Expressing concerns to colleagues or handling difficult behaviour can be challenging and may result in a difficult conversation. Dr James Thorpe and Dr Sarah Coope, Senior Medical Educators at Medical Protection, provide some insights that may help to navigate stressful conversations at work

Since the start of the pandemic, Medical Protection has received numerous requests for advice from doctors that relate to medicolegal topics such as remote consulting or working safely outside your comfort zone. Perhaps unsurprisingly, some doctors have also contacted us following difficult interactions with their colleagues. For instance, there have been disagreements regarding the adequacy of Personal Protective Equipment – how should you manage a conversation with a colleague when you have a difference of opinion over such a vital and emotive safety issue? 

Redeployment is another area that has generated friction. For example, a trainee in psychiatry being asked to work in acute medicine may feel that what they are being asked to do is very challenging. Many doctors are working outside their normal area of expertise and doing what they can to support the COVID-19 effort, so expressing concerns about redeployment is not easy. 

Clearly working during the pandemic has been and continues to be highly stressful for all healthcare staff. It is useful to consider factors that may contribute to difficult interactions in this environment, self-management in such situations and key communication skills that can help to bring about resolution.

The pandemic and difficult interactions

The Yerkes-Dodson law from over 100 years ago still stands – when we are under significant stress, it usually negatively affects our performance.

This includes how we interact with others and so there’s a greater chance that we, and our colleagues, may behave in a less optimal way. This leads to a higher chance of conflict, which creates even more stress and we can find ourselves on a downward spiral.

There are various factors that can contribute to difficult interactions and these can be grouped into four themes.

1. Relationship and respect factors

If there’s a history of conflict with a particular person, it may not take much to trigger a further disagreement within the context of the current pandemic. Other factors such as suboptimal leadership, poor communication or disrespectful attitudes also fit into this area.

2. Resource factors

Increased pressure on the workforce, time and the already over-stretched system.

3. Responsibility factors

Situations such as transitions of care or when more than one secondary care team is involved in the care of a patient.

4. Ourselves

We, ourselves, can contribute to difficult interactions and it is important to recognise the ways in which we may do this.

You may have heard the acronym HALTED before (Hungry, Angry, Late, Tired, Energy being low, Distracted). Any of these factors could lead to our own communication being sub-optimal when interacting with a colleague.

Managing our emotions

Although we can influence certain factors, the only thing we really have direct control over is ourselves. 

In a difficult interaction it is easy to let our emotions take over and we may end up regretting something we have said or done. For example, we may react defensively and reply with a sharp retort or verbal attack to someone else’s comment.

Perhaps we don’t really listen, interrupting the other person or dismissing their viewpoint. Professor Steve Peters wrote in his book The Chimp Paradox that in a conflict or disagreement, we have a choice to either react or respond, whether we’re aware of this or not.

Reacting is automatic, and it occurs at a primitive limbic level – the unhelpful fight/flight/freeze behaviours. This can seemingly happen before it feels like we’ve had time to think, because it has become unconscious due to repeated practice.

But it is possible to respond instead, even with the same trigger. This needs to happen at a more conscious, logical level – using our neocortex. It gives us a greater chance of behaving in a more constructive, positive way.

It may seem easier said than done, especially in the heat of the moment. A book called Crucial Conversations by Kerry Patterson and Joseph Grenny discusses this in more detail and talks about our internal ‘path to action’.

Firstly, we should ask ourselves what is behind the behaviour, or action. It starts with how we perceive a situation or person, what we notice or observe happening, what we see or hear and then focus on.

This then leads to us telling ourselves a story, making sense of what we’ve perceived and drawing a conclusion from what we’ve observed.

For example, when we see another person rolling their eyes, or hear them sighing in an exasperated way, or telling us that we are "wrong", we may tell ourselves a range of stories (eg. "they obviously don’t respect me" or "they are so impatient" or "they always think they’re right").

What conclusion you draw depends on your existing relationship with that person, your past experience of their behaviour, and your current state of mind. There is always more than one way to look at a situation and interpret it. What we tell ourselves then leads to our emotional reaction which affects our actions and behaviour at the end of the path.
The things that we observe in the situation and in the other person’s behaviour can be an emotional ‘trigger’ for us – we call them ‘hot buttons’. What triggers you, will be different to what triggers others around you, as our hot buttons reflect our past personal experiences, prejudices, attitudes and values. 

When your buttons are pushed 

There are three critical steps in controlling and working with your hot buttons.
Step one is to recognise your usual automatic reaction. What do you tend to do without thinking when faced with a conflict? Do you tend to push back or back down? 
How do you know this is about to happen? What are the early warning signs, eg .pulse racing, blushing, clenching your fists or feeling tearful?

In order to change this, you need to go back to firstly identifying what triggers this behaviour. What have you observed or perceived in others, and then what thoughts or story have you told yourself about this?

The next step is to engage your higher brain function to choose a more conscious, logical or rational response:

• Press pause for a few seconds to gain control of your thoughts and your physiology

• Metaphorically ‘step back’ from the potential heat of the moment and give yourself enough time to think about what ‘story’ would be more helpful to tell yourself instead about what has triggered you.

• ‘Reframe’ – is there another way of interpreting the situation that enables you to feel differently? This is not to excuse poor behaviour, but to help you approach a situation with a more open mind and explore other possibilities.

The third step is to learn from each interaction where a hot button has been pushed. By reflecting afterwards it reinforces the learning to help us respond more constructively the next time we are faced with a similar situation.

What if we’ve managed ourselves and responded logically and constructively, but conflict still develops? There are some key communication skills that can be useful to keep in mind in this situation:

1. Ask questions in order to understand the other person’s position clearly. For example, “What would you like to happen?” “What’s important to you about that?” 

2. Accept the feelings of others by empathising with any emotional response we notice. This doesn’t mean you necessarily agree, but it shows acceptance and validation for their position which builds a connection.

3. Acknowledge the other person’s position by showing that you’ve heard and understood where they’re coming from.

4. Answer by giving your position and reasons. Acknowledge this is a difficult situation, in that you have different views to each other on things, and that you want to negotiate an agreed way forward. 

5. Agree actions and solutions. Your colleague may need some encouragement to agree the alternative options or outcomes. You might say “I’m really keen to find a solution that is best for this patient. What other options do we potentially have here?”.

If these approaches fail and you feel that you or patient care are at significant risk, it may be appropriate to seek a second opinion from a senior colleague or clinical lead to help resolve matters. It is important to carefully document any discussions that you have.

Seeking expert advice can be a difficult step, but the alternative is to allow patients and yourself to be exposed to unacceptable risk  – including the risk of a challenge to your decision not to take action should there subsequently be an adverse patient outcome resulting from a communication failure.

If you would like to talk through any similar scenarios, or indeed for any medicolegal advice in general, please do call us at Medical Protection on 0800 952 0442.