Conflict Engagement &Emerging Communities of PracticeDebra Gerardi, RN, MPH, JDJune 2009

Center for American NursesLEAD Summit

“The basic contribution one can make to one’s community is not to add to the general unconsciousness of the time.”

Thomas Moore, Original Self, Living with Paradox and Originality, 2000

2(c) 2009 All Rights Reserved

(c) 2009 All Right Reserved3

Joint Commission Sentinel Event AlertIssue 40, July 9, 2008

Behaviors that undermine a culture of safety

Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.

Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment.

To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.

Culture of Safety and Quality, LD 3.01.01

Leaders create and maintain a culture of safety and quality throughout the hospital.

Elements of Performance:

4. The hospital has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.

5. Leaders create and implement a process for managing disruptive and inappropriate behaviors.

http://www.jointcommission.org

(c) 2009 All Right Reserved4

Conflict Management, LD 2.04.01

“The organization manages conflict between leadership groups to protect the quality and safety of care.”

www.jointcommission.com

5(c) 2009 Debra Gerardi All Rights Reserved

“Authentic accountability,

commitment and community come

from acts of consent, not

acts of mandate or direction.”

Peter Block

(c) 2009 Debra Gerardi 7

ANA Nursing Code of Ethics- Interpretive statement 2.3: Collaboration

• Collaboration is not just cooperation, but it is the concerted effort of individuals and groups to attain a shared goal.

• By its very nature, collaboration requires mutual trust, recognition, and respect among the health care team, shared decision-making about patient care, and open dialogue among all parties who have an interest in and a concern for health outcomes.

• Nurses should see that the questions that need to be addressed are asked and that the information needed for informed decision-making is available and provided.

(c) 2006 Debra Gerardi 8

ANA Nursing Code of Ethics

Nurses must examine the conflicts arising between their own personal and professional values, the values and interests of others who are also responsible for patient care and healthcare decisions, as well as those of patients.

Nurses strive to resolve such conflicts in ways that ensure patient safety, guard the patient’s best interests and preserve the professional integrity of the nurse.

“The future hinges on the accountability that citizens choose and their willingness to connect with each other around promises they made to each other.”

Peter Block

(c) 2009 Debra Gerardi All Rights Reserved 9

Approaches Enforcement

Power-based, not relationalFocus on right and wrongAt best, leads to compliance, not connection

EngagementCollaborativeFocus on contribution and learningOpportunity for resolution, restoration of

trustAt best, leads to accountable behavior and

connection

(c) 2009 All Right Reserved10

Conflict Engagement Conflict engagement refers to the capacity to

enter into and address conflicts of various types, at various depths and over differing time frames ranging from short-lived interactions to more complex and protracted disputes.

Not all conflict engagement leads to resolution, however, there is seldom resolution without some level of engagement.

Conflict Engagement

“Conflict is dynamic, emergent and contextual.”

“Engagement means finding the right level of depth at which to engage.”

Bernie Mayer, Beyond Neutrality, 2005

(c) 2009 All Right Reserved12

Depth of Engagement

(c) 2009 All Right Reserved13

Address behavior and code of conduct expectations for the future. Address consequences for failing to perform.

Address impact of behavior on others, address broken trust, consider apology, acknowledge relational needs of respect, trust, reputation, identity, etc.

Allow for emotional processing of the event.

Building Conflict Engagement Capacity

Collaborative mindset that invites participation

Skills for engaging effectively

Processes that are non-adversarial and that address the issues and the relationships while expanding options for solutions

Systems architecture- processes designed to fit within the culture of the organization; by those who will use them; and that allow emergent solutions that facilitate learning

(c) 2009 All Right Reserved14

Hickson Pyramid- Vanderbilt

(c) 2009 Debra Gerardi All Rights Reserved

15

Majority of professionals- no issues

Single unprofessional event

Apparent pattern

Pattern persists

Nochange

Informal conversation- “cup of coffee”

Awareness intervention

Authority intervention/ PI plan

Disciplinary action / termination

Hickson, 2007

Conflict Engagement Training

Training as intervention There are established

foundational skills/ theory Experiential/ skills-based

formats Customize to culture/ group Qualifications of trainers Build in assessment

(c) 2009 All Right Reserved16

Conflict Engagement Specialists

Are trained in conflict theory, group dynamics, negotiation and non-adversarial processes such as mediation, facilitation, dialogue, conflict coaching, appreciative inquiry, open space, and other social technologies.

May be internal or external to the organization

(c) 2009 All Right Reserved17

"The path forward is about becoming more human, not just more clever. It is about transcending our fears of vulnerability, not finding new ways of protecting ourselves.

It is about discovering how to act in service of

the whole, not just in service of our own

interests."

—Peter Senge(c) 2009 Debra Gerardi All Rights

Reserved18

Emerging Culture… As the shift toward a new way of delivering health

services proceeds there is tension created as the old ways of working dissipate and new ways emerge. The challenges that lie ahead are both exciting and daunting.

