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Conflict Management

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Author:    Patricia Hartley (RNC, MSN)

Objectives

At the completion of this module the learner will be able to:

  1. Define conflict
  2. Identify causes of conflict
  3. Identify characteristics of conflict specific to nursing
  4. Describe the model of conflict resolution
  5. List effective approaches to conflict management

INTRODUCTION

Conflict is present in all aspects of life and in all organizations due to the complexity of organizational relationships; the interactions among the members of the organization; and their dependence on one another. The presence of conflict does not necessarily mean that a negative process is occurring. Any organization in which people interact has a potential for conflict.

Healthcare institutions include many interacting groups: staff with staff, staff with patients, staff with families and visitors, staff with physicians etc. These interactions frequently lead to conflict. Conflict is defined as an acknowledged struggle from differences in ideas, values, actions or feelings resulting in increased stress levels between two groups or two people. Both parties are aware of the conflict.

Conflict cannot be prevented, but in fact needs to be expected. It is the nurse manager’s/charge nurses’ role to manage conflict situation by intervening in a mediating role with the staff. It is helpful for the nurse manager/charge nurse to have some knowledge of the characteristics of conflict situations and techniques to manage those situations. There are conflicts that need to be resolved and can only be resolved by the charge nurse. Typically these are disagreements about resources, assignments, and scheduling. These are legitimate charge nurse concerns and sources of power; decisions about these things are not to be delegated. The charge nurse must listen to all viewpoints, spend a reasonable period of time taking all suggestions under advisement and let the staff know of the decision. Overlapping assignments, duplication of efforts and inadequate staffing are charge nurse errors that need to be corrected quickly to eliminate confusion and conflict among staff.

CONFLICT

Conflict is neutral but the results of conflict can be constructive or destructive. Poorly managed conflict can create distance and distrust among workers and lead to lowered productivity. Well-managed conflict can stimulate competition, identify legitimate differences within organizations and serve as a powerful motivator. Conflict is inherent in the change process that is necessary for progress. It can serve as a stimulus in developing new facts or solutions when there is disagreement about the choice of a solution to a problem; a novel alternative solution is often discovered.

Conflict can be functional or dysfunctional. Functional conflict can be construction in the problem solving process when an open discussion of the problem surfaces and common goals are identified.Dysfunctional conflict continues to escalate stress levels and closes down communication, resulting in lose/lose results or destructive win/lose mentality. Conflict exists when two or more mutually exclusive ideas, attitudes, feelings or actions occur:

  1. Within an individual (intra-personal)
  2. Between two or more individuals (interpersonal)
  3. Within one group (intra-group)
  4. Between two or more groups (inter-group)

There are 3 attitudinal mindsets that people can have about conflict within a group.

  • Conflict is inevitable and agreement is impossible.
  • Conflict is not inevitable but agreement is impossible.
  • Conflict agreement is possible

Conflicts relate to feelings, including feelings of neglect; of being viewed as taken for granted; of being treated as a servant; of not being appreciated; of being ignored; and not being treated as worthy. The individuals’ feelings build into anger to the point of rage. This results in overt behavior like brooding, arguing or fighting. The individual can let feelings and behavior get in the way of work. Productivity declines, sometimes purposefully, and mistakes are made. Among the tools of successful charge nurses, the charge nurse must have awareness of the causes of conflict and the feelings of the staff to address conflict in a timely manner.

There are conflicts that need to be resolved and can be resolved best by the charge nurse. Typically these include disagreements about assignments and scheduling. These conflicts need to be resolved in a manner that protects the privacy of the individuals involved. For example it is seldom wise to publicize and openly deal with disagreements over personal issues (verbal attacks or boisterous laughter on night shift) or disagreements that involve disruptive individuals. The charge nurse may be able to manage disagreements with each individual separately.

CHARACTERISTICS OF CONFLICT

Conflict cannot be prevented and should be expected. It is the leader’s role to manage conflict by intervening in a mediating role. It is helpful to have some knowledge of the characteristics of conflict situations. Conflict situations can be characterized as being humanizing or dehumanizing.

