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Smithtown Cancer Center: Charlene Morgan and Nancy Steele are nurses on the same unit who typically work the same schedule. Nancy can't believe they both attended the same school and the same chemotherapy certification course. She thinks Charlene's patient care is lacking, and it is tough to make sense of her documentation, even though their unit uses a well-designed flow sheet. Patients seem to like her, commenting on her warmth and caring. But Nancy is uncomfortable with her standards, and has complained to the Nurse Manager twice. Nancy has hinted to Charlene at least three times about this and nothing has changed. She is frustrated! Hospital A, Surgical unit, 4-C: Michael Johnson has just left a monthly unit meeting with his new nurse manager, Marlys Stone, and is quite upset to discover that she has agreed to the implementation of Dr. Jones' post op protocol without consulting the nurses. In two weeks the staff are supposed to begin accepting Dr. Jones' patients, because, according to him, "4-C provides better care" than 3 North, where they would normally be admitted. This protocol requires more intense monitoring and documentation during the first 4 hours post-recovery than the "routine" patient on 4-C. Marlys has copied the new protocol for every member on the unit, and attached a note at the top stating that she expects this to begin in two weeks, on the day shift. When Michael talks to Dr. Jones, he says that changing the protocol was the hospital's idea, but that he is "fine with whatever Administration wants to do". Where do you begin? The Practice Partners: Joanne Wilson, RN and Linda Brown, LPN, have been paired as Practice Partners on their unit for the past three months. (Their state's Nurse practice Act includes a delegatory clause which allows RNs to delegate nursing care to individuals under their supervision, as long as certain requirements for training and ongoing evaluation of the person being supervised are met.) As Practice Partners, they work the same schedule, and together, care for a larger group of patients than either one of them could handle alone. Linda has complained to Kate Jones, the Nurse Manager, at least twice about the partnership, in particular, that she felt stifled. When Kate checked with Joanne, her reply was that "everything's just fine. Our patients aren't complaining, are they?" Kate has encouraged Linda to go along with it a little longer because partnering is still somewhat new to everyone and she knows that Joanne is really committed to making the concept work. The structure and size of the nursing unit do not allow for a change in partners, and Kate is very anxious for Joanne to have a good experience with this. Joanne is one of her most positive and motivating staff. Linda seeks Kate out one more time to tell her that she really needs help with the partnership. She tried telling Joanne about her feelings, but Joanne simply replied "I'm sorry you feel that way, but I have my responsibilities and license to look out for. " Each of the above scenarios is an example of a conflict that can be resolved using the techniques of alternative dispute resolution. Alternative dispute resolution (ADR) refers to any procedure, other than litigation, which can be used to resolve disputes. Two of these case situations will be further developed in this independent study module to demonstrate the application of ADR concepts. The state of today's health care delivery in the United States is characterized by turmoil, confusion and frustration. It seems that everyone is affected; patients/clients, direct care providers, administrators, insurers and even regulators. ADR is important to nurses and others providing health care for two important reasons. First, conflicts will always be with us and they are only likely to increase in health care for the immediate future. Second, using conflict resolution methods that are quick and less adversarial than litigation can help us respond rapidly to change, and maintain the relationships that are so necessary for our future survival, not to mention quality of work life. The increasing number of health care mergers has shown us that today's enemy may well be tomorrow's partner. The last century witnessed several important trends in the United States that have advanced the study and application of conflict resolution strategies. In the 1920s and 30s, collective bargaining was implemented as a way to try to control the violent labor conflicts that were common occurrences. This led to the use of arbitration to settle disputes, and the passage of the National Labor Relations Act in 1935, which protected the right of workers to bargain collectively to improve working conditions. After and between World Wars I and II, the scientific study of methods to avoid war was begun in earnest. The Journal of Conflict Resolution was first published in 1957. The 1960s saw the dawning of the civil rights era and other popular empowerment movements, such as women's rights, environmental protection and peace causes. Because these movements increased levels of public conflict, they also spurred interest in developing new approaches to conflict resolution. From1960 to the 1990s, the number of civil lawsuits between private citizens skyrocketed. Approximately 18 million new lawsuits are filed in our nation's courts annually. The median time between the date a lawsuit is filed and the beginning of a civil trial is 2.5 years. Today it is estimated that direct litigation costs, plus insurance premiums, amount to between $50-80 billion a year. (Crowley, 1994).