Conflict Management

The purpose of this activity is to enable the learner to recognize conflict, understand the different types of conflict and learn how to resolve conflict.

This course is designed so that the healthcare professional will be able to:

1. Define conflict;
2. Define when conflict is needed;
3. Identify four types of conflict;
4. Describe five basic strategies for managing conflict;
5. List five modes of conflict resolution;
6. Describe four types of managerial actions that cause workplace conflicts;
7. Identify four key managerial actions and structures to minimize conflicts;
8. List three key factors organizations need for resolving disputes.

In a field like nursing, where passions and tensions run high, learning to handle conflict effectively is a critical safety skill.¹ Conflict occurs when two or more values, perspectives and opinions are contradictory in nature and have not been aligned or agreed upon. Conflict will always be present in the workplace and is an inevitable condition that is essential for change. Stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources or needs of the worker.² Conflict may be:

• Intrapersonal: this happens when individuals do not live according to their own values;
• Interpersonal: this happens between individuals;
• Intragroup: this happens among members of a specific group;
• Intergroup: this happens between two or more groups

There are other types of conflict such as competitive, destructive or disruptive conflict. In these instances, the desired outcome is to “win” by overcoming one’s opponent.

Conflict exists in all work environments and has positive aspects, as it usually precedes change. Conflict occurs when individuals or groups have disagreements on goals, ideas, values, beliefs, attitudes, feelings, perceptions, opinions, or actions for issues of importance. The challenge is identifying the cause of conflict and working through the modes of conflict resolution in a constructive and healthy way.

Conflict and stress can be a healthy aspect of change. Healthcare professions must change their attitudes toward conflict and learn how to move toward resolution in a healthy and constructive manner. Conflict can be damaging, and many individuals actively avoid dealing with situations arising from conflict. Conflict can also be a natural, unavoidable prerequisite to positive changes.⁵

Stress is the natural and normal reaction to events that are unfamiliar and infrequent. When a person fails to control stress or cope with it, the individual may experience distress. Healthcare professionals must learn to cope with stress by understanding how to manage stress and to utilize time management techniques. To enhance workplace productivity and resolve the conflicts that occur, managers have to find ways to handle conflict in a constructive manner. We are able to appreciate that disagreeing with others is not always a negative or destructive process.⁴

Managers spend 25-40% of their time dealing with conflict according to various surveys and estimates. Since conflict resolution takes so much constructive work time from managers, the nurse must learn to become comfortable with the resolution process. There are several styles for dealing with conflict⁶:

• Accommodating: refers to smoothing things over with the goal being to yield to preserve harmony and relationships. If you use this style too often, you may be seen as weak, ineffective or fearful of change
• Compromising: refers to a bargaining process that often results in a less-than-ideal solution due to concessions being made. This tactic may be useful in arriving at a temporary settlement on a complex issue.⁶ This tactic is not used when patient safety is at risk.
• Collaborating: is true problem solving with the goal of finding a mutual solution when both sets of interests are too important to be compromised. This tactic is especially important when the issue of patient safety is the conflict.⁶
• Avoiding: is not the way to go, but this tactic can be used strategically, especially as a cooling down period.
• Competing: a negative way to manage conflict, with the goal to be “win” at all costs.⁶ If an emergency arises and quick action is needed, this method may be used.

Kathy is an excellent nurse, but is quick tempered and argumentative, especially with the unit manager. Even though they have worked together for two years, things have not improved. The unit manager, Denise, is frustrated and realizes Kathy’s moods have affected the entire team.  During a discussion with Kathy, Denise learns some of the reasons why Kathy is unhappy.   Scheduling and the lack of teamwork are the biggest concerns. Denise decides to bring the entire team together, including physicians, unit clerks, and the nursing staff. Using the shared governance approach, Denise hopes to make the team more comfortable. Shared governance fosters ownership of the work to be done by formally involving the team in exploring different of avenues of resolution. Organizations that embrace this philosophy experience profound growth because the staff understands as well as implement progressive changes. Bringing the issues brought to the table by Kathy, without implying Kathy, enabled the team to start the resolution process.

