Part of the work undertaken by all practitioners involved in helping people to change behaviour is predicated by their negotiation techniques used to achieve compliance, partnership and progress. Do you find that when working with clients and patients in which you can see many areas of change that would benefit them, that you become frustrated by their apparent intransigence to shift behaviour? It’s quite normal that resistance occurs, no-one likes to make whole scale changes as they see problems rather than solutions. Learning a skilled approach to negotiation can really assist with the transformations needed and get your clients on side and engaged.
Whilst it may at first seem a strange subject to cover, the ‘art of negotiation’ in clinical management, outside of acute intervention is an arena in which both parties are trying to achieve an outcome different from today, but may have different interpretations of how to get there.
Managing the process of change takes skill and experience, the following suggestions have been modified from a series of articles extracted from the excellent blog site Farnham Street and changed to better reflect the reality of a clinical situation.
The practice of Principled Negotiation (PN) is a technique you likely already employ to some degree, but maybe have not refined it enough to be able to use these skills effectively every time.
PN is a concept that is based on the book Getting to Yes by Roger Fisher and Bill Ury. This approach to negotiation focuses on the interests of the parties involved and emphasises conflict management and conflict resolution.
How does PN differ from the traditional kind? It is in reality an attempt to create a win-win in a situation that doesn’t always obviously offer one. There are 4 different types of negotiations recognised to exist and PN focuses on number 1:
- Win-Win,
- Win-Lose,
- Lose-Win,
- Lose-Lose;
Win-win is the only one that is sustainable over time. So to make your negotiated clinical outcomes sustainable consider learning how to utilise the PN techniques promoted by Roger Fisher.
He explains there is a third way to negotiate, a way neither hard nor soft, but rather hard and soft. It is this contrast between the two styles that typically reflects the discussions all practitioners have around their suggested strategies. Some requests are accepted with ease, but others need a change from ‘instruction’ to negotiation
The method of PN developed at the Harvard Negotiation Project was developed to help people decide issues on their merits rather than through a process of progressive haggling focused on what each side says it will and won’t do. In effect a search for mutual gains should be the primary focus whenever possible, and that where your interests or objectives conflict, the focus should remain that the result be based on some fair standards independent of the inherent will of either side.
PN in effect shows you how to obtain what you are entitled to or what you believe the best options for health promotion are, and still be decent about it. It enables you to be fair or in our world enables us to establish agreement to change while protecting you against those who would take advantage of your fairness by seeking to extract more of your time and expertise without remuneration.
The excessive delivery of information, provision of long reports and unrestricted telephone or e mail access is a reflection of a poorly managed negotiation, just as you may witness the intransigence in food changes or behaviour changes, that you have so enthusiastically recommended or instructed!
The most engaging aspect of PN is that it obviates the need for secrecy. In fact, Roger Fisher instigates the opposite, saying that unlike almost all other strategies, if the other side learns this one, it does not become more difficult to use; it becomes easier. In effect the discussion with your clients should be predicated with a declaration that both parties are working in a cooperative manner to achieve an outcome both of you have determined is reasonable and the actions required to get there. By engaging early in the meeting with the mutually agreed intention to achieve a solution that requires changes it is much easier to achieve engagement.
So where to start….
First: Separate the People from the Problem
Any method of negotiation may be fairly judged by three criteria: It should produce a wise agreement if agreement is possible. It should be efficient. And it should improve or at least not damage the relationship between the parties.
A successful agreement can be defined as one that meets the legitimate interests of each side to the extent possible, resolves conflicting interests fairly, is durable, and takes associated parties interests into account.
By which I mean that behavioural change rarely impacts on one person only, hence ‘buy in’ to the changes needs to be managed for all involved.
The first step of the process is to separate the people from the problem. Roger Fisher recommends the same method of depersonalising the position in negotiation just as he does in his advice on how to give better feedback. Feedback is an aspect of our work with clients and patient’s and understanding how to deliver this also facilitates greater negotiation outcomes, and supports the win-win objectives.
There are at least three different kinds of feedback that may be appropriate in your follow ups:
- Appreciation is expression of gratitude or approval of another’s effort. It is an expression of emotion, designed to meet an emotional need.
- Advice (or coaching) consists of suggestions about particular behaviour that should be repeated or changed. It focuses on the performance, rather than judging the person.
- Evaluation is ranking the subject’s performance in relation to that of others or against an explicit or implicit set of standards.
The habit you want to develop is to know your purposes when you offer feedback, and to make your comments in a form appropriate to accomplishing that purpose.
Why? Because it works! People are emotional creatures – all of us. In effect the management of a fair process requires a shift from personal attack into the realms of reason and merit, even when our every tissue is telling us to attack. If we don’t, we miss a chance to build the exact sort of win-win relationship we’d love to have. We need to understand our clients and people generally during the negotiation.
People fail, get stuck or become disengaged, despite their best earliest agreements still ringing in everyone’s ears, events from their past or present may be acting as a strong emotional or practical brake. Teasing out through discussion the type of feedback that they respond to will enable you to leverage this approach to liberate them to continue to progress to the mutually agreed objectives.
