NSG451 Diversity in Nursing Paper

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

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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). 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). 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. 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). 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. •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). 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 target overtime hours and another may eliminate the budget for continuing education. Values, opinions, and beliefs are much more personal, thus generating disagreements that can be threatening and adversarial. Because values are subjective, value-based conflicts often remain unresolved. Therefore a need to find a way for competing values to coexist is necessary for conflict management. Modes of Conflict Resolution Understanding the way healthcare providers respond to conflict is an essential first step in identifying effective strategies to help nurses constructively handle conflicts in the practice environment. Five distinct approaches can be used in conflict resolution: avoiding, accommodating, competing, compromising, and collaborating (Thomas & Kilmann, 1974, 2002). These approaches can be viewed within two dimensions: assertiveness (satisfying one’s own concerns) and cooperativeness (satisfying the concerns of others). Most people tend to employ a combined set of actions that are appropriately assertive and cooperative, depending on the nature of the conflict situation (Thomas, 1992). See the conflict self-assessment in Box 23-2. Exercise 23-2 Self-assessment of preferred conflict-handling modes is important. As you read and answer the 30-item conflict survey in Box 23-2, think of how you respond to conflict in professional situations. After completing the survey, tally, total, and reflect on your scores for each of the five approaches. Consider the following questions: • •Which approach do you prefer? Which do you use least? • •What determines if you respond in a particular manner? • •Considering the reoccurring types of conflicts you have, what are the strengths and weaknesses of your preferred conflict-handling styles? • •Have others offered you feedback about your approach to conflict? As you read the rest of this section, use this pattern of scores and your reflections to examine the appropriate uses of each approach, assess your use of each approach more extensively, and commit to new behaviors to increase your future effectiveness. Avoiding Avoiding, or withdrawing, is very unassertive and uncooperative because people who avoid neither pursue their own needs, goals, or concerns immediately nor assist others to pursue theirs. Avoidance as a conflict-management style only ensures that conflict is postponed, and conflict has a tendency to escalate in intensity when ignored. That is not to say that all conflict must be addressed immediately; some issues require considerable reflection, and action should be delayed. The positive side of withdrawing may be postponing an issue until a better time or simply walking away from a “no-win” situation (Box 23-3). The self-assessment in Box 234 will help you recognize your own avoidance behaviors and use them more effectively. Accommodating When accommodating, people neglect their own needs, goals, and concerns (unassertive) while trying to satisfy those of others (cooperative). This approach has an element of being selfsacrificing and simply obeying orders or serving other people. For example, a co-worker requests you cover her weekends during her children’s holiday break. You had hoped to visit friends from college, but you know how important it is for her to have more time with her family, so you agree. Box 23-5 lists some appropriate uses of accommodation. Individuals who frequently use accommodating may feel disappointment and resentment because they “get nothing in return.” This is a built-in by-product Box 23-2 Conflict Self-Assessment Directions: Read each of the following statements. Assess yourself in terms of how often you tend to act similarly during conflict at work. Place the number of the most appropriate response in the blank in front of each statement. Put 1 if the behavior is never typical of how you act during a conflict, 2 if it is seldom typical, 3 if it is occasionally typical, 4 if it is frequently typical, or 5 if it is very typical of how you act during conflict. • ________1.Create new possibilities to address all important concerns. • ________2.Persuade others to see it and/or do it my way. • ________3.Work out some sort of give-and-take agreement. • ________4.Let other people have their way. • ________5.Wait and let the conflict take care of itself. • ________6.Find ways that everyone can win. • ________7.Use whatever power I have to get what I want. • ________8.Find an agreeable compromise among people involved. • ________9.Give in so others get what they think is important. • ________10.Withdraw from the situation. • ________11.Cooperate assertively until everyone’s needs are met. • ________12.Compete until I either win or lose. • • • • • • • • • • • • • • • • • • ________13.Engage in “give a little and get a little” bargaining. ________14.Let others’ needs be met more than my own needs. ________15.Avoid taking any action for as long as I can. ________16.Partner with others to find the most inclusive solution. ________17.Put my foot down