Presentation on theme: "Managing Conflict & Negotiation Skills"— Presentation transcript:
1Managing Conflict & Negotiation Skills THERE ARE NOTES ATTACHED TO EACH SLIDE……PLEASE READ THEMDrs. Ramesh Mehay & Nick PriceProgramme Directors (Bradford VTS)
2Aims the causal factors leading to conflict systems and strategies that may prevent itskills in managing conflict positivelyto gain a deeper insight into the causal factors leading to conflictto highlight systems and strategies that may prevent itto gain some skills in managing conflict positively
3ScenarioJohn 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…….Role playIt’s okay if it all goes pear shapedThis is learning and fun at the end of the dayThree groups of 5-6Fishbowl type thing?
4What's all the Fuss? "An exhausting consultation between a doctor and a patient whichoften triggers off some powerful emotions eitherin the doctor dealing with them, in the patient or both!”Hooking the audience into this session
7You might carry those feelings back home stress, fear, anger, low morale, helplessnessThe patient might feel and take them home too……and that’s not fair nor good for either of you
8Can you relate to any of this Are you hooked?From you experiences thus far?
9So, 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 ?William Ury, Roger Fisher and Bruce Patton, Getting to Yes: Negotiating Agreement Without Giving in, Revised 2nd edition, Penguin USA, 1991,The win/win approach demands two commitments:To work towards better solutions that give everyone more of what they really need in the long term.To engage in as much consultation and joint decision-making as the situation will allow.
10The Session Plan from here CausationStrategies & Skills to Prevent ItStrategies & Skills to Halt EscalationRecovery strategies when things go really belly up
11CausationIndividually: take the next 5 minutes to reflect on a emotionally dysfunctional consultation and the factors you think led to itIn 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)SnowballingGet them either to present the flip chart or shout them out and we list them on a flip chartExercise should take 15 minutes
12Buckets of Shit: Causation Failing toICEillness vs diseaseMissing cuesempathisePersonalitiesLanguageEgotismBuckets of Shit: CausationUnidirectional ConsultationspatientdoctorBefore the consultation:accessibilityconflict with others (other patients, reception)Doctor running lateORGANISATIONThis slide is to help consolidate what they learned from the snowballing exercise they’ve just done.Consultations are meant to be a two-way thing (bidirectional). Unidirectional ones can lead to dysfunctional ones.Christie & Hofmaster (1986) “Ethical Issues in Family Medicine”, American BookSuggested :Patient behaviour that annoys the doctor:Characteristics that violate a physicians personal values, even though they are unrelated to the medical condition or progress of therapy eg laziness, seductiveness, malingering, social bludgers – in other words, those that fail to abide by the “hard work ethic” including self sufficiency, achievement, stoicism and persistence in the face of adversity & exerting rational efforts to improve ones’s situation.Characteristics that threaten or impede the course of therapy eg non-complianceCharacteristics that threaten a physician’s authority or prestige eg dr shoppingCharacteristics that impede the dr-pt communication eg stupidityIs the most commonThe Type of Medical IllnessConditions for which there is little hope of a cureConditions for which there is little hope for significant alleviation eg alcoholismConditions that doctors find too challenging eg TATT, headachesConditions which doctors feel it is the patients fault anyway eg syphilis, smoking related diseases, alcohol, ilicit drugsAnd 2. are the most commonPull Yourself Together Report (2000), Mental Health FoundationQuestionairre involving 550 patients suffering from mental illness45% reported discrimination from the GPEg GP says “snap out of it” or “I can only help you if you are suicidal!”Hence 1/5th of patients with mental illness feel they cannot talk to their GPRequest for more resources and funding into training GP’s.PERSONALITIESDifferent people have different personalities and characteristicsMathers et al (1996) Sheffield Survey of GP’s65% variance amongst GP’s in their selection of heart sink patientsYou can please SOME people ALL of the time BUTYou can never please ALL of the people ALL of the timeWhat one may regard as difficult, another doctor may not!Reported a 65% variance amongst a set of GP’s in their selection of heart sink patients.Doctors who are more likely to label patients as difficult were those that hadGreater percieved workloadLow job satisfactionA lack of counselling/communication skillsA lack of post graduate qualificationsPatient behaviour that annoys the doctor – Christie & Hofmaster (1986)“Pull Yourself Together” report (2000), Mental Health Foundation)Certain Medical Illnessses - Christie & Hofmaster (1986
13Doesn’t all this remind you of JoHari’s Window? Things the patient knowsThings the patient don’t knowThings I know about the patientArenaBlind spotThings I don’t know about the patientFacadeUnknown
14In trios, think about…….Things you can do to prevent consultations from going badHow you can recognise things are going badWhat can you now do to try and stop things getting worse(15 minutes)
15REDUCING THE CHANCES OF CONFLICT CONFLICT PREVENTIONREDUCING THE CHANCES OF CONFLICTBrainstorm what others hadNo need to flip chart as the slides will hopefully pool things together
16The Calgary Cambridge model You can’t go wrong! Look…….
