Ah, okay. Now we're cooking with gas. Okay. I have no conflicts of interest or other disclosures. So our session goals are to understand the nature of conflict, so I'm going to kind of define that for you and where it comes from, to explore the role of mediation in managing conflict, and I'll kind of define what mediation is and where it got its start, learn conflict resolution techniques, and then develop some effective communication techniques. And I always like to start with a case as a way to frame it and give it some context. So a 74-year-old man has been hospitalized in the ICU for three weeks with cavitary staph aureus pneumonia and bacteremia and septic shock, complicated by a multi-organ failure, including ARDS, aneuric AKI, and necessitating CRRT. He remains in shock on multiple days of active medications. He has persistent hypoxemic respiratory failure and is currently vented on 90% of sedated neuromuscular blocking agents, proned on inhaled prostacyclin. Hospitalization has been further complicated by DIC, a DVT, upper GI bleed. The ICU team recommends limiting life-sustaining therapies in the context of unremitting multi-organ failure. The family becomes frustrated and accusatory, claiming the team has given up and demanding that they do everything possible to keep him alive. Team members express frustration that he's suffering and that we're torturing him. Several of the nurses press you to be more forceful with the family and place limitations on life-sustaining therapies. And you're distressed over his unrelenting illness, your inability to rescue him despite providing exceptional critical care. Feeling pushed by team members to make him do not attempt resuscitation or DNR, DNAR, depending on your language at your institution, comfort care, and the suffering that you might be causing him. Anybody ever experienced a case like this before? This is pretty rare, obviously, in the ICU world. This case used to be a COVID case, but I have so much PTSD from all the COVID care that I've changed it to non-COVID over the years. So what is conflict? Conflict can be defined as a competitive or opposing action of incompatibles or an antagonistic state or action. And because it's competitive and antagonistic, by its nature, conflict tends to be win-lose. And the problem with win-lose when you're in a health care setting is we really don't want any losers. We want everyone to be able to win. And so one of the things that I'm going to try to hammer home in the next, let's say, 15, 17 minutes is this idea of finding the win-win scenario rather than having this adversarial win-lose. It really, that idea of a win-lose violates our obligation to provide good clinical care to patients and their families. So a little on moral positions. This is sort of the ethics portion of the talk. Moral positions, moral uncertainty. A moral position is a stance that an individual or group of individuals will take based on an underlying conception of right versus wrong. And typically, when conflict occurs, it most often revolves around individuals taking a moral position. This is the right thing to do. This is the wrong thing to do. And the problem with that is that we all live in this kind of state of uncertainty or perplexity, what the Greeks called moral aporia, where there's ethical ambiguity or ambivalence. There might be multiple moral principles that are in conflict with each other or in tension with each other. And there may actually be more than one justifiable moral outcome. And when you have more than one potentially justifiable outcome, it's very hard to look at someone and say, you're wrong, I'm right. It's actually easy to say that, but it's hard to actually be right about that. And so I think the first thing we need to do is recognize that moral perspectives are a plurality, and they're not uniform. And we're really not dealing with right versus wrong or unethical versus ethical. On rare occasions, you will deal with frank unethical behavior or unjustifiable behavior. But by and large, what we're really dealing with is different moral perspectives coming into conflict with each other. If you look into the law and business literature, you'll see that there are several sources of conflict that can be sort of categorized into substantive process and relational. I've sort of recategorized and given examples based in healthcare. But you could think about substantive as being someone has acted in a way that has really damaged trust, right? So unethical behavior, a medical error, or an adverse event. There's been something that's been done. You could think about process as being sort of something like medical legal. So if somebody has an advance directive, and the advance directive says, please don't intubate, and the power of attorney says, I want you to intubate them anyway, and you know that an advance directive is a legal document, but it's not necessarily an enforceable legal document. If the POA is overriding it, that is allowed in most states. And so it can be really challenging and morally distressing for us when we feel like we're doing something that's against the wishes of the patient, but you have family who are really advocating for them and trying to provide care. You could also think about hierarchy in the hospital or hospital policy. So I don't know how many of you had visitation policies during COVID. And I think what we've discovered in the literature is that visitation policies were not equitable. They were not handled appropriately in many institutions, and they were oftentimes punitive. And so that would be an example of process getting in the way, resulting in conflict. And then relational is really breakdowns in communication. It's where you have values-based judgments and differences