Humanizing

When disagreement and conflict are handled in a humanizing way the effect upon the group interpersonal climate tends to be constructive. There will be a tendency for wiser decisions to be made, decisions that are better than any one member could make alone. The effect of a humanizing approach is to promote personal and professional growth as well as an increase in motivation and commitment because of the high involvement interpersonally in analyzing and selecting the best possible resolution to the issue.

The problem solving discussions of issues broaden group members understanding of the nature of the issue and its implications. The members have an opportunity to share and clarify their values with one another. This humanistic approach also allows more alternatives to be identified from which the best possible solution can be selected.

In a humanizing approach, leaders and followers believe and behave in the following manner:

  • Everyone recognizes that it is normal for differences to occur and to expect conflict; they understand that conflict is necessary for effective problem solving; everyone learns to disagree in a productive manner.
  • Everyone needs to hear the different views, give fair consideration and critically evaluate each view, and reach a consensus after a full discussion of the issue.
  • Everyone supports the maintenance of an open climate of communications so that ideas can be expressed without punishment or embarrassment.

Dehumanizing

Conflict situations can also be approached in a dehumanizing manner. When disagreements and conflicts are approached in a dehumanizing manner, the effect tends to be disruptive to the group’s productivity as well as interpersonal climate.

Since the group’s energy is consumed by the disruptive and dehumanizing behavior and attitudes, the total effect is to impede progress toward the task. In addition, individual members tend to feel threatened, narrow their perceptual process, and increase their defensive behaviors.

In a dehumanizing approach, leaders and followers believe and behave in the following manner:

  • People do not believe disagreements or conflicts can be constructive, but are either win or lose situations.
  • The interpersonal climate is closed, competitive and unfriendly.
  • The group lacks a sense of direction, unity and commitments to a common good.
  • The members frequently and habitually display disruptive behavior.
  • Members tend to become frozen to their own viewpoints and to common good. They do not listen to one another due to a lack of credibility.
  • Discussions frequently and quickly move from issue to personal attacks as viewpoints polarize.
  • Once a solution or decision has been reached the members have little satisfaction about the outcome and tend to feel interpersonally cold and distant about one another.

TYPES OF CONFLICT

COMPETITIVE CONFLICT – follows basic rules and is not typically associated with anger and hostility. Victory is defined as a victory for one side and a loss for the other side. The process by which the conflict is resolved is determined by a set of rules. The goals of each side are mutually incompatible but the emphasis is winning, not the defeat or reduction of the opponent. When one side has clearly ‘won” the competition is terminated.

DISRUPTIVE CONFLICT – does not follow any mutually acceptable set of rules and does not emphasize winning. The parties involved are engaged in activity to reduce, defeat or eliminate the opponent. This type of conflict takes place in an environment charged with fear, anger and stress.

CAUSES OF CONFLICT

Defiant Behavior can create conflict. It produces guilt feelings in the person to whom it is directed. The charge nurses should take the position that the person expressing defiance is responsible for the conflict. Defiance is a threat to rational dialogue; it violates the acceptable protocols for adult interaction. The defiant person challenges the authority of the charge nurse through obstinate and intransigent behavior. This behavior may be both verbal and non verbal.

There are 3 versions of defiance:

  • Competitive bomber – simply refuses to work
    • Can be an aggressive underminer who plans deliberate assaults
    • Comment about unfair and terrible working conditions, manipulation and lousy schedules
    • Wants to provoke the charge nurse. If they do elicit a response they sulk and pout to win the pity of peers.
  • Martyred accommodator – uses malicious obedience.
    • They work and cooperate but do so mockingly and contemptuously.
    • They complain and criticize to enlist the support of others.
  • Avoider – avoids commitment and participation
    • Does not respond to the charge nurse when conditions change they avoid participating

Defiant Behavior

Defiant Behavior can create conflict. It produces guilt feelings in the person to whom it is directed. The charge nurses should take the position that the person expressing defiance is responsible for the conflict. Defiance is a threat to rational dialogue; it violates the acceptable protocols for adult interaction. The defiant person challenges the authority of the charge nurse through obstinate and intransigent behavior. This behavior may be both verbal and non verbal.

