Entrenched Conflict

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Learning Objectives

This module briefly reviews the Triple Aim for improving health care, presents a video case study in which the Triple Aim is not met, and analyzes types of interprofessional conflict and strategies for resolving them.

    After completing this module you will be able to:
  • Recognize signs of entrenched conflict in healthcare work encounters.
  • Identify how entrenched conflict impacts the Triple Aim (quality, cost, access).
  • Identify opportunities for addressing entrenched conflicts among and between healthcare professionals.
  • Analyze alternative strategies for addressing entrenched conflicts.


Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Check your knowledge

Before beginning the case study, check your knowledge about patient safety and team communication.

Choose the best answer to each question and then view the Feedback for a brief summary of the evidence.

1. The 1999 Institute of Medicine (IOM) report: “approximately 100,000 patients die in the hospital each year from medical errors and:

  • 22% resulted from communication errors.”
  • 42% resulted from communication errors.”
  • 72% resulted from communication errors.”

2. Five years later, the Agency for Healthcare Research & Quality (AHRQ) using Medicare discharge data found:

  • Patient safety had changed little with 101,000 preventable deaths each year from patient safety incidents.
  • Patient safety was declining with 191,000 preventable deaths each year from patient safety incidents.
  • Patient safety was much worse with 291,000 preventable deaths each year from patient safety incidents.

3. In 2013, James analyzed four studies that used a common method for identifying preventable harm, the Global Trigger Tool. This more robust estimate of patient harm caused by medical error found a weighted average of premature deaths associated with preventable harm estimated at approximately:

  • 440,000 deaths per year.
  • 190,000 deaths per year.
  • 100,000 deaths per year.

4. The 2009 Conflictus Study conducted in 323 ICUs in 4 countries with 7,498 ICU staff members found that the majority of conflicts (intra-team disputes) were caused by:

  • Personal animosity.
  • Decisions about End-of-Life care.
  • Disagreements about ICU procedures.




<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Introduction



<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Anna Stevens

    Anna Stevens is being admitted to Hospital ED with a serious infection in her right arm. She appears to be developing septicemia. The admission note states:
  • BP = 92/50
  • HR = 112
  • temperature = 39.2 C
  • arm is tender to touch, swollen and red
  • probable cellulitis and developing septicemia

The ED Staff believe Anna needs to be admitted, possibly to the ICU.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Triple Aim

The Triple Aim for improving healthcare

    The Institute for Healthcare Improvement (IHI) has identified three critical objectives that must be addressed simultaneously in order to develop better models for providing healthcare. The IHI calls this approach the “Triple Aim”:
  1. Improve the health of the defined population.
  2. Enhance the patient care experience (including quality, access and reliability).
  3. Reduce, or at least control, the per capita cost of care.

Learn More

The Triple Aim: Optimizing health, care and cost.
Institute for Healthcare Improvement, 2009

For additional information on each objective go to:
www.ihi.org


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

How did Anna’s care reach this point?

    In the case of Anna Stevens, the Triple Aims for improving health care are not being met:
  1. The patient is at risk for cellulitis and septicemia.
  2. The patient and the healthcare team are unfamiliar with each other and all are tense and distressed.
  3. The patient is seeking care in an Emergency Department, a high cost venue for receiving care.

How did Anna’s care reach this point?

Let’s go back in time to Anna’s visit to the Oncology Clinic two days prior to her visit to the ED to see how the Triple Aims began to fall apart for her.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Two days earlier at the oncology outpatient clinic

Dr. Park has a reputation for snapping at staff. He has been counseled that he has been dismissive of their concerns.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Twenty minutes later at the oncology infusion center

The nurse, Teresa, talks with her colleague.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

At the general infusion center

As instructed, Anna has gone to the general infusion center to receive her antibiotics. After a long wait, she approaches the receptionist.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Dr. Park and Theresa

Dr. Park is surprised to see Anna still in the oncology clinic. He greets her saying, “You’re still here!” She explains that the infusion center could not do the blood draw, and she is going to the lab now. The doctor is frustrated and tells Anna to wait there for a minute while he finds a nurse.

Dr. Park stops Teresa and demands to know why the patient was sent to the infusion center. Without waiting for an answer, he states that Anna needs to be taken care of in oncology as he ordered.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Back in the waiting room at the oncology clinic

Teresa reluctantly follows Dr. Park’s orders to accommodate Anna in the oncology infusion center.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Twenty minutes later in the oncology waiting room

Anna’s ride can’t wait any longer. Anna leaves without receiving the antibiotic infusion.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

How would Anna rate her experience?

Put yourself in Anna’s position. Complete this patient satisfaction survey as if you were Anna.

