Conflict Engagement & Emerging Communities of Practice

Conflict Engagement &Emerging Communities of Practice Debra Gerardi, RN, MPH, JD June 2009 Center for American Nurses LEAD Summit

“The basic contribution one can make to one’s community is not to add to the general unconsciousness of the time.” Thomas Moore, Original Self, Living with Paradox and Originality, 2000 2 (c) 2009 All Rights Reserved

Joint Commission Sentinel Event AlertIssue 40, July 9, 2008 Behaviors that undermine a culture of safety Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team. 3 (c) 2009 All Right Reserved

Culture of Safety and Quality, LD 3.01.01 Leaders create and maintain a culture of safety and quality throughout the hospital. Elements of Performance: 4. The hospital has a code of conduct that defines acceptable and disruptive and inappropriate behaviors. 5. Leaders create and implement a process for managing disruptive and inappropriate behaviors. http://www.jointcommission.org 4 (c) 2009 All Right Reserved

Conflict Management, LD 2.04.01 “The organization manages conflict between leadership groups to protect the quality and safety of care.” www.jointcommission.com (c) 2009 Debra Gerardi All Rights Reserved 5

“Authentic accountability, commitment and community come from acts of consent, not acts of mandate or direction.” PeterBlock

ANA Nursing Code of Ethics- Interpretive statement 2.3: Collaboration Collaboration is not just cooperation, but it is the concerted effort of individuals and groups to attain a shared goal. By its very nature, collaboration requires mutual trust, recognition, and respect among the health care team, shared decision-making about patient care, and open dialogue among all parties who have an interest in and a concern for health outcomes. Nurses should see that the questions that need to be addressed are asked and that the information needed for informed decision-making is available and provided. (c) 2009 Debra Gerardi 7

ANA Nursing Code of Ethics Nurses must examine the conflicts arising between their own personal and professional values, the values and interests of others who are also responsible for patient care and healthcare decisions, as well as those of patients. Nurses strive to resolve such conflicts in ways that ensure patient safety, guard the patient’s best interests and preserve the professional integrity of the nurse. (c) 2006 Debra Gerardi 8

“The future hinges on the accountability that citizens choose and their willingness to connect with each other around promises they made to each other.” Peter Block (c) 2009 Debra Gerardi All Rights Reserved 9

Approaches • Enforcement • Power-based, not relational • Focus on right and wrong • At best, leads to compliance, not connection • Engagement • Collaborative • Focus on contribution and learning • Opportunity for resolution, restoration of trust • At best, leads to accountable behavior and connection 10 (c) 2009 All Right Reserved

Conflict Engagement • Conflict engagement refers to the capacity to enter into and address conflicts of various types, at various depths and over differing time frames ranging from short-lived interactions to more complex and protracted disputes. • Not all conflict engagement leads to resolution, however, there is seldom resolution without some level of engagement.

Conflict Engagement “Conflict is dynamic, emergent and contextual.” “Engagement means finding the right level of depth at which to engage.” Bernie Mayer, Beyond Neutrality, 2005 12 (c) 2009 All Right Reserved

Depth of Engagement Address behavior and code of conduct expectations for the future. Address consequences for failing to perform. Address impact of behavior on others, address broken trust, consider apology, acknowledge relational needs of respect, trust, reputation, identity, etc. Allow for emotional processing of the event. 13 (c) 2009 All Right Reserved

Building Conflict Engagement Capacity Collaborative mindset that invites participation Skills for engaging effectively Processes that are non-adversarial and that address the issues and the relationships while expanding options for solutions Systemsarchitecture- processes designed to fit within the culture of the organization; by those who will use them; and that allow emergent solutions that facilitate learning 14 (c) 2009 All Right Reserved

Hickson Pyramid- Vanderbilt No change Disciplinary action / termination Authority intervention/ PI plan Pattern persists Awareness intervention Apparent pattern Single unprofessional event Informal conversation- “cup of coffee” Majority of professionals- no issues Hickson, 2007 (c) 2009 Debra Gerardi All Rights Reserved 15

Conflict Engagement Training Training as intervention There are established foundational skills/ theory Experiential/ skills-based formats Customize to culture/ group Qualifications of trainers Build in assessment 16 (c) 2009 All Right Reserved

Conflict Engagement Specialists Are trained in conflict theory, group dynamics, negotiation and non-adversarial processes such as mediation, facilitation, dialogue, conflict coaching, appreciative inquiry, open space, and other social technologies. May be internal or external to the organization 17 (c) 2009 All Right Reserved

"The path forward is about becoming more human, not just more clever. It is about transcending our fears of vulnerability, not finding new ways of protecting ourselves. It is about discovering how to act in service of the whole, not just in service of our own interests."—Peter Senge (c) 2009 Debra Gerardi All Rights Reserved 18

