Conflict resolution in a different culture

Dr. Chevrier and Dr. Winter were invited to the Kingdom of Saudi Arabia to teach a course on negotiation and conflict resolution at the King Faisal Specialist Hospital and Research Centre in Riyadh (Figure 1). The institution is a >700-bed tertiary referral center staffed by physicians, nurses, and other health care workers from 55 countries.

Figure 1.

Aerial view of King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia.

The hospital was established in the early 1970s with supervision by the Hospital Corporation of America, but its top management is being gradually taken over by citizens from Saudi Arabia in a process called Saudization. The change in management, the multinational staff of employees, universal changes in the delivery of health care, and the conservative male-dominated culture of the Saudi populace have resulted in stressors and conflicts in the hospital as it strives to become a worldwide leader in health care.

CONSULTING ASSIGNMENT

Dr. Chevrier and Dr. Winter prepared a 3-day course for 90 members of the senior medical staff and physicians (Figure 2). Top administrative personnel, physicians and nurses in leadership positions, and other leaders in key departments of the hospital were eligible to attend. The content and format were based on a course in negotiation and conflict resolution that is sponsored by the University of Texas at Dallas and the University of Texas Southwestern Medical School through the Alliance of Medical Management Education (AMME), which awards a certificate and a master's degree in medical management. This course was developed by Dr. Chevrier in consultation with Dr. John McCracken, director of the AMME program. Dr. Winter has graduated from the course and has been involved in teaching it.

Figure 2.

Dr. Winter and Dr. Chevrier, course instructors.

The course offers practical experience in negotiating and theoretical frameworks for organizing and more deeply understanding negotiation concepts. Teaching occurs through both targeted lectures and experiential learning. Through cases, exercises, and simulations, participants are assigned roles and then negotiate with each other using the techniques that are taught. The exercises and simulations are followed by extensive debriefing discussions, encouraging participants to reflect on the experience and draw important lessons from it. This interaction between experiential learning and interactive lecture-based learning has proven extremely effective at illuminating important concepts and helping participants retain the lessons for direct application in the workplace.

THE KINGDOM OF SAUDI ARABIA

Encompassing most of the Arabian Peninsula, Saudi Arabia is bordered by the Red Sea to the west and the Arabian Gulf, referred to as the Persian Gulf outside of Saudi Arabia, to the east (Figure 3). Mostly a sand desert, the country is just a bit larger than Texas. The population, which includes more than 5 million “nonnationals,” is around 27 million but is growing fast. The birth rate of 29 per 1000 population is one of the highest in the developed world, and the average number of children per family is almost 4. Saudi Arabia has a high unemployment rate, estimated to be between 13% and 25% for men. There is no official unemployment rate for women.

Figure 3.

The Kingdom of Saudi Arabia and surrounding countries.

Abdul-Aziz bin Abdulrahman Al-Saud unifed the country in an effort that began in 1902 with the storming of the Al-Mas-mak fortress in Riyadh when he was just 20 or 22 years of age. Eventually Abdul-Aziz conquered all of what is now Saudi Arabia and consolidated his rule, culminating with the proclamation and recognition of the Kingdom of Saudi Arabia in 1932. All of the subsequent kings have been Abdul-Aziz's sons, including the current King Abdullah bin Abdul Aziz Al-Saud.

The government is a monarchy ruled by the sons and grandsons of the first king, although a constitution based on Islamic law was decreed by the Saudi royal family in 1992. The first local elections took place in 2005; only male citizens could vote. There are no political parties or national elections.

SAUDI CULTURE

Anyone who attempts to work or negotiate in Saudi Arabia needs to understand its distinctive culture. Islam was founded by the prophet Muhammad in Saudi Arabia, and two of the most holy sites in all of Islam, Mecca and Medina, are in the western part of the country. The official title of the King is “Custodian of the Holy Mosques.” Islam is the only recognized religion in the country, and the national flag carries the Arabic inscription, “There is no god but God, Muhammad is His messenger.”

It is said that Islam is more than a religion in the Middle East; it is a code of behavior and a way of life. Indeed, Islam plays a dominant role in both private and public interactions, intertwining the two. Moreover, Islam is practiced in Saudi Arabia in the Wahhabi tradition, an 18th-century conservative reform movement of Islam. Prayer is one of the pillars of the religion and an important part of Saudi life, with five calls to prayer each day. Shops and restaurants close during prayer time, and interruptions will be experienced unless these important times are taken into account.