(1) In 1990 and 1996, the federal Dispute Resolution Acts authorized and encouraged federal agencies to use ADR processes as much as possible to informally resolve agency disputes. Litigation in health care is also on the rise. Since 1960, malpractice premiums have increased at least 100 times. (2) Once, "protected" by the hospital's deep pockets, nurses now are increasingly named as defendants. William McDonough, senior vice president for Marsh, Inc., the world's largest insurance brokerage firm, estimates that lawsuits naming nurses as defendants have increased at least ten percent since 1995.(3) Although the financial and personal costs of being involved in litigation are dramatic and frightening, ADR techniques can provide options that give much more control of the outcome. ADR techniques themselves are also appropriate for those circumstances that do not approach the likelihood of litigation; those day-to-day irritating conflicts and tensions in the workplace and beyond. ADR has applicability in every segment of a nurse's life. As much as we try to convince ourselves that it is possible to live in a conflict-free world, there is not one shred of evidence to support this idea. Conflict is inevitable, a fact of life. But we have many choices about how to respond to the conflict. We can ignore the conflict, confront it head on, attack the person on the other side of the table, work to resolve it or wait it out, to name just a few. Most people would agree that working it out is the most appropriate response, but the mechanics of working toward resolution are often unknown to us. How we handle conflict determines whether it is productive or non-productive. Productive conflict encourages us to solve the problem at hand and maintain or improve our relationship with others in the process. In addition, productive conflict may also lead to solutions that give us much more than we initially thought we could have. In the common negotiation parlance, productive conflict may end up "expanding the pie" rather than dividing it, and when that happens, satisfaction about the outcome far outweighs the initial tensions about the conflict. It is important to keep in mind that not all conflicts can be resolved, such as some deeply-rooted values conflicts for example. In these situations, people have to learn to live with the tension and manage the differences. Oftentimes, these situations need legislative remedies. But beyond the areas where ADR is not likely to be effective, there are many situations where it can work. Good communication is a concept that is critical to the success of any conflict resolution endeavor, particularly when tensions are high. Too many people focus on the skills related to debate and assertiveness. However, the communication skill that is most important to any ADR process, as well as the one most overlooked, is listening. Listening allows us to gather more information about another's point of view, and helps demonstrate that he or she has been heard. Understanding the other side's point of view is more important to arriving at a successful outcome than arguing one's own point of view. Alternative Dispute Resolution As mentioned earlier, ADR is the use of techniques other than litigation, to resolve conflict. Some people suggest that ADR should stand for "appropriate" dispute resolution, because although litigation is used to excess in the United States, it is not appropriate for every dispute. There are many options besides litigation to deal with conflicts. They include negotiation, facilitation, mediation and arbitration. Negotiation is the key process used to some extent in almost any ADR technique. Negotiation is both a separate process as well as one which is imbedded in the other techniques. Negotiation is the process that two or more parties use to come to an agreement, whether or not there is the perception of a conflict. There are no "official, standard" rules about how to negotiate, although there is a lot of propaganda surrounding the concept. In win-win negotiation there are no "secret weapons" other than to try to make sure that all parties are satisfied. In short, whatever the parties to the negotiation agree is fair is what the outcome will be. There are no rules about where a negotiation should take place, how long it should last and who speaks first. The parties have total control over the process and the outcome, and that is its main attraction. Facilitation is the process used to help others with an aspect of group process such as decision making, strategic planning or team-building. A facilitator is typically an outsider who is not involved in the ongoing group activities, but occasionally a group member can serve this function as well. As in negotiation, there are few rules, but the parties have given up some control. The group is no longer completely in charge of the process. The facilitator may be an expert in some form or style of decision making, although the outcome is usually within the total control of the group. Facilitation is appropriate when a group seeks to take on new directions and needs everyone who is a member of the group to be able to participate fully in the group. Facilitation is usually chosen when there are no apparent