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Running head: CONFLICT ENGAGEMENT 1

Nurses’ Perception of Conflict Engagement:

Does Training Impact Intelligence?

Sarah Koepp, Marla Michaels, Sandra Thorson, Becky Tomaselli

University of Mary

CONFLICT ENGAGEMENT 2

Acknowledgements

The University of Mary Graduate Student Team would like to acknowledge the following

individuals for their assistance with the success of this project. Judy Blauwet, DNP, MPH, BSN,

RN former Chief Nursing Officer with Avera Mckennan Hospital and University Center, for

serving as the initial Executive Project Sponsor and for her guidance and collaboration during the

initial phase. Lori Popkes, MBA, BA, RN, NE-BC current Chief Nursing Officer for her

continued support of the project within the organization. Carla Borchardt, DNP, MS, RN, NE-

BC Director of Professional Practice, for her advice and willingness to obtain information

needed during the entire project. Darcy Sherman Justice MS, RN, NE-BC for partnering with

Avera McKennan’s IRB Committee and assuring the project was completed correctly to the

standards of the organization and the committee. Courtney Ehlers, MSN, RN, CPN Director of

Women’s and Children’s Division at Avera McKennan Hospital and University Center, for her

enthusiasm, advice, supplying data and allowing the project to take place in her division. Lana

Shogren for assistance with scheduling meetings. Jamy Anderson, RN Nurse Manager for

providing feedback and immediate data whenever requested. Cinnie Noble, LL.B., LL.M.

(ADR), C.Med., PCC founder of CINERGY™ Coaching, for permission to use the Conflict

Intelligence Assessment tool. A hearty thanks to Jason Douma, Associate Professor of

Mathematics at University of Sioux Falls for his able assistance with statistical analysis. The

team would also like to offer thanks to Joshua Koepp, MA, Professor of Education at

Minneapolis Technical and Community College, for his willingness to edit the paper and offer

constructive feedback. Finally to Claudia Dietrich, MS, RN, NE-BC, University of Mary Project

Advisor, for guidance, support and suggestions throughout the project yet at the same time

allowing the team independence to create a meaningful and servant-focused initiative.


Table of Contents

Executive Statement 7

Problem Statement 10

Significance of Clinical Program 11

PICO Statement 13

Purpose Statement 14

Review of Literature 15

Literature Search 15

Synthesis of Current Literature 22

The Move to Conflict Engagement 22

Staff Satisfaction and Conflict 24

Patient Safety and Conflict 24

Problem Identification 25

Internal Evidence 25

External Evidence 30

Recommendations 31

Role of Emotional Intelligence 31

Educational Methodology 32

Project Implementation Plan 33

Change Theory 33

Key Stakeholders 34

Barriers and Drivers of Change 36


Business Impact 37

Organizational Planning 39

Implementation Plan 40

Project Measurement Plan 41

Human Subject Protection Statement 44

Implementation and Measurement 45

Implementation 46

Emotional Intelligence 46

Engagement Strategies 47

Conflict Engagement Education Session48

Project Outcome Measurement 49

Results 49

Recommendations and Hand-Off Plan 51

Conclusion 53

References 55


List of Tables

Table 1: PICO 14

Table 2: Review of External Data 16

Table 3: Level of Evidence 16

Table 4: Organizational Conflict Assessment Questions 26

Table 5: Avera McKennan Employee Opinion Survey 28

Table 6: Conflict Engagement Project SMART Goals 42

Table 7: Specific Engagement Strategies 47

Table 8: Plot Grid Results 51


List of Appendices

Appendix A: Fishbone Diagram 61

Appendix B: Lewin’s Change Model 62

Appendix C: Host Organization Letter of Support 63

Appendix D: Agenda for Education 64

Appendix E: PDSA Cycle 65

Appendix F: Conflict Intelligence Self-Assessment 67

Appendix G: Permission 69

Appendix H: IRB Application 70

Appendix I: Education Presentation 77

Appendix J: Statistical Comparison 81

Appendix K: Hypothesis Test Study 84

Appendix L: Leadership Presentation87


Executive Summary

The Chief Nursing Officer at a large, central mid-western hospital noted that

communication between nurses could be improved. She expressed this desire to a Registered

Nurse in the Women’s and Children’s Division of this facility. This RN also happened to be a

student in the Masters of Science in Nursing, Nurse Administrator program through University

of Mary. Could nurses have improved emotional intelligence after education about conflict

engagement? The beginning idea for an Evidence Based Practice project was born.

