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Conflict Resolution Share on facebook54Share on twitter3Share on linkedin0Share on reddit1More Sharing Services1.8K

by Antonie Hiemer MS RN

Tags: conflict resolution, tools, nursing, 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 SuccessIntroduction

“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 (Kemp-Longmore, 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 one’s 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 one’s efforts (Team Technology, 2005).

Responses to conflict

I don’t winI winYou winSubmissionAcquiescenceCollaborationAssertivenessYou don’t winWithdrawalBlocking/SabotageAggressionDominance

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.

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 person’s 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 Susie’s* healthcare organization to keep the narcotic cupboard, syringe drawers, medication fridge, and medication cart unlocked during a nurse’s shift and during shift change. So, imagine nurse Susie’s 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 Susie’s 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 Susie’s 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 patient’s 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.

Effective communication skills - DOs

DO maintain appropriate eye contact

Be aware of your own body language and tone

DO ask for clarification

DO ask open-ended questions

Paraphrase at the appropriate time

DO listen

Effective communication skills - DON’Ts

Do NOT look down

Do NOT mismatch your style

Do NOT assume

Do NOT interrupt

References

Baker, K. M. (1995). Improving staff nurse conflict resolution skills. Nursing Economic$, 13(5), 295-317.

College of Nurses of Ontario. (2006). Conflict prevention and standard of care. Practice guideline, 1-16.

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), 385-406.

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

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American nurses associationCarefronting: An innovative approach to managing conflict

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Publication Date: October 2012 Vol. 7 No. 10

Author: Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Nick Chase is an emergency department (ED) charge nurse. He and Michelle Stanley have

worked together for the past 3 years. Their relationship has always been what Nick

describes as “very rocky.” Nick was given the charge nurse role 1 year ago with only 2

years of nursing experience. Although Michelle isn’t interested in being in charge, she has

complained to others about Nick’s lack of experience and immaturity. At times, Michelle

demonstrates bullying behaviors toward Nick and continually questions leadership decisions

that he makes while in his charge nurse role. Clinically, she is a very good nurse. Nick relies

on her expertise to care for very acutely ill ED patients. He had hoped that over time he

would gain Michelle’s confidence and respect but this hasn’t happened. When Nick and

Michelle are scheduled to work shifts together, the atmosphere on the ED team is tense.

Nick has hesitated to discuss the situation with his nurse manager. He has felt that as a

leader, he should be able to manage the conflict and establish a better working relationship

with Michelle.

The dilemma that Nick is confronted with in the scenario above isn’t uncommon. One of the

most significant challenges that nurses face in their work is the management of conflict. In

today’s 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.

Carefronting versus conflict managementThe term carefronting was coined by David Augsburger, a professor of pastoral care, more

than 3 decades ago. Dr. Augsburger believes that conflict is to be expected. It’s the way

that it’s managed that affects relationships. Too often in conflict management, situations

become confrontational. Respect and concern for the individuals involved aren’t considered,

and participants in conflict feel personally violated.

Carefronting takes a different approach to managing conflict. In carefronting, the overall

goal is to attain and maintain effective, productive working relationships. Carefronting is a

method of communication that entails caring enough about one’s self, one’s goals, and

others to confront conflict courageously in a self-asserting, responsible manner.

Principles of carefrontingBetty 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

Nick’s situation in his conflict with Michelle to provide an illustration of how these tenets can

be applied in the practice setting.

1. Truthing it—A simplified speech styleIdentifying truths from different viewpoints is important if conflict is to be managed

sensitively. When “truthing it,” Nick would need to demonstrate the willingness and ability to

listen to Michelle’s viewpoints with empathy and a desire to understand. This will take

courage and humility. Some of what he will hear may be hurtful. He needs to listen carefully,

so he hears accurately what Michelle tells him. It’s also important that Nick is honest about

his own feelings and attitudes. Michelle’s bullying and lack of confidence in his leadership

have been stressful and are affecting staff teamwork. Throughout the discussion, Nick’s

behavior needs to demonstrate that he cares about their relationship.

2. Owning anger—Let both your faces showNick undoubtedly feels some anger toward Michelle for her unwillingness to accept him in

the leadership role. Michelle may feel angry about Nick’s 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 change—Careful 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 don’t 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 trust—A two-way ventureTrust 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 blame—Forget whose fault the conflict isAssigning blame in a conflict inevitably evokes resistance and resentment. Carefronting

ends the blame game. To move forward in conflict, Nick will need to put aside any feelings

that Michelle is responsible for the conflict. By ending the blame game, he can then talk with

Michelle and ask the following questions:

What is the respectful thing to do now?

