Pam Marshall, RN, LLB, LLM (ADR), Conflict Resolution Specialist, and Director, Patient Relations, The Scarborough Hospital
Dr. Rob Robson, MDCM, FRCP(C), Healthcare Mediator and System Safety and Accountability Advisor, HSSA Canada
Table of Contents
- The Nature of Conflict and Some Common Myths
- The Origins of Conflict
- The Importance of Communication and the Role of Emotion
- Other Factors that Contribute to Conflict in the Health Care Environment
- How Facilities Can Develop Conflict Management Processes
- Understanding and Recognizing Individual Approaches to Conflict
- Conflict and Patient Safety
- Strategies to Increase Individual Conflict Management Competence
- Methods for Conflict Resolution
In thinking about the nature of conflict, there are many myths that inform and often confuse the discussion.
Myth 1: Conflict can be avoided
Conflict is inevitable. It is one of the energetic forces that drives and often damages the social engine. To fully take part in social life is to desire, invite and initiate human contact—and contact begets conflict. Most human beings seek interaction and connection with others. The absence of such interest indicates pathology and is treated as abnormal. People want to relate to others, to know and be known and to be understood. This innate desire to be connected to others, to be with, rather than alone, is a source of much of life’s great experiences and frequently the source of friction.1
In going about our daily personal and professional lives, all of us come into contact with numerous other individuals. In both of these spheres, the private and the public, conflict and disputes will arise. Though the nature or substance of the dispute may differ, and the emotional context may change, disputes must be dealt with; they must be resolved in order for people to move forward. One of the questions that confronts the people involved in a dispute is how to deal with conflict in the most positive way possible. Conflicts in health care have some unique characteristics and originating factors, which we will discuss later; however, they are similar to all other conflicts in that they are unavoidable and inevitable. What is avoidable is escalation and negative outcomes.2
Myth 2: Conflict is bad
As health care professionals and conflict resolution professionals, the authors have experienced firsthand the reluctance of health care professionals, administrators and clients to acknowledge and admit that unresolved conflict is pervasive in today’s health care system. Health care professionals are not alone in avoiding conflict; most people fear conflict and do their best to keep out of it and away from it, despite the fact that conflict is an inevitable factor in our daily personal and professional lives.3
However, the fact that people disagree should be seen as a healthy and integral part of human interaction. Regardless of whether we call them disagreements, disputes or arguments, these situations are part of the normal ebb and flow of life and they often present an opportunity for learning about another person’s point of view. Not every disagreement will escalate into a situation that requires intervention. Most everyday problems are resolved simply and easily by the people involved, and life and work go on as usual.
This primer focuses more on those problems that are not dealt with and end up escalating into something that interferes with a practitioner’s professional life.
Myth 3: Conflict is impossible to resolve
Conflict is a normal result of interacting with our fellow humans. And yet most of us have never learned how to prevent it, keep it from escalating when it starts or manage it when it develops. Most of us are loath to admit we are in the middle of conflict. We suggest that we are having a “discussion,” a “disagreement” or a ”difficult situation,” and insist that we will work it out. Many health care facilities are quite prepared to hire people to facilitate meetings, assist with teambuilding or work on organizational strategic planning. Few are willing to admit that they need help in managing the conflict in their organization.4
When asked, most people would likely acknowledge that conflict is an inevitable factor in their daily personal and professional lives. They might go on to say that it is not so much the fact that conflict exists that challenges them, but rather that they just do not know how to deal with it. While most of us would admit that conflict is unavoidable, at the same time we do not want to admit that we are in conflict with someone. For most of us, acknowledging that we are in conflict is to admit a failure and to acknowledge the existence of a situation we consider hopeless. Clearly, we are all rather conflicted about conflict. We provide some strategies for conflict management later in this paper.
Myth 4: We need a lawyer
Since most people see conflict as negative, something to be avoided, to be ignored if possible, they think that if it must be dealt with, it should be dealt with quickly and by someone else. People often prefer to resolve serious conflict with as little personal involvement as possible. Clearly this is why people seek assistance with their problems, whether it be from doctors, therapists, lawyers, accountants or whomever. Many people feel inadequate to the task of handling both personal and public disputes. This avoidance reaction informs and shapes people’s negative reactions to conflicts and results in the perceived (and occasionally real) need to seek help to resolve them.
The result is cyclical: people feel inadequate to the task of dispute resolution; they make an attempt to deal with a problem and have little or no success; and they feel inadequate and seek help from “experts,” often lawyers, who reinforce the notion that dispute resolution requires special intervention.5 The outcome is often an escalation of the original conflict, a separation of the disputants from each other and a sharp rise in emotional and financial costs, with a concurrent decrease in a quick and satisfactory resolution. People come to believe that conflict is difficult, painful and costly to resolve.
Whether a solution is sought from “experts” or attempted individually, the common methods of dispute resolution for both private matters and public conflicts range from the most basic (one-to-one discussions or negotiation) to the most complex, expensive and time consuming (the courts). Of course, there is much in between these two extremes that can be helpful—particularly mediation, which is a form of assisted negotiation that includes help from a neutral third party.6
Myth 5: All disagreements escalate into conflicts
Disagreements do not spring to life as full-blown disputes; their development is more gradual. During their development, disputes are variously called quarrels, problems, disagreements, concerns, issues or troubles. As noted above, the parties themselves often settle many disagreements quickly and easily. Sometimes disagreements are avoided in the hope that they will go away, and occasionally they do.
Frequently, what begins as a quarrel or minor disagreement is not resolved easily or quickly and escalates, becoming a full-blown dispute. For this to occur the situation must be seen as important enough that it cannot be ignored; that is at least one person is unwilling to “let it go.” For the escalation to continue, the conflict must have more than a minor effect.7
Disputes follow a typical pattern. They begin as disagreements or grievances. At least one of the people involved believes that they are entitled to some kind of resolution or solution to the dispute. Therefore, for something to grow from a disagreement into a dispute, it must have moved past the private belief of one person to a mutual recognition of the problem with at least one other person. While the parties may not agree on the nature of the dispute, its origin or its substance, they must—at a minimum—agree that there is a dispute. If only one person sees a problem, it is not yet a dispute. However, a dispute may arise specifically because the other party does not recognize the existence of a problem or does not perceive that the other party is entitled to any redress. It is only when there is partial or total rejection of the other party’s claim that a dispute is born.
It is always best to seek to resolve a problem at the earliest point. In all conflicts, there is a point at which the situation has become recognized by the parties as a dispute and yet the matter has not escalated to the stage where it is impossible to resolve through negotiation or mediation. As mediators, we refer to this as the point at which a conflict is “ripe for resolution.”8
At the centre of all conflicts are basic human needs. Conflict occurs because our needs are unmet or because our needs are inconsistent with or in opposition to the needs of others.8
One of the first steps in helping health care professionals to manage conflict is to remind them that conflict is normal and common. Once we understand that conflict is natural, the next step is to look at where conflict comes from to better appreciate how we might start the process of resolving them.
