“Hot Seat” Simulation to Teach Conflict Management Skills to Residents

The ability to manage conflict so that effective communication occurs is a key competency in graduate medical education.¹  It has been recommended that these types of skills be treated as “verbal procedures” that residents must be able to demonstrate by the end of their training.²  Conflict management training has been shown to improve the work environment, decrease stress, increase confidence in managing conflict, and gain appreciation for the positive aspects of addressing conflict.³  However, methods to teach conflict management skills to residents have been under-researched, with only a few published descriptions of lectures and case discussions.^1,4,5 

One method to teach conflict resolution is the Shannon-Kim 4-Step Conflict Dialogue Model taught via “hot seat” simulation training.⁶  This technique improves performance, compared to an untrained control group on key conflict management skills.⁶  It includes active skills practicing in a group setting, while receiving real-time faculty coaching and peer feedback.

The purpose of this study was to evaluate whether it is feasible to incorporate this teaching method into a residency program's conference schedule, and whether residents perceive this training as acceptable and relevant to their professional development.

A workshop to teach conflict management to physical medicine and rehabilitation (PM&R) residents was developed (Table 1) and presented in 2015, 2017, and 2019. This is an urban, university-based program with 8 to 10 residents per year. In 2015 and 2019, postgraduate year 4 (PGY-4) residents participated in the workshop. Because of additional curricular time in 2017, PGY-2, PGY-3, and PGY-4 residents participated.

The 2-hour workshop began with a lecture about conflict management as a leadership skill essential for team function and to prevent medical errors. A 4-step model to address conflict was presented (Table 2).^6,7  A scripted conflict from the residents' perspective was presented. The group discussed the issues presented in the scenario and the cost to team functionality if the conflict went unaddressed. Three scenarios were developed by the authors based on their personal knowledge of common workplace conflicts. Scenarios were written to be multidimensional, highlight power differentials, and be slightly emotionally charged. A different scenario was presented each year (further details of the curriculum are provided as online supplemental material). The room was arranged with the residents in a circle, with the “hot seat,” facilitator, and trained actor set slightly apart from the group. Residents took turns spending 5 to 10 minutes in the hot seat practicing their conflict management skills with the actor, practicing the 4-step model as a guide. The resident in the hot seat and the faculty facilitator could “rewind” the scenario to try different approaches, and “time out” to seek assistance and feedback from the group as needed. When not in the hot seat, residents observed the conflict unfold and gave feedback and suggestions as requested.

The facilitator served as a coach to the resident in the hot seat. In addition, facilitators needed to create a comfortable environment, engage observers, and pace the session to allow many residents to practice and reach closure within allotted time. A facilitator road map was created to highlight how the steps of the model are used to work through the simulated conflict to assist the facilitator.

Anonymous paper surveys were collected immediately after the session (provided as online supplemental material). This evaluation was developed by the 2 clinician-educator authors without further testing. It consisted of 10 Likert-type, closed-ended questions and 5 open-ended questions. The percentage of residents who chose each response was calculated, and narrative comments were analyzed by the authors to search for themes.

This project was deemed exempt from review by the University of Washington Human Subjects Review Board.

The workshop was conducted in 2015, 2017, and 2019, and a total of 36 residents out of a cohort of 40 (90%) participated in the training. All residents who participated completed surveys. All the participants strongly or somewhat agreed that the topic session was relevant to residency training, thought that they were able to manage the conflict in the scenario, and that it taught them a skill they would use in the future. Ninety-seven percent (35 of 36) felt prepared to manage conflict following the session. Overall, residents reported confidence in their ability to implement each step of the model (Table 2).

Responses to the scenarios were positive. When given the choice between constructive, neutral, or poor outcome, all participants except one chose the statement, “In the simulated conflict, a constructive outcome of the scenario was achieved (ie, better than avoiding the conflict).” Many positive comments were written on the evaluation, such as “was so real,” “surprisingly effective,” and “information was presented in an efficient and tangible manner.” There were no negative comments.

Actors were obtained through the medical school's standardized patient program (cost of approximately $100.) Facilitators were trained by practicing the scenario with the actor and receiving coaching from coauthors prior to the session.

In this study, an interactive simulation workshop with real-time faculty coaching for learning conflict management skills was well accepted by PM&R residents. They perceived the need for this training and reported improved confidence in dealing with conflict situations.

The need for conflict management training is consistent with other studies that have noted the high amount of conflict in health care settings.^8–10  Studies of leadership and communication skills training demonstrated that practice and coaching is required to improve skills.^7,11,12  However, this training can be time and resource intensive. Simulation training of leadership skills has been proposed as one solution.¹³  This format allows multiple residents to practice sequentially and receive coaching in a reasonable time frame. This method also allows for the breaking down of skills and practicing discrete components. The opportunity while in the hot seat to “time out” the conflict and seek advice from their peers or the facilitator, and to “rewind” and try again, is not a viable option when handling a real-life conflict so it is well suited for simulation. This method of deliberate practice of discrete elements with frequent interruptions has been well received in other simulation training,¹⁴  but to our knowledge, it has not been studied in resident conflict management teaching. The opportunity to observe and reflect in a psychologically safe environment on a peer's conflict management attempts as well as their own is also unique to this model.¹⁵ 

Limitations of the study include that the workshop occurred at a single site within a single specialty. The resident-reported outcome does not measure whether the training changed resident behavior in actual work-related conflicts. In addition, the survey was developed by the authors and not tested for validity evidence; therefore, respondents may have interpreted questions differently than intended.

In the future, this approach could be implemented and studied with other specialties. Standardized testing with a simulated conflict to see if skills were improved and evaluating whether it improves skills in real-life conflicts would also be valuable. Comparing different types of conflict management training would allow a better understanding of the best approach to this common but understudied area.

Using a “hot seat” simulation model with faculty coaching and peer feedback to teach residents conflict management skills was well accepted and increased comfort and perceived skills. The 2-hour workshop required an actor as a standardized patient but few other resources.