conflicts within the group or specific positions in a conflict have not emerged. Mediation is the process used to help two or more parties come to an agreement. Typically the parties have tried to negotiate on their own, but it has not been successful. At this point, a conflict has escalated and the parties have specific opinions and positions about what should be done to resolve the conflict. The mediator is a neutral third party who assists the conflicting parties to arrive at an agreement through negotiation. "Neutral" means that the mediator has no investment in the outcome that is reached, but he or she does care that the process is fair and that it is followed. The mediator typically sets the stage and ground rules for the working sessions, controls the communications, separates the parties if needed, clarifies any vague aspects of a tentative agreement, leaving the parties free to participate fully in the discussion. A mediator may suggest that participants brainstorm ideas, or argue for each other's positions for example, which are things that two people negotiating for their own interests would have a difficult time doing. A mediator is a process expert. The parties have complete control of the outcome, but less control of the process. In this way, mediation and facilitation are similar processes, except that mediation usually involves the presence of a well-defined conflict, and facilitation does not. Arbitration involves the use of a neutral third party (usually an individual, sometimes a panel of three or five persons) who makes the decision for the conflicted parties. The arbitrator has control of the outcomes, and control of the process to the extent that the parties have given him or her control. For example, Mr. Jones and Ms. Smith have been unable to come to an agreement in mediation. In developing the agreement to mediate, they decided that they would submit their problem to arbitration if they were unsuccessful in reaching an agreement through mediation. They then follow the process they had developed to find an arbitrator and give him or her the guidelines they want to follow in the process of arbitration. If the parties have no specific wishes in terms of how the process should occur, the arbitrator will typically offer rules or guidelines h/she has used in the past. The American Arbitration Association offers guidelines for the mediation and arbitration of all kinds of disputes, and they are available at www.adr.org There are two types of arbitration, binding and non-binding. Binding arbitration means that the parties have agreed, in advance, to be bound by the arbitrator's decision, regardless of the outcome. Binding arbitration agreements are not appealed or overturned, except in very limited cases, such as incompetence of the arbitrator. Non-binding arbitration is more advisory. The parties can agree to accept the decision or not, as they see fit. It is important that the parties understand whether the arbitration is binding on non-binding before agreeing to participate. Consultation with an attorney regarding binding and no-binding arbitration in the state in question is advisable. Of the forms of ADR presented, arbitration most closely resembles the process of litigation, but there are some important differences. The process of discovery is significantly limited in arbitration, thereby shortening the time involved. The procedures for the arbitration hearing are much less formal than the courtroom. Table 1. ADR options
The benefits of using ADR are both tangible and intangible; reduced time, reduced cost, control of the outcome, maintaining relationships and empowerment. Reduced time: Time is a very significant issue when considering the use of ADR techniques. Given the typical length of time from a lawsuit's filing to the actual beginning of a case, parties in a lawsuit often complain about being burdened with the pressure of a case for a very long period of time. This quote from a nurse involved in a lawsuit is typical. "My life was totally consumed with thoughts about this case. I lost my ability to enjoy things that were a pleasure before the suit, and my focus now is solely on the outcome of the trial." (4) The longer the time between the notice of a suit and its conclusion, the greater the burden as well as the emotional effect. Time is shortened dramatically because the lengthy process of discovery does not occur, or it is significantly reduced, as with arbitration. There are no cumbersome court schedules to navigate, and generally fewer people involved. Reduced cost: "Time is money" is a familiar saying, and when time is reduced, money is saved. Costs can also be avoided because attorneys are usually not involved in each step of the process, as they are in litigation. It is important to note that many ADR practitioners are attorneys, and although their hourly charges may be the standard attorney fees, the number of hours devoted to an ADR process is significantly less than litigation. Other ADR practitioners' fees may be nearly as much as attorneys' fees, but still the time invested is less than litigation. Although litigation is not the method of choice when resolving every conflict, it is crucial to make sure that the parties' rights are protected. This is the natural role for attorneys in the process. Sometimes it is as limited as reviewing a draft agreement before the parties sign it. At other times an attorney may be the ADR