CONFLICT MANAGEMENT IN
SURGERY: THE IMPACT OF THIRD PARTY CONSULTATION
R. Wayne Boss
Professor
Graduate School of Business Administration
University of Colorado
Boulder Campus
and
Mark L. McConkie
Professor
Graduate School of Public Affairs
University of Colorado
Colorado Springs Campus
Abstract
This one-year study describes the impact of a third party consultation intervention in an operating room of a major medical center. The results show statistically significant levels of improvement on all six subscales of the Group Behavior Inventory, as well as improvements in group effectiveness, honest communication, comfort discussing organizational problems, and interpersonal trust. Additional results include an increase in the availability of surgical supplies and equipment, a 95% decline in physician abuse of scheduling privileges, a decrease of verbal abuse of nurses by physicians, the reconvening of the OR Standards Committee, and a decrease of nursing turnover from 30% the previous year to zero.
Conflict Management in Surgery: The Impact of Third
Party Consultation
Conflict
is inherent in all relationships and can arise from a variety of sources (Walton, 1987). For example, it can result from such substantive issues as task
orientation, pay rates, work methods, conditions of employment, and competition
over scarce resources. Conflict can
also develop from interpersonal issues, such as personality differences,
misunderstandings among group members, a lack of interpersonal skills, and the
emotional baggage people bring to relationships. Third party interventions focus on conflicts that arise between
two or more people in the same organization and are designed to address and
resolve conflicts that disrupt effective task accomplishment and work flow (Golembiewski & Rauschenberg, 2000).
In
an exhaustive study of conflict, negotiation and third party models, Lewicki,
Weiss and Lewin reported that,
historically, research on third party consultation has been categorized
according to style and the social context in which it occurred. Unfortunately, it was not until recently
that researchers began to reference one another's work, so most third party
research developed in relative isolation.
This unfortunate circumstance also "led to a general failure to
contrast various party styles within the same context, and a failure to compare
the impact and effectiveness of styles across contexts. Both consequences have hampered model
development" (Lewicki, Weiss &
Lewin, 1992, 230-231).
Nevertheless,
several models have emerged as dominant paradigms. For example the
Process/Decision Control model (Thibaut
and Walker, 1975), the Matrix
model, (Sheppard, 1984) and the
Process Consultation Model (Walton, 1987;
Schein.1969) provide theoretical frameworks for practitioners and
researchers alike. In addition,
attempts have been made to apply third party processes in a variety of
different problem-solving contexts, including problems with racial tension in
Rhodesia (Burton, 1969), a border dispute in East Africa (Doob, 1970), religious conflict in Northern Ireland (Alevy, Bunker, Doob, Foltz, French, Klein
and Miller, 1974); Arab-Israeli relations (Kelman, 1976; Cohen, et.al., 1977); and community organization
disputes (Fisher, 1983).
The model used in this study is derived from Walton's (I) research and includes preliminary interviewing, structuring the confrontation, facilitating dialogue between the parties, encouraging problem solving, and planning for the future. Specifically, the study describes a third-party intervention between an operating room director and the chief of surgery in a major medical center. (1) The results indicate that this intervention both improved the relationship between the two parties and had a wide-spread impact on the surgery department as a whole.
Background
Practicing physicians have ties to specific, and often multiple hospitals whose specialized facilities they use. Surgeons, for example, depend on access to operating rooms and, therefore, tend to associate with multiple institutions. Some have enough clout to demand from their hospitals special or extra resources and privileges. If such privileges are denied, they often threaten to move their patients to a different hospital more willing to meet their demands. Furthermore, a physician who has ties to high levels of authority within the hospital administration can use these connections to bring pressure on the staff to comply.
Such was the situation faced by Lincoln Hospital, a for-profit hospital that had several hundred beds to fill. The hospital's administrators, including its previous president, had usually complied with the demands of its surgeons, even reassigning or dismissing staff members with whom some surgeons did not like to work. The hospital's current president felt similar pressure but was reluctant to satisfy unreasonable demands or to lose control of hospital administration and policy to surgeons.
One specific challenge illustrating the problems
faced by this president was the conflict between the hospital's operating room
(OR) director and an orthopedic surgeon who enjoyed hospital privileges. Mary, the strong-willed OR director, was a
conservative, no-nonsense administrator, who strictly followed all the hospital's
polices and procedures. She felt that
her consistency and impartiality in her dealings with both staff nurses and
surgeons were personal and professional strengths, and that her decade-plus
history of trust from the administration, respect from the OR staff, and good
interactions with at least some of the physicians justified her management
style. Other physicians, however,
disliked Mary for her strong will and what they saw as inflexibility.