The goal of this project was to determine if nurses’ perception of their conflict

intelligence was improved after training. It is known that improved intelligence leads to better

resolution skills (Brinkert, 2010). When nurses engage in conflict, rather than avoid it, patient

safety, as well as staff satisfaction, improves (Scott & Gerardi, 2011).

With careful review of internal and external evidence, an implementation plan was

developed utilizing the Plan, Do, Study, Act (PDSA) methodology which is the primary method

utilized by Avera McKennan. Resource Nurses, a position similar to a charge nurse, were

educated about conflict engagement with an assessment pre- and post-training. The assessment

tool underscores the value of emotional intelligence in relationships and in self-perception. The

tool was created by CINERGY™ and permission has been given by the author to utilize this tool

in the project. The goal of the education was to have a 15% increase in conflict intelligence

assessment scores from pre-assessment to post-assessment.

Implementation consisted of two educational sessions attended by twenty two Resource

Nurses in the Women’s and Children’s Division of Avera McKennan Hospital and University

Health Center. This was a 40% participation rate, which was adequate given the complicating

weather conditions each day of the seminar. Provided in both a lecture and case study review


format, the sessions provided time for practice with accurate scenarios and strategies. The

Conflict Intelligence Tool was given pre and post education.

The project measurement of the conflict intelligence self-assessment scores provided a

result of an increase in 6.9%. Although this was not the anticipated 15% increase, it was still

statistically significant (p = 0.004 Mann-Whitney U-Test). Of note, the language of the survey

items refers to how the respondents act/react/behave, however the Resource Nurses did not have

time to practice these skills prior to reassessment. Their responses indicated a self-awareness

rather than an actual behavior. The recommendation of the Graduate Student Team is to provide

the Conflict Intelligence Self-Assessment to these same participants three to six months post

education for a true measure of applied conflict engagement behavior. This is also a valuable

program that will be presented to the Strategic Council for dissemination throughout the entire

organization, including the Nurse Residency program at Avera.

Conflict is present in every industry but has clear detriments to hospital personnel

involved in chaotic and emergent life situations. When the conflict is managed both tangible and

intangible rewards are seen. Educating the Resource Nurses at this facility is the first step toward

safer care and more satisfied staff. This approach aligns with the mission of this hospital: a

positive impact is made in the lives and health of persons and communities by providing quality

services guided by Christian values (Mission, Vision, Values, 2015).


Nurses’ Perception of Conflict Engagement:

Does Training Impact Intelligence?

Conflict is a situation in which personal interactions between two or more individuals

creates a difference of opinion leading to tension and frustration (Gerardi, 2015a). Due to the

complex and high-stakes setting of healthcare, the negative outcomes of conflict can be

devastating to professional relationships and patient outcomes. Not only does conflict affect

nurses horizontally, it can also occur vertically between disciplines such as physicians to nurses

or physicians to nurse managers (Scott & Gerardi, 2011). However, if the conflict is properly

addressed and a solution is reached, relationships can be strengthened and communication

between parties will be enhanced. It is important for nurse administrators to facilitate and

encourage conflict engagement among all members of their staff.

Nursing leadership should recognize nursing staff will encounter conflict in the

healthcare environment at some point in their career. Conflict is usually an ongoing process and

is not easily addressed in one conversation (Johansen, 2012). Once conflict is addressed, it can

lead to improved communication, trust built through the satisfaction of compromise, and a

stronger bond within the entire team (Gerardi, 2015a).

Failure to resolve the situation may lead to mistrust, negative impact on self-esteem,

possible loss of professional as well as personal growth, unwillingness to compromise in future

settings as well as physical and mental stress (Brinkert, 2010). Unaddressed conflict can also

affect the organization by a loss of team engagement, amount of time spent by the nurse manager

to assist staff with the issues, loss of staff due to resignations as well as the loss of a collaborative

environment (Scott & Gerardi, 2011). Unresolved conflict also has an impact on patient safety.

The Joint Commission (2008) makes a clear link between poor communication and its impact on


medication errors. It is in the key stakeholders’ best interest to address conflict and work towards

a solution which satisfies the goals of the organization. When unresolved conflict is recognized

at a healthcare organization (HCO), a process improvement project can assure advances are

made.