Conflict arises from a clash of perceptions, goals or values in an area where people care about the outcome. The breeding ground for conflict may lie in confusion about or disagreement with a common purpose and how to achieve it while also achieving individual goals. In addition, and in health care particularly, the competition for limited (internal and external) resources as well as the interdependency of health care professionals feeds the development of conflict.2
Our ability to accomplish our goals and objectives depends on the cooperation and assistance of others, which increases the opportunity for conflict. In health care, no one can do their job without the input of someone else. When the other person is late, has different priorities, misunderstands directions, challenges our decisions or values outcome over process, conflict is created. Recognizing and addressing the factors that give rise to the potential for conflict can have a positive impact on the health care working environment.
Factors that create conflict
Conflicts are often multi-layered and complex and have various origins that overlap and interweave. Most conflicts involve the same factors to a greater or lesser degree.8,9 We do not often recognize this because we are focusing on one or two factors that are foremost in our minds or hearts.
For example a physician may state “I deserve more money.” This declaration would lead others to believe that the conflict is about resources, or the lack thereof. However, there are many other factors underneath the stated position of “I deserve more money.” These include the following:
- History: “I have never been adequately compensated.”
- Relationship: “The Chief has never really respected me.”
- Emotions: “I feel unvalued by this organization.”
- Structures: “This public health care system does not work for physicians.”
- Needs: “I have responsibilities to my family that I need to meet.”
- Communication: “How can the Chief just send me an e-mail about this issue? He never talks to me directly.”
Understanding the various factors that contribute to conflict helps us begin to work toward resolution. Since communication is such a vital factor in the development and resolution of conflict, we will discuss it in more detail in the next section.
Engaging in good communication
It has been noted that communication is at the heart of both conflict and conflict resolution.8 The lack of effective, open and honest communication creates conflict and creates environments of misunderstanding, mistrust and hostility. Open and effective communication is the means by which disagreement can be prevented, managed or resolved. The health care workplace is a fertile breeding ground for conflict because of the dynamics and interdependency of the various relationships that exist, including those between physicians and other physicians; physicians and nurses; physicians and administrators; and physicians, patients and family members. While it seems obvious that good communication is an essential tool for successful relationships, communication is a skill that many of us do not excel at and yet, at the same time take, for granted. After all, we all know how to talk. However, most of us do not know how to talk so that others will listen, or how to listen so that others will talk.
Listening for understanding is more than just taking in information; it is a multi-layered technique that entails listening without judgment, without planning a response and without devising solutions or offering advice. Truly attempting to understand what is happening for another person requires centring, focus and presence. Taking in information that includes facts, emotions, body language and context enables the listener to develop an understanding of the needs, interests and values of the speaker.10 Listening at this level enables the listener to fully assess the problem before trying to diagnose or treat the situation.
When another person is speaking, we are usually gathering our arguments and thinking up a rebuttal to the points we think the speaker are making. Since we are not really listening, we do not really hear what the other person is saying. As soon as there is a break, we jump in to make the points we have been carefully planning in our heads. Because we have not really heard what the other person has said we are not responding to what he/she said, but rather trying to make points of our own. We cannot listen and think at the same time!
Effective communication should proceed in the following manner:
- Listen fully to what is being said. Do not plan your response.
- While the other person is speaking, listen for insights into what is important to the speaker. What values and beliefs is he/she expressing? At what points does the speaker get energized, upset, angry or sad? What matters to the speaker?
- Check in with the speaker to ensure that you got the message right. Say something like, “I think I heard you say … Is that correct?”
- Pause and think about what else you might need to know.
- Ask further clarifying questions.
- Respond to the speaker.
At this point you are probably thinking that this sounds tremendously formal, as well as impossible and time consuming, and that in our busy health care environment there is no time for this level of interaction. In fact, this technique can be applied to every interaction without an additional commitment of time. This approach may feel uncomfortable at first and it will probably take longer that your usual communication style. However, you will actually understand the underlying issues, which will enable you to address the correct problem rather than solving the wrong one. You will also understand what others are saying and they will understand you. You will ultimately save time, decrease misunderstandings, errors and conflicts, and have better relationships.11
The role of emotion and moral distress in conflict
Unresolved emotion is a critical contributor to the development and exacerbation of conflict between health care professionals and between providers and patients.8 Research has found that residents often experience conflicts because of their inexperience and their place in the hierarchy of the medical care team, particularly when there is disagreement between trainees and senior staff. It has been reported that the ability to deal and cope with these issues changes as physicians proceed through their training. Residents express more frustration and confusion around ethical conflicts in their early years of training, and have reported that support from peers and other residents was most effective in helping them to deal with and resolve these situations.12
While more senior physicians may become accustomed to dealing with ethical issues, the difficulty in handling the emotional tension surrounding ethical dilemmas remains a constant for all health care professionals. The emotional weight of decision-making is not shared with colleagues and is certainly never a topic for discussion at morbidity and mortality conferences, which routinely focus on the medical facts rather than the feelings of the patient or physician.
It is incumbent upon those responsible for postgraduate medical training to include study areas related to recognizing and effectively managing the emotional turmoil involved in ethical decision-making in the curriculum, as well as educational sessions and practical experience related to conflict resolution skills.
Just as crucial is the need for the topics of emotional responses to ethical dilemmas, the resulting moral distress and dealing with the conflict that arises from these issues to be understood and dealt with by those in positions of power within health care facilities and organizations.
We have come to understand that moral distress occurs when health professionals know or think they know the ethically appropriate action to take, but are unable to carry it out for various reasons. Continuing to provide care to a terminally ill patient because the family is refusing to stop treatment is a common situation that creates moral distress for caregivers. There are frequently conflicting views within the health care team, based on differing values and beliefs in what is the “right” or “moral” thing to do for the patient.13 Conflict is the natural result of the collision of these differing values and beliefs. Improving collaboration and communication between and amongst care providers will allow for the positive management and resolution of these difficult situations. Providers may not agree at all times, and yet they can and must learn how to respect and support each other.
Conflict is also created when medical errors occur. Albert Wu has identified the significant impact that critical incidents can have on health care providers. He notes that practitioners rarely receive the kind of support that is needed when an error is made.14 This lack of support, as well as covert or even overt criticism also occurs in the absence of an identified error. Health care professionals have difficulty providing emotional support to colleagues because they feel a need to stay dispassionate and detached. Empathizing with a distressed colleague makes people feel exposed and vulnerable to criticism from others. In addition, as Wu has pointed out, learning of the failings of others allows physicians to transfer or divest their own past errors, thereby making them feel less exposed.14
In addition to the factors noted above, there are other may other unique issues and situations within the health care environment that generate conflict.
