Properly used techniques can resolve most conflicts, whereas inappropriately applied strategies may actually exacerbate them. Conflict resolution begins with creating trust and effective listening.
Effective communication occurs most easily in an environment of trust and respect. Supervisors who reside in their offices except when criticizing staff or mandating new programs create an environment of apprehension and distrust. Leadership's responsibility is to get close to the people providing services, so they can understand the issues and conflicts first hand. Criticism of the night or weekend staff by ED leaders who never work nights or weekends often “falls on deaf ears.”
Alternatively, workers are more likely to listen to their leaders when they identify with them and their values, and believe that their leaders understand the issues. Leaders who first listen and acknowledge the team member's issues are more likely to be perceived as understanding and to be heard by the other side.
While effective ED care often requires rapid problem identification and response, there is a tendency in some situations to move too quickly. Some healthcare providers interrogate patients and staff in hurried and impatient tones, interrupting with questions. When rushed, there is tendency to gloss over subtleties. Obtaining nuanced information depends on building trust and rapport. When people with issues believe that the other person is not listening, they may become frustrated, reserved, and vague, resulting in a breakdown in communication. Effective listening is a first step toward resolving the problem.
Effective responses are neutral, without criticism, and often validating. Accepting the speaker's concerns creates the opportunity for clarification and further exploration (Box 8-5). Many effective listening styles and techniques have been described in the literature.33
Consider the responses to the following comment by a staff member:
“I just can't stop thinking about the child from the accident.”
Impatient response: “You're overreacting. You're getting too emotional about it. I would just put it out of my mind if I were you.”
Although perhaps well meaning, this advice attempts to substitute the perspective and experience of the listener for the feelings of the speaker. The speaker may inadvertently communicate criticism, dismissal, and lack of concern for the speaker's distress.
Passive response: “Oh, really?”
Passive listening simply requires the listener to be quietly attentive. This behavior generally may encourage the speaker to continue discussing the issue and possibly get to the crux of the problem. Difficult issues take time to divulge and, like onions, may require peeling away layers before getting to the center. This type of response can also help defuse angry reactions. To feel comfortable when revealing a problem, one needs time and, at the very least, a safe environment.
Reflective response: “It seems like it's difficult to get him out of your thoughts.”
Reflective listening involves providing objective feedback to the person speaking. In its most rudimentary form, this simply involves repeating back the words. This technique encourages the speaker to elaborate.
Empathetic response: “It sounds like you're worried about him.”
This listener has decided to try to understand the speaker, to get on the same side of the table. The listener has suspended a personal frame of reference and attempted to rephrase content and reflect feeling. This type of nonjudgmental and concerned listening allows the speaker to address his/her feelings about the problem.
Sympathetic response: “I understand what you're going through, the same thing happened to me.”
Sympathizing should be used with caution. Insincere sympathy may seem patronizing.
Acknowledging and validating response: “Yes, it is difficult to see a child suffer. Would you like to talk about it?”
When done correctly, acknowledging and validating responses allow the speaker to know that the listener has heard and is substantiating the concern. There is frequently an expression of confirmation in return, such as, “Yes, that's it exactly” or nodding in affirmation.
Skilled communicators maintain good eye contact when listening to and speaking with others.34 Napoleon said: “To make oneself understandable to people, one must first speak to their eyes.”
The pattern of eye contact (minimal, intermittent, or continuous) used by one person in a conversation will generally be copied unconsciously by the other person. Looking into another's eyes while listening (and speaking) communicates interest and attentiveness. Conversely, avoiding eye contact may be interpreted as a lack of interest. The listener can create an even greater sense of apparent interest by facing the other person with occasional nods of affirmation.
Using Skills from “Getting to Yes”
Focus on Interests, Not Positions
The effectiveness of interest-based rather than position-based bargaining is evident in conflict resolution, negotiation, and complaint management. Continuing to concentrate on the interests of both parties often mitigates difficult situations. Positions are generally driven by underlying issues. Some of the most difficult people exhibit positional bargaining, such as shown in the following example:
Admitting resident: “That's the third sick patient you've asked me to admit in the last hour. I won't do it.” The position is “NO!”
Responding to the position is “taking the bait” and getting hooked into a win-lose situation. A positional response might be
“Oh yeah! Well, you have to, and now! And if you don't, I'll call your attending.”
Positional bargaining may in fact get the desired result. However, it generally creates a winner and a (resentful) loser. Furthermore, if these two parties work with each other again, the loser typically remembers and may try to get even.
By focusing on the interest of the admitting resident, a solution may immediately become clear. The underlying message from the resident was
“I'm tired, overwhelmed, and feeling out of control. I don't think I can handle another patient right now.”
Responding to the message rather than the words would lead to a more effective reply:
“Yes, your night has been difficult. I can hold the patient here for another 45 minutes until 3 am, while you catch up. Can you commit to being here by 3 am?”
Avoiding a direct response to the resident's position and instead responding to the resident's interests and needs may require minor compromise but allows both sides and the patient to get their needs met.
