Article From Conflict Management to Healthcare Teams Effectiveness 2017

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From Conflict Management to Team Effectiveness in Healthcare Facilities:
A Comprehensive Approach
By Luis E. Ore, J.D. M.A., Consensus Building & Relationship Management Consultant
This article attempts to describe the foundations for a proposed comprehensive approach to team
effectiveness from a conflict management perspective using diverse frameworks to enhance
teamwork performance in healthcare settings by “on-site” training. Considering the environment
in which healthcare professionals interact, these professionals need to be in tune regarding how
they interact in different situations and how they address challenges on a regular basis.
Developing a framework to accomplish their goals can offer healthcare professionals some
guidance about how to better interact while acting their roles, sharing their diverse expertise and
facing their interaction as a constant learning experience.
Lencioni (2005) affirms that teamwork can be achieved if teams overcome five dysfunctions:
Absence of trust, fear of conflict, lack of commitment, avoidance of accountability, and
inattention to results. Trust is a fundamental condition for teamwork, Lencioni (2005) affirms
“When it comes to teams, trust is all about vulnerability. Team members, who trust one another,
learn to be comfortable being open, even exposed, to one another around their failures,
weaknesses, even fears”. (p.14). Therefore to build trust, more than time, teammates need
courage - courage to be vulnerable. In order to have teams able to overcome the absence of trust,
team members need to shift paradigms and adversarial mindsets. One way to accomplish this
paradigms’ shift is through conflict management training. Everyone has experienced frustrating
feelings when dealing with conflicting situations and the fact is that when dealing with conflict
all of us have an instinctive reaction of whether to fight or flight. Therefore, learning about
dealing with conflict and strategic choices can trigger strategic thinking in the way we interact
with others.
Conflict Management and Interest-Based Negotiation
Conflict management training could start by transferring knowledge and expertise about the
nature of conflict and the typical five strategies of dealing with conflict when assessing the
weight of issues and relationship at stake. Considering the importance of continuous working
relationships, the nature and purpose of teamwork, an emphasis on interest-based negotiations as
conflict management skill might be salient; however, competitive strategies might be an option if
the stakes are extremely high such as life or death and when timely response is an issue. Either
way, a mutual gains approach or interest-based negotiation can be the first option, most of the
time, if the healthcare professional decision-makers have a clear sense of their BATNAs (Best
_____________________________________________________________________________________
* Luis E. Ore is founder of ORASI Consulting Group Inc., a training and development consulting firm specializing in
negotiation, consensus building, relationship management, and conflict prevention. Ore assists businesses with
cross-cultural and international negotiations, strategic alliances, organizational changes, dispute resolution system
design, and foreign direct investment, especially between the United States of America and Latin-American
countries. Ore has Masters of Arts degree in conflict management and in organizational communication, a J.D.
from the University of Lima (Peru), and extensive training in negotiation and conflict management from CMI
International Group, Western Kentucky University, Lipscomb University, and the Program on Negotiation at
Harvard Law School. Ore was Chair of the Association for Conflict Resolution’s International Section and an active
associate of the American Bar Association. He can be contacted via email: oreluis@hotmail.com

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Alternative to a Negotiated Agreement). Training healthcare professionals on interest-based
negotiation skills might be the first building block toward achieving effective teams. If people
know how to deal and walk through their differences they will likely succeed on reaching shared
understanding which is crucial for working together. Training in interest-based negotiation will
help team members move away from finger pointing and toward joint problem solving,
improving communication processes and separating people from the problem.
The interest-based negotiation approach is based on seven elements, including: interests, options,
objective criteria (legitimacy), commitments, alternatives, communication and relationship. At
the core are the interest of the team members - the underlying needs, concerns, fears worries, etc
that motivate their positions on any issue, the brainstorming to create mutually beneficial options
to satisfy those interests, and the use of standards or objective criteria to legitimize those options
and to make acceptable a set of options beyond a simplistic contest of wills when dealing with
differences. This interest-based negotiation training can shift participants’ mindset from
adversarial to side-by-side negotiation. Beyond the strategic and rational analysis of negotiating
about conflicting situations and focusing on interest, options and standards; the relationship
(people) and communication elements of the interest-based negotiation framework deserve a
deepest exploration and can be supported by additional frameworks.
A Relationship (People) Framework
Fisher and Brown (1988) developed a framework for building positive working relationships that
enable people deal with differences. This is a strategy to be unconditionally constructive and to
improve the process of people’s interaction. Fisher and Brown (1988) affirm the ability to
develop and maintain effective working relationships depends on few basic elements:
Rationality, understanding, communication, reliability, persuasion not coercion, and acceptance.
1. Rationality, understood as balance of emotion and rationality constitutes a requirement when
dealing with others - too much emotion clouds judgment while too little impairs the motivation
for understanding. This improves the relationship. 2. Understanding, reached by asking questions
to learn people’s perspectives, reversing roles to see it from others’ view, and drafting a chart
listing their perceived choices in the matter. This will facilitate more constructive and fair
cooperation, if we treat others’ view as worthy of understanding. 3. Communication, this means
that people should engage the other team members, speak clearly, and use privacy to avoid
audience pressure over decisions. One person has to help the other’s active listening by having
them repeat what the other has said. These strategies of interpersonal interaction constitute the
base of the relationship - the key to unlocking understanding and to making the way towards a
working relationship. 4. Trust, the authors affirm that predictability, clarity of communication,
honesty, and honoring promises help the other person to open up and explain his or her interest.
This prevents opportunities for mistrust, and people should seek ways to limit situations
requiring blind trust. 5. Persuasion, which helps to attack the problem through reason, open
communication, and honesty. Not using coercion - this relies on force that may “solve” the
conflicting situation but does not improve the working relationship. 6. Acceptance, the authors
mention the importance to accept that differences occur between people and that these
differences can bring beneficial outcomes, so valuing different perspectives, the parties can open
better channels of cooperation.