practitioner, because of his or her special interests and skills. Still another way is for parties who are in negotiation, mediation or arbitration to agree to have their attorneys present during some or all of the meetings. Who pays for what services is a common question. In facilitation, the group collectively or the institution might pay a facilitator as part of a leadership development budget, for example. In negotiation there are generally no neutral's fees to pay, although part of the agreement may involve paying a third party for an expert appraisal or opinion. However the negotiators agree to pay is up to them. Mediators and arbitrators typically use a formal agreement, and will ask the parties to sign it before the processes begin. It is typical for parties in mediation to split the expense, and they may be asked to pay the mediator's fees at the beginning of each session, recognizing that the mediator has no control of the outcome of the process and the parties' satisfaction with it. It is common for the arbitrator's fees to be shared between the parties, and paid before a final report is issued. Different methods of handling fees can be created, depending on the relative power and financial resources of the parties involved. Some institutions or agencies will have members of the staff or the Human Resources Department prepared to function as facilitators, mediators or arbitrators. In this case, fees are generally not paid because the providers are salaried. Control of the outcome: When a plaintiff hires an attorney to file a lawsuit, the plaintiff usually believes he or she has a winnable case with great merit, and the jury in its wisdom will come to that decision without much trouble. But there are many unknowns in the process, and the ultimate control rests with the jury, sometimes the judge. In litigation, the plaintiff essentially gives control of the process to the attorney, believing that the attorney will be a more powerful advocate for the individual than the person him or herself. Besides having very little control over the outcome, another disadvantage of litigation is that the outcome itself ("remedy") is usually determined by law. And in civil cases, that outcome is usually money. Rarely do cases go to trial where there are not other issues more important to the plaintiff than monetary damages. Health care disputants often want an apology, an admission of wrongdoing, explanations or to be treated with respect. Those outcomes are not likely to be satisfied with litigation. But they can be with ADR because people can express those needs directly to each other or through a neutral third party. And conversely, using ADR methods can result in similar large financial awards as in jury trials. In the case of medical malpractice cases, people can still have their financial needs met using mediation or arbitration. An additional outcome to consider is that of confidentiality. The process and results of a lawsuit are public information, and open to public disclosure. Negotiation is private and only known about by others if the parties disclose information themselves. Mediation is a confidential process, the details of which are not discoverable later in court. An agreement arrived at in mediation, if it is filed in court, is public information, but the agreement does not include the details of the discussion. Mediators have an ethical responsibility to maintain confidentiality. Arbitration is confidential to the extent that the parties structure it is as such. They can ask that the arbitrator publish only a conclusion in his/her report, and not put any details of the discussion in writing. In both mediation and arbitration, all parties are expected to keep any of the discussions confidential. In a public courtroom, no one is asked to observe confidentiality. Maintaining relationships: One of the most powerful benefits of ADR methods is that relationships can be maintained much better than when using litigation. Litigants commonly talk about how much they have come to despise each other in the process. The conflict has only escalated during the process of preparing for trial, and people often think they have too much invested in the trial to consider the option of turning back. At this point, relationships may be so damaged that they are irreparable. In contrast, ADR methods try to keep parties talking together whenever possible, and because they address issues that are important to people as people (an apology, for example), the likelihood of not damaging relationships further, and even improving them, is enhanced. Empowerment: Another significant, thought less than obvious benefit of ADR is its ability to empower people. This empowerment takes two forms. First is the sense of empowerment that comes from negotiating one's own problems, even though a neutral third party may have assisted in the process. Second is the power that comes from having participated in an easy to learn process so that the parties may try some of the techniques on their own in the future. Negotiating the use of ADR may be prohibited under some circumstances, for example, in a collective bargaining agreement. In that situation the grievance procedure details how the conflict must be handled. It is possible that the grievance procedure itself will include the use of mediation and/or arbitration, but that use of ADR has already been negotiated as part of the collective bargaining agreement. If ADR has so many benefits, when is litigation preferred? Litigation is best when there is new law to test, and thus people's rights to carefully protect, or the case is a precedent-setting one. If there are significant power differences, if a public outcome is desirable, and/or if the case is so complicated that discovery, rules of procedure and evidence are needed, litigation is the preferable course. But if the situation is fairly straightforward, the power is fairly well distributed (i.e., both sides have something of value to negotiate with) and there is a need or desire to maintain a continuing relationship, ADR should be considered. Table 2. Appropriate use of litigation
