on how to improve their processes rather than foster a punitive environment that adds fuel to conflicts or drives them underground until the next adverse event occurs.
Skill development in conflict management can enhance the role of the clinician in their current role and can assist managers and administrators in negotiating the complexity of their environments. In addition, skill training programs can be designed specifically to develop health care professionals who are interested in becoming health care mediators or internal neutrals within health care organizations. Expanding the role of the mediator to include work within health care organizations will require training a core group of health care professionals who can integrate their clinical expertise with the practice of dispute resolution. Programs with this purpose are relatively new and are developing momentum as more health care professionals become interested in the field of dispute resolution.
Clinical training does not prepare health care providers for working collaboratively, running care conferences, conducting a root cause analysis or working effectively on committees. There is no training in facilitation, mediation, dialogue, or negotiation. There may be a few hours of training within a psych rotation on group work or active listening but that is geared toward a therapeutic outcome and rarely does the knowledge transfer to non-therapeutic situations. Core training in how to facilitate, how to run a committee, how to create a team, how to intervene after a crisis, how to balance competing interests and how to manage culture change is key in integrating conflict resolution into the health care setting. Applying the processes that dispute resolution professionals use with clinical activities allows an immediate application of the principles of interest-based negotiation and mediation. It also enables clinicians to have a consistent method for doing non-clinical problem solving and for enhancing collaborative work relationships that carry back over into bedside care of the patient.
Process training can be done through formal courses in facilitation and mediation, through retreats for managers and administrators, through role-modeling by going in as a facilitator or mediator in a clinical situation, and through professional schools or associations in conjunction with conferences. All trainings should be interactive and allow opportunity to apply the process to a clinical conflict. Health care professionals are “doers” and learn well with applied exercises and the challenge of trying new skills. Applying the process to actual conflicts they are having in their workplace enables them to work through the conflict in a neutral setting and reinforces how to apply the process to their work environment. Processes that are beneficial in the clinical setting are facilitation, mediation, negotiation, appreciative inquiry, dialogue, and conciliation.
If You Build It, Will They Come?
Finding forums for providing the training and education programs takes some planning and networking. Contacting a local hospital or provider group to provide an in-service, workshop or training session is one method. Submitting a proposal to a professional health care association to present at upcoming conferences or events is a great method for disseminating introductory information and promoting the idea of conflict resolution training. Working with a continuing education center at a hospital, school of medicine, or school of nursing is another forum for providing training. Identifying where health care professionals look for education and professional development is essential to the success of a training program. Additionally, designing the program to fit their unique time dependencies and quick attention spans is key in creating good word-of-mouth with attendees. Obtaining continuing education credits for physicians, nurses and other licensed professionals adds to the likelihood they will attend. Designing the training to be challenging and interactive will increase their knowledge retention and also make the courses more popular.
A culture change is occurring in health care as the system grapples with ways to provide more care with fewer resources and improve safety through collaboration and better systems. For this change to be successful, health care organizations are going to need a critical mass of professionals with good conflict management skills and a means for integrating collaborative processes into their day-to-day operations. ADR professionals can fill that need by providing well designed, interactive training programs that enhance the ability of health care organizations to provide safe and effective care and that enable health care practitioners to regain hope that complex problems can have creative solutions.
Ms. Gerardi is a mediator and health care dispute resolution consultant and Chair of the Program on Healthcare Collaboration and Conflict Resolution at the Werner Institute for Negotiation and Dispute Resolution at Creighton University.
Ms. Gerardi is a licensed critical care nurse with more than 15 years of clinical and administrative experience in academic health care organizations. Her healthcare background includes patient safety program design, management of surgical and medical intensive care units, administration of VIP medical/surgical services and of ambulatory health services. Her mediation experience includes complex multi-party disputes, organizational mediation, civic dialogue facilitation and community mediation. She has trained more than 5,000 professionals in conflict management, creativity, negotiation and communication skills.
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