Академический Документы
Профессиональный Документы
Культура Документы
Journal of Nursing
Conflict Resolution
Share on facebook54Share on twitter3Share on linkedin0Share on reddit1
More Sharing Services1.8K
by Antonie Hiemer MS RN
Responses to Conflict
Individuals respond in five distinct ways to conflict. These include avoidance, competition,
accommodation, compromise, and collaboration (Marshall, 2006). Avoidance is the most overused
technique as a conflict resolution method by nurses (Baker, 1995). It results in not addressing the
conflict (lose-lose situation). Competition results in pursuing ones own goals at the expense of
another (win-lose situation). This may be appropriate when a quick or unpopular decision has to be
made. Accommodation results in meeting the goals of the other person (lose-win situation). This may
be appropriate when the issue or goal is more important than winning, the other individual is more
powerful, or when an individual is wrong. Compromise combines assertiveness and cooperation
(lose-lose situation). This may be effective when individuals are of equal power and an expedient
answer is needed. A match between the action and the nature of the conflict will most likely result in
a resolution with desirable outcomes. Collaboration results in finding a mutual agreeable solution
(win-win situation) (Leddy & Pepper, 1998).
Collaboration
Collaboration is the most desirable approach in resolving a conflict. It is an assertive and cooperative
approach that allows individuals to be creative and find a solution that satisfies all concerns and
goals to be achieved (Baker, 1995; Leddy& Pepper, 1998; Kelly, 2006). Collaboration is viewed as
the opposite of avoidance and competition. The goal is for both parties to win. The problem-solving
process continues until each individual is satisfied with the resolution. Although this process is
growth producing, it takes a considerable amount of time (Leddy & Pepper, 1998).
Game theory
According to Team Technology (2005), based on the game theory (see responses to conflict
diagram), most people are trying to receive or achieve a payoff or benefit in a conflict situation. The
payoff is called a win, and not getting a payoff is called a loss. These can range from the individual
being able to gain a sense of achievement from completing a worthwhile and quality job or obtaining
financial reward, or making a profit for the company. Other wins include getting the job done as
quickly as possible in order to go somewhere, having a feeling of self-esteem or self-worth, and
being recognized for ones efforts (Team Technology, 2005).
Responses to conflict
I dont win
I win
You win
Submission
Acquiescence
Collaboration
Assertiveness
You dont win
Withdrawal
Blocking/Sabotage
Aggression
Dominance
Adapted from Conflict resolution in the workplace, by Team Technology, 1995, retrieved from
www.teamtechnolgy.co.uk/conflictresolution.html
Effective communication
Nurses can prevent or manage conflict by improving their communication skills. It is important for the
nurse to try to understand the other party. The nurse can then focus on being understood. Typically
in conversation an individual is already trying to think of a response to give to a person instead of
just listening to what is being said (Marshall, 2006). Effective communication occurs only when the
message received is interpreted in the way it was intended (Piotrowski, 2005). Individuals must
actively listen to each other and, maintain appropriate eye contact without looking down. The nurse
needs to be aware of body language and tone, thus avoiding a mismatch of styles (quiet vs.
boisterous personalities). The individual needs to ask for clarification by asking open-ended
questions and not assuming what is being said. Paraphrasing is a good technique to be sure you
have understand the message. Most importantly the nurse must listen, and not interrupt the other
individual, for good communication to occur.
as having locked everything on purpose, in retaliation for some unknown cause. By clarifying, and
asking open-ended questions nurse Betty was able to resolve the conflict between herself and nurse
Susie.
* names have been altered to protect the nurses identity
Conclusion
Nurses need to remember that the foundation of nursing care is the therapeutic nurse-patient
relationship, which contributes to the patients well-being and health. This therapeutic relationship is
threatened whenever there is conflict, either with the patient, the patients family, the patients
friends, or colleagues. It hinders communication, collaboration, and teamwork. Nurses need to
remember that they share the responsibility with their employers to create a healthy workplace
environment, ensuring that conflict does not negatively affect the patients health outcomes or the
relationships among colleagues (CNO, 2006). By becoming more accountable, nurses are able to
decrease, if not eliminate conflict in their organization by utilizing good communication skills and
assisting in facilitating conflict resolution between individuals.
References
Baker, K. M. (1995). Improving staff nurse conflict resolution skills. Nursing Economic$, 13(5), 295317.
College of Nurses of Ontario. (2006). Conflict prevention and standard of care. Practice guideline, 116.
Conerly, K. (2004, Summer). What is your conflict style? Understanding and dealing with your
conflict style. Journal for Quality and Participation. Retrieved on October 18, 2007 from
www.findarticles.com/p/articles/mi_qa3616/is_200407/ai_n9425833/print
Kelly, J. (2006). An overview of conflict. Dimensions of Critical Care Nursing, 25(1), 22-28.
Kemp-Longmore, C. (2000). Conflict resolution in the workplace. The Black Collegian, 131-3.
Lancaster, J. (1999). Nursing issues in leading and managing change. New York: Mosby.
Leddy, S., & Pepper, J. M. (1998). Conceptual base of professional nursing (4th ed.). New York:
Lippincott.
