Conflict Management

Wherever there is human interaction, there are bound to be differences in personality, communication style, and conduct which inevitably leads to conflict. These differences are particularly true for work environments that involve mentally and physically stressful tasks, long hours, and proximity to others, which is why healthcare settings like hospitals and clinics are prime locations for workplace conflict to develop.

In addition to the hours wasted in active conflict, negative interactions while at work can result in a poor mood and decreased productivity for several hours or days after the initial incident, eventually creating a toxic work environment altogether if not appropriately addressed. Poor employee retention and frequent absenteeism may follow. This problem has even more insidious effects in healthcare, as patient care may directly suffer if individuals or teams are frequently engaged in conflict.

When handled appropriately, conflict can be a good thing, as it leads to recognition of problems and development of positive solutions, and improvement in workflow and work environment. Teamwork, cooperation, and effective communication are all necessary for healthcare environments to function properly. Yet, it is estimated that nurse managers spend 25-40% of their time dealing with conflict among staff members (American Sentinel, 2020). Appropriate training in the skills needed to quickly and effectively recognize and deal with conflict is beneficial to management positions and all nurses and healthcare workers who may experience conflict. A healthy work environment with good conflict resolution protocols leads to increased staff longevity, increased productivity, and better quality of care for patients, making conflict management strategies an obvious priority for healthcare facilities everywhere.

At its most basic definition, conflict in the workplace is when there is any form of strife or discord between individuals or group members. Typically, the disagreement occurs in relation to beliefs, statements, or actions by one party that are perceived to be unacceptable by the other. These opposing views result in a state of unrest or antagonism (Mandalina, 2016).

Conflict may arise for a variety of reasons, but in healthcare, many unique factors contribute to the development of friction; including emotionally and physically demanding labor, staff shortages, long hours, rapid and frequent industry changes, integration of technology, patient perception of how care should be delivered, financial strain for the institution, etc. The larger the institution, the more probable and frequent conflict becomes (Jones et al., 2019).

In general, conflict can be divided into four main types, as reviewed below (Mandalina, 2016).

1. Intrapersonal conflict: This type of conflict occurs within an individual and involves an internal struggle of thoughts, emotions, or values. Intrapersonal conflict might occur when a nurse feels overwhelmed with patient care activities and prioritizes work tasks while finding necessary meal and bathroom breaks during a shift. This type of conflict can be difficult to identify but may have serious consequences such as burnout if left unnoticed.
2. Interpersonal conflict: This type of conflict occurs when two individuals do not agree on how to handle a situation. Interpersonal conflict may occur if a staff member feels a coworker is not pulling their weight during a shift or feels that a manager continually schedules them with an unfair amount of weekend shifts.
3. Intragroup conflict: This type of conflict occurs amongst members of a group or team, such as a particular unit of the hospital. Teamwork and a sense of community are necessary for a department to run smoothly. Differences or disagreements among team members can cause unrest for everyone, even if they are not directly involved in the conflict. If left unattended, the conflict can deepen and divide the group into cliques or "sides," leading to gossip, hostility, chronic complaining, competing for power, and decreased productivity.
4. Intergroup conflict: Intergroup conflict exists between members of different groups within the organization that are perceived to differ in values, beliefs, or goals. Opposing groups may be clinical team members who feel unheard of and undervalued by their administrators or different departments, such as intensive care. The pharmacy is not preparing and sending medications quickly enough. Intergroup conflict may lead to avoidance of communication between the groups, resulting in decreased productivity and interruption of patient care goals within the organization.