assertively for a quick solution. ________18.Negotiate for what all sides value and can live without. ________19.Agree to what others want to create harmony. ________20.Keep as far away from others involved as possible. ________21.Stick with it to get everyone’s highest priorities. ________22.Argue and debate over the best way. ________23.Create some middle position everyone agrees to. ________24.Put my priorities below those of other people. ________25.Hope the issue does not come up. ________26.Collaborate with others to achieve our goals together. ________27.Compete with others for scarce resources. ________28.Emphasize compromise and trade-offs. ________29.Cool things down by letting others do it their way. ________30.Change the subject to avoid the fighting. Conflict Self-Assessment Scoring Look at the numbers you placed in the blanks on the conflict assessment. Write the number you placed in each blank on the appropriate line below. Add up your total for each column, and enter that total on the appropriate line. The greater your total is for each approach, the more often you tend to use that approach when conflict occurs at work. The lower the score is, the less often you tend to use that approach when conflict occurs at work. Collaborating Competing Compromising Accommodating Avoiding 1. ________ 2. ________ 3. ________ 4. ________ 5. ________ 6. ________ 7. ________ 8. ________ 9. ________ 10. ________ 11. ________ 12. ________ 13. ________ 14. ________ 15. ________ 16. ________ 17. ________ 18. ________ 19. ________ 20. ________ 21. ________ 22. ________ 23. ________ 24. ________ 25. ________ 26. ________ 27. ________ 28. ________ 29. ________ 30. ________ Total ________ Total ________ Total ________ Total ________ Total ________ Throughout the rest of this section, there are descriptions of each approach and related selfassessment and commitment-to-action activities. Use these totals to stimulate your thinking about how you do and could handle conflict at work. Most important, consider if your pattern of frequency tends to be consistent, or inconsistent, with the types of conflicts you face. That is, does your way of dealing with conflict tend to match the situations in which that approach is most useful? From Hurst, J.B. (1993). Conflict self-assessment. Toledo, OH: Human Resource Development Center, University of Toledo. Box 23-3 Appropriate Uses for the Avoiding Approach • • • • 1. When facing trivial and/or temporary issues, or when other far more important issues are pressing 2. When there is no chance to obtain what one wants or needs, or when others could resolve the conflict more efficiently and effectively 3. When the potential negative results of initiating and acting on a conflict are much greater than the benefits of its resolution 4. When people need to “cool down,” distance themselves, or gather more information Box 23-4 Avoidance: Self-Assessment and Commitment to Action If You Tend to Use Avoidance Often, Ask Yourself the Following Questions: • • • • 1. Do people have difficulty getting my input into and understanding my view? 2. Do I block cooperative efforts to resolve issues? 3. Am I distancing myself from significant others? 4. Are important issues being left unidentified and unresolved? If You Seldom Use Avoidance, Ask Yourself the Following Questions: • • • • 1. Do I find myself overwhelmed by a large number of conflicts and a need to say “no”? 2. Do I assert myself even when things do not matter that much? Do others view me as an aggressor? 3. Do I lack a clear view of what my priorities are? 4. Do I stir up conflicts and fights? Commitment to Action What two new behaviors would increase your effective use of avoidance? • 1. • 2. of the overuse of this approach. The self-assessment in Box 23-6 asks you to examine your current use of accommodation and challenges you to think of new ways to use it more effectively. Competing When competing, people pursue their own needs and goals at the expense of others. Sometimes people use whatever power, creativeness, or strategies that are available to “win.” Competing may also take the form of standing up for your rights or defending important Box 23-5 Appropriate Uses of Accommodation • • • • • • 1. When other people’s ideas and solutions appear to be better, or when you have made a mistake 2. When the issue is far more important to the other(s) person than it is to you 3. When you see that accommodating now “builds up some important credits” for later issues 4. When you are outmatched and/or losing anyway; when continued competition would only damage the relationships and productivity of the group and jeopardize accomplishing major purpose(s) 5. When preserving harmonious relationships and avoiding defensiveness and hostility are very important 6. When letting others learn from their mistakes and/or increased responsibility is possible without severe damage Box 23-6 Accommodation: Self-Assessment and Commitment to Action If You Use Accommodation Often, Ask Yourself the Following Questions: • • • • 1. Do I feel that my needs, goals, concerns, and ideas are not being attended to by others? 2. Am I depriving myself of influence, recognition, and respect? 3. When I am in charge, is “discipline” lax? 4. Do I think people are using me? If You Seldom Use Accommodation, Ask Yourself the Following Questions: • • • • 1. Am I building goodwill with others during conflict? 2. Do I admit when I have made a mistake? 3. Do I know when to give in, or do I assert myself at all costs? 