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Pediatric Anesthesiology

Applying Conflict Management Strategies to the Pediatric Operating Room

Sinskey, Jina L. MD; Chang, Joyce M. MD; Shibata, Gail S. MD; Infosino, Andrew J. MD; Rouine-Rapp, Kathryn MD

Author Information

From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California.

Published ahead of print 8 January 2019.

Accepted for publication November 15, 2018.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Jina L. Sinskey, MD, Department of Anesthesia and Perioperative Care, University of California San Francisco, 550 16th St, San Francisco, CA 94158. Address e-mail to [email protected].

doi: 10.1213/ANE.0000000000003991
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Abstract

Conflict often occurs during interpersonal interactions because of differences in individual beliefs, values, and priorities. As medical practice shifts from solo practitioners to complex teams with increasing cultural diversity, the potential for these differences to lead to conflict increases.1,2 This shift requires health care providers to communicate and collaborate effectively because communication failures and conflict are associated with medical errors, poor patient outcomes, and clinician burnout.3–5 The potential for conflict is even greater in high-acuity and high-stress environments including intensive care units, emergency rooms, and operating rooms.6–8 Caring for pediatric patients has its own set of unique challenges because shared decision-making with parents and guardians adds complexity and treatment decisions are impacted by social, religious, and cultural beliefs of the child, family, and treating clinicians.9–11

Successful conflict management requires a fundamental shift in attitude toward conflict. Conflict is often viewed as negative because poorly managed conflicts lead to frustration, low job satisfaction, high staff turnover, patient safety issues, and poor patient outcomes.12–14 Yet conflict can also be viewed as positive because it can identify potential areas for improvement and stimulate beneficial change. Properly managed conflict results in better outcomes, stronger relationships, and increased job satisfaction.15 Health care workers who feel empowered to manage conflict by raising crucial concerns work harder, have better patient outcomes, experience higher job satisfaction, and are more committed to their institution.16

There is a paucity of formal education to teach conflict management skills and cultural competency. Physicians receive very little formal education in conflict management and tend to learn these skills by modeling the behavior of other physicians at work or family members at home.17–20 To address this deficit, the Accreditation Council for Graduate Medical Education has identified communication and professionalism as educational core competencies for residency training. However, education of currently practicing anesthesiologists, surgeons, nurses, and perioperative staff is lacking.21–23 Although the American Society of Anesthesiologists provides conflict management training through an Executive Physician Leadership Program,24 and the Joint Commission on Accreditation of Healthcare Organizations recently published a pocket guide to address cultural and religious sensitivity,25 educational opportunities for practicing anesthesiologists are limited. Continued improvements in anesthesiologists’ communication and conflict management skills are urgently needed to improve patient safety and increase job satisfaction. The focus of this manuscript is to provide anesthesiologists with the framework and tools to successfully manage conflict in a culturally diverse health care system.

THE COMMUNICATION IMPERATIVE

In today’s health care environment, multidisciplinary teams and handoffs are pervasive and good communication skills are crucial. Poor communication can lead to significant work-related stress. In nearly 2500 physician trainees, difficult interpersonal relationships, communication problems, and conflict were more stressful than long work hours and missing meals.26 Effective communication and training in communication skills increase patient and physician satisfaction.27,28 Anesthesiologists’ ability to build good rapport with patients and their families is shown to have a major positive impact on parent satisfaction scores in pediatric patients.29

The Joint Commission on Accreditation of Healthcare Organizations identifies communication failures as a leading root cause of sentinel events.3 In the operating room, the second leading cause of intraoperative errors is communication failure.4 The perioperative team is an example of a multidisciplinary team that must function effectively in a fast-paced, high-stress environment. Yet poor communication among key members of this team is common. Communication failures have been observed in approximately 30% of communication events in the operating room.30 Such communication failures may affect individuals who were not involved in the initial conflict. One study found that when tension arose due to conflicts between attending surgeons and nursing staff, surgical trainees responded either by mimicking the behavior of their attending or withdrawing from communication altogether.31 Poor communication and lack of teamwork are also associated with a higher risk of litigation.32 Surgeons who show a lack of respect for others are more likely to be associated with malpractice claims.33