Separating the People from the Problem
Everyone has irritating behaviors. Though most people seek mutually satisfactory and trusting relationships, when offended, suspicion and anger may quickly ensue. In a stressful and hurried environment such as the ED, communication may be truncated and inadvertently aggravate a situation. Successfully separating the person from the problem requires recognizing that people generally try to satisfy their own needs. To successfully resolve conflict, it may be necessary to discern the other person's underlying intent.
Note how differently the following scenario would conclude if the underlying intent was recognized.35
A: Did you discharge the patient yet?
I have some free time, so if it isn't done yet, I can do it.
B: I told you I would do it when I get the chance and I will! Don't continue to bug me about it!
I've been incredibly busy doing more important things and now I'm being criticized for taking 5 minutes for myself to get a cup of coffee.
A: Well, never mind!
That's what I get for offering to help.
When one perceives someone's intentions as dishonorable, further actions tend to be interpreted in that same light. To resolve this conflict, a participant must examine the other person's motivations in a sincere and uncritical way. This may be accomplished by simply asking: “What was your reason for asking me if I had discharged the patient yet?,” or “Why did you react negatively when I asked if you had discharged the patient yet?” Eventually, by continuing to explore each other's intentions, a positive outcome can be achieved and miscommunication can be averted.
It is tempting to respond emotionally to an obnoxious individual and reciprocate with anger. Responding emotionally by yelling, crying, door-slamming, or stomping away may provide temporary relief; however, it will make resolution and subsequent interactions more difficult. Emotional actions breed emotional reactions. Silence is a powerful alternative response to difficult emotional interpersonal conflicts, as escalation is less likely when one party avoids emotional engagement. Those who maintain composure and continue to focus on the interests of the other party enhance the resolution process.
The Mandate for Behavioral Feedback
To encourage change, it is frequently necessary to provide feedback. Behavioral feedback is mandated in the ACGME (Accreditation Council for Graduate Medical Education) training programs, which evaluate behavior using the competencies of “Professionalism” and “Interpersonal and Communication Skills.”36 Since inappropriate behavior can undermine the culture of safety, the Joint Commission mandates that “[institutional] Leaders create and implement a process for managing disruptive and inappropriate behaviors.”37 The best environments for process improvement are those in which feedback is encouraged (and received) in both directions; in other words a “culture of feedback.”
While feedback may be mandated or a consistent part of a program, behavioral commentary is often met with resistance unless structured in a manner that encourages receptivity. Feedback, therefore, should be constructed as positive, instructive, or constructive, and not critical or negative.
Structuring Feedback: The Gordon Model
The word criticism connotes judgment and disapproval, and should be avoided when commenting on behavior. Terms such as input or feedback are more readily accepted, as they connote more objective consideration. Additionally, feedback is received more favorably when it focuses internally, rather than on the other person, as this allows the other person to maintain self-esteem. Finally, labeling, personal attacks, and generalizations should be avoided. For example, the following comment voiced in an attempt to create positive behavior change is likely to be rejected:
“You are always too argumentative!”
Using the general terms “always” and “never” are forms of hyperbole that are poorly received when attempting to give feedback. Furthermore, the label “argumentative” is unlikely to be received positively. A more effective alternative is suggested by Gordon, who recommends behavioral feedback using “I statements.”38 He advocates structuring feedback in 3 parts, with a clear description of the behavior and how it affects the person offering the feedback (Box 8-6).
Box 8-6 Thomas Gordon Model
The “when” statement should be specific, concrete, and observable. It is important to simply and objectively recount the occurrence, “When we argue…” It is essential to avoid attacks and labeling, such as“When you argue with me…”
- “When you argue with me. .”
- act the way you do (nonspecific).
- behave like a jerk (labeling attack).
The “I feel” statement should express a sincere feeling that is consistent with the situation, such as anger, frustration, upset, or embarrassment. Avoid phrases that are blaming or don't connote a feeling, such as, “I feel like…”
- a child (how does a child feel?)
- an idiot (not a feeling)
- you are being mean (blaming)
- you don't care (accusing)
The “because” statement provides an opportunity to share motives and the desired outcome. Again, the temptation to blame must be avoided. Speakers should focus on the way the behavior affects them and their perception.
“When we argue, I feel frustrated because it seems my ideas are not respected.”
Another common example involves a person who believes his or her opinion is overlooked. In the first example, the recipient of the feedback is likely to perceive blame and disapproval. In the second example, the use of “I statements” is more likely to be met with receptivity and an effort to further examine the issue:
- Blaming feedback: When you ignore me, I get furious because you don't care about me or my ideas.
- “I Statement” feedback: When I'm ignored, I feel frustrated because my ideas aren't considered.
Giving feedback using the Gordon model clarifies the problem, describes the resulting feeling, and defines the underlying issue to address. Done well there is no blaming. This technique allows both parties to objectively examine ways to resolve the problem.
Patterson et al promote the mnemonic CPR (content, pattern, relationship) in their book Crucial Confrontations.39 When confronted with a difficult confrontation, rather than responding aggressively or with avoidance, CPR may be used to move toward a fair solution for all parties. This may be particularly valuable when a habitual pattern is noted. As an example:
- Content addresses the current situation. A practitioner might say to a colleague who takes multiple long breaks, “Janet, I've noticed that you have taken 5 or 6 long breaks during the shift today.”