There are 3 versions of defiance:

  • Competitive bomber – simply refuses to work
    • Can be an aggressive underminer who plans deliberate assaults
    • Comment about unfair and terrible working conditions, manipulation and lousy schedules
    • Wants to provoke the charge nurse. If they do elicit a response they sulk and pout to win the pity of peers.
  • Martyred accommodator – uses malicious obedience.
    • They work and cooperate but do so mockingly and contemptuously.
    • They complain and criticize to enlist the support of others.
  • Avoider – avoids commitment and participation
    • Does not respond to the charge nurse when conditions change they avoid participating

Stress

Conflict leads to stress, fear, anxiety and disruption in professional relationships. These conditions can, in turn, increase the potential for conflict.

Common stressors include:

  • Having too little responsibility
  • Lack of participation in decision making
  • Lack of managerial support
  • Having to keep up with increasing standards of performance
  • Coping with rapid technological change.

Burnout is a result of stress. Confrontation, disagreements and anger are evidence of stress and conflict. Stress and conflict are caused by poorly expressed relationships among people, including unfulfilled expectations.

Stress in patients leads to iatrogenic ailments, complications and delayed recovery. It may be created by depression and anxiety. Stressed staff cannot deal with stressed patients and this leads to inefficiency, job dissatisfaction and insensitive care.

Ultimately the staff is provoked into conflict. They too can develop iatrogenic ailments just like their patients. Families of patients can add to stress if they are not managed appropriately. Increased stress for patients and staff decreases effective use of time. Such problems increase patient care costs, as they increase the length of illness and decrease nursing efficiency and effectiveness.

Space

When nurses have to work in crowded spaces, they must interact constantly with other staff members, visitors and physicians. This is particularly true of crowded critical care units. A crowded workspace is annoying, noisey and interruptions are more frequent. Such conditions cause stress that can lead to burnout and turnover.

Workflow

Conflicts about how and when work is passed from one person or place to another are common in healthcare. Workflow conflict can arise between staff members, between shifts, between nursing units and between a nursing unit and another department.

For example, Emergency Departments and Intensive Care Units frequently have conflicts related to workflow. Conflict can result when one unit looks at the other, wondering who is doing more work. Feeling that they are working harder or are more stressed than the other unit develops into an "us vs. them" mentality, in which someone has to lose. Usually both units are without adequate resources to meet the consistently high level of stress with a steady influx of patients.

Physician Authority

Physicians are trained to be in authority over nurses. Today’s nurses want to be more independent, to have professional responsibility and accountability for patient care. They spend more time with patients than physicians do and often have valid proposals for altering therapeutic measures. Physicians sometimes ignore their suggestions, indicating they do not want feedback. Nurses become angry as their self-worth diminishes. Communication fails, particularly two-way communications.

Beliefs-Values-Goals

Incompatible perceptions or activities create conflict. This is evident when nurses hold beliefs, values and goals different from those of nurse managers, physicians, patients, visitors, families, administrators and so on. Nurses’ values may boil over into conflicts related to ethical issues that include “do not resuscitate” orders, callous statements that belittle human worth, abortion, abuse, AIDS, and other problems.

Personal goals frequently conflict with organizational goals, particularly with regard to staffing, scheduling and the climate within which nurse’s work. Nurses who have to violate their personal standards will lash out at the system. This is demeaning to them and causes loss of self-esteem and emotional stress.

Staff must know that they are valued, their beliefs, values and personal goals are respected. Like other people, nurses act to protect their personal or public images when confronted or invaded. They respond in terms of other peoples’ expectations of them, as they want approval. They will defend their rights and their professional judgments.

The ego is easily bruised and becomes a big problem in conflict. Defense becomes more heated when one or both parties to the conflict are uninformed or manipulated. When nurses are not recognized or respected they feel helpless and they feel hopeless when they are unable to control the situation.

Other Causes

Change creates conflict that in turn impedes change. People who are not prepared for change will fight it or fail to support it. They feel threatened.

Organizational climate and leadership style can create conflict if different managers set conflicting rules. Disciplinary problems can result from inadequate orientation, training and poor communication.

Problems outside of work can affect work performance, leading to disciplinary problems and conflict. These include marital discord, drug use, alcoholism, mental stress and financial problems.

Age can create stress and conflict. As employees age, they resent increased scrutiny of their work. Clinical nurses cannot keep up with physical demands of their work, as they grow older. They become fearful of being able to compete with younger nurses and build up resentment that can lead to conflict.