This human aspect of negotiation can be either helpful or disastrous. The process of working out an agreement will ideally produce a psychological commitment to a mutually satisfactory outcome. Going forward at each meeting this working relationship where trust, understanding, respect, and friendship are built up over time can make each new negotiation or change smoother and more efficient. And people’s desire to feel good about themselves, and their concern for what others will think of them, can often make them more sensitive to another negotiator’s interests. This is the arena we work in all of the time and one that needs to be nurtured.
On the other hand, as you may have seen, people get angry, depressed, fearful, hostile, frustrated, and offended. They have egos and fears or vulnerabilities that are easily threatened. As a result, they can then see the world from their own personal vantage point, and frequently confuse their perceptions with reality. Routinely, they then fail to interpret what you say in the way you intend and do not mean what you understand them to say.
These misunderstandings can then spiral, reinforcing prejudice and lead to reactions that produce counteractions in a vicious circle; the rational exploration of possible solutions becomes impossible and a negotiation fails. Here we see a loss of momentum, a disengagement, and expectations becoming unmet. Work becomes unsatisfactory, outcomes decline in usefulness and parties end up separating rather than engaging.
The purpose of the planning becomes scoring points, confirming negative impressions, and apportioning blame at the expense of the substantive interest of both parties, neither party gains, both lose and a disappointed client re-enters a world where his or her direction is inappropriate for optimal health.
It’s important to understand the point: There are major transmission errors in a negotiating process. What’s heard is frequently not what’s said or intended. Skilled communication begins with skilled listening and management of expectations. Listening with genuine intent to your clients case, managing their time and ensuring full disclosure before suggesting all likely points for PN is a very important part of this process.
For once a negative feedback loop has been initiated, it can be very hard to pull out. A certain critical volume of bad blood or disbelief builds up and ends the negotiation. This doesn’t have to happen — one thing that permits us to work with PN to progress people’s health is our ability to resist some of the baser instincts to simply react, when we know it’s a bad idea, and our actions in negotiation and change introduction is an arena where we’d be wise to learn how to do so.
Essentially there are three areas for you to manage: Perception, Emotion, and Communication.
- Perception suffers from our ability to successfully place ourselves in the shoes of our client, or even seeing them as a ‘partner’ in the process to start with. It’s almost impossible to influence somebody who you don’t at some level empathetically understand, except through brute force or in the case of acute interventions— we are after the successful management of chronic ill health and as such need to be partnering rather than directing. To be clear, just because you understand someone’s position doesn’t mean you agree with it. You may well change your mind, but even without that it allows you to consider the objective on its merits only.
- Emotional issues tend to fall into a fairly simple dichotomy: How do you feel during the negotiation and how does the other side feel? It’s quite appropriate to be vulnerable in this stage of the negotiation, in that we can make ours and their motions explicit, but avoiding drama. It can be useful to make a position statement such as: Do you think I have been fair with you so far as for us to make progress, we will need to establish mutual fairness as a goal. Otherwise, I think we will run into a stalemate. In effect clarifying your joint intent assists in both parties consciously aiming to get there – if the avoidance of grains for example is needed, then a discussion would be; I can see that the resolution of bloating is of vital importance to you, would that be a strong enough motive for you to explore the exclusion of certain grains for long enough to determine if they may be a factor?
- Communication problems are easy to grasp by anyone in a relationship. If we drift into a contentious negotiation, both parties tend to feel like they’re not being heard. Getting both to progress beyond this stage requires your deep listening skills and as with the perception issue, requires us to understand the person on the other side of the table at their level, not at ours. This can feel impossible and unnatural, but it works. Think of the last time you felt someone truly understood and empathised with you. Did you feel contentious towards them or were you more engaged and supportive? In effect making their needs your complete focus and intent, recognising how they fall into their own life and expressing a joint plan to achieve them assures a better compliance and engagement and if a correct strategy has been selected a better outcome – a win-win.
In the end, the environment we want to create is that of two people sitting next to each other, trying to solve a problem together. Even if you don’t have a great relationship with the other party, or any relationship at all, it helps to make the other person feel like you’re in it together.
Second: Focus on Interests, Not Positions
This is the simplest and probably the most important aspect on PN: What do I really want? And what does the other person really want? This is the key determinant in your planning, by really delivering a ‘solution’ to the needs of the client will make the behavioural changes seem easier and more realistic.
However, it’s not always as clear as it seems and in our haste to deliver sage advice or coaching the nuances if not considered can become problematic.
In this example a couple becomes engaged over who’s going to do the dishes. Both people, as the negotiation becomes heated, start to feel like it’s really all about the dishes. But viewed in large scale, we realise it’s probably more about fairness — they want to feel like both parties are doing their bit. A sense of fairness is a deeply held human need. And thus, if we focus on creating fairness and using the elementary idea of leading by going first, then we can end the negotiation fairly. (I’ll do the dishes tonight and then we’ll trade every night, sound good?). This notion of fairness and vulnerability is well discussed at the Ted Talk by Brene Brown. She explore notions of shame and vulnerability and its effects on decision making and growth – I recommend her talk for a periodic refresher on this important part of human interaction.
