Emergency Department Conflict Resolution is one of our most treasured and favourite courses to teach!
Let's discuss some key issues about how patients come into conflict and how caregivers, nurses and doctors can prevent or manage conflict in the A&E or ED setting.
What is the Chain of Encounters in the ED?
One of the first things we do in designing Emergency Department Conflict Resolution and Patient Experience training was to allow the staff to see that there are common patterns in conflict encounters, which reliably repeat themselves and can therefore be reliably prepared for.
It's so important for staff to know about what we call the “chain of encounters” when talking about Emergency Department Conflict Resolution.
For example, a person coming into the emergency department will at first encounter random hospital staff walking around, going here and there, (or smoking outside the building!) but not connected with or related to the emergency department at all. They'll have to walk past them in order to find their way to the emergency department. They may already feel confused, frustrated and ignored.
In some cases there'll be gatekeeper staff, such as security officers or reception staff who they will encounter who will direct them to the emergency department and meet the administrators there who will direct them to sit and wait before they're called for triaging.
Wouldn't it be great if every patient understood the reasons for triage and the process of going to the emergency department?
We visualize this as a chain of positive encounters that the person should have through their journey in the ED. What we don't want want to happen is for any positive link to be broken in this chain of encounters - what my friend and colleague, Gary Klugiwicz at Vistelar refers to as ‘starting the negative dance’ of escalating negative encounters.
Our friend and veteran hospital adviser Joel Lashley talks about upholding the social contract for Emergency Department Conflict Resolution, in that we have to treat each person that we meet with dignity by showing them respect. It becomes really important for us to consistently do that across the staff team, so as not to inadvertently begin a process which ends in a complaint or a poor patient satisfaction score
It was so interesting to explore triggers with the staff - things that upset, frustrate and grind their gears at work.
Triggers for conflict in the emergency department
Sometimes it felt like the staff were blaming patients and visitors for many of the things that the staff don't enjoy at work. And I'm sure that if we got a group of patients and visitors in a room, they would be blaming the nurses and doctors for all the things that are wrong in the emergency department, somewhere between these two islands of belief, we needed to create a bridge on our conflict resolution training course.
There are specific things in the emergency department that trigger people and cause conflict. Sometimes there is confusion because patients or visitors don't know how things work. Sometimes patients or visitors are afraid of things. They have anxiety, they have worries fears and so on that are all related to their medical issues as they come into the emergency department. Sometimes its a problem caused by how people speak to them!
In designing this training program, we had to review the data from the department's own Press Gainey system and their complaints log, looking both at the positive comments and the less positive comments that have been made by patients and visitors. Over the previous six months, we then analyzed the chain of encounters that a visitor or a patient coming into the hospital would normally go through and looked at the interactions that they would have with a series of different professionals.
Further to this, we understand that there are generic triggers that set people off:
- Being asked to wait for long time
- not being given information about how long that wait might be
- not understanding what the process is at the emergency department
- Not understanding that there is a triage process in effect
- people who are behind us in the queue may actually be seeing before us
Another thing that we need to know about in Emergency Department Conflict Resolution is that there are certain things that set off our emergency department staff. They often feel over pressured, understaffed. They feel misunderstood. They feel ordered-around and disrespected or disregarded. Sometimes they have patients who have high expectations, who throw around their weight (“I know Doctor Jamal, who is a member of the board!”) and who want it, (everything) to run their own way.
Somewhere in the middle between the patient and visitor triggers and the emergency department staff’s own triggers and the different needs, expectations, and desires of these two groups, we needed to find a way of creating peace and compassion between them to effectively achieve Emergency Department Conflict Resolution.
Patients want attention and may initiate conflict to get it
Research note: "for patients will the common cold, physician empathy in just one visit at the beginning is a significant predictor of duration severity and improved immune function” - imagine, empathy can have clinical outcomes!
Another thing I did in preparing for this particular visit and training program was I spoke to the Senior Emergency Physician who is responsible for the department.
“I've been discussing this with my surgical residents”, he said, “we know that it's so important to see the patient immediately as they wake up” (if they’ve been unconscious) - we had been discussing the importance of empathy and how patients crave the attention of their medical professionals.
I knew by talking with this ED Doctor, that the issues we would face in the emergency department are the central issue of the busy-ness, the need to be ruthlessly efficient, and the problem of forgetting that “it's their first time” in the emergency department.
“Morale is good” he told me, “the ED staff are feeling good. Service levels are good, but wait times are up slightly. The doctors and nurses have good relationships. What we face though, is that expectations of our patients as they come into this hospital are very high.“
“Our reputation and our pricing service levels are like coming into a five star hotel or a top restaurant. And people have huge expectations that we are going to look after them to a certain standard and make them feel really, really well cared for”.
