Conflict in the emergency department: Retreat in order to advance
Jan Ahuja, MD;* Pam Marshall, RN, LLB, LLM (ADR)†
*Associate professor, Department of Emergency Medicine, University of Ottawa, Ottawa, Ont., and Director, mediate.calm †Assistant Director, LLM in ADR program, Osgoode Law School, and Senior Associate, mediate.calm
Conflict that exists within a team providing services in an emergency department has the potential to be destructive to clinical care and professional relationships. A collaborative approach involving members of the team guided by a neutral facilitator can be effective in addressing important issues and creating solutions that are acceptable to the individuals and the group. By working together in such a facilitated setting, relationships between the team members can be strengthened while problems are being solved.
Les conflits existant au sein d'une équipe offrant des services au département d'urgence peuvent être néfastes pour les soins cliniques et les relations professionnelles. Une approche de collaboration impliquant les membres de l'équipe guidés par un médiateur neutre peut se révéler efficace pour aborder des questions importantes et créer des solutions qui soient acceptables tant pour les individus que pour le groupe. Le fait de travailler dans un cadre régi par la médiation ne peut que renforcer les relations entre les membres de l'équipe au moment de régler les problèmes.
Life begat disputes; disputes begat conflict; it was ever thus.1-3 Conflict is inevitable in emergency departments (EDs), other areas of health care, and life in general. Conflicts arise between patients and caregivers, patients and administrative staff, patients and physicians, not to mention the myriad of conflicts that arise between and within the nursing staff who are trying to care for too many patients without adequate resources. In addition, physicians are in conflict with administration, with nurses and with each other as they struggle to move patients through an overburdened hospital system. But why should this create a problem? After all, emergency physicians are trained to deal with all sorts of crises; they are the ultimate jugglers in the health care circus, experts at managing many simultaneous demands.
While disputes are a natural part of life, their positive and effective resolution requires that we learn certain skills and understand how to deal with conflict at various levels of interaction.1-3 And although conflict is inevitable, it is difficult for most to see that conflict is also necessary. Many people avoid conflict at all costs, but conflict actually stimulates us, drives us to cope and, inevitably, strengthens us. The problem with conflict is not its existence, but rather its management. When conflict erodes relationships, interferes with service delivery and jeopardizes safety, these are signs that it is not being properly managed.4,5
Health care workers share a common goal of improving patient outcomes; yet each may have a different framework or vision of how to achieve that goal. At first, issues that lead to conflict may not appear to influence patient care; yet, as relationships between providers erode, job satisfaction decreases and patient care inevitably suffers. The consequences of unresolved conflict are extensive and expensive, involving emotional and financial costs to care providers, clients, administrators and facilities.1-3
As Table 1 illustrates, individuals and organizations have many ways to deal with conflict, ranging from avoidance to a declaration of war. While early intervention through negotiation between conflicted parties is often the most desirable option, there may be situations where a dispute involves power imbalances, in which case resolution may be more achievable using the neutral facilitative approach provided by a third party mediator or arbitrator. As the field has developed, the different styles and approaches of dispute resolution practitioners have been analyzed and categorized. Approaches range from the hands-off or "transformative" to the more directive or "evaluative." Different styles or methods may be appropriate to certain types of problems and not others. The "facilitative" style is situated between these two approaches and results in a distinctive blended approach.2,3
|Avoidance||Collaboration||High authority||Unilateral action|
|Bury your head in the sand||Individual initiative||Ombudsman||Physical violence|
|Hope it goes away||Informal negotiation||Neutral evaluation||Strikes, lock-outs|
|Mediation||Boards or agencies|
A neutral third party may be an individual within the workplace who has experience in mediation. Alternatively, an outside agency can play the role of mediator or arbitrator, depending on the situation.3 Less desirable and more costly is the involvement of legal counsel or an imposed decision by the courts. As Table 1 illustrates, each step away from early resolution by the parties themselves results in diminished control of the outcome, increased delay in the process and escalating costs.
Fig. 1, the "Preferred Pathway," illustrates another way of viewing the options along the dispute resolution continuum, although many individuals and facilities choose not to follow the pathway. In reality, many disputes escalate quickly to step 5, bypassing more collaborative and less costly options.4,5 The example provided in this article highlights the personal and professional benefits of applying more collaborative and interactive approaches to conflict resolution.
A community hospital ED was embroiled in a conflict that had simmered for years. Physicians were divided among themselves, nurses were resigning, administration was alienated from staff, and the community was anxious and angry about the threatened loss or reduction in emergency services. Shrinking resources, increasing workloads and an increasingly demanding and educated public had led to an untenable situation that required immediate and effective intervention. This situation was similar in scope and effect to others being played out across the country.
