PSB TECHNIQUES &
PROCEDURES FOR
RAD/NUC DISASTER
RESPONSE
VIDEO CLIP
Click anywhere in frame above to view the video
Excerpt from Psychological First Aid in Radiological (or Radiation)
Disasters courtesy of Center for Disease Control and Prevention (CDC)
PSB TECHNIQUES AND PROCEDURES
FOR RAD/NUC RESPONSE
● Rapid assessment, triage, & stabilization (R.A.T.S.)
● Psychological First Aid (PFA)
● Risk communication
● Conflict resolution
R.A.T.S.
RAPID ASSESSMENT, TRIAGE, & STABILIZATION
Presenting Problems:
● Aggression: Can the person control violent impulses?
● Disruptiveness: Can the person regain composure and consider needs
of others?
● Self harm: Does the person have active suicidal intent or exhibit
behaviors involving potential risk of self harm?
● Anguish: Is the person inconsolable?
● Mental status: Does the person show confusion, psychosis?
RAPID ASSESSMENT, TRIAGE, & STABILIZATION
Acute phase rapid assessment activities:
● Talk with the person: get information, observe
- Allow the individual to tell you what is going on
● Model a calm demeanor
● Reflect understanding
● Problem-solve
● Proceed to deciding the person’s triage status
RAPID ASSESSMENT, TRIAGE, & STABILIZATION
Deciding the person’s triage status:
● Resolved after talking
● Apply de-escalation procedures
● Remove to safety/quiet area
● Seek medical/psychiatric opinion
● Call Security
RAPID ASSESSMENT, TRIAGE, & STABILIZATION
Rapid stabilization (and de-escalation if needed):
● May be needed for people so acutely distressed that they:
- cannot function
- are disruptive to others
- present a direct threat to their own or others’ safety
● Strong and overwhelming emotions are often brief in duration
- Give the person a few minutes of privacy to process cognitive
overload and calm down – may allow episode to blow over
- Tend to some nearby business, telling the person you will be
available and will check back shortly to offer help
RAPID ASSESSMENT, TRIAGE, & STABILIZATION
 If possible, separate disruptive individuals to a quieter place
 Enlist calm family/friends to comfort distressed individuals
 Main interventions for acute situations:
- Offer support
- Focus on manageable and immediate concerns
- Offer distracting and grounding techniques
 For very agitated individuals:
- Approach calmly; invite calm discussion
- Establish orientation (is the person confused/disoriented?)
- Offer specific choices (behave calmly/seek higher level of assistance
DYNAMICS OF CROWD BEHAVIORS
Initiation of crowd behaviors:
1) Seed: individual or small group who begins divergent activity that
entices others to join in
2) Crowd engagement: others engage in the seed activities,
producing the crowd behavior
Examples:
● Human waves at sporting events (harmless behavior)
● Stampedes started by a few people pushing (harmful behavior)
Zeitz et al 2009 Prehosp Dis Med 24:32-8
CROWD BEHAVIOR FLASHPOINTS
● Restriction of the flow of people  produces physical
pressure points in crowds
- eg, bottleneck at entrances and exits for major crowd events
● "Flight" response to a threat (either real or perceived)
- eg, crowd fleeing a bomb scare
● Craze: a competitive rush to gain a highly valued goal
- eg, physical competition to gain access to limited supply of
life-saving antidotes
Fruin 1971, Pedestrian Planning and Design, Metropol
Assn Urb Designers Envir Planners, New York
WORKING WITH CROWDS
Assessing and managing crowd behavior:
1) Assess & monitor ongoing behaviors
- Warning signs: noise level (shouting), cursing, agitation (pushing, shoving, running),
threats, aggression
2) Manage seed behavior
- Remove negative seeds (eg, redirect to a quiet location to de-escalate)
- Generate positive seeds (eg, get a group to start singing pleasant songs)
3) Inhibit harmful crowd engagement
- Redirect crowd attention to positive behaviors (eg, start filling out forms; form line)
- Set up & communicate ground rules – signage, announcements
- Maintain visible presence of security and support staff – enforce "house rules" to
discourage harmful seed behaviors from growing into collective behaviors
- Know when to call Security
Zeitz et al 2009 Prehosp Dis Med 24:32-8
SPECIFIC PSB TECHNIQUES FOR WORKING WITH
CROWDS GATHERING FOR SERVICES
● Open doors to facility earlier than advertised to prevent crowd buildup
● If possible, use more than one entrance to avoid bottlenecks
● Keep crowd informed about what is going on inside the facility
● Attend to people’s basic needs and comfort while they are waiting
 eg, water, restroom facilities, seating, special needs
● Train all responders in PSB techniques for working with crowds
Crowd Management: Report of the Task Force on Crowd Control and Safety.
