Introduction

Conflict between health professionals and patients has attracted increasing public attention in the last few years and even more so in the past 12 months. Some recent high profile public cases, such as those of Aysha King and Alfie Evans, have involved an apparent breakdown in relationships between the parents of children for whom no beneficial treatment was available and the clinical teams in charge of their care.

In many cases, these tragic situations are managed by careful discourse between doctors and healthcare staff. However, where disagreement results in an application to the courts, the same question is often asked; what has caused the conflict to escalate to the extent that it has, and could it have been avoided?

What is mediation?

The role of conflict resolution, or mediation, in healthcare has moved into the spotlight as an answer to that question. Mediation involves a neutral party - one or more mediators working with those involved in a conflict with the aim of achieving resolution and improving relationships.

A mediation involves certain non-negotiable elements. It is voluntary to all parties at all times, and it is a confidential process. The mediator is neutral; their role is to give the parties space to explore their conflict, and to try and find a solution that all can accept. The mediator doesn't provide solutions, but helps the parties identify solutions themselves and can help steer them through the process of conflict resolution.  

The process starts with the mediator meeting each party separately, to learn more about their specific issues, needs and hopes. A date is then agreed for all parties to meet together for a formally held session, which can conclude with or without agreement - or earlier than planned when the parties feel that the mediation has run its course, either because the parties feel that the mediation is not working for them, or they have reached some form of agreement.

If an agreement is reached, the mediator will reflect this in a formal document that the parties approve.

What is conflict?

Conflict isn't necessarily easy to describe. The Medical Mediation Foundation defines conflict in a clinical setting as 'a breakdown in trust and/or communication between health professionals and a child and/or family members/carers which has an impact on any or all involved, and affects the ability of a treating team to provide the care they deem optimal for the patient concerned'.

However we define it, we do know that conflict in healthcare is an everyday lived experience for clinical staff. A 2015 study focusing on paediatric care noted that 'despite conflict being a well-recognised facet of healthcare, it remains an under-researched phenomenon'.

The survey noted 136 episodes of conflict which took 448 hours of professional time to manage, concluding that 'considerable staff time is taken in managing conflict, indicating a need to focus resources on supporting staff to resolve conflict, notably managing communication breakdown'.

Managing conflict matters:

• Conflict is upsetting and time-consuming for families, patients and staff.
• Conflict can affect care of the patient.
• Conflict will escalate unless recognised and managed early and actively.

How can conflicts arise?

Healthcare is a fertile ground for conflict. Examples of sources of conflict include disagreements over a relative's care, seeing a loved one in pain or declining health, not knowing what will happen next, or conflicting messages from staff. There is no exhaustive list for what can fuel conflict, though a common factor is a sense of not being 'heard' or listened to. This exists on both sides of the patient/provider divide.

What are the causes of conflict?

The survey cited above found the following to be the most commonly cited causes of conflict:

1. communication breakdown
2. disagreements over treatment
3. parents 'micro-managing'
4. unrealistic demands and/or expectations.

Conflict isn't limited to patients. The examples of medical conflict that reach the public domain are often represented as 'patient vs provider', but conflict isn't always as simple as this.

Consider the following scenario: two siblings are arguing about a dying parent's care and are at odds with each other. The two consultants in the team don't agree with each other about the best approach. The nursing staff have an opinion, but they are reluctant to share it openly as they don't want to take sides. The ethics committee has given a view, and the in-house lawyer has been consulted, but their opinions on the situation don't neatly match up.

As you can see from this example, conflict is rarely neatly confined. Conflict can create a ripple effect which moves beyond the initial conflict situation. What might appear a 'contained' conflict (eg, a disagreement over the care of a dying patient between siblings and the clinical team) can escalate to involve a much wider pool of people - the nurse avoids contact with the family because he finds it too stressful, the consultant shouts at her colleagues because she doesn't feel listened to, the other patients on the ward get less time from the consultant…the list goes on. The conflict that people see often obscures a larger and wider ripple effect.

The warning signs of conflict

Although the circumstances of conflict can vary, we can draw together similarities about how conflict escalates, and the drivers of that conflict.

Stages of conflict escalation

The 2014 paper Conflict escalation in paediatric services: findings from a qualitative study concluded that 'conflicts escalate in a predictable manner. Clearly identifiable behaviours by both clinicians and parents are defined as mild, moderate and severe'.

Although this paper looked at paediatric care, in our experience the manner in which conflict escalates equally applies to other areas of healthcare, including primary care.

The 'mild' stage involves the triggering of potential conflict situations, through things like insensitive use of language, clinical staff making assumptions (about a patient's care or otherwise), conflicting messages by healthcare staff and a history of unresolved conflict. These areas of potential conflict can be skilfully negotiated, managed and defused if identified, but will escalate if they are engaged and left to escalate.

