Transforming Healthcare’s Conflicts

Healthcare professionals and institutions are confronting a host of threats and challenges. Despite the increasing volume and variety of those complications, there is one achievement that, if accomplished, has the potential to greatly impact them all.

The hospitals and provider organizations that find ways to deal effectively with workplace conflict will be the performance leaders in the years ahead. So the key question is how to bring about the individual and organizational behavioral changes so essential to improving workplace relationships and performance.

The Positive Side of Conflict

Conflict transformation is the new “watch word” among those who study and research conflict. It is thought to be a much better expression of the objective and desired outcome.

The work of social scientists and researchers indicates that conflict is a constant presence among interconnected units and affiliated groups (such as the workforce and staff of a hospital or group practice).[i] While that’s a sobering prospect, those same studies indicate that conflict has both negative and positive characteristics.

If so, the focus needs to shift from dispute management or resolution to the search for ways to alter conflict from its counterproductive and destructive manifestation in order to secure the positive and constructive benefits of our continuing differences and disagreements.

Overcoming the Challenges of Conflict

Conflict in healthcare certainly isn’t new! However, in this era of growing demand and increased treatment options and capabilities confounded by tighter budgets, the consequences and costs of conflict are simply unsustainable! Unfortunately, the nature of the industry’s disputes, the personalities involved, and the emotionally charged context in which they typically occur should caution us that meaningful improvement won’t be easy, nor will it come quickly.[ii]

In deciding to take on the challenge of transforming conflict within an organization, the institution’s leadership must recognize that progress won’t be a straight line and that on-going success will require a long-range commitment to the effort. To be successful an organization must be prepared to tackle the host of long-standing and established ideas and attitudes that continue to cause conflict in healthcare.

The code of ethics published by the professional organizations that represent an institution’s two key constituencies (doctors and nurses) shows the organizational and philosophical barriers that will need to be overcome.

The following statement is taken from the AMA’s committee on Ethics and Judicial Affairs, Principles of Medical Ethics, which outlines the organization’s stance on inter-professional collaboration:

E-3.00 Opinions on Inter-professional Relations: Nurses:

“…One of the duties in providing reasonable care is fulfilled by a nurse who carries out the orders of the attending physician.

When orders appear to the nurse to be in error or contrary to the customary medical and nursing practice, the physician has an ethical obligation to hear the nurse’s concerns and explain those orders to the nurse involved.

Debra Gerardi writes in the Ohio State Journal of Dispute Resolution (Vol. 23:1 2007) that, “the statement clearly underscores the assumption of dominate status of the physicians as related to the nurses and joint decision making does not seem to be valued…the assumption is that questioning a component of the treatment plan is assumed to be due to a lack of understanding rather than legitimate difference of opinion.”[iii]

In contrast, consider the ANA’s Code of Ethics. It states:

ANA Nursing Code of Ethics Interpretive Statement 2.3: Collaboration

“Collaboration is not just cooperation, but it is the concerted effort of individuals and groups to attain a shared goal. By its very nature, collaboration requires mutual trust, recognition and respect among the heath care team, shared decision-making about patient care and open dialogue among all of the parties who have an interest in and a concern for heath outcomes.

Nurses should…have a voice in decision-making about patient care issues…should see that the questions that need to be addressed are asked and that the information needed for informed decision-making is available and provided.”

As the example demonstrates, the differences in attitude, perspective, and orientation make healthcare’s conflicts particularly vexing. It also means they are going to continue to occur and are likely to do so with increasing frequently and intensity!

Physicians Spend Half Their Day Dealing With Conflict

Colby J. Anderson and Linda L. D’Antonio, in the Georgia State Law Review, “indicated that 62% of the conflict [healthcare professionals] experienced was with other health professionals and that 50% of each physician’s day was spent dealing with conflict.”[iv]

That sounds bad—and it is! But it also offers hope that things can get better!