4. Am I viewed as unreasonable or insensitive? Commitment to Action What two new behaviors would increase your effective use of accommodation? 1. 2. • • principles, as when opposition to mandatory overtime is voiced (Box 23-7). People whose primary mode of addressing conflict is through competition often react by feeling threatened, acting defensively or aggressively, or even resorting to cruelty in the form of cutting remarks, deliberate gossip, or hurtful innuendo. Competition within work groups can generate ill will, favor a Box 23-7 Appropriate Uses of Competing • • • • 1. When quick, decisive action is necessary 2. When important, unpopular action needs to be taken, or when trade-offs may result in long-range, continued conflict 3. When an individual or group is right about issues that are vital to group welfare 4. When others have taken advantage of an individual’s or group’s noncompetitive behavior and now are mobilized to compete about an important topic Box 23-8 Competing: Self-Assessment and Commitment to Action If You Use Competing Often, Ask Yourself the Following Questions: • • • • 1. Am I surrounded by people who agree with me all the time and who avoid confronting me? 2. Are others afraid to share themselves and their needs for growth with me? 3. Am I out to win at all costs? If so, what are the costs and benefits of competing? 4. What are people saying about me when I am not around? If You Seldom Compete, Ask Yourself the Following Questions: • • • 1. How often do I avoid taking a strong stand and then feel a sense of powerlessness? 2. Do I avoid taking a stand so that I can escape risk? 3. Am I fearful and unassertive to the point that important decisions are delayed and people suffer? Commitment to Action What two new behaviors would increase your effective use of competition? • 1. • 2. win-lose stance, and commit people to a stalemate. Such behaviors force people into a corner from which there is no easy or graceful exit. Use Box 23-8 to help you learn to use competing more effectively. Compromising Compromising involves both assertiveness and cooperation on the part of everyone and requires maturity and confidence. Negotiating is a learned skill that is developed over time. A give-andtake relationship results in conflict resolution, with the result that each person can meet his or her most important priorities as much of the time as possible. Compromise is very often the exchange of concessions as it creates a middle ground. This is the preferred means of conflict resolution during union negotiations, in which each side is appeased to some degree. In this mode, nobody gets everything he or she thinks he or she needs, but a sense of energy exists that is necessary to build important relationships and teams. Negotiation and compromise are valued approaches. They are chosen when less accommodating or avoiding is appropriate (Box 23-9). Compromising is a blend of both assertive and cooperative behaviors, although it calls for less finely honed skills for each behavior than does collaborating. Negotiating is more like trading (e.g., “You can have this if I can have that,” as in “I will chair the unit council taskforce on improving morale if you send me to the hospital’s leadership training classes next week so I can have the skills I need to be effective.”). Compromise is one of the most effective behaviors used by nurse leaders because it supports a balance of power between themselves and others in the work setting. The self-assessment in Box 23-10 will help you become more aware of your own use of negotiation and compromise and improve it. Collaborating Collaborating, although the most time-consuming approach is the most creative stance. It is both assertive and cooperative because people work creatively and openly to find the solution that most fully satisfies all important concerns and goals to be achieved. Collaboration involves analyzing situations and defining the conflict at a higher level where shared goals are identified and commitment to working together is generated (Box 23-11). When Box 23-9 Appropriate Uses of Compromise • • • • • 1. When two powerful sides are committed strongly to perceived mutually exclusive goals 2. When temporary solutions to complex issues need to be implemented 3. When conflicting goals are “moderately important” and not worth a major confrontation 4. When time pressures people to expedite a workable solution 5. When collaborating and competing fail Box 23-10 Negotiation/Compromise Self-Assessment and Commitment to Action If You Tend to Use Negotiation Often, Ask Yourself the Following Questions: • • • 1. Do I ignore large, important issues while trying to work out creative, practical compromises? 2. Is there a “gamesmanship” in my negotiations? 3. Am I sincerely committed to compromise or negotiated solutions? If You Seldom Use Negotiation, Ask Yourself the Following Questions: • • • 1. Do I find it difficult to make concessions? 2. Am I often engaged in strong disagreements, or do I withdraw when I see no way to get out? 3. Do I feel embarrassed, sensitive, self-conscious, or pressured to negotiate, compromise, and bargain? Commitment to Action What two new behaviors would increase your compromising effectiveness? 1. 