Conflict management checklist: a diagnostic tool for assessing conflict in organizations. (PART 1 CONFLICT MANAGEMENT).

CONFLICT INEVITABLY occurs in all work settings because people have different needs, preferences, and values. With the rapid changes in health care delivery and market systems, the opportunity for conflict among health care professionals increases greatly. Roles, incentives, and societal expectations are changing dramatically for most of the health professions, increasing ambiguity and uncertainty. The usual cognitive complexity of work for health care professionals is magnified by the need to redesign systems that increase value, implement new oversight systems, adapt to myriad reimbursement guidelines, and integrate both new knowledge and best practices. The burgeoning regulations of government and payers enhance fear of losing out or not measuring up. And the broad availability of specialized information on the Internet is perceived as an incredible opportunity by some physicians and an unheralded challenge to their cultural authority by others.

Conflict is a natural, inevitable part of life. It is both the constant companion and frequent trigger of change. As Dudley Weeks emphasizes In The Eight Essential Steps to Conflict Resolution, many of our views about conflict are misperceptions, not facts.1 Conflict is not inherently a disruption of order, a negative experience, a battle between incompatible self-interests, a struggle between absolutes, or a sign that a relationship is bad. Rather, we can choose to see conflict as a natural and inevitable consequence of growth and diversity and an opportunity for mutually beneficial change. We can view conflict as a call to understand competing, but not necessarily incompatible, preferences and values. And we can anticipate conflict as a periodic occurrence in any relationship that can be channeled toward growth or dissolution.

Depending on how the conflict is managed, the experience can be growth enhancing for the individuals involved or it can be destructive to relationships and selfesteem. Conflict well managed can tap the creativity and problem-solving skills of colleagues, taking advantage of different gender, cultural, and role perspectives to create mutually beneficial solutions. Conflict poorly managed or consistently avoided reduces productivity, undermines trust, and may spawn additional conflict.

Although the word "conflict' commonly evokes associations with anger, negativity, argument, stress, vulnerability, and battle, conflict itself is never inherently negative. Like so many other experiences in life, conflict is what you make of it. Kenneth Thomas2 and others have noted a family of definitions of conflict, all of which incorporate three themes: (1)

Interdependence of the parties, (2) perceived incompatibility of interests, and (3) some form of interaction. Conflict may be defined as 'the interaction of interdependent people who perceive Incompatible goals and interference from each other in achieving those goals." (3)

Conflict is rooted in beliefs that people hold about their own behavior and the behavior of others. The backgrounds, cultures, values, feelings, and previous experience of the parties to a conflict all influence their individual beliefs and, through their beliefs, their actions. Gender-based differences In communication, for example, may be a flashpoint for conflict. (4) Tensions between male physicians and female nurses, for instance, may be triggered in part by such differences in communication style. The male physician making rounds on hospitalized patients seeks report talk (medical data) and may be impatient when the female nurse engages in rapport talk, providing the data but also elaborating on the patient's feelings and recent family Interactions. He may leave the Interaction grumbling, "Why can't she get to the point" while she bemoans his insensitivity. Thus, uncovering and understanding one's own beliefs is central to the accurate diagnosis and skillful management of any conflict.

Diagnostic approach to conflict

The competent, caring physician would never presume to recommend action in a patient encounter without carefully assessing the person and situation before him or her. Yet we typically rush headlong to "deal" with conflict, propelled by feelings, often bereft of facts. This article introduces a diagnostic checklist, used with several thousand physicians over the last 15 years, which can greatly enhance one's ability to accurately assess any conflict situation. Careful, complete assessment is the prelude to defining an effective approach to managing the conflict.

The Conflict Management Checklist (please see Figure 1) was constructed after a search of the literature for the "how to" of conflict came up short. There was no published diagnostic tool for framing the types of organizational conflicts that plagued our clients. The checklist offers a frame from which to keep both the overall context and the salient details in mind when facing complex organizational conflicts. It was derived from clinical experience, basic psychological principles, the conflict management literature, and common sense. The checklist helps the user keep the big picture in mind as the conflict moves forward in time and clarify appropriate actions and decisions.

