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.

Keywords: conflict management, resolution skills

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 management14 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

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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.