Persistent racial prejudice and discrimination are also an important source of workplace conflict. People, who have been discriminated against, such as racial minorities, may harbor resentment against real or imagined slights. They May respond with confrontation, defensiveness, anger and other conflict-producing behaviors.

APPROACHES TO CONFLICT MANAGEMENT

Typical ineffective responses to conflict are strategies that attempt to deny or negate the conflict and thus avoid dealing with it. Nurses have been particularly adept at these strategies, probably because of their heritage in a profession with an emphasis on obedience and submissiveness.

Confrontation has been discouraged for nurses by society’s traditional mores. In fact, the image of a congenial person is a person who is compatible and agreeable, not confrontational. While some approaches to dealing with conflict are ineffective in resolving conflict, they may be useful in given situations.

Strategies to approach conflict include:

  • Withdrawing removes at lease one party, thereby making it impossible to resolve the situation. The issue remains unsolved and feelings about the issue may resurface inappropriately.
  • Soothing – is accomplished by complimenting one’s opponent, downplaying the differences, and focusing on minor areas of agreement as if little disagreement exists. Soothing may be appropriate in dealing with minor problems but produces the same results as withdrawing in response to major problems
  • Avoidingis similar to withdrawal, except the participants never even acknowledge that a conflict exists. Avoidance also exists in a group where members’ similarity is encouraged and differences discouraged. As a result the group becomes complacent and passive. The positive motivation of conflict is lost.
  • Forcing – is a method that yields an immediate end to the conflict but leaves the cause of the conflict unresolved. A superior can resort to issuing orders but the subordinate will lack commitment to the demanded action. Forcing may be appropriate in life or death situations but is otherwise inappropriate.
  • Competing – is an all-out effort to win, regardless of the cost. Competing, like forcing may be needed to prevail in situations involving unpopular or critical decisions.
  • Negotiation – involves give-and-take on various issues among the parties. It is used in situations in which consensus will never be reached. Negotiation often becomes a structured, formal procedure as in collective bargaining.
  • Collaboration – implies a mutual attention to the problem that utilizes the talents of all parties. In collaboration, the focus is on solving the problem, not defeating the opponent; the goal is to satisfy both parties’ concerns. It is useful in situations where the goals of both parties are too important to be compromised.
  • Compromise is used to divide the rewards between both parties. Neither gets what he or she wants. Compromise can serve as a backup to resolve conflict when collaboration is ineffective. It is sometimes the only choice when opponents of equal power are in conflict over two or more mutually exclusive goals. Compromising is also expedient when a solution is needed rapidly.

DISCIPLINE

In using discipline to manage or prevent conflict the charge nurse must know and understand the organization’s rules and regulations. If they are not clear the charge nurse should seek help to clarify them. Discipline is the last resort in correcting undesirable employee behavior. Rules and regulations must be reasonable and work related. Rules that are unreasonable or reflect personal biases invoke infractions.

Guidelines for disciplinary action:

  • Discipline should be progressive.
  • Punishment should fit the offense, be reasonable, and increase in severity for violations of the same rule.
  • Assistance should be offered to resolve on the job problems.
  • Tack should be used in administering discipline.
  • The best approach for each employee should be determined.
  • Charge nurse needs to be consistent and not show favoritism.
  • The individual should be confronted and not the group – disciplining a group for a member’s violation of rules and regulations makes them angry and defensive increasing conflict.
  • Discipline should be clear and specific.
  • Firmly stick to the decision.
  • Discipline produces varied reactions. If emotions are running too high, a second meeting should be scheduled.
  • The charge nurse performing the discipline should consult with her supervisor. One should expect to be overruled sometimes. Knowing the boundaries of authority will help the charge nurse to avoid being overruled.
  • A charge nurse should build respect, trust and confidence in her ability to handle discipline.

CONSIDERING LIFE STAGES

Most organizations will employee nurses at all life stages. Conflict can be managed by supporting individual nurses in achieving goals that pertain to their life stage:

  • Young Adult – establishing a career. People at this stage pursue knowledge, skills and upward mobility. Conflict can be prevented or managed by facilitating career advancement.
  • Middle Age – during which the nurse becomes reconciled with achievement of life’s goal. This nurse helps to develop careers of younger nurses.
  • After age 55 – adults integrate their own ego ideals with their accomplishments. At this stage the nurse is thinking in terms of completing her work and retiring.

