Conflict Management: Difficult Conversations with Difficult People

Abstract

Conflict occurs frequently in any workplace; health care is not an exception. The negative consequences include dysfunctional team work, decreased patient satisfaction, and increased employee turnover. Research demonstrates that training in conflict resolution skills can result in improved teamwork, productivity, and patient and employee satisfaction. Strategies to address a disruptive physician, a particularly difficult conflict situation in healthcare, are addressed.

Objectives: Upon completion of the article, the reader will: (1) Understand the importance of conflict resolution and management. (2) Recognize skill sets applicable to conflict management. (3) Summarize the steps necessary involved in a successful confrontational conversation.

Conflicts of various magnitudes occur frequently. You share a workspace with a colleague who consistently leaves the space disorganized and messy, which seems unprofessional to you since patients are seen in that office. Or a senior colleague insists being the first author on a research paper when you did all the work. In the preoperative area, the anesthesiologist disagrees with your surgical plan in the presence of the patient. A more extreme example would be a disruptive physician who yells or throws charts or instruments.

The frequency of conflict has been measured in several settings. In an observational study of operating rooms, conflicts were described as “high tension events”; in all surgical cases observed there was at least one and up to four high tension events.¹ Another study found on average four conflicts per operation emerged among operating room team members.² In a survey of 5,000 full time employees in nine different countries, 85% of employees dealt with conflict at work to some degree and 29% dealt with conflict frequently or always.³ Another viewpoint focuses upon “toxic personalities” defined as “anyone who demonstrates a pattern of counterproductive work behaviors that debilitate individuals, teams, and even organizations over the long term.”⁴ Conflict occurs frequently when working with such people. In a survey, 64% of respondents experienced a toxic personality in their current work environment and 94% had worked with someone like that during their career.⁴ In another study, 91% of nurses reported experiencing verbal abuse.⁵ The impact of these interactions on mood is significant. In a real-time study, employees recorded interactions with a coworker or superior at four random intervals daily; the employees rated the interactions as positive or negative and recorded their mood. The negative interactions affected the employee's mood five times more strongly than positive encounters.⁶

Some would argue that conflict may be beneficial in certain situations, but in others it has negative consequences.⁷ The proposed benefits of conflict include improved understanding of the task, team development, and quality of group decision making. The other line of thought suggests that conflict distracts from the immediate tasks and wastes resources on conflict resolution. Whether or not it is occasionally helpful, it is clear that many instances of conflict are harmful.

Conflict is associated with significant cost to organizations. In the study of employees from nine countries, the average number of hours spent per week on workplace conflict varied from 0.9 to 3.3 hours. In the United States, the average was 2.8 hours.³ The calculated expense based on average hourly earnings in 2008 was $359 billion in lost time. High rates of employee turnover and absenteeism are associated with environments where conflict is poorly managed.

Health care is a complex system that requires effective teamwork and cooperation to function well. Patient safety research reveals that patient outcomes are negatively impacted when conflict mismanagement and other dysfunctions occur.^{8 9 10} Another consequence of poorly managed conflict is disruption of care. In a national survey of physicians, almost two-thirds of respondents reported seeing other physicians disrupt patient care at least once a month.¹¹ More than 10% of the respondents reported witnessing that behavior daily.

Frequent causes of conflict include lack of clarity with expectations or guidelines, poor communication, lack of clear jurisdiction, personality differences, conflicts of interest, and changes within the organization.¹² Behavior that results in conflict could include bullying, limited communication or not sharing important information, and verbal or physical violence.¹³ Employees cite personality clashes, stress, heavy workloads, poor leadership at the senior and managerial levels, lack of honesty and openness, and lack of role clarity as the most frequent causes of conflict.³

Although conflict cannot be avoided, it can be managed. Since conflict will always be present on an individual and organizational level, it is important to develop the skills to appropriately manage a difficult conversation or interaction. Experts agree that the skills necessary can be acquired; they believe that conflict competence can be defined and learned. One definition of conflict competence is “the ability to develop and use cognitive, emotional, and behavioral skills that enhance productive outcomes of conflict while reducing the likelihood of escalation or harm.”¹⁴ The goal is to be competent in having difficult conversations. One model uses the terminology “crucial conversations and “crucial confrontations.” A “crucial conversation” is defined as “a discussion between two or more people where (1) the stakes are high, (2) opinions vary, and (3) emotions run strong.”¹⁵ Confrontations are those face-to-face conversations in which someone is held accountable.¹⁶

