Transcript Slide 1

Conflict Engagement &
Emerging Communities of
Practice
Debra Gerardi, RN, MPH, JD
June 2009
Center for American Nurses
LEAD 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
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Joint Commission Sentinel Event Alert
Issue 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.
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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
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Conflict Management, LD 2.04.01
“The organization manages conflict between
leadership groups to protect the quality and
safety of care.”
www.jointcommission.com
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“Authentic
accountability,
commitment and
community come from
acts of consent, not
acts of mandate or
direction.”
Peter Block
ANA Nursing Code of EthicsInterpretive 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 decisionmaking is available and provided.
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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.
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“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
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Approaches

Enforcement
 Power-based, not relational
 Focus on right and wrong
 At best, leads to compliance,

not connection
Engagement
 Collaborative
 Focus on contribution and learning
 Opportunity for resolution, restoration of trust
 At best, leads to accountable behavior and connection
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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
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Depth of Engagement
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.
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Building Conflict Engagement Capacity

Collaborative mindset that invites participation

Skills for engaging effectively
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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
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Hickson Pyramid- Vanderbilt
No
change
Disciplinary action / termination
Pattern
persists
Authority intervention/ PI plan
Apparent pattern
Single unprofessional event
Awareness intervention
Informal conversation“cup of coffee”
Majority of professionals- no issues
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Hickson, 2007
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Conflict Engagement Training
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Training as intervention
There are established foundational skills/
theory
Experiential/ skills-based formats
Customize to culture/ group
Qualifications of trainers
Build in assessment
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Conflict Engagement Specialists
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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
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"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
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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.
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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
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Double Loop Learning
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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.
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Chris Argyris
Reflecting on our own contribution
to difficult situations
expands 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
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Conclusions/ judgments about the facts, the other
person are fixed.
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Accusations or attributions of fault or blame are
wrapped around the facts
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All or nothing thinking
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Totalizing descriptions- this version of the story is
the total picture- simplified presentation of a more
complex situation.
A Conflict Story
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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.
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Mediator:
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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.
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Mediator:
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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
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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
“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
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Growing
communities of
practice…
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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
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“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
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“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
EHCCO, LLC
Emerging Health Care
Communities
Debra Gerardi, RN, MPH, JD
President & Chief Creative Officer, EHCCO
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[email protected]
Mobile: (650) 303-7313
Office: Toll free (877) 712-1240
Fax: (650) 745-2673
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