Don, an orthopedic surgeon, had long and often
spoken critically about the hospital.
The hospital administrators, while recognizing his professional
competence, had strong misgivings about his generally abrasive manner toward
professional staff. The nurses'
reaction to him was fear.
In
contrast, Don's physician peers valued these same abrasive qualities. Don was
articulate; moreover, he had access to the president and went to bat for his
fellow surgeons. His peers perceived that these qualities, together with his
aggressive approach to everything he did, would help represent them in dealings
with the hospital’s administration. Also, Don’s large practice provided him
with professional security. So he felt free to engage in, and powerful enough
to win, battles with the administration that his peers were reluctant to take
on. Finally, Don shared the other physicians’ dislike of Mary and wanted her
removed as OR director. For these and other reasons the physicians saw fit to
elect Don chief of surgery.
Still, the president himself was unwilling to
remove Mary from her position.
Satisfied with her performance generally as he observed it, he had
concluded that responsibility for the problems in the OR rested on the surgeons
as well as the nurses, not just on Mary alone. Furthermore, finding a new OR
director would not be easy. Therefore,
he directed Mary and Don to come together and resolve their problems; the
status quo was simply not an alternative.
Mary felt that it was futile to expect
any positive outcome from meeting with Don. For his part, Don could see only
loss of power and influence if he yielded any ground to Mary. The hospital’s
president had made it clear that they must reach a resolution, and the
situation itself demanded a change, but the total lack of trust between them
made it unworkable for them to meet alone.
Accordingly, Don and Mary agreed to have three hospital vice presidents
participate in their meetings as neutral observers to help them resolve their
differences. But the first meeting only worsened the situation. The two parties
wasted the time defending themselves and attacking each other, with much
shouting and no actual listening. All
attempts by the three observers to defuse the situation and move toward
compromises were only seen by each party as taking the side of the other.
As a result of this first disastrous meeting, a
skilled consultant was brought in as a neutral third party. He interviewed
first Don and Mary and then 25 surgeons, nine surgical nursing managers, three
vice presidents, and the president. Now the real problems, extending well
beyond the personal difficulties between Mary and Don or issues in the OR, came
to light for the first time.
Two positive findings emerged about Mary and
Don, personally. One was that technical competence in their respective
professions was not at issue. The other was that each saw that the problems
were major, and did want to resolve them. Nevertheless, differences in
personality and perceptions were enormous. Don wanted to make an example to the
rest of the medical staff by firing Mary, even though he admitted that only
some of the OR problems were due to her shortcomings. Mary, to her credit, did focus on Don alone; but she saw him as
an abusive, arrogant, egotistical clod unwilling to actually listen to input
from anyone else. Each had a strong need to control others, coupled with a
strong unwillingness to be controlled.
Their only meeting ground was a desire to resolve their differences.
It further
emerged that the conflict between Don and Mary was only the tip of the iceberg.
During the previous eight months, for various reasons, but at least partly in
response to verbal abuse of nurses by physicians, more than a third of the OR
nurses had quit, and the OR was still short seven surgical nurses. Because of
this turnover, and the replacements' lack of training and experience, the
general level of skill among the staff had been compromised--and with it,
patient care.
Don, in voicing his own feelings, spoke
also for many of the other surgeons:
I
don't think the administration has a clue as to how urgent this matter really
is. It takes at least five years for a surgical nurse to gain the necessary
skills to be useful. In the last two months, we have lost some of the best
nurses I have ever worked with in my life. As a result, I have had to start the
training process all over again. It has seemed like I've been working with a
group of student nurses! This turnover has cut my productivity by more than 50
percent. (Boss, 1989, pp. 29-30.)
Management of the OR also suffered
serious problems. On not just a few occasions nurses had failed to provide
equipment needed for surgery. Orthopedic surgeons had found in the middle of an
operation that the needed prosthesis either was the wrong size or had not even
been ordered. This, of course, caused needless pain and stress to the patient, and
great loss of time and resources on the part of the surgical staff and
hospital.
But many frustrations voiced by
physicians were directed not at OR nursing staff or general hospital staff, but
at other physicians. More than a third of the surgeons were labeled by their
own peers as perfectionist prima donnas who took no responsibility for their
own dysfunctional behavior, even while complaining about the same behavior in
their peers. Blind to their own selfishness, most of the surgeons felt that
their own time was far more important than anyone else's, and complained
bitterly when their schedule was delayed or things didn’t generally go
according to their wishes. Scheduling
in the OR had become a great problem; the tardiness of whoever was scheduled first
bumped all the subsequent surgeries for that operating room and also forced
postponements of surgeries in other rooms because the scheduled nurses were
still tied up with earlier operations not yet completed. Curiously, the loudest complainers were often
the greatest offenders.