2. • • Box 23-11 Appropriate Uses for Collaboration • • • • 1. When seeking creative, integrative solutions in which both sides’ goals and needs are important, thus developing group commitment and a consensual decision 2. When learning and growing through cooperative problem solving, resulting in greater understanding and empathy 3. When identifying, sharing, and merging vastly different viewpoints 4. When being honest about and working through difficult emotional issues that interfere with morale, productivity, and growth nurses use cooperative conflict-management approaches, decision making becomes a collective process in which action plans are mutually understood and implemented. An organizational culture that supports collaborative behavior among nurses and physicians is needed to merge the unique strengths of both professions into opportunities to improve patient outcomes (Nair, Fitzpatrick, McNulty, Click, & Glembocki, 2012). For example, when nurses and physicians work together, they can collaborate by asking, “What is the best thing we can do for the patient and family right now?” and “How does each of us fit into the plan of care to meet their needs?” This requires discussion about the plan, how it will be accomplished, and who will make what contributions toward its achievement and proposed outcomes. Use the self-assessment in Box 23-12 to determine your own use of collaboration. At the onset of conflict, involved collaborating individuals can carefully analyze situations to identify the nature and reasons for conflict and choose an appropriate approach. For example, a conflict arises when a direct care nurse and a charge nurse on a psychiatric unit disagree about how to handle a patient’s complaints about the direct care nurse’s delay in responding to the patient’s requests. At the point that they reach agreement that it is the direct care nurse’s responsibility and decision to make, collaboration has occurred. The charge nurse might say, “I didn’t realize your plan of care was to respond Box 23-12 Collaboration Self-Assessment and Commitment to Action If You Tend to Collaborate Often, Ask Yourself the Following Questions: • • • 1. Do I spend valuable group time and energy on issues that do not warrant or deserve it? 2. Do I postpone needed action to get consensus and avoid making key decisions? 3. When I initiate collaboration, do others respond in a genuine way, or are there hidden agendas, unspoken hostility, and/or manipulation in the group? If You Seldom Collaborate, Ask Yourself the Following Questions: • • • 1. Do I ignore opportunities to cooperate, take risks, and creatively confront conflict? 2. Do I tend to be pessimistic, distrusting, withdrawing, and/or competitive? 3. Am I involving others in important decisions, eliciting commitment, and empowering them? Commitment to Action What two new behaviors would increase your collaboration effectiveness? • 1. • 2. to the patient at predetermined intervals or that you told the patient that you would check on her every 30 minutes. I can now inform the patient that I know about and support your approach.” Or the direct care nurse and the charge nurse might talk and subsequently agree that the direct care nurse is too emotionally involved with the patient’s problems and that it may be time for her to withdraw from providing the care and enlist the support of another nurse, even temporarily. Discussion can result in collaboration aimed at allowing the direct care nurse to withdraw appropriately. Another, less desirable choice could be to compete and let the winner’s position stand (e.g., “I’m in charge; I’m going to assign another nurse to this patient to preserve our patient satisfaction scores” or “I know what is best for this patient; I took care of her during her past two admissions”). Differences of Conflict-Handling Styles Among Nurses The way in which conflict-management styles are used in health care has changed very little in the past 20 years. Previous studies suggest that avoidance and accommodation remain the predominant choices for direct care nurses and that the prevalent style for nurse managers is compromise, despite the emphasis placed on collaboration as an effective strategy for conflict management (Mahon & Nicotera, 2011). Nursing students and new graduates may be unprepared to handle conflict in the practice environment; Hasson, McKenna, and Keeney (2013) reported a number of barriers novice nurses faced when delegating tasks such as fear of causing conflict. This highlights the need to develop delegation strategies including conflicthandling skills to adapt to the evolving professional role. The prevalent conflict-management style for nursing students is avoidance and accommodation (Pines et al., 2011). Nurses who successfully managed disruptive workplace conflict reported a deliberate approach that included delaying confrontation, approaching the colleague calmly, and acknowledging the colleague’s point of view (Lux, Hutcheson, & Peden, 2012). Nurses working in specialty areas may adapt communication and conflict management strategies to respond to diverse patient populations and the unique mix of interprofessional colleagues. For example, in primary care settings, conflicts regarding scope of practice issues, role confusion, and disagreements over accountability for care are amplified (Brown, Lewis, Ellis, Stewart, Freeman, & Kasperski, 2011). See the Research Perspective, which describes conflicts and communication gaps common in intensive care units and in palliative care situations. Research Perspective Resource: Aslakson, R.A., Wyskiel, R., Thornton, I., Copley, C., Shaffer, D., Zyra, M., Nelson, J., & Pronovost, P.J. (2012). Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: A qualitative exploration. Journal of Palliative Medicine, 15(8), 910-915. Two sources of conflict that arise in critical care environments are end-of-life decisions and communication issues, both of which are most evident in interprofessional conflict and tension between team members and patients’ families. Intensive care nurses identified barriers to optimal communication regarding palliative care including discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. The ICU is particularly vulnerable because of the stressful work environment, complex network of interprofessional relationships, and a need for making life and death decisions under considerable time pressure and familial burden. Additionally, critical care resources (e.g., bed shortages, costs, and length of stay), values (e.g., ethical disputes over goals of treatment), and task conflicts (e.g., timing of ventilator withdrawal, pain management) can exaggerate conflicts. Implications for Practice Conflicts in intensive care units most negatively affect the Quality and Safety Education for Nurses (QSEN) competencies of patient-centered care, teamwork and collaboration, and safety (QSEN Institute, 2013). Reduced conflict in the ICU could be achieved with regular interprofessional unit and team meetings and when end-of-life decisions are made collaboratively with physicians, nurses, the family, and a healthcare ethicist as needed. Leaders and manager must model and coach bedside nurses in effective conflict handling strategies in order to favorably impact the practice environment. Nurses and physicians do not routinely collaborate with each other in conflict situations conducive to collaboration. Conflicts between nurses and physicians may be intensified because of the overlapping nature of their domains and lack of clarification between roles. Also, when asked to describe relationships with physicians, nurses frequently reported power as a dominant theme. The compromising mode is a common conflict-handling mode used in nurse/physician interactions. Compromise supports a balance of power in the workplace. A need exists to strengthen a healthy professional alliance that relies on collaborative practice to ensure favorable patient outcomes. Effective communication with other members of the health care team positively influences teamwork, staff satisfaction, and improves quality of patient care and safety (Institute of Healthcare Improvement, 2011; TJC, 2012). Compromise supports a balance of power between self and others in the workplace. The Role of the Leader Encouraging positive working relations among healthcare providers requires effective conflict management as part of a healthy working environment. The role of the nurse leader is to create a practice environment that fosters open communication and collaborative practices for achieving mutual goals that enable nurses to employ constructive approaches to conflict management. Specifically, leaders must adopt a strategic proactive approach that aligns conflict management approaches with the overall mission of the organization (Scott & Gerardi, 2011a, 2011b). TJC adopted new accreditation standards requiring that hospitals manage conflict between leadership groups to promote a culture of safety (TJC, 2012). The training of nurse managers as conflict coaches shows promise in creating a positive practice environment when integrated with other conflict intervention processes (Brinkert, 2011). This innovative model can increase the nurse manager’s conflict competencies and skill set in effectively impacting conflicts concerning diverse issues (e.g., scheduling; adherence to policies and procedures; difficult interdepartmental and interprofessional behaviors) with a multitude of stakeholders, including patients and their families, direct care nurses, other departments, physicians, and insurance companies (Brinkert, 2011). By providing an environment of open communication and acknowledgement of each team member’s viewpoint, the nurse manager can model and coach staff to independently and effectively resolve future conflicts themselves (Johansen, 2012). With the aging workforce and current nursing shortage, it is essential to create practice environments that will retain nurses and prevent premature departure from the discipline. Moreover, managers need to help challenge the stereotypical gender behavioral expectations and self-esteem issues frequently associated with a female-oriented profession and model effective management and leadership styles. One way to promote a positive work setting is to promote conflict prevention and ensure conflict resolution (Almost, 2006). The Literature Perspective on page 443 highlights the most recent and comprehensive concept analysis on conflict. Nurse leaders must provide the best example of advocacy and empowerment to their staff by coaching newer nurses to think strategically about a mode of conflict handling that is appropriate for the situation. Poor communication often creates conflict that jeopardizes patient safety, whereas inadequate leadership appears to be a contributing factor to most sentinel events (Scott & Gerardi, 2011a, 2011b). Nursing managers need to support their staff’s use of effective conflictmanagement strategies by modeling open and honest communication, including staffing decision making, and securing resources that meet the staff’s need in delivering quality care. Providing education on conflict management could empower nurses and physicians to use these newly acquired skills in negotiation and creative