Conflict Management

Introduction

Conflict within the field of surgery is inevitable. Considering the complexity of systems issues, the high stress of surgery, and imperfect people, we should expect to encounter conflict on a daily basis. In fact, some conflict should be welcomed because it can identify opportunities for improvement, to achieve better care. An operating theater or ward where people are afraid to speak up out of a desire to "avoid conflict" is a dangerous place indeed. So the focus of this chapter is not on how to avoid conflict, but how to maximize the productive type of conflict and minimize the personal and detrimental type.

Benefits of Conflict

Healthy, task-oriented conflict can produce numerous benefits: Conflict Encourages New Thinking

Although it is often assumed that people avoid conflict, many people actually enjoy conflict to a certain degree because it can be the stimulus for new thinking. Considering a different point of view, which sometimes comes with conflict, can open up new possibilities and help to generate new ideas that might otherwise have not been considered. Conflict Raises Questions Organizational conflict usually leads to a series of questions for those on both sides of any issues. These questions can lead to new ideas and breakthroughs in thinking that can benefit individuals, departments, and organizations. When there is no conflict, nothing changes. There is no need to question or challenge the status quo. Conflict represents an opportunity to reconsider, which can lead to breakthrough thinking. Conflict Builds Relationships Being agreeable is nice, but encouraging conflict can actually strengthen relationships. Organizational conflict between individuals, departments and even competitors can help to build relationships through mutual understanding and respect. Learning to listen and listening to learn leads to insights valued by both sides in any conflict situation. Leaders who sincerely value the opinions and ideas of their subordinates are not only more effective leaders, they are also considered more valuable by their employees. If an employee feels that management values their opinion, that employee will value the work more and overall morale will increase. Conflict Opens Minds Organizations that teach employees how to manage conflict effectively create a climate of innovation that encourages creative thinking. Minds are opened to new, previously unexplored possibilities. Considering new ways of approaching challenges and meeting the demands of a competitive business world can result in improvements that benefit staff as well as the organization. Conflicts Combats Stagnation Organizations that avoid conflict avoid change. Avoiding change is futile and can lead to the demise of even successful organizations. Companies that encourage staff to approach conflict in positive and productive ways can beat the stagnation that opens the doors to competitors, challenging their ability to provide customers with new and innovative solutions.

Managing Yourself

Consider each interaction in the overall context. To "win" the present "battle," while failing to achieve your long-term goal is an overall loss. The conflict that happens in the operating room should be part of the daily life of any surgeon. If there is no conflict, you should ask yourself whether the theater staff and you have the same vision for improvement. This is not to say that you should trigger conflict intentionally. Rather, when conflict happens, it means that your team members have their own solutions to the problems you face. Value their thoughts; often, the worker "on the ground level" knows the solution to the problems that vex leadership. The way you handle the present conflict is the key to winning or losing your team members' trust.

Consider your desired long-term outcomes. One example of a desirable long-term outcome is psychological safety, an environment where people continue to provide honest, accurate information. If your team members are afraid or otherwise unwilling to provide honest feedback, patient safety is compromised.

Psychological Safety exists when team members know they can share ideas, thoughts, and questions, or even admit mistakes, without being punished, humiliated, or having their reputation damaged.

You, the surgeon, function as team leader in the operating room. Your main goal is to influence your team members by creating an environment of comfort where everybody feels free to talk even during conflict. It is good for you to share with your team members what your objectives are and what works well for you.

Success requires clear communication. When leading a team, one of your primary responsibilities is making sure your team works well together. Often, individuals with varying personalities comprise these teams. The ability to recognize potential conflicts between individual team members and resolve them quickly is essential for the projects to proceed successfully.

Consider your own assumptions. Be willing to admit that you might be wrong about something that you think you know. As you may have noticed, this can be difficult for surgeons, since we often have in-depth knowledge about a highly specialized topic. We may have a hard time admitting that there are things we don't know. But there are many factors at play during a patient's care, most of which are not under our direct control or even occurring with our knowledge. Worse, people "under" us might have a different, perhaps even better understanding of some of these factors.

In a rapidly advancing and changing world, the advantage goes to the one who is willing to let go of assumptions when the evidence shows that they are incorrect. There simply is no room in healthcare for the "command and control" approach anymore. Those days are over; patient safety and everyone's workplace satisfaction are the better for it.

Preparing for Difficult Conversations

When you've had a negative interaction or anticipate there might be conflict, preparation makes all the difference. First of all, manage your own emotions. Conflicts escalate and often become unproductive when the involved parties are too emotionally charged to engage in rational dialogue.

Emotional Awareness is the ability to recognize and make sense of your own emotions and those of others. Possessing the emotional awareness to sense others' or your own emotional temperature rising in a situation is essential for engaging in task-oriented conflict. Emotional awareness helps keep healthy conflict from spilling over into personal attack.

The Ladder of Inference

One of the best tools for cooling down your own emotional temperature prior to engaging in a difficult conversation is the Ladder of Inference.