"Negotiation 101" Although there are no hard and fast rules for negotiation, there are four foundational principles designed to increase the likelihood of success. (5) They apply in any situation of negotiation; with children, spouses, business partners, superiors, direct reports, clients, colleagues, legislators and heads of state. When approaching a situation of simple negotiation between two parties, one person might suggest that they both read a basic negotiation book, such as Getting to Yes (6) before beginning. 1. Separate the people from the problem In any conflict of consequence, people who are on opposite sides of the issues begin to have tension with each other, and may even find they are beginning to dislike a previously likeable associate. It is important to remember that the person you are having conflict with is not the problem. He or she shares a part of the problem, just as you do, but he or she is much more than the problem. One way to do this is to mentally put yourself on the same side of the table as the other person. Visualize both (or all) of you looking at the problem together, studying it, turning it over. Imagine yourself united with the other person to figure out a solution that benefits everyone, not just one side. Even though the other person may have a personality you find difficult to deal with, or feelings have been hurt, the situation will not improve by your focus on his or her unpleasant characteristics instead of the problem. 2. Use interest-based bargaining This principle is perhaps the least understood, and yet it has the greatest potential for impact. When people begin to bargain for something, they typically focus on what they want, such as five hundred dollars, an apology or a surgical bill covered. This is called a position. People come to a decision about what they want based upon how well it satisfies a particular need. That need is called an interest. Our common experiences with negotiation are positional rather than interest-based. Think of the stereotype of the car salesman before the days of the fixed price offer. Negotiation occurred in a series of predictable steps, similar to a dance, with the salesman lowering the purchase price and the buyer increasing his/her offer incrementally. Very often an unwritten rule creeps in suggesting that the ultimate ending point is splitting the difference. Consider for a moment a hypothetical interest-based negotiation. The buyer might say that he or she is interested in a car that satisfies the need to maintain a certain level of car payment, that it fits his image of being a "sporty type", and that it should be dependable and easy to maintain. The salesman might say that he needs to spend less than three hours on this transaction as well as meet his company's expectation that they receive at least $1000 over the sticker price to cover its cost and his commission. How much simpler transactions would be if people felt they could be express their needs rather than their positions. Interest-based negotiation offers greater freedom and flexibility because more solutions can emerge to address the interests. Focusing on one position essentially focuses on one prescribed solution, stifling the creativity needed to explore other, more satisfying solutions. Interest-based negotiation is also more time efficient, because parties can get right to the heart of what is important to them. Table 3. Positions Versus Interests
3. Invent options for mutual gain When approaching the other person in negotiation, it is common for both parties to simply respond to each other's offers or position. "You want $500? I'll give you $350." A better approach would be first to discuss the interests both of you are trying to satisfy. You may want immediate cash, and not to prolong receiving money. Perhaps the other person will accept a little less because he wants the process to be over with. In selling the computer desk, you discover that the buyer really has no means of getting it home. She may be willing to pay $50 more if you will deliver it. And maybe you are willing to accept payments over three months instead of all at once. You know the buyer. She works with you and you trust that she will meet her obligations to you. In inventing options for mutual gain, first identify each other's interests or needs. Then consider options that will satisfy the interests of all sides instead of simply one. Or if a solution can only meet one party's needs, add an additional component to satisfy the other's. 4. Determine the criteria for success Before beginning a negotiation think about how you will know if it is a success. Will a certain position have to be met? Do you both have to agree that the negotiation is fair? Will you have