Where do we go from here?

When do we start to discuss the conflict—If not now, when?

Who will end the blame and help work toward the professional practice environment

we all deserve?

6. Getting unstuck—The freedom to changeGetting unstuck means owning the responsibility for one’s 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. Peacemaking—Getting together againNurse leaders who are peacemakers are caring people who take the risk to be present in

conflict no matter how difficult. This won’t be an easy role for Nick to assume but it’s

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.

Why carefronting mattersThe use of carefronting is especially important in healthcare settings where team synergy

and interdependence are required for high quality and safe patient care. Relationships on

healthcare teams live within the contexts of conversations that team members have, or

don’t have with one another. For Nick to create the type of teamwork that is needed in the

ED, he needs Michelle to support his leadership and open better lines of communication.

Will carefronting work in every situation? Probably not, but it’s worth trying. When it works, it

can lead to remarkable changes in relationships, which ultimately impact the quality of

patient care.

Rose O. Sherman is an associate professor of nursing and director of the Nursing Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton, Florida. You can read her blog atwww.emergingrnleader.com.Selected referencesAugsburger D. Caring Enough To Confront. Ventura, CA: Regal Publications; 2008.

Kupperschmidt B. Addressing multigenerational conflict: mutual respect and carefronting as

a strategy. Online Journal of Issues in Nursing. 2006.

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/

TableofContents/Volume112006/No2May06/tpc30_316075.aspx. Accessed September 6,

2012.

Kupperschmidt B. Carefronting: caring enough to confront. A reprint. The Oklahoma Nurs.

2006;51(2):22-23.

Kupperschmidt B. Conflicts at work? Try carefronting. J Christian Nurs. 2008;25(1):10, 17.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793934/dealing With Conflict

All too often, people avoid dealing with conflict. If you are just starting oncology practice, you may feel especially hesitant to confront conflicts. “Exposing yourself as the one rocking the boat is a little scary when you're first starting out,” comments a young oncologist who has been in practice just over a year, who asked not to have his name appear in this article. “You feel you don't have the authority. But it's just frustrating when everyone has just adapted to an inappropriate situation and doesn't do anything about it.” Indeed, the young oncologist's sensitivity about having his name used is a further example of how issues related to conflict are particularly difficult for those fresh out of fellowship.

Although confrontation is especially hard for those who are just starting out, or those who are not in positions of authority, avoiding it is a common human trait. “People are fearful of conflict,” explains California-based consultant Stanley Wachs, PhD, who has specialized in conflict resolution for more than 25 years. “We avoid confronting other people about difficult issues because we have three or four basic fears.”

Wachs describes the fears of confronting others as follows:

We're afraid confronting them will make the situation worse—that it will become an angry or tearful discussion.

We're afraid confrontation will hurt the relationship—we'll lose a friend or we will not be liked by an associate.

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 failings—“Who are you to raise this with me?”

We fear retribution in some way—“If 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. Disagreeing—the expression of differing opinions in open discussion—is 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:

Steps for Confronting a Difficult Issue

Wachs teaches skills that are “learnable and practicable” to help people confront difficult issues. Using these skills does not eliminate the fear of confrontation, he says, but people can learn the skills to manage their own emotions, their own vulnerabilities. Having such a skill set can help people stop avoiding confrontation—and start those discussions that they need to. For physicians, he draws a comparison to the skills learned during residency and fellowship training. “Physicians do things now that once frightened them, because they learned and practiced the skills.”

Wachs was asked to explain how he would advise confronting this real-life situation described by an oncologist we'll call Susan:

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 step—assessing 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.”

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Choose Words Carefully

The children's chant, “Sticks and stones may break my bones, but words will never hurt me,” is far from the truth. A biting criticism or personal attack can stay vivid in one's memory for years.

In addressing a difficult issue, words take on special importance. Avoid making generalized or absolute statements, such as “You never finish your charts on time” or “This behavior is destroying the office morale.” Avoid the use of superlatives such as worst, most, or highest. Instead, use moderating terms such as sometimes, often, a few times, and possibly.

Use of the word “but” is also a red flag in conflicts. For instance, telling your boss “I really like working here but I feel the call schedule should be changed” is likely to elicit a defensive response. Replace the word “but” with “and” by saying something like “I really like working here and hope the call schedule can be revised in some ways.” Using “and” instead of “but” can open the way to a constructive discussion and resolution without raising the other party's defensiveness.