Though the specific details may vary, most workplace conflict scenarios follow a predictable pattern. The five stages outlined by Robbins in 1998 are generally accepted to be true and are frequently used as a standard model when developing conflict management protocols. These five stages were reimagined and adapted by Jones et al. (2019) as detailed below and in Figure 1. The stages consist of:

1. Stage 1: Potential opposition or incompatibility – These are the environmental factors that set the stage for potential conflict and include communication (or lack thereof) within a department, role hierarchy and leadership styles within an organization or department, and personal variables different personalities or belief systems.
2. Stage 2: Cognition and personalization- This is where individuals or groups become aware of the environmental variables and view them as undesirable or incompatible. Negative emotions such as frustration, anxiety, or anger may develop. Employees may feel apathetic towards their jobs or confrontational towards coworkers or supervisors.
3. Stage 3: Intentions- Once the conflict is felt by one or both parties, decisions must be made about handling it. These decisions may be purposeful and thought out based on conflict resolution tactics, or they may be impulsive and based on learned behaviors or gut reactions. Potential intentions or styles for dealing with the conflict include competitive, collaborative, compromise, avoidance, and accommodative (discussed further below).
4. Stage 4: Behavior- This includes one party's behavior based on their intentions and includes the other party's reaction. This behavior is often where conflict is noticeable to observers, and management may need to mediate.
5. Stage 5: Outcomes- Depending on the behavior and any outside intervention, the outcome of conflict can be positive, with an increase in effective communication and group performance, or negative, with deepening divides and decreased teamwork and group performance.

(Jones et al., 2019).

Figure 1:

(Jones et al., 2019)

The way a person or group deals with conflict depends on many variables, including personality traits, learned behaviors and responses to conflict, presence, leadership style, and even training regarding conflict resolution. In general, the Thomas-Kilmann Conflict Model is used to organize conflict management into five categories. Though this model was developed in the 1970s, it has been updated and reimaged in recent years to include an easy to use online tool for individuals to learn more about their own conflict management style and what ways they may be handling conflict or how to improve their strategies (Kilmann Diagnostics, 2020).

The five categories of the model include:

• Avoidance: For some people, the thought of confrontation is very stressful, and they may choose to avoid or ignore the conflict altogether. While this may temporarily avoid an undesirable or uncomfortable situation, it does not resolve the conflict. The feelings of unrest or dissatisfaction will only continue to grow, eventually leading to even more conflict or a disproportionate reaction. It should be noted that, sometimes, this technique can be used positively to temporarily postpone addressing the conflict, either to de-escalate and allow both parties time to cool down or to complete necessary workflow and ensure patient safety before taking the time to address the conflict.
• Accommodative: This conflict management style involves a win-lose situation, where one party will receive the resolution they want while the other has their opinions disregarded or dismissed. An accommodative strategy requires one's party to yield to the direction of a supervisor cooperatively or to selflessly drops their argument for the sake of peace. Either way, resentment may result from the party losing the accommodation, and the cooperation necessary for this strategy may be difficult to maintain.
• Competitive: As the direct opposite of the accommodative style, competitive handling of conflict is considered the most confrontational and least cooperative. A power struggle takes place, and one party will win while the other loses at their expense. This strategy often involves both parties presenting their case to a manager, who then makes a quick decision about which party "wins." While the situation may be resolved with this approach, anger and frustration in its wake and unity between the parties may not necessarily be restored.
• Compromise: Both parties must sacrifice some of their position to reach a mutually acceptable solution in this strategy. This solution requires negotiation and cooperation from both sides and may require someone in a supervisory position to determine the solution and what the middle ground entails. While the situation may be resolved, resentment and dissatisfaction may be present amidst members of both parties as neither will receive all of what they wanted. Neither side gets as much as they initially hoped for, but neither loses as much as they potentially could either.
• Collaborative: In this strategy, the involved parties are brought together to work through the resolution process through actively listening and planning. This collaboration is the most creative and teamwork-centered solution strategy and may uncover other issues underlying the perceived problem. By working together to understand each other's concerns and meet each other's needs, this process should result in an understood and accepted solution. This process is also the most difficult solution to attain as it requires a conscious effort from all parties to be empathetic and understanding of viewpoints different from their own (Ronquillo, et al., 2020).

