■ Physician-team:

Leveraging the power of collaboration to foster safe care

Dealing with conflict

Two physician-colleagues arguing about test results. They are protected with face masks and gloves.

Addressing conflict promotes safe medical care

Published: May 2021
11 minutes

Introduction

Conflict is inevitable in our professional lives and can involve patients, families, physician colleagues, other healthcare professionals, and administrators. Well-managed conflict can lead to the discovery of broader perspectives or the identification of constructive changes, as well as opportunities to learn and to improve communication, processes, and interactions. By contrast, mismanaged conflict can undermine the creation or maintenance of a psychologically safe environment and can adversely affect the safety of medical care.

In rare instances, conflict can be so intense as to create an unsafe situation. If you feel you are in danger, leave the area and call for help. It is appropriate to call hospital security or police in cases of perceived imminent danger. This section provides considerations and good practices to manage conflict where there are no imminent threats to safety.

Psychological safety

Psychological safety is a shared belief that anyone on the care team can speak up and share their opinion respectfully without fear of retribution.1 In a psychologically safe environment, all individuals feel safe to:

  • ask questions without fear of being labelled ignorant
  • ask for feedback without fear of being considered incompetent
  • be respectfully critical of a plan without fear of being regarded as disruptive
  • offer suggestions for improvement without being branded as negative

The importance of managing conflict

Addressing conflict within a team is key to promoting the safety of medical care and achieving a workplace culture that values respect and collegiality. Mismanaging conflict can be detrimental to healthcare providers’ workplace engagement and personal wellbeing and can affect the delivery of safe, quality care to patients by eroding team communication. Conflict can lead to the development of dangerous “workarounds,” such as deviations from procedure or the avoidance of communication with key individuals. It is important to have a plan for addressing conflict and minimizing the risk that conflict may compromise safe patient care.

Good practice guidance

Individuals have different predominant styles of handling conflict. Having awareness of our own inherent tendency to manage conflict in a certain way can be valuable in helping us manage team interactions more effectively. Each conflict resolution style offers advantages and disadvantages and some are better suited to certain situations than others.

Here are some examples of conflict resolution styles:

Avoiding

Useful when:
  • Issues are of low importance
  • A delay is of no consequence
  • You need to buy some time
  • Emotions are so raw that discussion is not possible
  • You already have control of the situation
  • You have little or no power
Downsides:
  • Lack of resolution
  • Issues may fester
  • Others may become frustrated or confused

Compromising

Useful when:

  • Issues are time sensitive but of low importance
  • Parties are equal
  • Temporary solutions are needed
  • Other solutions have failed

Downsides:

  • Everyone may be dissatisfied
  • Real issues are not addressed
  • Solutions may be short-lived
  • Creative, collaborative options may never be found
  • May be viewed as indecisive

Controlling or competing

Useful when:

  • Quick action is required (emergencies)
  • You are the most qualified decision-maker
  • Reaching your goal is more important to you than what others think

Downsides:

  • Others may feel ignored and become resentful
  • Others may never provide feedback
  • Creative solutions may be lost

Collaborating

Useful when:

  • Creative, long-term solutions are required
  • Creating a positive environment is important
  • Sustaining relationships is necessary
  • The issue is too important to permit compromise
  • Exploring or expanding into new areas

Downsides:

  • Time consuming
  • Frustration if used in situations where prompt decision needed

Accommodating

Useful when:

  • Creating goodwill
  • Situations are of limited long-term importance
  • You can’t defend your position
  • Pushing your view would damage the relationship

Downsides:

  • Your input may be ignored
  • Your influence may be restricted
  • You may feel undervalued

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Conflict arises from real or perceived differences in individual needs, interests, or values. Difficult behaviours on the part of patients, families, staff, or colleagues may evoke negative reactions in providers and be perceived as threatening. In order to avoid or manage conflict effectively, providers need to be mindful of their own responses to a perceived threat.