Be especially wary of labeling people, even in your private thoughts. It's common to categorize or label certain people whom we consider difficult: “Mariella is a whiner”; “Johnson's just dead weight”; Connelly's a real blowhard.” Such labeling is a way we work to classify and organize information, including people, but it can set up negative expectations and generalizations that can be counterproductive. Work at broadening your own views of others to see them as a whole person, not as an embodiment of a specific irritating behavior.

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Mediating Conflict Between Others

Whether in a private practice or a teaching environment, you may be called on to help others resolve conflicts between them. Avoid the temptation to take responsibility for resolving the conflict; as a mediator, your role is to help the parties in conflict explore acceptable options and develop agreement. Even if one of the parties is a “difficult personality” whom you yourself have had problems with, as a mediator you must demonstrate objectivity and fairness, giving the parties equal time and attention, and sufficient time to express themselves.

Establish a Win-Win Approach to Resolution

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:

Take Steps to Resolve Conflict

Returning to our example at the beginning, what if you are that oncologist who has been with the group just 6 months, and the promised health care coverage has not come through? You've followed up with the office manager several times already, but you are afraid to confront the group president about it. You have several fears about talking to him. Maybe the partners aren't really happy with your work. Also, he's very aloof and a little brusque, and you've always felt ill at ease around him. Finally, he might think all you care about is your compensation package instead of focusing on the patients.

Presented with this scenario, Wachs goes right to the protocol outlined for starting a difficult discussion. “It's the same approach whether you are equals or not,” he says. “You start the discussion—‘I need to talk to you about a difficult issue.' You admit your reservations and explain why you are doing it anyway: ‘I hesitated to bring this up because I felt it was just a paperwork problem and I felt anxious about bringing a trivial thing to your attention. I'm mentioning it now because I feel the lack of insurance is putting my family at risk.' You state the facts and ask how he sees it.”

Wachs admits that it really takes courage to confront difficult issues. “We do feel vulnerable and anxious about conflict. But we have to find the compelling reason within ourselves to do it anyway, despite the fear. We say to ourselves, ‘I'm finding the alternative so unbearable, or so inappropriate, I don't want to live like this.' It's really about affirming ourselves as people.”

Using “I” Messages

Use “I” messages when you talk to someone about a problem. “I” messages state a problem without blaming someone for it. This makes it easier for the other person to help solve the problem without having to admit that he or she was wrong. For example, say, “I felt my suggestions were brushed off” rather than “You didn't even listen to what I had to say.”

“You” messages suggest blame and encourage the recipient to argue. Responses to a “you” statement such as “No, I didn't,” or “Well, you were way off-base” are likely to escalate emotions and are not conducive to resolving the situation.

Using “I” messages takes practice—it'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 Options—July 2006, page 187

The Interview: Make It Work for You—September 2006, page 152

Employment Contracts: What to Look for—November 2006, page 308

Joining a Practice As a Shareholder—January 2007, page 41

Principles and Tactics of Negotiation—March 2007, page 102

Professional Advisors: They're Worth It—May 2007, page 162

Building and Maintaining a Referral Base—July 2007, page 227

Malpractice Insurance: What You Need to Know—September 2007, page 274

Develop Effective Communication Skills—November 2007, page 314

Go to:

Additional Resources

1. Wachs Stanley R.: Wachs Associates (www.wachs.com): wachs@wachs.com2. 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

3. Dana D: Managing Differences: How to Build Better Relationships at Work and Home, (ed 4), Mission, KS, MTI Publications, 2005

4. Lancaster LC, Stillman D: When Generations Collide: Who They Are. Why They Clash. How to Solve the Generational Puzzle at Work. New York, NY, HarperCollins Publishers, 2003

Source: http://www.nursingcenter.com/journalarticle?Article_ID=593915

NursingCenter®

AACN Advanced Critical CareJune 2004, Volume :15 Number 2, page 182- 195

Join NursingCenterto get uninterrupted access to this Article

Keywordsconflict, healthy work environments, mediation, working relationships 

Authors Gerardi, Debra RN, MPH, JD

AbstractHealthcare 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 ContentAs 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. 

Costs and Consequences of ConflictThe consequences of unresolved conflict are serious and greatly impact retention of qualified staff, clinical outcomes of patients, the satisfaction of patients and their families, and an organization's financial success. 2-4 The direct and indirect costs of ongoing conflict organizationally include: diversion of resources to litigation, workman's compensation and disability claims; employee grievances, increased turnover, decreased morale, clinical errors, diversion of management time, unwelcome publicity, and disruption of professional relationships. 5-7 Table 1  outlines several of the direct and indirect costs associated with organizational conflict.  