Submitted to Sylvester Murray, City Manager, Cincinnati, Ohio, July 8, 1980
VIGNETTE
A young mother who is certain she and her baby were exposed
to radiation shows up at the health department seeking medical
advice. She will not keep her place in line at the registration
desk, pushing ahead of others. She has been asked to wait with
the others, but she begins wailing loudly and shouting that if she
doesn’t get her baby treated quickly the baby will surely succumb
to radiation exposure. It is clear that her agitation is becoming
contagious; the crowd is becoming restless.
You are a public health staff person called to the scene to
help: What can you do to address this situation?
PSYCHOLOGICAL
FIRST AID
(PFA)
PSYCHOLOGICAL FIRST AID (PFA)
A form of mental health assistance provided in the
immediate aftermath of disaster, to address acute distress
and promote coping and functioning
 Provided by mental health and other disaster response workers
 Flexible for use in a variety of settings, populations, and cultures
 Developed through expert consensus
(PFA is intuitive and is consistent with available scientific
evidence, but research to demonstrate efficacy is needed)
Psychological First Aid Field Operations Guide, Natl Child Traumatic Stress Network & Natl Center for PTSD.
North, Hong, Pfefferbaum 2009, Practical Front Line Assistance for Support and Healing, version 3 (P-FLASH III).
PSYCHOLOGICAL FIRST AID (PFA)
10 elements of PFA:
1) Being there – physical support, engagement
2) Safety and acute stabilization
3) Supportive listening & information gathering
4) Education & reassurance
5) Coping & stress management
6) Problem solving
7) Connect with support
8) Symptom management
9) Know when more help is needed
10) Caring for the caregivers
1) BEING THERE
Be unobtrusive, helpful, and compassionate
 Approach the setting first as a caring helper, not as a worker with a mental
health mission
 Be an anchor: your focused, calming presence will influence others
Address immediate physical needs, comfort, and concerns
 This is a powerful mental health function!
 Your presence in itself can be comforting ("ministry of presence")
 Ask: “Is there anything you need?” “Is there something I can do to help you
be more comfortable?”
 Your care for people’s needs is also a means to an end....preparatory
activity to intentional mental health work (helps connect you)
Clothing – dry socks, warm shirt, blanket; food, water, coffee; kleenex;
ambiance (warm/cool, dry, light/dark, clean, quiet); quiet comfortable place to
sit/talk/be alone; restroom, shower; phone; medical needs, medications (don’t
forget special medical needs)
BEING THERE....