If doctors and nurses are truly spending half of their time in conflict (or even if it’s just 1/3 or 1/4), consider the potential upside for the delivery of patient care if that dynamic can be changed! Given more productive use of their time, we should see dramatic increases in treatment capacity, enhancements in patient care, improvements in financial performance, and almost unimaginable gains in patient satisfaction.

So how does a hospital change that dynamic?

Steps to Resolve Conflict

Phase 1: Gauging an Institution’s Conflict

The first step is quantifying the current state of conflict within an institution.[v] Many hospitals conduct routine employee satisfaction, employee engagement, and/or culture of safety surveys. Likewise, many hospitals are actively assessing the attitudes of their medical staffs. The accumulation of this data may be sufficient to establish a meaningful baseline for measuring the extent of conflict experienced in the institution and the impact of future conflict improvement initiatives.

Or supplemental surveying may be necessary. If so, the additional information gathering can be accomplished via internet-based survey tools. Alternately, the data can be gathered by conducting on-site, one-on-one interviews of representatives from the various constituencies that make-up a hospital’s workforce and staff.

The Internet approach offers the advantage of widespread involvement and participation. The individual interviews afford the opportunity to explore issues in greater detail and to pursue inquiry into areas not initially identified or included in a fixed survey document.

Regardless of the survey method deployed, the topics to be explored include:

  • Communication
    • Individual assessment capability
    • Identification of colleagues and co-workers thought to be effective communicators
    • Personal observations of examples of poor communication
      • Impact of those incidents
      • Future implications of these instances
    • Ideas for improvement
  • Professional Relationships
    • What’s working
    • What’s not
    • Ideas for improvement
  • Conflict
    • Attitudes about causes and consequences
    • Individual approaches for dealing with conflict
      • Methods
      • Experiences and expectations
      • Effectiveness
    • Impact of existing conflict on:
      • Relationships
      • Productivity
      • Patient care and safety
    • Organizational/Systemic Contributors to Conflict
      • Policy conflicts
      • Procedural conflicts
      • Cultural conflicts
      • Mission conflicts

Regardless of how the conflict baseline is established, once it’s done, the real efforts to effect change can commence.

Phase 2: Normalizing Conflict

Meaningful direction on ways for hospitals to address conflict can be gained from examining the experiences of other principled organizations (those bound by an overarching philosophy or guiding belief), especially those that routinely experience frequent and disruptive conflict. Foremost among these are religious institutions and congregational groups. Among other things, the experience of these organizations and membership indicates that there is a critical need to “normalize” conflict within the hospital’s staff and workforce. [vi]

In addition to the emotional toll of the conflict itself, church members and staff frequently experience enormous guilt over having allowed their disputes to disrupt the church’s higher calling and purpose. That guilt deepens the divisions and intensifies the conflict.

In his book, Never Call Them Jerks, Arthur Paul Boers identifies 13 reasons, “Why Churches are Vulnerable.”[vii] His book was written as a tool to aid other pastors and clerics in dealing with conflicts within their parishes or congregations. To fully appreciate his perspective, realize that the “jerks” he’s referring to are his parishioners!

How many times in a healthcare setting do we hear the parties to a dispute or the ones tasked with resolving that dispute using similarly descriptive terminology? Not surprisingly, one can replace the word “church” with “hospital” in each of Mr. Boers’ thirteen reasons and not alter the substance or accuracy of any of his statements.

Similarly, evidence suggests that healthcare workers are also burdened by the realization that their conflicts are interfering with their higher calling (“to do no harm”). So a critical step in the process is to help them appreciate that conflict in the healthcare setting is a constant and when appropriately confronted, improves patient care and safety. Achieving that understanding starts the process of de-intensifying theirs and the institution’s conflicts.

But normalization is just the opening phase of an extensive education program designed to improve communication and conflict handling skills. At the conclusion of the initial education phase there will be an on-going need for refresher courses. Additionally, implementing a dispute resolution system can’t be completed until sufficient numbers of hospital personnel can receive the specialized training needed to provide the services and resources to be included in the system.