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A Communication Framework
Fisher, Ury and Patton (1991), and Fisher and Brown (1988) highlighted the importance of two-
way communication when dealing with people and differences. In this line, Stone, Patton, and
Heen (1999) developed a framework to understand and achieve effective communications and
excel difficult conversations. The authors affirm that what it gets in the way of effective problem
solving and what we can do about it rests in our own thinking. Our actions (external behavior)
reflect our thoughts. All our perceptions are partisan and incomplete. The world is complex like
a puzzle and we don’t have all the pieces. None of us know all of the truth. We all see the world
with our own lenses which are framed and influenced by our own interests, own past experiences
and own culture. As diverse regions of the planet and organizations around the globe have
different cultures, it is fair to state that professionals from different fields have diverse cultures;
every profession has its own culture. We all take in information with our own worldview and
among healthcare professionals here several distinct professionals therefore; there are diverse
cultures and worldviews in the healthcare industry. Then, in order to reach team effectiveness in
healthcare settings, we need to be able to understand each other’s views and be open to seek
understanding of each other’s culture, and create a new culture while working together. Stone,
Patton, and Heen (1999) suggest using a “ladder of inference” tool to explore differing
perceptions and to explore each other’s reasoning. The three steps of “ladder of inference” are
the facts that we notice, our interpretations of those facts and our conclusions based on our
interpretations, this explain our views. Our actions reflect our thoughts and our thoughts are
problematic, but our thoughts can be shifted. We can move away from over confidence in our
perceptions (I know what happened and I’m right) toward a mindset that believes there may be
more than one way to see a situation. Away from all-or-nothing thinking or blaming mindset (the
other is to blame) toward a thinking that states that probably each of us has contributed in some
way to what happened. This moves the parties dealing with a difficult conversation from blame
games to contributory systems that understand that many factors contribute to the result of any
situation. Our thoughts can be shifted from an assumption that we know the other people’s bad
intentions (attributing bad intentions) toward a way of thinking that highlights that we are not
sure what the other people are trying to accomplish, and we would like to find out – we can
always try to test attributions. For effective two-way communication is crucial to share views
and conclusions as hypothesis instead of judgments and explore the information (data) and
reasoning behind conclusions. As Stone, Patton, and Heen (1999) assert “At heart, blame is
about judging and contribution is about understanding” (p.59).
Stone, Patton, and Heen (1999) explain that a challenging point when interacting with others is
when a conversation can threat our identity – “the story we tell ourselves about our selves”
(p.112). Competence or to be competent is a core identity that can be threaten when interacting
with other people. The all-or-nothing thinking can knock off balance. All-or-nothing thinking
such as “I’m either competent or incompetent” makes us unstable and makes us hypersensitive to
feedback. This all-or nothing mindset leads us to deny negative feedback or exaggerate and let
the negative feedback define our identity. The fact is that we are humans, complex individuals,
not perfect, and our intentions are complex too. In order to move away from all-or-nothing
identity we need to understand that we are complex and accept that sometimes we will make
mistakes, and if we do not acknowledge and recognize our mistakes and learn from them we will
make the same mistakes again. Another crucial step to move away from all-or-nothing thinking
is to acknowledge that sometimes we all have contributed to the problem at hand. At the end of