The Ladder of Inference. During times of conflict, it is all too easy to subconsciously move up the ladder, adding meaning to others' behavior moving "upwards" from there. It is much less instinctive to climb downwards examining and questioning whether your assumptions and conclusions are valid. Source: Biogeographist, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0 via Wikimedia Commons

Simply, the ladder helps us strip away our assumptions and deal with facts, enabling us to consider alternative explanations. Similar to the process for creating a differential diagnosis, using the Ladder of Inference can prevent us from anchoring on specific and often negative narratives. The following vignette is a classic example of the ladder of inference in action.

Imagine you're in heavy traffic and already late to work. A saloon car from two lanes over front of you cuts in front of you requiring you to slam on your brakes. You mutter something under your breath and wonder why some people think they're more important than everyone else. As fate would have it, that car takes the same route to the hospital that you do. It hurriedly pulls into the parking spot in front of you at which point the driver hurriedly gets out and sees you. You roll down your window to give him a piece of your mind! But before you can, he apologizes profusely for cutting in front of you in traffic while opening the passenger door to help his wife who is actively in labor. You smile and tell him it was ‘not a problem at all,' wishing them the best as they scurry into the emergency room door.

Did you notice the difference between your initial assumption in traffic as compared to your final emotional state? An initial narrative about another person's selfishness was actually a story created in your mind because you had incomplete facts.

In the world of healthcare, most people are truly invested in providing great care to patients, but we often assume the worst. The ladder of inference helps us deconstruct these assumptions, in order to construct more positive ones. When you know you need to engage a consultant, a nurse, a trainee, or even a patient about something that has the potential to cause conflict, or already has caused it, try using the ladder of inference via the following two questions:

1. What are the facts of this situation?

2. Why would a reasonable, rational, kind person

behave this way?

To illustrate, let's apply these two questions to an example closer to home:

You're the senior trainee of the thoracic surgery service. While rounding in the morning you notice that a lobectomy patient on postoperative day 3 has a new 3 cm pneumothorax after his chest tube was removed yesterday. The patient is asymptomatic but you think the patient probably needs another chest tube. After rounds, you call the consultant surgeon who asks that you not place a chest tube but instead carefully watch the patient during the day and repeat an x-ray in the afternoon. You communicate the plans for all the patients to the other trainees under your supervision and head off to the operating room.

Later on, while you are in the patient care area, a nurse approaches you and asks you how much suction he should be using for the patient's chest tube because he forgot to ask the intern after she placed the tube at bedside.

No doubt a conversation with your intern is warranted. But as you feel the hairs on the back of your neck rising in anger, you realize that maybe the ladder of inference might be helpful here. Well, at least you'll give it a try before you go have a very difficult conversation with your intern. First, what do you actually know? The intern placed a chest tube without your permission? The intern defied the plan from the consultant surgeon?

Actually, none of that. Those are narratives laced with inferences. All you know is that the nurse is reporting that a patient has a new chest tube. What if you did a little more fact finding? For instance, suppose you ask the nurse which patient he is referring to and you find that there is a trauma patient who just got admitted and needed a chest tube? Suppose the patient actually has a nasogastric tube and the nurse just misspoke? Do you feel your anger cooling off already? Much more fact finding, as addressed in Question 1, is necessary in this situation.

But, for the sake of the exercise, let's say that you go into the room and indeed see the patient in question, sitting with a chest tube in. How could your intern do something so horrendouschange the plan and not even discuss it with you? How could she be so insubordinate? Feel the anger rising again? See those inferences sliding in again? Question 2 helps us not move up the ladder of inference so quickly. Ask yourself, "why would my intern, who I know is well intentioned, reasonable, and rational place this chest tube?" Immediately, this assumption of positive intent leads to alternate explanations. For instance, what if the patient started decompensating acutely and a tension pneumothorax was suspected? Or what if the consultant came in and rounded with the intern and he asked for the chest tube to be placed? Simply considering these possibilities is likely enough to bring the emotional barometer down to a reasonable place. With a better understanding of the facts and an assumption of positive intent, you're ready to contact your intern and dig further. The Advocacy-Inquiry Technique As a surgeon, you must be aware of the implicit hierarchy. You are at the "top." The people you interact with have interacted previously with surgeons; likely they have been reminded, in not-sosubtle ways, about this hierarchy and their place in it, below the surgeon's. But the best way to resolve conflict, and to encourage effective communication, is to not use the "command and control" behavior that this hierarchy suggests. The Advocacy and Inquiry technique is based on two ideas 1. You have a clear understanding of what is happening with the patient. In most cases of conflict, you have observed that the plan has not been followed somehow.

2. Since the plan has not been followed, the person you're addressing must be aware of some information that you are not.

