Mileva Saulo Lewis Ed D RN Professor Emerita

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Agenda for Today • • • Conflict and current events Impact of conflict on patient outcomes Learner’s perceptions about conflict and its impact Learner’s own styles/preferences Learner situations – Woulda, Coulda, Shoulda • Part Two: Conflict and Health Professionals (HPs) • Conflict and HPs • Patient scenario – problem analysis • Theory in action: Nurse leaders and conflict • Part Three: Horizontal/Lateral Violence and Healthcare – May need to defer to another session based on time/needs • Definitions; Experiences; Resources Dr. Mileva Saulo Lewis, All rights reserved • Part One: Learner – Know thyself and your role 2

Relevance to the Staff Nurse in a Professional Role • Leadership at the Point of Care Understand • • • Role of values Professional Role Deliberate decision making models Patient/Family centered care and Relationship Based practice Change and impact upon patients/families, persons working in health care, the system The importance of the use of self (emotional and social intelligence) “In tune with others” Role of leaders and followers Systems thinking – complexity of the work and the health care delivery system New approaches for managing differences to keep patients safe, create healthy work environments, improve quality and outcomes.

Outcomes: Upon completion of this session, learners will be able to: • Determine the “real problem” in a conflict as opposed to how it appears or is felt. • Define conflict engagement and it’s relevance to conflict in healthcare settings. • Advocate in the interest of patient safety using contemporary approaches to conflict engagement. • Analyze a conflict situation for appropriate style of engagement Dr. Mileva Saulo Lewis, All rights reserved • Identify how conflict adversely impacts patients and health care providers 4

Dr. Mileva Saulo Lewis, All rights 5 reserved Questions for which you seek answers

Why we care: Impact Unresolved Conflict • Increased patient mortality (ICU) • Knaus & Draper, 1986 • Patient’s worry about healthcare • Forte, 1997 • Mc. Neese-Smith, 2003 • Lateral Violence, • Griffin, 2005 • Patient Outcomes – VA • Rosenstein & O’Daniel, 2005 • Moral Distress in Medical ICUs • Elpern, Covert, & Kleinpell, 2005 • Silence Kills • Maxfield, Grenny, Lavandero, & Groah, 2010 • Sentinel Event # 40 – Joint Commission – Behaviors that prevent a culture of safety • Crescendo effect • Epstein & Hamric, 2011 Dr. Mileva Saulo Lewis, All rights reserved • RNs leaving the workplace 8

Crescendo Effect Mileva Saulo Lewis All rights 9 reserved Epstein, E. G. , & Hamric, A. B. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 33042. Solid lines indicate moral distress; dotted lines indicate moral residue.

Nursing Code of Ethics • Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. • Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. Dr. Mileva Saulo Lewis, All rights reserved • Provision 7: The nurse, in all roles and settings, advances the professional through research and scholarly inquiry professional standards, development, and the generation of both nursing and health policy. 13

Could there be a middle ground? Another Political View • https: //www. youtube. co m/watch? v=La. ANnxd. XSI o • https: //www. youtube. co m/watch? v=UH 9 r. C 0 Ma. B Jc Dr. Mileva Saulo Lewis, All rights reserved One Political View 14

Defining the issues? • What is the Right of the individual - Self-Determination under the Constitution • When does life begin? • What is a person? Who does the US Constitution project? Dr. Mileva Saulo Lewis, All rights reserved • What is the law of the land regarding abortion? 15

Dr. Mileva S. Lewis, All rights 17 reserved

• • • Reactions - conflict? How do you know? Usual pattern Does it work? What would you like to do? What stops you? (C) Mileva Saulo Lewis, All rights 20 reserved Self-Awareness & Experience

Patient Safety Demands a new approach • Bad or good • About principles or about preferences (what’s good for me and others) Dr. Mileva Saulo Lewis, All rights reserved • A problem to be solved, or a battle to be won • Disch, 2001 21

Defining our Terms Conflict • Coleman, Deutsch, & Marcus, 2014 • Dispute, disagreement, or difference of opinion to the management of a patient involving more than one individual and requiring some decision or action. • Studdert, et, . al, 2003, in Back & Arnold, 2005 Dr. Mileva Saulo Lewis, All rights reserved • Incompatible concerns, interests, actions that prevent, obstruct, interfere with or injure, or make goal attainment less likely 22

Transitions in Conflict Thought Traditional View • Bad • To be avoided • Equated with violence, destruction • Irrationality Interactionist View • Minimal levels can be motivators • Dysfunctional conflicts hinder performance • Task • Relational • Process • Robbins and Judge, 2012