Marcus, L. J., & Roover, J. E. (n.d.). Healing the conflict that divide us. Retrieved on January 18,
2007, from www.hcna.net
Marshall, P. (2006, May). Conflict resolution: what nurses need to know. Retrieved October 18, 2007
from www.mediatecalm.ca/pdfs/what%20nurse%20need%20to%20know.pdf
Montoro-Rodriquez, J., & Small, J. A. (2006, June). The role of conflict resolution styles on nursing
staff morale, burnout, and job satisfaction in long-term care. Journal of Aging and Health, 18(3), 385406.
NYSNA (2005). NYSNA position statements. Retrieved on January 18, 2007, from www.nysna.org
Pettrey, L. (2003). Who let the dogs out? Managing conflict with courage and skill. Critical Care
Nurse, 21-4.
Piotrowski, M. B. (2005, January/February). Are you listening? Tips on improving your
communication skills. Biomedical Instrumentation & Technology, 1-2.
Robin, D. (2004). A better workplace. Retrieved on January 18, 2007, from
www.abetterworkplace.com
Shortell, S. M., & Kaluzny, A. D. (2006). Health care management organization design and behavior
(5th ed.). New York: Thompson Delmar Learning.
Staneart, D. (2001). Workplace conflict resolution and anger management skills. Retrieved on
January 18, 2007, from www.leaderinstitute.com
Team Technology (1995). Conflict resolution in the workplace. Retrieved on October 18, 2007, from
www.teamtechnolgy.co.uk/conflictresolution.html
Back to the Journal of Nursing
The dilemma that Nick is confronted with in the scenario above isnt uncommon. One of the
most significant challenges that nurses face in their work is the management of conflict. In
todays environment, nursing teams are composed of staff from different backgrounds with
divergent values, attitudes, and beliefs. These differences can and do lead to conflict. If not
managed well, conflict can become a patient-safety issue in healthcare environments.
Carefronting is an important competency for nurses that can help them to resolve conflict
and create healthier work environments.
Principles of carefronting
Betty Kupperschmidt, an associate professor of nursing at the University of Oklahoma
Health Sciences Center, has been a pioneer in bringing the concept of carefronting to
nursing practice. In her work, she describes seven basic tenets of carefronting. We will use
Nicks situation in his conflict with Michelle to provide an illustration of how these tenets can
be applied in the practice setting.
Nick undoubtedly feels some anger toward Michelle for her unwillingness to accept him in
the leadership role. Michelle may feel angry about Nicks selection for the position and lack
of experience. Anger is a natural part of conflict. When acknowledged in a constructive way,
it can be a positive and self-affirming emotion. When one feels ignored or rejected, the
normal response is anger. Nick would want to let Michelle know that the situation has been
upsetting to him. Letting Michelle know this will make her more aware that Nick is a person
of worth and should be respected. Nick and Michelle both have to accept responsibility for
choosing how they have responded and reacted to one another during the conflict.
3. Inviting changeCareful confrontation
A key principle in carefronting is that those in the conflict are invited to participate in
changing the situational dynamic. Nick would invite Michelle to participate in changes that
could improve their relationship but he would not demand it. When leaders like Nick invite
change, they need to focus on the behaviors that they would like to see changed. This
should be presented based on observations, not conclusions. Nick needs to be specific in
his descriptions so they dont appear judgmental. Ideas for change should be presented for
discussion in a way that encourages the discussion of alternatives. Nick would want to
avoid statements such as, You need to improve your attitude. Change should be invited by
carefronting in a caring manner, one that is clear but gentle and constructive.
4. Giving trustA two-way venture
Trust is the foundation of effective relationships. High trust environments correlate positively
with high degrees of staff engagement, commitment, and organizational success. Trust is
essential in work relationships but can quickly erode in conflict situations. As a leader, Nick
needs to learn to confront situations openly, frankly, and responsibly. He should approach
this and other conflicts with the viewpoint that the other person will assume his or her
responsibility to be equally honest and frank. Although he may not feel a great deal of trust
in Michelle at this point, he will need to work hard to build a trusting relationship.
5. Ending blameForget whose fault the conflict is
Who will end the blame and help work toward the professional practice environment
we all deserve?
Getting unstuck means owning the responsibility for ones role in the conflict. It also involves
refusing to waste time assigning blame. Nick and Michelle have worked with each other for
3 years. Their conflict has a long and rocky history. The freedom for both of them to change
will only come if they are able to get unstuck from past behaviors and feelings. A release
from this toxic situation, and all of the negative feelings involved, could be quite liberating
for Nick and Michelle.
7. PeacemakingGetting together again
Nurse leaders who are peacemakers are caring people who take the risk to be present in
conflict no matter how difficult. This wont be an easy role for Nick to assume but its
important that he works to be a peacemaker in this conflict. To do this, he will need to value
Michelle and at the same time understand his own values. Conflict usually involves some
compromise. There are always multiple viewpoints in every conflict that need to be
appreciated.
We're afraid confronting them will make the situation worsethat it will
become an angry or tearful discussion.
We're concerned that we're not so clean ourselves. Because we have our own
faults, we fear the other party will attack us and switch the topic to our own
failingsWho are you to raise this with me?
We fear retribution in some wayIf I confront this the powers that be will
come down on me.