Birthing a new culture requires that we redirect our resources toward strategies for collaborating effectively.

Surfacing old assumptions and evaluating their validity in the current environment requires open and reflective conversations across the professions.

(c) 2009 All Rights Reserved

Reflective Practice

“Reflective practice is the process of exploring a pattern of action, making adjustments during the action, or thinking about past action.

It brings knowledge to action in a way that assists in making more informed decisions.”

US Institute for Peace(c) 2009 Debra Gerardi All Rights

Reserved20

Double Loop Learning Single loop learning- respond to an error or undesirable

outcome by changing techniques or reinforcing original approaches Create a code of conduct with stricter enforcement

Double loop learning- reflect on the assumptions or beliefs that underlie the action to begin with and make changes to the underlying assumptions. 1. It is ok to behave badly if you generate a lot of

income; 2. It is ok to behave badly if you are clinically very good; 3. It is not ok to speak up or redirect bad behavior

because confrontation can lead to exclusion or ostracizing and I should protect my reputation at all costs.

Chris Argyris

21

(c) 2009 All Rights Reserved

Reflecting on our own contributionto difficult situationsexpands the space around us,And gives us room to make the other person look good.

“In the telling of what most deeply touches our life, others see they are not alone.

And in the process both the storyteller and the listeners are healed.”

Natalie Goldberg

Narrative Mediation Focus is on how the person has constructed their

story of the conflict and the impact that story is having on them rather than purely the facts or truth of the story.

The story creates the reality for the person and how it is constructed limits how they perceive the situation and the options available to them.

Winslade and Monk, Narrative Mediation, 2008

Story Characteristics Conclusions/ judgments about the facts, the other

person are fixed.

Accusations or attributions of fault or blame are wrapped around the facts

All or nothing thinking

Totalizing descriptions- this version of the story is the total picture- simplified presentation of a more complex situation.

A Conflict Story We are in this mess because she continues to

lie and withhold information. Every time there is an eruption, it is linked to her manipulation and sabotage.

She is targeting our department because she sees us as a threat to her turf and until they get rid of her, there is no way that things are going to work.

Appreciating Impact

Mediator:

It is clearly important that you are able to rely on the information you receive in order to make decisions and to be able to trust those you work with.

Tell me what the impact has been on you of not being able to rely on your colleagues…

Externalizing the Conversation

Externalizing conversations move the story outside the person to give them more opportunity to see it as separate from themselves.

Mediator: What about this situation has invited you to feel such a

strong sense of mistrust? What other experiences have you had where this has

happened? To what extent is blame stopping you from finding a way

through this situation?

Opening Space for a New Story By honoring and respecting their capacity as creators

of the new story, it both empowers and opens the space for what could be possible.

Mediator: Describe what it was like before things got so bad. How is it different now? What is the likelihood that things will return to the way

they were given what you have heard today? How would you like things to be?

Creating Coherence Mediator:

It seems that this situation has been hard for everyone.

Trying to make sense of something that seems so unfair can be very difficult. Given the information you all have now, what has changed for you?

What helps you to make sense of what has happened? What is the story that you would like to tell after this is all over?

“Fragmentation consists of false division, making a division where there is a tight connection and seeing separateness

where there is wholeness.

Fragmentation is the hidden source of the social, political, and environmental crises facing the world.”

David Bohm

(c) 2009 Debra Gerardi All Rights Reserved

32

“There are very real conflicts in the world, and the worst of them do not seem to go away. But there is a fantasy abroad. Simply stated, it goes like this: “If we can resolve our conflicts, then someday we shall be able to live together in community.”

Could it be that we have it totally backward?

And that the real dream should be: “If we can live together in community, then someday we shall be able to resolve our conflicts?” M. Scott Peck

(c) 2009 Debra Gerardi All Rights Reserved

33

Growing communities of practice…

Communities of practice

“Communities of practice are groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis.”

Wenger et al.,

Cultivating Communities of Practice, 2008(c) 2009 Debra Gerardi All Rights

Reserved34

(c) 2009 Debra Gerardi All Rights Reserved

35

“The key to creating or transforming community, then, is to see the power in the small but important elements of being with others.

The shift we seek needs to be embodied in each invitation we make, each relationship we encounter, and each meeting we attend.

For at the most operational and practical level, after all the thinking about policy, strategy, mission, and milestones, it gets down to this:

How are we going to be when we gather together?”

Peter Block, Community- the Structure of Belonging, 2008

“There is no power for change greater than a community

discovering what it cares about.”

Margaret Wheatley

“Healing may not be so much about getting better, as about letting go of everything that isn’t you - all of the expectations, all of the beliefs - and becoming who you are.”

Rachel Naomi Remen

(c) 2009 Debra Gerardi All Rights Reserved

38

Debra Gerardi, RN, MPH, JD President & Chief Creative Officer, EHCCO

• debra@ehcco.org• Mobile: (650) 303-7313• Office: Toll free (877) 712-1240• Fax: (650) 745-2673

EHCCO, LLCEmerging Health Care

Communities