The culture of an organization and the leadership styles used by those in supervisory positions will determine which conflict management strategies are used and how effective they are. The seriousness of the problem also plays a role in which approach is most appropriate, as simple, one-time-only issues can be effectively resolved through avoidance or accommodation and do not require the time and effort spent on a collaborative solution. However, larger, more far-reaching issues should involve compromise or collaboration to address underlying issues and prevent recurrence of the problem. Figure 2 below, from Madalina (2016), demonstrates how varying levels of cooperation and assertiveness from either party can affect which resolution technique.

Figure 2

(Madalina, 2016)

After an individual understands why conflict occurs and how personal and group differences affect how it is managed, this knowledge can be applied to effective conflict management. People in supervisory or managerial positions will most often mediate conflict and restore a peaceful work environment. Still, anyone who works in a hospital setting can learn to manage conflict and contribute to effective communication and a smoothly flowing department.

There are many existing models for managing conflict best, but at their core, they all have the same basic principles in common.

• Remember that conflict is inevitable and can be a positive move towards growth if appropriately managed
• Resolution is likely to be easier and more satisfactory to all if both parties participate in the conflict management rather than avoiding it
• Individuals or groups must want to participate in the resolution process for it to be effective
• Behavioral, cognitive, and communication skills require self-awareness and can be learned with practice
• The environment where conflict resolution takes place should be neutral and safe for all parties

Once a neutral environment and rules of respect have been established, both parties should be allowed to present their side without interruption. The opposing party should use this opportunity to listen closely and let go of any preconceived ideas about the issue. Sometimes, it may even be discovered that each party has a different idea about what is causing the conflict, which would make it nearly impossible to resolve without realizing it. Once the problem has been identified and agreed upon, solutions may be proposed. The type of management strategy needed for the situation determines who might propose the solution, and it can consist of a variety of acquiescence, compromise, or collaborations. In the most collaborative scenario, each side would be allowed to develop proposed solutions for review (Ronquillo, et al., 2020).

A helpful acronym to use when solving conflict is VALUED.

• Validate: people want to feel heard and understood. Even if a solution is not what individuals are hoping for, they are more likely to accept it peacefully if they feel valued and acknowledged throughout the process.
• Ask open-ended questions: To get to the bottom of what someone is feeling, open-ended questions provide the opportunity for them to express their view on the matter at hand.
• Listen: Don't just assume you know what someone is thinking or feeling. Really listen and try to understand the point of view being presented.
• Uncover interests: What underlying factors might be influencing a person's viewpoint? Why do they think/feel/believe the way they do, and what experiences or perceptions of theirs may be different from your own?
• Explore options: Discuss ways that the problem could be solved. Try to be creative and think of multiple approaches and consider how each approach may benefit or disadvantage each party differently.
• Decide: Finally, you must conclude which solution is the best for your unique scenario.

Once conflict management has occurred, managers need to ensure that the issue has truly been resolved and not just pushed aside to resurface later. This assurance is best achieved through clear communication in four steps(Mandalina, 2016):

• Feedback: Touch base with everyone involved individually and make sure they have a clear understanding of the solution that was reached and do not have any lingering concerns. This understanding makes sure everyone is on the same page but conveys concern and caring for employees as important team members. It is important for team members to feel heard and appreciated, even if the conflict was not resolved in a way they would have preferred.
• Informal and formal communication: Summarizing the details of what was discussed and what solutions were agreed upon should be communicated both verbally and in conversation and as a follow-up in writing, usually in the form of an email. For simple, easily solved conflicts, formal communication is not always necessary. Still, in most cases, this added step does ensure that everyone is on the same page and has something to refer back to if any confusion arises.
• Clear and concise communication: It is important to be clear and to the point. Verbose communication, being vague to avoid negative reactions from others, or talking in circles can lead to confusion, further conflict, or staff feeling unheard and unappreciated. Even if a manager's information is likely to be poorly received, communicating it is extremely important.
• Delivering messages as facts: What you say should be true, detailed, and supported by your actions. A manager who says one thing but does not follow up with actions that support their words will lose the trust and respect of their subordinates. Whatever solution is reached must be how supervisors address the conflict moving forward.