As discussed here, conflict is not simply disagreement, which can be a healthy and effective
characteristic of work groups. Disagreeingthe expression of differing opinions in open
discussionis not laden with negative emotions like those that accompany conflict. Indeed,
honest disagreement is often intellectually stimulating, and in effective work groups it is
encouraged.
Conflict, in contrast, is associated with negative emotions such as resentment, anger, impatience,
and bitterness. You may feel a conflict over a situation without expressing disagreement, and, in
fact, the other person may not even be aware of the conflict. Once you recognize that you have
an emotionally negative feeling about a situation, the road to resolving it is confronting the other
person, and that's the challenge.
Wachs notes, My clients always refer to the work I do as conflict resolution.' But I like to think
of it as knowing how to have discussions about difficult issues. This is easy to say, but how do
you do it?
Go to:
At the weekly tumor board held at a community hospital, one particular pathologist is
chronically ill prepared. He's been there a long time and is basically not doing his job. He is
supposed to familiarize himself with the cases beforehand, but makes no effort whatsoever. He's
not helpful to the basic goals of a workable conference. When guest speakers attend, it's
embarrassing and affects our current initiative to develop an ongoing relationship with regional
specialists.
In confronting this issue, Susan has completed the first stepassessing the situation. These are
the subsequent steps Wachs advises to deal with this conflict:
1. Susan should make an appointment to meet privately with the pathologist. In
this face-to-face meeting, she should look him in the eye and say, I need to
talk with you about a difficult issue. Then she should pause briefly.
Wachs points out that these initial words are important. She is not saying
she wants to chat' with him; she is not saying he is a difficult person, or
suggesting that he is slacking off because he is near retirement; she is not
saying she is angry. She is simply saying she needs to talk with him about a
difficult issue.
2. After this initial statement, Susan should say what she sees. This step
includes stating in a factual way what she has observed. For example, You
come to the tumor board without having reviewed the specimens, and you
have been unprepared to discuss the cases. This is hurting our ability to
network with outside experts. Susan should again pause briefly after this
statement. Wachs notes that it's important to be forthright in describing both
the behavior and the impact of the behavior. Don't be judgmental or offer an
opinion about why he didn't come prepared. State your observations but do
assign motivations to the behavior you have observed.
3. The next step is for Susan to acknowledge her role in the situation or her
reservations about the topic. For example, I didn't bring this up before
because I thought the situation would change, or I held back from speaking
to you sooner because I was new to the hospital.
4. An optional step at this point is for Susan to state the good intentions of the
pathologist. For example, she might say, I know you want to contribute to
the reputation of the hospital within the region, or You are known for your
contributions to good patient care. If, however, Susan's honest view is that
the pathologist really doesn't care, or she can't make a positive statement in
good faith, she should skip this step.
5. Next, Susan should ask the pathologist for his thoughts. How do you see it?
or Do you see the situation differently? Wachs stresses that at this point it's
essential to be genuinely prepared to listen and understand the other's point
of view. She must not debate or argue, but hear his side fully, without
interrupting him. She must listen deeply and curiously, abandoning control
about how she sees it. He may be angry with her for bringing it up. He may
say he hasn't been well. He may say he's withdrawn because he's tired of
dealing with a bunch of incompetents. Susan doesn't know what he will say
and must not try to control it. Her job is to hear his emotions and his passions
as well as the content.
6. After the pathologist has stated his perspective, Susan should summarize
what she has heard and compare their two views of his behavior at the
cancer conferences.
7. Finally, Susan should ask the pathologist what it would take for him to
participate more fully at the tumor board. She should explore with him what
needs to change or what he needs in order to come to the meeting prepared.
Susan should work with him to create solutions that will address his needs
and her concerns.
The skills for confronting difficult situations like this can be learned, Wachs states.
Harvey Bichkoff, MPH, CEO of California Cancer Care, a 10-physician group in Northern
California, agrees. Bichkoff's group worked with Wachs in 2007 to develop conflict resolution
skills at the group's annual retreat. We learned a set of skills to deal with conflict, he says. On
the second day, after role playing and practice, we participated in a very constructive exercise of
confronting one another.
Bichkoff, who has been with California Cancer Care for 13 years, encourages those who report
to him to work out conflicts directly with each other. They're the ones who are going to have the
working relationship. The group's retreat on conflict resolution reinforced that approach, he
says. The take-home message is that confronting conflict is healthy. Dealing with it makes for
better relationships in the long run.
Go to:
Define your mediator role as one of supporting winning for both parties. A key to success is for
each individual to change from thinking of the other as an adversary to considering him or her a
partner in reaching a solution. When both people win, both are committed to the solution because
it actually suits them.
Model Good Conflict Management Behaviors
Remain neutral and be an active listener. Focus your full attention on the individual speaking.
Don't allow distractions or interruptions. Show that you are taking the situation seriously and are
committed to the problem-solving process.
Create a Constructive Foundation
Create an environment in which people feel safe to open up. Use caring language. Actively
discourage judgments about who is right and who is wrong. If necessary, set ground rules that
prohibit behavior such as put-downs, blaming, threats, bringing up the past, or getting even.
Let Your Communication Skills Help the Process
Slow down the conversation when needed. Keep your voice low and modulated, and use a
relaxed body language. For instance, folding your arms can be off-putting.