The men of Saudi Arabia typically wear Saudi dress, consisting of a long shirt called a thobe and head covering called a ghutra, although some wear Western-type attire. Outside of their homes, all women wear a long-sleeved, ankle-length black robe, called an abaya (Figure 4). Many of the hotels provide an abaya to foreign women when they arrive. Most women in the country cover their hair with a veil or risk arrest or harassment by the religious police (mutawwa). While this is a Saudi “rule,” many Western women do not cover their hair in public but keep a veil nearby in case the mutawwa demand that they do so. Most Saudi women cover their face as well as their hair, exposing only their eyes. Mixing of the sexes in public areas is strongly discouraged—both men and women are subject to arrest if the woman is not accompanied by her father, husband, or brother. Men are not supposed to talk to the opposite sex except out of necessity. Women are not allowed to drive or ride bicycles on public roads and often sit in the back seats of cars.

Figure 4.

Saudi couple in native clothing.

Men have separate, preferred seating in most restaurants, and women follow behind men when walking in streets and malls. Few Saudi women hold jobs, and many institutions of higher learning are for men only. This fact is reflected in the literacy rate, which is 15% lower for women than for men. Nonetheless, women who occupy important positions in health care, though deferential to men, can be strong and assertive in their roles.

The long tradition of Saudi Arabian culture has produced strong, decisive male roles, yet Saudis are known for their hospitality, pleasantness, and courtesies. Indeed, many Saudi men are so polite that they resist saying no. A hesitant or slow response may thus be interpreted as a negative answer.

Saudi citizens have a strong devotion to family. It is said that the basic unit of identification for the individual is not the state, the ethnic group, or the professional association, but the family. Attention to family takes precedence over all other matters and can lead to missed meetings or delays when family matters intervene.

NEGOTIATION TECHNIQUES

The basic negotiation techniques for resolving conflict are relatively universal but must be adapted for different cultures. The process of integrative (as opposed to distributive) negotiations in any country begins with defining the problem to be solved as well as the issues contributing to the problem. An understanding of one's interests and those of the other parties, as well as alternatives to negotiating a resolution to the conflict, are also essential components of the process. Recognizing all shared and opposing interests and identifying different priorities across issues allow disputants to construct proposals that trade of issues of disparate priorities. This process can lead to agreements that are better for all parties than their alternatives. The pursuit of so-called win-win negotiation allows both parties the opportunity to create new solutions that can benefit both sides. Power and privilege are present in most negotiations and must be recognized, especially in different cultures. Techniques for negotiating with difficult people and the approach to teamwork in negotiation are principles that can apply across cultural lines.

Culture is a group-level phenomenon in which a defined group of people share beliefs, values, and behavioral expectations. Those traits are learned and passed on to new members of the group, though not every member of the group shares the characteristics to the same degree.

The importance of promptness in deliberations, acceptance of interruptions, requirements for detailed introductions, eye contact, physical closeness and touching, and comfort with silence vary across different cultures and must be understood for effective communication. Citizens of Saudi Arabia tend to prefer thorough introductions. The scheduling of an important meeting during our visit was delayed until curricula vitae could be reviewed. Eye contact seems to be important in deliberations, though eye contact with unfamiliar women in public is discouraged. Handshakes are common among men, though men may decline the offered hand of a woman. And touching can be touchy. A Canadian health care worker told us that his casual touch of a woman's shoulder almost led to a fight.

Out of respect for the ambient culture, the authors suspended their own typical greetings to each other and avoided hugging or any form of touching while in the country. Many Arab men hold hands with one another in public. We often saw men walking together, gently holding hands without embarrassment; this behavior is not unusual and simply indicates friendship or fondness. Arab women were never seen holding hands with other women or with men in public.

Another body language taboo in the Middle East is to display the sole of one's foot. It is common for Westerners to cross their legs when sitting, and this can allow the toes to point upward, “exposing the sole” to another. This happened to one of us when talking to a Saudi who had invited us over for Arabic coffee at a park. He was quite friendly and repeatedly expressed his appreciation to America and to all Americans, but he seemed uncomfortable when he was able to glance at the bottom of the foot. Discreet repositioning of the legs eased the tension in this situation.

National culture and customs define only one set of influences at King Faisal Specialist Hospital. Universally, the traditional medical culture is authoritarian rather than egalitarian, with the physician exercising greater power and authority than other players in the hospital setting. Most of the hospital administrators in the King Faisal Specialist Hospital had medical degrees in addition to business degrees, which added to their authority. The multinational staff introduces other cultural influences into the mix. Western workers seem to be well accepted, but workers from less developed countries may be treated less attentively.

An important concept in all negotiations is to understand that counterparts may see things very differently. An appreciation of this concept can help each side to be more understanding and less judgmental, smoothing the process of negotiations. For example, time orientation varies in different cultures, with some preferring that meetings begin and end promptly. In the Western tradition, we enforced our classroom schedule; however, in accordance with the multinational audience, allegiance to the clock varied. There were also issues of several people talking at the same time. As in America, strong leadership and reminders as to the educational purpose for all helped to reduce overlapping discussions. Space orientation also varies across cultures. We observed that Saudis preferred more space between discussants than many Westerners do.