- Health care is a classic example of a complex adaptive system. Such systems are prone to generate errors on a regular basis; they are also capable of achieving innovation if the correct conditions are created.
- The complexity of the health care system means that misunderstandings and conflict usually occur on multiple levels at the same time.15
- The health care system involves a wide disparity of knowledge, power and control experienced by various players. While most conflicts involve some disparity between parties, it is unusual for this to be as markedly institutionalized, as is the case in health care.
- The ethnic diversity of both consumers and providers of health care services in many communities is striking and can generate potential barriers to helping parties create solutions. In addition, gender inequalities in health research and the provision of health care are widely acknowledged.
- Health care involves people interacting with other people to repair and preserve the health and personal integrity of patients. Often this involves issues about which people may have strongly held personal or religious values that may seem to be, and often are, irreconcilable.
- Health care professionals face ethical challenges and dilemmas that are not easily or simply resolved. Health care professionals are expected to possess values such as compassion, respect and integrity. They are expected to be patient, non-judgmental and tolerant of those who may make choices in their personal lives that negatively affect their health. They are expected to be understanding when patients and/or their families disagree with the recommended treatment plan, even when the choice or decision to be made in the best interest of the patient is, in the physician’s view, clear.
- Such behaviour on the part of patients often creates strong negative emotional responses such as frustration and anger. Health care professionals must consciously monitor and control their behaviour so that their patients’ needs remain the principal motivation for their actions at all times. In dealing with the anger and frustration that many experiences as a result of unsatisfactory interactions with patients, health care workers often unleash these negative emotions on their colleagues. This is somehow seen as “better than yelling at the patient.”
- Another area that creates conflict within health care workplaces is when colleagues openly criticize each other in front of patients or other colleagues. At all times, health care professionals must project a respectful working relationship with their colleagues. Discussing colleagues in a negative manner in front of patients is clearly unacceptable behaviour and unnecessarily creates a feeling of anxiety and distrust of all health care providers in the patient.
- Expressing negative comments about colleagues also places other health care professionals in a difficult position. They are torn between their desire to avoid conflict, to defend their colleague and to identify that the speaker is behaving in an in appropriate manner. This dilemma is increased if the speaker is in a superior position within the health care hierarchy, for example when one physician criticizes another in front of a nurse or when the Chief of the department criticizes another physician. As Sir William Osler said, “From the day you begin practice never under any circumstances listen to a tale told to the detriment of a brother practitioner … Never let your tongue say a slighting word of a colleague.”16
- Research indicates that when facing conflict situations, especially ethical conflicts, physicians are faced with potentially competing goals. As in many other situations, one of the main goals is to avoid conflict. In pursuit of that goal, physicians may seek assistance in determining that their treatment decisions were supportable. The purpose of seeking such assistance is to protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the treatment discussions and decisions.
Clearly the goals of avoiding conflict, seeking support and protecting one’s own integrity and reputation, as well as the integrity and reputation of others, could conflict with each other or with ethical goals in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively and encourage them to seek ethical consultation more frequently in assisting with the management and prevention of conflict.17
All of these factors combine to make health care environments particularly prone to conflict. It is therefore important for health care professionals and administrators to understand the origins of conflict and to develop strategies to manage the conflicts that they will experience.2
In health care, the use of alternative approaches to conflict resolution has been slow to take hold.2 That situation is beginning to change as people recognize that the conflict resolution methods used to date have largely failed. By and large, these methods have been variations on an adversarial theme, with the result that many parties, including patients, have been left out of the process. Most health care facility risk management efforts adopt the classic “self-protective” stance encouraged by the insurance industry. While concern with the institution’s “bottom line” is not unreasonable, in most cases this approach results in practices that alienate patients and their families, creating major barriers to effective communication.
Many organizations are able to identify the direct costs of conflict, and consider them to be one of the costs of doing business. However, the indirect costs of conflict that exist in health care are hidden and often not recognized. The table below suggests just some of the indirect costs of conflict that are rarely quantified, although they are always in play.
Litigation (e.g., lawyer’s fees, expert testimony depositions, lost work time, transcripts, document production)
Team morale effects (e.g., motivation for organizational change, workplace relationships damaged, ongoing tensions that lead to future conflicts)
Management productivity: time spent on resolving conflicts keeps managers from other work
Lost opportunities for pursuing capital purchases, expanding services, enhancing purchases
Customer satisfaction programs neglected
Training new staff
Staff leaders ignored
Patient condition can deteriorate due to delays in traditional dispute resolution approaches, creating increased costs for care than if disputes were handled more expeditiously
Cost to reputation of organization and of health care professionals
Worker’s compensation claims
Negative publicity, media attention
Regulatory fines for non-compliance
Increased incidence of disruptive behaviour by other staff
Loss of contracts
Culture of poorly managed conflict causes fear; fear leads to non-disclosure and repeat errors; no learning takes place
Emotional costs for those involved
Increased care for patients harmed
Sabotage, theft, damage to facilities
Clearly, the ideas discussed above can be useful in improving health care environments and culture.6 However, organizations may still experience difficulty in putting these ideas into practice. A multi-faceted approach is often needed. The following steps can build conflict management strength within organizations.2,4
Conduct an organizational conflict assessment
Determine how your organization currently deals with conflict. Most organizations deal with conflict through avoidance, power plays, resorting to higher authorities or, less commonly, collaboration. An organization needs to determine which method or option is encouraged and rewarded. High-reliability organizations, that is, those with low rates of medical error, are more likely to use collaboration as the preferred problem-solving method. Organizations need to determine where they are now and where they want to be. They must also identify the current resources available to assist with culture change and decide what extra resources will be required to move toward a culture of conflict management and positive collaboration.
Design a conflict management system that incorporates prevention and early intervention as key components
Staff and patients should have multiple entry points into the conflict resolution process; that is, there should be various ways in which a problem can be handled, including direct contact between individuals, access to senior management or human resources assistance and via identified internal conflict resolution mentors.
The process should be designed with loop-backs throughout. For example, if a patient has an issue with a physician, he/she may wish to first discuss it with the nurse manager. The nurse manager would encourage the patient to loop-back and discuss the matter directly with the physician. If this is unsuccessful, the patient could then access an internal mediator who could bring the parties together to discuss the situation.18,19
Provide training in conflict prevention and management
To ensure that staff, management and physicians are adept at managing conflict, organizations must commit resources to train everyone in basic conflict resolution and communication skills. This training must include opportunities for role playing and group exercises that give individuals practice in dealing with difficult situations. In addition, yearly “touch-ups” should be held so that everyone can renew their skills. Talented internal individuals should be identified to receive additional training to act as internal conflict coaches and mediators. Maintain a roster of these individuals and ensure that their availability is widely known by staff and patients.
