Managing Conflict in Health Care

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One reason that health care is in crisis is preventable workplace conflict. The avoidable costs* resulting from conflict between people who should . . . and could . . . work together cooperatively drive up the cost of care. An example is the retention of good employees, particularly nurses and other direct patient-care providers. The national average of voluntary resignations that result substantially from unresolved conflict is 65% a figure surely higher in health care. A study reported in the American Journal of Maternal/Child Nursing (March/April 2005) shows that the cost of replacing a specialty nurse is 156% of annual salary. So, the cost-benefit of retaining just one nurse by resolving a conflict is over 300 times the cost of attending an upcoming Certification Course. The Joint Commission on Accreditation of Healthcare Organizations recognizes this important fact. JCAHO issued a Sentinel Event Alert on July 9, 2008 amending its Leadership Standards to include among other requirements/recommendations: y Develop an organizational process for addressing intimidating and disruptive behaviors (LD.3.10 EP 5) that solicits and integrates substantial input from an inter-professional team including representation of medical and nursing staff, administrators and other employees. Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution.

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

CONFLICT RESOLUTION -TOOLS FOR NURSING

by Antonie Hiemer MS RN Abstract The nursing profession is one that is based on collaborative relationships with both colleagues and patients. It requires individuals to work closely with others with varying backgrounds or cultures. Individuals can hold diverse values, potentially affecting these relationships, which may result in conflict. Good communication or conflict resolution skills can decrease the risk of conflict. Conflict Resolution - Tools for Nursing Success Introduction Conflict is neither good, nor bad, it just is, (Marshall, 2006). It can occur at anytime and in any place, originating between two individuals or groups when there is a disagreement or difference in their values, attitudes, needs, or expectations (Conerly, 2004), miscommunication or lack of information (Marshall, 2006). Over time individuals learn how to respond to conflict, making it an unconscious process. Dealing

with conflict properly requires the individual to develop conflict resolution skills. This is a conscious effort to control the individuals behavior of poor communication (Conerly, 2004). Nurse-Patient Relationship A therapeutic nurse-patient relationship is the foundation of nursing care. It contributes to both the patients well-being and their health. Conflict can impede these collaborative relationships by not allowing the nurse to fully support the patient in attaining his or her health goals (CNO, 2006). It requires individuals to work closely with others who have varying backgrounds or cultures and, hold diverse values that can potentially result in conflict. Good communication or conflict resolution skills can decrease the risk of conflict. Evolving Roles of the Nurse Healthcare organizations are dramatically changing the way they operate due to initiatives to increase productivity and the quality of services provided. These initiatives are forcing hospitals to break down traditional hierarchal structures and move toward a team-managed environment. As a result, nurses no longer function on nursing units in a typical subordinate role, but are finding themselves in new roles. Nurses are participating members of a multidisciplinary team improving the overall delivery of care (Baker, 1995). Diversity can Lead to Conflict Cultural diversity, combined with the stress of providing quality care, often results in conflict (Pettrey, 2003). According to the New York State Nurses Association (2005), unresolved conflict leads to barriers for employees, teams, organizational growth, and productivity, which results in a cultural breakdown within the organization. Conflict is a natural phenomenon (Kelly, 2006), and an inevitable aspect of life (Kemp-Longmore, 2000). It is a disagreement between individuals who perceive a threat to their needs, interests, and or concerns (Kelly, 2006). Improperly managed conflict can result in the nurses inability to provide quality care, and can escalate into violence or abuse (CNO, 2006). The Importance of Conflict Resolution In general, nurses have difficulty in dealing with conflict in an open manner and avoid conflict, harboring emotions that the conflict creates leading them to act out in covert ways. Nurses need to achieve effective team building skills within nursing groups in order to deliver quality and productivity required for the organizational structure. The decisions nurses make in team-managed environments are more superior to decisions made in a hierarchal environment in terms of both quality and cost effectiveness. Nurses must possess effective conflict resolution skills to be able to function successfully in the evolving healthcare system (Baker, 1995). The process of conflict resolution is an opportunity for growth and change in a work environment, with great potential for a positive outcome. On an individual level, conflict resolution is important for personal achievement. On an organizational level it is important for the bottom line and overall success (KempLongmore, 2000). Proper conflict management results not only in successful conflict resolution, but also contributes to higher effectiveness, trust, and openness (Kelly, 2006). Research has concluded that styles of conflict resolution are strong predictors of the level of morale, burnout and job satisfaction of the nursing profession. The use of negative coping mechanisms, such as confrontation and avoidance styles, result in increased negative outcomes, increased burnout and occupational stress (Montoro-Rodriquez & Small, 2006). The use of avoidance as a conflict resolution method results in ineffective and unproductive outcomes, since it only postpones the conflict. By avoiding the conflict, individuals are neglecting their own needs, goals, and concerns, while trying to satisfy those of others. This approach has an element of being self-sacrificing and simply obeying orders or serving other people (Kelly, 2006).

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 occu Nurses as Facilitators of Conflict Resolution Nurses need to become proactive and learn how to effectively communicate with their patients, the patients families and friends, as well as their colleagues (Pettrey, 2003). Good communication skills (see effective communication table) allow the nurse to resolve his or her own conflicts or facilitate conflict resolution between other individuals. As a facilitator, the nurse must protect each persons self respect by focusing on the issue(s), and not the personality of the party involved. It is also important not to blame the participants for the problem. This hinders open and complete discussion of the issue. Encouraging discussion of both positive and negative feelings will increase the chances of both parties expressing all of their concerns. Fostering active listening and understanding enhances this. The facilitator must allow for equal time for all parties to participate expressing their opinions. The nurse must summarize key themes in the discussion and assist in developing alternative solutions to the issue. At a later date or time the facilitator must follow up on the progress of the conflict resolution and give positive feedback to both parties related to the use of problem solving skills (Leddy & Pepper, 1998). Case Study It has been an accepted practice at nurse Susies* healthcare organization to keep the narcotic cupboard, syringe drawers, medication fridge, and medication cart unlocked during a nurses shift and during shift change. So, imagine nurse Susies surprise when without warning nurse Betty locked the narcotic cupboard, syringe drawers, medication fridge, and the medication cart. Nurse Susie had learned to respond to conflict with retaliation, resulting in her deciding to act out her frustration in covert ways. She decided to not only report to work late whenever she would receive keys and report from nurse Betty, but also preceded to unlock and count everything in an exaggerated slow manner. It quickly became apparent to nurse Betty that nurse Susies attitude toward her had changed. Nurse Susie decided to utilize her good communication skills, to resolve the possible conflict between them. Nurse Susie told nurse Betty that since nurse Susie was locking everything on purpose, she was retaliating and reporting late, unlocking and counting slow on purpose. The policy at nurse Susies healthcare organization is that everything is to be locked when not in use; it had been accepted practice to not lock anything. After a State inspection by the Commissioner, a citation was issued for failure to comply with the policy. Nurse Betty had decided to break the social norm and follow the policy, to prevent another possible citation. She did not communicate her change in routine, because she thought that it was an obvious response to the citation. Since she did not communicate this to her colleagues, she was perceived 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

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