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Chapter 23 Conflict: The Cutting Edge of Change Victoria N. Folse Appropriate conflict-handling strategies are essential in professional nursing practice because conflict cannot be eliminated from the workplace. To resolve conflicts, nurse leaders must be able to determine the nature of a particular issue, choose an appropriate approach for each situation, and implement a course of action. This chapter focuses on maximizing the nurse leader’s ability to deal with conflict by providing effective strategies for conflict resolution. Learning Outcomes • • • • • Use a model of the conflict process to determine the nature and sources of perceived and actual conflict. • Assess preferred approaches to conflict, and commit to be more effective in resolving future conflict. • Determine which of the five approaches to conflict is the most appropriate in potential and actual situations. • Identify conflict management techniques that will prevent lateral violence and bullying from occurring. Key Terms accommodating avoiding bullying collaborating competing compromising conflict horizontal violence interpersonal conflict intrapersonal conflict lateral violence mediation negotiating organizational conflict The Challenge Miranda J. Kennedy, BSN, RN, CCRN Staff Nurse, Medical Surgical Intensive Care Unit, Presence Saint Joseph’s Medical Center, Joliet, Illinois Fresh out of orientation, I was walking down the hall and I heard the wife of one of my patients holler, “Miranda!! In here quick! It’s happening again!” I raced into the room to find my patient diaphoretic and hypotensive, but still coherent. I quickly called my charge nurse and then called a rapid response. It was another busy day on the unit; I had just finished giving two stat meds to two different patients and recognized that another one of my patients required a sitter. Because the charge nurse was busy, the assistant nurse manager came in the room to assist. The MD happened to be nearby so he was also present for the rapid response along with two critical care nurses. While we were reviewing what had occurred, the MD asked what medications that patient had received that AM, his 0800 vitals, and symptoms at the time of the episode. As I was looking vitals up, the assistant nurse manager said to me, “Yeah, did you even check your blood pressure before you gave all of his meds?!?” • o What do you think you would do if you were this nurse? Introduction Conflict is a disagreement in values or beliefs within oneself or between people that causes harm or has the potential to cause harm. Folger, Poole, and Stutman (2012) add that conflict results from the interaction of interdependent people who perceive incompatibility and the potential for interference. Conflict is a catalyst for change and has the ability to stimulate either detrimental or beneficial effects. If properly understood and managed, conflict can lead to positive outcomes and practice environments, but if it is left unattended, it can have a negative impact on both the individual and the organization (Scott & Gerardi, 2011a, 2011b; Wright, 2011). In professional practice environments, unresolved conflict among nurses is a significant issue resulting in job dissatisfaction, absenteeism, and turnover. Patient dissatisfaction is lower in hospitals in which nurses are frustrated and burned out, which signals a problem with quality of care (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011; Wright, 2011). Successful organizations are proactive in anticipating the need for conflict resolution and innovative in developing integrated conflict resolution strategies that apply to all members (Brinkert, 2010). Conflict can be desirable at times and can be a strategic tool when addressed appropriately. Some of the first authors on organizational conflict (e.g., Blake & Mouton, 1964; Deutsch, 1973) claimed that a complete resolution of conflict might, in fact, be undesirable because conflict also stimulates growth, creativity, and change. Seminal work on the concept of organizational conflict management suggested conflict was necessary to achieve organizational goals and cohesiveness of employees, facilitate organizational change, and contribute to creative problem solving and mutual understanding. Moderate levels of conflict contribute to the quality of ideas generated and foster cohesiveness among team members, contributing to an organization’s success (Almost, 2006). An organization without conflict is characterized by no change; and in contrast, an optimal level of conflict will generate creativity, a problem-solving atmosphere, a strong team spirit, and motivation of its workers. Conflict on an interdisciplinary team can result in better patient care when collaborative treatment decisions are based on carefully examined and combined expertise (Tschannen, Keenan, Aebersold, Kocan, Lundy, & Averhart, 2011). The complexity of the healthcare environment compounds the impact that caregiver stress and unresolved conflict has on patient safety. Conflict is inherent in clinical environments in which nursing responsibilities are driven by patient needs that are complex and frequently changing and in practice settings in which nurses have multiple professional roles (Brinkert, 2010). Healthcare providers are exposed to high stress levels from increased demands on a limited and aging workforce, a decrease in available resources, a more acutely ill and underinsured patient population, and a profound period of change in the practice environment. Conflict among healthcare providers is inevitable and is compounded by employee diversity, high nurse-topatient ratios, pressure to make timely decisions, and status differences (Wright, 2011). Diversity in Nursing Paper
Nurses employed in better care environments report more positive job experiences and fewer concerns about quality care. Interprofessional collaboration has been characterized by effective communication and is a key factor in reducing error and improving patient outcomes (Tschannen et al., 2011).