Provide ombudsperson services
External ombudsperson services that can be easily accessed should be provided for those situations that cannot be resolved internally. Again this process should provide for a loop-back to the internal conflict coaches to complete the process if the external ombudsperson is able to resolve some of the outstanding issues. From a purely practical point of view, smaller facilities may find an external ombudsperson an economically preferable solution to trying to provide this service in-house.
Provide external mediation services as necessary
A well-developed internal conflict management process should be able to handle most of the conflicts that arise. However, there will still be situations that require the assistance of trained, experienced health care mediators. The goal should always be that disputes will be handled internally, but people should also know that there is expert assistance available if required.
We have looked at some of the myths that exist about conflict and identified realities of the nature of conflict. We have also identified where conflict comes from and the unique characteristics of health care that serve to generate conflict, and we have reviewed the direct and indirect costs of conflict to organizations. Now we turn our attention to the various ways in which individuals react when faced with conflict.
Each of us responds to conflict in a number of ways, and we all use various responses in different ways at different times and with different people. For example, we rarely respond to conflict at work in the same way that we respond to conflict at home. Our approach to a dispute with a colleague is often far different to our approach to a disagreement with a loved one. Once we understand the various approaches and responses that we may have to conflict, we can determine the approach that may work best and try to moderate those approaches that may not be effective.
Various experts have identified the ways that people respond to conflict. One tool that is widely used is the Thomas–Kilmann Conflict Mode Instrument, which identifies five ways in which people respond to conflict: competition, avoidance, compromise, accommodation and collaboration. In general, peoples response to conflict are determined by whether they are more concerned with maintaining or improving relationships with others or whether they are more concerned about themselves and their ability to win.
Each of the various styles is discussed below, with tips on when each should be used and the disadvantages of each approach.
The competing style
- These are the “my way or the highway” people.
- This approach is highly aggressive and minimally cooperative.
When to use
- When it is more important to win than to consider what others may want.
- When quick action is needed.
- For protection in a situation where cooperative behaviour can be exploited.
- Issues will resurface because people do not feel heard.
- There may be silent acquiescence and a possibility of sabotage.
- It can create an environment of fear and lack of transparency.
- There may be reduced learning.
- Feedback from colleagues is unlikely (surrounded by “yes” people).
The avoiding style
- These are the “head in the sand” people.
- This approach is low on assertiveness and cooperation.
- It is unlikely to satisfy anyone’s concerns.
When to use
- When an issue is of low importance and delay is of no consequence.
- To buy time.
- control of the situation.
- Results in a low level of input.
- It is decision-making by default.
- Issues will fester and people will become frustrated at the lack of action.
- Communication breakdowns can result.
The compromising style
- These are the “let’s split the difference” people.
- This approach is moderately assertive and moderately cooperative.
- It moderately satisfies everyone’s concerns.
When to use
- When an issue is of low importance and time-sensitive.
- When both parties are equal and their relationship is not important.
- When temporary solutions are needed.
- Creative, collaborative options remain undiscovered.
- This approach can be seen as feeble or indecisive.
- Real issues are unresolved, so solutions are short-lived and fragile.
The accommodating style
- These are the “whatever you want” people.
- This approach is low on assertiveness and high on cooperation.
- It satisfies other’s concerns and while foregoing one’s own.
When to use
- When you want to show you are reasonable and to create goodwill.
- In situations of little or no long-term importance.
- One’s input risks being ignored.
- People who uses this style frequently may have a restricted level of influence.
- Giving in often may build resentment later.
The collaborating style
- These are the “let’s work it out together” people.
- This approach is highly assertive and highly cooperative.
- It satisfies all parties equally.
When to use
- As often as possible.
- This is the preferred method of conflict resolution.
- It leads to creative, durable outcomes.
- It supports open discussion of issues and equal distribution of work.
- It creates learning positive environments.
- It can take time to develop mutually agreeable outcomes.
- This approach can be overused and lead to frustration for those who need a decision.
Why is collaboration the preferred method?
In most situations, the best outcomes are achieved when the parties involved in the problem work toward resolution in a collaborative way. Using collaboration means that the parties who are in conflict focus on the interests or needs that lie beneath the conflict, rather than focusing on the positions that individuals may be proclaiming. The goal is to work toward a resolution that allows everyone to get what they need, not to try to win or defeat the other person. This approach was popularized in the book Getting to Yes written by Harvard-based professors Roger Fisher and William Ury.20
Interest-based or collaborative approaches include negotiation, mediation and, to a lesser extent, arbitration. You may be familiar with the terms “alternative dispute resolution” or “appropriate dispute resolution,” also known as ADR. When people speak of ADR they are usually referring to processes such as negotiation, facilitation and mediation, as opposed to the legalistic and adversarial approaches that are found in litigation.
In addition to being more timely and cost-effective, using a collaborative, interest-based approach also allows the parties to maintain their relationships and create long-lasting, mutually satisfying outcomes.
Throughout this article we have discussed the importance of recognizing the inevitability of conflict and the advantages of understanding the nature of conflict and its origins. We have discussed the role of communication, provided some examples of the types of conflict that physicians are likely to experience and offered some strategies to enable physicians to become more competent in managing personal and professional conflicts.
If none of the information presented here has created an interest in understanding more about how to manage conflict, perhaps discussing the unquestionable connection between unresolved conflict and the risks to patient safety will provide the impetus needed.
Despite the fact that most health care professionals are dedicated to providing high-quality, effective patient care, the predominating culture of most health care organizations is not one of safety but of fear. Health care professionals fear litigation, professional discipline and coroner’s inquests. Patients fear becoming one of the statistics of the unsafe system that they hear about in the media. Administrators fear bad publicity, lawsuits and increased insurance premiums.21
What this really means is that health care professionals fear being blamed and punished for making a mistake and, most of all, they fear being seen as incompetent. Fear creates anxiety and mistrust, which lead to communication failures and a lack of collaboration and teamwork. The inevitable result is high levels of conflict among and between health care professionals. However, while conflict is a daily, often hourly experience for most health care professionals, it is rarely acknowledged and even more rarely dealt with. As a result, mistrust persists, anxiety grows and conflict increases—creating and perpetuating an unsafe culture.
In this climate of fear, doctors and nurses are loath to report their errors or even their close calls.22 The result is that patient care suffers not only because of error, but also because of what health care professionals do, or do not do, as a result of fear. In a recent study, 76% of physicians reported believing that their ability to care for patients had worsened as a result of medical malpractice fears. Nearly half of all nurses (43%) said they felt prohibited or discouraged from doing what they thought was right for the patient because of rules or protocols set up for legal liability protection. Only one-quarter or fewer of physicians, nurses and hospital administrators said that their colleagues were “very comfortable” in discussing adverse events or uncertainty about proper treatment with them.23 Other research has shown that organizational and individual barriers to communication create underreporting and self-blame as a response to error rather than system improvement.24,25 Fear creates shame, which leads to silence and missed opportunities for learning, change and improvement.
