Getting to Yes: “Heal Thyself”
You can picture it: the Medical Director, Head Nurse, and Clinic Manager sitting around a table, steam coming out of their ears, each holding the line and unwilling to compromise. As they wrestle with a tough decision about how to manage budget cuts—do we cut physician salaries, nursing positions, support staff, or supplies—each argues intensely for his/her own interests. By digging in their heels, these managers have become unable to work together for healthy, effective solutions. In the end, the loudest, most stubborn voice will win out, and the other two will harbor bitterness.
Almost everyone who works in health care started out with the desire to help or heal others. But the re
alities of day-to-day life in a clinic are often at odds with those simple wishes. Competing interests—of the clinicians, nurses, administrators and clerical staff—who often see the world only in terms of their own roles—get in the way of high quality patient care. The end result is tension and the inability to recognize that we do share common ground with one another.
Think about the conflicts we commonly see in health care settings. Administrators are looking at the bottom line of revenue verses expenses, knowing that if there’s not enough money coming in, the clinic won’t survive. Physicians focus on continuity of care and having adequate time for their patients. Head nurses cope with shortages by shuffling staff to cover more than one clinical area, making staff consistency a challenge. And patients too often are caught in the middle.
What happens then, as managers or front-line staff wrestle with these “competing interests?” They hunker down and defend their own positions on scheduling patients, staff assignments, or allocation of resources. In such tense interactions, people can become angry and lash out at one another, and even escalate to personal attacks. In these debates, the common goal of providing excellent patient care is often completely overlooked.
But there is an approach that can help all of us work together to negotiate agreeable solutions to difficult problems.
In their book, Getting to Yes: Negotiating Agreement Without Giving In, Roger Fisher and William Ury prescribe a method of “principled negotiation” which focuses on problems and effective solutions while preserving our work relationships. The authors define “negotiation” as:
A basic means of getting what you want from others. It is back-and-forth communication designed to reach an agreement when you and the other side have some interests that are shared and others that are opposed.
According to Fisher and Ury, any effective negotiation should accomplish three things:
- Produce a wise agreement
- Be efficient
- Improve the relationship
In other words, good negotiation will not result in a watered-down compromise that leaves everyone frustrated. Neither will it require months of discussion that depletes everyone involved. Finally, effective negotiation prevents one party from winning out over the other through brute force, leaving the relationship irreparably damaged.
The pattern is familiar: time and again we see the strongest person win, rather than the best solution. A hardnosed administrator unilaterally sets a policy without regard for how it might affect staff or patients. An articulate physician gets her way because she’s the best debater in the room, and finally everyone else is worn down by her arguments and acquiesces—grudgingly—to her position. Or a veteran head nurse, who is both very experienced and absolutely inflexible, gets his way because everyone knows that he can make life hell for them if he doesn’t.
The problem can be stated this way: in most situations we find ourselves bargaining over positions. It’s my way or the highway.
Fisher and Ury allow us to break down these worn out patterns. Their method, called “Principled Negotiation” or “Negotiation on the Merits” can be distilled into four basic points:
- Separate the people from the problem
- Focus on interests, not positions
- Invent options for mutual gain
- Insist on using objective criteria
First, in separating the people from the problem, the authors acknowledge that as people feel thwarted in resolving problems, they attack one another. We may have experienced this in a clinic all-staff meeting, when out of frustration, someone launches into a bitter tirade about another person. The advice of Fisher and Ury is to “attack the problem, not each other.” This takes some reconditioning on everyone’s part, along with a group commitment to avoid personal attacks. The authors encourage us to “put yourself in their shoes”—and not in a superficial way, but genuinely attempting to understand the other person’s behavior.
The second point, “focus on the interests, not positions,” recognizes that it is all too easy to get locked into one solution and not be open to any others. There are two key ways of breaking down that inflexibility: 1) Ask “Why?” and 2) Ask “Why not?” Of your own interests, ask why you are approaching things the way you are and why the other person has a different perspective. And of other points of view or alternative solutions, constantly ask “why not?” “Why couldn’t we try…?” The authors extol us to “be hard on the problem, soft on the people.”
Thirdly, rather than narrowing the options, Fisher and Ury tell us to “invent options for mutual gain.” The error, they write, is that “people see their job as narrowing the gap between positions, not broadening the options available”. Instead, effective negotiation blows the doors off limited thinking, using brainstorming to open up possibilities no one has yet considered. These new solutions are almost invariably more creative and more effective than the ones people started out with.
The final point in the methodology is to “insist on using objective criteria.” These may include precedent, professional standards, efficiency, cost, or other measures. Decisions should be made based on factual information, rather than relying solely on gut feeling or opinions.
Health care settings can be extremely intense places, and people who work in those settings know it. To make them less stressful, we must work to avoid the old patterns of bad decision-making in which the loudest voice wins out, and move toward a healthier, more collaborative model of solving problems.
So picture it again—the budget discussion: the Medical Director, the Head Nurse, and the Clinic Manager site down together. They sit on the same side of the table with the budget numbers in front of them—the focus is on the problem—rather than sitting across the table from each other with fingers pointing. Each listens to the other’s concerns—demoralized doctors, nurses spread too thin, billing errors due to lack of support staff, not enough paper, pens, and light bulbs.
The managers then pull out a flip chart and start coming up with as many creative ideas as they possibly can about how to rethink the budget. Their own interests are in the background, and now they are working together. The problem is still a tough one—that hasn’t changed. But the solution they derive will be better for everyone, their relationships with one another will actually be strengthened by working together to sort out a tough problem, and they will present a unified vision to staff about why they have made the decisions they have made.
Written by Jeff Olivet