Phase 3: System Components and Design

The economic and logistical benefits of a dispute resolution program have been documented in a research study commissioned by the American Arbitration Association.[viii] Additionally, business and management literature is replete with articles and studies highlighting the benefits of these initiatives.

William Ury (author of Getting to Yes) envisions a system that brings about “negotiation as early as possible…and at the lowest possible level”[ix]…(within the organization). Ury and others suggest consideration and inclusion of a wide variety of elements or resources into these programs.

However, the final determination of what, when, and how is made by a local design team comprised of representative personnel from throughout the institution. That team is multi-disciplinary, comprised on both professional and managerial as well as rank and file staff personnel.

The prospects of the use of procedures like mediation and arbitration (see the list of possible program components below) can be very concerning to many healthcare executives, especially those with experiences with EEOC challenges and/or a unionized workforce. However, remember in this context, it will be the peers of rank and file personnel and staff members that deliver these services. And they’ll deliver them to fellow employees and physicians as those individuals endeavor to find ways to more effectively resolve their differences so they can continue to work together.

In these circumstances, the hospital may not even be a party to the dispute. Conversely, in those situations in which the dispute is between supervisor and subordinate or involves hospital policy or practice, the institution may have an interest. However, allowing the parties to the dispute to have the means and opportunity to find ways to address the issues in ways that work for them may well obviate the need for the hospital to take a position on the outcome or an active role in the process.

These systems are not usually intended to replace or interfere with the grievance procedures contained in the union agreements. Interestingly, it is union members who are often among the first to make use of the coaching and mediation elements. They too are seeking effective resolution rather than the continuation of the dispute or the deliberations.

Some of the elements, stages, and/or interventions that may be selected by the design team include:

Transforming Healthcare's Conflicts blog image

Phase 4: Prevention

As a part of their deliberations, the design teams with their multi-disciplinary membership frequently have both the cause and opportunity to focus on actual conflict episodes and incidents. Supplemented with historic survey data, these spirited debates surface and discuss the details of current and past conflict situations. Frequently that leads to the discovery of a startling number of commonalities and shared characteristics among the various incidents.

Those discoveries, in turn, lead to the identification of procedural or organizational shortcomings that caused, contributed to, or intensified the conflict. Working with senior leadership, the design team then brainstorms and may even experiment with ways to address the systemic triggers so that similar conflicts in the future are avoided or the intensity of future disputes are lessened.

Finally, the success of these multi-disciplinary discussions and examinations highlight the benefits of on-going review of future conflicts as a means of securing continuing improvement. The result is often to formalize this multidisciplinary review process, completed by the managers, employees and staff persons of the unit or department that experienced incidents (rather than senior management or leadership personnel). This becomes the standard follow-up to any significant upsets that occur within a particular unit or department—especially those incidents that complicate or compromise staff communication and relationships and/or patient care.

The objectives of these continuing and detailed examinations (or debriefs) of future incidents are intended to first, quantify the extent of the damage to the workplace relationships. Second, to identify the actions needed to address that damage in order to limit its future impact on the ability of the affected personnel to work together.

Thirdly, the staff members and employees engaged in these reviews are empowered to search for procedural or organizational contributors to the incident and to report those findings up the institution’s chain of command. In return, management commits to conduct further review of the identified contributors and to inform the affected employees of their conclusions and, when warranted, the planned or implemented actions intended to correct the identified deficiencies.

Phase 5: Implementation

Once the various system components are considered and approved by the design team, the hospital’s senior leadership proceeds with the system’s implementation. In doing so, administration will need to adopt and revise policies in order to accommodate their employees’ access to the methods and resources envisioned by the resolution system. Among other things, administration will need to provide the means and opportunity for the personnel selected to be peer coaches and mediators to receive the appropriate specialized training.

Likewise, the medical staff and the medical executive committee will need to revise medical staff policy. Particular attention will need to be given to the provisions of the code of conduct policy that specify options available to physicians for resolving behavioral complaints.