problem-solving techniques (Kaitelidou et al., 2012). Research confirms that healthcare providers do not always voice concerns about patients and actively avoid conflict in clinical settings (Lyndon, Zlatnik, & Wachter, 2011). Healthcare leaders and managers who promote effective conflict resolution skills and who discourage the use of avoidance as a strategy have the potential to reduce employee stress and burnout as well as promote higher job satisfaction (Wright, 2011). For example, a manager’s need to give clear direction to a team automatically places less emphasis on the team deciding on the direction themselves. However, for the team to be successful, eventually that manager must recognize the need for the team to work on its own even though the manager may at times need to intervene. Imagine a nurse manager was confronted by an angry team whose members felt like they were being treated like children, always being told what to do. Working together, they initiated team meetings and decisionmaking procedures (actions emphasizing participatory management, as in self-scheduling practices) that resulted in more ideas, a sense of ownership, and a noticeable self-direction from the team and its individual members. However, after a few months of continually emphasizing participation, the team began to lose its focus and cohesiveness and once again came to the manager for more direction. The manager listened and provided clarification, and the team regained its focus and efficiency. The nature of the differences, underlying reasons, importance of the issue, strength of feelings, and commitment to shared goals all have to be considered when selecting an approach to resolving conflict. Preferred and previously effective approaches can be considered, but they need to match the situation. Sometimes, a third party may be introduced into a conflict so that mediation can occur. Mediation is a learned skill for which advanced training and/or certification is available. Principled negotiation can produce mutually acceptable agreements in every type of conflict. The method involves separating the people from the problem; focusing on interests, not positions; inventing options for mutual gain; and insisting on using objective criteria. The mediator is usually an impartial person who assists each party in the conflict to better hear and understand the other. In society, for example, much focus is on who can control whom and on who is the “winner.” The successful individual involved in conflict resolution and negotiation often Literature Perspective Resource: Almost, J. (2006). Conflict within nursing environments: Concept analysis. Journal of Advanced Nursing, 53(4), 444-453. A concept analysis, including the development of a conceptual diagram of antecedents and consequences of conflict (Figure 23-2), in nursing work environments was performed following an exhaustive review of the literature published from 1980 to 2004. Sources of conflict originate from individual characteristics, interpersonal factors, and organizational dynamics. Individual differences, typically generated by differing opinions and values, create potential conflict. Demographic dissimilarity (e.g., gender, educational levels, age, race, ethnicity) can stimulate conflict as well. Interpersonal factors such as distrust, perceptions of injustice or disrespect, and inadequate or poor communication style can lead to conflict. Organizational factors including the interdependence among team members and the changes that result from restructuring can set the stage for conflict within the practice environment. Similarly, the effects of unresolved conflict are visible in individual characteristics, interpersonal factors, and organizational dynamics. Individual effects include job stress and dissatisfaction, absenteeism, and intent to leave, whereas interpersonal factors such as hostility and avoidance are dominant. The organizational impact of negative conflict management includes reduced productivity and ineffective teamwork. Implications for Practice Sources of conflict within the practice environment must be anticipated and addressed to enhance organizational effectiveness. Healthcare leaders must engage in conflict-management strategies to prevent or resolve conflict within nursing environments to ensure quality and safety. Nurses in managerial positions spend inadequate time on conflict resolution. Many lack the educational preparation to manage conflict or do not feel qualified or sufficiently experienced to effectively deal with conflict. Moreover, some staff can be difficult, so managers must remain focused on the problem and not the personalities of the team members. Nurse managers must also remain cognizant of other pitfalls of effective conflict resolution. For example, a common way for managers to avoid conflict in the workplace is to delay responding to colleagues’ concerns voiced in staff meetings, to not reply to voice mails or e-mail messages, or to cancel or postpone important meetings. If this behavior is known and continues, the avoiding behavior is said to be endorsed or approved, leading to an unhealthy practice environment. Fostering collaboration requires a commitment of time and interpersonal energy to be effective, which many nurse leaders report as a barrier. Figure 23-2 Diagram of antecedents and consequences of conflict moves beyond avoidance, accommodation, and compromise. In the nursing practice arena, added difficulty occurs in negotiating conflicts when at least