 People needing your assistance may be:
- Those who seek out your help
- Those who clearly need help and will tell you if you inquire
- Those who do not obviously need help but will tell you if you inquire
- Those who reject your help (later they may possibly be more receptive)
 Respect interpersonal styles (sometimes cultural)
- Touch – some people find it comforting, others find it invasive
- Physical distance – too close is invasive (varies by individual)
- Eye contact – in some cultures, prolonged eye contact is inappropriate
- Privacy and trust – some people will be slow/hesitant to open up
Be sensitive to interpersonal cues about touch, distance, and privacy
2) SAFETY AND STABILIZATION
Protect people from further harm
 Attention to physical safety is actually a mental health
intervention:
If you can help keep people safe from physical harm they are less
likely to suffer psychological trauma from that harm
 Protect people from ongoing disaster-related and postdisaster hazards (such as contaminated areas, unsafe building
structures, broken glass, and sharp objects)
SAFETY AND STABILIZATION…
Protect people
 Protect people from other harm such as:
- Exposure to traumatic images (eg, witnessing horrific
scenes in the disaster aftermath)
- Reminders (eg, through extensive media viewing)
- Loss of privacy (eg, to media personnel, onlookers,
attorneys)
 Protect people from people: individual and crowd level
redirection, stabilization, and de-escalation
3) SKILLED LISTENING
 Listen to the stories with concerned interest
- a mental health function
 Invite thoughts - gently probe for detail
- don't extract unnecessary painful trauma details
(follow the person’s lead; take cues from the person)
- don't force feelings; let them emerge spontaneously
(and prepare for intense emotions)
 Gather appropriate information: exposures, injuries,
medical history, medications, psychiatric history
4) EDUCATION & REASSURANCE
Varies by whether a psychiatric disorder is present or not:
If NO psychiatric disorder  Normalize the experience:
 Validate common emotional reactions
 Disturbing feelings don't equal mental illness
("Normal responses to abnormal events")
 Most people don't develop mental illness - symptoms subside with time
If psychiatric disorder is present  Overcome stigma:
 Biological basis of persistent emotional changes and medication mechanisms
 Many treatment options available: treatment is effective
5) COPING & STRESS MANAGEMENT
 Lend permission to cry, feel bad, be nonproductive, focus on self
for a period of time
 Regain control of some aspect; restore routine
 Utilize social supports
 Positive self talk
 Appropriate use of humor
 Self care (easy to neglect in crisis)
- sleep, meals, hygiene, exercise, habits, down time, relaxation,
pleasurable activities – achieve a healthy balance (avoid excesses)
 Active coping is the healthiest
....FINDING MEANING & PERSPECTIVE
 Natural part of the healing process
- Making meaning
- Finding greater perspective in one's life
 Discover and respect personal values
- What is important to the individual
- Avoid judgment; avoid "blaming the victim"
 Personal roles: "victim," "survivor"
- Listen to the person's language in self description
 Philosophy, spirituality, world view
6) PROBLEM SOLVING
● Make a list; prioritize
● Weigh advantages and disadvantages of potential choices
● Develop more than one approach
- allows a backup if Plan A doesn't work
● Try new behaviors and develop new skills
● One step at a time - manageable units first
● Keep sight of larger perspective and progress
7) CONNECT WITH SUPPORT
● Two main sources of support can help people in times of disaster:
 Family and friends
- People who know the individual are best situated to comfort and
support that person
 Support services (eg, social workers, medical providers, FEMA,
welfare services)
- Professionals have skills and resources that may help people get
back on their feet
● Social supports and needed resources can go a long way toward
helping people feel better
● People who lack social supports may be at increased risk for
psychological adjustment problems
8) ACUTE SYMPTOM MANAGEMENT
● In the early post-disaster period, the most bothersome post-traumatic
symptoms are likely to be hyperarousal symptoms:
 Feeling jittery, jumpy, restless, irritable
 Nervousness, anxiety, worry, fear, panic
 Insomnia
● Ways to manage these acute hyperarousal symptoms:
 Distraction – engage in absorbing or pleasurable activities (games,
puzzles, reading, movies, social events); selective focus
 Relaxation techniques – deep breathing, muscle relaxation, pre-hypnotic
induction
 Pharmacotherapy
RELAXATION: DEEP BREATHING
 To help people calm down or relax - good in office settings
(originally used to help pregnant women to relax) or in crises
 Ultimate goal is to use in critical or stressful conditions
– but learn it in calm situations to develop mastery
 Use comfortable chair, plant feet on floor, close eyes, take deep
breath and hold as long as possible, then slowly exhale with
suggestion: "the more slowly you let out the air the more
relaxed you will feel."
 Practice in sets (max. 5-6) with same instructions every time
(max. 2-3 times a day). Compare heart rate before and after.