All of this unspoken fear and anxiety creates an environment of disarray and dysfunction. This dysfunctional state leads to conflict within disciplines, between teams and between clients and care providers. We know that poor-quality work environments lead to an increase in errors. On the other hand, we also know that positive working relationships within health care teams have a significant effect on the safety and efficacy of the care given to patients.26,27
While the experts in the field of patient safety have identified the need for culture change in order to improve patient safety, little has been written about the fact that a significant contributor to unsafe cultures is the presence of unacknowledged and unresolved conflict.28,29 Ignoring the real and inevitable conflicts that arise in health care is not only costly in terms of personal and professional impacts on health care professionals, but it also creates unsafe organizations and teams and situations that may lead to increased harm and death for the patients we have pledged to help and protect.25,29–32
Get education and training in conflict and conflict management
We have ample and longstanding evidence that communication, collaboration and respect among health care team members are vital components of providing safe, quality care to patients. Yet health care professionals have little or no training in—or understanding of—the factors that can help to prevent and manage conflict. Health care facilities do not routinely include conflict management as a required competency when hiring staff.
Training and education in conflict resolution can provide health care professionals with skills to help them deal with workplace conflict and, in turn, allow them to provide a safer environment for patients. Conflict resolution education and skills training should be part of all health care professional programs and the continuing education programs of all health care facilities. Training should include an overview of basic conflict principles and approaches, as well as practical skills training in negotiation, mediation and facilitation.
Improve your communication skills
Stephen Covey’s well-known maxim “Seek first to understand, then to be understood”33 may be intuitively logical, but most of us ignore or forget its sensible and sensitive approach, especially when we are in highly charged emotional situations.11 Practise the techniques for good communication outlined in the earlier section “Engaging in good communication” and assess how differently your conversations proceed.
Recognize that men and women have different communications styles and responses to conflict
Over the past few decades, women have made great gains to ensure equality in their personal and professional opportunities. In working hard toward these goals, many have tried to ensure and maintain equality by insisting that men and women are the same.34 While there is no doubt that men and women should have equal opportunities and access to jobs and services, there are some fundamental differences in the way men and women communicate. In the area of conflict resolution particularly, research has indicated that while men adopt the “fight or flight” response to stressful situations, women are more likely to “tend and befriend.”35 In general, women seek each other’s company in times of stress to discuss and share their experiences. Women tend to turn outward, whereas men tend to turn inward.36 It is important for physicians to be aware of and understand the affect gender may have on communication styles and approaches to conflict.
Adopt an AVID approach to others
Health care professionals are not alone in being surrounded by stressful, conflict-laden situations on a daily basis. Our 21st-century lives are packed with commitments and busy schedules; we are all dealing with various demands and requests from employers, colleagues, clients, family and friends. As we have discussed throughout this primer, conflict is inevitable as we attempt to interact and communicate with others. In order to deal with the stress of everyday life, the following simple method of thinking about situations may help you to stay focused and positive in your interactions with others.
A: Assume the positive about others and their behaviour. Assume that they are reasonable and are not trying to cause you grief or pain. Assume that if someone is difficult to deal with, that they have something problematic going on in their life. Assume it is about them and not about you.
V: If you cannot assume the positive then you must Validate the unknown. Talk to the individual and find out what is going on with them. Remember to seek to understand others before you angrily tell them what you think of their behaviour. Validate your negative assumptions about the other person by talking directly to them.
I: If you are unable to assume the positive and you are unable (or unwilling) to validate the unknown by talking to the individual, you must Ignore the unchangeable and let it go. Sometimes, despite our best efforts, we cannot think positively about a person, maybe due to past experiences. There are also times when we can’t talk to a person directly, for example a patient who has been discharged or is deceased. In other situations, we might not want to take the risk of talking to the person, especially if that person is a “difficult” colleague. In these situations it is imperative that you consciously decide to let the matter go. We all pick the battles we will engage in, and there are many times when avoidance is a perfectly acceptable option to choose. One important caveat, however, is that you cannot continually choose to avoid and ignore situations that repeat themselves over and over. At some point you must decide to take action.
D: If you cannot think positively, if you cannot or will not validate the uncertain and if you can no longer ignore the unchangeable, you must Do something productive. If you do not act, the stress of an unresolved situations will build up and inevitably be detrimental to your health and the health of those around you. We can all think of examples of angry, bitter individuals who constantly carry the burden of past hurts and injuries with them, whether these are real or perceived. These are not pleasant people to be around. Do not be one of them! There are a number of things you can do in this situation. Not all of these involve resolving the conflict, but may instead help you to cope with its results.
- Do debrief the situation with a trusted friend and ask for their advice.
- Do discuss the situation and your response with a therapist.
- Do drink something healthy and calming (e.g., herbal tea or a glass of wine), remembering that moderation is key. The overuse of alcohol will only exacerbate problem situations, not help them.
- Do introduce relaxing activities and techniques into your lifestyle. Try walking, riding a bike, hiking, canoeing, yoga or other non-competitive activities.
- Do consider meditation as a way to become more self-aware and positively focused.
Before looking at specific examples of conflict it is important to examine three basic questions:
- Who is affected by the conflict (and, therefore, who should be sitting at the table when efforts are made to resolve the conflict)?
- What are the main issues underlying the conflict? (There are usually more than one.)
- What are the origins of the various issues (e.g., rule-based, interest-based or values-based)?
Who should be sitting at the table?
This is an important question. If the involved players are not all participating in efforts to resolve the conflict then it is unlikely that a satisfactory and durable solution will be reached. However, ascertaining who should be sitting at the table usually requires some reflection on who might have an interest in the various issues underlying the conflict. Frequently, only the obvious “suspects” are included in resolution efforts. This can lead to frustration, wasted time and energy and, ultimately, loss of faith in the process.9
What are the main issues?
This is equally important question with an often equally unclear answer. It is useful to apply our “differential diagnosis” techniques to conflict situations in the same way that we apply them to clinical questions. Once again, the obvious “suspects” often tell only part of the story. Part of the preparation phase of efforts to resolve conflict should include a careful survey of the various issues that may be at stake.
Once the issues have been identified it is important to establish an order of priority, since it is extremely difficult to successfully negotiate more than one issue at a time. The priority of issues may be one of the first items to be negotiated (after collaboratively establishing ground rules for the resolution efforts) by the parties.
What are the origins of the various issues?
Once the parties have established a list of the main issues and reached consensus on the priority listing of the issues, it is helpful to pause and consider the broad basis of the issues. Are the issues primarily centred on disagreement about rules? Do they involve more profound disagreement based on divergent values? Are the issues primarily reflective of differing interests of the parties? The answers to these questions will often involve some overlap. It is nonetheless useful to ask them.