Moreover, hospitals with good nurse-physician relations are associated with better nurse and patient outcomes, making collaboration and conflict resolution among nurses and physicians crucial in promoting quality of care outcomes (Aiken et al., 2012). An important factor in the successful management of stress and conflict is a better understanding of its context within the practice environment. The diversity of people involved in health care may stimulate conflict, yet the shared goal of meeting patient care needs provides a solid foundation for conflict resolution. Because nursing remains a predominately female profession, this may contribute to the use of avoidance and accommodation as primary conflict handling strategies. An international study, however, found that both physicians and nurses were likely to use avoidance as the main strategy to handle conflict (Kaitelidou et al., 2012). The stereotypical self-sacrificing behavior seen in avoidance and accommodation is strongly supported by the altruistic nature of nursing. Avoidance may be appropriate during times of high stress, but when overused, it threatens the well-being of nurses and retention within the discipline. Types of Conflict The recognition that conflict is a part of everyday life suggests that mastering conflictmanagement strategies is essential for overall well-being and personal and professional growth. A need exists to determine the type of conflict present in a specific situation, because the more accurately conflict is defined, the more likely it will be resolved. Conflict occurs in three broad categories and can be intrapersonal, interpersonal, or organizational in nature; a combination of types can also be present in any given conflict.
Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with one’s sense of self. Questions often arise that create a conflict over priorities, ethical standards, and values. When a nurse decides what to do about the future (e.g., “Do I want to pursue an advanced degree or start a family now?”), conflicts arise between personal and professional priorities. Some issues present a conflict over comfortably maintaining the status quo (e.g., “I know my newest charge nurse likes the autonomy of working nights. Do I really want to ask him to move to days to become a preceptor?”). Taking risks to confront people when needed (e.g., “Would recommending a change in practice that I learned about at a recent conference jeopardize unit governance?”) can produce intrapersonal conflict and, because it involves other people, may lead to interpersonal conflict. Interpersonal conflict is the most common type of conflict and transpires between and among patients, family members, nurses, physicians, and members of other departments.
Conflicts occur that focus on a difference of opinion, priority, or approach with others. A manager may be called upon to assist two nurses in resolving a scheduling conflict or issues surrounding patient assignments. Members of healthcare teams often have disputes over the best way to treat particular cases or disagreements over how much information is necessary for patients and families to have about their illness. Yet, interpersonal conflict can serve as the impetus for needed change and can accelerate innovation in approach. Organizational conflict arises when discord exists about policies and procedures, personnel codes of conduct, or accepted norms of behavior and patterns of communication. Some organizational conflict is related to hierarchical structure and role differentiation among employees. Nurse managers, as well as their staff, often become embattled in institution-wide conflict concerning staffing patterns and how they affect the quality of care. Complex ethical and moral dilemmas often arise when profitable services are increased and unprofitable ones are downsized or even eliminated. A major source of organizational conflict stems from strategies that promote more participation and autonomy of direct care nurses. Increasingly, nurses are charged with balancing direct patient care with active involvement in the institutional initiatives surrounding quality patient care. A growing number of standards set by The Joint Commission (TJC) target improving communication and conflict management (Scott & Gerardi, 2011a, 2011b).
