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CHAPTER 26 Negotiation and Conflict Resolution

Leslie A. Flores, MHA

INTRODUCTION Hospitalists face the potential for conflict every day. They work in highly complex organizations and in order to be successful they must interact effectively with a wide variety of individuals in what is often a challenging, emotionally charged environment. Hospitalists must learn to navigate not only the formal organizational bureaucracy of rules, systems, and processes, but also the informal political hierarchy that influences power and decision making. Often, they must do so with little or no formal training in conflict management at an early stage in their medical careers. In addition, they may encounter conflicts between what others would like them to accomplish and their own workload demands and professional expectations.

Hospital Medicine is also a young, evolving specialty that has enjoyed unprecedented growth by serving the needs of multiple competing stakeholders. Although the specialty is maturing, it is still populated by a high proportion of recent residency graduates and early- career clinicians who may not have a complete understanding of the specialty or even have career advancement on their radar screen. The potential exists for the service obligations—both clinical and in the area of institutional performance improvement—of hospitalists to overwhelm opportunities for professional development, and this may promote career dissatisfaction, turnover, and symptoms of burnout. Leaders of hospitalist services may find themselves isolated as they advocate for the professional development and job satisfaction of group members while meeting the service expectations of their employers or supervisors. The professional medical society for hospitalists, the Society of

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Hospital Medicine, is rapidly developing flexible support resources for hospitalists relating to business and clinical practice, engagement and career satisfaction, core competencies, and role expectations. Until these standards become widely disseminated and health care services become better designed and hence less prone to error, hospitalists will continue to work in a hospital environment where they will increasingly be expected to perform as change agents at a time when change may not be welcomed by their hospitalist colleagues or others at their institutions.

For the purposes of this chapter, it will be important to distinguish between disagreements and conflicts. Disagreements happen regularly in human interactions, and occur whenever two or more individuals have differing opinions about something. A disagreement need not devolve into a conflict, and many do not. Conflicts arise when a party perceives that another party has negatively affected or will negatively affect agendas that the first party cares about. Conflicts are defined as processes that occur when tensions develop, that is, the emotions associated with a disagreement become so elevated that they impede the ability of the parties to interact with each other effectively.

Almost all conflict is a result of unmet expectations. For hospitalists, this commonly arises when there is a lack of understanding or a difference in expectations about their role. Hospitalists may assume that primary care physicians have explained to patients that someone else will be seeing them in the hospital. Patients and families, however, may not understand why their primary care physician is not present in the hospital and directing their care. Emergency Medicine physicians may expect the hospitalist to respond promptly to take a complicated social admission off their hands whereas hospitalists may feel that it is the role of the emergency room physicians to discharge patients who do not require admission. Emergency Medicine physicians and staff may expect for patients be triaged to hospital floors (to reduce emergency department length of stay) before critical information is available, or may expect hospitalists to care for patients in the emergency department when no beds are available. Meanwhile, floor nurses may expect hospitalists to be immediately available to address nonurgent requests. There may be differences of opinion among specialists and generalists regarding diagnosis, workup, and treatment or the role of the hospitalists in comanagement of specialty patients. All physicians expect to be treated professionally, to have some autonomy over clinical decision making, and to have a reasonable work-life balance. Hospital administrators and employers, however, may demand that hospitalists to perform nonphysician tasks or solve problems for other physician groups without taking into account the perspectives of the hospitalists or staffing needs for time-consuming tasks. When such expectations go unmet, people get frustrated or angry. They often respond in ways that then heighten frustration or anger on the part of others. Emotions on both sides become elevated, and the stage is set for a conflict.

PRACTICE POINT

Almost all conflict is a result of unmet expectations. For hospitalists this commonly arises when there is a lack of understanding or a difference in expectations about their role.