Rather than changing their own behavior
and working constructively to resolve problems, the surgeons mostly just
engaged in gossip and backbiting. Much of their hostility was directed unjustly
at the nurses. Consequently, morale was
very low. Physicians and nurses ignored each other rather than cooperating, and
both groups saw the administration as ineffective in doing anything to relieve
the situation. Worse yet, two groups of surgeons were planning to build their
own outpatient surgical centers.
Because of Mary’s responsibility for the
OR, and Don’s position outside the formal authority structure of the hospital
(which meant he couldn't be forced to do anything), the first step in problem
resolution was for the consultant to see whether Don and Mary even shared any
commitment to improving their working relationship. They did. Both Mary and
Don privately defined the kind of help they wanted and explained how they
wanted it to be given; they pledged to do all they could to make things work,
on condition that their basic values be held inviolate.
The
Intervention
The strategy for helping Don and Mary improve their working relationship rested upon (a) sharing perceptions, (b) identifying problems, and (c) following-up ( Fordyce & Weil, 1971). Specifically, Mary and Don responded in writing to three questions:
1.
What does he or she do well?
2.
What do I think I do that that bugs him or her?
3.
What does he or she do that bugs me?
Then Mary and Don each explained their responses
to the consultant while the other listened. To negotiate around their mutual
hostility, the consultant first had them talk only to him. Their responses are shown in Figure 1.
Figure 1
Participants’ responses to questions in
the third-party consultation model.
1a. What does Mary
think Don does well?
·He is very concerned about patient care.
·I admire him for his skills as a surgeon. I would have no
problem sending a member of my family to him.
·He is interested and wants to work out issues that we have
with each other.
·He can be very gentle and considerate at times.
·He is well respected for his skills by his peers and by the
OR nursing staff.
1b. What does Don think that Mary does well?
·She is honest in her work.
·She has met my needs in orthopedics in getting us the
instruments and equipment we need.
·She has a lot of external pressures on her and she has
handled them well.
·She deals well with the various groups that are pulling at
her: patients, staff, administration, and physicians.
·She manages the overall picture very well in the OR.
2a. What does Don
think he does that bugs Mary?
·I am impatient. (Mary agrees)
·I am demanding of personnel in surgery, but everyone can't
always get what they want, when they want it. (Mary disagrees)
·She is uncertain about how much I am willing to support her
this coming year. (Mary agrees)
·I am not the best listener. (Mary agrees)
2b. What does Mary
think she does that bugs Don?
·I don't listen to him. (Don agrees)
·I appear defensive at times. (Don agrees)
·My response to some directives is too detailed. (Don agrees)
3a. What does Mary
do that bugs Don?
·She is difficult to communicate with. I can talk to her, but
I am not sure that she is listening.
·She doesn't assume the responsibility for some specific
problems, such as not being able to do an operation without a full set of
prostheses available.
·She doesn't effectively manage the personnel that she
supervises in OR. Specifically, there is a great deal of disruption that is
going on. And there are also morale problems among employees, caused by their
lack of trust of her and her lack of trust of them in the OR.
3b. What does Don do
that bugs Mary?
·He generalizes and is not very specific with examples, even
when questioned.
·The staff labels him as a whiner, in terms of nothing is
ever right; his complaining, etc. This also relates to laying out problems and
then walking away.
·He sometimes says one thing but means another; he gives
mixed messages. For example, I ask him how things are going, he says fine, but
I then find out that he has problems later in the day.
·I do not feel a full measure of support from him, and that
bugs me.
·He doesn't always listen (Boss, 1989, pp. 32-33).
An essential benefit of this design was
that the writing down of specific liked and disliked behaviors introduced an
element of rationality into an otherwise emotionally weighted process;
subjective statements, value judgments, and gross generalizations were
unacceptable. By listing their observations, each realized that the things that
actually bothered them about each other were not permanent and irremediable, as
they had imagined. Also, the simple act of writing things down diffused
hostility by guaranteeing that each would be able to tell his/her own story without
interruption; afterwards, each was more willing to listen respectfully.
By allowing both participants to
concentrate on the positive aspects of their relationship, the design helped
each to dampen hostility toward the other’s negative traits and to begin
cooperating. Don later commented:
I
was stunned to hear her say those positive things, particularly the part about
me taking care of her family. For a long time, I had seen her as my enemy, and
I expected only the worst. I was amazed that she had so much respect for me. As
a result, many of my negative feelings for her began to disappear. It is really
tough to stay angry at someone who says so many nice things about you. I also
found that I was much more willing to listen to what I do that bugs her.
Somehow, criticism is always easier to take when it is accompanied by something
positive (Boss, 1989, p. 34).