CONFLICTS IN PEDIATRIC PATIENT CARE AND THE OPERATING ROOM

Conflicts in children’s hospitals are most commonly attributed to “communication breakdown,” “disagreements about treatment,” and “unrealistic expectations.”34 Religious and cultural beliefs of the child, family, and health care team can profoundly impact treatment decisions.11 Parents or guardians are often involved in shared medical decision-making for their child, which can increase the potential for conflict.9,10 Parents may disagree with each other and the clinical care teams regarding the best course of action. There may be conflict between pediatric patients and their parents, especially in older children and adolescents.35 In the pediatric intensive care unit, when patients require long-term care, conflicts occur more frequently between the parents and care team than among care team members.36

In the operating room, effective patient care requires seamless communication among the anesthesia, surgical, and nursing teams; yet it has been reported that an average of 4 conflicts occur per routine surgical procedure.37 Most conflicts arise during clinician–clinician interactions due to poor communication and incomplete patient information.6 Long surgical times, case postponement, staff shortages, sleep deprivation, and production pressure can further increase stress and conflict.31,38–42 Personal conflicts due to interpersonal or organizational issues can hinder communication and disrupt team functionality.42 Surgeons are more likely than nurses or anesthesiologists to display disruptive behavior, but all members of the perioperative team may contribute to poor team dynamics.39,42

PHASES AND TYPES OF CONFLICT

A critically ill 5-year-old boy is scheduled for an emergent exploratory laparotomy. His operating room arrival was delayed 30 minutes due to transport issues. The anesthesiologist induced the patient uneventfully and quickly placed an endotracheal tube and additional IV catheters. While the anesthesiologist was attempting to place an arterial catheter, the surgeon remarked that an arterial catheter was not necessary and made rude comments about the anesthesiologist’s lack of skill contributing to the delay in getting the case started. The anesthesiologist responded with a comment about the surgeon’s long surgical times. The situation escalated into a verbal argument between the surgeon and anesthesiologist.

This case illustrates the 4 phases of conflict (Table 1).43,44 The “first phase” is when conflict occurs and results in frustration for those involved. In this example, the surgeon made a rude comment about the anesthesiologist’s skill and questioned his judgment in placing an arterial catheter. The “second phase” occurs when the involved parties attribute a cause for the conflict. This tends to occur rapidly, and if inaccurate, can lead to misunderstandings that further escalate the conflict. The anesthesiologist assumes that the surgeon is questioning his overall ability and clinical judgment, and feels that the surgeon is making a personal attack. “Phase 3” represents the behavioral response toward the “cause” formulated in phase 2. The anesthesiologist escalates the conflict by commenting on the surgeon’s long surgical times. At this phase, it becomes hard for people to be objective and see the other person’s perspective. Finally, “phase 4” occurs when the behavioral response leads to a suboptimal outcome. The interpersonal relationship between the surgeon and anesthesiologist is damaged, and both physicians are distracted from their primary responsibility of taking care of this critically ill child.

T1
Table 1.:
Phases of Conflict
T2
Table 2.:
Types of Conflict

Conflict can be categorized into 3 types: task, relationship, or process (Table 2).45,46 “Task (or cognitive) conflict” occurs when there is disagreement regarding the outcome or content of the task, such as the decision to place an arterial catheter in the previous scenario. This type of conflict can enhance team performance because it provides an opportunity for people to problem solve in a synergistic fashion.15 “Relationship (or emotional) conflict” occurs when the conflict is due to a clash in personalities. A long-simmering tension between the surgeon and anesthesiologist could provide motive for the conflict. Relationship conflict may arise from differences in values, goals, and cultures between individuals. These factors can contribute to challenges in communication and understanding the other person’s perspective.47 Disparities in knowledge or power can exacerbate this type of conflict and lead to dehumanization, stereotyping, stigmatizing, or ignoring the other person.38 Overall, relationship conflict negatively impacts both individual and team performance. “Process conflict” is a disagreement about how to do a task. Using the previous example, it refers to how the decision should be made regarding placement of the arterial catheter. The 2 physicians may disagree on who has the final decision rights, the anesthesiologist or the surgeon. Unresolved process conflict can be detrimental to team performance.48

CONFLICT MANAGEMENT STYLES

Each conflict situation calls for a different conflict management approach.49 The most successful approach requires knowledge of the relationship between the parties involved, the importance of the issue, and the amount of time available to resolve the conflict. We will discuss a framework to better determine which conflict management style is most appropriate for a given situation.