COMMUNICATION

Communication is an art essential to maintaining a therapeutic environment. It is necessary to accomplish work and resolve social and emotional issues. Charge nurses prevent conflict with effective communication and should make it a way of life.

Active listening is essential to managing conflict and goes hand-in-hand with effective communication. The charge nurse should validate her perceptions by paraphrasing what the angry or defiant employee is saying. Paraphrasing clarifies the message for both. It can help to cool off the situation as it gives the employee time and opportunity to hear the charge nurses’ perceptions of the emotions expressed.

MEDIATION

In mediating disagreements and conflicts among staff it is appropriate for the charge nurse to bring clashing groups together. The charge nurse has certain responsibilities when mediating conflict:

  • Determine whether one or both groups want to find a mutually satisfactory solution, if not, there is no point in attempting to mediate and negotiate.
  • Choose a time and place for opposing parties to meet and serve as discussion leader or referee.
  • Because certain people (low-status minorities) tend to speak less frequently and defer to others (high-status ethnic groups) provide opportunities for everyone to speak.
  • Redirect conversation as necessary to keep comments focused on the topic or theme. Keep the group moving forward toward their goal.
  • Restate arguments or positions of each party to one another. This requires that each listen to each other. Each side needs to be encouraged to give feedback to the other.
  • Respect the dignity of each participant and require the same of all involved.

Before coming together for mediation, everyone in the groups needs to agree on the following:

  1. To get together to work on problems.
  2. That there are problems that can be solved.
  3. That all individuals have some responsibility for working toward solving the problems.
  4. That they are not expected to like one another at the conclusion but to understand one another better and be able to work together.
  5. That they are not expected to place blame on someone for the problem, but are expected to consider differences and come to a consensus about solutions.

OUTCOMES

There are three basic strategies for dealing with conflict according to the outcome: win-lose, lose-lose and win-win.

In a win-lose outcome one party exerts dominance usually by power of authority and the other party submits and loses. Majority rule is an example of the win-lose outcome. It may be a satisfactory method of resolving conflict if various factions vote differently on different issues and the group functions over time so that members win some and lose some. Another example of the win-lose method is railroading. Railroading occurs when a minority rules the majority. This can happen with an apathetic or passive majority or when the minority intimidates the majority and the latter acquiesce.

In a lose-lose outcome, neither side wins. The settlement reached is unsatisfactory to both sides. One strategy involves using bribes to influence another’s cooperation into doing something he dislikes. For example the manager may promise a future raise in an attempt to coerce a staff member to work an extra weekend. Using a third party as arbitrator is another strategy that usually has a lose-lose outcome. Since an outsider may want to give something to each side, neither gets what is desired. This is common in arbitration of labor management disputes.

Win-win outcomes are achieved by focusing on goals and attempting to meet the needs of both parties. The two strategies used in win-win methods are consensus and integrative decision-making. Consensus involves attention to the facts and to the position of the other. It avoids trading, voting or averaging. The consensus decision is often superior to even the best individual decision.

Integrative decision making methods focus on the means to a problem solution rather than the end of the solution. It is most useful when the needs of both parties are polarized. Using integrative decision-making methods, both parties jointly identify the value needs of each; conduct an exhaustive search for alternatives that could meet these needs; and then select the best alternative. Like the consensus methods, integrative decision-making focuses on defeating the problem, not each other. Integrative problem solving is a constructive process, which emphasizes that the parties jointly identify their needs. The focus of the group is to solve the problem. Not a focus of domination, suppression, or compromise behaviors.

In a conflict situation, the opposing factions have differing expectations. If the nursing staff is able to openly discuss their own expectations and carefully listen and understand the other’s expectations, then the staff may be able to change their shared expectations and become committed to common goals. This is part of the process of negotiating positive outcomes.

The management of conflict has not always been a complicated process. One of the oldest forms of conflict management is suppression or elimination of the opponent. David used this method in his conflict with Goliath. While there are a number of approaches to conflict management, there are only a limited number of situations where suppression or termination is warranted.