Evidence-based practice (EBP) is defined as “a clinical problem-solving strategy that

emphasizes the integration of best available evidence from disciplined research with clinical

expertise and patient preferences” (Polit & Beck, 2012, p. 727). It includes the patient clinical

state, the setting, and the circumstances. EBP integrates primary research as the basis for change

in practice. EBP is an ideal choice for nurse administrators to use in practice. The competency

standards of The American Organization of Nurse Executives (AONE) explain nurse leaders

need to have a keen sense of the healthcare environment, including evidence based practice (The

American Organization of Nurse Executives, 2005, p. 4). EBP projects reflect the daily existence

of a competent nurse leader. Utilizing evidence based nursing and evidence based management

to the fullest yields true and lasting results. It is up to the nurse leaders of the future to foster and

encourage these projects. This paper will serve to outline the steps involved in the EBP project

related to conflict engagement at Avera McKennan by surveying nurses about conflict

intelligence as completed by the Graduate Student Team at University of Mary.

Problem Statement

In the complex, dynamic, and chaotic health care delivery environment, and within each

patient care setting, the ultimate goal of an organization is to provide a climate of optimal patient

care by the medical team and ancillary staff (Roussel, 2013). This can only be achieved by

adhering to a set of standards including the ability to enhance collaborative relationships,


embrace change and innovation, manage resources effectively, negotiate and resolve conflict,

and communicate effectively using information technology (Roussel, 2013).

The highly technical, intense, personal, and emotional work that nurses do, and the

critical nature of outcomes, predicates the need for organizations to provide an optimal teamwork

supported environment. The nursing administrative and leadership group at Avera McKennan

Hospital and University Health Center has indicated that due to a noted presence of poor

communication patterns among nurses, they are requesting the inquiry for this project be focused

on educational interventions for nursing staff revolved around the development of skills needed

to recognize and improve communication techniques and conflict engagement.

Managing conflict among staff members in the high-stress, high-stakes health care arena,

which is heavily regulated by internal and external entities, and under constant, complex

transformation to remain compliant and competitive, can be quite challenging. In the past, the

focus has been on conflict resolution. However, while the complete resolution of conflict is the

most desired outcome, it is rarely the case (Gerardi, 2015a). More recently, there has been a

movement towards the practice of continuous conflict engagement. With the problem identified,

it was important to investigate the significance that mismanagement conflict can have in

hospitals today.

Significance of Clinical Problem

Conflict is inherent in every industry and every workplace, but healthcare poses unique

challenges. Workflow demands continue to change as a result of health care reform and value

based purchasing forcing organizations to adopt new care delivery models, processes and

structures. (Kim, Nicotera, & McNulty, 2015; Rosenstein, Dinklin, & Monroe, 2014). In

addition, advances in technology, computerization, and knowledge, as well as increasing


demands for access and expectations for care, have added even more stressors into nursing

practice globally (Rosenstein, Dinklin, & Monroe, 2014). All of these factors can create stressful

working conditions and intense emotions. Conditions like these make it more difficult for nurses

to set aside differences and conflict to work as a cohesive team (Gerardi, 2015a; Gerardi, 2015b).

Porter-O’Grady & Malloch (2011) point out that conflict engagement takes into account

the wide range of factors in which people differ: culture, race, gender, social status and income

group. Education, intelligence, personal values, attitudes, and emotional maturity are also factors

that typically result in individuals or groups perceiving themselves with an equality disparity in

some way and can influence conflict (Porter-O’Grady & Malloch, 2011). While conflict is a

normative part of the human experience, and present in every profession, nursing has a serious

issue with persistent, constant conflict between colleagues that has been found to be on the rise

all over the world (Binkert, 2010; Porter-O’Grady, T., & Malloch, K., 2011).

Conflict among nurses affects HCOs in all aspects, including clinical outcomes, the well-

being of staff, patient safety, and cost of services (Girardi, 2015a). Most often, poor

communication is at the heart of conflict and rather than dealing with it head on, most

individuals would rather just avoid it (Trossman, 2011). Nurses generally do this by creating

innovative ways to work around conflict, which puts teamwork, patients, and joy at risk.

Complex adaptive system (CAS) theory places less focus on prediction and control with

more focus on creating conditions and fostering relationships. This focus creates the opportunity

to allow the evolution and production of positive creative solutions for effective conflict

engagement strategies (Roussel, 2013). Change is difficult for most individuals. Actively

engaging nurses in the process of change will create an atmosphere of constant learning while

building and sustaining trust with constructive honesty among nursing staff. (Roussel, 2013).