By working on the practical – what you want and what they want, and satisfying each, leads us to win-win style outcomes. Viewing a a recommendation as something to be “won” is the best way to lose. In effect the victory in clinical care is in the generation of a partnership in which both parties understand their actions and the expectations are clear.
Reconciling interests rather than positions works for two reasons.
- First, for every proposed outcome or need there usually exist several possible positions that could satisfy it. All too often people simply choose to target the most obvious position. Maybe giving up smoking is an aim both parties recognise as being the end objective, but the emotional importance of it makes the fear of taking this as a defining part of the change too hard, so rather than instructing or losing a PN at this stage, consider what both of you may propose for future plans.
- Second examining the background behind opposed positions for the motivating interest, means you can frequently uncover an alternative position which meets not only your objectives but theirs as well. Allowing the person to explore some of their own history via the retelling of their story sometimes facilitates a release of events that have become clouded or forgotten but which are now getting in the way of a PN outcome, permitting the review may uncover an alternative approach that is much more successful.
Third: Invent Options for Mutual Gain
Start off by avoiding being rigid in the solutions you have to offer, focus on the interests and then get creative with these, there is not only one way to reach a win-win outcome in most cases.
In his book Roger Fisher indicates 4 typical reasons why this does not happen – by understanding these possible limits to your ideas then adjustments can be made.
Most negotiations have four obstacles that inhibit the inventing of an abundance of options:
- Premature judgment;
- Searching for the single answer;
- The assumption of a fixed pie (only one area of expertise); and
- Thinking that “solving their problem is their problem” when they have come to you to make it an ‘our’ problem.
Any negotiation around change can get pretty complex when all relevant interests are brought to the table, but the principle to heed is pretty simple: Where do our interests overlap, and where do they not? In the cases where they don’t, what is a mutually satisfying solution?
This takes some creative thinking, of course. Rigidity doesn’t work. The “combat of negotiation” is only in our minds. In effect we can use our minds to create any solution we want as long as both parties get taken in the right direction – towards their mutually agreed outcome or desire. Aim to establish clear areas of agreement, explore those that may be problematic and seek a resolution based on best outcomes by remaining focussed on the interests, not the people.
This doesn’t mean you’d want to comply to end the negotiation without argument, or to give in. That’s the “softie” style of negotiation. You should have your objectives and plans fairly satisfied. But you don’t need to do so at the expense of the other party if it can at all be avoided. Win-lose will eventually trouble you, whether you realise it or not.
Effectively do not bully or be bullied into making changes that do not resonate with the safe clear strategic routes that exist, some clients will try and dominate the meeting and in PN you have to absorb and then reflect these issues back to allow them to hear from a different perspective – they too may be fixed on what they think will work, even if many times before it has failed.
Fourth: Insist on Using Objective Criteria
Fairness and equal perspective of fairness can run into a challenge of comprehension. If two parties can’t agree here, it’s hard to create a win-win solution that maintains and builds the relationship.
To solve this, Fisher insists on finding objective criteria by which to measure the fairness of proposed solutions. In effect he requires that both of you find mutual agreement in a position of fairness.
For example, you suggest that excluding alcohol from the diet will achieve an improvement in health, they say that it will impact on his social life and he has already agreed to cut out wheat.
By determining what the overall objectives are – in this case to resolve a long standing non pathological fatigue – you can negotiate to markers used to address an ability to live a good social life also includes energy and recovery, and that alcohol if excluded is likely to increase these.
Therefore, you agree an objective criterion to determine need and or benefit, perhaps by measuring liver enzymes and or by using a standardised fatigue scale. Then based on either or both it is possible to track outcomes related to behaviour and make a more objective agreement.
The idea is to stick to principles over back-and-forth PN. Refuse to trade tit for tat without setting some standards upon which the decision can be made. Fisher refers to the sound parenting idea of having one child cut the piece of cake and the other choose the piece. No one can cry foul.
And so there are three main principles to abide by:
- Frame each issue as a joint search for objective criteria – what can you agree is the aim of the meeting/consultation, establish this early on.
- Reason and be open to reason as to which standards are most appropriate and how they should be applied. – Consider whether tests are adding to this, by clarifying end points, or by assisting compliance, determine between you what is required between clinical need and enhanced outcomes.
- Never yield to pressure, only to principle. Do keep a clear view of what you set out to achieve, get this principle embedded so that it remains in focus throughout.
Pressure can take many forms: a bribe, a threat, a manipulative appeal to trust, or a simple refusal to budge. In all these cases, the principled response is the same: invite them to state their reasoning, suggest objective criteria you think apply, and refuse to budge except on this basis. Never yield to pressure, only to principle.
The last is worth really considering not just for clinical issues but for much of life. When the heat comes, as it can in many negotiations, can you stick to your guns? If you’re stuck in a traditional battle of wills, you may not be able to. But if you’ve taken some of the steps outlined here and stuck to objective criteria, sticking to the issue and not the person, you may find it’s a lot easier to hold your ground and achieve a win-win position. In this way, fairness is helpful to you as much as to the other party.
A useful mantra for all of life’s challenges?