Define the Issue in Neutral Terms
Take personalities out of the definition of the problem. For example, state the problem in
objective terms, such as determining an equitable holiday call schedule rather than deciding if
Brent or Marsha should have a 3-day holiday. Be prepared to revise the statement of the issue as
your understanding of the conflict evolves. Be objective and resist advising. Your role is to steer
the process, not the content.
Help the Parties Communicate Clearly
Use open-ended questions such as By difficult you mean and Help me to understand what
you mean by . Be aware of nonverbal cues and point out the triggers that are escalating
emotion or being used to avoid discussing the issue. For example, if someone points a finger or
rolls his or her eyes, calmly mention this behavior and explain that such body language is
counterproductive.
Identify Underlying Needs
Invite both parties to state their impression of the problem at hand. Find out what matters to
them. Ask thoughtful questions about what they want and what is important to them. Focus on
the why, not the what. An individual's position is usually based on a deeper interest or need,
so listen carefully to explore the hidden or underlying assumptions of each party. The better you
understand why something matters to individuals, the better you will be able to explore options
that will satisfy their real interests.
Probe Feelings
If they do not express their feelings, solicit the information: How did that affect you? or How
did you feel about that? Assess nonverbal cues as well as what is actually articulated.
Collect Information
In addition to finding out about the individuals' needs and concerns, obtain background
information. Be sure the facts are all out in the open. Ask questions about details that haven't
been expressed: How much will it cost? What happens when the informed consent is not
signed? How often does this happen? If someone makes a general statement such as I
thought it was out of line, ask for specifics about to what aspects he or she objects.
Check Understanding
Paraphrase what you hear the parties saying, and at various points ask each to state what he or
she heard the other one say. Sometimes individuals are surprised when they hear their
perspective articulated by someone else.
Engage Them in Problem Solving
Invite the parties to suggest ways to reach agreement. Ask them to list their choices and the
consequences of each.
Add Objectivity
Focus on the issue, not on personalities. Reinterpret an attack on a person to focus it on the issue.
This will help individuals not to be defensive. Where possible, turn to outside sources for
guidance or data. Using objective resources can also sometimes make it possible for individuals
to back down without feeling humiliated, by justifying a change in their opinion or their position
because of new information.
Reach Consensus
Identify the solutions that seem to have the greatest potential to address the interests of all
parties. Lay out the solutions for discussion, watching for cues from all parties about which
options are most appealing. The parties must believe the agreement is fair and recognize that
they have gained something.
Go to:
Using I messages takes practiceit's a skill that has to be learned. Use of I statements
doesn't come naturally, because we aren't used to talking about our feelings. In addition, it's a
normal response to see a conflict as the fault of the other person. Thus, expressing the problem in
terms of a you message just feels more natural, because it's more consistent
with our perspective about the problem.
But it's worth the effort to change our language. Using I messages not only diminishes the
negative responses of the other person, it helps reframe the way we think about the conflict
ourselves, thereby increasing the likelihood that a resolution can be found.
More Strategies for Career Success!
Deciding About Practice OptionsJuly 2006, page 187
The Interview: Make It Work for YouSeptember 2006, page 152
Employment Contracts: What to Look forNovember 2006, page 308
Joining a Practice As a ShareholderJanuary 2007, page 41
Principles and Tactics of NegotiationMarch 2007, page 102
Professional Advisors: They're Worth ItMay 2007, page 162
Building and Maintaining a Referral BaseJuly 2007, page 227
Malpractice Insurance: What You Need to KnowSeptember 2007, page 274
Develop Effective Communication SkillsNovember 2007, page 314
Go to:
Additional Resources
1. Wachs Stanley R.: Wachs Associates (www.wachs.com): wachs@wachs.com
2. Weeks D: The Eight Essential Steps to Conflict Resolution: Preserving
Relationships at Work, at Home, and in the Community. New York, NY,
Tarcher/Putnam, 1994
Source: http://www.nursingcenter.com/journalarticle?
Article_ID=593915
NursingCenter
AACN Advanced Critical Care
June 2004, Volume :15 Number 2, page 182- 195
Join NursingCenterto get uninterrupted access to this Article
Keywords
conflict, healthy work environments, mediation, working relationships
Authors
Abstract
Healthcare organizations must find ways for managing conflict and developing effective working
relationships to create healthy work environments. The effects of unresolved conflict on clinical
outcomes, staff retention, and the financial health of the organization lead to many unnecessary
costs that divert resources from clinical care. The complexity of delivering critical care services
makes conflict resolution difficult. Developing collaborative working relationships helps to manage
conflict in complex environments. Working relationships are based on the ability to deal with
differences. Dealing with differences requires skill development and techniques for balancing
interests and communicating effectively. Techniques used by mediators are effective for resolving
disputes and developing working relationships. With practice, these techniques are easily
transferable to the clinical setting. Listening for understanding, reframing, elevating the definition of
the problem, and forming clear agreements can foster working relationships, decrease the level of
conflict, and create healthy work environments that benefit patients and professionals.