Encouraging collaboration, with the goal of a cohesive team, Denise guides the staff to examine all the issues one at a time, ensuring that each member of the team has the opportunity to discuss their feelings. The staffing issue was resolved by the staff working on the schedule together, with the unit needs in mind, to allow a smooth-running unit. They decided, as a team, to be cross-trained in all aspects of the unit to cover any holes in the schedule. Weekly meetings were set up to update the schedule as needed. Denise told the team that as long as the unit was covered, and patient care was not affected, she would not intervene. 

The issue of cohesive teamwork was addressed by inviting the hospital nursing education department monthly classes until everyone felt comfortable with the changes needed.

Conflict may be either functional or dysfunctional. Dysfunctional conflict is destructive and leads to decreased productivity; functional conflict may encourage greater work effort and promote improved performance.

The types of conflict that managers might have to deal with are intrapersonal, interpersonal, intragroup and intergroup conflicts

Managing conflict is a team effort with nurse leaders, department heads and charge nurses working together to develop managerial actions and structures to minimize conflicts. They have an obligation to handle conflict in a constructive manner and with a positive attitude, using effective communication and listening skills. There are three strategies used to manage conflict: win-lose, lose-lose, and win-win.

Win-lose scenarios often involve groups and intragroup conflicts. When the group votes on an issue and majority rules, there is a winner and a loser. This scenario can erode the cohesiveness of a group and may diminish the group leader's authority. Another scenario could involve a nurse who has 30 years of seniority and wants a specific holiday off and another new employee also requested the same holiday off. The senior nurse refuses to give in and wants to win this argument.

Lose-lose scenarios involve losses to both parties. This scenario is often the case when a union arbitrator in union contract negotiations gives something to both parties and yet neither party gets what it wants.

Win-win scenarios involve collaboration: all groups or parties work together to meet the goals and objectives of all involved. Group consensus is reached after a careful investigation of the situation, specified needs of the group are understood by all, and a workable solution is reached. In this type of win-win scenario, there is no voting or other traditional dispute measurements: only the true group. Some of the advantages of collaborating include solving the actual problem, it reinforces mutual trust and respect, builds a foundation for effective collaboration in the future and shared responsibility of the outcome.10

Modes of conflict resolutioncome from the TKI or Thomas-Kilmann Conflict Mode Instrument. The TKI is a questionnaire designed to measure how an individual tends to handle inter-personal conflict. "Conflict Situations" are situations in which the concerns of two people appear to be incompatible. In such situations, a person's behavior is described along two basis dimensions¹¹:

1. Assertiveness - This is the degree to which an individual try to satisfy their own concerns when faced with a conflict.
2. Cooperativeness - The extent to which an individual try to satisfy the other person's concerns when faced with a conflict.

The TKI was developed in the early 70's by Kenneth W. Thomas and Ralph H. Kilmann. It was originally developed as a research tool and has grown into a wonderful training tool. The five conflict resolution modes are:

Avoiding - This is unassertive and uncooperative which involves avoiding or withdrawing and not dealing with the conflict. The individual does not pursue his/her concerns, or those of the other person, and the conflict is not addressed. This mode may be done for diplomatic reasons, to wait until a better time, or to withdraw from a threatening situation.

Accommodating - The exact opposite of competing, accommodating is unassertive and highly cooperative. The individual might neglect their own concerns to satisfy the concerns of another person. This mode to conflict resolution could be self-sacrificing, but it can also represent selfless generosity or charity or obeying orders when one would prefer otherwise. Individuals tend to use this strategy when they want to maintain a peaceful, workable environment.

Competing - This mode is considered to be very assertive and very uncooperative. Sometimes the term power-oriented is associated with this mode. It can be represented by an individual who pursues his/her beliefs at another person's expense, using whatever power is appropriate to win his or her position. Although there might be some negative connotations to the way this mode is described, there are times when it is the best and most effective way to resolve a conflict. Losing parties often are left angry and frustrated with the outcome. Managers often use this strategy when making quick decisions.