Specifically, TJC requires that healthcare organizations have a code of conduct that defines acceptable and inappropriate behaviors and that leaders create and implement a process for managing intimidating and disruptive behaviors that undermine a culture of safety. Standards pertaining to medical staff also include interpersonal skills and professionalism (TJC, 2012). The Magnet Recognition Program® of the American Nurses Credentialing Center (ANCC) identifies interdisciplinary relationships as one of the Forces of Magnetism necessary for Magnet™ designation (2012). Diversity in Nursing Paper
Specifically, collaborative working relationships within and among the disciplines are valued, demonstrated through mutual respect, and result in meaningful contributions in the achievement of clinical outcomes. Magnet™ hospitals must have conflict management strategies in place and use them effectively, when indicated. Diversity in Nursing Paper
The following are other “forces” that are particularly germane to conflict in the practice environment: • •Organizational structure (nurses’ involvement in shared decision making) • •Management style (nursing leaders create an environment supporting participation, encourage and value feedback, and demonstrate effective communication with staff) • •Personnel policies and programs (efforts to promote nurse work/life balance) • •Image of nursing (nurses effectively influencing system-wide processes) • •Autonomy (nurses’ inclusion in governance leading to job satisfaction, personal fulfillment, and organization success) Exercise 23-1 Recall a situation in which conflict between or among two or more people was apparent. Describe verbal and nonverbal communication and how each person responded. What was the outcome? Was the conflict resolved? Was anything left unresolved? Stages of Conflict Conflict proceeds through four stages: frustration, conceptualization, action, and outcomes (Thomas, 1992). The ability to resolve conflicts productively depends on understanding this process (Figure 23-1) and successfully addressing thoughts, feelings, and Figure 23-1 Stages of conflict. behaviors that form barriers to resolution. As one navigates through the stages of conflict, moving into a subsequent stage may lead to a return to and change in a previous stage. To illustrate, the evening shift of a cardiac step-down unit has been asked to pilot a new hand-off protocol for the next 6 weeks, which stimulates intense emotions because the unit is already inadequately staffed (frustration). Two nurses on the unit interpret this conflict as a battle for control with the nurse educator, and a third nurse thinks it is all about professional standards (conceptualization). Diversity in Nursing Paper
A nurse leader/manager facilitates a discussion with the three nurses (action); she listens to the concerns and presents evidence about the potential effectiveness of the new hand-off protocol. All agree that the real conflict comes from a difference in goals or priorities (new conceptualization), which leads to less negative emotion and ends with a much clearer understanding of all the issues (diminished frustration). The nurses agree to pilot the hand-off protocol after their ideas have been incorporated into the plan (outcome). Frustration When people or groups perceive that their goals may be blocked, frustration results. This frustration may escalate into stronger emotions, such as anger and deep resignation. For example, a nurse may perceive that a postoperative patient is noncompliant or uncooperative, when in reality the patient is afraid or has a different set of priorities at the start from those of the nurse. At the same time, the patient may view the nurse as controlling and uncaring, because the nurse repeatedly asks if the patient has used his incentive spirometer as instructed. When such frustrations occur, it is a cue to stop and clarify the nature and cause of the differences. Conceptualization Conflict arises when different interpretations of a situation occur, including a different emphasis on what is important and what is not, and different thoughts about what should occur next.