The most common reasons that expectations go unmet include:

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Lack of Clarity About What is Expected, or About How the Expectation Will Be Met. It is easy to assume that because one’s expectations are clearly understood by oneself, they are clear to others as well. Hospitalists may assume a patient understands the proposed treatment plan, but the patient or family member may fail to understand the implications for likely discharge plans. Even when expectations are carefully explained, the other party may hear or interpret them differently than the speaker intends. The other party may also react more to the emotional aspect of the discussion or who is doing the talking rather than to the content. Lack of Agreement About What is Expected Or How to Achieve It. The high degree of complexity in error prone health care systems, stress and pressure, and the need for rapid change are important sources of potential conflict. Sometimes each party’s expectations are clearly understood by the other party, but they simply disagree with each other about the desired outcome, the method of achieving it, or both. This can occur if the parties have competing needs or interests. For example, although resident work hour restrictions are clearly delineated in the academic setting, stress and pressure develop for hospitalists when the increased service obligations resulting from such restrictions conflict with their expectation for professional advancement. All parties may agree on the importance of improving patient flow from the Emergency Department to the inpatient floor, but may disagree about the specific methods to be employed by Emergency Medicine physicians, hospitalists, and others to achieve this goal. Changing hospital processes to promote improved quality or greater efficiency often demand changes to hospitalist work flow that are stressful for the hospitalists.

In addition, age, gender, and cultural differences may play a role in the development and management of conflict. A generational gap may result in differences in work expectations, a paternalistic view of who is actually in charge, or resistance to changing to new work requirements. Men and women may have different expectations of their work, and often have different ways of responding to stress, emotion, and conflict. In the United States, men often tend to use a competing or forcing style when faced with conflict, whereas women often tend to use compromising, accommodating, and avoiding.

A key aspect of cultural differences is the degree to which a person tends to identify most strongly with the group of which he or she is a part (a “collectivist culture”) as opposed to identifying with the self (an “individualistic culture”). Individualistic cultures, which are the dominant cultures found in North America and Western Europe, value autonomy, creativity, and personal initiative. Much of the rest of the world is composed of collectivist cultures, which instead value conformity and harmony. A meta-analysis of studies on culture and conflict resolution styles found that people in individualistic cultures tend to choose forcing as a conflict style more often and people who come from collectivistic cultures tend to choose withdrawing, compromising, or problem-solving styles instead.

THE POTENTIAL BENEFITS OF CONFLICT Conflicts are inevitable in human interactions. The increasingly complex and collaborative nature of the work that hospitalists do as team-based care models have emerged increases the risk that interpersonal conflicts may arise. The increasing cost pressures and competition for scarce resources that exist in an era of national health care reform have

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increased stress and opportunities for conflict for all health care professionals. These conflicts can be destructive if not effectively managed. But a healthy approach to conflict management acknowledges that not all conflict is entirely negative. There are potential benefits that may be derived from conflicts under certain circumstances. DeChurch and Marks (2001) reported that the ways in which groups handle conflict help to determine whether or not benefits were realized, noting that “the relationship between task conflict and group performance was positive when conflict was actively managed and negative when it was passively managed.” This suggests that Hospital Medicine physicians will be well served to develop effective conflict management skills that can help them increase the likelihood that the conflicts they will inevitably face may yield positive results. In order to do so, it will be important for hospitalists to think strategically about how one may extract the maximum benefit from conflicts that do occur. Some of the potential benefits of appropriately managed conflict include:

Catalyst for Change. Conflicts can force needed change by surfacing problems that otherwise might not be recognized, and by elevating latent issues to a level that demands attention. This can be especially valuable in tradition-bound, change- resistant organizations. Improved Outcomes. Similarly, conflicts can ultimately yield improved outcomes when they facilitate learning in the search for better solutions and bring to the forefront useful information and emotions that lie below the surface. Balance. Healthy conflict helps to ensure that balance is maintained among competing needs and perspectives. Increased Accountability. Because conflicts involve strong emotions, healthy conflict resolution usually involves careful articulation of what the parties have agreed to do to resolve it, and a significant degree of accountability to ensure that the agreements are followed through. Improved Relationships. When people skillfully manage a conflict in healthy, respectful ways, it can actually serve to strengthen their relationship going forward. They end up understanding each other better, and building greater trust because they have demonstrated that they can overcome differences.

KEY PRINCIPLES IN CONFLICT MANAGEMENT

This chapter offers five key principles that represent a good start for those who wish to build better conflict management skills (Table 26-1). However, more detailed treatments of all of these principles and others are contained in the references at the end of this chapter.

