Managing Conflict & Negotiation Skills

1. Managing Conflict & Negotiation Skills Drs. Ramesh Mehay & Nick Price Programme Directors (Bradford VTS)

2. Aims • the causal factors leading to conflict • systems and strategies that may prevent it • skills in managing conflict positively

3. Scenario • John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you. • One day, on a home visit to someone else, you see him working in his garden. • You’ve asked him to come in. • Call him in…….

4. What's all the Fuss? "An exhausting consultation between a doctor and a patient which often triggers off some powerful emotions either in the doctor dealing with them, in the patient or both!”

5. And it can affect the next consultation

6. AND

7. You might carry those feelings back home stress, fear, anger, low morale, helplessness • The patient might feel and take them home too ……and that’s not fair nor good for either of you

8. Can you relate to any of this Are you hooked?

9. So, What are we after? • A (patient) lose – lose (doctor) aproach ? • A (patient) win – lose (doctor) aproach ? • A (patient) lose – win (doctor) aproach ? • A (patient) win – win (doctor) aproach ?

10. The Session Plan from here • Causation • Strategies & Skills to Prevent It • Strategies & Skills to Halt Escalation • Recovery strategies when things go really belly up

11. Causation • Individually: take the next 5 minutes to reflect on a emotionally dysfunctional consultation and the factors you think led to it • In trios, pool together your thoughts and discuss new items (flip chart) • Team up with another trio and pool together your thoughts and discuss new items (flipchart)

12. Failing to • ICE • illness vs disease • Missing cues • empathise • Personalities • Language • Egotism Buckets of Shit: Causation ORGANISATION Unidirectional Consultations patient doctor • Before the consultation: • accessibility • conflict with others (other patients, reception) • Doctor running late Patient behaviour that annoys the doctor– Christie & Hofmaster (1986) “Pull Yourself Together” report (2000), Mental Health Foundation) Certain Medical Illnessses- Christie & Hofmaster (1986

13. Doesn’t all this remind you of JoHari’s Window? Things the patient knows Things the patient don’t know Things I know about the patient Arena Blind spot Things I don’t know about the patient Facade Unknown

14. In trios, think about……. • Things you can do to prevent consultations from going bad • How you can recognise things are going bad • What can you now do to try and stop things getting worse (15 minutes)

15. CONFLICT PREVENTION REDUCING THE CHANCES OF CONFLICT

16. The Calgary Cambridge model You can’t go wrong! Look…….

17. INITIATION • Read the patient’s notes • Acknowledge and apologise • for running late etc • “you told me to come in” • Any others? • Establish Rapport – and attend to patient’s comfort (physical, emotional) • Figure out their agenda • Neutralise YOUR feelings • Be aware of your own negative verbal/non verbal cues

18. GATHERING INFORMATION • Explore ICE properly • Figure out the ILLNESSvs disease • Really show EMPATHY • Figure out the patient’s agenda, Identify your agenda, and BLEND the two….(SHARED AGENDA SETTING)

19. EXPLANATION & PLANNING • AVOID PREMATURE REASSURANCE • PITCHING explanation • SHARED planning WITH the patient • CHECK understanding and acceptability (seeking agreement before moving on)

20. Paying attention to your language • Prefacing your remarks “Sounds like…", "So,…", "In other Words…", "You’re saying…" • Avoiding absolute words such as "always" and "never" • Replacing "loaded" words with neutral words. "wastes time"  "takes time to…" • Using words/phrases that have positive connotations "She always wastes time"  "You want to work more efficiently.“ • Reflecting the emotional tone of the message as well as the words eg sound like you feel xxx because of yyyy”

21. Responding to Cues • Verbal/Non-verbal • Suchman 1997: patients seldom verbalise their emotions directly and spontaneously, but tend to offer cues instead • Skills to Consider: Encouragement, Silence, Repetition (echoing), Paraphrasing

22. Following the helical model • ie what I say influences what you say in a spiral fashion (ie what you then say influences whay I say next) • reiteration and repetition • coming back around the spiral of communication at a little different level each time are essential

23. RECOGNISING THE PATIENT WHO’S GOING OFF ON ONE

24. Read the patient continuously • Verbal (HEAR) – tone, pitch, rate, content • I sense that you're not quite happy with the explanations you've been given in the past. Is that right?' • Non-Verbal (SEE) – facial expressions, posture, agitation • 'Am I right in thinking you're quite upset about your daughter's illness?‘ • Check how you are feeling

25. DE-ESCALATING CONFLICT BRINGING A STOP TO ESCALATION

26. Principles • Take a deep breath, stay calm. Neutralise YOUR feelings • Be aware of you own negative verbal/non verbal cues • Don’t fight anger with anger, Don’t be defensive • Look for the reason for the reaction, remember, it’s often not personal • Recognise and accept the feelings as natural and reasonable • Remember that the irrational component of anger may have it origins from previous experiences and you may need to explore this (with care)

27. Specific Communication Skills • Get down physically to the patient’s level • Feedback what you see or hear • Go back and revisit the patient’s framework + other contributory reasons for the anger (INFO GATHERING) • Listen to the patient’s distress • Express empathy, concern and support • Apologise that they feel upset (and mean it!) • Reformulate the main problems for the patient (INFO GATHERING) • Move on with the patient re: possible solutions, ways forward (JOINTLY) = PLANNING • Offer realistic and achievable help (PLANNING)

28. Try it again……… • John is a 54 y old man you have been seeing for low back pain and has been getting repeat sick notes from you. • One day, on a home visit to someone else, you see him working in his garden. • You’ve asked him to come in. • Call him in…….

29. Confrontation with a little C • Sometimes, a little bit of confrontation can be good • eg challenging an attitude, belief or behaviour, to bring something to someone’s attention, an uncomfortable truth • Your aims in this case would be to • Allow the pt to hear and acknowledge you without destroying to Dr-Pt relationship • To address behaviour whilst affirming the patient’s worth as a person • BUT: our own anxiety gets in the way: our past experiences of confrontation (personal and professional) and the present situation lead us to either to sledgehammer or pussyfoot or avoid

30. How DO You Do IT Then? • Be honest, be supportive • Feedback what you have seen or heard directly from the patient – it’s hard to argue with the evidence • BUT • Do this sympathetically…. Heron shows you how…..

31. Heron (1975) says… • Signpost your intent • State what the problem is & the effect it has effect on U and patient, use I statements • State what you would like to happen and why (eg the benefits for both of you) • Make a valueing statement about the person separate the pt’s behaviour from them as a person • Overtly demonstrate your care/empathy • Then give plenty of time, ask about feelings, explain difficulty fo u too, negotiate how to move on (planning)

32. CONFLICT RESOLUTION HOW TO RECOVER A STITUATION THAT’S GONE REALLY BAD

33. Why recover? Let it go??? • It is cost saving • Avoids polarization of parties • It is educative thru understanding • Probes wider issues • It promotes fairness • Gives disputants more control over the dispute process

34. Principles • You may need a “cooling off” period before engaging • Both parties (Dr and Pt) must be willing to participate • Establish ground rules • Ensure both you and patient understand win =win aim; • own volition into engaging, not enforced • No interrruptions whilst other is talking

36. How to Do IT • An agreement to talk about a set agenda • One party speaks without other interrupting healthy venting of emotions, what the problem is for them • Other party paraphrases what they heard • First party corrects any miscommunication • Process repeats the other way round • What does each party need or want to happen…..in light of what’s been said • Boulle, L (2005) Mediation: Principles Processes Practice, Australia, LexisNexis Butterworths

37. Key Message if you resolve conflict positively you can really build upon a foundation of loyalty and trust in the relationship