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the day, moving away from all-or-nothing thinking will lead us to building trust because we will
learn to feel comfortable being open to one another around our mistakes, failures, and
weaknesses. As Lencioni (2005) affirms “People who are not afraid to admit the truth about
themselves are not going to engage in the kind of political behaviors that wastes everyone’s time
and energy” (p.14). And as Stone, Patton, and Heen (1999) affirm “The more easy you can
admit to your own mistakes, your own mixed intentions, and your contribution to the problem,
the more balance you will be during the (difficult) conversation, and the higher the chances it
will go well” (p.119).
Team members need to change a blame-game mindset for a contributory system way of thinking
to look forward to problem solving. Another way to share views without raising defensiveness
among others is to share thinking and feelings as “I” statements, expressing the impact that some
objective and observable behavior or actions had on you, instead of attributing bad intentions to
others behaviors or words. When working with teams, people need to be aware of the word
choices because words can trigger emotions and hostile environments preventing us to reach
understanding of the reasoning of some expressions. As part of the communication piece during
training, team members need to be aware of the differences between dialogue and debate, while
dialogue seeks understanding of each other ideas, debate listen with the purpose to refute what
has been said.
Being conscious about the words we use in specific settings, having clear purpose and generating
some common language to revisit the team’s interaction can create the conditions needed to
improve performance and reach effectiveness. A common language not only describe but also
construct and shape our reality as we select words to describe it. As Lingard and et all (2002)
affirm “This directs attention to the role of language in socialization and identity formation.
Words act on us; they both make possible and constrain our understanding of our lives” (p.729).
In this sense, we can affirm that the use of common language can be use to reframe the way
healthcare professionals deal with conflicting situations and create a new organizational culture
in healthcare settings.
An Emotions Framework
Gedney Baggs and Schmith (1997) argue that in order to get nurses and medical resident
physicians working together there are two preconditions: Being available (in the right place,
having time and having appropriate knowledge) and being receptive to the idea of collaborating
which translates into engaging in discussion with active listening, openness, questioning; respect
and trust.
When Fisher, Ury and Patton (1991) explained the relationship element of interest-based
negotiation model, they remark that “To find your way through the jungle of people problems, it
is useful to think in terms of three basic categories: perception, emotion, and communication.”
(p.22). When Fisher and Brown (1988) assert their framework for positive working relationships
and its principle ‘balance emotions with reason’, they affirm “to varying degrees, emotions affect
all our relationships. They affect how we think and how we behave”. (p.43). Fisher and Shapiro
(2005) go further and developed a framework to help negotiators deal effectively with emotions.
The authors focus on five core concerns that are important to most of the people: appreciation,
autonomy, affiliation, status, and role. This “core concerns framework” can be use to stimulate

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positive emotions that facilitates collaboration (cooperative behavior). Appreciation is related to
having our thoughts, feelings, and actions devalued or acknowledge as having merits. Status is
about our standing treated as inferior to others or given recognition when deserved. Finally role
refers to the roles we play being meaningless or personally fulfilling. Considering healthcare
professionals and their view about respect, knowledge and trust as preconditions for working
together, training in negotiation, conflict management and team effectiveness should include a
segment of this core concerns framework. Healthcare professionals could build affiliation with
some shared values such us working toward the well-being of the patients. For instance,
considering the Status core concern, there is a “social status” and “particular status” - understood
as high standing in terms of particular expertise, experience or education. There might be cases
in which a nurse should be consulted and appreciated by doctors and physicians. Doctors are
regularly seen as with a “high-social status”, but nurses have several important areas of
“particular status” in which they might outrank the doctors. Nurses acquire information that
needs to be communicated. Sometimes doctors who hold high social status fail to listen to the
nurses or to ask good questions. In any case, by appreciating the nurse perspective, doctors can
build rapport, improve communication, and enhance patient treatment. As Fisher and Shapiro
(2005) affirm “By acknowledging another’s (healthcare professional) negotiator’s particular
status, you can shift their perception of themselves from that of an adversary pressing for a sale
to that of a high-status expert working with you to help formulate a decision that will best meet
interests on which are the experts” (p.110).
A Teamwork Framework
Once healthcare professionals have learned and have had a chance to practice these new
frameworks and skills to deal with differences, and shifted paradigms about how they need to
think to work together productively, they are ready to jump into teamwork and face the
challenges innate to this dynamics. A framework that might help is the one developed by Fisher
and Sharp (1998). We have reviewed some of the conditional elements for having effective
working relationships, now we can place a framework for group collaboration and effective team
work.
Fisher and Sharp (1998) developed a framework to produce joint behavior that produces results.
This approach highlights five basic elements to reach collaboration. “1. Purpose: Aim by
formulating results to be achieved”, in order to achieve results team members needs to have a
clear purpose of what they are trying to do and why they are doing it. Purposes should be
realistic, actionable, and inspiring. If teammates have a chance to influence the purpose, they will
work harder toward it. “2. Thinking: Harness the power of organized thought”, an organized way
of thinking together and structuring discussion can help to generate ideas and turn them into
action plans. The authors suggest dividing the process of thinking into four quadrants and
explain the reasoning: a) Data: what is the problem? (Not who but what); b) Diagnosis: what are
the possible causes of the situation? c) Direction: brainstorming about what strategies might be
wise to do; d) Do Next: what are specific next steps? (Who does what when and where). “3.
Learning: Integrate thinking with doing”, this means that team members need to implement and
test their ideas by experimenting in the real world. Teammates need to plan, act, and evaluate
(preparation-action-review); in this sense, they will be able to integrate thinking with doing by
planning, acting, and checking to see what worked well and what to do differently. This will help
the team to adopt learning habits. “4. Engagement: Offer everyone a challenging role”, each

