Introduction

Conflict is a disagreement in values or beliefs within oneself or between people that causes harm or has the potential to cause harm. Conflict is a catalyst for change and has the ability to stimulate either detrimental or beneficial effects. If properly understood and managed, conflict can lead to positive outcomes and practice environments, but if it is left unattended, it can have a negative impact on both the individual and the organization (Almost, 2006; Morrison, 2008; Vivar, 2006). In professional practice environments, unresolved conflict among nurses is a significant issue resulting in job dissatisfaction, absenteeism, and turnover. Successful organizations are proactive in anticipating the need for conflict resolution and innovative in developing conflict resolution strategies that apply to all members (Behfar, Peterson, Mannix, & Trochim, 2008).

Conflict can be a strategic tool when addressed appropriately and can actually deepen and develop human relationships. Some of the first authors on organizational conflict (e.g., Blake & Mouton, 1964; Deutsch, 1973) claimed that a complete resolution of conflict might, in fact, be undesirable because conflict also stimulates growth, creativity, and change. Seminal work on the concept of organizational conflict management suggested conflict was necessary to achieve organizational goals and cohesiveness of employees, facilitate organizational change, and contribute to creative problem solving (Morrison, 2008). Moderate levels of conflict contribute to the quality of ideas generated and foster cohesiveness among team members, contributing to an organization’s success (Almost, 2006). An organization without conflict is characterized by no change; and in contrast, an optimal level of conflict will generate creativity, a problem-solving atmosphere, a strong team spirit, and motivation of its workers (Strack van Schijndel & Burchardi, 2007).

The complexity of the healthcare environment compounds the impact that caregiver stress and unresolved conflict has on patient safety. Conflict is inherent in clinical environments in which nursing responsibilities are driven by patient needs that are complex and frequently changing (Siu, Spense Laschinger, & Finegan, 2008). Healthcare providers are exposed to high stress levels from increased demands on an ever-limited and aging workforce, a decrease in available resources, a more acutely ill and underinsured patient population, and a profound period of change in the practice environment (Kelly, 2006). Nurses employed in better care environments report more positive job experiences and fewer concerns about quality care. Positive practice environments and high core self-evaluations (self-esteem, self-efficacy, locus of control, and emotional stability) predicted nurses’ constructive conflict management, and in turn, greater unit effectiveness (Siu et al., 2008). Favorable core self-evaluation was also a predictor of quality leader-staff relationships, empowerment, and job satisfaction for nurse managers (Laschinger, Purdy, & Almost, 2007). Moreover, hospitals with good nurse-physician relations are associated with better nurse and patient outcomes (Aiken, Clarke, Sloane, Lake, & Cheney, 2008).

An important factor in the successful management of stress and conflict is a better understanding of its context within the practice environment. The diversity of people involved in health care may stimulate conflict, yet the shared goal of meeting patient care needs provides a solid, ethical foundation for conflict resolution (Saltman, O’Dea, & Kidd, 2006). Because nursing remains a predominately female profession, this may contribute to the use of avoidance and accommodation as primary strategies. Emotions of empathy, compassion, and caring should not be suppressed, but neither should assertive communication and behavior. The stereotypical self-sacrificing behavior seen in avoidance and accommodation is strongly supported by the altruistic nature of nursing (Kelly, 2006). Avoidance may be appropriate during times of high stress, but when overused, it threatens the well-being of nurses and retention within the discipline.

Types of Conflict

The recognition that conflict is a part of everyday life suggests that mastering conflict-management strategies is essential for overall well-being and personal and professional growth. A need exists to determine the type of conflict present in a specific situation, because the more accurately conflict is defined, the more likely it will be resolved. Conflict occurs in three broad categories and can be intrapersonal, interpersonal, or organizational in nature; a combination of types can also be present in any given conflict.

Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with one’s sense of self. Questions often arise that create a conflict over priorities, ethical standards, and values. When a nurse manager decides what to do about the future (e.g., “Do I want to pursue an advanced degree or start a family now?”), conflicts arise between personal and professional priorities. Some issues present a conflict over comfortably maintaining the status quo (e.g., “I know my newest charge nurse likes the autonomy of working nights. Do I really want to ask him to move to days to become a preceptor?”). Taking risks to confront people when needed (e.g., “Would recommending a change in practice that I learned about at a recent conference jeopardize the unit governance?”) can produce intrapersonal conflict and, because it involves other people, may lead to interpersonal conflict.

Interpersonal conflict transpires between and among patients, family members, nurses, physicians, and members of other departments. Conflicts occur that focus on a difference of opinion, priority, or approach with others. A manager may be called upon to assist two nurses in resolving a scheduling conflict or issues surrounding patient assignments. Members of healthcare teams often have disputes over the best way to treat particular cases or disagreements in determining how much information is necessary for patients and families to have about their illness. Yet, interpersonal conflict can serve as the impetus for needed change and can accelerate innovation in approach.

Organizational conflict arises when discord exists about policies and procedures, personnel codes of conduct, or accepted norms of behavior and patterns of communication. Some organizational conflict is related to hierarchical structure and role differentiation among employees. Nurse managers, as well as their staff, often become embattled in institution-wide conflict concerning staffing patterns and how they affect the quality of care. Complex ethical and moral dilemmas often arise when profitable services are increased and unprofitable ones are downsized or even eliminated.

A major source of organizational conflict stems from strategies that promote more participation and autonomy of staff nurses. Increasingly, nurses are charged with balancing direct patient care with active involvement in the institutional initiatives surrounding quality patient care. Nurses who perceive themselves to work in a positive practice environment that creates a cooperative work context are more likely to report effective conflict-management approaches (Siu et al., 2008). The Magnet Recognition Program® of the American Nurses Credentialing Center (ANCC) (2008) identifies interdisciplinary relationships as one of the “Forces of Magnetism” necessary for Magnet™ designation. Specifically, collaborative working relationships within and among the disciplines are valued and must be demonstrated through mutual respect. Magnet™ hospitals must have conflict-management strategies in place and demonstrate effective use, when indicated. The following are other “forces” that are particularly germane to conflict in the practice environment:

Stages of Conflict

Conflict proceeds through four stages: frustration, conceptualization, action, and outcomes (Thomas, 1992). The ability to resolve conflicts productively depends on understanding this process (Figure 23-1) and successfully addressing thoughts, feelings, and behaviors that form barriers to resolution. As one navigates through the stages of conflict, moving into a subsequent stage may lead to a return to and change in a previous stage. To illustrate, the evening shift of a cardiac step-down unit has been asked to pilot a new hand-off protocol for the next 6 weeks, which stimulates intense emotions because the unit is already inadequately staffed (frustration). Two nurses on the unit interpret this conflict as a battle for control with the nurse educator, and a third nurse thinks it is all about professional standards (conceptualization). A nurse leader/manager facilitates a discussion with the three nurses (action); she listens to the concerns and presents evidence about the potential effectiveness of the new hand-off protocol. All agree that the real conflict comes from a difference in goals or priorities (new conceptualization), which leads to less negative emotion and ends with a much clearer understanding of all the issues (diminished frustration). The nurses agree to pilot the hand-off protocol after their ideas have been incorporated into the plan (outcome).

Categories of Conflict

Categorizing a conflict can further define an appropriate course of action for resolution. Conflicts arise from discrepancies in four areas: facts, goals, approaches, and values. Sources of fact-based conflicts are external written sources and include job descriptions, hospital policies, standard of nursing practice, and The Joint Commission (TJC) mandates. Objective data can be provided to resolve a disagreement generated by discrepancies in information. Goal conflicts often arise from competing priorities (e.g., desire to empower employees vs. control through micromanagement); frequently, a common goal (e.g., quality patient care) can be identified and used to frame conflict resolution. Even when agreement exists on a common goal, different ideas about the best approach to achieve that goal may produce conflict. For example, if the unit goal is to reduce costs by 10 percent, one leader may target overtime hours and another may eliminate the budget for continuing education. Values, opinions, and beliefs are much more personal, thus generating disagreements that can be threatening and adversarial. Because values are subjective, value-based conflicts often remain unresolved. Therefore a need to find a way for competing values to coexist is necessary for conflict management.