Values-based conflicts or conflicts that raise ethical issues are often challenging to resolve and it may be wise to seek help from a neutral third-party from the outset. Surely all health care providers believe that meeting the needs, values and preferences of the person receiving care should be the primary consideration in the provision of quality health care. However, disagreements frequently occur about the goals of care as well as the route to take to achieve those outcomes. When there are limited resources as well as organizational priorities that must be taken into consideration, it may be difficult to meet patients’ and families’ needs and values. It is precisely because people’s values and preferences are different, and that as a result conflict and disagreements can arise from many sources, that facilities must ensure that they enact flexible and multi-faceted policies for managing conflict.
Rule-based conflict may appear to be simple to resolve by referring to the rules that govern particular situations. Of course, that assumes that all parties feel the rules are relevant and equitable. A purely rule-based conflict may be fairly easy to resolve if all the parties subscribe to the rules.
Finally, interest-based conflict is common and often underlies the other forms of conflict. Resolution requires some understanding of the basics of conflict as well as some experience in the techniques and skills of managing and resolving disputes.28
Examples of Health Care Situations that Can Escalate into Conflict
Example: Challenges in the ICU
ICU beds in a tertiary-care referral centre are urgently needed. One of the patients presently occupying an ICU bed is a 62-year-old man in acute respiratory failure following surgical drainage of an abscess that had caused a bowel obstruction—possibly related to the metastatic spread of an aggressive colon cancer with multiple liver metastases. It is possible that aggressive treatment of the respiratory failure, including intubation, will help the patient to survive for several months.
In preparation for discussing treatment options with the 62-year-old man’s family, the ICU physician urges some “tailoring” of the discussion with emphasis on the probable future discomfort that will be experienced by the patient as his metastatic colon cancer progresses. The surgeon is content to leave the ICU physician to discuss this matter with the family. The nursing staff in the ICU are concerned that this is not entirely correct and want the ethics service involved.
This is an example of a multi-faceted, multi-layered ethical conflict. Everyone involved has a point of view or position that they will argue should take priority. The situation also illustrates the power imbalance between patients and their families and care providers: the ICU physician can adjust the information that is provided in order to increase the likelihood that the patient and his family will make the choice that the physician favours.
In order to resolve this matter in an ethical and fair manner, collaboration between all the parties is advisable. All interested parties, including the patient, family members, nurses, the surgeon, ICU physicians, an ethicist, and a senior administrator, should be at the table. This kind of collaborative discussion will be very emotional and difficult for all parties. It would be helpful to have someone from the ethics service involved as well as a neutral facilitator. Of course, in the real world, there is often not the time or inclination to have this kind of collaborative discussion. This can create unexpressed conflict from other care providers, as well as later difficulties if the family comes to realize there were other options available that had not been offered.
Physician–physician conflicts are commonly reduced to clashes between strong personalities or may even be presented as the playing out of a “dysfunctional personality disorder” on the part of one of the players. While these may be contributing factors, they rarely tell the whole story.
Example: Are we really arguing about 24 square feet of office
Three sub-specialty physicians in a large community hospital are unable to resolve a dispute that has been brewing for more than two years. Ostensibly, the conflict originates in the fact that two of the physicians have offices of 400 square feet in size, while the third has an office of 376 square feet. The hospital is concerned about the impact the conflict is having on patient care.
The three physicians are a 59-year-old who has practiced in the community for 26 years, a 50-year-old who has partnered with the original physician for the past 15 years and a 34-year-old who has joined the group in the past two years. The younger physician is perceived as being “unwilling to fit in.”
After extensive one-on-one discussions between the mediator and the physicians, it is clear that the issues include remuneration, call schedules, vacation schedules, access to patients, willingness to incorporate newer treatment modalities into the practice, relative status within the hospital hierarchy and the nature of the contract describing relations within the group. These are more challenging issues to resolve than disputes about 24 square feet of office space. The physicians are also less comfortable putting these issues on the table.
This example illustrates an interesting web of power and knowledge imbalances. Clinically the three seem to be on a par, all respected sub-specialists. Professionally, the older physician may appear to have more credibility and power related to his many years of service in the community. From a knowledge perspective, the younger physician may bring more current knowledge and practical experience with newer techniques. Ultimately the issues that are feeding this conflict will probably be resolvable by uncovering all of the interests of the parties, and especially finding those areas where the interests converge and common ground can be found. It is quite possible that at the end of the resolution process the three will not become friends. However, that is not the goal of conflict resolution efforts.
On the surface physician–resident/trainee conflicts may appear to be conflicts with a significant imbalance of power, weighted in favour of the staff physician. A careful examination will usually reveal that the residents and trainees in fact have more influence than they might imagine. The circumstances of the conflict may vary, and will often engender significant frustration because they are played out within a framework that has many “unwritten rules” and loaded assumptions. The role of conflict resolution efforts is to bring these elements to the surface so the parties can begin to deal with them openly. This is also a situation where it is easy to “forget” about some parties—such as the postgraduate training institution—whose absence from negotiation efforts may be much like the metaphorical “dead moose on the table.”
Example: Call schedule during an elective
On the request of her residency director, a PGY3 resident is helping with a sub-specialty clinic for two weeks in an area unrelated to her specialty interest. On arrival in the unit she is told she will be on-call one night in three, plus two weekend nights. This is clearly in contravention of the negotiated agreement covering all trainees in that province. The resident points this out and is told very curtly that “In my day we did one in two and got along just fine.” Aside from being “old school,” the staff physician is also on the residency training evaluation committee.
In this example, there is a basis for considering this a rule-based conflict—there is a contract that clearly stipulates what is appropriate. However, underlying the reaction of the staff physician is a strong sense of professional devotion and pride—the basis for a values-driven conflict. Ultimately, gathering more information and involving a third party may lead to an understanding of the interests that are really driving this situation. This is also an example in which the various Thomas–Kilmann Conflict Mode Instrument options can be tested, both in theory and in practice.
Conflicts with other health care providers
Physicians frequently underestimate or are unaware of the extent to which there is perceived conflict in their relations with other health care providers, particularly those who are part of the same clinical unit or team. While there is growing awareness of the importance of the complex care being provided by several members of a team, acting in a coordinated and planned manner, there is still relatively little active training available to physicians about the optimal way in which to participate as a member of a treatment team. This inevitably leads to conflict, and patient outcomes have been shown to be linked to the degree of conflict that exists within a unit and between members of different units as patients move through transition and transfer points in large facilities.37
Example: Drug-seeking behaviour—or not?
A fundamental difference in the assessment of a patient’s request for narcotics during a visit to an emergency department for flank pain leads to a formal complaint by an emergency department nurse about a physician’s prescribing habits. This is countered by a formal complaint about the nurse’s insubordination and refusal to follow physician orders. By all accounts the perceptions are not new and the differences have been apparent for more than a year. It is not clear why this particular patient encounter has become the straw that threatens to break the camel’s back.