Compromising or Negotiating - This mode to conflict resolution involves a give and take from both parties. It is the middle ground regarding assertiveness and cooperativeness. Parties find a mutual solution that partially satisfies both parties. The individual gives up more than they would when they are in the competitive mode, but less than they would if they were accommodating. Instead of avoiding the conflict, the issue is addressed directly, but the issue is not given as much attention and analysis as is done with the collaborating mode. Compromising or Negotiating could mean splitting the difference, exchanging concessions or seeking a quick middle -ground position whereby both parties offer concessions. This method is often used in contract negotiations to placate both sides.

Collaborating - This is assertive and cooperative, it is the opposite of avoiding. This method is the most creative form of conflict resolution. An individual attempts to work with the other person to find a solution that satisfies both parties' concerns. Together they investigate the issue and identify their underlying concerns. A commitment among group members and higher levels of problem analysis are often seen when using this mode. Both parties work to understand each other's needs and perspectives so that together they can find creative solutions.

The Manager set up the mandatory brainstorming meeting with the Supervisors and Staff, and as a result, they discovered that there were specific managerial actions that were causing workplace conflicts. Some of the conflicts stemmed from:

1. Poor or no communications
   1. Employees not understanding reasons for decisions which affected them.
   2. Employees experiencing continuous changes, new programs and decisions they were not informed of or involved in making.
   3. The "rumor mill" seemed to be the only means of communication.
2. Insufficient resources for all shifts.
   1. Stress from working with inadequate resources.
   2. Disagreement about assignments and who should be doing what.
   3. The alignment of resources is inadequate.
3. Conflicting values or actions among managers and employees
   1. Strong personalities do not match.
   2. Dislike in others what they do not like in themselves.
   3. Lack of trust.
4. Leadership problems, e.g., inconsistency, perceived or actual lack of leadership, an autocratic leadership style, or a bureaucratic or uniformed leadership.
   1. Employees see limited or no changes in workplace issues
   2. Avoiding the conflict with little follow-through on decisions that affect everyone, including customers
   3. Supervisors do not understand the responsibilities and jobs of their subordinates
   4. Lack of support from management when dealing with nurse-patient issues.

The Manager shares what was discovered with the department heads and works on a plan to minimize conflict. Key managerial actions were discussed and implemented.

Key Managerial Actions included the following:

1. Implement "Shared Governance." Get employees involved in decisions that affect them and obtain their support.
2. On a regular basis hold management and employee meetings to communicate new initiatives and the status of current programs.
3. Regularly review job descriptions and get employees' input. Job descriptions must be clearly defined including dates. Ensure the job roles do not conflict with each other and no tasks are left undone.
4. Intentionally build relationships with all subordinates and work on building a trusting relationship.
   1. Meet monthly on a one-to-one basis.
   2. Ask employees about their challenges, accomplishments, and issues needing to be addressed.
5. Get regular written status reports that include:
   1. Plans for the upcoming period.
   2. Accomplishments.
   3. Current issues and needs from management.
6. Conduct training sessions about:
   1. Interpersonal communications
   2. Conflict management
   3. Delegation
   4. Lateral violence
7. Include Employees' input in developing procedures for routine tasks.
   1. Have employees write procedures when appropriate.
   2. Distribute procedures.
   3. Train and educate employees about new procedures.
   4. Obtain employees' review of procedures and their suggestions to improve procedures.
   5. Change procedures as warranted.
8. Have an anonymous suggestion box in an accessible area.
9. Set up an incentive program for positive suggestions to improve patient care, safety, and organizational productivity.

Programs were initiated to help individuals at all levels in the organization learn how to manage intrapersonal conflicts. Highlights included:

1. Identifying the conflict: include what you want and are not getting.
2. Writing thoughts down to come to a workable conclusion.
3. Having someone you trust for consultation and assistance. Consider how important the issue is, does the issue seem worse when you are tired or angry at something else, and what exactly is the role you play in this issue.
4. Deciding if you want to take this issue as your problem or if it should belong to someone else.
5. Chose one thing you can do about the conflict.
   1. Identify at least three reasonable courses of action.
   2. Write down the pros and cons of each action.
   3. Select an action that is doable and will not hurt oneself or others
   4. Discuss the course of action with a trusted friend.
   5. Follow through and do what needs to be done.
6. Give yourself a cooling-off period prior to doing anything about the conflict and then take action.
7. Set a tentative date in which you will act again if there has been no improvement in the situation.