There are 2 validated tools used to assess conflict management styles. The Thomas–Kilmann Conflict Mode Instrument describes 5 different conflict management styles (competing, accommodating, avoiding, collaborating, and compromising) as a function of 2 dimensions: assertiveness and cooperativeness (Figure 1).50,51 The Dutch Test for Conflict Handling also describes 5 conflict management strategies (forcing, yielding, avoiding, problem solving, and compromising) as a function of 2 dimensions: concern for self and concern for others (Figure 2).52,53

F1
Figure 1.:
Matrix of Thomas–Kilmann Conflict Mode Instrument. The 5 conflict styles are based on interactions between 2 dimensions: degree of assertiveness and degree of cooperativeness. Figure modified from Thomas.50 Reprinted with permission from Vasilopoulos et al.22
F2
Figure 2.:
Matrix of the Dutch Test for Conflict Handling. The 5 conflict styles are based on interactions between 2 dimensions: degree of concern for self and degree of concern for others. Figure modified from De Dreu et al.52 Reprinted with permission from Vasilopoulos et al.22

Thomas–Kilmann Conflict Mode Instrument and Dutch Test for Conflict Handling profiles can vary considerably depending on an individual’s cultural background. For example, unlike Western cultures, many Asian cultures lean toward managing conflict in a more indirect manner, and individuals from Asian cultures may avoid conflict to preserve the relationship.15,54,55 One study looking at Thomas–Kilmann Conflict Mode Instrument profiles in Chinese and British executives in Hong Kong found that Chinese executives favored compromising and avoiding while British executives favored collaborating and competing.55 Further research on the interplay between culture and conflict management is necessary.

The Thomas–Kilmann Conflict Mode Instrument and Dutch Test for Conflict Handling have been used to examine approaches to conflict management among health care providers (Table 3). Although each person may have a different style, individuals within a specific health care provider group tend to have similar Thomas–Kilmann Conflict Mode Instrument profiles.22,56–60 One study compared physicians to head nurses and found that collaborating was chosen more frequently by head nurses than physicians.56 Another study specifically examined conflict management behaviors of anesthesia residents.22 This study found that postgraduate year-1 residents leaned toward compromising and accommodating. In contrast, residents in obstetrics and gynecology and radiology tended to choose the avoiding mode.59,60 Certain conflict management styles may correlate with particular desirable and undesirable behaviors. Obstetrics and gynecology chief residents with administrative duties had a Thomas–Kilmann Conflict Mode Instrument profile high in competing and collaborating but low in avoiding and accommodating, while residents in remediation had the opposite Thomas–Kilmann Conflict Mode Instrument profile.58 Individuals may be inclined to use a certain conflict management style, yet successful conflict management requires the ability to identify and use the most appropriate style for the given conflict.49

T3
Table 3.:
Conflict Management Styles

“Collaborating/problem solving” is often the best strategy for conflict resolution because it results in an integrative solution that satisfies all parties involved. However, identification of a mutually acceptable solution mandates commitment to the time intensive process of understanding others’ viewpoints, motivations, and goals. An example of collaboration would be holding a series of discussions among the patient, parents, and health care providers to establish goals for end-of-life care in a child with a progressive, fatal illness.

“Competing/forcing” is most useful when the stakes are high and decisive action is essential. Consider the patient with a post-tonsillectomy hemorrhage who must return to the operating room emergently. The parents are adamant that they be present for induction in the operating room. In this case, the anesthesiologist may deny the parents’ request for the sake of patient safety.

“Accommodating/yielding” may be appropriate when it is more important to preserve the relationship than the immediate issue or when the issue is more important to the other person. Consider a patient with neuroblastoma scheduled for tumor resection. The operating room is behind schedule, and the surgeon is ready to proceed. The patient’s mother has stepped away, and the patient wants to await her return. In this case, the anesthesiologist will accommodate the child’s request and wait for the mother to return.