Modes of Conflict Resolution

Understanding the way healthcare providers respond to conflict is an essential first step in identifying effective strategies to help nurses constructively handle conflicts in the practice environment (Sportsman & Hamilton, 2007). Five distinct approaches can be used in conflict resolution: avoiding, accommodating, competing, compromising, and collaborating (Thomas & Kilmann, 1974, 2002). These approaches can be viewed within two dimensions: assertiveness (satisfying one’s own concerns) and cooperativeness (satisfying the concerns of others). Most people tend to employ a combined set of actions that are appropriately assertive and cooperative, depending on the nature of the conflict situation (Thomas, 1992). See the conflict self-assessment in Box 23-2.

BOX 23-2

Conflict Self-Assessment

Directions: Read each of the following statements. Assess yourself in terms of how often you tend to act similarly during conflict at work. Place the number of the most appropriate response in the blank in front of each statement. Put 1 if the behavior is never typical of how you act during a conflict, 2 if it is seldom typical, 3 if it is occasionally typical, 4 if it is frequently typical, or 5 if it is very typical of how you act during conflict.

________  1. Create new possibilities to address all important concerns.

________  2. Persuade others to see it and/or do it my way.

________  3. Work out some sort of give-and-take agreement.

________  4. Let other people have their way.

________  5. Wait and let the conflict take care of itself.

________  6. Find ways that everyone can win.

________  7. Use whatever power I have to get what I want.

________  8. Find an agreeable compromise among people involved.

________  9. Give in so others get what they think is important.

________ 10. Withdraw from the situation.

________ 11. Cooperate assertively until everyone’s needs are met.

________ 12. Compete until I either win or lose.

________ 13. Engage in “give a little and get a little” bargaining.

________ 14. Let others’ needs be met more than my own needs.

________ 15. Avoid taking any action for as long as I can.

________ 16. Partner with others to find the most inclusive solution.

________ 17. Put my foot down assertively for a quick solution.

________ 18. Negotiate for what all sides value and can live without.

________ 19. Agree to what others want to create harmony.

________ 20. Keep as far away from others involved as possible.

________ 21. Stick with it to get everyone’s highest priorities.

________ 23. Argue and debate over the best way.

________ 23. Create some middle position everyone agrees to.

________ 24. Put my priorities below those of other people.

________ 25. Hope the issue does not come up.

________ 26. Collaborate with others to achieve our goals together.

________ 27. Compete with others for scarce resources.

________ 28. Emphasize compromise and trade-offs.

________ 29. Cool things down by letting others do it their way.

________ 30. Change the subject to avoid the fighting.

Conflict Self-Assessment Scoring

Look at the numbers you placed in the blanks on the conflict assessment. Write the number you placed in each blank on the appropriate line below. Add up your total for each column, and enter that total on the appropriate line. The greater your total is for each approach, the more often you tend to use that approach when conflict occurs at work. The lower the score is, the less often you tend to use that approach when conflict occurs at work.

Collaborating	Competing	Compromising	Accommodating	Avoiding
1. ________	2. ________	3. ________	4. ________	5. ________
6. ________	7. ________	8. ________	9. ________	10. ________
11. ________	12. ________	13. ________	14. ________	15. ________
16. ________	17. ________	18. ________	19. ________	20. ________
21. ________	22. ________	23. ________	24. ________	25. ________
26. ________	27. ________	28. ________	29. ________	30. ________
Total ________	Total ________	Total ________	Total ________	Total ________

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