These essential practices in the nursing work environment have been identified and

outlined in an effort to keep patients safe (Roussel, 2013). In the end, it is the responsibility of

organizational leadership, managers, and educators to ensure conflict inconsistencies are

addressed and endeavor to break the barriers that stand in the way of progress toward positive

patient and nursing outcomes. Implementing educational initiatives to manage conflict among

nurses must be a priority for HCOs. This focus will provide healthy work environments for

nurses and protect the delivery of quality, safe patient care (Scott & Gerardi, 2011).

PICO Statement

PICO is an acronym for a process which involves identifying the patient population, an

intervention, a comparison, and an outcome. If the question is too broad, searching for wrong or

irrelevant information could occur (Melnyk & Fineout-Overholt, 2011). It is important to be

able to find the appropriate research when making an inquiry about patient practice. Melnyk and

Fineout-Overholt (2011) state a PICO question helps the practitioner hone in on the correct

evidence.

This conflict engagement project employs a meaning question as opposed to an

intervention, diagnosis, or etiology framed question. A meaning question address how one

experiences a phenomenon (Melnyk & Fineout-Overholt, 2015, p. 537). Meaning questions are

very different than what is typically seen with a PICO question as they are qualitative in nature.

Meaning questions frequently do not require a comparison or exact timeframe. Instead, this

framework concentrates on the Population’s (P) reaction to a certain phenomenon (Melnyk &

Fineout-Overholt, 2015, p. 36). For this inquiry, the PICO question is found below and in table 1.

Do nurses who are surveyed pre and post educational intervention perceive having

increased conflict intelligence?


Table 1

PICO Statement

Population Nurses who work in the Women’s and Children’s Division

Issue of Interest Conflict Engagement Education

Comparison Pre and Post Education

Outcome Increased conflict intelligence

A well-crafted question can be the key to a successful EBP project or one that fails to

impact change (Melnyk & Fineout-Overholt, 2011). Additionally, a well-written PICO question

can aid in communicating the exact project’s intent. Finally, a clear PICO question will assist in

driving the purpose statement.

Purpose Statement

A component of the scientific research methodology, which carries into EBP, is the

importance of setting a direction for the project by creating a purpose statement. Polit and Beck

(2012) state a purpose statement is “a broad declarative statement of the overall goals of a study”

(p.743). The purpose of this EBP project will be to increase conflict intelligence in nurses who

practice in the Women’s and Children’s division of a hospital located in the central Midwest

with use of conflict engagement education and self-assessment of intelligence scores. By

increasing intelligence, staff satisfaction and patient outcomes will be indirectly impacted. For

this project, Gerardi’s (2015a) definition of conflict engagement is utilized where one

“intentionally engages in conflict by using relational intelligence to understand systematic

patterns and group dynamics” (p. 56). Conflict intelligence is defined as the awareness of


knowing and understanding of how one engages in conflict (Conflict Intelligence Self-

Assessment, 2015).

Review of Literature

A literature review regarding conflict was obtained through personal evidence, research,

and information provided by Avera McKennan. External and Internal data are necessary

components of an EBP project’s success. One of the first steps is to conduct a literature search

for relevant external data.

Literature Search

Conflict is a normal occurrence in all industries. Nursing has a serious issue with

persistent, continuous conflict between colleagues and is on the rise across the globe. There is

considerable research on conflict in the workplace but minimal research is available related to

the new concept of conflict engagement. The American Nurses Association (ANA) and

American Organization of Nurse Executives have recommended the change from conflict

resolution to conflict engagement which in turn provided the focus for the literature review for

this project.

The literature review for this project utilized the following search engines: Cumulative

Index to Nursing and Allied Health Literature (CINAHL), Medline, PubMed, and Google

Scholar. The time frame for searches for current periodicals was limited to 2009 to 2015, with

the exception of any core literature to support the key concept of conflict resolution as the basis

for moving to the new model of conflict engagement. The robust review of the literature pointed

to three common themes: conflict engagement replaces conflict resolution, conflict engagement

tied to patient safety, and conflict engagement enhances staff job satisfaction. There exists a

plethora of literature on adult learning principles which is addressed in discussion of barriers to


the project. The following tables describe the search terms, number of results, selected articles,

and levels of evidence.