“Avoiding” may be most appropriate when the issue is inconsequential compared to the task at hand. Discussion of the conflict may be postponed until a more suitable time. For example, right before induction of general anesthesia, the circulating nurse complains about the anesthesia resident. The anesthesia attending may choose to ignore the circulating nurse’s comment until they can speak in private after the case. While avoidance can be advantageous in the short-term, long-term use of this conflict management style can be detrimental.

“Compromising” is often necessary when collaboration is not feasible. In this mode, each party must give up something to achieve conflict resolution. For example, a patient at high risk of developing complications from general anesthesia due to cardiac disease is scheduled for a long and extensive surgery. The surgeon and anesthesiologist may agree to a less invasive and shorter surgery to minimize overall risk.

CONFLICT MANAGEMENT TECHNIQUE 1: ACKNOWLEDGE AND MANAGE YOUR EMOTIONS

Traditionally, physicians have been taught during medical training to practice “detached concern” by distancing themselves from their emotions.61 Physicians who express their emotions often are viewed as unprofessional. However, there is emerging evidence that physicians must possess emotional intelligence to be successful.62 Emotional intelligence refers to the ability to control and express one’s own emotions and to empathize with others. Physicians need emotional intelligence to effectively lead interdisciplinary teams, coordinate care with other providers, and facilitate change in patients and colleagues.62

An important aspect of conflict management is acknowledging and embracing emotions that arise in conflict situations. The brain naturally reacts to conflict as a threat and as a result, “amygdala hijack” occurs.63 The amygdala is responsible for the “fight, flight, or freeze” response. The body is flooded with stress hormones leading to a cognitive response that shuts down the prefrontal cortex, which is responsible for logical thought.

When the amygdala threatens to take over, we must recognize what is happening and manage our emotions before we react. One approach is termed “going to the balcony.”64 In other words, distance yourself from your emotions as if you were watching the conflict from a balcony to assess the situation more objectively. We may not be able to control the other person’s emotions, but we can learn to control our own emotions and reactions. For example, instead of thinking “that person is unreasonable and he is making me angry,” we can shift our thinking to “I believe the person is being demanding and I am feeling anger.”

Another strategy is to reroute the brain’s attention toward the prefrontal cortex. Thomas Jefferson once said, “When angry, count to 10 before you speak. If very angry, count to one hundred.” Counting encourages the brain to think logically, which shifts gears toward finding a mutually acceptable solution to the problem. A similar strategy is to focus on a certain object in the room. By concentrating on a task, we can decrease our emotional reactivity. This approach is widely used in mindfulness-based stress reduction.65–67 Mindfulness-based stress reduction, initially developed as a coping strategy for patients with chronic pain, encourages individuals to view their thoughts in a nonreactive manner.68 In addition, it empowers each person to control his/her emotional response to stress and now is being studied in healthy individuals.66,67

The following scenario illustrates an example of managing the emotional response of anger. A 16-year-old girl is scheduled for an awake craniotomy for tumor resection. On the morning of surgery, the anesthesiologist approaches the family. He introduces himself and begins his preoperative assessment. The father interrupts the anesthesiologist and states that he only wishes to speak to the neurosurgeon. It is easy to imagine how this situation could trigger the amygdala, resulting in an angry response to the patient’s father. This response would worsen the situation and not benefit the patient. It is important to acknowledge the anger one feels, but also to try to work toward a solution objectively and calmly. The anesthesiologist can pause, speak to the neurosurgeon and understand the reasons behind the father’s actions. The neurosurgeon, who has a more established relationship with the family, may relay the father’s extreme fear and anxiety about the procedure to the anesthesiologist. The anesthesiologist can ask the neurosurgeon to help the father understand the importance of the anesthesiologist’s preoperative assessment. By remaining calm and working together as a team, the anesthesiologist and neurosurgeon can allay the father’s fear and anxiety.