Using formal dispute resolution mechanisms (appealing to higher authorities who will make a decision about who is right and who is wrong) is unlikely to result in any significant change in the beliefs or behaviour of either party. This is the kind of situation in which colleagues are inclined to become exasperated and advise the parties to “Get over yourself, already.” However, this kind of persistent irritant has an impact on unit functioning, absenteeism, sick time and patient outcomes. If the conflict is not dealt with and is allowed to fester then the impact will be felt by more than a single patient or a single pair of caregivers. What seems like a simple situation may end up involving a much wider group and result in reconsideration of treatment protocols, performance evaluation processes and even the way in which facility bylaws encourage early resolution of differences that on the surface seem to be matters purely of clinical judgment.
The range of conflict that may develop between physicians and other caregivers reflects in a significant way the “uneven table” (in terms of knowledge, power and control) that is such an inherent characteristic of health care as a complex adaptive system. It is a major challenge for physicians to understand how they are perceived by others who work side by side with them; understanding the inequality that is built into hierarchical organizations is a necessary first step to entering into meaningful dialogue with a goal of resolving conflict in the health care workplace.
Effective communication between physicians and other health care workers is built on a foundation of recognizing the different perceptions of other members of the team. In the same way that physicians tend to underestimate the extent of conflict within a clinical team, they also tend to overestimate the extent of effective communication. This complicates the other imbalances that exist, and makes conflict resolution of issues involving team members more challenging.
Conflict involving patients and families
The ultimate challenge for physicians is the dissatisfied, even combative patient or family member. Strangely enough, the initial source of the conflict is often a disarmingly simple issue—a request for information, an expectation of compassion in the face of difficult life choices, a desire for respect and dignity during treatment. These are not difficult issues to comprehend on a human level and, to their credit, most physicians do an excellent job in dealing with these issues, even when they themselves are coping with severe resource constraints and stresses related to competing priorities within the health care system resulting in inadequate support for patient needs.
When a lack of training and support (e.g., how to conduct difficult conversations with patients) is combined with pressured working conditions and insufficient resources, it is not difficult to understand why simple requests from patients can be misunderstood. Once established, the misunderstanding leads to a lack of trust on one side and defensiveness on the other, and minor irritants are magnified into major challenges that quickly require some expertise to sort out. When these circumstances are then combined with significant patient harm, the tension and stress can be extremely overwhelming for both patient and physician. Simple conflicts that are not resolved lead to resentment at a minimum followed by dissatisfaction and complaints, which may then be followed by more formal escalation of the patient’s unhappiness.
Example: A sore throat that won’t go away
A couple in their twenties visits an active polyclinic. The woman is seen for a vaginal discharge and the man is seen by a physician for a sore throat. A throat swab is taken and the man is advised to wait for the results. He returns within 18 hours because of persistent pain and sees another physician, who prescribes an antibiotic after noting purulent exudates on examination of the throat. The patient returns two days later because of no improvement and is told by a third physician that the antibiotic was unnecessary as the throat swab indicated no bacterial infection. The patient asks who will pay for the rather expensive and unnecessary prescription. A flippant answer is unsatisfactory to the patient.
The woman is called on the fifth day and told that her cultures indicate a Chlamydia infection and that she and her partner require treatment. Prompted by this information, the (male) patient meets with a fourth doctor and an angry exchange occurs between the physician and patient. A formal complaint is made to the licensing body and proceeds for several months through a multi-stage review. Eventually, the polyclinic contacts the patient and suggests a mediated discussion. This is successful, and the complaint is set aside after the patients write a letter expressing satisfaction with the process and the discussion that occurred.
It is not surprising that physicians often inadvertently contribute to misunderstandings when patients are seen as questioning their clinical judgment or expertise. That is probably not the intention of the patient, but it may be perceived that way by physicians who lack formal training in conducting difficult, stressful or emotionally charged conversations. Physicians #1 and #2 might well have unwittingly contributed to the situation by providing unduly brief or succinct information for a common clinical circumstance which seemed quite straightforward. Physician #3 was now in an uncomfortable position of responding to the patient’s complaint about the cost of the “unnecessary” antibiotic. Disclosure discussions after harm to a patient, end-of-life decision-making for a patient’s family and a range of circumstances that understandably are accompanied by emotional overlay for patients constitute major challenges for physicians.37
Even though physicians experience a similar gamut of reactions when they themselves are patients, it seems very difficult for those memories to be recaptured by physicians when dealing with stressed patients who are making demands on their time, personal self-esteem and professional self-image with a series of “pesky” questions. This is the essence of an “uneven table” in terms of the knowledge differential, and the fact that most of the initiating events centre on relatively straightforward requests for information makes the subsequent conflict that develops even more paradoxical.9
One of the factors that appears to be behind physician hesitation about fuller disclosure or more transparent and honest discussions with patients is the fear of litigation. As has been pointed out by Lucian Leape, there is no evidence that disclosure, or even an apology when appropriate, leads to increased risk of litigation.21,38 In Canada, the more serious challenge for those who would urge caution when it comes to a more robust process of conflict resolution in health care (which necessarily involves honest exchanges between patients and physicians) is the steady drop in the total number of law suits naming physicians to levels previously seen in the early to mid-1980s.29
The theme that links the various scenarios outlined above is skilful communication, or lack thereof.8 When dealing with patients, the misunderstandings that arise from less than ideal communication lead to a breakdown in trust and eventually to conflict, which, if neglected, will fester like an occult pathogen, both for the physician and the patient. The trust relationship (which in legal terms is known as the fiduciary relationship) is at the heart of the healing exchange that occurs in providing treatment to patients. When poor communication undermines trust it also undermines the possibilities for optimal treatment and outcomes. All of this leads to conflict, which in the main is avoidable.
When less than optimal communication involves a physician’s colleagues or other health care providers, the result is similar misunderstandings, fuelled by an imbalance in power and control, leading to breakdowns in the bonds that make for good teamwork. The patient suffers directly and the care providers suffer indirectly. Harm is not restricted to the direct participants (the patient and care providers). What is less well appreciated is the tragic harm inflicted on the patient–provider relationship—harm that has consequences far into the future.32
In virtually all of these cases, conflict is avoidable and in all cases it is manageable, if physicians are provided with the knowledge and skills needed to respond to conflicts that arise in health care.
Conflict resolution skills are perfectly suited to the health care field and are easily understood and adopted by health care professionals once they have been explained, demonstrated and practised.
Administrators and academics often doubt that seemingly simple measures such as effective communication, positive collaboration and the involvement of the affected parties can have any measurable effect on health care culture, patient outcomes and job satisfaction. Many health care organizations resist the need to design and implement conflict management processes, and argue that there are already well-defined processes within union agreements, individual contracts or human resources policies.
However, conflict management processes are not used in place of already existing contracts and policies, but as complementary additions. In many instances, conflict resolution processes allow for the early resolution of issues so that other, more adversarial options are not required.
