conflict

138

CM E C

RE DIT

EX PIR

ED ETHICS CME, Part 3 of 3

Target audience: All physicians

Learning objectives: 1. Identify the harm caused by a dysfunctional physician and explain

how to intervene to prevent further disruptive behavior. 2. List ways to prevent conflict and violence in the workplace. 3. Explain the importance of emotional intelligence.

Faculty credentials/disclosure: Michael A. E. Ramsay, MD, is medical director of the Department of Anesthesiology and Pain Management and president of Baylor Research Institute. He receives grant support from Abbott Labora- tories. Dr. Ramsay does not address unapproved/off-label uses of any product.

Before beginning this activity, please read the instructions for CME on p. 214. This page also provides important information on the method of physician participation, estimated time to complete the educational activity, medium used for instruction, and date of re- lease and expiration. The quiz, evaluation form, and certification appear on pp. 214–216.

CME

Conflict in the health care workplace MICHAEL A. E. RAMSAY, MD

From the Department of Anesthesiology and Pain Management, Baylor Univer- sity Medical Center, Dallas, Texas; and the Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center at Dallas.

Corresponding author: Michael A. E. Ramsay, MD, Department of Anesthesiol- ogy and Pain Management, Baylor University Medical Center, 3500 Gaston Av- enue, Dallas, Texas 75246 (e-mail: [email protected]).

Managing conflict in the workplace is a time-consum-ing but necessary task for the physician leader. Con-flicts may exist between physicians, between physicians and staff, and between the staff or the health care team and the patient or patient’s family. The conflicts may range from disagree- ments to major controversies that may lead to litigation or vio- lence. Conflicts have an adverse effect on productivity, morale, and patient care. They may result in high employee turnover and certainly limit staff contributions and impede efficiency.

Litigation is now readily available for those who feel that they are working in a hostile work environment. The hostile environ- ment may be the result of abusive behavior by other employees, supervisors, or physicians. The abuse may take the form of a de- meaning attitude, ridicule, off-color jokes, sexual harassment, or even physical violence. Societies have significantly decreased their tolerance of disruptive behavior. A group or organization can now hold vicarious liability for condoning a hostile work environment if it fails to act when a complaint is made.

DISRUPTIVE PHYSICIANS Physicians, both male and female, often have hard-driving,

type A personalities and little training in interpersonal skills. They may have high IQs but lack emotional intelligence. In the

past, physicians were revered as charismatic people who could do no wrong; now they are seen as one part of the health care team. Temper outbursts—with throwing of instruments and loud profanity directed at any unfortunate person who happens to be near at hand—are no longer tolerated. Nurses and technicians have the right to be treated with respect, and they know it.

The dysfunctional physician presents an insidious cost to any practice or health care organization. He or she increases the stress in the work environment and the accompanying loss of efficiency. In a stressful workplace, such as the operating room with a berat- ing physician, morale and team spirit suffer, which results in an increased turnover of staff and a dysfunctional team. Once this stage is reached, various negative factors begin to interplay. Com- munication is poor, and staff withhold information because of fear of an outburst. The information withheld may be vital for patient well-being. The physician loses staff support and may become isolated. If the problem is severe, retaliation may occur, and this may take many forms: failure to properly assist, the initiation of lawsuits, the support of the plaintiff in a malpractice suit against the physician, or even malicious sabotage of the practice.

Once this dysfunctional behavior pattern is recognized, an intervention should be made. This action is necessary not only for patient safety but also because lack of action could be inter- preted by the courts as negligent or as condoning a hostile work environment. When a confrontation is necessary, a team ap- proach should be used, and if possible, a member of the team should be a close acquaintance of the individual, setting up a “good cop–bad cop” scenario. If only one person is involved, the physician may view the intervention as a personal confrontation instead of a peer-related issue. Specific incidents should be docu- mented, and the focus should be on behavior, not personality. Empathy should be expressed but change must be demanded, with a delineation of the consequences if behavior is not im- proved. The communication should be direct and clear, with the subject not given an opportunity to respond until the end of the dissertation. In this manner, a potential indignant response is often overwhelmed by the data and the presence of peers, and

BUMC PROCEEDINGS 2001;14:138–139

APRIL 2001 139

the physician will respond positively to the guidance given or help offered. The goal is to correct the situation and allow the highly trained physician to perform to an optimal degree. Those participating in the confrontation should look for the good in any situation. In this way, the good can be built on, and a posi- tive outcome becomes more likely.

The competent leader will be able to handle difficult people and tense situations with diplomacy and tact. If possible, a win- win solution should be looked for, where the physician sees the advantage to his practice and patient care if resolution can be obtained. However, individuals who have a destructive effect on the workforce should be asked to leave before they cause harm.

PREVENTION OF CONFLICT To prevent conflicts, a professional code of conduct should

be established, not only in the hospital but also as part of group practice policies and medical staff bylaws. Ground rules make it easier to discipline, as they take personality out of the equation. A disciplinary structure should be developed, so that the mecha- nisms and the referral pattern to higher authority are well un- derstood. General knowledge of this discipline pathway can often facilitate resolution at a lower level. Everyone needs to under- stand that there are firm limits on inappropriate behavior.