- For insomnia, jumpiness, hypervigilance, anger
MUSCLE RELAXATION
 Lie supine on flat surface – get comfortable, close eyes
 Tense one muscle group (eg, both eyes; one thigh) and hold
for several seconds, then release and feel the muscles relax
 One at a time, systematically tense and release all muscle
groups of the body (eg, head  toe)
 On completion, bask in the sensation of relaxed muscles
 Repeat as many times as desired
- For insomnia, jumpiness, hypervigilance, anger
RELAXATION: PRE-HYPNOTIC INDUCTION
Instruct individual to lie comfortably on floor, eyes closed. Read
scenario in hypnotic, calm, quiet tone of voice.
SCRIPT: "Imagine yourself on a beach, contemplating the clear blue
water, waves slowly lapping up along the shoreline. It’s a perfect day—
the air is warm and slightly breezy; the sun warms your skin. The salt
air is refreshing and nostalgic. You walk to the edge of the water and
scoop up some seashells. A gentle wave laps up over your hand and
carries some of the smaller shells off into the ocean with it. The
receding waves gently wash the sand from around your toes and you
burrow them into the soft wetness again...." (and it goes on)
- For insomnia, jumpiness, hypervigilance, anger
9) KNOW WHEN MORE HELP IS NEEDED
 Indications that more help may be needed:
- Intolerable symptoms persist or escalate despite interventions
- Pre-existing psychiatric/substance use disorder requiring ongoing care
- The person requests additional assistance
- The person worries you
 Indications that urgent help may be needed:
- The individual is too overwhelmed to be able to care for self and/or dependents
(eg, stops eating/drinking; neglects child)
- Indications of impending harm to self (suicidality) or others
(homicidality/assaultiveness/extreme agitation)
- The person cannot be oriented (eg, delirious)
10) CARING FOR THE CAREGIVERS
Disaster workers may themselves experience psychological distress
or even become mental health casualties in difficult circumstances of
disaster settings:
 Extended exposure to intense emotional distress
 Personal exposure to injury and contamination
 Personal exposure of self and loved ones to the disaster; worry about
safety of loved ones and personal property
 Difficult working conditions, chaos
 Long work hours, cumulative fatigue
 Separation from usual supports and familiar comforts
 Ethical dilemmas
...THE CAREGIVERS....
Stressors experienced by disaster workers:
 Exhaustion, inefficiency, loss of enthusiasm or interest for the work
 Diminished ability to focus and concentrate
 Preoccupation, inability to put thoughts and images aside, dreams
of the post-disaster setting and people
 Guilt feelings, worry, despondency, irritability, anger
 Frustration (over inability to do enough; with response of leadership
and authorities; with circumstances)
 Burnout, "compassion fatigue"
 Interpersonal conflict and damage to relationships
ADVICE FOR CAREGIVER SELF-CARE
 First, follow the same basic advice recommended for those you are
caring for (rest, nutrition, hygiene, exercise, relaxation, healthy balance)
 Care for your colleagues
- Give them a break
- Offer positive support and encouraging words
- Keep an eye on their fatigue level and help them accept needed rest,
nutrition, and time off
 Spend restorative time together (eg, breaking bread together; follow-up
meetings to review the operation and work out the kinks for next time)
ADVICE FOR CARING FOR THE CAREGIVERS
Supervisors can help disaster personnel by:
 distributing work loads equitably
 monitoring workers for signs of distress and fatigue
 communicating with workers to keep them informed and
learn about problems/needs that arise
 providing encouragement
 facilitating opportunities for peer support
 providing psychological support through formal group or
individual therapy
VIGNETTE: PFA
A teenage girl is brought to the emergency
department for evaluation. As soon as the nurse
calls her to the exam room, she begins to panic
and hyperventilate. She asks, "Am I going to die?"
How can the nurse help this girl?