Real life examples prove their statements and the benefits of improved conflict management. One group demonstrated that teaching the necessary communication skills resulted in 10% improvement in their habits of confronting difficult issues.¹⁶ With that change, customer and employee satisfaction, productivity, and quality also improved. An information technology (IT) group found that improved communication practices resulted in 30% improvement in quality, almost 40% increase in productivity, and near 50% decrease in costs.¹⁶ CPP Global report “Workplace Conflict and How Business Can Harness it to Thrive” study found “training does not reduce the occurrence of conflict, but it clearly has an impact on how conflict is perceived and can mitigate the negative outcomes associated with conflict.”³

Various models of successful conflict management have been proposed.^{14 16} The models typically include discussions of common responses to conflict and ways to effectively address conflict. These models will be combined and summarized in this article.

The common underlying principles of all the models are that

1. Conflict is inevitable and that both positive and negative consequences may occur depending on how the conflict is managed.

2. The results are likely to be better with active engagement rather than avoidance.

3. People must be motivated to address conflict.

4. Behavioral, cognitive, and emotional skills can be acquired.

5. Emotional skills require self-awareness.

6. The environment must be neutral and feel safe.

Response to Conflict

To begin this process, it is important to cultivate self-awareness in regards to one's physical and emotional reaction to situations involving conflict. The most common responses on approaching conflict include: avoiding, accommodating, competing, compromising, and collaborating.¹⁷ Avoidance (or silence) refers to an individual recognizing conflict in a situation and actively deciding to not engage or deal with the problem. Avoidance may be prudent when the issue is minor in nature, as a temporary response when emotions are high or when others can resolve an issue more efficiently. This approach would be the opposite of someone whose response is to compete, which is categorized as being forcing, uncooperative, and assertive in the situation. Competition might be appropriate in emergent situations or actions known to be unpopular need to be taken on an important issue. People whose response is to accommodate others generally do not have their own needs met. Accommodation may be necessary when one is wrong, if the issue is more critical to others or if the value of harmony in the situation outweighs the benefit of a conflict. When accommodation is used, the conflict is resolved but if the pattern repeats itself frequently residual resentment may affect the relationship. Accommodation is also referred to as yielding.¹⁸ Compromise and collaboration are both a balance of assertiveness and cooperativeness. The difference between the two is that compromise is often a negotiation between two parties with equivalent power, whereas collaboration is focused on finding a solution where all parties involved have their needs met. Compromise is focused on fixing a problem with a set amount of resources and collaboration allows for a broader view on problem solving. A combination of compromise and collaboration has also been defined as a problem-solving response.¹⁸ Although there is not a correct response, responses characterized by open-mindedness to the ideas and perspectives of others promote positive outcomes.¹⁷

Conflict Management Skills

When a conflict exists, the first step is to decide whether to address it. That decision involves balancing the reward against price of addressing the issue; that balance is unique to each circumstance. Some general rules are that if the issue is troublesome enough that it is affecting your behavior or weighing on your conscience, it should be addressed. It is important not to confuse the perceived difficulty of the conversation with determination of whether it will be beneficial and appropriate to proceed. Perceived differences in power often impact a decision to address a conflict; however, lessons from aviation and other industries illustrate the benefits of open communication and the risks of silence even in situations of different levels of authority or power.^{19 20}

Once it is been decided to address the conflict, there are several steps involved in preparation for the conversation. One step is to determine the exact nature of the conflict. When considering the exact nature of the conflict, some authors offer the following guidance.¹⁶ If the issue occurs once, it is appropriate to discuss the content of the issue; if it has occurred repeatedly, one should focus on the pattern of events. If the problem impacts your relationship with the other person or team members, then the topic should be your relationship. One pitfall of conflict management is allowing task or pattern type conflict to deteriorate to relationship conflict by overpersonalizing the issue. Another system appropriate for team conflict divides conflict into task, process, and relationship conflicts. Task conflict is similar to content conflict, while process conflict refers disagreement over team processes.²¹