Step 1: Identify critical information

Like any good diagnostic assessment, the first step is to take a thoughtful history. In a conflict situation, this means gathering information about the context, the parties involved, and the evolution of the situation, as outlined in Section 1 of the checklist. Defining the conflict situation requires identifying the current pertinent issues and the historical events that seeded the situation. Co beyond the usual, "I said,. .he said" and ask, "What is this disagreement really about and how did we get to this point?"

If you feel drawn into an existing conflict as a new member of a practice group or other health care organization, be sure you understand the history of the situation and the roles and power of the parties before choosing to get involved. Identify the primary players, the people who are in disagreement. Consider also other parties who may have a significant stake in the outcome, especially those who have power by means of positional authority or influence. Which stakeholders might try to influence the behavior of the primary players?

You should also identify other stakeholders affected by the conflict. For example, the hospital or clinic director may have a significant interest in the outcome when procedural specialists are challenging each other over the standard of care and so might try to influence the outcome. And the patients, though unaware of the conflict, may be the most affected by its outcome.

Another category of critical information is organization factors. These include current policies, environmental influences (emergence of new and powerful competitors, financial crisis, pending lawsuit, change in ownership), and relevant working conditions. What policies give some guidance or boundary in the situation? What factors in the workplace or outside environment are influencing the conflict? For example, has the dispute between operating room supervisor and surgeon just emerged since recent reductions were made in the nursing staff or were tensions apparent earlier?

Personal factors, such as values, stress level, self-confidence, religious beliefs, or the use of drugs/alcohol affect the tenor of interactions, Such factors may sabotage or facilitate one's best efforts in conflict conversations. For example, the current level of personal stress or Job satisfaction can color interactions with disputants; one party may unleash frustration at subordinates when the strain really relates to the demands of an aging parent or pressure from an over-controlling boss.

Because anger can be one of the most mismanaged aspects of conflict,5 awareness of one's own anger expression and quickness (or lack thereof) to anger becomes critical in reacting to the tension Inherent to conflict situations. Are you prone to volcanic eruptions of anger, do you simmer slowly without coming to a boil, or are you propelled toward revenge? What are your early warning signals of rising anger-- clenched jaw, tightness in the chest, headache, neck tension? Be aware of the meanings that you attach to the behavior of others, especially those that elicit intense feelings. Do you, for example, interpret finger pointing as condescension or blaming? Knowing what 'trips your trigger' allows you to better manage your reactions.

Step 2: Assess issues and interests

The questions in Section II guide the user to face the realities of the conflict situation, just as the behavioral history guides the patient to see his or her role in maintaining or restoring health.

Whose problem is this? Its not unusual for others to draw you into their conflict. Resist involvement if you are not a primary player or if the issues are trivial. Remember, you are the one to decide whether your involvement is appropriate and warranted. For example, when a conflict situation arises among people you supervise, your role usually should be that of coach, facilitator, or mediator, not participant.

How does my behavior contribute to the dynamics of the conflict? This question demands a great deal of honesty. It requires that you consider the impact of your own behavior on the course of the conflict. Regardless of your Intentions, what behaviors of yours might be contributing to the maintenance or even escalation of the conflict? Is there any small action on your part that might defuse the conflict or move it toward resolution?

The next two questions, (1) what elements of the situation am I able and willing to change? and, (2) what are the time and resource constraints? orient the user to what's changeable and where to most effectively channel personal energy. Much of the heat in conflict stems from pushing against factors that are outside our personal sphere of influence or resisting small changes that could reap big gains. You can choose to change your own beliefs and behaviors and you may ask others to change some behavior. But It Is not reasonable to expect that others will alter their values or attitudes.