For the most part, the system should be voluntary with any staff member or employee able to make use of it or not. Regarding physicians, the opportunity to make use of coaching or mediation could be included as additional elements of the collegial intervention phase of the code of conduct process.

As a part of the voluntary nature of a dispute resolution system, employees, staff or physicians should be able to access the system at any level. As such, some design teams choose to limit the range of levels or options within the system. But in every case, the education and promotion of the program is designed to encourage the individual disputants to see the value and wisdom of learning to resolve their own disputes. And if they can’t do it themselves, they are encouraged to continue their efforts, this time with coaching and/or mediation assistance from their designated and trained peers.

There is also the option of adding a compulsory extension to the dispute resolution system. In this sense, the addition may not be viewed so much as an element of the dispute resolution system but in a way in which the institution and its workforce can gain maximum benefit from the personnel trained as coaches and mediators.

For example, if a code of conduct complaint progresses beyond the collegial intervention phase, and especially if a physician has not opted to seek coaching or mediation assistance voluntarily, medical staff policy might be revised to enable its leadership to direct the physician’s participation in one or both of these activities.

Likewise, the hospital’s personnel policy might be revised to allow for managers or supervisors to direct disputants to coaching or mediation as an option before consideration of other remedies available under its progressive disciplinary policy.

Ironically, the biggest obstacle to the meaningful consideration and effective implementation of a dispute resolution system may be the institution’s management staff and leadership. Healthcare managers and administrators have long accepted the challenge and responsibility of resolving the conflicts encountered by their employees and staff. Many view this as an integral part of their day-to-day activity and take considerable pride in efforts in this regard.

However, much as they may want to help their direct reports resolve their differences, the evidence overwhelming indicates they may be doing more harm than good. As such, the first hurdle may be convincing those well-intentioned managers and supervisors that they need to stop.

And when they do, the entire organization’s culture will change. Then the challenge and responsibility for dealing with conflicts will shift to those that are directly involved in the dispute. And even though management won’t continue to be directly involved in the dealing with the dispute, managers will still have considerable influence on the outcome of these transformational efforts.

That’s because in order to improve their employees’ and staff members’ prospects for success, management must commit to a new role. They must ensure that the resources, systems, and support those employees and staff need are in place. When they do, then their staff and employees will be encouraged, empowered, and enabled to take on the challenge of addressing and transforming the conflicts they encounter, themselves!

[i] Kirk Blackard, James W. Gibson, Capitalizing on Conflict, Davis-Black, 2002

[ii] Debra Gerardi, The Culture of Heath Care: How Professional and Organization Culture Impacts Conflict Management, 21 GA. St. U. L. Rev. 857 (2005).

[iii] Debra Gerardi, The Emerging Culture of Heathcare – Improving End of Life Care Through Collaboration and Conflict Engagement Among Health Care Professionals, Ohio State Journal of Dispute Resolution, Vol. 23:1 2007.

[iv] Colby J. Anderson & Linda L. D”Antonio, A Participatory Approach to Understanding Conflict in Heathcare, Ga. St. U. L. Rev. 817 (2005).

[v] Kirk Blackard, James W. Gibson, Page 169.

[vi] Carolyn Schrock-Shenk, Lawrence Ressler, Making Peace with Conflict – Practical Skills for Conflict Transformation, Herald Press, 1999.

[vii] Arthur Paul Boers, Never Call Them Jerks – Healthy Responses to Difficult Behavior, The Alban Institute, 1999.

[viii] Dispute-Wise Business Management – Improving Economic and Non-Economic Outcomes in Managing Business Conflict, American Arbitration Association, Dispute Resolution Services Worldwide, 3/2006.

[ix] William L. Ury, Jeanne M. Brett & Stephen B. Goldberg, Getting Disputes Resolved: Designing Systems to Cut the Cost of Conflict, Cambridge, 1993.

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