Everyone involved develops an idea of what the conflict is about, and this view may or may not be accurate. This may be an instant conclusion, or it may develop over time. Everyone involved has an individual interpretation of what the conflict is and why it is occurring. Most often, these interpretations are dissimilar and involve the person’s own perspective, which is based on personal values, beliefs, and culture. Regardless of its accuracy, conceptualization forms the basis for everyone’s reactions to the frustration. The way the individuals perceive and define the conflict has a great deal of influence on the approach to resolution and subsequent outcomes. For example, within the same conflict situation, some individuals may see a conflict between a nurse manager and a direct care nurse as insubordination and become angry at the threat to the leader’s role. Others may view it as trivial complaining, voice criticism (e.g., “We’ve been over this new protocol already; why can’t you just adopt the change?”), and withdraw from the situation. Such differences in conceptualizing the issue block its resolution. Thus it is important for each person to clarify “the conflict as I see it” and “how it makes me respond” before all the people involved can define the conflict, develop a shared conceptualization, and resolve their differences. The following are question to consider: • •What is the nature of our differences? • •What are the reasons for those differences? • •Does our leader endorse ideas or behaviors that add to or diminish the conflict? • •Do I need to be mentored by someone, even if that individual is outside my own department or work area, to successfully resolve this conflict? Action A behavioral response to a conflict follows the conceptualization. This may include seeking clarification about how another person views the conflict, collecting additional information that informs the issue, or engaging in dialog about the issue. As actions are taken to resolve the conflict, the way that some or all parties conceptualize the conflict may change. Successful resolution frequently stems from identifying a common goal that unites (e.g., quality patient care, good working relations). It is important to understand that people are always taking some action regarding the conflict, even if that action is avoiding dealing with it, deliberately delaying action, or choosing to do nothing.
The longer ineffective actions continue, though, the more likely people will experience frustration, resistance, or even hostility. The more the actions appropriately match the nature of the conflict, the more likely the conflict will be resolved with desirable results. Outcomes Tangible and intangible consequences result from the actions taken and have significant implications for the work setting. Consequences include (1) the conflict being resolved with a revised approach, (2) stagnation of any current movement, or (3) no future movement. Constructive conflict results in successful resolution, leading to the following outcomes: •Growth occurs. •Problems are resolved. •Groups are unified. •Productivity is increased. •Commitment is increased. • • • • • Unsatisfactory resolution is typically destructive and results in the following: •Negativity, resistance, and increased frustration inhibit movement. •Resolutions diminish or are absent Diversity in Nursing Paper
. •Groups divide, and relationships weaken. •Productivity decreases. •Satisfaction decreases. • • • • • Assessing the degree of conflict resolution is useful for improving individual and group skills in resolutions. Two general outcomes are considered when assessing the degree to which a conflict has been resolved: (1) the degree to which important goals were achieved and (2) the nature of the subsequent relationships among those involved (Box 23-1). Box 23-1 Assessing the Degree of Conflict Resolution I. Quality of decisions o A. How creative are resulting plans? o B. How practical and realistic are they? o C. How well were intended goals achieved? o D. What surprising results were achieved? • II. Quality of relationships o A. How much understanding has been created? o B. How willing are people to work together? • o C. How much mutual respect, empathy, concern, and cooperation have been generated? Modified from Hurst, J., & Kinney, M. (1989).Diversity in Nursing Paper
Empowering self and others. Toledo, OH: University of Toledo. Categories of Conflict Categorizing a conflict can further define an appropriate course of action for resolution. Conflicts arise from discrepancies in four areas: facts, goals, approaches, and values. Sources of fact-based conflicts are external written sources and include job descriptions, hospital policies, standard of nursing practice, and TJC mandates. Objective data can be provided to resolve a disagreement generated by discrepancies in information. Goal conflicts often arise from competing priorities (e.g., desire to empower employees vs. control through micromanagement); frequently, a common goal (e.g., quality patient care) can be identified and used to frame conflict resolution. Even when all agree on a common goal, different ideas about the best approach to achieve that goal may produce conflict. For example, if the unit goal is to reduce costs by 10%, one leader may targ … Diversity in Nursing Paper
Diversity in Nursing Paper