The first step in managing conflict is to know yourself, your biases, and your triggers, and to acknowledge and reflect on your role in the conflict. Your communication and manner are just as important as the other individual’s in influencing the outcome of the conflict. Avoid escalating the conflict, use non-confrontational and non-blaming language, and attend to non-verbal cues. Getting angry, blaming the other individual, or being accusatory usually does little to move the issue toward resolution. In a conflict situation, it is important to convey respect for the individuals involved, to remain calm, and to focus on seeking to understand the reasons for the other individual's behaviour. Pause and consider how best to respond.

Distinguishing positions from interests

In any conflict, parties typically exhibit behaviours or make statements that signal their frustration. Statements like “I won’t take calls anymore!” signals a person’s position: their stance on the matter or their demand. When individuals are entrenched in their position, it may be difficult to explore the issue that lies at the core of the matter in order to find a mutually acceptable solution.

A person’s interest(s) reflect their underlying reasons or true motivation for seeking a mutually acceptable resolution to a conflict: “I am no longer able to be up at night and look after my family and I had a near miss with a recent call situation”. Such reasons are often complex and may never have been fully articulated, even by the individual in question. A person who says “I won’t take calls anymore!” may be signaling that they find it difficult to work in their environment. They may have concerns about their safety, the availability of resources, or a colleague who may be exhibiting bullying or undermining behaviours. Understanding each one of these factors as interests for solving the situation would lead to the identification of very different potential solutions.

Exploring a person’s interests generally leads to the identification of a common understanding of issues, which can then be leveraged to find a lasting solution to the conflict. Exploring the various components that contribute to interests is not easy, however. It requires great trust, courage, and a commitment to working together. Sometimes, only a trained mediator may be able to achieve positive results in finding a way forward in a conflict situation.

We often wait too long to manage conflict. Typically, by the time an issue surfaces and a sense of urgency develops, the work environment has been suboptimal for a long time. Issues have festered, rumours have circulated, behaviours were tolerated, and workarounds were devised until informal accommodations can no longer maintain the status quo and the issue comes to a head. By this point, it is often too late to save the working relationships between colleagues and come to an acceptable resolution. Addressing conflict early and seeking to understand the interests that underlie the other individual’s positions can create opportunities to identify lasting solutions.2 Outside of formal negotiation, we can each seek to move beyond taking positions towards exploring common interests and finding lasting solutions.

Taking ownership of conflict situations and seeking to resolve them quickly is much easier in a supportive, psychologically safe environment that values and promotes interprofessional collaboration and respectful dialogue.

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We all have an expectation of reasonable and courteous behaviour from others. Nevertheless, lapses in civility sometimes occur—both in others and in ourselves. People under stress may become upset and angry, especially when they are fatigued. By taking a step back and with insight, most people recognize their own inappropriate behaviour, regret it, and apologize. Unfortunately, insight is variable and we all have a role to play in respectfully pointing out lapses in others’ behaviour in order to foster insight and signal that inappropriate behaviour will not be tolerated.

What we tolerate, we condone

Creating a culture of respect and collaboration is everyone’s responsibility. Although leaders may be formally tasked with managing unprofessional behaviour, each healthcare professional, as an individual, establishes the culture of the team through the way they treat others and react to witnessing unprofessional behaviour. When it comes to conflict, how we respond to a concerning situation is what creates the culture. Witnessing inappropriate behaviour and not addressing it tacitly condones the behaviour. Conversely, politely speaking up helps surface the issue, opens the way to dialogue, and signals what is and is not appropriate behaviour.

Discuss it over coffee

Because people who behave in an inappropriate manner may not realize the impact their behaviour has on members of their team, it is important to address matters of concern when they occur. This helps turn conflict into an opportunity for learning and growth.