The patient satisfaction data for this department was generally good. However, a few patients had wondered about the delays in getting them their test results, which is a procedural issue.
Interestingly, I had learned that when you improve procedures in an emergency department or anywhere in the hospital, in fact, you don't necessarily get an uplift in patient satisfaction!
What you discover when looking into this area, is that how we made the patient feel when they were with us is far more important than whether or not our procedures were efficient, or even that we alleviated their pain or fixed their medical problem. It's an odd feature of medical health care that how we make people feel matters much more to them than whether or not we make them.
Fred Lee, author on the patient experience, defined Compassion in Health Care as follows:
“"doing something or saying something that shows genuine concern for the patient's state of mind”Fred Lee
Managing Expectations to Resolve Conflicts before they happen
I sat with an experienced doctor in the ED one night, who relayed to me her strategies for managing expectations with patients and their relatives.
“I sat with a doctor in the emergency department that night. She told me how the records that she's looking at before she goes to see the patients sometimes show interactions with the patient that happened earlier in the day at the clinic where they first presented themselves.
The doctor turns to me, she says, “for example, this patient is already upset. She's had late lab reports. She's been waiting and waiting.”
She turned to one of the nurses. “I need a per-minute estimate of lab results, so I can tell her when they are coming exactly”
I suggested that she should add five minutes to that estimate, so that she can be sure to meet expectations, just in case people on the other side of the lab report are delayed.
“This is a tough crowd”, she says, “impatient and angry!”. I make sure to explain everything using baby language. I watch my body language. I watch my tone of voice, and I make sure to give them lots of information to increase certainty.”
Later on, I would see this doctor being spontaneously hugged by the wife of a man that had been brought in with chest pains. I could see that the doctor listening to her and explaining calmly what the processes would be to find out what was wrong with the man and how they would treat him, and that everything was going to be all right. That he was in the best place now to keep him safe and get him well. It was having a visible effect on the woman's level of stress, anxiety, and concern
Children in the emergency department. I learned get lollipops when they're compliant. I randomly thought, wow, we give lollipops to the children for their patience, forbearance and compliance with our requests. What is it that we offer to the adults when they do what we've asked them to do the difficult things that we ask them to do in the emergency department?
A curtain moves aside. A woman pops her head out from inside the cubicle and says, “er…nurse….we’ve been waiting for a long time”. This is a request for attention. People - worried, scared, and anxious in the emergency department - crave attention.
I ask the doctor about some of the complaints that I've been able to see on their system particularly about people not getting their test results and not understanding the processes.
“I use a closed loop communication”, the doctor says, “I ask the patient to repeat back to me what they understood about my instructions with respect to test results and next steps in their care, et cetera. I make sure that they understand and before they leave. And that way I think they're prepared for any waiting or any questions they need to ask later on. Baby language - as simple as I can make it”
The doctor tells me that whenever there's an aggressive or upset patient in the department, her colleagues call for her, “because I know how to do it”, she says, “I learned how to do it in my training”.
It turned out that this conflict expert, to whom all her colleagues turn to for interacting with patients who are already escalated, had already had training, and that I was the person who had trained her, some 8 years previously at another hospital!
The Emergency Department Waiting Room
Here are a night of observations in a normal, run-of-the mill Emergency Department waiting room.
“On the night that I visited the emergency department, there were maybe 22 to 24 people waiting in the room, but a quarter of them were children under 12. I saw children and babies and they were all waiting in an environment that was very grown-up. There were no toys, no jigsaws or puzzles or games for the children to use. Mostly (I’d learned later) this was because of COVID. The toys had been taken away because of infection risk. There were two babies that were intermittently crying and many adults sitting around, avoiding watching the TV, which was showing international news.
In one corner, a woman sat with her husband rocking back and forward to ease the pain she was feeling in her back. The man sitting next to her who obviously didn't really feel like being in the emergency department this evening. They talked together and then they got up and they approached The Magic Door in the corner of the ED.
This Magic Door, like the mythical door to Ali Baba’s cave in the story of Alibaba and the 40 thieves - every now and then it would open and people would spill through it in one direction or another. And every time it opened, everybody in the waiting room became focused intently on what was happening there. Behind that door was what everybody in the waiting room was there to look for.The staff are careful not to reveal the secret password ‘Open Sesame!’ which grants entry to the special place (and consistency, even in the face of abuse, is so important on this point).
An opaque and magical ‘black box’ system called Triage seems (for most people) to randomise the order at which people arrive into the waiting room and then gain entry to the hallowed interior.