Costs of Unmanaged Conflict

Patients and their families are often aware of the level of teamwork and collaboration within a unit and are dependent upon the ability of the nursing staff to respond to their concerns. 4 Energy that is put into managing a dysfunctional environment is energy that is unavailable for addressing the concerns and needs of patients and families. 5 Clinically, outcomes are directly affected by the extent of collaboration and coordination of care. 8-10 Coordinating care of critically ill patients requires clear communication and effective teamwork. The culture of the unit impacts the

effectiveness of the team. Units in which staff members accept poor communication as status quo expose patients to errors and bad outcomes. 11 A negative culture that perpetuates a "blame and shame" response to adverse events further contributes to an unsafe care environment. 12 Additionally, once a negative culture develops, recruitment and retention of qualified nurses becomes difficult. 1,2 Loss of experienced staff contributes to the stress and unit dysfunction. 

Barriers to Managing ConflictDue to the unique culture of healthcare delivery, there are many barriers that prevent effective resolution of disputes. These barriers include: time constraints, inadequate access to information, poor communication structures, unclear roles, conflicting policies, diversity of education/experience of clinicians, power imbalances, practice variations, high stakes, emotionally charged situations, and fatigue. 13-16 Additionally, competing clinical and operational priorities prevent consistent focus on the management and prevention of conflict situations. 15 For many nurses and physicians, there is little training or skill development in negotiation, listening, communication, or conflict resolution. 13,14 With limited training and with little priority placed on the importance of developing collaborative working relationships, there are few mentors or role models for modeling effective skills and techniques. 13,14There may be an expectation of collaboration and team-work, but there is rarely a clear definition of collaboration, and perceptions vary across clinical disciplines. 2,17,18 Feedback within hierarchical organizations as to appropriate communication and professional interactions is skewed. 19Additionally, nurses have a tendency to avoid addressing conflict directly. 20 With organizational barriers, skill-based deficiencies, few role-models, inconsistent feedback, and avoidant behaviors, it is little wonder that conflict has become an integral part of the clinical setting. The goal for successful collaboration is to overcome these barriers and stay engaged in resolving the issues. 

Organizational ComplexityAssessing 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 

Interdependencies and Working RelationshipsComplex systems have distinct interdependencies that enable coordination of resources and information. These interdependencies exist among departments, professional groups, administrators, and clinicians. 21 Nursing relies on the pharmacy to procure medications for the unit 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? 

Observed Needs: Information

 

Possible Unspoken Psychological Needs: Control, reassurance, to appear responsible. 

Possible Unspoken Emotional Needs: Fear, worry, frustration, guilt. 

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.  

Assessing the Conflict*

Mediation TechniquesMediators 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

The Role of the Advanced Practice NurseThe advanced practice nurse (APN) can play a role in creating a healthy work environment by fostering collaborative relationships. 29 Components of the APN's role include educating staff, serving as a role model, developing and working in collaborative and interdependent relationships, negotiating resources, and establishing effective linkages to accomplish goals. 29 Incorporating mediation techniques into the daily work of the APN allows nursing and physician colleagues to observe effective conflict management strategies, helps meet the needs of patients and families in a nonadversarial manner; and minimizes the consequences of unresolved conflict within the unit. 

Exercises for Learning Mediation TechniquesThe systematic management of conflict makes use of a broad continuum of complementary techniques and processes for addressing differences. Just as clinical care includes alternative treatment modalities, the process of conflict management also has a range of alternatives for 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.

 

Technique 1: Listening for UnderstandingListening for understanding is more than just receiving information, it is a multilayered technique that entails listening without judgment, without planning a response, and without devising solutions or offering advice. Truly attempting to understand what is occurring for another person requires centering, focus, and presence. Taking in information that includes facts, emotions, body language, and context enables the listener to develop an understanding of the needs, interests, and values of the speaker. Listening at this level enables the listener to fully assess the problem before diagnosing or treating the situation. In a busy critical care environment, there is often a perception that there is insufficient time for this level of interaction. However, this technique can be applied to every interaction without an additional commitment of time. Additionally, achieving an understanding of the underlying issues enables the listener to address the correct problem rather than solve the wrong problem, which results in long-term time savings. A method for practicing this technique is described below.