of opinion, but there's not one specific thing that someone necessarily does that triggers that conflict. And that's where we're going to spend most of our time in the next few minutes. I'm not going to read all of these here, but you could imagine that there are just a tremendous number of triggers that can result in conflict in the hospital setting. And so you could think about things like uncertainty of prognosis, mistrust with a family of the healthcare system or team members. You could think about ourselves. The environment of care is very familiar to us, but not familiar to patients and families. You could think about our own biases that we bring to the table, our own lived experiences as human beings, because we are still, despite being in healthcare team members, we are still human beings. You could think about challenges around values and preferences, uncertainty in how we communicate, prior experiences that family bring in, culture that they bring to the table. So your background, your unique family culture, your community culture, perhaps ethnic culture. Maybe you're not from the United States originally. You have a very different sort of concept of what healthcare should look like than sort of our very kind of focused Western view of healthcare. And all of these things can kind of conspire to generate conflict. And what happens is you get this kind of cycle where you get communication breakdown because conflict ensues. People get entrenched in their positions, which I'm going to talk a little bit more about positions in a moment. You develop moral injury and moral distress, what we in the sort of moral injury world call a residue, a moral residue, where it builds over time. And then you disengage. Maybe you don't go into the patient's room that day. Maybe you don't talk to the family that day. Maybe the family's not coming in. Maybe if it's an interprofessional conflict, you stop calling the primary, or they stop seeing you, or has anyone ever experienced where the consulting team sneaks in and talks to the family, but doesn't actually talk to you, and then you find out what they told the family is totally different than what you're telling the family, and the family's wondering why we're not agreeing with each other. Does that resonate? That happens not infrequently in the healthcare system. And so you can imagine that it results in tremendous distress for patients and families with complicated grief, anxiety, depression. For teams, it can break down a relationship with team members. It can affect our profession, how we're viewed. And it can affect ourselves with burnout and cynicism and erosion of our professionalism. So we work in an environment that is rife with conflict that can happen at any time, in any moment. And so what can mediation kind of bring to the table, both literally and figuratively? And so this is one of my favorite cartoons. That's me in the middle there, the balding guy, between the squirrel and the dog, saying, hey, can we agree it's a big backyard, right? There's lots of room for all of us to play. And that's really what mediation is. It's a process where there's a neutral party with no skin in the game, no stake, who brings the disputants together to find a common ground for compromise, with the hope of achieving this win-win. What can I do to try to create a safe space where we can find an outcome that is maybe not exactly what you wanted, but reasonable, so that you walk away feeling heard, validated, and with an outcome that you can live with? You've got to start in law and business. The number one role of the mediator is to bring the emotional temperature down in the room. So people are coming in hot, they're coming in at a level five, right? And you want to try and get them to a place, maybe not a one, but you want to get them somewhere where they can actually talk to each other and not be yelling at each other or not even speaking. And so the mediation process, there's a standard for this. I'm a certified mediator and when you go through bioethics or healthcare mediation, you start by listening, by trying to understand the nature of the conflict between the individuals and facilitate dialogue, not through me as the mediator, but actually to each other, speaking to each other to try to problem solve, educate where there's uncertainty, and then resolve that dispute. There's a few rules of conflict management that I think are essential. One is that most often in conflict, you're experiencing something like anger or something akin to anger. There's a lot of frustration. It's a reactive emotion. The key is to try to find the source of that anger, to dig down and really appreciate where it's coming from. I think that we have a tendency with anger, it's very easy when someone is feeling sad, guilty, hopeless, dejected, you lean in, you put the hand on the knee, you put the hand on the back, you tell them it's going to be okay, you say, I hear you, it's normal to feel this way, I'm sorry for what you're experiencing. All those techniques that you all know, hard to do because it's easy to become defensive when somebody's angry at you and they're yelling. Your instinct is to be like, hey, I'm just trying to take care of your dad. Why are you yelling at me? This behavior is not okay. You need to calm down. None of that is going to be effective when someone is angry. You've got to find the source. It can take just seconds like lighting a match to escalate a brewing conflict. Calling someone out for their bad behavior, you can't behave that way, will only make things worse. Anybody here a parent? You ever told your child, that's not okay, you can't behave that way? Did they ever say to you, oh, yeah, dad, good point, yeah, I should behave differently. It