One must also thoroughly understand one's own position. It is critical to gather all of the background information and any data necessary to discuss the conflict. Then one needs to achieve clarity about what is desired from the confrontation as well as what one is prepared to give up or compromise. Another key element is awareness of which outcomes one considers undesirable. Part of the preparation is consideration of one's own motivations and goals as well as the motivations and goals of the other party. This step seems obvious but is frequently not done or only superficially evaluated. Considering why a rational and ethical person would have behaved in the manner troubling you often opens an alternative view of the situation. The authors of Crucial Confrontations label this preparation as “mastering your story.”¹⁶ In short, it is understanding from as many vantage points as possible how the problem situation might have developed.

The level of intensity of the conflict is another consideration in determining how best to approach the issue. One model divides the intensity of conflict into five levels.¹⁴ Level 1 is differences. Those are situations in which two or more people have different perspectives on the situation; they understand the other person's viewpoint and are comfortable with the difference. This level of conflict can be an asset for a team or organization because it allows individuals to compare or analyze without an emotional overlay. Level 2 are misunderstandings in which two people understand the situation differently. Misunderstandings are common and can be minor, but can also escalate when stakes are high. If there are negative consequences such as missed events or obligations people tend fault and accuse one another which adds negative emotions to the situation. If the misunderstandings are frequent, it may indicate problems with communication. Level 3 is disagreements; these are times when people have different viewpoints of the situation, and despite understanding the other's position they are uncomfortable with the difference. This level can also easily escalate if ignored. Level 4 is discord. In those instances, conflict results in relationship issues between the people involved even after a specific conflict is resolved. There is often constant tension between those individuals. Level 5 is polarization, which describes situations with intense negative feelings and behavior in which there is little to no hope of resolution. For those conflicts, the mandatory first step is the agreement to communicate.

Another aspect of preparation is to recognize your emotional response and how it might affect your view of the situation. Addressing a difficult situation when one is angry or frustrated is more likely to be ineffective than when one is calm. Several famous quotes illustrate the point.

“Speak when you are angry and you will make the best speech you will ever regret.”

–Ambrose Bierce

It is therefore important to postpone the discussion until one is able to think more calmly and clearly. It is helpful to have an awareness of behaviors that “push your buttons.” One list of possibilities comes from an assessment instrument, “Conflict Dynamic Profile (Center for Conflict Dynamics Eckerd College, St. Petersburg, FL)” that includes the following behaviors: abrasive, aloof, hostile, micromanaging, over analytical, self-centered, unappreciative, unreliable, and untrustworthy.²² A technique to reduce tension is cognitive reappraisal or reframing which refers to looking at alternative perspectives and outcomes of the situation to “reframe” it in a different, generally positive, light. Some other suggested techniques to manage one's emotions are consciously identifying and addressing one's fears about the outcome of the conflict or possible consequences. Centering techniques, which are based on martial arts, offer a way to calm oneself and focus on the positive aspects of the situation.¹⁴

“The great remedy for anger is delay”

–Thomas Paine

All conflict management research confirms that setting a safe environment is a critical element in successful management of conflict. In a safe environment, all participants believe they will be respected and treated fairly. The authors of Trust and Betrayal in the Workplace present a model that includes three different types of necessary trust.²³ One is contractual trust or trust of character which is confidence in the intentions of others. The second is communication trust or trust of disclosures. In an environment with communication trust, everyone is comfortable that people will share information, be honest, and keep private information confidential. The final type is capability trust; when present, the participants have confidence in others' abilities to deliver on promises. That model recognizes that trust can be harmed by betrayal, but also rebuilt.

Another description of a safe environment is one with mutual respect and mutual purpose.¹⁶ Mutual respect involves using a tone of voice and words and facial expressions that convey respect for others as human beings. Mutual purpose is having the common goal of problem solving. Although the first model may seem difficult to achieve in all situations, mutual respect and mutual purpose are basic required elements for an effective discussion of a conflict.