You give your perspective, usually an observation, then give the other person a chance to explain the reasons for your observation. In effect, you give them the benefit of the doubt and refuse to climb up the Ladder of Inference. You strive to be "curious rather than furious." The Advocacy – Inquiry technique is demonstrated in statements such as: ● "I see that the patient did not receive their enoxaparin this morning. Why is that?" ● "I see the patient has not yet been taken to the operating theatre. Are you encountering some obstacles?" There are always obstacles in the way of what is best for the patient. Most are system issues, not personal ones. Create an atmosphere where your team knows you want to help them solve these problems.

The opposite of this approach is a direct confrontation. "Why haven't you given the enoxaparin?" "Why haven't you taken this patient to the theatre yet?" The unspoken assumption, conveyed clearly by your tone of voice, is that the person you are addressing must be either lazy, stupid, or insubordinate.

You are much less likely to create a culture of safety with the latter approach. The system issues, the ones that really stand in your way, will remain unsolved as you engage in useless conflict against people, rather than useful conflict to find solutions to these issues.

You may also find that people around you, offended by your assumptions, begin to passively resist you and engage in small acts of "sabotage." Healthy Team Dynamics Studies of patient safety clearly show that the patient is safest when all members of the team are empowered to speak if they have a concern. Patient outcomes clearly improve as communication and team dynamics improve. The advantage that a wellfunctioning team brings is as clear as the advantage of using the right medicine or performing the right operation.

As a leader, you set the tone in the patient's care. Your example will determine whether there is good team dynamics. Model excellent communication by speaking clearly, listening carefully, and acting on the concerns. Be gracious and grateful for others' input, even when it's negative. In fact, you should seek out negative feedback. Serious personality differences between some members of the team must be set aside for the common goal of excellent patient care.

Ad hoc / On the Spot conflict management

Despite the utility of all the techniques above, there are often situations which don't allow for any rehearsal. These acute moments of conflict are often the most dangerous because we're likely to let our emotions get the best of us. Try to convert acute conflicts to planned, emotionally calmer ones if at all possible. For instance, in a heated moment with a consultant, you might consider asking if it would be okay to call her back shortly or, in the operating room, to speak in private after the case. This should give you time to enact some of the techniques described above. For those moments where this is not possible, here are a few brief thoughts:

First, try to remain emotionally aware. If you sense your pulse skyrocketing, acknowledge it. Some find that a few deep breaths through the nose helps slow down an accelerating sense of fury or outrage.

Second, try to assume positive intent. Reminding yourself that the person on the other side of the conflict is a good person and wants good for the patientthis approach can help you view her/him differently. Similarly, try reminding yourself to be curious about why someone is doing something seemingly egregious, understanding that they intend good for the patient.

Third, humble yourself, no matter who is at fault, and ask for help. This approach will often defuse any difficult situation. Virtually all who are in healthcare went into the field in order to help others. Frequently we can appeal to this sense of service. For instance, imagine you're calling a consultant in the early hours of the morning. Your opening statement may lead to conflict or prevent it. "Hi, this is a consult for…" as compared to "Sorry to bother you at this time, but we need help with a difficult situation and I think your expertise would be really useful." Finally, and most importantly, prioritize the patient. No matter the conflict among team members, providers, or systems issues, choosing to do the right thing for the patient in front of you is typically something everyone can agree on. Finding this common ground is likely the best place to start for resolving any conflict.

Conclusion

It's worth concluding with three quick thoughts regarding growth from conflict both personally and interpersonally. Great leaders use their experiences to promote growth. It's been said that we don't grow from our experiences, we grow from reflecting on them. If you want to improve the way you manage conflict, try scheduling regular time to review your past week and consider how you performed during times of duress, particularly as it relates to conflict. How well did you manage your emotions? Did you assume positive intent? Did you prioritize the patient? If you had to do it all over again, how might you have done it differently? Is there anyone that you need to reach out to in order to resolve something that still feels unsettled? Do you maybe even need to apologize? Admittedly, making room in our busy schedules for this time of reflection is challenging. But if we don't, we're unlikely to make any changes next time.

Second, try your best to view episodes of conflict (and any failures in management on your part) as opportunities to grow, not indictments of your ability. Adapting a growth mindset, even to your worst failures, puts you in a frame of mind that will maximize your learning and avoid burnout. Encouraging this type of mindset into your team is equally as important.

Finally, consider scheduling regular, bidirectional feedback sessions with critical team members, direct reports, or learners. The higher you move in the hierarchy of surgery, the more reluctant people are to give you honest input about your performance. It will be up to you to solicit this crucial information. Scheduling these sessions regularly and informing colleagues that they will be expected to give and receive performance-based feedback, normalizes a culture where feedback is expected and appreciated. This type of culture is essential for handling inevitable conflict and developing a thriving, productive workplace climate. Robert Sinyard, MD MBA Massachusetts General Hospital USA Gady Barutwanayo MBBS AIC Kijabe Hospital Kenya Richard Davis MD FACS FCS(ECSA) AIC Kijabe Hospital Kenya December 2022