Introduction • • Personal security Identity Safety Relational integrity • Grounds: • Ideological, Identity, personality • Psychodynamic, intellectual difficulties • Skills take the noise out of conflict and facilitate a change in dynamics • Porter-O’Grady & Malloch, 2015 Dr. Mileva Saulo Lewis, All rights reserved • Conflict is normative; Metaphor for differences • Embedded fears are issues of: 24

Patient Safety Demands a new approach • Bad or good • About principles or about preferences (what’s good for me and others) • Disch, 2001 Dr. Mileva Saulo Lewis, All rights reserved • A problem to be solved, or a battle to be won 25

• No one can diminish you unless you give them permission to do so. • Be the change you wish to see; A ‘No’ well uttered from deepest conviction is better and greater than a ‘yes’ uttered to please, or what is worse, to avoid trouble • Our lives begin to end the day we become silent about things that matter. • (C) Mileva Saulo Lewis, All rights 26 reserved Wisdom Through the Ages

• Management is essential • Every conflict is not a contest • There can be more than one winner • Well managed conflict is key • Ability to integrate concern for • Relationships • Outcomes and Productivity Dr. Mileva Saulo Lewis, All rights reserved Conflict is Inevitable 27

• Highest number in which column – There are no right/wrong answers • • • Column one (9/1) Column two (9/9) Column three (5/5) Column four (1/1) Column five (1/9) (C) Mileva Saulo Lewis, All rights 29 reserved Your Modus Operandi TKMI-MODE – Collect data at each table

Thomas-Kilmann ACCOMMODATE (1/9) COLLABORATE (9/9) COMPROMISING (5/5) AVOIDING (1/1) COMPETE (9/1) Dr. Mileva Saulo Lewis, All rights reserved A S S E R T I V E N E S S 31 UNCOOPERATIVE CONCERN FOR OTHERS

Metanalysis-Health Care (1976 -2007) • (USA) Collaborate, Avoid, • (Bahrain) Compromise • Student nurses-Compromise, Compete • Deans-Avoid (USA) Accommodate (India) • Educators – Avoidance • Health Professional Students • RN: Compromise, avoidance • Others: Avoid, compromise, accommodate • 9. 8% Collaborate Dr. Mileva Saulo Lewis, All rights reserved • MDs - Compromise • Staff RNs -Avoid, Accommodate • Nurse Managers- 32

Changing Old Patterns • What do you believe stands in the way? • Supplemental materials – Yoder. Wise • Graphic Terry Deane (C) Mileva Saulo Lewis, All rights 33 reserved • What habit or pattern do you wish you could change?

Theory to the Rescue • Selye-General Adaptation Syndrome • Lewin-Change Theory • ID resistance factors • ID favorable factors • Assign weight or value • Cognitive Dissonance - Festinger • Reduce dissonance • Magnitude • B = F (P & E) • Interest based negotiation/mediation • Ethical theory Dr. Mileva Saulo Lewis, All rights 34 reserved • Flee • Fight • Mediate (Lewis)

Dr. Mileva S. Lewis, All rights 35 reserved When the pain of where you are is greater than the pain to change (Festinger - Cognitive Dissonance)

Dr. Mileva Saulo Lewis, All Rights 36 Reserved Cultural Awareness

Cultural Considerations • High context cultures • E. g. , China, Korea, Japan, Vietnam • Rely on non-verbal & subtle situational cues • Hi importance of verbal agreements • What is not said is as important as what is said • Lo context cultures • Europe and No. America • Spoken and written word • Body language & titles are secondary • Robbins & Judge, 2012 • Cultural Guide • Assume differences until similarity is proven • Emphasize description rather than interpretation or evaluation • Practice empathy • Treat an interpretation as a working hypothesis • Robbins & Judge, 2012

Dr. Mileva Saulo Lewis, All rights 40 reserved. What do you see?

