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JMM
15,2 Conflict management in a
hospital
Designing processing structures and
156 intervention methods
Morten Skjùrshammer
Diakonhjemmet College, Oslo, Norway
Keywords Conflict resolution, Hospitals, Human resource management
Abstract This article presents a case study describing the development, structure and operation
of a comprehensive system for managing conflicts in a Norwegian city hospital. This was done in
an effort to further develop the dispute mechanisms available in the hospital and to strengthen the
management skills of clinical leaders and managers in general. By changing the ways managers
and professionals handle their disputes, the hospital hopes to reduce the cost of conflicts and
realize its benefits. The new conflict management system includes new procedures for managers
and professionals to process disputes. The design process of the new system was framed
according to an action research approach characterized by creating change through dialogue and
the use of local expertise.

Introduction
A well coordinated interaction among the different actors participating in the
treatment process is of critical importance in order to deliver high quality
patient treatment (Gerteis, 1993; Hietanen et al., 1993; LeTourneau and Curry,
1998; OÈ stergren and Sahlin-Andersson, 1998).
In order to facilitate such processes, the hospital as an organization needs
mechanisms to handle and negotiate coordination and collaboration problems
and to manage disputes and conflicts arising as a result. The tasks of problem
solving and conflict management are delegated to the individual professional
or clinician, or to leaders of units, wards or other defined systems. Today, these
actors are facing higher expectations for handling these tasks with a
constructive outcome and thus to focus more on this part of their professional
functioning. However, many professionals and managers feel this is a neglected
part of their training.
There are few empirical studies on these challenges and issues within health
care (Skjùrshammer and Hofoss, 1999). In so far as available studies provide
recommendations for conflict management in health care settings, the main
focus is on encouraging professionals and clinical managers to sharpen their
skills in negotiation, mediation and use of creative problem-solving techniques
(Preston, 1988; Slaikeu, 1989; Gupta and Labbett, 1994; Miller, 1998). évretveit
(1995) points out the importance of improving team functioning and, in
Journal of Management in Medicine,
Vol. 15 No. 2, 2001, pp. 156-166.
particular, decision making in teams in order to prevent unnecessary conflicts.
# MCB University Press, 0268-9235 Slaikeu (1989) also recommends using the generic model of ``dispute systems
design'' (Brett et al., 1990, p. 97) in order to reduce the costs of conflict and Conflict
realize its benefits. In summary, these studies indicate that in order to management in a
strengthen the conflict resolution capability of the hospital as an organization, hospital
there should be a dual focus on improving organizational processes and
structures as well as the negotiation skills of clinical leaders. However, there
are few descriptions in the literature of efforts to introduce and assess such
processes and changes. 157
The present study aimed at assessing the methods for managing conflicts
and disputes at the study hospital, and aimed at proposing and
implementing desired changes. This article is a description of how this was
done.

Method
An action research method was used to implement and study the intervention
(Cope, 1981; Bryman, 1989; Gustavsen and Engelstad, 1990; évretveit, 1998).
Designing and implementing changes in conflict management in an
established organization is as much a political task as it is a technical one.
Thus, the design process was framed according to an action research
approach, characterized by creating changes through dialogue and the use of
local expertise. In action research the investigator becomes part of the arena
being studied with an explicit concern for developing findings that can be
applied in the organization. A defining characteristic of action research,
therefore, is its action or intervention phase. Another distinguishing feature is
the collaboration between individuals inside the system, in this case hospital
employees, and individuals outside the system, the author as a researcher. The
author's role was that of an independent researcher in gathering data and
describing the action process. In addition the author functioned as a
consultant to the task force.