RISK
COMMUNICATION
…in a terrorist incident involving
radioactive materials, effective
risk communication may be the
most important way to reduce
morbidity and mortality…
Becker 2007 BMJ 335:1106-7, p. 1107
RISK COMMUNICATION
A process of providing information for the purposes
of reducing anxiety/fear and promoting appropriate
responses to a major crisis
 Communication with populations through media
and in person with groups and individuals
Risk communication is your job…
...it is the business of all responders
RISK COMMUNICATION
Purpose:
 Provide guidance to help people respond appropriately and safely
 Offer appropriate reassurance
 Inform people of what is being done for them and what are the plans
People feel better and act more safely when:
 they feel they know what is going on
 they have confidence in the reliability of the information provided
Covello et al 2001 J Urb Health/Bull NY Acad Med 78:382-91
KEY CONCEPTS & FACTS FOR RAD/NUC
Some key concepts and facts are so basic to
RAD/NUC incident response that all responders
should know them
 Knowing this information can help responders stay
safe in the RAD/NUC response environment
 Communicating this information can reassure people
and help them respond appropriately and safely to
their situation
EXPOSURE VS. CONTAMINATION
● Exposure occurs when energy traveling in waves or particles (radiation)
penetrates the body (irradiation)
● Contamination occurs when radioactive material in the form of dust,
powder, or liquid comes into contact with the body, and the radioactive
source continues to emit radiation
- External: radioactive material on a person's exterior (skin/hair/clothes)
- Internal: radioactive material entered the body through open wounds,
absorption through skin, mucous membranes, swallowing, or breathing
IMPLICATIONS OF EXPOSURE VS. CONTAMINATION
● People who have been exposed/irradiated (without
contamination) are not radioactive
For example, having an X-ray taken, which exposes you to
radiation, does not make you radioactive
● Contaminated people have loose particles of radioactive
material (dust/dirt) that emit radiation and may be spread to
contaminate others and the environment
Decontamination should be done as soon as possible
Contamination is easily removed by changing clothes and
showering (use simple soaps and don't abrade skin)
RESPONDERS: DON'T FREAK OUT
Addressing contamination issues should not delay
treatment of life-threatening injuries
● Externally exposed patients do not become radioactive
- Not a radiation risk to medical responders
● Levels of radioactivity emitted by patients with external or
internal contamination are unlikely to cause medical harm
to care providers
- Decontaminate external contamination as soon as possible
without delaying critical care (use respiratory precautions)
Centers for Disease Control and Prevention 2005. Radiological Terrorism: Emergency Management
Pocket Guide for Clinicians. http://www.bt.cdc.gov/radiation/pdf/clinicianpocketguide.pdf
3 FACTORS DETERMINE EXPOSURE
● TIME: The more time you spend near the radiation source, the greater
your exposure will be
● DISTANCE: The closer you are the source, the greater your exposure
will be
- Radiation exposure decreases with distance according to the inversesquare law: if you triple your distance from a radiation source, your
exposure decreases by a factor of 9 (ie, 32)
● SHIELDING: The greater the shielding between you and a radiation
source, the less you will be exposed
- Lead and concrete are best, but staying behind vehicles, buildings, or other
objects can also decrease exposure
US Environmental Protection Agency 2010. Radiation Protection Basics.
http://www.epa.gov/rpdweb00/understand/protection_basics.html
FRIENDLY FACTS FOR NUKES
● Immediately after a nuclear detonation, the safest action is to seek
shelter for 24 hours in a location deepest within the biggest building
that has the thickest brick, stone, or concrete walls (wood and thin
metal are not as good), or underground
- Eg, optimal location within a large solid building can reduce exposure by a
factor of 50 (being in a vehicle provides little fallout protection)
- This is why immediate sheltering in place can be far safer than evacuation
● A "dirty bomb" is not a nuclear bomb and causes far less destruction
and injury
- The greatest harm is likely to be from the explosion itself
Homeland Security Council 2009. Planning Guidance for
Response to a Nuclear Detonation. http://bit.ly/aeVGl2
RISK COMMUNICATION FOR RAD/NUC
Acute risk communication needs in RAD/NUC incidents
1. Immediate population safety
 Eg, after nuclear event: shelter in place – "Get inside NOW!"