to try on an ongoing arrangement for two months to see how it impacts your schedule? Thinking about evaluation criteria in advance helps to make sure that it is a well-designed negotiation, and if ongoing, will have a good chance of being followed through. Common Problems in Negotiation What if your negotiations are getting further away from what you need? One approach that helps this process is called BATNA, or Best Alternative To a Negotiated Agreement. The BATNA represents a "walk away" point. If you can't get what you really would like to have to satisfy your needs, at what point do you leave the negotiation without giving everything up? In the case of the car deal, there is a monthly payment the buyer doesn't want to exceed, a color that absolutely does not convey "sporty", and a maintenance and repair report that he considers too risky to purchase. But aside from these exceptions, maybe there is a car that he hasn't thought of that satisfies his needs, and completes the transaction in less than three hours for the salesman. However you arrive at it, you should know your walk away point in advance. What if the other side won't negotiate openly with you? There are several actions you could consider. If you are stuck, agree to take a break. Give yourselves some time before walking away from the conflict. Something else may occur to you to help move you both forward. Remember, negotiation is a process with no rules, and it can feel awkward and messy in the middle. Maybe it is time to re-evaluate your BATNA or talk with someone else. Step up a level, and see yourself as an actor. Are you being as open as you possibly can be? Change the flow of the discussion and ask the other side to tell you what is wrong with your offer. Ask her how her solution satisfies both of your needs. Make it easy to say yes by adding some non-consequential items. Be flexible and stay open to the possibility that the other side's offer may actually satisfy your own interests. Allow the other person to save face. Face saving is one of the most important points is conflict management, and should not be discounted as a trivial issue. Oftentimes people so strongly identify with a position or issue that they interpret your lack of response to their position to be a personal attack. Seldom if ever are these dynamics addressed openly, but an increase in defensive, resistive behavior when everything appeared to be going so well may signal the perception of a face attack. And finally, if you are negotiating by yourselves, consider whether the addition of a neutral third person would help. It is not a sign of weakness to ask others to come in and help. It shows that you value the ongoing relationship and the future possibilities more than the difficulty in working things out. Case A: The Practice Partners Two weeks earlier Kate had attended the negotiation/mediation skills for managers class the hospital offered. She asked to meet with Linda and Joanne together to see if she could help them work out a new agreement. Kate opened the meeting by asking what concerns each had about the partnership. Joanne said she was stressed, but satisfied: Linda said she felt like Joanne didn't trust her. Linda didn't understand why Joanne would not let her give medications independently when the hospital's job description for LPNs allowed it. Joanne replied she had never felt more responsible than in a partnership arrangement. She considered giving medications a perfect time for teaching and assessment, and more importantly, for noticing subtle changes which may be the first warning of a more serious complication. In helping them sort out their interests, Kate helped them see that both wanted the very best for their group of patients, and each wanted to perform to the best of their abilities. In addition she discovered that Joanne was concerned about not being surprised by a sudden change of patient condition, and Linda thought the other nurses must have thought her inept because she wasn't giving medications like the unit's two other LPNs were. Joanne assured Linda that she was very happy with her work, and felt very comfortable with her skills, "but maybe I don't know how to manage everything just right, because this is the first partnership I've been in, and I want it to be perfect for the unit." Kate asked them for some ideas about how they could manage the partnership so that Joanne felt comfortable and prepared to respond to a change in patient condition if necessary, and Linda felt like she was trusted and viewed as competent. Joanne reluctantly agreed that Linda could give all the scheduled medications independently, and the PRNs only after consulting with her. They both thought that the need for a PRN medication might signal an important change in condition. In addition they agreed that Joanne would check in with Linda weekly for the next two weeks about her sense of being "stifled", and that both would follow up with Kate in two weeks, sooner if needed, about the overall expectations for their partnership. Michael Johnson, RN, being upset with his new nurse manager, Marlys Stone, approached her the next day to discuss the protocol and its impact on the nursing staff. He wondered why she felt she could implement the new protocol without consulting the staff first. Didn't she value their points of view? He told her the staff was against following the protocol, and didn't see why it was necessary. Marlys