one of the parties is on an unequal or uneven playing field. This disadvantage is made even worse when the other party to the conflict does not even acknowledge the disparities involved. Interest-based bargaining, a negotiation strategy that produces agreements that satisfy common interests and balance opposing positions, has been effectively used in complex organizational conflicts such as in collective bargaining situations. This approach has been implemented by the healthcare giant Kaiser Permanente whose national agreements with its labor unions cover not only wages and benefits but also performance goals related to service, care quality, and affordability. They also address workforce and community health and workforce development (Kaiser Permanente, 2012). Managing Lateral Violence and Bullying A significant source of interpersonal conflict in the workplace stems from lateral violence— aggressive and destructive behavior or psychological harassment of nurses against each other. Nurses are particularly vulnerable because lateral or horizontal violence involves conflictual behaviors among individuals who consider themselves peers with equal power—but with little power within the system. Bullying is closely related to lateral or horizontal violence, but a real or perceived power differential between the instigator and recipient must be present in bullying. Bullying is associated with psychological and physical stress, underperformance, professional disengagement, increased job turnover, and the potential for diminished quality of care (Dzurec & Bromley, 2012). Understanding the sources of intraprofessional conflict in the practice environment is essential (see also Chapter 25). Nurses are in positions to identify and intervene on the part of their colleagues when they see or experience horizontal violence or bullying. With increased awareness and sensitivity, nurses may be better able to monitor themselves, as well as assist their peers to recognize when they are participating in negative behaviors. Identifying and understanding particular incidences when nurses are most vulnerable and apt to engage in negative behavior (e.g., heavy workload, short staffing) and establishing performance expectations has the potential to reduce lateral violence in the workplace (Walrafen, Brewer, & Mulvenon, 2012). Incorporating workplace civility in nursing orientation programs and modeling professional behaviors provides a foundation to promote a healthy work culture. Nursing students and new graduates often lack the confidence and skill set to prevent interpersonal conflict and must rely on experienced nurse managers and leaders to reduce the likelihood of horizontal violence or bullying (Weaver, 2013). Nurse educators have a similar responsibility to develop nursing curricula that educate and encourage dialogue about horizontal violence to increase awareness and provide nursing students the skills to combat horizontal violence (Walrafen et al., 2012). In hostile work environments, the ability to provide quality patient care is compromised. TJC (2012)acknowledges that unresolved conflict and disruptive behavior adversely affect safety and quality of care. The vulnerability of newly licensed nurses as they are socialized within the nursing workforce and deal with interpersonal conflicts is a significant challenge. Longo and Smith (2011) reported it is common for nursing students to report being put down by a direct care nurse and, in turn, for direct care nurses to experience horizontal violence at work. Lateral violence affects newly licensed nurses’ job satisfaction and stress, as well as their perception of whether to remain in their current position and in the profession. Similarly, nursing students are particularly vulnerable to lateral violence and bullying in the transition to becoming a nurse and may begin to question their long-held belief that nurses are caring and supportive professionals. See The Challenge and The Solution, which present the experiences of a new graduate nurse in a situation related to this chapter. Lateral violence may be a response to the practice environment, in which ineffective leadership may exacerbate the problem. TJC (2012) acknowledges that incivility and disruptive behavior that intimidates others and affects morale or staff turnover can be harmful to patient care. It mandates that organizations have a code of conduct that defines acceptable, disruptive, and inappropriate behaviors and that leaders create and implement a process for managing these conflictual situations. One-on-one conflict resolution must be encouraged, but a mechanism for confidential reporting is also necessary. Training on conflict management that includes how to recognize and defend against lateral violence is necessary to ensure a positive professional practice environment. Senior level leaders and nurse managers are responsible for ensuring appropriate policies are in place to confront negative workplace behaviors, including lateral violence and bullying. Exercise 23-3 Consider a conflict you would describe as “ongoing” in a clinical setting. Talk to some people who have been around for a while to get their historical perspective on this issue. Then consider the following questions: • •What are their positions and years of experience? • •How are resources, time, and personnel wasted on mismanaging this issue? • •What blocks the effective management of this issue? • •What currently aids in its management? • •What new things and actions