41 A Story: Theory & the Conflict Process Antecedent Conditions: Communication Structure Personal variables Overt Conflict Felt Conflict Robbins, S. (2012). Organizational behavior. (15 th ed. ). NJ: Pearson, Prentice-Hall, p. 196 Conflict-Handling Behaviors: Competition Collaboration Accommodation Avoidance Compromise Decreased Group Performance Dr. Mileva Saulo Lewis, All rights reserved Perceived Conflict Increased Group Performance

The Conflict Process Filey, A. adapted in Robbins & Judge, 2012

Ethics in Practice – Real world conflicts - Students of Nursing • Identify the content (objective) • Identify the emotional component (subjective) Dr. Mileva Saulo Lewis, All rights reserved • Review student scenarios 43

Landmark study: Conflict New Grads (Reality Shock) • Intrapersonal* • Interpersonal *– conflicts with others • Communication styles • Multiple roles • Competing demands • Bureaucratic-Role* – conflicts within organizations • Scarcity of resources • Change • Kramer & Schamlenberg, 1976 Dr. Mileva Saulo Lewis, All rights reserved • Conflicts from within, e. g. expectations and reality 45

More Theory Factors Affecting Outcome (Coleman, Deutsch, & Marcus, 2014 • Expand Escalate • Time to "unpackage“; Reduce to vital few • Provide opportunity for each participant to be heard and understood. • Assist the participants to understand the perspective of the other • Acknowledge emotional, financial costs and benefit of joint resolution • Acknowledge emotions • Recognize Differences • Humanize the participants • Save face • Investment in needs, mutual interests, or concerns • Time to develop • Size & number of issues • Number of motives, goals & values of participants • Size and number of principles and precedents • Costs • Emotions • Perception as Enemy; Loss of face • Investment in a position Cooperative- Constructive Factors Competitive - Destructive Factors Dr. Mileva Saulo Lewis, All rights reserved Reduce and Resolve 46

Ethical Issues Facing Students of Nursing Cameron, M. E. , Schaffer, M. , & Park, H. (2001). Nursing students’ experience of ethical problems and use of ethical decision-making models. Nursing Ethics, 8 (5), 432 -45. Not reporting medication errors Conflicting responsibilities and loyalties Failure to use aseptic technique Quality of life/dying/death Unprofessional conduct of nurses, of physicians Delegation of licensed and unlicensed personnel Deviations from standard practice Medication error due to negligence Withdrawal/withholding treatment Advance directives; D. N. R. Surrogate decision making Dr. Mileva Saulo Lewis, All rights reserved Conflict about the right thing to do Resource allocation 47

Silence Kills • Dangerous shortcuts: • • 84 percent of respondents say that 10 percent or more of their colleagues take dangerous shortcuts. Of those respondents, 26 percent say these shortcuts have actually harmed patients. Despite these risks, only 17 percent have shared their concerns with the colleague in question. • 82 percent say that 10 percent or more of their colleagues are missing basic skills and, as a result, • 19 percent say they have seen harm come to patients. • Shockingly, only 11 percent have spoken to the incompetent colleague. • Disrespect: • 85 percent of respondents say that 10 percent or more of the people they work with are disrespectful and therefore undermine their ability to share concerns or speak up about problems. • And yet, only 16 percent have confronted their disrespectful, colleague. Fortunately, not all • AACN/AORN (2010). www. silenttreatmentstudy. com Dr. Mileva Saulo Lewis, All rights reserved • Incompetence: 51

• Fear of loss of employment • Fatigue & Frustration • Inadequate education • Institutional constraint • Lack of support; power • Retribution • Lack of education • Hanks, R. G. (2007). Barriers to nursing advocacy: A concept analysis. Nursing Forum, 42(4), 171 -177. DOI: 10. 1111/j. 1744 -6198. 2007. 00084. x Dr. Mileva Saulo Lewis, All rights reserved What prevents RNs from carrying out their advocacy role? 52

AACN/AORN: The Good News • They assumed the best, and spoke up. Sometimes it just takes one person to pave the way. • They explained their positive intent—how they wanted to help the caregiver as well as the patient. • They took special efforts to make it safe for the caregiver – to avoid creating defensivenss • They used facts and data as much as possible, often taking the other person into the actual situation Dr. Mileva Saulo Lewis, All rights reserved • When the issue wasn’t urgent, they collected facts, ran pilot tests, and worked behind the scenes. 54

AACN/AORN: The Good News • They avoided telling negative stories or making accusations. • NOTE: None used threats; none showed frustration or anger • • • THEMES of SUCCESS: Spoke up in the past and a patient had been protected RCA – debrief of harm by MDs – new protocol developed Trusting relationship with person they confronted One or more MDs made it clear – they appreciate it when a RN speaks up Dr. Mileva Saulo Lewis, All rights reserved • They diffused or deflected the person’s anger and emotion. 55