17INITIATION 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 agendaNeutralise YOUR feelingsBe aware of your own negative verbal/non verbal cues
18GATHERING INFORMATION Explore ICE properlyFigure out the ILLNESS vs diseaseReally show EMPATHYFigure out the patient’s agenda, Identify your agenda, and BLEND the two….(SHARED AGENDA SETTING)
19EXPLANATION & PLANNING AVOID PREMATURE REASSURANCEPITCHING explanationSHARED planning WITH the patientCHECK understanding and acceptability (seeking agreement before moving on)PREMATURE REASSURANCE This is when reassurance is given before adequate information has been obtained, before patients’ concerns have been discovered and before rapport has been developed. Unless we obtain sufficient information first, reassurance may sound false. Unless we understand our patients’ fears, we may be addressing the wrong concern. Unless we have developed rapport with the patient, reassurance may well be interpreted as indifference or as being dismissive. And lastly, unless appropriate and relevant information is provided to back up our reassurance, patients will not understand the basis for our assertions (Kessel 1979).Reassurance should beappropriately timed ie not before you’ve done enough information gathering (clinical history + ICE) and examinationproperly explained (why you think it so) andmatched to the patient’s concerns. Sometimes, without further investigation, it is difficult to reassure the patient about a specific disease. However, we should still be able to reassure that we will give careful attention to their concerns.
20Paying 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 wordseg sound like you feel xxx because of yyyy”Prefacing your remarks with "Sounds like…", "So,…", "In other Words…", "You’re saying…"Avoiding absolute words such as "always" and "never"Replacing "loaded" words that carry emotional messages with neutral words. For example "wastes time" could be rephrased as "takes time to…"Using words and phrases that have positive connotation in the paraphrase. For example "She always wastes time" could be reflected as "You want to work more efficiently."Reflecting the emotional tone of the message as well as the words. A suggested sentence frame to use in reflective listening is: "Sounds like you feel _______ because ______".
21Responding to Cues Verbal/Non-verbal Suchman 1997: patients seldom verbalise their emotions directly and spontaneously, but tend to offer cues insteadSkills to Consider: Encouragement, Silence, Repetition (echoing), ParaphrasingHowever, in most of the consultations, the physicians allowed both cues and direct expressions of affect to pass without acknowledgement, returning instead to the preceding topic, usually the direct exploration of symptoms. With emotional expressions so terminated, some patients attempted to raise the topic again, sometimes repeatedly and with escalating intensity. Conclusion: We need to be able to recognise when emotions may be present but not directly expressed, invite exploration of these unexpressed feelings and effectively acknowledge these feelings so that the patient feels understood. The frequent lack of acknowledgement by doctors of both direct and indirect expressions of affect poses a threat to the doctor-patient relationship.
22Following 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 repetitioncoming back around the spiral of communication at a little different level each time are essential
24Read the patient continuously Verbal (HEAR) – tone, pitch, rate, contentI 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
25DE-ESCALATING CONFLICT BRINGING A STOP TO ESCALATION
26Principles Take a deep breath, stay calm. Neutralise YOUR feelings Be aware of you own negative verbal/non verbal cuesDon’t fight anger with anger, Don’t be defensiveLook for the reason for the reaction, remember, it’s often not personalRecognise and accept the feelings as natural and reasonableRemember that the irrational component of anger may have it origins from previous experiences and you may need to explore this (with care)
27Specific Communication Skills Get down physically to the patient’s levelFeedback what you see or hearGo back and revisit the patient’s framework + other contributory reasons for the anger (INFO GATHERING)Listen to the patient’s distressExpress empathy, concern and supportApologise 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) = PLANNINGOffer realistic and achievable help (PLANNING)
28Try 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…….