'Moderate' involves a deterioration of trust and a breakdown of communication and relationships. As conflict grows, behaviours begun during the mild stage become entrenched and avoidance becomes identifiable. There may also be increasing micro-management in the form of taking notes, recording conversations, asking to see what is being written, and a sense of moving into different camps.

'Severe' marks a disintegration of working relationships, characterised by behavioural changes including aggression and a shift in focus from the patient's best interests to the conflict itself, and clinical decision making is often hamstrung, to the detriment of the patient. As the severe stage progresses, physical and verbal threats may be made. At the most extreme end, there may be physical violence.

The process of conflict resolution

When we teach clinicians about mediation, we introduce them to the PIN model (Position - Interests - Needs) as a simple way of illustrating how we try and move people through conflict to resolution.

Think of a person in conflict as an iceberg; the area above the surface, what you see, is a person's position. 'Position' describes their behaviours, what they say and do.

Under the surface lie a person's 'interests' and 'needs'. Interests are what that person is trying to accomplish by adopting the positions they have. If an individual's position results in them shouting at a nurse for painkillers for their child, their interest will be to ease their child's suffering.

Needs sit below interests. Needs are the basic impulses and fundamental requirements a person has. These include physiological needs (sustenance, shelter, sleep), safety needs (security), belonging (relationships, family), self-esteem and, less relevant to our purposes, self-actualisation.

Conflict resolution work in healthcare is different to other settings because it involves situations that engage threatened needs; a dying parent, an unwell child, tests that may or may not come back positively. It is perhaps unsurprising given these 'existential' threats that clinical settings are fertile ground for conflict to arise.

What might be going on here for the parents of the baby girl? What are the interests and needs that drive the position they have adopted (ie, their reluctance to be discharged)?

In real life we would explore this with the parents, which may involve the following:

Interests:

• We want our daughter to receive the best care possible.
• If we don't agree to the discharge, we won't need to go to an inferior hospital.
• We have to fight for our daughter and her right to the best care.
• We don't mind being difficult to the staff if it means we can keep our daughter here.

Needs:

• We will be putting our daughter at risk if we leave.
• If we go to the other hospital, they might not know what they are doing, and she might get worse or die.

There is a direct threat to basic 'needs' here; safety, security and family integrity are very strong drivers.

De-escalating a conflict

The essence of mediators' work is to help people identify who they're in conflict with and see their perspective. Thinking back to the PIN model, consider the continuation of our case study.

Both the parents and the consultant have adopted positions they feel represent their interests, and are in a seemingly intractable dispute. What can be done?

Conflict prevention techniques

• Cue recognition and acknowledgement.
• Open, exploratory questions.
• Appropriate closed questions.
• Avoidance of premature reassurance.

At the core to the mediator's approach is the principle that while each party's positions may be at odds, they are likely to have shared interests and needs. In this example, the consultant and the parents are likely to share the following:

1. a desire for the child to receive the care she needs
2. for that care to be of a standard acceptable to everyone
3. for the child to continue on her track to better health
4. for her interests not to be lost in the conflict.

A mediator faced with this challenge would seek to do the following:

1. listen to both sides, to understand the interests and needs underlying their positions
2. help the parties articulate what they feel is driving the conflict
3. help the parties articulate their thoughts, feelings and emotions to each other in relation to the conflict
4. encourage dialogue between the parties in order to help them empathise with each other
5. identify common ground to help establish a way forward on areas of disagreement.

A mediator will seek to understand, explore and finally move the parties towards resolution. The process is independent and confidential, and the mediator does not provide a solution. Instead, they hold the space for the parties to explore their way forward.

Complaints procedure

The NHS complaints procedure emphasises that patients have a right to complain about any aspect of NHS care, treatment or service, and can do so through a number of different gateways depending on their circumstances.

NHS England's guidance states that 'everyone who provides an NHS service in England must have their own complaints procedure. You can either complain to the NHS service provider directly - such as a GP, a dentist surgery, or a hospital - or to the commissioner of the services, which is the body that pays for the NHS services you use'. It's important to note that a patient can't apply to both.

The NHS has increasingly embraced conflict resolution. For more information on how to use mediation within the NHS, take a look at A bite-size guide to: Mediation between patients, carers and the NHS or visit medicalmediation.org.uk to see an overview of the work we do in the area.

Practical top tips

• Don't be afraid to talk: don't avoid the people or the issues hoping they will go away. They won't.
• Do listen: respond to people appropriately, but listen; most people just want to be heard.
• Don't say: 'There's nothing to worry about.'
• Do say: 'What is it you're worried about?'
• Don't say: Difficult patient/parent.
• Do say: Difficult situation.
• Don't say: 'I'm sorry you feel that….'
• Do say: 'I'm sorry that what's happened has made you feel so upset/angry/let down etc'.
• Try: to put yourself in their shoes.
• Remember: talk like a human being, not an institution.