What matters most to me/to the other party? gets at the interests of parties and the meanings attached to those interests. Be clear about what you really want in the situation. It is reasonable, for example, for a woman physician to insist on fair treatment in the call schedule, but not realistic to ask a male colleague to abandon personal views about working mothers, Unless you have asked the other party these questions directly, remember that you are making a best guess about their responses. And, of course, avoid involvement in conflict if the issues are not significant to you.

The final question in this section, what is at stake for me/for the other party? helps clarify the significance of the conflict and helps the user determine how much time and energy it warrants. It also helps identify imbalances in stakes that may affect the intensity of the situation. What might each of the parties expect to gain by mutually beneficial resolution of the conflict? What might each stand to lose if it becomes a competitive battle? These last two questions may call attention to shared interests or creative solutions.

Step 3: Act effectively

Section III offers suggestions to increase personal effectiveness in a direct approach to the conflict. Focus on issues relevant to the situation. Make this a short list of the most important factors. A long list will unnecessarily irritate the others at the table and make the task of talking about them too large to accomplish. Let go of the slights that you remember from Interactions years ago. Define the situation in terms of a problem that calls for a solution, not a threat that calls for an attack. (6) Adopting this cognitive frame increases the possibility of constructively influencing the conversation toward resolution. In fact. looking at the conflict as a problem may unleash creative solutions that improve the situation for all parties and stakehoiders beyond expectations.

Acknowledge feelings. Understand that others may be just as frustrated or disturbed by this conflict as you are. You don't give away the farm by recognizing this and by saying so during the discussion. Avoid telling others how they feel. Rather, offer a tentative interpretation ("You seem disgusted..."), then give the other party an opportunity to agree with you or clarify. Most importantly, listen to their feelings without judgment or challenge.

If you are in a position to do so. either by title or relationship, ask for the specific behavior change you want. Avoid vague language like asking for a change of attitude or more efficiency. Be specific about the behavior so that you and the other party will understand what's being asked and can easily observe when change occurs. Too often in health care, we ask others for more accountability, greater cost-effectiveness, a higher standard of care, or more collegiality without agreeing on what behavior is desired or expected. Be clear about what you are willing to do in this situation. It may be as simple as providing resources to more easily get the work done or a willingness to offer positive feedback as the behavioral changes are observed.

Conclusion

All conflicts Involve interaction and the patterns of interaction influence both the development of the conflict and the manner In which it is played out. Using the Conflict Management Checklist will expand your ability to assess conflict situations calmly and rationally. Benefits from using this checklist include: (1) increased self-awareness of one's thinking and behavior in a conflict situation; (2) enhanced understanding of the possible meanings of the conflict for other parties; (3) decreased anxiety around the conflict; and (4) conservation of personal energy by clarifying where active engagement of the conflict is appropriate and realistic.

A thorough diagnostic assessment of the conflict situation Increases awareness of the historic and possible patterns of interaction and lays the foundation for effective strategy to manage conflict. In a subsequent article, the authors will discuss the uses of the five major strategies for conflict management.

FIGURE 1

THE CONFLICT MANAGEMENT CHECKLIST

This checklist is a diagnostic tool for systematically assessing conflicts that arise in organizations.

I Identify the critical information:

A. Define the conflict situation

1. Pertinent issues

2. History of the conflict

3. Primary players

4. Other stakeholders in the conflict

B. Organization factors

1. Current policies/objectives

2. Environmental influences

3. Relevant working conditions

C. Personal factors

1. Personal issues

2. Usual method of anger management

3. Beliefs about behaviors of others that trigger intense feelings

II Ask yourself these questions:

A. Whose problem is this?

B. How does my behavior contribute to the dynamics of the conflict?

C. What elements of the situation am I able and willing to change?

D. What are the time and resource constraints?

E. What matters most to me/to the other party in this situation?

F. What is at stake for me/for the other party in this situation?

III Steps to facilitate your personal effectiveness in a direct approach to the conflict situation:

A. Focus on issues relevant to the situation

B. Define the situation in terms of a problem that calls for a solution, not as a threat that calls for attack (6)

C. Acknowledge feelings

D. Ask for specific behavior change

E. Identify what you are willing to do in the situation

Cathie T. Skiers, PhD, & Carol A. Aschenbrener, MD

References

(1.) Weeks, D. The Eight Essential Steps to Conflict Resolution. Los Angeles, california: Jeremy Tucher, 1992.