How does one establish a safe environment? The conversation must be held in a private, preferably neutral, setting with enough protected time for the discussion. Some experts suggest that a potentially neutral way to establish the goal of joint problem solving is to start the discussion by describing the gap between the expected and observed behavior. Other options include asking for permission to discuss a topic or beginning with the facts from your perspective or your observations. It sets the wrong tone to start the conversation with your conclusion, particularly if it is harsh. One should share all appropriate and relevant information and avoid being vague.¹⁶ Other tips to maintain a safe environment include asking open-ended questions, focusing initially on points of agreement and using “I” statements. Some examples of “I” statements are “I feel frustrated” and “I am concerned.” One must be aware of one's body language as well as tone and volume of voice.

Common mistakes to avoid are trying to soften the message by mixing it with complimentary statements or using an overly familiar tone of voice initially before addressing the problem. Most people feel they are being manipulated or treated dishonestly when the messages are mixed. Inappropriate humor or comments disrupt the rapport needed for a safe environment. Another common error is using nonverbal hints or subtle comments with the belief they can successfully address a conflict. This technique is risky because one is never clear on the other person's interpretations of the hints or comments. It also does not work to blame someone else for a decision or request you are making. It ultimately undermines any respect or authority you may hold. Asking people to guess the reason for the meeting, essentially to read your mind, is irritating and ineffective at problem solving.

Once a decision has been made and a neutral environment decided upon for the conversation, there are key elements to conducting the conversation. One organization (CMP Resolutions) terms this first phase as scoping.²⁴ It includes the time to understand what is happening, each person's perspective of the conflict, and what is important to them, as well as establishing ways the involved parties can work toward a solution. The first step in the conversation is to allow all parties to state their opinions and their perspectives on the conflict. Before beginning, the ground rules regarding confidentiality and decision making should be outlined. Listening, respectively, to each participant during this step is very important. Asking clarifying questions without imposing one's own view of the situation is a skill that often requires practice. One must be aware of the tone and volume of voice to ensure that the environment remains respectful. Expressions of empathy such as “that sounds really difficult” are helpful in setting the tone and encouragement of information sharing. One should avoid judgmental or blaming statements. Listening skills are one of the primary skills to be developed when working on one's ability to manage conflict. Utilizing “AMPP” helps to remember four main listening skills that are helpful when faced with a problem.¹⁶ “A” stands for ask which starts the conversation and allows the other person to discuss their feelings about the situation. Mirroring (M) is a tool to encourage the speaker to continue or offer more information when they seem reluctant. The technique involves statements about what you are observing (e.g., you seem down today) in the other person and then asking a question. The third technique, paraphrasing (P), is the restating of their responses in your own words which shows active listening and makes clear whether you both have the same understanding. Finally, prime (P) refers to priming the pump. It is useful when someone is clearly emotional about the issue but reluctant to talk despite the use of the first three techniques. With this method, one makes a guess out loud about what the other person might be thinking or feeling. One must choose the words carefully and use a calm tone to avoid worsening the situation. The goal is to make the other person feel comfortable speaking. Other potentially helpful acronyms to use during conflict management are seen in Table 1.

Table 1. Helpful acronyms related to conflict management^{14 16} .

VALUED conflict model

Validate

Ask (open-ended questions)

Listen (to test assumptions)

Uncover interests

Explore options

Decide (on solutions)

Four main listening skills

Ask

Mirroring

Paraphrasing

Prime

TSA's four R's of conflict management

Recognize

Respond with Respect

Resolve and manage

Reflect

The next part of the conversation is defining the problem. A consensus on the definition of the problem is necessary for participants to be able to compare and discuss solutions. As noted earlier, the problem might be defined as the issue with one occurrence, a pattern of episodes or the working relationship. After creating a mutually agreed upon definition, the next step is to brainstorm possible solutions to the conflict. If possible, these solutions should address the needs of all parties involved.

After a list has been created of alternative solutions, each participant should discuss their preferred solution. There also needs to be a “reality check” with the decision makers. Perhaps the ideal solution is too expensive or not feasible because of existing regulation or organizational policies. The goal is finding commonality and acceptable compromises that allow for all participants to feel like their needs are met and the conflict is being addressed. Once this solution is chosen, an action plan that outlines the “who, what, and when” of fixing the problem needs to be devised. Making sure that everyone involved understands their role and tasks are an important step to accomplish the solution.