The conflict resolution skills, processes and approaches that are discussed here may appear simple and obvious to many, and yet they are skills that require ongoing education, training and practise. Most people do not communicate effectively, especially when under stress.
Collaboration is often ignored in favour of individual decisiveness, even though such decisions may not create the optimum results. Furthermore, getting all of the parties to the table is avoided for fear of emotional reactions and time-consuming discussions.
Most organizations do not have well-developed conflict management systems in place, even though addressing the issue of conflict management is inherent in improving the culture of health care organizations. Moving away from hierarchical, secretive, blame-focused structures to create cultures of learning and openness requires all of the skills that we have discussed. High-reliability organizations have generally incorporated effective conflict management processes and principles into their fabric and culture. Health care cultures must adopt strategies to manage conflict positively and place a priority on continuing education and training in conflict resolution. Conflict assessment, management and prevention are essential elements for successful culture change within health care.
- Goldberg S, Sander F, Rogers N, Cole SR. Dispute resolution: Negotiation, mediation and other processes. New York: Aspen Publishers; 1999.
- Marshall P, Robson R. Using dispute resolution to resolve health care conflicts: An essential tool in hospital risk management. Risk Management in Canadian Health Care 2003; 4: 73–81.
- Ury W. Getting past no: Negotiating your way from confrontation to cooperation. New York: Bantam Books; 1991.
- Marshall P, Robson R. Conflict resolution in health care: An overview. Interaction 2003; 16.
- Miller R, Sarat A. Grievances, claims, and disputes: Assessing the adversary culture, 15. Law & Society Review 1980–81; 15: 525–66.
- Marshall P. The case for mediation in health care. Conflict Resolution Today: Special HealthCare Edition 2006; 18: 8–12.
- Felstiner W, Abel R, Sarat A. The emergence and transformation of disputes: Naming, blaming, claiming… 15. Law & Society Review 1980–81; 15: 631–54.
- Mayer B. The dynamics of conflict resolution: A practitioner’s guide to clear thinking. San Francisco: Jossey-Bass; 2000.
- Kritek P. Negotiating at an uneven table: Developing moral courage in resolving our conflicts, 2nd ed. San Francisco: Jossey-Bass; 2002.
- Goleman D. Emotional Intelligence: Why It Can Matter More than IQ. New York: Bantam Books; 1995.
- Stone D, Patton B, Heen S. Difficult conversations: How to discuss what matters most. New York: Penguin Books; 1999.
- Hilliard RI, Harrison C, Madden S. Ethical conflicts and moral distress experienced by paediatric residents during their training. Paediatrics & Child Health 2007; 12: 29–35.
- Hamric AB, Davis WS, Childress MD. Moral distress in health care professionals. The Pharos of Alpha Omega Alpha-Honor Medical Society 2006; 69: 16–23.
- Wu A. Medical error: the second victim. The doctor who makes the mistake needs help too. British Medical Journal 2000; 320: 726–7.
- Weick KE, Sutcliffe KM. Managing the unexpected: Assuring high performance in an age of complexity. San Francisco: Jossey-Bass; 2001.
- Silverman M, Murray TJ, Bryan CS, editors. The quotable Osler. Philadelphia: American College of Physicians; 2008.
- Hurst S, Hull S. DuVal G, Danis M. How physicians face ethical difficulties: A qualitative analysis. Journal of Medical Ethics 2005; 31: 7–14.
- Slaikeu K, Hasson R. Controlling the costs of conflict: How to design a system for your organization. San Francisco: Jossey-Bass; 1998.
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- Fisher R, Ury W. Getting to yes: Negotiating agreement without giving in. New York: Penguin Books; 1981.
- Leape LL. Error in medicine. Journal of the American Medical Association 1994; 272: 1851–7.
- Leonard M, Frankel A, Simmonds T, Vega K. Achieving safe and reliable health care: Strategies and solutions. Chicago: Health Administration Press; 2004.
- Common Good. Fear of litigation: The impact on medicine. Harris Interactive; 2002. Available from: http://commongood.org/healthcare-reading-cgpubs-polls-6.html.
- Institute of Medicine. To err is human: Building a safer health system. Washington, DC: National Academy Press; 2000.
- Dekker S. The field guide to understanding human error. Hampshire, UK: Ashgate Publishing Ltd.; 2006.
- Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Critical Care Medicine 2003; 31: 956–9.
- Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE. The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit. Heart & Lung 1992; 21: 18–24.
- Marshall P, Robson R. Preventing and managing conflict: Vital pieces in the patient safety puzzle. Health Care Quarterly 2005; 8: 39–44.
- Robson R. Safety and conflict in health care: A few messy details. Conflict Resolution Today: Special HealthCare Edition 2006; 18: 4–7.
- Baker GR, Norton P. Making patients safer! Reducing error in Canadian health care. Healthcare Papers 2001; 2: 10–31.
- Baker GR, Norton PG, Flintoft V, Blais R, Brown A, et al. The Canadian adverse events study: The incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal 2004: 170: 1678–86.
- Berlinger N. After harm: Medical error and the ethics of forgiveness. Baltimore: Johns Hopkins University Press; 2005.
- Covey S. The seven habits of highly effective people, 2nd ed. New York: Harper Collins; 2004.
- Tannen D. You just don’t understand: Women and men in conversation. New York: Harper Collins; 2001.
- Taylor S. The tending instinct: Women, men and the biology of our relationships. New York: Times Books, Henry Holt & Company; 2002.
- Kolb D. The shadow negotiation: How women can master the hidden agendas that determine bargaining success. New York: Simon & Schuster; 2000.
- Baggs, J.G., S.A. Ryan, C.E. Phelps, J.F. Richeson, and J.E. Johnson. 1992. “ The Association Between Interdisciplinary Collaboration and Patient Outcomes in a Medical Intensive Care Unit”. Heart & Lung 21 (1): 18-24.
- Dubler NB, Liebman CB. Bioethics mediation: A guide to shaping shared solutions. New York: United Hospital Fund of New York; 2004.
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Further Reading and Resources
Conflict (health care)
Joint statement on preventing and resolving ethical conflicts involving health care providers and persons receiving care. Canadian Healthcare Association, Canadian Medical Association, Canadian Nurses Association, Catholic Health Association of Canada; 1998.
Patient safety Institute of Medicine.
Crossing the quality chasm: A new health system for the 21st century.
Washington, DC: National Academy Press; 2001.
Reason J. Human Error. New York: Cambridge University Press; 1990.
Reason J. Human error: models and management. British Medical Journal 2000; 320: 768–70.
The Joint Commission on the Accreditation of Health care Organizations:
Thomas–Kilmann Conflict Management Instrument. Available from: http://web.mit.edu/collaboration/mainsite/modules/module1/1.11.5.html.