(2.) Thomas, K. conflict and conflict management: Reflections and update. J Org Behav 13: 265274, 1992.

(3.) Hocker, J.L. & Wilmot, W.W. Interpersonal Conflict. Dubuque, Iowa: William. c. Brown, 1985.

(4.) Tannen, D. You Just Don t Understand: Women and Men in Conversation. New York, New York: Ballentine Books. 1990.

(5.) Novaco, R.W. The functions and regulation of the arousal of anger. Am J Psychiatry 133: 1124-27, 1976.

(6.) Fisher. R. & Ury. W. Getting to Yes: Negotiating Agreement without Giving In. New York, New York: Penguin Books, 1983.

RELATED ARTICLE: THE ALIGNMENT MODEL

The alignment model is a step above the usual win-win method, where each side has to give up something to get to a solution and people usually don't leave with high regard for the other side. Alignment refers to the state-of-mind with which one approaches the conflict, looking for agreement rather than points of contention.

1. Observe the situation and the people in it without bias, in a neutral, non-judgmental way

2. Set and keep the tone high--build rapport at the beginning, don't approach the problem until everyone is on "the same wavelength."

3. Look for areas of agreement and steer clear of disagreements. Usually when the people involved all feel that they are being listened to non-judgmentally and the problem is not the focus of the discussion, they can rise above it themselves. As areas of agreement become clear, the areas of conflict fade into less importance and the solutions emerge in a way that everyone can buy into.

4. If the discussion is getting bogged down in the problem, take a break from the discussion, even for a few minutes and perhaps as simply as cracking a joke. Getting peoples' minds off the problem allows the solution to emerge.

This is an effective way to resolve conflicts and does not require expending great energy or emotion, yet results in high level solutions.

Marsha Madigan, MD, MPH, is an executive consultant and an Associate Clinical Professor at MSU-CHM in Laingsburg. Michigan. She can be reached via email at [e-mail].

Set Expectations

If you have two reasonable people who will meet with one another, that helps a lot toward resolution, but have found that physicians do not want to "give up" much to resolve an issue, They have memories like elephants and wait for just the right moment to "get even" for something that was "done" to them a long time ago.

The ideal way to deal with these conflicts is for the whole medical staff, led by the medical staff leadership, to set standards that do not allow conflicts to become an issue...easier said than done, as this requires the medical staff leaders to stick their necks out. But, a good set of medical staff officers and department chairs helps a lot, as often they can talk to the conflicting parties on a peer level and set expectations in a collegial manner, generating some respect for these expectations.

Lee P. Van Voris, MD, is Senior Vice President of Medical Affairs at Hamot Medical Center in Erie. Pennsylvania. He can be reached via email at Lee Van [e-mail].

GET YOUR EGO OUT OF THE WAY

* The secret to successful conflict resolution is understanding one's own inner dialogue. I have found most often the main barrier to successful conflict resolution is ones own ego or sense of expectations. Clarifying, by using the fivewhy's behind one's expectations, helps in discovering the root issue.

* A second pearl is recognizing that conflict is our work, not a detraction from "other duties," As long as physicians experience conflict as something to be avoided or as preventing them from "real work." they lose an important perspective--and it leads to burnout." He not busy being born is busy dying" --Bob. Dylan

* A third perspective is what has been called the "five-year view:" Five years from now how important will this issue or event really be perceived, and how would you like to have it recorded as resolved? This comes from the work of Eric Fromm and Victor Frankl's Man's Search for Meaning All too often, the tendency to attribute great significance to events elevates the stakes beyond their real importance. The effect is to enhance power games rather than recognize the relationship and its context. This also speaks of moving from "a point of view" to a "viewing point."

