Pediatric Pearls: Conflict Resolution

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Nurses Edition Commentary

Mel Herbert, MD MBBS FAAEM, Lisa Chavez, RN, and Kathy Garvin, RN
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CAMILLE H. -

What do you do when you cannot establish a common goal?
When the goal of the individual is to be right rather than well. When the goal of the individual is to get disability and you think they would be inappropriate for disability. When the administration has it " in " for a physician and wants them out despite no evidence to dismiss the physician.
I think there is an assumption here that most people are good and reasonable, but it has been my experience that conflict resolution does not work with sociopaths and people who are unwilling to be considered " wrong " or incorrect for a better term.

Nathan M. -

Awesome session! Emotion is always at the heart of conflict. The LP refusal is a great example. I've now come to expect it as the norm rather than the exception. I've seen many residents butt heads with parents and they run out of the room after giving up. In the neonatal fever situation, I usually start the conversation with, "what did your pediatrician tell you about coming to the ED?" to get a sense of their expectations. Usually, they never brought up the need for a LP (which I actually understand, because some may not come). I then go into the risk of meningitis and the need to make the diagnosis early. They usually are then freaked out and I respond, "most of the time we don't find it, but we don't want to miss it either. Spinal taps are very safe... much like getting an IV...and sometimes easier." I have the nurses get the blood, urine and give lot's of IVF (so the tap isn't dry) and let them ruminate on it. When I come back I usually read their faces to see how scared they are. Then, I acknowledge, "Yea, I know, It's very scary." Usually at that point, I can see the tension fade a bit. I have a few stories in my back pocket, depending on how much convincing I need to do. I also acknowledge that their desire to refuse is very common (they're not alone). One story is of a 7 day old with ALTE (turned blue), no fever in the ED, that had a physician as a parent and a surgeon aunt (who was very confrontational) that we spent over an hour convincing to get a LP. "And good thing we did, because she had bacterial meningitis." Usually after a few minutes of acknowledging their emotions, they're willing to negotiate. "OK, but you have to do it, not the residents." I usually don't bring up the "I would do it if it was my child," unless they ask me. And I do have three kids. I sort of feel that it's the topic of last resort. I focus more on empathizing with what they're going through.

ilene c. -

Good points. Usually (with parents in particular) there is some good intent under all the frustration and some way to find a common goal of looking out for the best interest of the children. But there are times when a patient's agenda is so out there that a common ground cannot be reached, in which case good charting and ending the encounter politely but quickly and firmly are the best bet. Dealing with admin should incorporate the same skills, but sometimes I wonder :)

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