TABLE 26-1 Five Key Principles of Effective Conflict Management

1. Commit to confronting 2. Attend to the conditions 3. Identify one’s personal contribution 4. Consider what is underlying others’ behavior 5. Clarify

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1. Commit to Confronting. Most people tend to shy away from conflict. It is tempting to believe that the problem will go away by itself if left alone; that others will soften their positions, forget about the issue, or change their minds, if given enough time. But when pressed, most people will acknowledge this is simply a convenient excuse for avoiding a confrontation that they fear could become uncomfortable or out-and- out unpleasant. Another important reason that people avoid conflict is their fear that openly confronting the situation will make things worse, rather than better. They may worry about handling the confrontation badly and unintentionally causing the situation to deteriorate, or they may fear that the conflict is intractable and that no matter how carefully and skillfully the situation is handled, the outcome will be negative.

In fact, conflicts cannot be resolved if they are not confronted. They may be glossed over or pushed into the background, but not truly resolved. And such conflicts are likely to surface again, often in unanticipated and damaging ways. Thus, a willingness to acknowledge the existence of a conflict and to step up and confront it is a precondition to effectively managing the conflict.

PRACTICE POINT

A willingness to acknowledge the existence of a conflict and to step up and confront it is a precondition to effectively managing the conflict. This requires an open and honest discussion of the issue, usually face to face, with the goal of understanding the root causes (the unmet expectations) that led to the conflict and addressing them.

In this context, the term “confrontation” is not intended to mean an angry, emotional exchange of verbal attacks. Instead, “confrontation” refers here to an open and honest discussion of the issue, usually face to face, with the goal of understanding the root causes (the unmet expectations) that led to the conflict and addressing them. The remaining principles in this secion are intended to assist the confronter, once the decision to confront has been made, to carefully plan the confrontation (when time permits), and to handle it successfully.

2. Attend to the Conditions. Patterson et al (2002) note that there are two components to every successful crucial conversation: the actual content of the conversation, and the conditions under which the conversation occurs. Most people, when planning to confront or actually engage in a confrontation (a “crucial conversation”), think primarily about the content of the conversation: “What is this conflict about? What steps will resolve it? What points do I need to be sure to make? What will I say to get my points across? What will the other person say?”

People skilled in conflict management realize that the conditions matter just as much as—in fact, maybe more than—the content does. What types of conditions matter? The physical conditions matter a great deal. Is the conversation taking place in a private place instead of in public? Are the people involved in the conversation sitting or standing so they can engage each other at eye level, or is one person sitting with the other standing over

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him? Is there a desk or other impediment between the participants? Is the room too large or too small, too hot or too cold to be comfortable?

Psychological conditions matter even more. The hospitalist who wishes to be skilled at conflict management must learn to pay attention to what the other person or people involved in the conflict are experiencing emotionally. Are they feeling attacked or are they feeling safe? Do they feel that the hospitalist respects them and has their best interests at heart, or do they feel that their interests will be ignored or belittled? Do they sense that the hospitalist is going to push her agenda or opinion and ignore theirs, or do they believe the hospitalist is willing to listen and take their point of view into consideration? Do they feel that the hospitalist’s opinion matters, or that dialogue should occur at a “higher level” with senior physician leaders to the exclusion of hospitalists?

Before the actual content—what the conflict is about and how it should be resolved— can be effectively addressed, the skilled conflict manager must take steps to set up conditions that allow all parties to feel comfortable, safe, and heard. The necessary steps to creating these positive conditions involve ensuring mutual respect among the parties, and identifying or creating a mutual purpose. In other words, do others believe the hospitalist sees them as individuals worthy of the respect and consideration due to every human being, and do they believe that the hospitalist is mindful of their interests as well as his own in seeking an acceptable resolution?

PRACTICE POINT

3. Identify One’s Personal Contribution. Conflicts occur when emotions get in the way of resolving disagreements. This is true not only of others with whom a hospitalist may come in conflict, but of the hospitalist himself. Another important competency for skilled conflict managers is the ability to step back from their own emotions and assess their personal contribution to the situation; in other words, what impact are their own biases, assumptions, emotions, and actions having on the conflict itself, and on their approach to managing it? Do they truly intend to seek mutually acceptable solutions or do they just want to win?

For example, the person seeking to manage a conflict must pay attention not only to what others are experiencing emotionally but also to what he is experiencing emotionally himself. He needs to ask, “Am I feeling safe or am I under attack? Do I believe the others involved in this conflict will listen to me and take my interests into consideration, or not?” However, simply identifying one’s own emotional state is not adequate. Effective conflict managers should also have the self-awareness to understand how their emotions will tend to influence their behavior in the confrontation. These tendencies are described as a person’s “style under stress.”