2. Surge prevention
 Providers of medical care and information become overwhelmed
- Cesium-137 incident killed 4 in Goiânia, Brazil in 1987: 112,000 people
sought radiological monitoring in special facilities
 Highways become clogged after nuclear event
- Three Mile Island: for every person asked to evacuate, 45 did (150,000 in all)
Collins & Carvalho 1993 Behav Med 18:149-57;
International Atomic Energy Agency 1988. The radiological accident in Goiania, STI/PUB/815. Vienna: IAEA;
Erickson 1994, A New Species of Trouble: The Human Experience of Modern Disasters, New York: Norton
RISK COMMUNICATION: GETTING STARTED
 A two-way communication process
 Start by soliciting and listening to people’s specific concerns
 Respond with timely & regular updates
 Concerns to expect based on experience and research
 Personal safety
● How to keep my self / family / pets safe?
● Where should I go to be safe? How can I avoid exposure?
 Health
● How do I know if I have been exposed?
● What symptoms should I look for?
● How (and when) can I get tested?
● What will they do if I have been exposed?
● What effects will I have short / long term if I have been exposed?
HAVE MESSAGES READY
Having a repertoire of audience-tested, scientifically
grounded prepared messages available means that vital
information can be released almost immediately
Types of messages to have ready for RAD/NUC incidents
● Seek safety (eg, shelter in place)
● Stay put: shelter in place until radiation subsides
● Determining one's exposure
● Health measures to take (eg, decontamination)
Becker 2004 Biosecurity & Bioterrorism 3:195-207
DEVELOPING YOUR MESSAGE
● Have an objective – eg, stir people to action; wait for instructions
● Target the intended audience – eg, uneducated groups, children,
parents of small children
● Develop an approach – get people's attention and motivate them to
take the appropriate action
● Organize your message – prepare in advance
 Have your facts in order
 Be concise/brief
 Short sound bites (but not to the extent of losing the information)
 No more than 2-3 major take-home messages ("talking points")
EXERCISE: MESSAGE PREPARATION
A fallout cloud from a nuclear detonation is moving toward your city
and is expected to cover a wide area of the city, beginning within
the next hour. You need to craft a message to provide immediate
safety information to save the lives of people in the affected area.
Now construct your message – Consider:
● What is your risk communication objective?
● Who is your intended audience?
● How do you capture their attention and motivate them to
take appropriate action?
● What facts do you need to support your arguments?
TIPS FOR DELIVERING YOUR MESSAGE
● Speak in terms of "we"
 Builds unity/sense of strength ("I" and "you" can be isolative and divisive)
● Avoid humor
 May be perceived as offensive, not taking situation seriously, and lacking
compassion
● Avoid jargon/define terms
 Shelter in place, plume, "dirty bomb"
● Avoid being sidetracked by questions that lead you away from your
message
 Eg, if you are asked a question that requires speculation or derails the
discussion to an unhelpful topic, don't go there and instead segue to the
message you want to get out
Covello et al 2001 J Urb Health/Bull NY Acad Med 78:382-91
ESTABLISHING TRUST AND CREDIBILITY
IN RISK COMMUNICATION
 Find the right person to deliver the message
 The spokesperson's credibility is as important as the credibility of
the message
 Partner with known credible sources
 Model calmness, confidence, and compassion
 Be honest and forthcoming
 Do not mislead people (eg, by withholding information needed to
understand the issues)
 Admit not knowing – rather than guessing
 Avoid "no comment" – sounds suspicious, like a cover-up
Covello et al 2001 J Urb Health/Bull NY Acad Med 78:382-91
RISK COMMUNICATION:
MANAGING AMBIGUITY
When available information is ambiguous or insufficient:
 Don't speculate or forecast what you don't know as fact
Stay with the current situation
 Avoiding making ultimate projections or guarantees
- Promise only what you can deliver
 Focus on what is known:
 Identify known safe zones
 Provide practical measures people can take
 Say when & how more will be known / communicated

Norwood et al 2001 Milit Med 166 S2:27-81;
Covello et al 2001 J Urb Health/Bull NY Acad Med 78:382-91
RESPONDING TO ANGER AND HOSTILITY
 Anticipate anger, hostility, and blaming
 Avoid blaming and criticizing others during the heat of the crisis
 Do not repeat accusations/allegations when responding to questions
 Attack problems, not people or organizations
 Listen to people’s concerns and frustrations
 Seek to understand the source of the anger and hostility
(eg, fear/anxiety, frustration, hurt/loss)
 Indicate you have heard the person – reflect back
 Validate the person’s feelings
 Communicating empathy, caring, and compassion may help
de-escalate anger and hostility
 Respond to emotion with understanding – not just providing facts
 Target your responses to concerns expressed
VIGNETTE: RISK COMMUNICATION
A dirty bomb was detonated in the southwest quadrant of
the city. Weeks later, even though the area has been
completely cleaned up, people are avoiding stores,
restaurants, and schools in the area because they fear they
will be contaminated with radiation. If this pattern
continues, it will cause severe economic crisis in the area.