The design process of ``conflict management program''


The design consisted of two phases; an assessment phase including an analysis
of current practices of conflict management and existing systems for
resolution, and a planning phase that involved developing a proposal for a new
comprehensive system.
The assessment phase was based on data from the author's ethnographic
study of hospital employees' conflict behaviour and management, having the
purpose of ultimately contributing to the development of more adequate
dispute mechanisms and intervention methods in health care organizations.
The study included interviews with selected representatives from all levels of
the hospital hierarchy, observation of meetings arranged with the purpose of
resolving conflict issues and review of written materials such as minutes and
protocols. In addition to reviewing what hospital employees and managers
were already using, interviews also included questions asking what they would
choose to use if it were available.
JMM The setting
15,2 The study hospital is a middle-sized city hospital in Norway, serving a
catchment area of approximately 100,000. The hospital provides treatment
services in the area of general surgery, internal medicine and psychiatry.

Assessment of existing resolution system and conflict behaviours


158 The present study does not include any quantification of the prevalence or
extent of conflict at this particular hospital. An indication, however, may be
extrapolated from the results of a work environment questionnaire in 1992,
where an average of 27 per cent of employees across the hospital said there
were ``unsolved conflicts at their work unit''. However, according to participants
in the present study who had prior work experience from other Norwegian
hospitals, there were no more conflicts at the study hospital than at their other
work places.
The hospital has pre-existing institutionalized resolution systems that are
used more or less automatically when there is a disagreement, dispute or
conflict. These resolution systems can be divided into two major types, the
employer-union system and the work process system, and as systems these
vary in terms of formalization, the type of dispute they are designed to handle,
when they are to be used, and who should be involved.
The employer-union system deals with the formal relationship between
employer-employee, handling demands and agreements related to employees'
working hours, work-shift arrangements, local wages, work environment issues,
and grievances related to the interpretation of contracts and rights. The resolution
behaviour in this system is first and foremost characterized by negotiations where
the outcome is formalized in local agreements or protocols. Participants are
mainly the top echelon of the hospital, local union leaders or representatives from
national employer or professional associations and, in conflicts related to
individual work contract or legal work rights, the grievant person. This system is
a well-developed formal system that ties into the Norwegian welfare state's way
of structuring and handling employer-labour issues.
The work process-resolution system encompasses all activities related to
helping bed units/floor, teams, departments, professions and individuals to
cooperate in terms of coordinating their activites and providing the continuity
in medical work and patient care that is required in order to achieve the
objectives of the hospital. In doing this, they use both formal and informal
structures and arenas to influence staff and clinical professionals to behave in
``desired'' directions as defined by the goals of the unit. When there is a conflict
in the work process system this has the potential to negatively affect
productivity and quality. Such conflicts may also have a negative forming
effect on the work environment and the work climate, and thus spill over to
other areas of the work unit.
The assessment points, in particular, to an improvement potential in the
work process resolution system and in the interface between this system and
the employer-union system in case of grievances. There are no guidelines or
procedures for either managers or employees on how or where to go with their Conflict
conflicts, thus leaving choice of system, procedures and selection of management in a
participants to informal and random influences. Unit/floor management, hospital
commonly the first line involved in a dispute or conflict, use primarily
behaviour strategies involving avoidance and unilateral forcing and use
negotiation and mediation to only a limited degree. This is often also the case
for management at the departmental level. One reason for this is that clinical 159
management experience conflicts as a fairly new challenge, and they feel their
own professional background in dealing with these is insufficient. Not least,
they are unclear about their role and responsibility, what means and sanctions
they have at their disposal, and the limits of their action range. This results in
their giving such challenges lower priority and not spending sufficient time on
such issues. This may account for employees' mainly using their professional
union or informal helpers when striving to clarify their rights or asking for
support and advice in terms of how to proceed with a dispute, or to strengthen
their position when they want to bring a dispute forward.
Higher hierarchical levels like department management and the hospital's
top echelon, mainly deal with employer-union issues, inter-unit/departmental
disputes or conflicts that have not been resolved at a lower level or have been
pushed by union representatives, the office of work health services or other
informal helpers to a higher level. A common experience at all hospital levels is
that managers get involved in active conflict management too late. Often they
do not become involved until the participants are on a collision course with
each other and have already invested a lot in maintaining divergent positions.
If a conflict has already escalated to a level where unions or higher leadership
levels are involved, the conflict gets more complex for several reasons. There
are now more actors, the conflict becomes more formal, the framing of the
conflict changes and there are more interests to realign. Often the principal and
legal aspects of the conflict are more in the foreground and the precedence
aspects of the outcome of the conflict become more important. In many ways,
the number of alternative solutions decreases.
When participants in a conflict make contact with each other in order to find
a common way out of the issue at stake, the planning of a joint negotiation
process is limited. Often, the participants plan their strategies in closed
meetings, negotiations happen without a shared and clear framework and there
is a loose connection to what has happened before and what is going to happen
next. The result may be an unnecessary escalation of the conflict.