Emerging Culture… As the shift toward a new way of delivering health services proceeds there is tension created as the old ways of working dissipate and new ways emerge. The challenges that lie ahead are both exciting and daunting. Birthing a new culture requires that we redirect our resources toward strategies for collaborating effectively. Surfacing old assumptions and evaluating their validity in the current environment requires open and reflective conversations across the professions. (c) 2009 All Rights Reserved

Reflective Practice “Reflective practice is the process of exploring a pattern of action, making adjustments during the action, or thinking about past action. It brings knowledge to action in a way that assists in making more informed decisions.” US Institute for Peace (c) 2009 Debra Gerardi All Rights Reserved 20

Double Loop Learning 21 • Single loop learning- respond to an error or undesirable outcome by changing techniques or reinforcing original approaches • Create a code of conduct with stricter enforcement • Double loop learning- reflect on the assumptions or beliefs that underlie the action to begin with and make changes to the underlying assumptions. • 1. It is ok to behave badly if you generate a lot of income; • 2. It is ok to behave badly if you are clinically very good; • 3. It is not ok to speak up or redirect bad behavior because confrontation can lead to exclusion or ostracizing and I should protect my reputation at all costs. • Chris Argyris (c) 2009 All Rights Reserved

Reflecting on our own contribution to difficult situations expands the space around us, And gives us room to make the other person look good.

“In the telling of what most deeply touches our life, others see they are not alone. And in the process both the storyteller and the listeners are healed.” Natalie Goldberg

Narrative Mediation • Focus is on how the person has constructed their story of the conflict and the impact that story is having on them rather than purely the facts or truth of the story. • The story creates the reality for the person and how it is constructed limits how they perceive the situation and the options available to them. • Winslade and Monk, Narrative Mediation, 2008

Story Characteristics • Conclusions/ judgments about the facts, the other person are fixed. • Accusations or attributions of fault or blame are wrapped around the facts • All or nothing thinking • Totalizing descriptions- this version of the story is the total picture- simplified presentation of a more complex situation.

A Conflict Story • We are in this mess because she continues to lie and withhold information. Every time there is an eruption, it is linked to her manipulation and sabotage. • She is targeting our department because she sees us as a threat to her turf and until they get rid of her, there is no way that things are going to work.

Appreciating Impact Mediator: It is clearly important that you are able to rely on the information you receive in order to make decisions and to be able to trust those you work with. Tell me what the impact has been on you of not being able to rely on your colleagues…

Externalizing the Conversation • Externalizing conversations move the story outside the person to give them more opportunity to see it as separate from themselves. • Mediator: • What about this situation has invited you to feel such a strong sense of mistrust? • What other experiences have you had where this has happened? • To what extent is blame stopping you from finding a way through this situation?

Opening Space for a New Story • By honoring and respecting their capacity as creators of the new story, it both empowers and opens the space for what could be possible. • Mediator: • Describe what it was like before things got so bad. • How is it different now? • What is the likelihood that things will return to the way they were given what you have heard today? • How would you like things to be?

Creating Coherence • Mediator: • It seems that this situation has been hard for everyone. • Trying to make sense of something that seems so unfair can be very difficult. Given the information you all have now, what has changed for you? • What helps you to make sense of what has happened? What is the story that you would like to tell after this is all over?

“Fragmentation consists of false division, making a division where there is a tight connection and seeing separateness where there is wholeness. Fragmentation is the hidden source of the social, political, and environmental crises facing the world.” David Bohm

“There are very real conflicts in the world, and the worst of them do not seem to go away. But there is a fantasy abroad. Simply stated, it goes like this: “If we can resolve our conflicts, then someday we shall be able to live together in community.” Could it be that we have it totally backward? And that the real dream should be: “If we can live together in community, then someday we shall be able to resolve our conflicts?” M. Scott Peck (c) 2009 Debra Gerardi All Rights Reserved 32

Communities of practice “Communities of practice are groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis.” Wenger et al., Cultivating Communities of Practice, 2008 (c) 2009 Debra Gerardi All Rights Reserved 34

“The key to creating or transforming community, then, is to see the power in the small but important elements of being with others. The shift we seek needs to be embodied in each invitation we make, each relationship we encounter, and each meeting we attend. For at the most operational and practical level, after all the thinking about policy, strategy, mission, and milestones, it gets down to this: How are we going to be when we gather together?” Peter Block, Community- the Structure of Belonging, 2008 (c) 2009 Debra Gerardi All Rights Reserved 35

“There is no power for change greater than a community discovering what it cares about.” Margaret Wheatley

“Healing may not be so much about getting better, as about letting go of everything that isn’t you - all of the expectations, all of the beliefs - and becoming who you are.” Rachel Naomi Remen

Debra Gerardi, RN, MPH, JD President & Chief Creative Officer, EHCCO debra@ehcco.org Mobile: (650) 303-7313 Office: Toll free (877) 712-1240 Fax: (650) 745-2673 EHCCO, LLC Emerging Health Care Communities (c) 2009 Debra Gerardi All Rights Reserved 38

Conflict Engagement & Emerging Communities of Practice