Patient Satisfaction Survey

Waiting Great
    5 		Good
     4 		Ok
 3 		Fair
  2 		Poor
    1
Time in waiting room
Time in exam room
Waiting for tests to be performed
Waiting for tests results


Staff – Provider: Physician, Dentist,
Physician Assistant, Nurse Practitioner 		Great
    5 		Good
     4 		Ok
 3 		Fair
  2 		Poor
    1
Listens to you
Takes enough time with you
Explains what you want to know
Gives you good advice and treatment


Staff – Nurses & Medical Assistants Great
    5 		Good
     4 		Ok
 3 		Fair
  2 		Poor
    1
Friendly and helpful to you
Answers your questions


Staff – All Others Great
    5 		Good
     4 		Ok
 3 		Fair
  2 		Poor
    1
Friendly and helpful to you
Answers your questions

<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Missed Opportunities

Anna Stevens was admitted from the ED with possible septicemia. However, two days earlier when she was in the oncology clinic, her condition was not that serious. There were at least three opportunities for the oncology team to advert this frustrating, painful and costly outcome for Anna.

Watch two videos and listen to one audio clip to consider these missed opportunities.

1. Teresa and Dr. Park in the exam room



2. Teresa and Dr. Park outside the exam room



3. Teresa and her colleague at the nurses’ station



<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Conflict in healthcare

Conflict is endemic in healthcare, but not all conflict is the same. Identifying the type of conflict enables you to choose the strategy that will work best to resolve it.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Types of conflict


Task-Based Conflict

  • Awareness of differences in viewpoints and opinions pertaining to a group task.
  • Tends to not involve intense interpersonal negative emotions although may be animated.

Relationship-based Conflict

  • Awareness of interpersonal incompatibilities, includes affective components such as feeling tension and friction.
  • Involves personal issues such as dislikes, annoyance, frustration, irritation.

Disruptive behavior

  • Intimidating and disruptive behaviors.
  • Verbal outbursts and physical threats.
  • Refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes.

<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Task-Based Conflict

Errors

  • Honest and inevitable
  • Slips and errors

Factors

  • Simple communicating misunderstandings
  • Poor handwriting, confusing labels
  • Competing tasks, language barriers, distractions (workload)

Solutions

  • Hand-off protocols, checklists, CPOE, automated medication dispensing systems, alerts
  • TeamSTEPPS strategies:
  • CUS:
    • C – I’m concerned.
    • U – I’m uncomfortable.
    • S – This is a safety issue. We need to STOP.

  • Two-challenge rule: Obligation to raise concern at least twice to ensure you have been heard.
  • DESC:
    • D – Describe the specific situation or behavior; provide concrete data.
    • E – Express how the situation makes you feel/what your concerns are.
    • S – Suggest other alternatives and seek agreement.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Relationship-Based Conflict

Errors

  • People know of risks yet do not speak up
  • Complex communication errors
  • Often presents as longstanding conflicts

Factors


Solutions

  • Understand and recognize the fundamental attribution error: our universal tendency to attribute our own behavior to contextual factors while attributing similar behavior in others to stable personality traits (also called misattribution)
  • Conflict management training

<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Disruptive Behavior

Errors

  • Clustered around few individuals

Factors

  • Culture of tolerance in healthcare
  • Power differentials endemic to all disciplines in healthcare (medicine, nursing, hospital culture, etc)
  • Fear of retaliation
  • Revenue-generating employees versus paid-employees

Solutions


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Match your strategy to the conflict

Typically, we approach conflict without considering what type of conflict we are encountering. Your first challenge is to assess the type of conflict that you’re faced with.

With task-based conflict, our challenge is usually to speak up. We often have critical information for the situation, and we need to use a skill that allows us to find our voice. TeamSTEPPS strategies (such as CUS, Two Challenge Rule, and DESC script) are focused on these important skills.

In relationship-based conflicts, our challenge is to overcome the attribution errors and assumptions that we are making about the other person or team’s behavior. We need to use a skill that helps us to listen to the full story.

Finally, in situations where our colleagues are engaging in disruptive behavior, we are challenged to establish boundaries. In these situations, we need to communicate clearly what is acceptable behavior. The Joint Commission Sentinel Event Alert, Issue #40, “Behaviors that undermine a culture,”  of safety addresses these relatively rare, but serious situations.

When you are faced with a conflict, your first task will be to decide what type of conflict you are facing. Then you must choose the best strategy to approach it. The remainder of this module will focus on strategies for relationship-based conflict.

What do you think?

What type of conflict did Teresa and her colleagues face with Dr. Parks?

  • Task-based
  • Relationship-based
  • Disruptive behavior






<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Summary of conflict types and strategies

Strategies for Managing Different Types of Conflict

Task-Based Conflict

Find one’s voice

Relationship-based Conflict

Find one’s ears

Disruptive Behavior

Find one’s boundaries


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Approaching relationship-based conflict

We suggest a four-step framework for approaching relationship-based conflict. Click on each button below to learn more about each step.

1

Get Ready

2

Create Space

3

Do the Work

4

Close & Affirm


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Summary of the four-step approach


Step

1. Get Ready

Key Elements

  • Prepare: consider setting, timing, emotional state
  • Adopt respectful, curious attitude

Threats & Tips

    Threat:
  • Your own biases or judgments can hijack the dialogue
    Tips:
  • Avoid rehearsing your anger
  • Ask yourself, “I wonder…” questions to prepare
  • Consider practicing your start with a colleague

Step

2. Create Space

Key Elements

  • Offer neutral start
  • Suggest mutual goal

Threats & Tips

    Tip:
  • Shared goals might be patient safety, quality of care, coordination of care, efficiency, teamwork, etc.