Nurse Managers and department heads realized that there were interpersonal conflicts among members of the management team. These had to be addressed before building a cohesive team that could meet the challenges of positive changes.

In managing interpersonal conflicts steps to take include completing a self- analysis before taking action. It is important to write down 5 or 6 traits that irritated you, becoming your "hot buttons."

Suggestions included the following:

1. Being in control of yourself and your actions towards others who are demonstrating negative behaviors.
   1. Stay in control and establishing eye contact.
   2. Listen and show you are interested in what the other person says and feels.
   3. Speak in a moderated tone and nod your head as you listen.
   4. Give the person time to vent and do not interrupt them or judge them.
   5. Prevent blaming the person and look at the process.
2. When an individual is speaking with you about their concerns, verify that you understood what they have said once they have finished speaking. 
   1. Ask the person if it is permissible to rephrase what you are hearing from them.
   2. Ask open-ended questions and avoid asking "why" questions to prevent them from becoming defensive.
3. Ask the individual to verify if what you said is accurate and avoid the words "You" and instead use the word "I." Speak in terms related to the present and mention your feelings.
4. Acknowledge where you disagree and where you agree.
5. Discuss the issue or the process, not the individual. Get the individual's suggestions on how to fix the problem. Keep focusing on the issue and what can be done.
6. Identify one action that can be done by you and the individual.
   1. Ask the person if the action chosen is agreeable.
   2. If not, ask for a "cooling off period" and then work on an alternative solution.
   3. Thank the individual for their input and for sharing his/her perspective on the issue at hand.
   4. Help the individual to feel appreciated and valued.
7. If the situation remains in conflict, conclude whether or not the individual's behavior conflicts with current policies and procedures. Consult with your superior to discuss the issues presented. Decide whether to agree or disagree with the individual who has the issue.
8. Consider whether or not a third party is needed to be a mediator.

The Joint Commission on Accreditation of Healthcare Organizations recognizes the dangers of conflicts and the potential for workplace violence. JCAHO issued a Sentinel Event Alert on July 9, 2008, amending its Leadership Standards to include these requirements/recommendations:¹²

• Develop an organizational process for addressing intimidating and disruptive behaviors (LD.3.10 EP 5) that solicit and integrates substantial input from an inter-professional team including representation of medical and nursing staff, administrators and other employees.
• Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution.

It also recommends that JCAHO-accredited organizations utilize the practice of mediation in their workplaces. Read the 2009 Joint Commission Standards for conflict resolution (on-page PDF), Standard LD.02.04.01.

Organizations developing a dispute resolution process need to be aware of some key factors to success:

1. A leadership group committed to the process of conflict resolution;
2. A leadership group who perceive this process as in their best interest and in the best interests of the people they serve;
3. Strategic cooperation among historical competitors;
4. Satisfactory and realistic outcome;
5. Setting a limit on negative conflict - seeking behaviors.

Leaders also need to be aware of the barriers to success such as

1. Fear of losing control and power
2. No perceived benefit
3. Unwilling to negotiate
4. Corporate philosophy
5. Lack of knowledge about alternative dispute resolution
6. Top leadership reluctance
7. Lack of success stories to share

Training and education in conflict resolution can provide healthcare professionals with the skills and expertise to help them deal with workplace conflicts. Conflict resolution provides a safer and more satisfying environment for everyone.

Conflict is an inevitable aspect of life. In healthcare organizations, if the conflict is not dealt with effectively, the end result affects customers/patient care, employee's satisfaction, and the desire to do the best job possible and provide a safe and progressive environment. If the process of conflict resolution is viewed as an opportunity for growth and change in a work environment, the potential for a positive outcome is great.

On an individual level, the ability to solve problems and manage change plays a vital role in one's success. In the same way, the overall ability of a company - whether it is a healthcare organization or not - in solving problems through collaborative efforts, has a strong impact on the organization's bottom line and overall success.

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