Article Content
As care of critically ill patients has advanced over the past few decades, there has been a
tremendous evolution in the development of technology, advances in less invasive therapies,
miraculous drugs for fighting infections and enabling organ transplantation, and an increased
knowledge of physiology and genetics. The growth in the scientific aspects of care has enabled
patients to receive treatment with fewer complications and better outcomes. The dramatic advances
have changed the system of care delivery and will continue to expand the options for critically ill and
injured patients. Unfortunately, healthcare organizations have not evolved as quickly as clinical
advances, and the environment of care has evolved into a difficult and complex setting filled with
poor communication, unclear policies, role confusion, turf battles, and stressful interpersonal
conflicts. 1
Creating a healthy work environment is as important, and perhaps more important, as mastering the
newest technology. The challenge of how to develop solid working relationships in a complex and
hectic clinical setting is the next step in the evolution of healthcare delivery. To address this
challenge, it is beneficial to understand the costs of conflict, the effects of organizational complexity,
the barriers to managing conflict, and techniques for effective resolution of disputes. Integrating
collaborative conflict management strategies into the daily activities of clinical care can improve
patient outcomes, improve retention of nursing staff, and create an environment that optimizes
scientific advances through enhancement of effective working relationships. 2 Incorporating the skills
and techniques used by mediators can facilitate collaborative working relationships and create
healthy work environments. This article provides an overview of factors impacting management of
clinical conflicts and an introduction to techniques used by mediators to resolve conflicts, foster
collaboration, and prevent dispute escalation.
Organizational Complexity
Assessing the complexity of the clinical environment can help to focus the way in which conflict is
managed. Throughout each day, patient care relies on a complex series of interactions to coordinate
scheduling, resources, information, and people. Within complex systems, it is common for patterns to
form. What may appear from the outside to be chaotic, is actually a patterned network of loose
linkages between multiple components of the system. 21 These patterns are familiar to those who
work within these complex environments.
The basic routine in an intensive care unit (ICU) is quite similar from hospital to hospital. There are
parallels in how clinical orders are written and transcribed, how medications are obtained, how
treatments are scheduled, and how procedures are conducted. An experienced traveling nurse or
float nurse can learn what he or she needs to know to care for patients with just a few minutes of
orientation as to location of medications, use of phones, and access to physicians and supplies.
Additionally, communication flow and behavioral norms exhibit patterns that become familiar over
time and constitute the culture of the organization. 22 These patterns are learned through
experience, observation, and sharing of information from person to person. Most nurses can
navigate the clinical environment by asking questions and learning from others. The reliance on
information sharing and relationships with coworkers allows clinicians to make sense of the
environment and do the work of caring for patients. Making sense of a chaotic environment is a basic
skill for those working within complex systems. 21 Fostering collaborative relationships is the key to
ensuring success for professionals working within complex environments and serves as a foundation
for dealing with differences when they arise.21,23
The complexity of delivering critical care makes conflict management difficult and often the
complexity prevents resolution of underlying causes of conflict. 24 Quick fixes have become a
common mode of problem solving as staff and managers feel overwhelmed by what it takes to
achieve true issue resolution. Frequently, problems arise that become a tangled web of related
issues that make it routinely difficult to develop sound comprehensive solutions that can be
implemented throughout the unit or organization. For example, examining the repeated difficulty of
obtaining a particular medication can result in discovery of related issues such as a shortage of
pharmacy technicians, Drug Enforcement Agency or other regulatory restrictions, policy changes,
vendor back-orders, or outdated medication profiles. These issues are not easily addressed and with
typical management structures are definitely not within the realm of control of the staff nurse or staff
pharmacist who is attempting to collaborate to meet the patients' needs. This cascade of complex
problems can result in poor working relationships between the nursing unit and the pharmacy, which
can lead to unresolved conflicts that resurface repeatedly and cause burn-out, frustration, apathy,
and disengagement. 25 The continued exposure to systemic conflict taxes the emotional resources
of staff and contributes to the development of toxic environments. 19 Over time, it becomes easier to
walk away or to stop trying to resolve the constant stream of difficulties than invest energy in events
that distract from patient care. This disengagement can fuel further frustration, decreased morale,
loss of trust in the organization, and a lesser tendency toward giving colleagues the benefit of the
doubt when difficulties arise. 19,20
on time. Pharmacy relies on the physicians to write the correct orders for medications. Unit staff
depend on management to secure resources and provide information. Patients depend on
practitioners, clinicians depend upon support personnel, and the list goes on. These
interdependencies make it essential that there be strong working relationships for care to be
delivered within these complex systems.
The presence of poor working relationships leads to operational and social hassles that impact the
staff's ability to provide quality care and affects recruitment and retention of nursing
staff. 25Adequacy of qualified staff directly impacts patient safety. 5 Additionally, the inherent stress
associated with delivering care to critically ill patients can foster inappropriate disruptive behavior that
further affects retention, morale, and quality of care. 26 Understanding the components of effective
working relationships and intentionally integrating techniques for improving collaboration helps to
manage conflict by developing the capacity to deal with differences.
As part of the Harvard Negotiation Project, Fisher and Brown 24 conducted seminal research on the
qualities that ensure a good working relationship. The researchers defined a working relationship as
having the ability to deal with differences. Having a good working relationship depends upon
balancing reason and emotion, understanding the other's needs and interests, fostering good
communication, being reliable, using persuasion rather than coercion, and mutual
acceptance. 24 These collaborative relationships can serve as the foundation for responding to more
difficult conflicts and create an atmosphere where common differences are prevented from
escalating into protracted disputes. Mediators are frequently called upon to assist with conflict
situations and help establish functional working relationships. Developing skills in each of these six
areas is important for improving clinical negotiations and in managing conflict situations. Providing
staff training is one method for developing collaborative skills. Skill development can occur through
formalized training programs as well as through modeling of mediator techniques in daily clinical
practice. Incorporating the techniques used by mediators is an effective way to teach collaborative
skills and create functional working relationships.