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The Style Under Stress Inventory3 in Table 26-2 is based on the concept of conversational safety, and will assist individuals in assessing their own personal style under stress. In completing the questions, one should answer “T” for true or “F” for false, based on one’s most common tendencies when in conflict situations in the work setting. People feel safe in a crucial conversation if they believe that they will be listened to respectfully and if they do not feel attacked or ignored. They feel that the other parties have their interests at heart, or at least that others’ interests and their own are not diametrically opposed without room for finding common ground. The inventory is designed to help people understand how they tend to behave when they do not feel safe in a crucial conversation.

TABLE 26-2 Style Under Stress Test

1. Rather than tell people exactly what I think, sometimes I rely on jokes, sarcasm, or snide remarks to let them know I’m frustrated.

T F

2. When I have got something tough to bring up, sometimes I offer weak or insincere compliments to soften the blow.

T F

3. Sometimes when people bring up a touchy or awkward issue I try to change the subject.

T F

4. When it comes to dealing with awkward or stressful subjects, sometimes I hold back rather than give my full and candid opinion.

T F

5. At times I avoid situations that might bring me into contact with people I’m having problems with.

T F

6. I have put off returning phone calls or e-mails because I simply did not want to deal with the person who sent them.

T F

7. In order to get my point across, I sometimes exaggerate my side of the argument.

T F

8. If I seem to be losing control of a conversation, I might cut people off or change the subject in order to bring it back to where I think it should be.

T F

9. When others make points that seem stupid to me, I sometimes let them know it without holding back at all.

T F

10. When I’m stunned by a comment, sometimes I say things that others might take as forceful or attacking, comments such as “give me a break!” or “that’s ridiculous!”

T F

11. Sometimes when things get heated I move from arguing against others’ points to saying things that might hurt them personally.

T F

12. If I get into a heated discussion, I’ve been known to be tough on the other person. In fact, they might feel a bit insulted or hurt.

T F

Excerpted with permission from Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools for Talking When Stakes are High. New York, NY: McGraw-Hill; 2002.

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Individuals responding “true” for several of the first six questions are said to be going to silence when under the stress of a challenging conflict situation. This means they will tend to try to downplay or sugarcoat an issue, or even avoid it outright by changing the subject or disengaging when they do not feel safe. In such cases, they may believe that they have raised an issue and articulated their concerns, but others may be left confused or unaware of how strongly the person feels about the issue because of his silence tendencies. On the other hand, answering “true” to some or all of questions 7 through 12 means the person tends to go to violence when feeling unsafe in a conversation. These people will often try to force their opinion on others by controlling the conversation and either prevent others from speaking or belittle their contributions when they do.

Both silence and violence can be extremely damaging, when the goal of the conversation is to confront disagreements and work toward mutually acceptable solutions. When people understand their own silence or violence tendencies, they can begin to pay attention to how they are responding during conflict situations. They can look for evidence that they are not feeling safe and then step back to assess the impact their silence or violence is having on the conversation and adjust their interactions accordingly. As awareness of these tendencies grows over time, people can begin to anticipate situations in which safety may be at risk and to proactively develop plans to manage their own tendencies to go to silence or violence.

When thinking about one’s personal contribution to a conflict situation, one should also be cognizant of individual assumptions and biases about others involved in the conflict, and especially one’s beliefs about others’ intentions. For example, it is usually helpful to consider the problem of intent versus impact. When analyzing a conflict, one should consider asking, “Is it the impact (ie, the outcome) of the other person’s behavior that is bothering me so much, or is it what I believe about the person’s intentions?”

This distinction is important because humans tend to overemphasize dispositional factors such as personality type or motives, and to discount situational factors such as external stressors, when interpreting the behavior of others; this phenomenon is known by psychologists as the fundamental attribution error or correspondence bias. Because of this bias, the emotions a person experiences about a disagreement, and thus the level of conflict that ensues, may be heightened as a result of presumed negative intentions on the part of others (“that surgeon is just lazy”) and discounting the circumstantial factors that may be influencing others’ behavior (“that surgeon is under real pressure to produce good outcomes, and does not have the training or experience to manage these complex medication regimens”).

The fundamental attribution error may be exacerbated by a related tendency known as the actor-observer bias in which one tends to attribute others’ behavior to their dispositions but to attribute one’s own behavior to the circumstances (“that family member lost her temper because she’s a demanding jerk, but I only lost my temper because she pushed me over the edge”). Self-awareness is critical for effective conflict management, especially awareness of one’s own assumptions and biases.