Two admin staff were sitting behind a counter, screened away from everybody by plastic Plexiglas. Here is where everyone registers their interest in services. And I couldn't help but think that as I looked at the top of their heads, as they sat behind the high counter, that they looked like they were in a bunker, protected and separated from the people on the other side.
From behind the magic door, staff appeared waving barcode stickers and calling names. Sometimes they would walk up and down the waiting room, calling those names and nobody would answer. Sometimes visible relief would spill across the faces of the people whose names were called and they would stand and approach the staff, soon to be taken in to see a clinician.
There was very little signage in the waiting room, certainly no information about expected waiting times, how long it was likely before a waiting person could get to see a doctor. I looked around to see if there was anybody to ask a question. As we often observe in a healthcare environment, the staff are busy doing healthcare things, but often not able to address the questions of visitors and patients who want desperately to find more information.
Parents were doing what they could with the children, to alleviate their boredom or their anxiety. A woman approached the counter to make a payment. She was waving a piece of paper and she loudly said, “We didn't know that my niece wasn't covered by insurance when we came here. Give me the bad news!”
Communication at this counter was difficult - made more difficult because of the screens, because of the hustle and bustle of people and because of cross-cultural communication barriers.
A voice rang out from somewhere: “Bed 14 has left” ,the reply to which was, “what, the Broken Arm in Bed 14?” Patients were being abstracted to the name of their conditions and their bed/bay.”
Perspective Taking in the Emergency Department
“One perspective-taking exercise that I went through with the staff was as follows: I asked them to consider that standing in front of them was a young man in sporting attire who was holding his arm close to his body with one hand clasping his lower forearm. He looks in pain, he looks worried and scared. And then I ask the staff to tell me, what's he worried about? I give them a prolonged period of time to think about “what is the man worried about?”
This exercise, which they may very rarely get a chance to do actually in their work, especially for a prolonged period of time, engendered all kinds of insights about what short, medium, and long term things that the man might be feeling and be worried about at that moment.
This is an exercise we call perspective taking.
He could be worried about the pain. He could be worried about the long term effects of the injury. He could be worried about taking time off work. We don't know if this man is a professional athlete and that this injury will interfere with his plan to compete or his plans to go to a competition. It is possible that he won't be able to go to work tomorrow of for a long time, because of this injury - what will happen?.
He is in a place of deep uncertainty.
What effects will this have on his ability to earn, will this have an effect knocking-on into his relationships with his partner or the person he lives with, who depends on him for his part of the rent or the mortgage payment that month?
It may be that the man has had poor experiences in hospital - such as experiencing pain or loss , or mistreatment, or that he has felt disrespected before, or that he doesn't trust doctors or nurses.
There are all kinds of reasons why this man might have that look of worry on his face. And it is appropriate for staff to take this perspective and to knowledge it, and to slow down as they interact with this man, and to consider what these issues might be, as they ask questions in triage, and as he transforms into “the Broken Arm in Bed Six”.
To empathise, we acknowledge their perspective. We seek understanding, and we anticipate the person's needs.
Every person arriving into the emergency department is experiencing some level of stress, of course.
This is an important component of what we like to do at Dynamis, which is to understand as completely as we can the scenarios in which conflict flash-points arise so that we can better design and tailor a training program to have the best effectiveness for the staff who will go through it.
During discussions with the team, we understood that as with many modern hospital environments, the staff team is multicultural and multi-ethnic, and of course multilingual. Likewise, the patients and visitors coming into our emergency departments come from all over the world.
Not every hospital provides emergency services for free (the UK is rather unique in this regard, still) and our patients will have varying degrees of insurance at different quality levels, and varying ability or ability or desire to pay for the expensive emergency treatment that they may need at the hospital.
It is easy to see that more stress (financial issues, family issues, work issues) is added to a situation where there is already pain, discomfort, worry, fear, and anxiety, sitting in the waiting room of this emergency department.
“Sitting in that waiting room, it struck me that we have a complex mix of issues there, for example overt crises, which are obvious medical issues that people are suffering from when they've hurt a part of their body or are experiencing an acute symptom. They've been in an accident. There are obvious stressors in this sense, but also I think we can see that there are covert crises - hidden problems that people bring with them on a social level, on a relational level and on a level where they're actually fearing for the consequences of them being sick and being in the emergency department.
All of these stresses converge to create a very difficult pressure-filled time for each person sitting in the waiting room. When will I be seen, what cascading issues does that create for me, my household and my work… We need to be sensitive to these issues, or risk having encounters with people who are already escalating and with whom we unwittingly step on vital points of sensitivity.”
- Gerard O'Dea
Dynamis provides a comprehensive conflict management training programme which spans the whole spectrum of encounters in a hospital environment. In this series of posts, our Director of Training reflects on key ideas in addressing conflict in the hospital (also known as violence reduction).