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person needs to have an active and attractive role so one will want to play. The role should
command respect from others and allow one use it demonstrating his/her abilities. We all have
emotional interests in our jobs; if the role serves the team member’s interests the teammate will
be committed and if team members have some measure of control over what they do they will be
committed to the tasks. Team members need to assume that contributing ideas is everyone’s job
and if teammates are invited to set purposes, it will signal respect and their thoughts will be
validated. People will be committed to goals that they have helped set. It is important to have
everyone taking part responsibly in negotiating and dividing the work, ask each team member to
disclose information to reveal strengths and skills, list tasks and then distribute responsibilities,
“task assignment are floor on responsibility, not a ceiling” (p.150). Asking for input does not
mean delegation of authority or decision-making power, but “allowing workers to suggest in the
light of well-chosen criteria allows them to feel they have chosen their own task”. (p.151). In
general, setting purposes, thinking systematically, and learning from experience provides a
framework for inviting everyone to offer ideas. “5. Feedback: Express appreciation and offer
advice”, expressing appreciation motivates people, the need for appreciation is an emotional
need, direct the appreciation to the team members as human being rather than the teammate’s
actions. When offering advice make it a conversation and first understand what the teammate is
trying to accomplish, ask the advice’s recipient what s/he thinks about her/his performance and
offer direction or suggestions sharing specific data and reasoning. Giving and receiving feedback
allows us to learn from mistakes. Teammates can share with each other what sort of feedback
they find more useful. In sum, clarifying the purpose of what the team wants to accomplish;
understanding how to manage the power of organized thinking; learning how to integrate
thinking with doing; getting team members engaged; and, learning how to give feedback is a
practical framework to reach team effectiveness.
Even in the heat of the moment, healthcare professional can always stop, have an “inter-
professional moment” as named by Dauer (2008), and make a decision on the way to proceed
next. Team members will have their voice heard, their knowledge and experience validated, and
the person in charge of the team will make a decision. In any case, when the stakes are high and
a decision needs to be made in a timely manner, and the decision might be made, but to maintain
a positive working relationship, the team will needs to reconvene to be able to debrief about what
went well and what can be done differently next time and integrate it as a learning experience
moment.
Once team members go thought a training that includes several of the skills and lessons learned
from this set of organizing frameworks, they will likely have shifted or questioned their own
paradigms, and we can move away from finder pointing toward problem solving. We have
addressed the Lencioni’s (2005) ‘five dysfunctions of a team’ from a conflict management
perspective. This proposed training in conflict management and development of effective teams
has intended to share the belief that cultural changes in healthcare settings from bottom-up are
feasible. Through conflict management training and building effective teams, healthcare
professionals can change the healthcare organizational culture to do better, improve working
relationships and work together toward the patient welfare enhancement.

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Reference
Dauer, E. (2008). Class presentation May 1, at Lipscomb University.
Fisher, R. , & Brown, S. (1988). Getting together: Building relationships as we negotiate.New
York: Penguin Books.
Fisher, R. , & Shapiro, D. (2005). Beyond Reason: Using emotions as you negotiate. New
York: Pinguin Group.
Fisher, R. , & Sharp, A. (1998). Getting it done: How to lead when you’re not in charge New
York: HarperCollins Publishers.
Fisher, R. , Ury, W. , & Patton, B. (1991). Getting to yes: Negotiating agreement without
giving in. New York: Penguin Books.
Gedney Baggs, J. & Schmith, M.H. (1997). Nurses’ and resident physicians’ perceptions of the
process of collaboration in an MICU. NResearch in Nursing & healthcare, volume 20,
71-80 pp.
Lencioni, P. (2005). Overcoming the five dysfunctions of a team: A field guide for
leaders, managers and facilitators. San Francisco: Jossey-Bass.
Lingard, L., Reznick, R., DeVito, I., & Espin, S. (2002). Forming professional identities on the
health care team: Discursive construction of the ‘other’ in the operation room. Medical
Education, volume 36, 728-734 pp.
Stone, D. , Patton, B. , Heen, S. (1999). Difficult conversation: How to discuss what
matters most. New York: Penguin Books.