Research has shown that the vast majority of individuals who exhibit an episode of unprofessional behaviour will cease that behaviour if their attention is drawn to the fact that it is affecting others.3, 4 People do not usually intend to create acrimonious work environments; they simply learn to behave in certain ways over time. People will generally judge their own behaviour based on their intent while others will judge the same behaviour based on the impact it has on them. Addressing this “insight gap” is key in helping people who exhibit inappropriate behaviour identify opportunities for personal growth. Unfortunately, avoidance of conflict may often lead to missed opportunities to engage in difficult yet potentially beneficial discussions that can lead to increased workplace harmony.

Except in those rare circumstances where a person’s difficult behaviour is the result of a personality disorder or other psychiatric condition, helping someone develop insight into their impact on others should not be onerous. Such a discussion should take place privately and informally, perhaps over coffee, without intention to argue and convince, but rather as an awareness-raising exercise. The intent should not be to change the person but rather to inform them that their behaviour has been noticed and has an impact on others.

A tiered approach to promoting professionalism can help to manage disruptive behaviour. For example, the Vanderbilt model for addressing disruptive behaviour is based on a tiered intervention pyramid with four graduated interventions.4 A single unprofessional incident may be subject to an informal intervention such as the “cup of coffee conversation” with a colleague. If the behaviour recurs or a pattern is apparent, a documented intervention with the physician’s or provider’s direct supervisor is appropriate. A persistent pattern of disruptive behaviour unresponsive to lower level intervention may require escalation to a higher authority figure, with further documentation and an action plan. Failure to respond to the authority intervention would lead to disciplinary action. Leaders using this or similar tiered intervention models need a fair and balanced process for reviewing allegations of unprofessional behaviour, a follow-up system that includes meaningful and effective conversations, and the skills and authority to conduct interviews.

While a collegial approach may seem simple, it is often difficult to implement owing to the nature of team culture. Healthy conflict management is difficult to support in the absence of a culture that promotes, fosters, and supports speaking up, psychological safety, and learning.

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The following skills are important to de-escalate conflict: active listening, agreeing, acknowledging, apologizing, and acting as a team.

1. Active listening

Active listening is a key skill in de-escalating conflict. Individuals involved in conflict may see issues differently or want different things, but through good communication and a commitment to resolving conflict, one should be able to identify the underlying common interests.

Active listening is a specific communication technique that involves giving the speaker your undivided attention and patiently listening without interrupting. The “active” element involves taking steps to draw out details you may have missed by rephrasing what you think you heard and providing the other party with an opportunity to either confirm your understanding or correct it. Active listening techniques build trust, show concern, and establish rapport. In addition to listening to what is said, observe non-verbal behaviour to notice any hidden meaning. Facial expressions, tone of voice, and other behaviors can sometimes tell you more than words alone.

As you listen, be open, neutral, and withhold judgment. Avoid offering advice or solutions until you have fully understood the interests and needs of the other person. Premature solutions can be frustrating to involved parties, and distract them from clarifying all the thoughts and emotions about the problem. Some people will simply “shut down,” outwardly appearing passive and compliant, but inwardly having disengaged.5

Active listening techniques include:

Communication skills:

  • Ask open-ended questions
  • Ask specific questions for clarification
  • Resist interrupting
  • If it is necessary to interrupt, do so professionally and compassionately5
  • Use “I” statements instead of “you” statements (e.g., “I feel that” vs “you always”)
  • Encourage the expression of concerns
  • Be respectful
  • Wait to give an opinion
  • Employ attentive silences
  • Do not abruptly change the subject

Attentive body language:

  • Utilize posture and gestures that show engagement
  • Employ nonverbal cues such as nodding, eye contact, and leaning forward to demonstrate interest
  • Be aware of your own and others’ facial expressions

Reflecting skills:

  • Paraphrase to show understanding
  • Use brief verbal affirmations like “I see,” “I know,” “sure,” “thank you,” or “I understand”
  • Summarize the major concerns