Table 2

Review of External Data

Key Search Terms PubMed CINAHL Medline Google Scholar

Conflict + Resolution + Patient Safety 119 86 89 184,000Conflict Engagement 467 26 51 1,620,000Adult Learning 136,435 1,000 2,366 3,220,000Adult Learning Styles 861 25 23 1,100,000Adult Learning Strategies 6,051 34 36 3,310,000Adult Learning or Adult Education 301,309 2,690 5,452 3,250,000Nurse + Satisfaction + Conflict + Engagement

8 4 2,543 71,400

Nurse + Conflict + Education + Engagement

16 7 6,409 119,000

Nurse + Conflict + Education + Engagement + Satisfaction

4 3 1,593 61,800

Adult + Education 108,334 2,779 3,275 3,530,000

Table 3

Level of Evidence

Reference Citation Research

Methodology

Level of

Evidence

Key Findings

Baker, Gustafson, Beaubien, Salas, & Barach (2003)

Expert Opinion VII Medical errors can be reduced by providing a training program for teams of health care providers. This provides a pragmatic and effective strategy to enhance patient safety. There remains many opportunities for future research on interdisciplinary team


training and promoting effective teamwork.

Brinkert (2010) Systematic Review V Synthesis of literature on conflict communication causes, costs, benefits and interventions. Sources can be managed, costs decreased, and benefits increased with both direct and indirect interventions.

Brinkert (2011) Qualitative Study VI Conflict communication competencies of nurse managers can benefit from conflict coaching. Specific scenarios used to manage better coaching approaches.

Donabedian (1988) Article VII Landmark article presenting a Model of Patient Safety. Provided validation that errors are tied to system or process issues, not individuals.

Gerardi (2105a) Article VII Focus moving from conflict resolution to conflict engagement. In complex adaptive systems, understanding conflict is a key component of conflict intelligence.

Gerardi (2015b) Article VII It is important to look for patterns related to conflict and not focus on a single event. Nurse managers are challenged to interfere with dysfunctional


patterns and promote positive relational engagement.

Gerardi (2015c) Article VII Conflict engagement encourages processes that bring the affected individuals together in a safe space, as soon after the event, to promote early and direct resolution of the conflict. Focus should be on trust and encouraging collaboration.

Gerardi (2015d) Article VII Conflict intelligence in complex systems requires an organization to build the capability to engage in conflict by understanding the relationships within healthcare. Adopting a relational stance encourages conflict engagement.

Gerardi (2015e) Article VII Emotional intelligence competencies, such as, self-awareness, self-regulation, correlate with the use of collaborative conflict engagement. Social intelligence is built from emotional intelligence.

Gerardi (2015f) Article VII Creating connection and cultivating curiosity builds trust and demonstrates the importance of relational values and mutuality, in turn encourages


collaborative problem solving.

Harris, Treanor, & Salisbury (2006)

Article VI Patient safety can be improved with team coordination. Although there may be a formal program there are recognized challenges to changing the culture and transforming an organization to one of safety first.

Johansen (2012) Article VII Conflict resolution is a required element of a healthy work environment. The skill to handle conflict efficiently and effectively allows for improved quality care, improved staff satisfaction and morale, and corrals work stress. Nurse managers must develop their skills for effective and sustainable conflict resolution.

Kim, Nicotera, & McNulty (2015)

Qualitative Study VI Nurses perception of constructive conflict management include the use of collaboration and cooperative communication. The result is quality patient care and increased staff satisfaction and morale.

Lux, Hutcheson, & Peden (2014)

Qualitative Study VI New graduates are faced with many complex issues when entering the work


force. Communication skills that encompass dealing with hostile personalities, and giving and receiving constructive criticism, should be incorporated into nursing curriculum.

Marshall & Robson (2005) Article VII Incorporating conflict resolution skills into the workplace assist in managing and increasing patient safety. Effective communication, collaboration, connection, and bring the right people together are all components of a successful conflict resolution program.

Roche & Teague (2012) Quantitative Study VI There are many literature references to the theory of conflict management systems. The design of these programs vary but the study validated that the managers involved in the conflict management system must be involved in the design and evaluation of such systems.

Rosenstein, Dinklin, & Munro (2014)

Article VII The complexity of the current health care system has placed pressure on workers and negatively impact attitudes, feelings, and behaviors which may then result in poor work relationships


and patient care. Organizations need to understand these stressors and build a multidisciplinary collaborative approach to conflict resolution.

Scott & Gerardi (2011) Expert Opinion VII The Joint Commission provides expert opinion for a strategic framework to address conflict as an essential step of providing safe patient care. Leadership should be actively engaged to develop methods for improving organizational conflict competence. Conflict assessment is the first step in moving from conflict avoidance to conflict engagement.

The Advisory Board Company (2014)

Article VII Nurses are more comfortable telling doctors about errors rather than approaching peers.

The Joint Commission (2008)

Expert Opinion VI Landmark opinion that described behaviors that undermine a culture of safety. Identification of root causes and contributing factors helped to establish the Joint Commission’s recommendations to organizations for program implementation.