The second question forced them to
examine their own inconsiderate behaviors in detail, as neither had been
willing to do earlier. Mary explained:
It
had never really occurred to me that I may be doing something that caused Don
to react that way. Vaguely I suspected that I may be doing something that he
didn't like. But I was hard pressed to identify what it was. I really had to
stand back and say to myself, "What is it that I am doing that is making
this working relationship go sour?"
I had spent so much time concentrating on what he was doing that bugged
me that I hadn't looked at myself (Boss,
1989, p. 34).
Once they discovered that they had been far less hard on
each other than on themselves, the subsequent criticisms they did pronounce
upon each other seemed, by comparison, much less offensive. This question also
helped each come to appreciate for the first time that neither had been intentionally
causing problems for the other. Consequently each became willing to begin
giving the other the benefit of the doubt.
Mary and Don’s responses to the third
question were listed on a large sheet of paper. Each then indicated the
intensity of his or her dislike for a particular behavior by an arrow whose
length indicated the perceived magnitude of the problem.
Both were surprised to realize that some
behaviors offensive to the other could be corrected immediately, even though
others might take longer. Each discovered major barriers that needed to be
removed to improve their working relationship. And this cooperative process
continuously helped each to begin to trust the other. Both came to realize that
neither could improve their mutual relationship nor resolve problems in the
department without full cooperation from the other.
Each was asked to develop action items in
response to the following questions:
·What
will I do to help resolve this problem?
·What
will the other person do to help me succeed?
Through this process, both participants
changed from competing to collaborating. Each defined the specific behaviors he
or she wanted the other to change, and also negotiated those behaviors he or
she personally was willing to address. In effect, each informally contracted
with the other to reduce or eliminate identified problems. The consultant
documented their decisions. At the meeting’s end each received a copy of the
agreements.
The consultant and the three observing
vice presidents met with Mary and Don every three months for one year. Before
each meeting, the consultant interviewed each of the five people privately to
evaluate progress. The agenda for each
meeting began with a review of commitments made and kept. The follow-up
included a status report on how Mary and Don were improving their interaction
and what was happening in the OR. Each reported specific behaviors of the other
that he or she noticed and appreciated, as well as positive things that had
taken place in the department because of those behaviors. Where commitments had not been kept and
progress was less than desirable, plans were made to ensure future
follow-through. To their credit, both Mary and Don had in almost all instances
acted as they had agreed to do. This adherence to agreements from one quarter
to the next continued to build interpersonal trust and strengthened the
foundation for further identification of problems and planning of new or
continued action.
Methods
The
major instrument used to measure the effectiveness of this intervention was
Friedlander's Group Behavior Inventory (GBI).
All subjects were asked to complete the instrument with the other person
in mind, and some of the questions were slightly modified to reflect a group of
two people. The GBI (Friedlander,
1968) measures group performance and group interaction in an organizational
setting. The six dimensions or
subscales include Group Effectiveness, Leader Approachability, Mutual
Influence, Personal Involvement and Participation, Intragroup Trust, and Worth
of Meetings.
The participants also responded to four
additional questions designed to measure the degree to which they worked
effectively together, the honesty of their communication, their comfort in
discussing organizational problems, and their trust for one another.
Respondents rated these questions from 0= Not
At All to 10=Completely. The questions were phrased as extremes
(e.g., "The degree to which you
trust [the other person].").
Mary and Don completed the instrument
three times: immediately before and after the intervention and one year
later. The Comparison Group members,
made up of an OR director and chief of surgery in a sister hospital in the same
health care system and located in the same general geographical area of the
U.S., completed their questionnaires one year apart. All data were analyzed by one-way ANOVA (analysis of variance) (Winer, 1991). (2) The design of this
study is shown in Figure 2.
Figure 2
Design for data
collection.
Time in Months
0 1 2 3 4 5 6 7 8 9 10 11 12
E1 O1X1O2-------------------------------------------------O3
C1 O1--------------------------------------------------------O3
O1 = Pre-intervention measure
O2 = Post-intervention measure
O3 = 1-year after measure
X1 = Third Party Intervention
Results
Several
factors suggest that the third party intervention reported in this study played
a significant role in improving both Don and Mary's working relationship and
the effectiveness of the department as a whole. First, Table 1
contains the one-way ANOVA results on the six GBI subscales for Don & Mary
and the Comparison Group.
Figure 3
Presents the mean GBI scores for each
subscale in a graphical format, and Figure 4 shows the same information for the
Comparison
Group. The data show a statistically
significant improvement between the Before and After measures and a continued
improvement during the following 12 months, while the Comparison Group shows no
statistically 
significant differences during the
12 month period.