CONFLICT MANAGEMENT TECHNIQUE 2: ACTIVE LISTENING

In a conflict, one must understand the situation from the other person’s perspective. Active listening is a powerful empathic communication skill that is useful in the presence or absence of conflict. It can be a valuable tool for physicians to establish strong patient–doctor relationships and increase patient satisfaction.69 Active listening takes into consideration 2 aspects of a message: (1) the content and (2) the emotions underlying the content. Emotions during a conflict situation are mostly driven by 5 “core concerns.”70 These concerns include appreciation (desire to feel recognized and valued), affiliation (sense of connectedness with others), autonomy (freedom to make decisions for oneself), status (desire to feel acknowledged), and role (desire to have a fulfilling purpose). One can use active listening to acknowledge and address these core concerns.

The technique of active listening requires genuine curiosity about the other party’s perspective and close attention to what is being said.71 The active listener must pay attention to both verbal and nonverbal cues such as facial expressions and body language.72,73 The active listener expresses interest in the other person’s opinions, acknowledges feelings, and responds by paraphrasing what has been said. When the other person feels heard, the words of the active listener can have a greater impact. Active listening induces positive emotions toward the active listener and can strengthen relationships over time.74

Consider the following scenario. A 3-year-old patient is scheduled for an elective tonsillectomy and adenoidectomy. On the morning of surgery, the anesthesiologist learns that the patient has an upper respiratory infection that began 4 days ago. The patient is afebrile without respiratory distress; however, she has a productive cough and rhinorrhea as well as a history of poorly controlled asthma. The anesthesiologist may feel apprehensive when approaching the surgeon about possible case cancellation due to the potential for conflict. It is easy for misunderstandings to occur due to underlying assumptions. The surgeon may perceive that the anesthesiologist wants to cancel the case to lighten the day’s workload while the anesthesiologist may presume that the surgeon wants to proceed regardless of patient safety.

Active listening can be used to elicit the concerns of each participant. The surgeon may be unaware of the severity of the patient’s respiratory symptoms and medical history. If the anesthesiologist acknowledges the surgeon’s point of view, the surgeon is more likely to listen to the anesthesiologist’s concerns and agree to reschedule the case once the patient’s symptoms have resolved. When conflict is managed well, both parties develop positive feelings toward each other that promote better conflict resolution in the future.

CONFLICT MANAGEMENT TECHNIQUE 3: ALIGN INTERESTS

Many people approach conflict by becoming adamant and arguing about who is right. Instead of focusing on positions, we should focus on interests of the parties involved to find a collective solution.71 Your position is something you have decided on, while your interests are the driving force behind your decision. Separating positions from interests makes it easier to think creatively and work together. This is because several different positions can satisfy a given interest and these positions do not necessarily have to conflict with each other. There are 3 types of interests in a conflict: substantive, procedural, and psychological.75 “Substantive interests” refer to the “what” or tangible outcomes and benefits from conflict resolution. “Procedural interests” refer to the “how” or preference for the process of conflict resolution. “Psychological interests” refer to the emotions that arise during conflict resolution. These 3 interests must be met, at least to some degree, to achieve long-term solutions. If a conflict is resolved through an equitable process with a good outcome but the involved parties develop negative emotions toward each other, it is unlikely that this solution will be sustainable.

T4
Table 4.:
Conflict Management Techniques

Consider the following case. A 5-year-old patient is scheduled for an orthopedic surgery. The anesthesiologist recommends a peripheral nerve block, while the orthopedic surgeon does not want a nerve block. A postoperative block is not a realistic option because of the patient’s age and inability to cooperate with block placement while awake. The positions of the anesthesiologist and surgeon are “block” versus “no block,” respectively. These positions may initially seem incompatible. Focusing on the interests of the anesthesiologist and surgeon, rather than their positions, makes it easier to resolve this conflict. The anesthesiologist wants a block because she believes that it will decrease the patient’s postoperative pain and minimize opioid use. The surgeon does not want a block because she believes that it will interfere with a postoperative neurological examination. Once all parties are aware of these concerns, the anesthesiologist and surgeon may agree to place the peripheral nerve catheter while the patient is anesthetized without local anesthetic. In the recovery room, after the surgeon establishes that the neurological examination is normal, the anesthesiologist can deliver local anesthetic via the peripheral nerve catheter. Focusing on interests instead of positions can result in integrative solutions that address the needs of both parties and achieve the common goal of optimizing the patient’s care.71 Emphasis on commonalities rather than differences aligns interests. During conflict, people tend to focus on minor differences instead of considering the “big picture,” which is that overall, they actually agree on most issues. The anesthesiologist and orthopedic surgeon agree that the patient requires orthopedic surgery under general anesthesia and that the patient should receive adequate pain control. The only disagreement here involves the question of how to manage the patient’s postoperative pain. Discovery of common ground can shift the mindset from “no” to “yes” and smooth the transition from conflict to agreement.64 It is important to see the other person as a partner rather than an opponent to defeat. Excellence in patient care is the “common ground” for health care providers. By redirecting focus to this shared goal, health care providers can align their interests. These conflict management techniques are summarized in Table 4.

