The Nature of Conflict in Health-Care

Fig. 11.1

Areas of risk for conflict within working relationships
1.

Communication: Communicating about complex issues, especially when distressed, is difficult. Many interpersonal, internal and external factors influence how well we communicate. Some examples include: language, ethnic culture , gender , age, social-status, education, organizational status, organizational culture. Discomfort and common errors in our attempt to hold critical conversations often relate to inaccurate or incomplete understanding of the problem, stereotyping, differences in world-view, and premature foreclosure on solutions without a fulsome attempt to understand the problem. Communication requires effortful processing, especially in stressful situations that often tempt us with resignation to hopelessness or reaction .
 
2.

Emotions: Understanding emotion is important because it both fuels conflict as well as being important in de-escalating conflict [12]. One of the challenges faces in resolving conflict is both understanding and tolerating the expression of difficult emotion . Expressing distress is important for the patient-practitioner relationship as well as for teams wrestling with the challenges of change. There is a narrow pathway between useful expression of difficult emotion and unhelpful polarization of relationships [12].
 
3.

History: People bring their own complex history of experiences to the table when addressing conflict. The way we have successfully and unsuccessfully dealt with conflict in the (immediate and distant) past will present a powerful influence on the present. History is cautions us against seeing conflict in isolation.
 
4.

Values: Conflict becomes more emotionally charged and intractable when it is influenced by differences in core beliefs or by a perception that values are being questioned [12]. Values can be so ingrained as to be ‘invisible’ without careful reflection and often present obstacles to acknowledging the perspective of others. Reflecting explicitly on values can assist people to become more open to different possible resolution pathways.
 
5.

Knowledge: At the simplest level, discrepancies between how people understand a situation or the information needed to make a decision are common knowledge-based issues that drive conflict. Lack of necessary information, being overwhelmed by too much information or misunderstanding information leads to much conflict in patient-practitioner relationships. In teams, holding knowledge (or having expertise) but being excluded from decision-making processes also readily leads to conflict within teams.
 
6.

Interests/Needs: Needs range from primary human survival needs to more latent interests. Misinterpreting needs or interests may lead us along unhelpful resolution pathways. For example, suggesting family counseling for a homeless parent and child is unlikely to be an effective resolution to primary problem driving relational conflict–instability of homelessness.
 
7.

Culture/Organizational structure: The organizational structure and culture provide an important guiding framework for the expression of conflict within relationships and groups—does the culture allow or encourage conflict to be expressed? How is the expression of conflict tolerated? Is hostility permitted or is passivity prioritized? Issues related to available resources, decision-making authority and processes (power), time constraints, communication protocols, and physical settings can play central roles in conflict driving people towards competitive rather than cooperative positions. Group dynamics comprising organizational culture will be discussed later in this chapter. A series of questions, that will help in assessing the nature of conflict are summarized in Table 11.1 [7].
Table 11.1

Conflict assessment
1.
What is the emotion about?
2.
What is the person seeing, feeling or experiencing that I am not yet aware of?
3.
Are there aspects of the person’s culture, ethnicity, gender, age etc. that might be helpful in explaining his/her unique experience?
4.
How do these things fit with what else I know about the person?
5.
Are there any distortions or exaggeration between the event and the person’s experience of the event?
6.
What is the impact of this conflict on the person, their private relationships, their working relationship and other people around the conflict?
7.
How might I assist this person to become more aware of their role in this situation?
8.
Is this person representing any small group alignments that might be having a dynamic influence over this conflict?
9.
What is the contribution of the group’s culture in this event?
10.
What are the options available for containing the distress of the conflict, and what must be carefully considered in avoiding further escalation?
 

Part 2: Conflict at Work

Conflict Between Patients and Practitioners

Patient-practitioner conflict is frequent in an intensive-care environment. For example it is reported that up to 78 % of parent/family-care teams face conflict at some point during the baby’s NICU admission [10]. Poor communication with patients is common and conflict often arises in everyday decision-making. Learning to share difficult and often complex information is essential for hospital staff. However, too often the staff prioritize what to say (content) without understanding the relational process that safeguards the conversation (interpersonal process). Dorr Goold, Williams, Arnold [14] identified features of the patient, practitioner, and wider organization that contribute to common conflict scenarios (Table 11.2).
Table 11.2