How can the city council work to resolve this problem?
CONFLICT
RESOLUTION
GUIDELINES FOR CONFLICT RESOLUTION
 First priority: good relationships
 Stay calm, be patient, respect others' opinions, be courteous, remain constructive
under pressure, be flexible
 Listen first, talk second
 Use active listening skills to ensure you hear others’ positions and perceptions
 Listen with empathy – appreciate the conflict from the other person’s viewpoint
 Restate, paraphrase, summarize, clarify feelings
 Use "I" statements
 Separate people from problems
 Debate real issues without damaging working relationships
 Do not assume that the other person is just "being difficult" – real and valid
differences can underlie conflictive positions
 Avoid attacks on personality – focus on achieving the mission
Lee et al, World J Surg 32:2331-5, 2008; Levine 1998, Getting to Resolution:
Turning Conflict into Collaboration, Berrett-Koehler Publishers, San Francisco
CONFLICT RESOLUTION
STEP 1: DEFINE THE PROBLEM
 Agree on problems to be solved and set mutual goals
 Openly seek the other party's cooperation to solve the problem
 The conflict is likely to be a mutual problem, but people may have
different perceptions of the problem
 Objectify effects of the conflict on the operation's performance, team
work, and decision-making
 Identify areas of agreement and areas of disagreement
 Clarify interests on each side
 Identify the other person's interests, needs, concerns, perceptions, and
motivations underlying the position adopted
 Understand the other person's position before attempting to defend yours
 Try to appreciate the effects of your actions on the other person's position
Lee et al, World J Surg 32:2331-5, 2008; Levine 1998, Getting to Resolution:
Turning Conflict into Collaboration, Berrett-Koehler Publishers, San Francisco
CONFLICT RESOLUTION
STEP 2: BRAINSTORM POSSIBLE SOLUTIONS
 Brainstorm solutions together
 Allow all interested parties to give input
 Together consider many options
 Be open to all ideas, including ones you never considered before
 Because problems may have multiple solutions, creativity helps
 Respect individual differences but encourage flexibility
 Accept that people can have different approaches and motivations
 Earnestly consider various options to help people avoid becoming too
entrenched in a fixed position
 Seek to keep discussions positive & constructive
 Helps circumvent antagonism and dislike that can escalate conflict
Lee et al, World J Surg 32:2331-5, 2008; Levine 1998, Getting to Resolution:
Turning Conflict into Collaboration, Berrett-Koehler Publishers, San Francisco
CONFLICT RESOLUTION
STEP 3: NEGOTIATE A SOLUTION
 Try to resolve real differences identified between parties
 Avoid getting stuck on positions, which can lead to entrenchment of ego
to blindly defend perceived personal threat and "save face"
 Focus instead on shared interests and basic guidelines toward achieving
mutual goals
 Resolution can begin once both sides understand one another
 By now, a mutually satisfactory solution may be apparent to all parties
 If not, seek a solution that satisfies everyone (or is at least tolerable to
everyone) to achieve a "win-win" solution
 Operationalize steps to be taken once an acceptable solution is found
Lee et al, World J Surg 32:2331-5, 2008; Levine 1998, Getting to Resolution:
Turning Conflict into Collaboration, Berrett-Koehler Publishers, San Francisco