What Is Mediation?
Mediation is a conflict resolution process in which a neutral person facilitates communication, the
development of understanding, and the generation of options for creative dispute
resolution. 27 Unlike a judge or jury, the mediator does not decide the outcome of a dispute. A
mediator's role is to help participants surface issues, to create a safe space to discuss issues that
may be emotionally or psychologically difficult, and to foster agreement as participants seek options
that could move them forward toward workable solutions. Mediation is a useful process to use when
the goal of preserving the working relationship is as important as resolving the substantive problems.
Unlike litigation or arbitration, mediation allows the participants in the dispute to remain in control of
the process and to contribute to the outcomes. 27 Through facilitated dialogue, the participants are
able to identify what is important to them and what they need to reach a solution. Mediation is
voluntary and relies on the good faith participation of the people involved in the process. One of the
fundamental tenets of mediation is confidentiality. To encourage honest and open communication
among participants, all conversations associated with the mediation process remain confidential. As
a process, mediation can be used within and external to the clinical setting and requires the use of a
trained "neutral" or mediator. With sufficient training and practice, anyone can serve as a mediator
provided they have no stake in the outcome of the dispute.
In the critical care setting, many conflicts arise in the normal course of care delivery. Common
examples include conflicts related to end-of-life decision-making, differences regarding plan of care,
scheduling and assignment making, visiting hours, access to equipment and supplies, and
placement of patients. More serious disputes can arise when a medical error or adverse outcome
occurs or when a patient's family is in conflict with the clinical team. Often these conflicts are
managed at a cursory level, addressing obvious or expressed needs but frequently leaving
underlying causes of the conflict unaddressed.23,27
It is uncommon for people to clearly identify what is driving their discomfort, whether it be a need for
control, fear, perceptions of mistreatment, or allegations of injustice or unfairness. 27 In a busy
critical care unit, it is particularly unlikely that someone will identify their emotional or psychological
needs. Generally, healthcare organizations value being in control; asking to have your emotional
needs met can foster fears of appearing weak. 28 The inability to express needs directly can also be
seen with patient's family members. The following is an example observed in an intensive care unit:
Patient's Husband: What is the hematocrit level? Has it come back yet? Why is her blood pressure
so low? It was higher when I was in here before. Will I be able to come back in to see her if I leave to
get something to eat? Last time I left, I wasn't able to get back in for 2 hours. Have you taken care of
her before? She had a really good nurse yesterday. When will the doctor be here for rounds? Has he
seen her scans yet? Do you know when she will be scheduled for her procedure?
Addressing the husband's need for information meets one of his needs. Failure to assess and
address the unspoken needs can lead to a continued barrage of questions that can result in
frustration by both the nurse and the family member. Failure to acknowledge them does not lessen
unspoken needs or make them disappear. Continuing to discount or ignore them can lead to
stressful interactions that may result in a conflict situation.
All too often, when faced with frequent or recurring demands for information, the nurse or physician
will repeatedly provide further explanation of clinical physiology, or reiterate unit policies that only
serve to cause further anxiety for the family member or patient whose underlying fears remain
unacknowledged. Table 2 provides examples of "symptoms" of conflict and common underlying
needs and interests. Accurate assessment and avoidance of premature assumptions (Table 2) can
facilitate resolution of clinical conflicts. Mediation techniques are very effective at surfacing
underlying needs and interests and helping people communicate their interests in a supportive
environment.
Mediation Techniques
Mediators use several techniques that are effective at resolving conflicts. Not every situation requires
a mediator, and frequently differences can be managed early and directly by those involved in the
situation. Mediation techniques can be integrated into clinical care to assist nurses in recognizing
issues and addressing the actual needs of patients, families, and coworkers in order to prevent
escalation of conflicts, to address underlying motivations, and to save time and resources by solving
the correct problem. These techniques can be integrated into routine clinical care situations.
Effective techniques for improving collaboration and resolving conflicts include listening for
understanding, reframing, elevating the definition of the problem, and creating clear agreements.
Use of these techniques helps to manage conflict by fostering understanding and acceptance,
surfacing and acknowledging underlying interests or needs, identifying common ground, and
communicating clearly regarding future actions that enable each person to feel that his or her needs
have been addressed. Table 3 summarizes these four techniques; exercises for practicing each of
these techniques appear below.
Mediation Techniques
preventing, addressing, deescalating, and resolving disputes. Effective conflict management requires
a combination of skills and processes for meeting the needs and interests of various stakeholders.
Integrating these techniques into the clinical environment can effectively reduce the level of conflict
and prevent a unit from becoming dysfunctional. The techniques listed below are but a few of the
complementary tools that are useful in managing healthcare conflicts.