Planning the new comprehensive conflict management program


The assessment was presented to the hospital's top echelon in a report
including suggestions regarding how to improve the present system and with
recommendations to establish a task force to create a new comprehensive
conflict management system for the entire hospital.
The task force was established after the report was discussed in the
hospital's leadership council, and consisted of the personnel director
JMM (chairman), chaplain, director of food services, nurse manager of psychiatry,
15,2 nurse manager of medicine, medical director of intensive care and the author.
The task force reviewed and elaborated the reported findings of the assessment
and continued thereafter to develop a new proposed system that was presented
to the hospital's leadership council and approved.
The task force decided that the conflict management program at this
160 hospital should focus on what it could do about internal conflicts using its own
personnel and resources, minimizing reliance on outside parties or expertise.
Further, the task force formulated a set of 15 guiding principles for the new
resolution system, the most salient being:
. Conflict is an inevitable and ``normal'' part of cooperation.
. The hospital takes responsibility for its own conflicts by providing
managers and employees opportunities to intervene in their own affairs
through a visible and comprehensive conflict management system.
. Conflicts should be solved on the premises and as close as possible to the
disputants and immediate manager.
. Conflicts should be dealt with early, preferably informally and in an
exploratory way, and provide the parties with as many alternatives and
options to solve a given issue as possible.
The task force developed a new system that it hoped would increase the
probability of early identification of disputes and that would allow these
disputes to be resolved by the parties themselves at the levels of negotiation
and mediation, with the use of higher authorities only as a last resort. Further,
the task force members hoped that the program would reduce the costs of
conflicts by preventing poor work environment and leakage of personnel
energy and motivation. Furthermore, the task force hoped to reap the benefits
from conflicts in terms of learning and innovation.

Conflict resolution program; structure, levels and flow


The conflict resolution program as visualized in Figure 1, has a structure
composed of four levels, where each level represents a different approach to
conflict management. Together, these levels make up a comprehensive system
similar to the flow of a potential escalation of a conflict, from avoidance to the
end point of litigation/arbitration.
The basic idea of the system is that all conflict management should be
processed along the ``line'' of the hospital organization. That is to say, that the
immediate superior is the first line to become involved and has the
responsibility for initiating the management and follow up of a conflict.
However, this may not work when the immediate superior is part of the conflict
and the employee for his/her own reasons does not want to use ``the line'' or the
conflict management comes to a standstill. In such situations, the system
provides alternative ways or channels around the immediate superior, and
means of breaking up a deadlock such as asking for a conference.
Conflict
management in a
hospital

161

Figure 1.
Graphic presentation of
the conflict management
system

Level 1: ``Open door''


The objective of the ``open door'' level, is to lower the threshold for raising an
issue, dispute or conflict in order to work it out early and as close as possible to
the parties' own work role, work group and immediate superior. Early
diagnosis and intervention is an important design principle which serves to
prevent disputes from progressing to more formal and higher levels. This early
approach is preferably based on the first contacts between the parties being
informal, exploratory and confidential in nature. Such an approach may
contribute to keeping open the parties' options and alternative solutions. Level
1 also provides a means of circumventing the line management when necessary
and provides guidelines for how to proceed with a dispute if it is not resolved at
this level.
Level 1 has three channels; immediate superior, personnel department, and/
or other helpers.
Immediate superior. This is the primary channel for early resolution of
disputes, and employees and lower level managers may contact their
immediate superior in an effort to resolve their frustrations, disputes, and
conflicts. For most employees, the immediate superior is the floor or unit
manager who has, in turn, the department manager as superior. However, this
primary channel may not work when the immediate superior is part of the
dispute or has taken a position in an ongoing dispute. It may not work either if
JMM the immediate superior has a pre-history, image or relationship to the party
15,2 that prevents raising a dispute. In such circumstances, the program provides
two alternative channels, either the use of the personnel department or the use
of ``other helpers'', as a procedural detour back to immediate superior or to
advance to level 2 conference