Understanding how conflicts arise is important in their pre- vention. From an employee’s perspective, triggers include lack of communication, colleagues who don’t pull their weight, unfair criticism, silly rules, preferential treatment, sexism or racial in- equality, being put down, unreasonable expectations, and verbal abuse. On the management side, problems arise from poor com- munication, inappropriate responses, poor prioritizing, personal work interfering with professional work, and clock-watching.

Pitfalls that leaders should be careful to avoid include tak- ing people for granted, failing to keep promises, failing to take responsibility for one’s own errors, and failing to practice what one preaches. The key to survival as a leader is to develop emo- tional intelligence and to engender it in the work environment.

EMOTIONAL INTELLIGENCE Emotional intelligence has been recognized as necessary not

only to be a successful leader but also to be successful in life. A high mental intelligence quotient revolves around a narrow band of linguistic and mathematical skills, whereas emotional intelli- gence involves self-awareness, management of emotions, empa- thy, “people skills,” and motivation.

The development of interpersonal intelligence allows under- standing of other people—what makes them “tick,” what moti- vates them, and how to work with them. This not only enables leaders to “get inside the other person’s head,” it lets them un- derstand and recognize their own emotions, making control of those emotions easier. If emotional control is lost, smart people become stupid.

Anger is the most difficult mood to control; it can be ener- gizing, exhilarating, and even seductive. It fuels itself and even- tually becomes rage. Rage is a state beyond reason that revolves around revenge and reprisal, with no concern for the conse- quences and with minimal cognition. Early intervention provides the best chance of successfully defusing the angry situation. A cooling-off period may actually exacerbate the anger. Leaders

should stay cool, avoid direct accusation, be good listeners, and repeat the argument in their own words to demonstrate that they are trying to understand the problem. Asking a meaningful ques- tion can be a powerful distraction. However, if all is lost, the leader should leave and return another day. Out-of-control emo- tions can paralyze cognitive function.

VIOLENCE IN THE WORKPLACE The workplace is becoming more violent as people are unable

to handle the stresses of life. Over 1 million workers are assaulted each year in the US workplace, and the health care industry is no exception to this frightening statistic. Violent incidences have been reported between physicians, as the changing pattern of medical practice creates enormous stress on both work and fam- ily. If the warning signs are not heeded, disastrous consequences can occur. Similarly, interactions with families of very sick pa- tients can turn physical as emotions overcome rational thought.

The signs of impending violence include verbal threats, pro- fanity, belligerence, and intimidating statements. Threats should always be taken very seriously. Physical signals of a violent con- frontation are the gripping of fists, agitated movement, speak- ing through clenched teeth, and a paranoid stare. The leader should try to defuse the situation by being nonthreatening and by taking verbal control: using a calm, controlled voice, he or she should be very clear and respectful. The leader should take a nonaggressive posture—by not cornering the individual or getting into his or her “space,” by allowing a buffer zone to ex- ist, and by always staying at least an arm’s length plus 1" distance! The leader should ensure that no objects that could be used as weapons are readily available. When a threatening situation appears to be developing, the leader should take it very seriously and summon help. Potentially vulnerable work areas should have a security evaluation. Access to certain areas should be con- trolled, particularly at night, so that the staff can feel safe. A protocol should be set in place that can be readily activated if a potentially violent situation arises. The safety of the staff must be a major concern of all administrative leaders.

Suggested reading

Andrew LB. Conflict management, prevention, and resolution in medical set- tings. Physician Exec 1999;25(4):38–42.

Blum LA, Hunt DW, Hanks J, Nordberg M, Goldstein SN, Spiro DC, Ludwig GG. Rude awakenings. Emerg Med Serv 1995;24(5):31–34, 73–75, 80–85.

Fowler AR Jr, Bushardt SC, Jones MA. Retaining nurses through conflict reso- lution. Training staff to confront problems and communicate openly can improve the work climate. Health Prog 1993;74(5):25–29.

Goleman D. Emotional Intelligence: Why It Can Matter More Than IQ. London: Bloomsbury Publishing, 1995.

Goleman D. Working with Emotional Intelligence. New York: Bantam Books, 1998. Grant W. How to Turn Conflict into Co-operation. Shaftesbury: Element Books

Limited, 1997. Lowes R. Taming the disruptive doctor. Med Econ 1998;75(19):67–68, 73–74, 77–80. Pfifferling JH. The disruptive physician. A quality of professional life factor.

Physician Exec 1999;25(2):56–61. Robinett J, Cruser A, Podawiltz AL. “But doctor, someone has to do something”:

resolving interpersonal conflicts in the workplace. J Am Osteopath Assoc 1995;95:333–336.

Sotile WM, Sotile MO. Part 1, Conflict management. How to shape positive rela- tionships in medical practices and hospitals. Physician Exec 1999;25(4):57–61.

Sotile WM, Sotile MO. Part 2, Conflict management. How to shape positive rela- tionships in medical practices and hospitals. Physician Exec 1999;25(5):51–55.

CONFLICT IN THE HEALTH CARE WORKPLACE