The opposite of suppression is a form of conflict resolution that stresses harmony or a “don’t rock the boat” attitude. One party is dominated by the other without resistance. The task for the charge nurse is to find the appropriate method to handle the conflict for each particular situation.

 

AFTERMATH

The aftermath of a conflict has implications for future relationships among the people involved. If the outcome is a defeat for one group or a concession of some sort, the resulting attitudes are about the same. One group will perceive themselves as winners, the other as losers. If people feel they are losers, then they will probably feel cool and alienated interpersonally toward the winners and expect to win next time. They will be less cooperative, less trustful and quick to negatively distort what is said to them. This environment will lead to more conflicts.

The approach the charge nurse selects has been found to be related to the degree of assertive and cooperative behavior the nursing staff will displace in the aftermath period. Both parties need to believe that they are winners and have been dealt with fairly. The solution needs to be an integration of the needs, expectation, values and perceptions of both parties. Integrated solutions are necessary to maintain an integrative group of nurses.

CONFLICT RESOLUTION MODEL

 

 

 
  1. Conflict
  2. Group Interaction
  3. Identify problem (values, purposes, and goals)
  4. Encourage free exchange of ideas, feelings,
  5. attitudes and values in an atmosphere of trust
  6. Search for alternative ways to resolve problems
  7. Ask for help from outside sources as needed
  8. Set up means for evaluation of solutions
  9. Keep interacting until all members want the solution
  10. Resolution

 

While each conflict will vary, there are some common themes that tend to occur, as the conflict is resolved. As a mediator in the resolution process, it is helpful to be sensitive to the direction in which the opposing individuals need to move. After getting the individuals to agree to try to resolve their differences, it is necessary that values, purposes and goals be clarified and understood in addition to defining the issue or problem.

Development of an open climate and free exchange of feelings and facts will tend to move the group toward collaborative communication behaviors and problem solving. When appropriate, others may be drawn into the discussions as resource people or as consultants. The group must describe their hopes or goals. These descriptions become the criteria for evaluating the alternative solutions.

Only when everyone in the group is satisfied with decision or solution and feels good about it will conflict be resolve. This is a process that needs to be activated again and again with each issue that arises. Consistent humanistic behaviors and attitudes on the part of the leader tend to have a positive and releasing effect on the followers and can increase the integrative processes with the group.

SUMMARY

Conflict can be a positive source of energy and creativity. It can be constructive when properly managed. Managed conflicts do not escalate.

Poorly managed conflict can become dysfunctional and destructive, drawing energy and reducing both personal and organization effectiveness. It can destroy initiative or creativity and cause hostile and disruptive behavior, loss of team spirit and loss of the desire to work toward common goals, resulting in deadlocks and stalemates.

The interrelationships among nurses and other personnel, patients and families offer much potential for conflict. For this reason the charge nurse should know how to manage conflict.

Causes of conflict include defiant behavior, stress, crowded space, physician authority and incompatibility of values and goals. Conflict can be prevented or managed by discipline, consideration of people’s life stages, communication, and active listening. Aims of conflict management include broadening understanding about problems, increasing alternative resolutions and achieving a workable consensus on decisions and genuine commitment to decisions made.

Specific strategies include avoidance, accommodation, compilation, compromise and collaboration. In addition charge nurses can learn and used specific skills to prevent and manage conflict. Conflict management keeps conflict from escalating, makes work productive and can make conflict a positive or constructive force.

REFERENCES

Hersey, Paul and Duldt, Bonnie Weaver, (1998) Situational Leadership in Nursing, Appleton and Lange, Norwalk, Connecticut.

Hersey, Paul and Blanchard, Kenneth H., (1998) Management of Organization Behavior Utilizing Human Resources 6th edition, Prentice Hall, Englewood Cliffs, New Jersey.

Nurse Week (2002) – Learning to Lead: From Staff Nurse to Charge Nurse – Conflict Management – Causes of Conflict.

Sullivan, Eleanor J., & Decker Phillip J., (1998) Effective Management in Nursing, Addison-Wesley Publishing Company, Menlo Park, CA.

Swansbury, Russell C., (2000) Introductory Management and Leadership for Clinical Nurses, Jones and Bartlett Publishers, Boston Mass.