2. Agreeing

  • Seek common ground
  • Look for potential solutions and possible barriers

3. Acknowledging

  • Acknowledge the other individual’s feelings to demonstrate empathy
  • Be open to the possibility that you may be wrong

4. Apologizing

  • Offer and accept apologies as appropriate

5. Acting as a team

  • Work together without blame or judgment
  • Clarify who is responsible for the next steps

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  1. Know yourself (biases, triggers, etc.)
  2. Be aware of and manage your own role in the conflict
  3. Be proactive in trying to prevent and resolve conflict
  4. Reflect on the situation, process, and desired outcomes
  5. Create a safe environment in which to address conflict
  6. Clarify needs and identify interests underlying positions on all sides of the conflict
  7. Be flexible in assessing the options and in problem solving
  8. Manage the impasse with calm, patience, and respect
  9. Know when to ask for help
  10. Encourage creative problem solving

Managing conflict is particularly challenging when the other individual is angry, aggressive, intimidating, or threatening. Little can be done to change another person’s feelings and behaviours. Conflict, however, requires two people. You are in control of your own actions, feelings, and behaviours. Instead of seeking to change others, focus on exploring your role and your biases and their contribution to the conflict. It may be that, in times of conflict, you will need to “take the high road” to de-escalate the situation.

Anger is typically a secondary emotion. By understanding what is underlying an individual's anger, physicians can learn to confidently negotiate many of these situations. When the other individual is agitated and confrontational, remaining calm and speaking politely in a soft voice often helps to defuse emotions. Strive for discussions that are non-judgmental and that take place in a safe environment.

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Checklist: Dealing with conflict

Addressing conflict effectively promotes a culture of respect and dignity

To manage your role in conflict, have you:

  • Addressed the issue in a timely fashion?
  • Reflected on your contribution to the situation?
  • Reflected on whether your intrinsic conflict resolution style is suited to the situation?
  • Remained calm?
  • Been patient?
  • Been respectful?
  • Been inquisitive? There is a reason why this conflict exists.
  • Moved to a private and safe environment for discussion?
  • Encouraged the expression of concerns?
  • Focused on underlying needs, interests and concerns instead of positions?
  • Used “I” statements rather than “you” statements?
  • Remained open to feedback?
  • Respectfully acknowledged others’ viewpoints?
  • Used nonverbal communication to show you are engaged?
  • Tried to find common ground by:
    • Looking for shared interests?
    • Considering potential solutions and possible barriers?
    • Reflecting on your own actions?
    • Offering and accepting apologies if appropriate?
  • Established next steps?
  • Clarified accountability for next steps?

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Additional resources

Additional reading

  • Fisher R, Ury W, Patton B. Getting to yes: Negotiating an agreement without giving in. London: Random House Business books, 2012.
  • Patterson K, Grenny J, Mcmillan R, et al. Crucial Conversation: Tools for Talking When Stakes Are High. Maidenhead: McGraw-Hill, 2011.
  • Stone D, Patton B, Heen S. Difficult conversations: How to discuss what matters most. New York: Penguin Books, 1999.


References

  1. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Adm Sci Q. 1999 Jun;44(2):350-383. doi https://doi.org/10.2307/2666999
  2. Boivin D, Lefebvre G, Bellemare S. Natural justice and alternative dispute resolution: their importance in managing physician performance. Physician Leadership and Wellbeing: Canadian Society of Physician Leaders. 6(2). doi: https//doi.org/10.37964/cr24707
  3. Hickson GB, Pichert JW, Webb LE et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine 2007 Nov; 82(11):1040-1048. doi: 10.1097/ACM.0b013e31815761ee
  4. Hickson GB, Pichert JW. One step in promoting patient safety: Addressing disruptive behavior. Physician Insurer. 2010 Fourth quarter:40-43
  5. Mauksch LB. Questioning a Taboo: Physicians' Interruptions During Interactions With Patients. JAMA. 2020;323(17):1704-1705. doi:10.1001/jama.2020.2980
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DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.