Step

3. Do the work

Key Elements

  • Explore their story
  • Share your story

Threats & Tips

    Threat:
  • Avoid making and/or responding to statements of moral superiority
    Tips:
  • Ask, at least, 3 questions to explore their story
  • Avoid point-counter point exchange when sharing your story
  • Acknowledge emotional content with respect

Step

4. Close & Affirm

Key Elements

  • Offer neutral start
  • Suggest mutual goal

Threats & Tips

    Threat:
  • Avoid letting this conversations end without a positive statement
    Tips:
  • Avoid tempting to solve “world peace”
  • Note the value of the conversation versus achieving agreement
  • Link back to your mutual goal

<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Entrenched Conflict

Over time, relationship-based conflicts become entrenched conflicts and you may see the terms used interchangeably.

    Entrenched conflict can threaten the Triple Aims of healthcare:
  1. Improve the health of the defined population
  2. Enhance the patient care experience (including quality, access and reliability)
  3. Reduce, or at least, control the per capita cost of care

Entrenched or relationship-based conflict can affect patient safety and quality of care. It also can affect the entire healthcare team.

    Consequences of not dealing with entrenched conflict include:
  • feelings of incompetence or misery
  • unwillingness to communicate with the team
    Benefits of addressing entrenched or relationship-based conflict include:
  • greater satisfaction for teams
  • improved patient safety

Click here to learn more about conflict in the OR


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Conclusion

    Anna Stevens’s experience demonstrates the critical importance of team communication in:
  • enhancing the patient care experience, including quality, access and reliability
  • preventing or resolving entrenched conflicts.

“Professionalism” is not an intuitive concept; it is a learned set of behaviors.


<< Back
Next >>
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

References

Rogers, D. A., Lingard, L., Boehler, M., Espin, S., Klingensmith, M. E., Mellinger, J.D. “Teaching operating room conflict management to surgeons: clarifying the optimal approach”. Medical Education 2011:45 939-945.


<< Back

This work was supported in part by grants from the Cambia Health Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Cambia Health Foundation.


Published Modules


Narrative Patient Centered Care

Understanding your patient’s story, including their illness and life beyond their illness, helps you provide them the best care possible. These modules, presented in three parts, will introduce you to the communication skills needed to elicit the patient and family narrative.



Entrenched Conflict

This module briefly reviews the Triple Aim for improving health care, presents a video case study in which the Triple Aim is not met, and analyzes types of interprofessional conflict and strategies for resolving them.


After completing this module you will be able to:

  • Recognize signs of entrenched conflict in healthcare work encounters.
  • Identify how entrenched conflict impacts the Triple Aim (quality, cost, access).....




GOALS OF CARE

Setting goals and making a plan for achieving them fosters hope and allows individuals and families to feel they have some control in their lives. As healthy aging progresses or incurable illness advances, individuals will change and adapt their health care goals...



Working with an Interpreter

The number of individuals who speak English with limited proficiency (LEP) or who don't speak the language at all is growing in the United States as the population becomes more diverse. Language differenced can create barriers between practitioners and patients and affect the quality of patient care.


In the case of Mrs. Rodriguez, you will learn how professional interpreters facilitate important clinical communication, enhancing the patient-practitioner relationship and the quality of care....






Responding to Emotions

Given how much there is to learn about facilitating family conferences, focusing attention on emotions may seem like a strange use of time. However, we’ve found that effectively addressing patient and family emotions helps avoid many of the common pitfalls in these encounters, including conflict...



Interprofessional Conflicts

Patients, families and members of the interprofessional palliative care team draw upon deeply held personal values and professional standards to set goals of care.


Differing values and standards for care may give rise to conflicts between...



Alternative Medicine

Patients with chronic or life-limiting disease may supplement their treatment with complementary and alternative medicine (CAM). However, less than 40% of patients tell their provider about their CAM use. Even when the physician asks them directly, they may be reluctant to discuss their CAM use....









Close
Close
Close
Close
Close
Close
Close
Close
Close

Conflict in OR

31 nurses  |  35 surgeons

Most common conflict

Task-related conflicts

  • Equipment needs, scheduling

Relationship-based conflicts

  • Bad moods or attitudes, rudeness and inexperience on the part of staff members.

31 nurses  |  35 surgeons

Positive effects of addressing conflict

Task-related conflicts

  • Working efficiency

Relationship-based conflicts

  • Satisfaction for team
  • Working relationship between team members

31 nurses  |  35 surgeons

Negative effects of not addressing conflict

Task-related conflicts

  • Incidence of mistakes
  • Time required to perform tasks
  • Contribution of team members toward the completion of a task

Relationship-based conflicts

  • Feelings of incompetence or misery
  • Willingness to communicate with the team

31 nurses  |  35 surgeons

Permanent negative effects

Task-related conflicts

Relationship-based conflicts

  • Dismissal from team
  • Refusal to work with a team
  • Resignation

Rogers, et al. 2011