ASA Meeting Review

Communication Leadership in the Perioperative Setting: Managing Conflict and Dyscommunication

Reviewed by Rita Agarwal MD, FAAP
Stanford University Medical Center
Stanford, CA

There are many books and seminars on communication leadership in the business world. That is perhaps, not surprising, since many businesses will have conflicting goals, products, consumers, clients and agendas. In medicine that should not be the case, after all our “product” is the same – “excellent”, “optimal”, “world class” patient care; our consumers or clients are (or should be) our patients. Ideally our agendas and goals should be aligned.  Of course, in our real world perioperative environment that does not always happen.  I have been lucky enough to be part of a workshop developed and run by Drs. Susan Staudt (Children’s Hospital Milwaukee), Meir Chernofsky (Uniformed Services University) and Neil Farber (Wisconsin) on communication leadership in the perioperative setting. This was an interactive workshop with lots of table top and group activities discussing vignettes and analyzing common situations in the peri-operative setting. Unlike many other communication workshops it focuses specifically on anesthesiologists and their interactions with the rest of the health care team.

At the very core, there are two basic types of conflict: Task Associated conflicts (equipment not ready, patient not transported, surgeon late, no ICU bed, etc.) and the Interpersonal conflicts (criticism in public, misuse or abuse of position). Task Associated conflicts are usually easier for us to deal with, but if persistent or unresolved, can lead to interpersonal conflicts.

Poor or inadequate communication underlies many of the situations that lead to conflict. A study of communications between all the personnel in an OR showed at least 30% of all communications in the OR failed and of those 1/3 lead to patient harm (Qual Saf Health Care 2004, 13, 330-4). The failures were classified as occasion, content, purpose and audience. Occasion involved poor timing of the communications; content failure was when information was missing or not accurate; purpose included situations that were not resolved; and audience failures occurred when key personnel were missing from the discussion.

Another major factor in conflict creation is emotion and interpretation of intentions. “If we bring the patient down now, maybe we have a faster turnover than the last case”. You want a faster turnover, but your nurse may perceive this as a criticism of her and feel hurt or upset. This tends to happen more with people or situations we are unfamiliar with or with people and situations we do not like or trust. It is important to be aware of our biases (implicit and explicit) and strive to be transparent, predictable and clear.

Participants of the workshop were asked to take a conflict inventory (Thomas Kilman Inventory-TKI) that characterizes their approach to difficult situations. There are five major modes of conflict resolution:

• Avoiding
• Competing/Forcing
• Collaborating
• Accommodating
• Compromising

Each person tends to have more than one conflict resolution style, but usually one primary style and one or more secondary style(s). All the styles may be appropriate at times, and all may have negative consequences when overused. There are some situations in which there really is only one good choice. For example, if your morbidly obese patient with OSA and poorly controlled diabetes undergoing a Whipple needs to go to the ICU but the ICU is full,  avoiding (hmm let’s just wait and see what happens), accommodating (well maybe we can try to follow him on the floor with additional monitoring), and collaborating (how about I help work with the intensivists to discharge another patient) may not work. You may have to FORCE the issue (we’ll be happy to anesthetize this patient as soon as there is an ICU bed available…..).

Communication in the perioperative setting should be easy, but it is not. More often than not when conflict arises, there can still be a lot of finger pointing and blaming, “Well we would have brought the patient in on time, but the nurse didn’t have……..” or “Well we were waiting for anesthesia………..”. Poor conflict management in our work environments can lead to poor morale and has been shown to have a direct effect on patient outcome and quality of care. Learning and practicing simple conflict resolution techniques can have a huge impact. Dr. Farber discussed positive psychology and the importance reframing negative actions into positives to avoid or prevent conflict. Ascribe good intentions and motivations instead of assuming bad. “She must hate me. She always criticizes my set-up” can be reframed as “Wow, she really cares about my education and is making sure I can take optimal care of this patient”.

Finally, a summary of the ANTI-PRINCIPLES; how to stir up conflict, anger people and lose friends:

• Make listening and speaking difficult - attack, provoke, confuse, ignore, judge, act on assumptions and make suggestions instead of listening (sound like anyone you know?)
• Ensure stagnation or destructive escalation - be rigid, assume useful dialogue is impossible, ignore your contributions to the problem, blame, shame and humiliate.
• Prevent positive developments - ignore conflict, assume there is only lose-lose, vague promises and agreements, ignore potential future problems.

Just to finish on a positive note the Principles of Conflict Resolution are the opposite of the ANTI principles:

• Facilitate listening and speaking - don’t hear the attack, don’t attack, assume the best, acknowledge emotions, LISTEN, differentiate between needs and wants, test your assumption, differentiate between evaluation and observation.
• Change the conversation - be curious, assume a dialogue and solution is possible, don’t make things worse, forget fault.
• Look for ways forward - acknowledge and expect conflict, assume undiscovered options exist, plan for the future, be explicit.

For more information and references please feel free to contact me at agarwalr@stanford.edu or Susan Staudt (the real expert) at SStaudt@chw.org.