Examining how the conflict was handled after the fact, considering how communication could be improved in the future, and holding regular training on conflict management are ways that a supervisor can maximize conflict management skills for themselves and staff and keep a department or team running smoothly. Conflict itself is inevitable, but the response to it can delineate the entire culture of a healthcare team and determine its long-term success.

You are the nurse manager on a pediatric unit. A nurse, Hannah, comes to you one day and asks to have her schedule changed because she does not want to work with another nurse, Aubrey, anymore. She states that Aubrey is lazy and does not do her share of department responsibilities, and she is finding it increasingly difficult to work alongside her.

Since changing the schedule for the immediate future is difficult last minute, and hearing that another staff member is not contributing equally is concerning, you decide to call Aubrey in for a meeting with you and Hannah. You choose your office as the meeting place and let each nurse know she will be given a chance to speak, and that polite language and behavior are expected.

You allow Hannah to express her concerns first. She states that the unit responsibilities such as restocking supply cabinets in the patient rooms, performing a supply check on the crash cart, and wiping down surfaces at the nurse's station are supposed to be performed once per shift. Hannah reports that about halfway through her shift, if these things are not done, she will do them but that typically the responsibilities are equally shared when she works with other nurses. Whenever she works with Aubrey, she ends up doing all of these tasks by herself, making her feel frustrated or angry for the remainder of the shift. She states it has gotten to the point where she feels annoyed even starting a shift with Aubrey and would like to be scheduled opposite of her from now on.

Aubrey is visibly upset by the meeting and these accusations. When she is given her turn to talk, she states that she is aware of the unit responsibilities and prefers to leave them towards the end of her shift, as she feels that is when the most restocking and cleaning are needed. She states that whenever she works with Hannah, she finds that they have already been completed if she completes any of the tasks about ¾ through her shift. She is aware that Hannah does not seem to like her and seems to avoid her, but until this meeting did not know why.

As the miscommunication at the root of the conflict is revealed, Hannah softens her stance. Aubrey suggests more open communication at the start of the shift regarding who will complete each task, and Hannah agrees. It is determined that each nurse will choose tasks to complete but then be allowed to complete them in their own time frame. As the manager, you incorporate this routine as part of each shift's beginning to avoid this issue in the future. About a week after the meeting, you check in with Aubrey and Hannah, who report that the tasks are being shared equally, and they are communicating much more openly with each other, which has led to a better work environment.

Mike is a nurse who asks his coworker Amanda to cover a shift for him one weekend to attend a concert. She agrees but asks Mike to cover a shift for her next month in exchange so she can be off on her son's birthday.

Amanda works the agreed-upon shift, but Mike says he cannot cover Amanda's shift and is busy that weekend when the next month comes. Amanda is angry and goes to their manager. The manager says that since the exchange of shifts was not reported in writing, she can do nothing, and Amanda must work the shift as scheduled. Amanda is furious and calls in sick on her son's birthday, leaving the department short-staffed.

• American Sentinel. (2020). Conflict resolution in nursing: how strong leadership can help. Visit Source.
• Jones, L., et al. (2019). Workplace conflict: why it happens and how to manage it. Nursing time, 115(3); 26-28. Visit Source.
• Kilmann Diagnostics. (2020). Take the online TKI. Visit Source.
• Mandalina, O. (2016). Conflict management, a new challenge. Procedia Economics and Finance, 39 (8-7-814). Visit Source.
• Ronquillo, Y., Ellis, V. L., Toney-Butler, T. J. (2020). Conflict management. Stat Pearls. Visit Source.