Conflict Engagement • Of various types • At various depths, and • Over differing time frames, ranging from short-lived interactions to more complex and protracted disputes. • Mayer, B. (2009). Staying with conflict: A strategic approach to ongoing disputes. San Francisco: Jossey-Bass. Dr. Mileva Saulo Lewis, All rights reserved • The term “conflict engagement” refers to the capacity to effectively enter into and address conflicts: 57

Conflict Engagement This fits with the dynamic and emergent nature of human relationships” • Mayer, B. , 2009 Dr. Mileva Saulo Lewis, All rights reserved “Conflict engagement signifies an ongoing process, not just a one-time conversation. 58

Complexity Science • Cause and effect only is an incomplete theory • Quantum physics – subatomic particles are synchronized, cooperative, and interlinked Dr. Lewis All rights 59 reserved • Paradigm shift from mechanistic dualism to quantum physics • Essential Ingredients – Interconnected Universal Web of Energy • Impact of awareness • Relationship between observer and observed • Koerner, J. (2009). Insight: The application of complexity science in decision making. Creative Nursing, 15(4), 165 -171.

Engagement/Resolution Models • Fisher, Ury, & Patton, 2001 • Conflict Resolution • Separate Problem Solving from Decision Making • ID Needs, Resources, Values • Katz, Lawyer, & Sweedler, 2011. • Mediation • Saulo & Wagner, 2001 • Management Approach • Rigolosi, 2013 • Confront, Search & Cope • Adapted from Lippitt, Saulo Lewis, (1995) • Conflict Engagement • Mayer, 2009 Dr. Mileva Saulo Lewis, All rights reserved • Interest Based Negotiation 60

Change Agents Understand Systems • Open systems – flows and constraints • 1972 - Bertlanfy researching international postal system – WW II Inputs Throughputs Outputs • Social Systems – Seeing the world through interactions - Social groups • Perceptions that shape social interactions • Purpose and goals of the system • Process Systems - Seeing the world from information flow • Living systems – Seeing the world through the interactions of self -creating entities • Senge, P. (1991). The fifth discipline: The art & practice of the learning organization. New York: Doubleday Currency. Dr. Mileva S. Lewis, All rights 61 reserved • • •

Foundations • Selye-General Adaptation Syndrome • • • Flee Fight Mediate (Lewis) • • • ID resistance factors ID favorable factors Assign weight or value • Cognitive Dissonance - Festinger • Reduce dissonance • Magnitude • B = F (P & E) • Interest based negotiation • Ethical theory Dr. Mileva Saulo Lewis, All rights 62 reserved • Lewin-Change Theory

• Between the stimulus and the response there is a space, and in this space lies our power and our freedom • Viktor Frankl – Man’s Search for Meaning • Courtesy, Debra Gerardi, RN, MPH, JD Dr. Mileva Saulo Lewis, All rights reserved Courage to Confront and Engage The Case of Kathryn 63

The Story of Kathryn Three Volunteers • Listen to narrative from the perspective of three stakeholders: • CLASS OBSERVERS: • Identify the substantive (subjective content) from each stakeholder • Identify the emotional content from each stakeholder. • Is there anything that you believe the nurse and the manager have in common? • What is to be negotiated? Dr. Mileva Saulo Lewis, All rights reserved • The Patient • The Nurse Manager representing hospital administration 64

Applied Mediation: Another Model • What do these issues, barriers represent? • Reframe • Listen for • Content - Objective component • Emotional - Subjective component • Reframe your response Mileva Saulo Lewis, All rights 68 reserved. • Hear the Story: Listen under the issues

• “I’m sorry, but I’ve go to sound off to someone and you’re the first one in here. I can’t understand why I’m not getting more care. This is the third day I haven’t had any help with my walking. I’m trying to get better and nobody’s helping me. You call yourselves a helping profession” • Initial response (C) Mileva Saulo Lewis, All rights 71 reserved Patient screams out….

