Conflict has become an increasingly frequent phenomenon in healthcare over the last 20 years. It is upsetting and time-consuming for professionals and patients alike. However, ask doctors and other health professionals how much training they have been given in recognising and managing conflict and the answer is usually none –or, at least, very little.
So Independent Practitioner Today asked medical mediation expert Sarah Barclay to produce this basic toolkit to help navigate those difficult conversations.
1 Acknowledge conflict – don’t avoid it
Ignoring conflict and hoping it will go away can be as detrimental to relationships between doctors and patients as ignoring the symptoms of a disease would be for a patient’s physical health.
Conflict can be the elephant in the room, because acknowledging its presence demands a response and, without the confidence to manage conflict appropriately, it’s often not clear what that response should be.
Acknowledging and naming conflict is the first step to managing it.
2 Understand the triggers for conflict
Being aware of what can trigger conflict with a patient or their family is an important step in preventing it.
These are five key triggers:
Inappropriate use of language: What you say and how you say it can make the difference between conflict and genuine connection with a patient.
Avoid using complex medical jargon. It can leave patients and their families feeling confused and lost, especially if the news is bad.
Speaking too quickly and filling silences with more information leaves little time for what you’re saying to be heard and absorbed.
Writing notes and/or looking at a screen at the same time as speaking to a patient can make them feel they’re not being listened to – or worse, unimportant.
Conflicting messages: Patients and their families often report that they are being told different things by different health professionals, leaving them uncertain about whom to believe and, most importantly, whom to trust.
Try to manage communication as a team, particularly if the seeds of conflict have been sown. This avoids important messages getting lost in translation.
Making assumptions: Labelling a patient or family member as ‘difficult’ is one of the key triggers for conflict.
There are certainly patients or family members whose behaviour is challenging, but describing the situation as difficult or challenging rather than the patient themselves can make a real difference to the way that person is perceived by a treating team.
Labels, once attached, can be hard to remove.
Previous history of unresolved conflict: If a patient or family member has had previous experience of healthcare which has damaged their confidence and trust in health professionals – including medical error, unkept promises or cancelled appointments – this needs careful exploration and authentic apology, where appropriate, in order to prevent further conflict escalation.
3 Recognise the warning signs
When conflict is brewing, conversations start feeling like battles and positions become entrenched –with professionals in one camp and the patient and/or their family in another.
Avoidance can become the norm because professional-patient encounters have become strained and unproductive.
Disagreements about treatment and ‘unrealistic’ expectations are often the cause of conflict, but what seems unrealistic to the professionals – particularly in relation to the limits of medical treatment – may seem very reasonable to patients and their families desperately searching for hope.
Professionals often describe patients and families attempting to ‘micro-manage’ care and label them as ‘difficult’. However, this behaviour – which can feel threatening and frustrating to professionals – is often caused by a loss of trust.
If conflict is left unmanaged at this point, it can escalate significantly and fast, affecting all those involved.
4 Be curious: explore before you explain
Conversations between health professionals and patients often go off course because they focus on the giving or extraction of information rather than the acknowledgement and exploration of emotion, particularly anxiety or fear.
If health professionals are giving information to patients, especially if the news is unexpected or difficult, it is important to allow space in the conversation to explore how that news has been received and to allow time to acknowledge their response.
When time is short – as it all too often is – this can be the part of the consultation which gets left out and it can lead to conflict further down the line, because the patient is left feeling that their understandable emotions have been left unexplored.
5 Avoid premature reassurance
If a patient tells you ‘I’m worried about the operation’, the response will often be ‘You don’t need to worry’ or to tell the patient all about the operation, how expert the surgeons are or how often they perform that particular procedure.
The result can be that the patient feels their fears have been dismissed and genuine concerns left unexplored. It’s called premature reassurance and can be an important trigger for conflict.
Patients often say ‘I told them I was worried about… but they told me not to worry.’
Instead, be confident to ask the obvious question: ‘What is it you’re worried about?’
That question hands the agenda back to the patient, opens up the possibility of a much longer conversation than the available time allows and leads to questions that might feel more difficult to answer.
There are many reasons why a patient might be worried about their operation, but unless those worries are explored, the worry will remain, the patient will feel unheard and potentially serious concerns ignored.
6 Listen to understand – don’t dismiss or try to fix
Many health professionals – doctors particularly – tell us that they have been trained to be problem-solvers, to find solutions, to fix. But the landscape of conflict can require the opposite.
This quote, from the surgeon and author Atul Gawande in his book Being Mortal sums up this conundrum perfectly: ‘I am in a profession which has succeeded because of its ability to fix. If your problem is fixable, we know just what to do. But if it’s not?’
Gawande is writing about the point at which curative treatment is no longer an option, but conflict can also lead us into what feels like unfixable territory.
One of the things we hear patients and their families say is ‘They’re just not listening to me/us.’ Professionals often say the same.
One of the more painful consequences of conflict is that those involved stop being able or willing to listen to each other with genuine compassion.
For professionals, conflict can make them feel as if they’ve failed and that, in turn, can make them feel demoralised and defensive.
Patients feel dismissed and judged. If patients and professionals alike are experiencing similar emotions, it’s not hard to see why conflict can start to take root.
Listening with the intention of exploring and understanding not fixing is a core component of resolving conflict.
7 Don’t be afraid of anger
Where there’s conflict, anger is inevitable, but it’s the response to it which can make the difference between escalation or resolution.
If an angry patient or family member is met with defensiveness, dismissal, avoidance or punishment, the conflict is likely to escalate.
If, however, they’re met with calmness, compassion and a genuine willingness to listen, this is much more likely to result in de-escalation. It’s hard to stay angry when the response is empathic.
That does not mean that professionals should be asked to accept behaviours which cross a threshold and are felt to be unacceptable.
But acknowledging that, in healthcare, anger is frequently triggered by fear, unmet need or expectations can help make it feel less like a personal attack.
8 Prepare yourself
Challenging conversations need preparation.
Who needs to be there, what needs to be explored or agreed, who will facilitate, how will you begin and last, but definitely not least, how are you feeling?
Are you anxious, exhausted, hungry, thirsty? Is this the third difficult conversation you’ve had to have today?
Give yourself time – even if it’s only a few moments – to give yourself a quick MOT before you start that conversation. Clear your head, try to adopt a neutral stance rather than a defensive one.
You don’t have to agree with the patient or family member in front of you, but being willing to listen will go a long way to being able to re-establish trust if it has broken down.
9 Don’t say ‘I’m sorry you feel that…’
Apologies must be authentic if they’re to make a real difference. Telling a patient you’re sorry they feel let down by you or your colleagues can sound patronising and dismissive.
Instead, try ‘I’m really sorry this has happened and that it’s made you so angry/upset/frightened’. This statement acknowledges the impact that the situation has had on them. It doesn’t mean you’re accepting liability.
10 Talk like a human not an institution
Faced with a conflict, the instinctive response of many health professionals can be to ‘armour up’ and adopt a defensive stance.
They might talk about hospital ‘policy’ or tell a patient or family member that they ‘need to calm down’.
Far from resolving the conflict, this approach can have the opposite effect.
Having the confidence to remove your institutional hat and trying to engage on a human level can be the key to making a person feel heard. That, in turn, can begin the process of building trust.
Try saying ‘I can’t imagine what this situation must be like for you, but I really want to try and understand’. It’s surprising how often this can de-escalate a challenging conversation.
Sarah Barclay (right) is director of The Medical Mediation Foundation, www.medicalmediation.org.uk