Our educational technique included many interactive exercises that often called for role play. It was gratifying to observe top administrators take on the assignment of lesser roles when asked, though the force of personality did propel some to inevitably lead, despite which group or role they assumed. Members of the class demonstrated mutual respect for all, even across national and gender lines. As is true in America, having physicians talk to physicians typically leads to better communication.

Silence can have different meanings, varying from thought-fullness and consideration to a lack of intelligence or a negative response. Those in higher positions in the Saudi hospital hierarchy seemed more comfortable with silence and used the time to thoughtfully develop responses. As is often the case, top leaders were also more likely to offer their opinions and lead discussions.

The relationships among the negotiating participants are important to some, while others believe that the issues under consideration take priority over relationships. Middle Eastern health care workers frequently emphasize families and relationships, and this can be an important part of every discussion. To ask about one's family sets a favorable tone to discussions. Jumping right into business issues without a warm-up discussion of family can be viewed as abrupt or even rude.

Family members and elders are respected, and their opinions about important issues may be sought. Thus, decisions in meetings are often delayed. Westerners must respect and allow time for this additional consultation. The tendency to defer to higher authorities extends to the hierarchy of the hospital, where decisions are often referred upstream. Traditionally there seemed to be less delegation at King Faisal Specialist Hospital, though many in administration mentioned the desire to delegate. The new emphasis on teamwork in health care was understood at the hospital. Surgical “time-outs” and team rounds were in place. Still, one has the sense that medicine's autonomous heritage is quite prevalent.

Given the strong patriarchal society in Saudi Arabia, male dominance in all relationships can be expected. We witnessed a paucity of women in high administrative positions. Western-trained female physicians were present but were a distinct minority. Nursing leadership was concentrated among women, though male nurses could be found. Nonetheless, we worked with a number of bright, dedicated women who seemed very effective in their roles and had garnered and earned the respect of their male coworkers.

THE COURSE

Participants in the class were required to attend by senior management, and not all were initially excited about the time away from their regular schedules. The initial resistance was confronted directly by our pointing out that if their current methods were working satisfactorily, the course would be unnecessary. The case was also made that difficulties facing health care stem from advancing complexity in the field and from unnecessary and often poorly understood variation in the application of health care. These messages were well received, and those who initially seemed hesitant began to pay greater attention.

Solutions to improve the delivery of health care include committed teamwork and leadership to advance change. The tools revolve around negotiation tactics, which, when performed skillfully, are more effective and less costly in all dimensions except for time. Alternative methods to resolving conflicts, such as the use of power and rights, were exposed for their deficiencies in a series of interactive exercises. The lively group dynamics in these exercises generated memorable exchanges.

A common response to those freshly learning negotiation skills is that their effectiveness will be compromised in environments with “difficult people.” We also taught techniques for recognizing and dealing with behavior in conflict situations that can be difficult and frustrating. We conducted exercises for students to recognize their own conflict behaviors and to behave with greater deliberateness in the midst of conflict.

In addition to basic negotiation techniques and processes, the course emphasized the fragility of trust in resolving conflicts. Class participants were very aware of the power structure at the hospital. In addition to the typical administrative structure, Saudis, particularly those with strong connections to the royal family or other influential families, have a source of power not typically available to non-Saudis. Most of the participants, however, were not aware of the effects of the power structures within the institution and of the abilities of even those with lesser power to influence the design and the successful implementation of policies and procedures. An exercise designed to illustrate the effects of power structures was both frustrating and eye-opening for the participants.

Stereotyping of genders, nationalities, work roles, and cultures was also robustly discussed, both for its usefulness and for its negative consequences. It was rewarding to witness each member of the class finish the course with a wider appreciation of the need to help improve teamwork in the hospital setting. The newly learned negotiating skills are likely to help, though the final message delivered was that a full grasp of effective negotiating techniques and the management of conflict behaviors requires more than 3 concentrated days of training.

LEARNING OPPORTUNITIES FOR TEACHERS

Teachers are fortunate to be able to learn and broaden their experiences while they teach. Teaching in a different culture extends these opportunities. The distinctive dress of the Saudi men and women, the strong patriarchal society, and the dominant family and religious traditions may seem foreign to others. This is countered by the warmth and deep respect extended by the Saudi people to those who bring useful ideas from outside.

Hiking among the red sands, riding camels, and exploring ancient ruins of Saudi Arabian history add to the experience of travelers to the Middle East (Figures 5–7). The authors extend gratitude to the administrators of the King Faisal Specialist Hospital and Research Centre for this stimulating educational experience.

Figure 5.

Exploring the desert sands.

Figure 7.

Historic ruins in the desert.

Figure 6.

Close encounter with a camel.