Exercise 2: Practice this with a patient's family member who has a concern or with a coworker who
has a problem at work: Listen for 90 seconds without interrupting, asking questions, or offering
advice. Listen as you did in Exercise 1 for what is important, for what needs or interests you hear
identified. Are there points in the story in which the individual seems more upset? What is the person
discussing when there is more energy in his or her speech? Are any words or themes being
repeated? While you are listening, be aware of yourself. Are you planning a response? Are you
preparing mentally with a solution to the problem? Have you decided you know what the problem is
before the speaker finishes talking? What does it feel like to listen without the obligation of replying?
What is this family really requesting? What do they need? Would it be difficult to listen to this string of
questions without interrupting or becoming frustrated? What would be your response to this family?
What sentence could reflect what you hear and summarize what is important for the family member,
such as: "It must be frustrating to not have the information you need to make decisions," or "You
sound like you are concerned that he is not getting the attention he needs." Would these statements
have a different effect than trying to answer each question or giving detailed clinical explanations of
why the patient cannot have sedatives during vent weaning?
Technique 2: Reframing
Listening for understanding provides information as to what is happening for someone and helps to
surface the issues. The next step is deciding how to respond to the information. The response
should let the speaker know that you have heard what he or she is trying to say. Additionally, if the
person is emotionally upset, it is difficult for them to hear any response. Deescalating a person who
is upset allows him or her to better hear your comments. Reframing the statements as you respond
is one way of surfacing the issues while helping the patient or family member stay engaged and hear
your message. Reframing accomplishes many functions. Through reframing, it is possible to remove
inflammatory language, acknowledge or clarify the underlying issues, inform the speaker that you
understand what he or she is saying, and redirect the conversation from a confrontational mode into
a problem-solving mode.
Reframing is a technique that requires practice, particularly for those who are uncomfortable when
an individual's words feel like an attack or an insult. Mediators frequently use reframing to create a
safe space for individuals to have difficult conversations. Reframing strong language while
acknowledging the emotion helps people stay in the dialogue. Too frequently, a confrontational
statement elicits a "fight or flight" response that can lead to a caustic reply, withdrawal, or walking
away. Practicing the technique of re-framing allows the others to stay in the conversation in order to
work toward solving the problem. Often, the person who is upset will make a strong statement that
places blame on someone who is not present. Reframing helps to focus the conversation back on
the speaker and away from the person who is not present. This helps to create a space for surfacing
the issues and for removing blame from the conversation.
Examples of Reframing
Statement 1: "Doesn't anyone know what they are doing around here?"
Reframed: "You sound upset. What would help you feel assured that your dad is receiving good
care?
Reframing Exercise
There are many variations in crafting a re-framed statement. Reframe the following statements:
Statement 1: "I can see you have to be a friend of who's in charge to get a decent assignment
around here!!"
Statement 2: "You know, any first-year resident would know the dosing for digoxin; this guy must be
some kind of idiot!!"
In this issue
Search String
Advanced >
Saved Searches >
ARTICLE TOOLS
Save to My Profile
Request Permissions
Abstract
Article
References
Cited By
View Full Article (HTML) Enhanced Article (HTML) Get PDF (73K)
Keywords:
conflict;
conflict management;
Publications
Browse by Subject
Resources
www.hadassah.org.il/.../leadershipstyleandchoiceofstrategyinconflictman...
rn.sagepub.com/content/19/1/40.refs
Home
OnlineFirst
All Issues
Subscribe
RSS
Email Alerts
Ranking: 2014 SJR (SCImago Journal Rank) Score: 0.242 | 7/10 Research and Theory (Scopus)
Zaid Al-Hamdan
Assistant Professor, Faculty of Nursing, Jordan University of Science and Technology, Jordan
Peter Norrie
1.
Principal Lecturer and Senior Research Fellow, School of Nursing and Midwifery, De Montfort
University, UK
Peter Norrie, School of Nursing and Midwifery, De Montfort University, Bosworth House, Leicester LE1
5RR, UK. Email: pnorrie@dmu.ac.uk
Denis Anthony
1.
Professor of Nursing, School of Nursing and Midwifery, De Montfort University, UK
1.
1.
1.
1.
Abstract
Aim: This paper is a report of a study of conflict management styles used by nurses in Jordan.
Background: There are five main styles used to deal with conflict. At present research into their utilisation is
dominated by reports from Western countries. This research is the second to investigate their use by nurses in
an Arab country and it illustrates similarities with the earlier work, allowing an initial profile to be constructed
which may be applicable to the larger Arab world of healthcare.
Methods: Cross-sectional quantitative survey of nurses in Jordan using the Rahim Organisation Conflict
Inventory (ROCI II) questionnaire.
Results/Findings: The nurses were most likely to prefer an integrating style of conflict management, followed
in rank order by compromising, obliging, dominating and avoiding.
Conclusion: A tentative model of the styles which nurses in Arab countries prefer to manage conflict is
proposed, which suggests that they are likely to provide stable workplaces.
Arab countries
conflict management
Jordan
nursing
References
1.
1.
2.
Adler R,
Towne N
(1990) Looking Out Looking In, Interpersonal Communication,New York, NY: Holt, Rinehart & Winston.
Google Scholar
2.
3.
Al-Hamdan Z (2008) Conflict management styles used by nurse managers in the Sultanate of Oman.
PhD Thesis, De Montfort University, UK.
