Structural Problems

Howard Gadlin

Ombudsman, Center for Cooperative Resolution, National Institutes of Health

Interviewed by Julian Portilla, 2003

This rough transcript provides a text alternative to audio. We apologize for occasional errors and unintelligible sections (which are marked with ???).

Q: Can you think of an example for me from the second half of the first part of your description of your work? In other words, someone comes to you what seems to be at first a personal dispute but ultimately has some sort of structural implications.

A: I will have to be a little vague because of confidentiality considerations. There was a situation a couple of years ago where three nurses who worked together in a particular unit in a clinical center here, one that conducts medical research and treatment. All of the treatment is part of research here. It is not truly a research program; there is actual ongoing treatment of patients who are in experimental protocols testing particular procedures and the three nurses were referred to us because of what was described as a high level of interpersonal conflict among the three of them.

There was indeed a high level of interpersonal conflict among the three of them. As we talked with them about the sorts of issues that they were in conflict over, you know when the conflict occurred. We learned more and more about the way in which in this particular medical unit was performed and how the process of communication occurred and who reported to whom. We noticed that there were some contradictory reporting relationships, so that if you are reporting to two different people, and I am reporting to two different people, and those two people are not getting along well, and it is unclear over who is in charge on any one particular activity that we are involved in, the potential for conflict is just enormous.

If the people to whom we are reporting are in conflict and are not facing up to the fact that they are in conflict, then often times the conflict is carried out by the people who are underneath them. That gets exacerbated by a variety of personal factors: Who feels that they have better access to the people that are above them? Who feels that they are liked more? Rivalry between the parties.

You have a structural arrangement that supports rivalry between nurses who have to work together collaboratively.

Ok? Some uncertainty about where nurse A's responsibilities end, and where nurse B's responsibilities begin, and where nurse C's . Ok? It was that kind of a situation. We had to go back to the leadership of this unit and suggest to them, while they we were willing to work with those kinds of disputes, we really thought there was something about the way in which there work was being organized that was perhaps part of the problem. And asked for their cooperation to interview all of the twenty-some odd people in this working to get some sense of how the whole unit was going.

The stories we were hearing from the nurses were indicating a wider set of problems then personal disputes between three people. On the basis of those confidential interviews with everyone. Separately. Privately. Doctors, nurses, anesthesiologists, technicians, clerical people, and so on and so forth. We then made about identifying particular people, a report back to the leadership structure of this organization that identified areas in which there were problems. And on which they needed to do some rethinking about how they did things to keep these kinds of conflicts Otherwise they had an organizational structure that was going to keep churning out conflict. And would have appeared, if you think about intractable conflicts, it would have appeared that this was intractable because they were just generating.

On the basis of that we then set up to facilitate an all day retreat of the entire unit in which they re-engineered their work and we were the facilitators. We don't have the medical expertise to do that kind of work, we could just point out how the way in which they were organizing what they were doing. We did that and we had a follow up retreat one month later, in part to do a kind of assessment and fine tuning of what went on. At that retreat it was actually We got to the point after the first few hours they realized that they could facilitate the retreat on their own at that point. Things were turned around enough, we could let the actual leaders of the unit take over the role.