PRACTICE POINT

Self-awareness is critical for effective conflict management, especially awareness of one’s own assumptions and biases.

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4. Consider What is Underlying Others’ Behavior. One of the keys to effective conflict management is the ability to analyze why others respond the way they do in conflict situations (taking into account both dispositional factors and situational factors), and to modify one’s interactions accordingly. The concept of conversational safety applies to the other parties involved in a conflict situation, as well as to oneself. Skilled conflict managers become adept at not only reading and adjusting their own behaviors, but also at looking for signs that others are not feeling safe. Hospitalists may become more accepting of the anger expressed by patients’ families, the critical comments from other medical staff members, or the sugar-coated change of subject by the hospital executive when they realize that these behaviors often result from others’ fear(s) that they will be treated with disrespect, attacked, or ignored. If they can then work to address those underlying fears (part of paying attention to conditions) before launching into the content of the conversation, they will be more successful.

PRACTICE POINT

One of the keys to effective conflict management is the ability to analyze why others respond the way they do in conflict situations (taking into account both dispositional factors and situational factors), and to modify interactions accordingly. When someone acts in ways that contribute to a heightened level of conflict, it is worth considering whether that person has underlying human needs that are going unmet and that are contributing to his or her challenging behavior.

Another way of thinking about this issue is to anticipate that the more significant the conflict, the greater the chance that people will respond to it emotionally rather than logically. While it is not a clinically accurate model, it may be useful to think of peoples’ brains as having a logical core, surrounded by a layer of emotion (Figure 26-1). Every interaction a person has, no matter how logical it is, passes through this emotional filter on its way in or out.

Figure 26-1 Logic and emotion diagram.

For most people and under normal circumstances, the layer of emotion surrounding the logical core is relatively thin and the information from the interaction passes through it

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in both directions, informed by the emotion but not substantially altered by it. In a conflict situation, however, the emotional layer surrounding the logical core inflates like a balloon. In this situation, the expanded emotional layer takes over and prevents logical conversation and data from passing through. The person is responding from her or his emotion, rather than from logic. A hospitalist may be attempting to have a very logical conversation with a family member, assuming that she is addressing the family member’s logical core. But the hospitalist’s logical words cannot get through the family member’s inflated emotional layer. The hospitalist is talking logic, and the family members are responding from emotion; so no wonder they are unable to relate to each other. In such situations, it is necessary to let some air out of the balloon—to give the emotional layer a chance to deflate—before it will be possible to re-engage the logical core in problem solving or conflict resolution. Sometimes this requires stepping away from the conversation for a while and coming back to it later.

In addition to the overwhelming influence of emotion on how others respond to conflict situations, Heifetz and Linsky (2002) have argued that there are powerful and universal human needs that influence behavior, sometimes in dysfunctional or disruptive ways:

Every human being needs some degree of power and control, affirmation and importance, as well as intimacy and delight…. We all have hungers, which are expressions of our normal human needs. But sometimes those hungers disrupt our capacity to act wisely or purposefully. Perhaps one of our needs is too great and renders us vulnerable. Perhaps the setting in which we operate exaggerates our normal level of need, amplifying our desires and overwhelming our usual self-controls. Or, our hungers might be unchecked simply because our human needs are not being met in our personal lives.

When someone acts in ways that contribute to a heightened level of conflict, it is worth considering whether that person has underlying human needs that are going unmet, and that are contributing to his or her challenging behavior.

5. Clarify. When confronting another person about a conflict situation, effective communication skills are essential. It is important to clarify what one is attempting to convey; it is also important to clarify the other person’s point of view. Important communication skills include

Setting the stage. Keeping in mind the principles of mutual respect and mutual purpose, it may be valuable to start out by communicating one’s own positive intentions to the other person(s) in a way that builds toward these goals. Managing expectations. Hospitalists should clearly communicate what their own expectations were in the situation that gave rise to the conflict, and seek to understand what the other person’s expectations were. This will create a foundation for further dialogue about the differences between what each party expected and what actually occurred. Active listening. Active listening skills involve not just hearing what the other person says, but also

actively engaging the other person with eye contact and body language;

working to enable the other person to feel comfortable sharing potentially difficult information; listening “between the lines” for what is not being said, as well as what is being said; acknowledging the reality and legitimacy of the other person’s emotions; paraphrasing and reframing to ensure understanding of the other person’s perspective; asking questions and probing to understand root causes; staying focused on the other person, rather than one’s own planned response.