CONFLICT MANAGEMENT EDUCATION

Learning the theory behind successful conflict management can be the first step toward mastering this skill. Ideally, an anesthesiologist has the opportunity to apply conflict management concepts before working in the operating room. In reality, few formal curricula exist. Several educational methods can be used to teach conflict management skills including videos, case studies, role-play exercises, and high-fidelity simulations. At our institution, the office of medical education offers several classes including a workshop series on conflict management. These workshops are available to all employees and incorporate a combination of didactics and role-play exercises. Another example is Crisis Avoidance Resource Management for Anaesthetists, which teaches communication skills to anesthesiologists through classroom and simulator sessions.76 Conflict management training is more effective if it includes all members of the perioperative team. Anesthesiologists who attended the Crisis Avoidance Resource Management for Anaesthetists course suggested that participation in the simulator session by providers from other disciplines would enhance the educational benefit.76

Health care providers encounter colleagues, patients, and families from vastly different backgrounds every day. Cultural diversity increases the potential for conflict because it encompasses divergent beliefs, values, customs, and religions.2 Enhanced cultural competency can improve communication and conflict management. At our institution, we provide diversity, equity, and inclusion champion training for faculty and staff. This class provides coaching on addressing implicit biases and training in applying empathy and active listening to support a more diverse, equitable, and inclusive environment. Facilitated small-group discussions and problem-based learning models have been successfully incorporated into medical education to improve cultural competency and awareness of multicultural issues.77,78 Problem-based learning discussions at national meetings can provide a safe and interactive environment for participants to enhance their conflict management and cultural competency skills.

DISCUSSION

Reconsider the arterial catheter-related conflict between the surgeon and anesthesiologist presented earlier. Surgery proceeded uneventfully, and the anesthesiologist spoke with the surgeon privately after care was transitioned to the pediatric intensive care unit. He calmly asked her why she made comments about his inefficiency and lack of skill. The surgeon shared that she had been under considerable time pressure due to a long patient waitlist and was concerned that with the delay in procedure start time, the following case would not proceed. The anesthesiologist reassured her that the case would proceed as scheduled. They decided to meet later in the week to discuss how to improve operating room efficiency.

In the previous scenario, both the anesthesiologist and surgeon reacted emotionally in the operating room, leading to an escalation in conflict. The anesthesiologist readdressed the conflict postoperatively. By controlling his emotions and actively listening to the surgeon, he better understood her concerns and perspective. He then aligned their interests by demonstrating his intent to proceed with the second case. This opened the path to collaboration; the anesthesiologist and surgeon planned to engage in problem solving when both parties had more time to commit to the issue.

One example of conflict management at our institution was the formation of an enhanced recovery after surgery pathway for patients with adolescent idiopathic scoliosis. This multidisciplinary team was formed after the primary orthopedic surgeon expressed frustration at the inconsistent care of his adolescent idiopathic scoliosis patients in the perioperative period (“task conflict”) leading to parental anxiety and stress due to unclear expectations. Relationships were strained since providers were unfamiliar with the plan of care (“relationship conflict”), causing further communication breakdown. We viewed this conflict as an opportunity to identify areas of improvement and apply the conflict management approaches discussed previously. We used “collaboration” as our primary “conflict management style,” but at times “compromising” was most appropriate. We “decreased emotional reactivity” by meeting outside the operating room during dedicated times in a neutral, low-pressure environment. The next step was “active listening.” The anesthesiologists/pain management physicians, surgeon, nursing staff, child life specialists, and physical therapists raised their concerns and questions at team meetings. Understanding each provider’s perspective through active listening was essential to the pathway’s success. Active listening also revealed the commonality of goals, which promoted “aligning interests.” For example, 1 common goal was to optimize pain management to facilitate early mobilization after surgery. By aligning interests, we were able to develop a comprehensive plan with buy-in from all providers.