* Treat failure as learning opportunities, not as personal deficiencies.

* The most successful way I've learned about conflict and how to handle it was to be videotaped and then to review the tape with an experienced and trusted colleague. This helped me understand communication behavior, both verbal and non-verbal, and clarify issues. Understanding more about how language is both the vehicle and driver of thought is most helpful in gaining perspective.

A. Peter Catinella, MD, is Assistant Professor and Vice Chair of Clinical Services at the University of Utah. School of Medicine in Salt Lake City He can be reached vie email at [e-mail].

Shuttle Diplomacy 

1. The most successful approach to conflict resolution is conflict prevention. This requires constant monitoring to detect early signs of problems and to intervene before a real "conflict" takes hold.

2. If prevention fails and one is unfortunate enough to have to deal with a full-scale conflict, the most useful advice is to stick to the facts. Facts are powerful as long as they are presented in a non-accusatory way.

3. "Shuttle diplomacy" is also very helpful. To do this, you meet separately with the conflicting parties, identify and understand their real issues, build trust, defuse emotions, and gradually show them that the other party is not as evil or stupid as they imagine--and that the other party really wants a solution. When the time is right, and both sides have been "softened up." then a faceto-face meeting is arranged--generally over a light meal like breakfast.

James E. Casanova, MD, CPE, FACPE, is Associate Dean of Clinical Affairs at the Medical College of Wisconsin in Brook field. He can be reached via email at [e-mail].

Guidelines for Conflict Resolution

1. The credibility of the leadership is imperative. The boss needs to clearly talk and walk the core values of integrity, service before self, and excellence.

2. The senior leadership needs to be seen as committed to resolving problems and becoming personally involved, when necessary. Don't be afraid of getting your fingernails dirty.

3. A fine art is judging between a cooling off period and an incubation period.

4. Never lose your cool. Never speak in anger.

5. Never, in your mind, confuse the issues with the personalities. Just because you and another person see an issue differently that doesn't make the other person a minion of Satan.

6. Think of what you want to accomplish in the long run. You may have significant differences over issues that need to be resolved, but you usually want to be able to maintain a professional relationship with that person.

7. Seek win-win solutions where they might be possible. The basic principles of negotiating apply to conflict resolution.

8. Many potentially hostile situations can be avoided or defused early with copious communication The biggest problem in any large organization is the lack of adequate communication...up, down, and horizontally. Make the time to talk to folks, especially if you are initiating change,

9. Never take it personally when people don't lovingly embrace your pet projects. There may be good reasons for their hesitation.

Colonel Lloyd Dodd, Jr., MD, MPH, is Command Surgeon at Peterson Airforce Base in Colorado, He can be reached via email at [e-mail].

Pejournal club

The Physician Executive Journal Club will further explore the theme of Conflict Management and its application to health care. We invite you to join us online from July 15- August 10 to discuss the articles published in this issue, such as the "Conflict Management Checklist," by Cathie T Siders, PhD, and Carol A. Aschenbrener, MD, who will facilitate this discussion. Please log onto the American College of Physician Executives' Website at www.acpe.org to participate.

AUTHORS' BOOK PICK

Working through Conflict: Strategies for Relationships, Groups and Organizations by J. P. Folger, MS. Poole, and R.K. Stutman (New York: Longman, 1997) is an excellent text that is good on theory and strategies in conflict.

Cathie T. Siders, PhD, is a psychologist specializing in organizational consulting and executive coaching She completed mediation certification through the Boston University School of Public Health ("Conflict Resolution Strategies for Health Care" directed by Dr. Leonard Marcus). She can be reached by calling 202/338-1407 or via email at [e-mail].

Carol A. Aschenbrener, MD, is a Clinical Professor of Pathology at George Washington University Medical Center and a Washington, DC-based consultant. She serves as Chair of the National Board of Medical Examiners. She can be reached by calling 202/298-2800 or via email at [e-mail].