In this case, although the ED was the initial site of conflict, the situation had escalated and the problems expanded to embroil the entire hospital, including the board of trustees. Ultimately, many members of the community became involved and were publicly taking sides. Recognizing that the nature of the conflict made it impossible to resolve internally, the administration sought the assistance of a conflict resolution company (which included the authors of this paper) that specializes in collaborative health care solutions. The possibility of failure was considered significant since, in previous hospital-wide conflicts, the administration had utilized consultants whose reports and recommendations were received but, by and large, not adopted.
Identifying the issues
Representatives of all stakeholders formed a working group that met regularly over many months, using an Interest-based process to identify and prioritize several core issues. The group then developed potential solutions using a consensus approach. This broad process successfully addressed some of the ED issues, but other unique problems remained. For a number of reasons, the decision was made to address remaining ED issues at a retreat involving all ED clerical, nursing and medical staff. The aim of this facilitated process, as with any interest-based negotiation or mediation by neutrals, was to encourage the entrenched parties to develop solutions upon which they could agree and for which they would take ownership. Experts from the conflict resolution company agreed to facilitate this one-day retreat.
To assure it was seen as an ED initiative, the retreat was planned by the ED Chief and Nurse Manager. Prior to the retreat, all ED staff members were asked to complete a questionnaire (Table 2), indicating what they enjoyed about working in the department as well as what made it difficult to do their work effectively. Concerns about departmental function fell into 5 categories: interpersonal relations, patient care, policies and procedures, relationship with hospital, and community relations. Ninety percent of staff completed the questionnaire, and the facilitators compiled the results.
|Q1.||What are the main reasons you enjoy working in the emergency department (ED) at the hospital?|
|Q2.||What are the things that make it difficult for you to do your job effectively?|
|Q3.||For each of the following categories, please describe the problems you see or the concerns you have regarding the functioning of the ED at the hospital:|
|A) Interpersonal relations
(getting along with other staff in the department)
|B) Patient care
(how patients are cared for in the department)
|C) Policies and procedures
(ED protocols that guide how things are dealt with)
|D) Relationship with hospital
(how ED functions with other parts of the hospital)
|E) Community relations
(how the ED interacts with the town)
|Q4.||If there are issues particular to your job as clerk, nurse or physician that should be discussed only within that group, please describe them.|
Exploring the options
After introducing the day's agenda, the facilitators clarified ground rules for the discussion process. Members of the group agreed to treat each other with respect, without interruptions or negative non-verbal behaviour, and to reach decisions by consensus through a process of interest-based negotiation. Interest-based approaches encourage and value all points of view, looking beyond the positions that people express to identify the interests that underlie them. For example, if someone expresses the position that they want more money, the underlying interest may be that they need more recognition of their value to the organization or department. Where positions cannot be met (e.g., there is no more money), it may be possible to recognize and address important interests.
Next, the issues identified in the questionnaire responses were explored, refined and verified. The staff was divided into 5 working groups, each with clerical, nursing and medical staff representatives. Each group was asked to brainstorm solutions for the identified issues pertaining to 1 of the 5 domains identified above, and the facilitators circulated among the groups to encourage fruitful discussion. Considering possible solutions in such an interest-based and collaborative fashion enhances the generation of new ideas by coworkers in a non-threatening environment.
Useful techniques in this type of process include brainstorming, option generation, and considering all ideas as valid -- avoiding critical analysis until a later defined time when the most viable options are identified and refined. Table 3 outlines the steps that are classically taken to bring parties in conflict from entrenched positions to common goals by the process of facilitated negotiation by experienced mediators. Each stage -- from storytelling to solutions -- requires commitment by all parties to the process, including the facilitator.
|Facilitator responsibilities||Participant responsibilities|
Welcome and introduction
|Explain the process and the role of the facilitator/mediator||Agree on ground rules: confidentiality, respect and timeliness|
Telling the story
|Ask questions to clarify the issues||Each person speaks in turn about the situation|
|Help create list of issues Reinforce ground rules as necessary||Agree on the issues in dispute Seek to find common ground|
Generating options for resolution
|Help parties generate options Help parties stick to identified issues||Suggest as many options as possible Assume all ideas have merit No criticism of ideas|
|Foster development of agreement Write down agreement developed by parties||Decide on points of agreement Sign agreement if ready Agree on next steps if more time required|
|Closing||Ensure parties understand agree-ment as reached and next steps Acknowledge everyone's hard work||Ensure agreement is acceptable to all Acknowledge everyone's contribution Determine next steps as required|
Over lunch the participants socialized and continued discussions in a relaxed setting, gazing out at the countryside instead of toward a waiting room full of anxious patients. Subsequently, each group presented their possible solutions, and the facilitators encouraged discussion and debate in order to reach consensus. A few issues were set aside to be dealt with by the physician group at a later date because these required collaboration with the hospital administration.