indicated that the overall running of the unit was up to her, and she had been hired to turn things around so that both the physicians and Administration were pleased with the results. Michael was more frustrated when he left the meeting with Marlys, as was she. Marlys talked with the Director of Nursing about the situation, who recommended that she consult Carolyn Bowers, the Performance Improvement Coordinator, to see if she would be willing to conduct a meeting with nursing staff representatives, Dr. Jones and Marlys. Marlys agreed with the suggestion, because she really wanted to correct this problem. Three staff nurses were present at the meeting, one of them Michael, with Dr. Jones and Marlys. Carolyn opened the meeting with her understanding of the purpose. "You have come here to try to resolve the situation about Dr. Jones' protocol. I think I understand the issues, but it would be better if you each presented your view of the situation. I'll record them as you bring them up. Let's start with the staff, then Dr. Jones, then Ms. Stone." As spokesperson for the staff, Michael summarized their concerns. First was the issue of not being able to handle the monitoring requirements with the patient care demands on them at this time. The staff had calculated that the nurse monitoring this patient would be tied up an additional two hours post-operatively, and this could seriously impact his or her other patients. They didn't see how it was possible for a nurse, no matter how skilled, to assume additional responsibilities without corresponding changes in staffing. Furthermore, they didn't believe staffing changes were possible given all the messages from administration about "working leaner". Secondly, they had questions about the studies that indicated this was necessary. Third, and probably most important, they were feeling left out and disregarded because they had not been consulted. As a manager new to the unit and the hospital, Michael stated that they felt Ms. Stone should have relied on the staff more and that were surprised when she didn't consult them at all. It was Dr. Jones turn to speak, and he indicated that he felt somewhat to blame in this mess, that he didn't want to cause havoc with the staff, but he wanted them to know how much he appreciated the care they provided for all his patients before, and now he wanted the very best for his patients by being sent to 4-C. He had a copy of two current studies on small groups of patients about the post-op monitoring and both used the protocol that he was proposing. If he couldn't get the staff to agree to do the monitoring, he would have to take his patients elsewhere. Marlys had two primary concerns; to keep everyone happy, and to do it safely. She just didn't know how she could keep them all happy. Caroyln asked what each one wanted to achieve. Through more discussion, it became obvious that they all wanted the best for their patients, and they wanted to provide safe care to these new post-op patients as well as to the other patients that would be receiving care on the unit. She then asked them to assume for the moment that the protocol would be implemented as printed in the articles. What were the issues that still needed to be addressed to do this safely and effectively? Together they came up with a list of five items: (1) Decide whether the staff needed more education about the protocol (2) Make more monitoring devices available (3) Evaluate CNA assistance available to the monitoring nurse (4) Contact the authors of the two studies to determine how they had handled the situation (5) Project how many patients Dr. Jones expected to admit for this purpose and determine whether additional revenue would be generated to offset the possible cost of adding support staff Each of the participants volunteered to gather more information to address the issues, and they scheduled another meeting in one week to make a decision about implementation of the protocol. Gradually the tension in the room shifted from one of opposing viewpoints to a cooperative approach where everyone's opinion was respected and invited. Each person left the meeting believing they were working on the issue together. Conclusion ADR techniques offer a great deal of benefit for conflicts in health care. Litigation should be used when it is appropriate, but the techniques of facilitation, negotiation, mediation and arbitration should be considered when there is a need to maintain ongoing relationships, reduce cost and time involved, and maintain as much control as possible over the process and the outcomes. Nurses can easily learn and apply negotiation skills to minimize and resolve conflicts with patients, colleagues, administration and other health care providers. Encountering conflict is not negative. Learning to respond appropriately to conflict and thus minimize its impact and preserve relationships are necessary skills in today's health care arena. References 1 Crowley, T. (1994). Settle It Out of Court. New York: John Wiley & Sons. 2 Crowley, T. (1994). Settle It Out of Court. New York: John Wiley & Sons. 3 Stein, T. (2000) "On the Defensive: More Patients are Naming Nurses in Malpractice Suits." (online available: http://www.nurseweek.com/features/00-05/malpract.html) |
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For additional information on the nurse practicing as employee, see Chapter 5 of 
© 2001 American Nurses Association