Joint problem solving. Engaging all parties to the conflict in joint problem solving will help to clarify what needs to happen to resolve the conflict, and what the alternatives are for moving forward out of conflict. It will also help build mutual support of and commitment to the agreed-upon approach. Articulating next steps. Establishing a clear path of next steps and assigning responsibilities are vital components of a clear and effective communication process. It is worth talking both about the expected outcome, and about the method or process by which the outcome will be achieved: it is not uncommon for new conflicts to arise inadvertently when two parties believe they understand what will happen, only to clash over how it will be accomplished.

PRACTICE POINT

When confronting another person in a conflict situation, effective communication skills are essential. It is important to focus on ensuring clarity, both in what one is attempting to convey, and in understanding the other person’s point of view. Important communication skills include setting the stage, managing expectations, active listening, joint problem solving, and articulating next steps.

STRATEGIES FOR EFFECTIVE CONFLICT MANAGEMENT: CONFLICT RESOLUTION AND NEGOTIATION

1. The Talking Stick. Stephen Covey (1989) highlighted the importance of empathetic communication in describing the principle, “Seek first to understand, then to be understood.” Covey (2004) further described the use among Native American cultures of the Talking Stick as a tool to help people resolve differences by creating greater mutual understanding and respect.5 The Talking Stick is passed from one person to another, and only the person who is holding the Talking Stick is allowed to present her or his perspective. This ensures that only one person talks at a time, and increases the ability of others to listen because they are not permitted to argue or make their own points until the person holding the Talking Stick has finished.

The most powerful aspect of the Talking Stick, however, is that the person holding it does not relinquish it until she is satisfied that she has been fully understood by the others. It is the responsibility of the listeners to listen carefully and with empathy, and to

ensure that the speaker feels understood—not necessarily agreed with—just understood. Once the speaker is satisfied that others understand him, she passes the Talking Stick on and assumes the responsibility to listen and make the next speaker feel understood. Covey describes the value of the Talking Stick as follows:

This way, all of the parties involved take responsibility for one hundred percent of the communication, both speaking and listening. Once each of the parties feels understood, an amazing thing usually happens. Negative energy dissipates, contention evaporates, mutual respect grows, and people become creative. New ideas emerge. Third alternatives appear.

One does not need to use a physical Talking Stick to gain these benefits. It is possible to establish a framework for interacting in which the parties agree that they will alternate the responsibilities of talking and listening until both feel fully understood. This process can be very effective in facilitating the resolution of conflicts between hospitalists and other specialists regarding scope and service issues. Some parties may be able to do this independently, while others may benefit from facilitation by a third party mediator.

2. Unhappy Patients and Families: Take the HEAT. Some of the most challenging conflicts that hospitalists must manage are those that involve the unmet expectations of patients and families. Keeping in mind the role of emotion in conflict, Byham (1993) recommends the following approach for those who are responsible for addressing the needs of unhappy patients and families, as summarized by the acronym “Take the HEAT”:

Hear them out. Active listening without interrupting, disagreeing, or defending is the crucial first step. Angry patients and family members need to be able to express their emotions in order to let some of the air out of the emotional balloon. Empathize. As with Covey’s Talking Stick example, patients and families need to feel understood. It is not necessary to agree with them, but it is important to acknowledge their feelings and to attempt to understand the issue from their perspective. Apologize. Byham points out that even if one does not wish to admit fault, it is important to apologize for the situation, and for the fact that the patient’s expectations were not met. Take responsibility for action. Once the emotional balloon has been deflated, it is often possible to re-engage the patient or family member on a logical basis. A good way to make this transition is to take some concrete action, either to resolve the problem on the spot or to demonstrate a desire to improve the situation.

3. Principles of Effective Negotiation. Hospitalists frequently find themselves in potential conflict situations in which negotiation is an effective strategy for addressing the issue. These may include formal negotiations such as the development of professional service agreements, employment contracts, or incentive compensation metrics, or they may be less formal interactions such as working with specialists to define admitting responsibilities or co-management services. Strong negotiation skills are also valuable for hospitalists working on

medical staff committees or quality improvement projects when the diverse interests of many parties must be reconciled.