162 Personnel department. An employee may contact any of the officers working at
the personnel department if deemed necessary. Their role, above all, is to help
the employee to clarify his/her case and give advice on how to proceed within
the scope of the conflict management program. In case the employee prefers
more ``neutral'' consultation than available at the personnel department, which
is a part of the hospital's management structure, the officers may provide
contact with other helpers at the hospital. The personnel department may also
contact the immediate superior at the request of the employee or if information
justifying such an initiative comes up through the consultation. Such a contact
may lead to arranging a conference between the parties, thus moving to level 2.
This option is also available to middle management. Even though it is
assumed that they more regularly use their superiors for consultation in cases
of disputes and conflicts, they may contact any officer or the personnel director
for consultation. In case they are involved in disputes where termination of the
work contract is a potential outcome, they are expected to report such cases as
early as possible to the personnel director.
Other helpers. The third channel is the use of what here is called ``other helpers''.
The assessment of the present resolution system showed that officers at the
employee health services, the chaplains and other ``natural'' helpers were
frequently used by employees in their efforts to resolve a dispute. The hospital
wants to legitimize this option without jeopardizing its strength of informality
through a full integration in the new system. This channel provides employees
with an avenue to consult with someone completely outside the hierarchical
lines of management and thus provide a higher level of confidentiality and
neutrality than the other two channels. Such a consultation gives the employee
an opportunity to talk to a neutral person about issues, processes and related
feelings. Other helpers may also answer questions, go through available
options, function as a ``devil's advocate'', mediate contact with other actors, or
just ``help the employee to help him/herself''. Employees may also be referred to
other helpers by their immediate superior or personnel department as a
strategy to provide the employee with support and an additional processing
opportunity.
``Other helpers'' may consult with the personnel department, if they find a
need for clarification or advice.
As part of the implementation of the conflict management program, the
hospital has trained all managers, including other helpers and union
representatives (approximately 120 in all). The training course describes the
new program, provides the knowledge base for such an operation and
introduces a tool for conflict intervention that has been named ``next move''.
``Next move'': Description of an intervention method. The intervention method Conflict
``Next Move'' is meant as a mental map for managers to use when their usual management in a
way of managing a dispute is not working (Table I). The method builds on hospital
published experiences in the field of conflict management, and is characterized
by combining a hermeneutic and rational approach to conflict resolution
(Donohue and Kolt, 1992; Thomas, 1992; Schwenk and Cosier, 1993; Sitkin and
Bies, 1993; De Dreu and Van de Vliert, 1997). The hermeneutic part covers the 163
first three sequences and the purpose is to get out the parties' stories and
cognitively process the involved affects. The rational part covering the last
three sequences represents more of a traditional problem solving approach
focusing on the issues.

Level 2: conference
If the dispute is not resolved as a result of efforts at level 1, the next step in the
conflict management system is to arrange a conference between the parties that
is facilitated by a mediator. The objective of such a conference is not to resolve
the dispute or conflict, but for the parties to discuss the process so far and to
make a joint decision as to how to proceed in handling the dispute. The purpose
is to ascertain an optimum of procedural fairness as an important prerequisite
for resolving the dispute. Separating the process from the issues in this way,
may serve to lower the threshold for an early adjustment in the dispute process
by this time is escalating or has perhaps reached a deadlock.
The immediate superior may advance a dispute to the conference level when
it is perceived that the dispute is not resolved, that it is escalating or simply
involves issues requiring another arena, more participants or higher
negotiation skills. The personnel department may also arrange a conference if
they receive information warranting such an initiative.
A conference is normally mediated by the personnel director, but can be
mediated by another person if that is preferred by the parties.
The outcome of a conference may lead to a return to level 1 or a transfer to
level 3 mediation or level 4 litigation. A return to level 1 may be a viable option
if the parties' assessment is that it is still possible to resolve the dispute on a
low level. All channels at level 1 will still be available, in addition to other