- Pattern addresses the related history of previous similar events. “I've noticed the same pattern when we've worked together recently.”
- Relationship addresses the continuing interactions and trust of the parties. “Janet, I must be able to rely on you when we are working together. This pattern leads me to question whether or not I can.”
CPR is deceptively simple, yet difficult to put into practice when there is emotional content. With practice, CPR helps transition conflict from confrontation to resolution.
Occasionally, an angry person may verbally abuse another person at a public venue. This behavior makes most observers uncomfortable, and the unfortunate recipient of the ridicule is likely to feel humiliated by this public exposure. The person expressing discontent may not even recognize the inappropriateness of the behavior.
It may be possible to interrupt this dysfunctional communication and change behavior. When a patient, coworker, medical staff member, etc, is inappropriately expressing emotion in a loud and disruptive manner in public, an intervention is appropriate. The following process may help resolve the situation. The intervening person can
- Walk up to and stand in front of the speaker.
- Gain his/her attention and establish eye communication.
- Quietly and firmly say: “I see you're upset. I'd like to talk with you about this issue…over here.”
- Move toward a more private space.
- Address the issue.
Most angry people will go with the person who has offered to address the problem. Physically moving will itself begin to decompress the situation. (Note: This technique should not be used if there is any potential danger.)
Responding to a Complainer
In a busy ED, expectations are often unmet. The two most common complaints from patients are “It's taking too long!” and “Nobody cares!” People who wait for a prolonged time and are treated rudely may be particularly vocal or hostile when expressing their discontent.
When a complaining person confronts (blames) another with his or her dissatisfaction, the opportunity exists to address the concern. The response may lead to immediate resolution or may substantially exacerbate the problem.40,41 Habitual blamers tend to be angry and believe they should get their way; anything less is a catastrophe. They may believe that they have not gotten what they deserve because people are insensitive and purposefully obstinate. Blamers use personal pronouns, generalizations, and extremes of language to make their point. They tend to be dramatic, both in tone and gesture. Blamers may shake their finger, pound their fist, and even be verbally threatening. The blamer, in essence, tries to place the responsibility for his or her problem on someone else. For example, a blaming patient who is tired of waiting might exclaim:
“Why is it that every time I come here, I always have to sit around and wait for hours and hours! Don't any of you people care about anyone! Can't you see that I'm in agony!”
Translation: “I want to be taken care of now!”
There are many ways to respond to this person. Before choosing, it is critical to recognize that this verbal assault is not necessarily directed at the unfortunate recipient. Although tempting, one should avoid “taking the bait.” Taking it personally, a blaming professional might “blame the blamer” back and respond by saying
“Can't you see that we're busy! We're working as fast as we can! Your constant interruptions are actually delaying our getting to you. If you will just sit quietly and wait, we'll take care of you when it is your turn. There are people here who are really sick!”
Blaming a blamer puts the responsibility back on the blamer. Joining this mud-slinging contest gets everyone dirty. There are no winners. Inevitably, blaming back leads to escalation of the conflict. When the opportunity arises, the blamer will take their frustrations to the next level, with a letter to the CEO or to the editorial section of the local newspaper.
Placating is in many ways similar to blaming.40 The placater acts as if he, she, or the system is personally responsible for the problem. The placater, like the blamer, uses many personal pronouns, generalizes, and places emphatic stresses on words. However, instead of aggressively placing the responsibility for the problem on others, a placater is apologetic and appears to assume responsibility. A placater who is frustrated with waiting might say:
“I don't know why it is that I always seem to come when it is so busy. I don't like to complain, and I know that you doctors and nurses are so busy and my problem is so insignificant…”
Translation: “I want to be taken care of now!”
It is quite common for professionals in a service industry such as healthcare to placate. The placating professional apologizes and either assumes personal responsibility or apologizes for the inadequacy of others, such as
“I'm very sorry, I wish I could have been here sooner. You must be upset. It's been so busy and one of the x-ray machines is broken. I'm very sorry.”
Placating in response to conflict works—to some degree—, avoids escalation and allows the other side to blame the obliging apologizer. This behavior, however, causes the placater to feel inept and impotent. Furthermore, it does not substantially improve the situation.
An effective alternative to placating is the blameless apology. This approach is reassuring and expresses concern for the perceived issue without assuming responsibility for the problem. It demonstrates that the provider cares and is listening.
“I am sorry that you've had to wait so long.”
A particularly effective way of responding is to acknowledge and validate the expressed complaint.36 Ideally, the provider addresses the underlying concern. This approach eliminates blame, deals directly with and validates the concern, and provides the complainer with what he or she really wants—attention, empathy, and responsive behavior. This technique avoids ascribing responsibility. For example:
“Yes, it's frustrating to wait when you're in pain. I'm here to take care of you now.”
Objectively repeating the complaint back to the complainer from their perspective demonstrates an understanding of the issue. When possible and appropriate, the provider should immediately offer the complainer the care and caring that he or she wants. If unable to provide the solution now, then it is appropriate to let complainer know when to expect it.