In traditional negotiations, each party stakes out a formal position and then proceeds to bargain from that position, using various tactics to “win” points that bring the final compromise outcome closer to this position. By contrast, the Principled Negotiation model developed by Fisher and Ury (1981) focuses on understanding all the parties’ underlying interests and on identifying objective, fair options that can satisfy everyone. The four tenets of Principled Negotiation are as follows:

Separate the people from the problem. This principle addresses the role of emotions and relationships in influencing one’s perceptions about the negotiation. The authors suggest that negotiators seek to identify when relationships (either as friends or adversaries) may be getting in the way of seeking the best outcome, and that negotiators address these emotional aspects directly and openly with the goal of moving beyond them into objective and collaborative problem solving. Focus on interests, not positions. It is crucial to look beyond the formal stance a person has taken and attempt to understand his underlying interests, the “root causes” of his position. By understanding all parties’ basic interests (both one’s own and the other person’s), one increases the chances of identifying new perspectives or solutions that will meet both parties’ interests. Invent options for mutual gain. The authors argue that once emotional and relationship issues have been separated from the substantive problem, and all parties’ underlying interests are understood, the role of the parties is to invent better options. The steps in this process are: separating the identification of options from the act of judging them, looking for many options rather than a single answer, focusing on options that result in mutual gains, and then coming up with ways to make the decisions easy. Insist on using objective criteria. Finally, Fisher and Ury acknowledge that despite one’s best efforts, negotiators will sometimes face situations in which interests are truly in intractable conflict and mutually acceptable options may not be available. In these cases, effective negotiators will insist that decisions be made using objective, usually externally validated, criteria.

In addition to the tenets of Principled Negotiation outlined above, it is important to recognize that when the issues are complex, even the best and most carefully documented negotiation will probably fail to anticipate every nuance that may arise going forward. For example, when hospitalists negotiate and memorialize a “service agreement” with a group of specialists to define who will admit which types of patients, invariably a patient will present who does not fit neatly into any of the categories specified in the service agreement. If the potential for this to occur is not acknowledged and planned for up front, additional conflicts may arise despite the parties’ careful efforts. The most valuable asset in such situations is a strong underlying relationship of mutual trust and respect that will enable the parties to resolve these issues on a case-by-case basis. The bottom line is that even the best negotiation skills and most clearly drafted documents cannot substitute for strong relationships.

CONCLUSION

Conflict is inevitable in human interactions, and the potential for serious conflict will grow as the complexity of interactions increases. The extremely challenging milieus in which hospitalists practice are rife with misunderstandings, disagreements, and unmet expectations, placing hospitalists at risk for conflict on a daily basis. Therefore, the ability to understand and effectively manage conflict should be a core competency for all hospitalists. The first step in building effective conflict management skills is to understand the causes and potential benefits of conflict. Next, hospitalists should learn and apply key principles of conflict management; and finally, hospitalists need to develop competence and confidence in implementing useful strategies for managing different types of conflict.

SUGGESTED READINGS Covey SR. The 7 Habits of Highly Effective People. New York, NY: Simon and Schuster;

1989:235-260. DeChurch LA, Marks MA. Maximizing the benefits of task conflict: the role of conflict

management. Int J Conflict Manag. 2001;12:4-22. Gilbert DT, Malone PS. The correspondence bias. Psychol Bull. 1995;117:21-38. Holt JL, DeVore CJ. Culture, gender, organizational role, and styles of conflict resolution: a

meta-analysis. Int J Intercult Relat. 2005;29:165-196. Jones EE, Nisbett RE. The Actor and the Observer: Divergent Perceptions of the Causes of

Behavior. New York, NY: General Learning Press; 1971. Patterson K, Grenny J, McMillan R, et al. Crucial Conversations: Tools for Talking when

Stakes are High. New York, NY: McGraw Hill; 2002. Ross L. The intuitive psychologist and his shortcomings: distortions in the attribution

process. In: Berkowitz L, ed. Advances in Experimental Social Psychology. vol. 10. Orlando, FL: Academic Press; 1977:173-240.

Thomas KW, Thomas GF, Shaubhut N. Conflict styles of men and women at six organization levels. Int J Conflict Manage. 2008;19:148-166.

Triandis HC. Individualism and Collectivism. Boulder, CO: Westview Press; 1995.

REFERENCES 1. Patterson K, G