Common features associated with conflict in intensive care medicinea
Family Features
Family Features
Understanding complex medical information, adjusting to illness and making critical decisions is influenced by individual differences in
 Longitudinal appraisal of the acute event (i.e. the current episode is usually a small part of a much longer story
 Information obtained from various sources—the media, internet, other practitioners, friends and relatives
 Beliefs about causes, consequences and prognosis of the patient’s condition
 Psychological adjustment to receiving bad news, for example
  Emotional readiness to hear bad news and safe expression of strong negative emotion—guilt, shame, grief etc.
  Coping style—denial, “acopia”, acute stress reaction may lead to attentional biases interpreting information (e.g. avoidance of or hyper-focus on less salient but controllable information; or positive/negative attributions to prognostication
  Education and ability to understand complex medical information and hearing key messages without confusion  Memory retention for bad ness is fraught often leading to repetition of bad news—while ignoring a person’s tolerance for the repetition that may further drive defended responses and escalate conflict
  Differences in meaning of the language of illness (e.g. “death with dignity” or “he seems more alert today”
  Cultural/family beliefs as different from practitioner(s)—often lead to rumour and innuendo, which is grossly unfair to families honestly struggling with situation
Practitioner Features
 Discomfort with prognostic uncertainty leading to hesitation or over-confident responses to treatment and counsel
 Discomfort talking about death, serious injury, long-term disability and confronting ‘medical failure’ or ‘medical impotence’
 Underestimation of quality of life for their patient relative to patients and their families
 Knowledge and skill deficits can catalyze conflict with families, including prognostic inconsistencies, lack of knowledge or experience to manage ethical, legal and policy factors
 Limited interpersonal experience and training required for critical conversations
 Fatigue, frustration, stressed, and otherwise beset with competing obligations
Organizational Features
 Culture of health care to prioritize emergent decisions, technology and speedy discharges may increase emphasis on “high tech” interventions and the avoidance of time-consuming conferences with families
 Training emphasis on procedural techniques
 Economic pressure
 Hospital policies at odds with family of patients (e.g. restricted visiting to control infection) and legislative obligations to write treatment orders (e.g. paperwork), legal ramifications for end-of-life treatments or management of serious injury
aDistilled from Dorr Goold et al. [14]
1.

Communicating Illness: In health-care, conflict often results from people’s attempts to cope with overwhelming stress [15]. Emotion-laden thinking (“hot cognition”) and the ‘social contagion’ (or spread) of extreme negative emotion often precipitate conflict in the absence of any real differences in perspective between parties. We will discuss more about “hot cognition” later in this chapter. Understanding that conflict expressed through relationships is an indicator of distress is important for ‘reading’ the emotional landscape driving conflict and in providing an insight into possible resolution pathways. Resolution in such conflict scenarios is often synonymous with a person’s psychological adjustment to illness .
 
2.

Understanding adjustment to illness: Understanding some principals of psychological adjustment to adverse events is important to the resolution process because it can play a critical role in emerging and escalating conflict. When we talk about a person’s emotional adjustment to diagnosis, poor prognosis or loss what are we looking for? Certainly, there are critical periods in a person’s adjustment to stress when the risk of conflict is higher. And, this can occur between the practitioner and patient, as well as between the members of a patient’s family or members of the caring team as they strive to cope with their emotions . Understanding the relational dynamics of distress and adjustment may better prepare us for preventing conflict with patients. This is especially true when the expression of distress is overwhelming, uncomfortable or “prickly”.
Briefly, it can be helpful to think about a person’s current mental state along a continuum of positive adjustment, rather than pathology. Some people may be quicker, or slower to adjust to bad news . Struggling to accept bad news is simply an unfolding process toward a ‘new normal’ for that person (what does life look like after the death of a partner, or living with cancer or parenting a child with disabilities). Just as in other life changes, equilibrium must be disturbed before a ‘new normal’ (homeostasis) can be achieved. Learning to ‘read’ even the most intense or unusual expressions of distress in this way, may assist us in accurately identifying the issues driving conflict, and assist the patient to absorb information and accept support, to contain their fear.
From this relational perspective, it is important then to differentiate expression of emotion from the meaning of the distress. In this sense, interpersonal interactions can be thought of in terms of ‘layers’ of meaning [16, 17

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Nov 16, 2015 | Posted by in General Dentistry | Comments Off on The Nature of Conflict in Health-Care
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