would add to its management in the future? Conclusion Conflict occurs in all walks of life. The major issue of conflict in nursing is that patients could suffer. Knowing how to respond appropriately in conflict situations helps leaders, managers, and followers focus on quality and safety rather than disagreements and disruptions. The Solution —Miranda J. Kennedy I replied that his pressure was in the 130 s that morning, which meant every medication I had given him was appropriate, based on the parameters in the MAR. The physician probably responded better to her than I did, he said, “I’m not looking to assign any blame to anyone, I am just trying to get a picture of what we are working with here.” Her comment stung though and left a lasting impression. I thought in nursing and healthcare we are supposed to be a TEAM. During times of stress, if we spend our time trying to assign blame instead of recruiting each other onto the team, we can shut other people down in a way that is detrimental to the patient. That day was also very reaffirming for me personally that I was going to be leaving that job, as that is not the foundation to grow as a new nurse. Overall, that experience really impacted my attitude as a nurse and made me consider what type of leader, colleague, and person I wanted to be perceived as at work. The positive attitude that the physician took towards my level of abilities as a professional was much more empowering than my own assistant manager. I try to empower and value my colleague’s inputs and their skills each day I work, realizing how much power our words and attitudes affect those around us, and overall affect the care delivered to the patient. • o Would this be a suitable approach for you? Why? The Evidence Conflict in the professional practice environment results in negative outcomes for nurses and other healthcare professionals, organizations, and patients. Lateral violence is toxic to the profession through its negative impact on the retention of staff and on detrimental outcomes for patients. It is essential for registered nurses to work in an effective and collaborative manner with other members of the healthcare team to enhance retention and eliminate lateral violence and bullying from the workplace (Wright, 2011). The need for a culture change to abolish lateral violence has been endorsed by a number of professional organizations (e.g., American Nurses’ Association, The Joint Commission, International Council of Nurses, National Student Nurses Association). Bullying, lateral violence, and all forms of disruptive behaviors have a negative impact on the retention of nursing staff and the quality and safety of patient care. Nurses must enhance their knowledge and skills in managing conflict and promote workplace policies to eliminate bullying and lateral violence. Nurse leaders and followers must eliminate hostile work environments, workplace intimidation, reality shock for new graduates, and the acceptance of inappropriate professional interactions. What New Graduates Say • • • • Interprofessional communication simulations were helpful, but I’m still afraid to call a physician in the middle of the night. I have to remember we share a commitment to quality patient care. • I could have used more practice communicating with older nurses. I am working on disagreeing without coming across as disrespectful. • It was good to complete the Thomas-Kilmann Conflict Mode Instrument as a student because I am aware of my need to reduce my use of avoidance when a conflict arises on my unit. Chapter Checklist A more thorough understanding of conflict within the professional practice environment will enable the nurse to prevent or successfully manage nonproductive conflict. Navigating desirable conflict within the work environment will promote change resulting in organizational growth and personal and professional enrichment of nurses. • • • • • • • •Types of conflict •Stages of conflict o •Frustration o •Conceptualization o •Action o •Outcomes •Categories of conflict •Modes of conflict resolution o •Avoiding o •Accommodating o •Competing o •Compromising o •Collaborating •Differences of conflict-handling styles among nurses •The role of the leader •Managing lateral violence and bullying Tips for Addressing Conflict • • • • • • • Recognize that conflict is a necessary and beneficial process typically marked by frustration, different conceptualizations, a variety of approaches to resolving it, and ongoing outcomes. • Assess the work environment to see what behaviors are endorsed and fostered by the leaders. Determine if these behaviors are worthy of imitation. • Determine any similarities and differences in facts, goals, methods, and values in sorting out the different conceptualizations of a conflict situation. • Assess the degree of conflict resolution by asking questions about the quality of the decisions (e.g., creativity, practicality, achievement of goals, breakthrough results) and the quality of the relationships (e.g., understanding, willingness to work together, mutual respect, cooperation). • Remind yourself of your preferences for resolving conflict (e.g., which of the five approaches do you not use often enough and which do you overuse?) and assess each situation to match the best approach for that type of conflict regardless of which is your favorite approach. • Assist others around you in assessing conflict situations and determining how they can best approach them. 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