never works. Naming the concern of the individual, I hear that, I sense that, it sounds like, can really demonstrate alliance and avoids creating an adversarial relationship and then sincere apologies or expressions of consolation can go a long way in diffusing tense interactions. I think the one thing I would say is bioethics mediation is great, but, and I say this as an ethicist, it is inconvenient in the healthcare space. You don't have the luxury when patients are crashing in the ICU and families are upset or you have interprofessional conflict to be like, time out, let's get a table, let's sit around the table, we're going to spend four hours, we're going to hash this out, we're going to arbitrate, we're going to mediate, we're going to find some common ground and we're going to resolve this conflict. That works great in business and law when you're paid by the hour, right, and you can just arbitrate. Doesn't work in healthcare. It's time sensitive. So my goal for this session is for you all to develop some of these skills and be aware of some of the skills that you can continue to work through and work on to be able to use some of these techniques in the healthcare space where you're not necessarily a neutral, you're a party to the process, but at least you have some skills that you can use and fall back on to be able to help resolve conflict. So what are the goals of conflict management for professionals? I would say that there's three main goals. One is to develop what I call situational awareness of when conflict is brewing, to be able to separate positions from interest, which I'll define in a moment, and to use relational communication skills to deescalate conflict. So what is situational awareness? Well, it's this idea that people typically have moral emotions that drive their conflict. It's typically anger, frustration, resentment, indignation. There's something that you did that made me feel this way. And obviously that's perception and not reality, but perception is the only thing that matters, right? It may not be that I did something to anger you. It may be that there's something else going on, but I need to lean into that and understand where that's coming from. I need to be able to understand that there are specific triggers that will worsen conflict, and I need to be able to identify those triggers. And those triggers are what I referred to earlier, where I had sort of the different elements of being in a hospital with that conical-shaped idea that it generates conflict. Those are the different types of triggers that can be both internal and external. It can be based on prior experiences. Maybe you've been exposed to health disparities. Maybe there's racial injustice. Maybe you've gotten bad care in the past. Maybe you weren't listened to well. There's also the external triggers of just being sick in an ICU and being stressed and being very affective and not cognitive, sort of, in your emotional space, and not being able to reason normally. These are all sort of things that play in. And then having the capacity to diagnose impending conflict as it's brewing and act preemptively rather than reactively. I want to talk a little bit about this idea of positions and interests, and I think if you're going to take away one thing from these slides, this would be the one, which is to say, and this comes from, it's adapted from one of my mentors in bioethics, Autumn Feaster, who is a philosopher and bioethicist at Penn, but it really comes from Fisher and Urey, who are part of the Harvard Business Project, and they wrote a book way back in the 80s called Getting to Yes, which is how to sort of negotiate and find the win-win scenario, and that's where a lot of bioethics mediation comes from, is originally from law and business. And so they describe this idea of a tree, and what you see of the tree above the ground is the trunk, the branches, the leaves, and then what's underground are the roots. And you can think of the positions as what you see. It's what I want. I want dialysis for my parent. We don't want to do dialysis for your loved one because we don't think it's going to work, whatever the reason is, right? That's the what. And that's very binary, right? So you can see, I want dialysis, I don't want dialysis. There is no real in-between, right? Those are in opposition with each other. And so what you want to do is you want to try to dig into the earth, underground to the roots, metaphorically. The interest is why I want it. Why do they want dialysis? What is important about that particular intervention? And what are we feeling? What are our colleagues who are in conflict with us feeling? What are we feeling? And trying to get to that why is what really allows you to then resolve conflict, because that's where you can find common ground. That's where you can find opportunities for consensus building. So once you identify individual perspectives and how they differ, and you start to develop that answer to the why, you can really find opportunities for collaboration. And this is an old, old slide. It's from 1977. Some people in this room might not have been born yet. It's from Kilman and Thomas, and this is the conflict mode instrument. And we all exist in our personal and professional lives somewhere in this, on this X, Y axis. And so you can imagine, we have all professionally at some point been very assertive and very uncooperative, right? Be competing, where we just said, like, no, I'm not going to do that. We've also been unassertive and uncooperative, avoiding, right? Who here has said, man, I had a really tough conversation with that family yesterday. I think today I'm just not going to go in the room. I'm just going to kind of look and see, are they here today? If