Many models suggest that reflection on ways to prevent or more effectively handle similar conflicts in the future at the end of the conversation is beneficial. A follow-up plan is critical. If a plan with timelines is not designed and implemented, the behavior will typically change for a period of time but then slip back into old patterns. Whether the plan is another meeting, completion of certain tasks, or a system of monitoring, it should be defined clearly.

A particularly complex issue in conflict management is the disruptive physician. Historically, that issue has been addressed reluctantly if at all. The physician is often a high revenue producer and organizational leaders fear the consequences of antagonizing the physician or there is concern about a potential conflict of interest. The term is defined in various ways. One definition of disruptive physician behavior is “a practice pattern of personality traits that interferes with the physicians' effective clinical performance.”²⁵ The Ontario College of Physicians and Surgeons defined it as “inappropriate conduct whether in words or action that interferes with or has the potential to interfere with, quality health care delivery.”²⁶ An occasional bad day or overreaction does not constitute disruptive behavior. Rather it is the pattern of repeated episodes of significant inappropriate behavior.

The typical behaviors are often divided into aggressive and passive aggressive categories. Aggressive behaviors include yelling, abusive language, intimidation, and physically aggressive actions. Passive-aggressive behaviors include intentional miscommunication, impatience with questions, racial, general or religious jokes, and implied threats. Despite estimates that only 3 to 6% of physicians qualify as disruptive physicians,²⁷ the negative impact on the health care system is significant. The behavior undermines morale and productivity as well as the quality of care and patient safety. For example, nurses are less likely to call physicians with a history of disruptive behavior even when they need to clarify an order or report a change in a patient's condition. According to the Joint Commission, these behaviors “can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.”²⁸ In an academic environment, this behavior is associated with poor role modeling for students and trainees. Because of the impact, both the Joint Commission and the Federation of State Medical Boards addressed the issue in their standards and policies.^{28 29}

If the pattern of behavior is recognized early, a conversation with a trusted colleague or physician leader using the techniques described above might be sufficient to change the pattern of behavior. One model of corrective feedback starts by preparing the physician for the meeting with advanced notice and provision of a private setting and respectful atmosphere. Often asking the physician to provide a self-assessment of their interactions with others is a good starting point that can be followed with the observations of specific disruptive behaviors. Strategies for change and improvement as well as set expectations and a monitoring program need to be discussed and articulated before concluding the meeting.³⁰

There is evidence that an organization that sets standards for behavior and uses the principles of “action learning” to address variances will have desirable outcomes with disruptive physicians. Briefly, the principles of action learning, which was developed by Reginald Revans, are that the best learning occurs through active questioning and reflection rather than instruction.³¹ The people involved tackle a real-life problem by asking questions, discussing alternative solutions, reflecting on change, and monitoring progress. In an interview study of independent, single-specialty surgical practices representing 350 physicians, the investigator determined whether the use of action learning principles correlated with desirable outcomes with disruptive physicians.³² Desirable outcomes include retention of the physician with a change in the troublesome behavior. In 20 practices, action learning resulted in successful management of the problem.

However, most disruptive physicians require more intensive intervention. Reynolds argues that “constructive change in disruptive physicians comes through requiring adherence to expected behaviors while providing educational and other supports to teach the physician new coping skills for achieving the desired behaviors.”²⁵ A comprehensive evaluation including medical, chemical, and psychiatric evaluation is the first step. It is important to identify an underlying treatable condition. A program of remediation including educational and psychological training to foster new coping skills is outlined. A critical part of the program is long-term follow-through and monitoring. For most disruptive physicians, it is the threat of imposed consequences rather than internal motivation to improve that guides their compliance with the program.²⁵ Several well-established programs offer resources for the training including the Physician Assessment and Clinical Education (PACE) program at the University of California School of Medicine, San Diego³³ and the Distressed Physician Program at Vanderbilt University School of Medicine in Nashville.³⁴ A composite case study of transformative learning to address disruptive physician behavior illustrates the process used.³⁵

Conflict occurs frequently and often results in significant disruption and cost for individuals and organizations. Although often avoided or poorly managed, evidence suggests the skills for effective management of conflict can be learned. Multiple studies confirm when conflict is successfully addressed, and multiple benefits accrue to the organization and individuals.