For each solution agreed upon, an implementation plan was devised, including a goal statement (expected outcome), a mechanism to measure progress (performance indicators), and specific implementation steps detailing the responsible person or committee, a start and end date, and any supports required, including financial implications (Table 4). Inherent in implementation action plans is the concept of ongoing collaboration. The development of a departmental code of conduct is important; it clarifies the expected behaviours of coworkers and defines guidelines for non-compliance. The action plan that arose from this ED retreat may resemble plans developed by administrators of other departments, but this plan was achieved by consensus, involving not just a few administrators or committee members but a majority of the providers involved in daily workplace activities. The process is as important as the solution itself because it affords all parties the opportunity to work together to solve problems rather than reacting to an outside imposed solution. In many other facilitated situations a working group representing the various parties is empowered by the larger group to discuss the issues, explore options and define action plans for the larger group. It should be noted that this process is facilitation rather than mediation, both being examples of ADR (appropriate dispute resolution).*
|GOAL STATEMENT / EXPECTED OUTCOME|
|MEASUREMENT OF EXPECTED OUTCOME / PERFORMANCE INDICATORS|
|Steps to implement||Responsible party||Start date||End date||Supports required||Financial needs|
|Develop ED code of conduct
(give respect / receive respect)
|Establish joint nursing / physician meetings||ED chief and nurse manager||Feb||Ongoing||Clerical||Minimal|
|Develop ED resource manual||ED chief and nurse manager||Feb||Mar||Clerical||No|
|Recognize and celebrate successes||ED team||Immediate||Ongoing||No||No|
|Recommend appointment of an ED representative to new communication committee||Communication committee chair||Jan||Ongoing||No||No|
In any process such as the one described, there are potential risks. If the mediator is unskilled or the participants ignore the rules, the retreat can degenerate into a complaint session where hostility and frustration are expressed but little is accomplished. If retreats are held but the action plans developed are not implemented, participants may become cynical and frustrated. If retreats inadvertently exclude relevant participants, these people feel increasingly marginalized and new conflicts may arise. If the main source of conflict relates to a relatively "fixed" problem (e.g., hospital resource shortages), having a retreat focusing on other factors may be of limited value unless the hospital and appropriate government agencies take part.
Cost is an important consideration, but measuring costs and benefits may be difficult because many are intangible. The dollar costs of this ED retreat, including venue rental, catering and expert facilitation were less than $4000, but this does not consider the time committed by staff who participated during off-duty hours. The potential benefits, equally difficult to quantify, include reductions in sick time generated by stressed and disgruntled employees, reduced costs for hiring casual replacement nurses and dealing with union grievances, less time spent in meetings to address conflicts among providers, and lower cost for recruiting and training new health care workers -- not to mention the relationship costs of conflict between staff members working in an environment where teamwork is critical.
At the conclusion of the process the ED Chief and Nurse Manager had a blueprint for action, achieved in a collaborative manner by the entire ED team. The ED Chief has reported that significant advances were made during the 6-month period after the retreat, particularly regarding department staffing, enhanced clerical and full-time nursing personnel, successful recruitment of full-time emergency physicians, and improved coverage on night shifts. Team members felt energized by the process, which involved them in decision-making and allowed them to get to know each other outside the hospital setting. Another result is a sense of improved teamwork and positive attitude by the majority of staff members. The facilitators sensed that the group had taken positive steps to resolve divisive conflicts and were now better able to deal collaboratively with inevitable future conflicts.
*This type of facilitated process has been used effectively in numerous other situations. For an example see: Robson R, Marshall P. Using dispute resolution to resolve health care conflicts: an essential tool in hospital risk management. Risk Manage Can Health Care 2003;4(7):73-81.
- Costantino CA, Sickles Merchant C. Designing conflict management systems: a guide to creating productive and healthy organizations. San Francisco: Jossey-Bass Publishers; 1996.
- Fisher R, Ury W. Getting to Yes. 2nd ed. New York: Penguin Books; 1991.
- Mayer B. The dynamics of conflict resolution -- A practitioner's guide. San Francisco: Jossey-Bass Publishers; 2000.
- Macfarlane J, editor. Rethinking disputes: the mediation alternative. Toronto: Emond Montgomery Publications; 1997.
- Moore CW. The mediation process: practical strategies for resolving conflict. 2nd ed. San Francisco: Jossey-Bass Publishers; 1996.
Dr. Jan Ahuja, Director, mediate.calm, PO Box 332, Ottawa ON K1C 1S7; 613 866-590-7195, fax 613 590-7195, firstname.lastname@example.org