What do I do now? • Emotion • Response (C) Mileva Saulo Lewis, All rights 72 reserved • Content

A Process: Confront, Search, & Cope • Acknowledge • Analyze • Act • Phase II - Search (POLICE) • Prepare, Open, Listen • Interests/others, Collaborate, Evaluate • Phase III - Cope • BATNA, WATNA Dr. Mileva Saulo Lewis, All rights reserved • Not linear - cyclical • Phase I - Confront (AAA) • Lippitt, 1966, Lewis, 1995 73

Acknowledge • • How do you know you’re in a conflict? What bodily signals does your body give you? What theory? What do we know about the long term effects of stress on the body? • Conscious assessment • Ignore at your peril • Saulo, 1995 Dr. Mileva Saulo Lewis, All rights reserved • Somatic Signals 74

• Whose problem? • Shoes of the other? • Risk/Benefit analysis • Stakeholder analysis • Importance • Mutual interests • What happens if you avoid? • CHOICE • Saulo, 1995 Dr. Mileva Saulo Lewis, All rights reserved Analyze 75

• • • Collaborate Bargain Accommodate Avoid Compete Dr. Mileva Saulo Lewis, All rights 79 reserved. Act - Choices

Collaborate • • • Complex issues Synthesize ideas All stakeholders Merge insights Learn Longer lasting resolution - not a quick fix • Creative • Disadvantages • Requires time • Commitment • Process skills • Yoder-Wise, 2013 Dr. Mileva Saulo Lewis, All rights 80 reserved. • Advantages

Compromise/Bargain • Time for cooling off • Other styles have failed • Temporary resolution • Disadvantages • • Power struggles Temporary resolution Win/lose Semi-win, semi-lose • Yoder-Wise, 2013 Dr. Mileva Saulo Lewis, All rights 81 reserved. • Advantages

Accommodate • No time for problem solving • When you’re wrong • Other’s ideas are better • Outmatched, losing • Preserve harmony • More important to the other • Disadvantages • May use to build up “social credits” • Not always a conscious choice • May lead to resentment • Yoder-Wise, 2013 Dr. Mileva Saulo Lewis, All rights 82 reserved. • Advantages

Avoid • • Non-critical issue No chance to “win” Cooling off period Unwilling to reach consensus • Inappropriate time and place • Disadvantages • Unresolved issues are buried • Issue grows • Yoder-Wise, 2013 Dr. Mileva Saulo Lewis, All rights 83 reserved. • Advantages

Compete • Immediate action necessary • Unfavorable outcome is costly • Protect yourself • Threatening situation • Potential to ruin relationship • Power struggle • Win-Lose • Yoder-Wise, 2013 Dr. Mileva Saulo Lewis, All rights 84 reserved. • Advantages • Disadvantages

Professional Agency Personal Agency – Acting: • In the interest of professional standards • When your license is in jeopardy because of others • When personal and professional values are in conflict • This is not optional; it is an obligation - Sec 2725 – Nurse Practice Act Dr. Mileva Saulo Lewis, All rights reserved • In the interest of patient safety 85

BATNA - Evaluate • Is a compromise possible? • How can your losses be minimized? • Can you "live" with a negotiated agreement? • ·What is the status of the relationship? • ·Can the relationship be preserved? WATNA – Evaluate: • ·What is the status of the relationship? • ·Can the relationship be preserved? • ·Do you need to walk away from the table and cut your losses before it gets beyond repair? • Adapted: Fisher, Patton, & Ury, W. (1991). Getting to Yes. . NY: Penguin Books. Dr. Mileva Saulo Lewis, All rights reserved COPE 86

When Buttons Get Pushed (C) Mileva Saulo Lewis, All rights 89 reserved • Remember, you installed them • You can uninstall them

Marcus, Dorn, Kritek, Miller & Wyatt, 1995 (C) Mileva Saulo Lewis, All rights 90 reserved “Resolving conflict is rarely about who is right. It is about acknowledgment and appreciation of differences. ”

Class 23 October • 10 am to 12 Noon • Career Services Seminar • Kathryn Ward, Assistant Director, Student Services • Bring your Resume • Dr. Mileva in Houston –American Society of Bioethics and Humanities Conference 21 October through 25 October • Will answer e-mail as I can

International Institute for Restorative Practice Respond to challenging behavior • What happened? • What have you though about since? • Who has been affected by what you have done? In what way? • What do you think you need to do to make things right? Dr. Mileva Saulo Lewis, All rights reserved • What were you thinking at the time? • http: //www. iirp. edu 95

International Institute for Restorative Practice: To help those harmed by the actions of others • What impact has this incident had on you and others? • What has been the hardest thing for you? • What do you think needs to happen to make things right? Dr. Mileva Saulo Lewis, All rights reserved • What did you think when you realized what had happened? • http: //www. iirp. edu 96

Circles: Sample Topics for Community Building • Check-in-Circle • Check-Out-Circle Dr. Mileva Saulo Lewis, All rights reserved • Getting acquainted • http: //www. iirp. edu • With appreciation to the San Francisco Unified School District at James Lick Middle School 97