they're, are they not here? Oh, I'm going to go examine the patient, and then I'm not coming back, right? I have done that. I admit it, right? And then we also have been highly cooperative and unassertive, which is accommodating. You want dialysis? Okay. Dialysis it is. You want CPR on your loved one who's on four pressers and 100% on the vent? Okay, we'll do CPR, where we want to be is at least collaborating, where we're assertive but also cooperative, or perhaps compromising, and compromising is this idea that you have achieved a minimally acceptable result to be able to maintain the relationship with the other individual, and those are where we want to spend most of our time. All right, so then the third piece is using relational communication skills to deescalate conflict. Nothing I'm going to present to you in the next few slides is going to be earth shattering, but it's a way to sort of structure what you already inherently know, which is the process for talking and listening to our patients, talking to and listening to our patients. So listen first, express curiosity, show empathy, acknowledge perspectives, and validate those perspectives. Write any wrongs, and I put wrongs in quotations because it can be a wrong, right? It could be a medical error, an adverse event. It could also be a perceived wrong, right? So that patient who comes to your MICU after being in the SICU for a month, and while they're in the SICU, they developed a deep tissue injury, and the family doesn't understand why at your institution they have a deep tissue injury, but you know that they went through a 15-hour operation and they're critically ill, and it's been a month, and the nurses are doing a great job of protecting the skin, but it happens, right? And the family is so angry that they can't compromise and partner with us until we really get past that, right? And then find those avenues for compromise. And then using these relational communication skills to deescalate conflict, I give you some examples here of active listening being reframing and rephrasing statements. Inquisitiveness is asking open-ended questions, expressing concern for their experience. Empathizing is that traditional nurse mnemonic that hopefully many of you are familiar with, naming, understanding, respecting, supporting, exploring. It's one of the key sort of classic validated mnemonics out there for communication, which we'll look at in a moment. Empathizing, acknowledging perspective, so messaging the plurality of positions, so recognizing that what you believe and what I believe may not be the same, and that doesn't mean that we don't both care about your loved one, it's just that we're not in the same place right now, and that it's okay to have different perspectives. Being able to name the emotions, abandoning that moral high ground, this idea of like checking your ego at the door. If they get angry, this is not about you. And if you let yourself be part of the problem by getting frustrated or defensive, then you're only going to make things worse. You have to recognize this is not about you. Making sure to validate the individual's experience through righting wrongs and then finding that opportunity for a win-win scenario. I mentioned this nurse mnemonic earlier. This has been validated since the 1980s, first in the cancer world and then much more expansively. If you're not familiar with it, I highly recommend it. It also works at home with your children. So just some example language here for naming. Many people in your situation would feel this emotion. Is that how you feel? Right? Or I imagine if I were in your situation, I would feel really frustrated. Is that how you're feeling? Right? Trying to really get drilled down on exactly what emotion they're expressing. Showing understanding. You're not alone in feeling this way. It's very common to feel this way. It's normal to have that anger. It's normal to be frustrated. You're going through a lot. Showing respect. This must be so hard. You've done an amazing job as an advocate for your loved one. I'm so thankful that you're here to partner with us. You're not alone, so supporting them. You're not alone. We will be here with you. We're here for your loved one, but we're here for you too and we're going to do everything we can to try to help you through this and then exploring. I imagine this has been so hard. Tell me more about what you're feeling. How are you doing? Is there anyone that's supporting you? Right? Is there anything that you've been feeling that you'd like to share? Are you satisfied with the care that we've been providing? Is there anything we could do better? You'd be amazed what you find out from patients and families by asking that question. In summary, I think conflict management training should be a core competency for us. I think it's important for us to be technically competent in the ICU, but it's also important for us to be relationally competent, to know how to speak with our patients and their families. It can provide you a moral intuition for when something is going on, something is amiss. It can enhance your active listening skills. It can help you find your patient, their family, maybe your colleague's truth. What is it that is driving them to feel the way that they're feeling? To allow you to explore options for how you can build consensus. It can provide you a framework for how you can respect and demonstrate respect for other people's values and preferences to handle complex, very morally charged emotions and find that compromise through good communication so you can really achieve that win-win with the individual that's struggling.

conflict management

healthcare mediation

ICU conflicts

ethical ambiguity

communication breakdown

moral perspectives