29Confrontation with a little C Sometimes, a little bit of confrontation can be goodeg challenging an attitude, belief or behaviour, to bring something to someone’s attention, an uncomfortable truthYour aims in this case would be toAllow the pt to hear and acknowledge you without destroying to Dr-Pt relationshipTo address behaviour whilst affirming the patient’s worth as a personBUT: 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 avoidRole Play – Fish bowl type thingDoctor InstructionsScenario : Sarah Nopes, age 51, morbidly obeseKnown COPD 10 years, still smokes 40 per day – smells of fag ashGetting worse againAlso has arthritis – again worseningCall her inPMH : COPD, Arthritis, Morbid Obesity, non exerciserCall her in……………..(NB You are allowed to offer her any medication you feel fit – antibiotics, already on inhalers)Encourage self help – eg stop smoking, exercisePatient InstructionsDoctor will ask you “How are You” .Response : In an mellow tone : - “As you can see, I’m out of breath doctor. I think I need some more steroids and antibiotics. I’m also a bit fed up of these pains my legs….they’ve been going on for a while and nothing seems to have worked so far”“I need you help doctor to sort it out for me”If depressive symptoms enquired about – respond negatively ie NO to not sleeping, low moods, anhedonia etc etcOnly offer the following information if asked: (again in a MELLOW TONE)Accept any antibiotics, steroids or incrementation of inhalers.If smoking advice offered – “I’ve smoked for years and it aint done me any harm. My grandmother lived til 92 and she smoked all of her life…..so I can’t see that smoking is bad. And there was my aunt and friend too…so I really don’t think that will do anything…..and I gave up for 6 months and it didn’t help then either!”Same for exercise – “ I really don’t feel it would help doctor. Besides, I find it very difficult to exercise now and the local gym charges a fortune..I can’t afford it”If the doctor asks what you want – suggest antibiotics and steroids.You worries: just worried that your chest will get bad if you don’t get antibiotics and steroids….they’ve worked before.PMH : bronchitis, arthtritis ……but you don’t know the specific termsWhen doctor offers a treatment….accept any drug treatment. Reject self help measures……show you are not keen on them. Instead of exercise ask for slimming pills. Keep asking “Can You sort this out”.On Leaving (non-aggressive tone) – “What ever would I do without you doctors to sort my body out”Facilitator InstructionsChest – infective exacerbation of COPD signs. Walks without aid, despite morbid obsesity. Pain control – cocodamol 30/500 qdsPMH COPD, Arthritis, morbid obesityAfter Role Play :What sort of patient is this according to Groves? (discuss definition of Self Help Rejector). Why…what sort of characteristics helped you in your classification?How did she make the doctor feel, can others identify the scenario with their experiences?What factors before the consultation could you identify that might have led to the dysfunctional consultation.What bits of the consultation led to doctor feelingsWhose fault – doctor or patient? Why do they behave the way they do?What good methods did the doctor use to tackle the situation? Any methods of controlling behaviour? Any unhelpful doctor behaviour?Any other methods the audience can suggest of controlling patient behaviour?
30How 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 evidenceBUTDo this sympathetically…. Heron shows you how…..
31Heron (1975) says… Signpost your intent State what the problem is & the effect it haseffect on U and patient, use I statementsState what you would like to happenand why (eg the benefits for both of you)Make a valueing statement about the personseparate the pt’s behaviour from them as a personOvertly demonstrate your care/empathyThen give plenty of time, ask about feelings, explain difficulty fo u too, negotiate how to move on (planning)Abnormal consultationMultiple complaints requiring regular reassurance over minor problemsAbnormal illness behaviour, Abnormal language eg excruciating, violentDoctor shoppingHostilityStrong BeliefsThat something is wrong – “you just haven’t found it!”Demand more services eg referrals and often complain about existing onesFrequent Ix which are negativeSocial DifficultiesJob, home relationshipsChronic DepressionNothing WorksHigh level of denialDR: “Have you tried xxxx” ; PATIENT : “Oh yeah, and it was crap”Refuses to accept behaviour affects illness and not willing to alter such habits
32HOW TO RECOVER A STITUATION THAT’S GONE REALLY BAD CONFLICT RESOLUTIONHOW TO RECOVER A STITUATION THAT’S GONE REALLY BAD
33Why recover? Let it go??? It is cost saving Avoids polarization of partiesIt is educative thru understandingProbes wider issuesIt promotes fairnessGives disputants more control over the dispute process
34Principles You may need a “cooling off” period before engaging Both parties (Dr and Pt) must be willing to participateEstablish ground rulesEnsure both you and patient understand win =win aim;own volition into engaging, not enforcedNo interrruptions whilst other is talking
36How to Do IT An agreement to talk about a set agenda One party speaks without other interruptinghealthy venting of emotions, what the problem is for themOther party paraphrases what they heardFirst party corrects any miscommunicationProcess repeats the other way roundWhat does each party need or want to happen…..in light of what’s been saidBoulle, L (2005) Mediation: Principles Processes Practice, Australia, LexisNexis ButterworthsGet agreement from both people about a basic willingness to fix the problem.Let each person say what the problem is for them. Check back that the other person has actually understood them.Guide the conversation towards a joint problem solving approach and away from personal attack.Encourage them to look for answers where everybody gets what they need.Redirect "Fouls" (Name Calling, Put Downs, Sneering, Blaming, Threats, Bringing up the Past, Making Excuses, Not Listening, Getting Even)Where possible you reframe the negative statement into a neutral description of a legitimate present time concern.
37Key Messageif you resolve conflict positively you can really build upon a foundation of loyalty and trust in the relationship