 

Exercise: Listening for UnderstandingExercise 1: Pair up with a coworker. One person is the listener and the other the speaker. For 60 seconds, tell the listener about your favorite teacher from school, a preceptor, a mentor, or a family member. The listener should listen for insight into what is important to this person. What made this person choose this story to tell? What do the characteristics of the teacher described in the story tell you about the speaker's interests or values? Validate your observations with the speaker. Now switch roles and repeat the exercise. What level of understanding were you able to gain by listening in this fashion? Was it more time consuming to listen in this way for 60 seconds than it would have been if you were just listening to the facts of the story? 

Application to Clinical PracticeDo this exercise with a new staff nurse. Consider the information that you obtain. Are the needs or interests you identified a match with the type of preceptor with whom he or she has been? Is the way orientation is structured compatible with what matters to this person? For example, a nurse describes a teacher who took the time to encourage her to explore many different ways of solving a particular problem, and she describes the happiness she felt upon being able to problem solve on her own. Is a very structured and compulsive preceptor a good fit for this individual?

 

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? 

Application to Clinical PracticeAssume that in doing Exercise 2, a patient's family member expressed the following concerns:"No one has come to talk to us today. We don't know what is going on with him. Isn't there a doctor we could talk to? When will he be taken off the ventilator and transferred to the other unit? We thought he would be extubated yesterday and he is still here. He doesn't like the ventilator; can't you do something to make him more comfortable? The nurse last night gave him medication to help him sleep. Why can't you do that? We have been here for a week and there is never the same nurse. Will you be here tomorrow or will there be someone else? We have other family who would like to see him. When will he move out of the ICU?" 

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: ReframingListening 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.

 

There are four steps in reframing a statement:

 

* acknowledge the emotion

 

* remove the inflammatory language

 

* restate the problem or issue

 

* request or wait for clarification or validation from the speaker.

 

 Several examples of reframing, and a re-framing exercise, are listed below:

 

Examples of ReframingStatement 1: "Doesn't anyone know what they are doing around here?" 

Reframed: "You seem to be frustrated, what information would be helpful to you?" 

Statement 2: "He is the most incompetent doctor I have ever seen!!" 

Reframed: "You sound upset. What would help you feel assured that your dad is receiving good care?

 

Reframing ExerciseThere 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!!" 

Journal of nursing managementonlinelibrary.wiley.com › ... › Vol 14 Issue 3

by CG VIVAR - 2006 - Cited by 84 - Related articlesArticle first published online: 14 MAR 2006 ... Journal of Nursing Management. Volume 14, Issue 3, pages ... conflict;; conflict management;; nursing case study

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Putting conflict management into practice: a nursing case study1. CRISTINA GARCÍA VIVAR BSc, MSc, RGN

Article first published online: 14 MAR 2006

DOI: 10.1111/j.1365-2934.2006.00554.x

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Volume 14 ,   Issue 3 ,   pages 201–206, April 2006

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Keywords:

conflict;

conflict management;

nursing case study Aim This paper is intended to put knowledge in conflict management into practice through reflecting on a nursing

case study.

In this issue

 Background Nursing organizations are particularly vulnerable to conflict as the context of nurses’ work may be

difficult and stressful. Power conflict is argued to be an important source of tension within nursing units. Learning to

manage conflict at an early stage is therefore crucial to the effective functioning of nursing organizations. Evaluation A nursing case study that illustrates power conflict in an oncology nursing unit is displayed and reflection

on conflict management from the case is provided. Key issues There is no appropriate or inappropriate strategy to deal with conflict. However, detecting initial

symptoms of conflict and adopting the most effective behaviour to conflict resolution is essential in nursing units. Conclusion Further nursing education in conflict management for staff nurses and nurse managers is greatly

needed.View Full Article (HTML) Enhanced Article (HTML) Get PDF (73K)

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Conflict management styles used by nurses in Jordan1. Zaid Al-Hamdan

1. Assistant Professor, Faculty of Nursing, Jordan University of Science and Technology, Jordan1. Peter Norrie⇑

1. Principal Lecturer and Senior Research Fellow, School of Nursing and Midwifery, De Montfort University, UK

1. Peter Norrie, School of Nursing and Midwifery, De Montfort University, Bosworth House, Leicester LE1 5RR, UK. Email: pnorrie@dmu.ac.uk

1. Denis Anthony1. Professor of Nursing, School of Nursing and Midwifery, De Montfort University, UK

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

nurses’ organisational behaviour

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