1. Encounter with the dispute; Who are the parties? What are the issues, emotions and
context? How to get the parties together?
2. Going through the dispute; parties tell their stories. Uninterrupted presentation while
the other party listens
3. Defining the dispute; what is the core challenge? What are the parties willing to work
on and how? What are the points of agreement? Is there a need for a conference?
4. Alternative solutions. The parties work out and present alternative solutions
5. Evaluation and decision-making. Evaluation of the suggested solutions and their Table I.
consequences. Decision making through negotiation Sequential presentation
6. Contract (written agreement). Contract stating what is to be done and how and when to of the intervention
review the agreement method ``next move''
JMM resources or possibilities that may have been identified in the course of the
15,2 conference.
A dispute may also be transferred to level 4 litigation. This is particularly
the case when the dispute centres around legal rights or employer-union wage
and work agreements. Instead of a long in-house negotiation process, it may be
more efficient to loop forward to litigation. In order to do this, it must be
164 clarified that the issue is one of such a nature.
Mediation is the third possible outcome of a conference and may be used
when the parties concerned perceive that the dispute process would benefit
from using an external facilitator.

Level 3: Mediation
Formal mediation is an internal effort on the part of the hospital to resolve the
dispute and find an amicable settlement within its own boundaries. This is
initiated when considered to be more efficient and economical than litigation.
An internal mediator, normally the personnel director, leads the mediation
process unless this is considered disadvantageous to one of the parties. Formal
mediation may, in addition to the disputants themselves, involve union
representatives, department director, and others whom the parties agree to
include.
Formal mediation is similar to a negotiation process with the presence of a
mediator processing and facilitating the presentation of viewpoints and the
efforts to reach a settlement. Formal mediation most often is resolved with the
parties accepting a compromise.
If formal mediation does not resolve the conflict, it is transferred to litigation.

Level 4: Litigation
Litigation represents the end point to the conflict management system. If the
parties have not reached an agreement at an earlier point in time, a definite
decision about the dispute will be made through litigation. A litigation process
means that representatives of the employer association and labour union
become involved in the conflict management process. Litigation is processed
according to the work agreements and work laws in force. Eventually the
conflict will end in court if not resolved by these parties.

Implementation and operation


The conflict management program started 1 January 2000, and is administered
by the personnel department. At this initial stage of operation, it is directed by
the head of the department. All personnel officers are in a position to provide
consultation and to give advice to managers and employees requesting such. In
addition, a part-time position is specifically set aside for implementing and
following up the program in its first year of operation.
The conflict management program was implemented through a training
course required of all managers (approximately 120), and a letter was
distributed to all hospital employees informing them about the new policy and
the program. Subsequently this has been followed up at staff meetings on the Conflict
various units and floors in the hospital. This information is also part of the management in a
introductory program for new employees. hospital
The training course covered a step by step introduction of the new conflict
management program and a description of its concepts and design principles.
In addition, managers were specifically coached not to suppress conflicts, to
approach conflicts early and to increase their use of negotiation. They were also 165
exposed to the intervention method ``Next Move'' (Table I). All course material
is organized in a manual carrying the logo of the program, and provides
addition information of relevance to conflict management in hospitals.
An evaluation is planned to take place at the end of the first year of
operation. At this point, the program is allowed to settle, and the development
is monitored through the eyes of personnel officers. They make note of the
various requests, comments and observations directed toward the program and
discuss these at bi-monthly meetings. At this early stage of operation, the
conflict management program seems to have increased the level of awareness
among managers and has created a more conscious effort on their part to deal
with conflicts. There are also requests for a training course for non-managers
and continuing education and supervision groups for managers already
trained. These are indications of the usefulness of the present approach for
increasing coordination and collaboration among hospital employees.

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