Conflict, if managed well, can help perioperative teams evolve. Proper conflict management requires knowledge of different conflict styles, the capacity to identify the most suitable strategy for a given situation, and the ability to execute the applicable strategy. One must also be aware of one’s own tendencies and determine the other party’s conflict management style.

Appreciating the nature of the conflict allows the use of techniques to effectively manage the situation. Acknowledging and managing emotions can prevent escalation of conflict. Active listening makes the other party feel heard and more likely to engage in problem solving. Similarly, aligning interests helps foster an environment of collaboration.

Furthermore, one can help achieve conflict resolution even before a conflict occurs. Building a positive working relationship helps ensure that the lines of communication are open during a conflict situation. Multiple studies have demonstrated the negative impact of disruptive behavior on medical teams.79–81 In addition, studies outside of medicine show that positive emotions toward team members improve team dynamics and performance.82 Solid interpersonal relationships make it easier to deal with conflict effectively and efficiently, which further strengthens the relationship.

Although the Accreditation Council for Graduate Medical Education identifies interpersonal and communication skills and professionalism as core competencies, education of these skills should not be limited to trainees. Such skills are often taught in the clinical setting through lessons embodied by the phrase, “Actions speak louder than words.”19,20 Discussions about cultural diversity have positive effects on clinical practice,77,78 but sincere respect for a cultural preference during a preoperative discussion or postoperative visit adds the impact of action to the teaching. Similarly, physicians in training learn more about conflict management by watching others successfully navigate conflict in the operating room versus learning conflict management theory in the classroom. Thus, education of practicing physicians and physician leaders is essential to build a culture where conflict is seen as an opportunity for positive change with the expectation that all team members actively manage conflict. The support and active involvement of physician leaders such as department chairs and division chiefs is important to promote this shift in culture. Four domains can impact organizational culture: (1) policy development, (2) evaluation, (3) resource allocation, and (4) institutional “slang” or nomenclature.20 One example of an initiative using these domains is mandatory annual cybersecurity training: (1) development of an annual training policy, (2) self-tests and training completion as a means of evaluation, (3) resources to create and implement training modules, and (4) “cybersecurity” as a phrase used throughout the institution. Mandatory ongoing training in conflict management may be a useful tool to effect culture change. Such mandatory training has the added benefit of reaching team members who may not think they are deficient in these areas. For example, although most people believe that they are at low risk of a cybersecurity breach, all members are still required to participate in training, which serves as a refresher and often does improve their skills. Using such methods and emphasizing the shared goal of excellent patient care can help build a culture of active conflict management.

We must provide anesthesiologists with the tools and training to effectively manage conflict and lead perioperative teams. This may take the form of formal curricula for both anesthesia trainees and established physicians. Ideally, such training would involve all team members including surgeons and nurses. Furthermore, a shift in mindset toward embracing and actively managing conflict is necessary. This will improve the operating room work environment and increase job satisfaction of the team members, and ultimately lead to better patient outcomes.

DISCLOSURES

Name: Jina L. Sinskey, MD.

Contribution: This author helped conceptualize, write, and revise the manuscript.

Name: Joyce M. Chang, MD.

Contribution: This author helped write and revise the manuscript.

Name: Gail S. Shibata, MD.

Contribution: This author helped write and revise the manuscript.

Name: Andrew J. Infosino, MD.

Contribution: This author helped write and revise the manuscript.

Name: Kathryn Rouine-Rapp, MD.

Contribution: This author helped conceptualize, write, and revise the manuscript.

This manuscript was handled by: James A. DiNardo, MD, FAAP.

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