1.
2.
3.
Al-Hamdan Z,
Shukri R,
Anthony DM
(2011) Conflict management styles used by nurse managers in Sultanate of Oman. Journal of Clinical
Nursing 20(34): 571580.
CrossRefMedlineOrder article via InfotrieveGoogle Scholar
4.
1.
2.
Bell C,
Song F
(2005) Emotions in the conflict process: An application of the cognitive appraisal model of emotions to conflict
management. International Journal of Conflict Management 16(1): 3054.
5.
1.
2.
Blake R,
Mouton J
(1964) The Managerial Grid: Key Orientations for Achieving Production Through People, Houston, TX: Gulf
Publishing.
Google Scholar
6.
1.
2.
3.
4.
Bousari MP,
Ebrahimi H,
Ahmadi F,
et al.
(2009) The process of nurses interpersonal conflict: Qualitative study. Research Journal of Biological
Science 4(2): 236243.
Google Scholar
7.
1.
2.
Cheung CC,
Chuah KB
(1999) Conflict management style in Hong Kong industries.International Journal of Project
Management 17(6): 393399.
CrossRefGoogle Scholar
8.
1.
2.
De Dreu CK,
Van De Vliert E
(1997) Using Conflict in Organization, London, UK:Sage Publications.
Google Scholar
9.
1.
2.
Domenici K,
Littlejohn S
(2001) Mediation: Empowerment in Conflict Management,Long Grove, IL: Waveland Press.
Google Scholar
10.
1.
Field A
(2009) Discovering Statistics Using SPSS (and Sex and Drugs and Rock n Roll), London, UK: Sage
Publications.
Google Scholar
11.
1.
Forte PS
(1997) The high cost of conflict. Nursing Economics 15(3): 119123.
MedlineOrder article via InfotrieveGoogle Scholar
12.
1.
2.
Hocker J,
Wilmot W
(2001) Interpersonal Conflict, Upper Saddle River, NJ: Prentice Hall.
Google Scholar
13.
1.
Hofstede G
(2001) Cultures Consequences: Comparing Values, Bahaviors, Institutions, and Organizations Across
Nations, Thousand Oaks, CA: Sage Publications.
Google Scholar
14.
17.
1.
2.
Kantek F,
Kavla I
(2007) Nursenurse manager conflict: How do nurse managers manage it? The Health Care
Manager 26(2): 147147.
18.
1.
2.
3.
4.
Kunaviktikul W,
Nuntasupawat R,
Srisuphan W,
et al.
(2000) Relationships among conflict, conflict management, job satisfaction, intent to stay, and turnover of
professional nurses in Thailand. Nursing and Health Sciences 2(1): 916.
CrossRefGoogle Scholar
19.
1.
Marriner TA
(1982) Managing conflict. Nursing Management 13(6): 2931.
CrossRefMedlineOrder article via InfotrieveGoogle Scholar
20.
1.
Marriner TA
(1995) Strategies for managing conflict. Journal of Multicultural Nursing and Health 2(1): 69.
Google Scholar
21.
1.
Rahim MA
(1983) A measure of styles of handling interpersonal conflict. Academy of Management Journal 26(2): 368
376.
22.
1.
Rahim MA
(1986) Managing Conflict in Organizations, 1st ed. New York, NY:Praeger Publishers.
Google Scholar
23.
1.
Rahim MA
(2001) Managing Conflict in Organizations, 3rd ed. Westport, CT: Quorum Books.
Google Scholar
24.
1.
Rahim MA
Google Scholar
25.
26.
1.
2.
3.
Rahim MA (2004) Rahim Organizational Conflict Inventory. Center for Advanced Studies in
Management, Western Kentucky University, USA.
Rahim MA,
Magner NR,
Shapiro DL
(2000) Do justice perception influence styles of handling conflict with supervisors? What justice perceptions
precisely? International Journal of Conflict Management 11(1): 913.
27.
1.
Skorhammar M
(2001) Conflict management in a hospital: Designing processing structures and intervention
methods. Journal of Management in Medicine 15(2):156166.
28.
1.
Thomas KW
(1976) Conflict and conflict management. In: Dunnette M, Hough LM(eds) Hand Book of Industrial and
Organizational Psychology, Chicago, IL: Rand McNally, pp. 889935.
Google Scholar
29.
1.
2.
Thomas KW,
Kilmann RH
(1974) Thomas-Kilmann Conflict Mode Instrument,Sterling Forest, NY: Xicom, Inc.
Google Scholar
30.
1.
2.
3.
4.
Ting-Toomey S,
Yee-Jung KK,
Shapiro RB,
et al.
(2000) Ethnic/cultural identity salience and conflict styles in four US ethnic groups. International Journal of
Intercultural Relations 24(1): 4781.
CrossRefGoogle Scholar
31.
1.
Tjosvold D
(2006) Defining conflict and making choices about its management: Lighting the dark side of organizational
life. International Journal of Conflict Management 17(2): 8795.
32.
1.
Valentine PE
(1995) Management of conflict: do nurses/woman handle it differently.Journal of Advanced
Nursing 22(1): 142149.
33.
1.
Vivar CG
(2006) Putting conflict management into practice: a nursing case study.Journal of Nursing
Management 14(3): 201206.