Timmins (2011) Article VII Good communication skills are the


framework for conflict competence. Managers have a responsibility to assure formal support methods are provided to staff.

Trossman (2011) Article VII American Nurses Association (ANA) provides program details for a conflict engagement program. The program consists of online education module, facilitator led skills based learning session, and coaching component.

Synthesis of Current Literature

A variety of external data sources exist which include systematic reviews, randomized

controlled trials, meta-synthesis, and case control studies. It is important to gather the right

evidence from the right sources to support the PICO question. Three themes were determined

while conducting a literature review related to conflict: engagement, staff satisfaction, and

patient safety.

The Move to Conflict Engagement. Conflict is inherent in any environment from

personal to workplaces. The increased complexity of the current health care system puts

additional strains on resources and creates an environment ripe for conflict. Managing conflict is

an important program for all health care organizations. The American Nurses Association (ANA)

along with the American Organization of Nurse Executives (AONE) recognize the importance of

providing a grounded program. Conflict is not always resolved. ANA and AONE have


recommended a change from conflict resolution to conflict engagement (Trossman, 2011).

Conflict engagement is a relational model which cultivates conflict competence (Gerardi,

2015a). As complex adaptive systems, organizations need to build conflict engagement programs

that recognize the quality and pattern of relationships as a key to conflict engagement.

It is important to look for patterns related to conflict and not focus on a single event.

Nurse Managers are challenged to interfere with dysfunctional patterns and promote positive

relational engagement (Gerardi, 2015b). Workplace dynamics point to the ever-changing

complexities associated with conflict engagement. Barriers to engagement must be assessed.

This assessment can lead to the ability of staff to begin to engage relationally to conflict.

Recognizing conflict engagement is a collaborative process is key to developing a

successful and sustainable conflict engagement program (Gerardi, 2015c). “Processes that

encourage engagement include mediation, coaching, facilitation, dialogue, and collaborative

problem solving” (Gerardi, 2015c, p. 67). All of the processes should be evaluated for inclusion

in the program. Creating a safe place for collaboration is an aspect that nurse managers must

recognize and support.

Developing systems that support a sustainable conflict engagement program takes time,

commitment, and ongoing refreshing. An environment that cultivates connection provides the

basis for building trust, demonstrating respect, and encouraging discussions pointing to

resolution of issues (Gerardi, 2015f). Practicing the skills that create connection can be

accomplished by utilizing an approach called PEARLA: “presence, empathy, acknowledgement,

reflect or reframe, listen openly, and ask questions” (Gerardi, 2015f, p. 61). Case scenarios and

role playing should be incorporated into any conflict engagement program so the participants can

practice their new skills in a safe environment; this recommendation was followed for the


conflict engagement education sessions. These recommendations built the infrastructure to

support and sustain increased conflict engagement intelligence.

Staff Satisfaction and Conflict. A qualitative study conducted by Kim, Nicotera, &

McNulty (2015) pointed to nurse job satisfaction when constructive conflict engagement was

utilized. “Results showed that quality patient care and cooperative communication contributed to

the perception that conflict is constructive in nature” (Kim et al., 2015, p. 2073). Another

qualitative study completed by Lux, Hutcheson, & Peden (2014) discussed the need for new

graduates to be provided with education on conflict engagement and dealing with constructive

criticism in order to increase retention and job satisfaction. Providing all staff with the tools to

manage and engage in conflict, rather than running from it, will continue to enhance job

satisfaction, create a culture of patient safety, and increase positive outcomes.

Patient Safety and Conflict. Patient safety has been linked with conflict in the

healthcare environment. The first known research to show that outside influences contribute to

errors was Donabedian’s sentinel research. Donabedian (1988) stated errors are tied to a system

or process not necessarily individuals. This model proved to be the founding model for modern

quality improvement work in HCOs today. Kunkel, Rosenqvist, and Westerling (2007) further

incorporated Donabedian’s (1988) Model of Patient Safety to positively show that the

hypothesized relationships between structure, process, and outcome are related. Almost all

medical errors can be attributed to a structure or process failure which results in a poor outcome

(Kunkel et al., 2007).

The Institute of Medicine’s (IOM) 1999 report To Err is Human: Building a Safer Health

System outlined the financial, personal, and societal cost of medication errors (Baker, Gustafson,

& Beaubien, 2003). Out of that report came an increased focus to determine causes of such


errors; miscommunication was a primary contributor. As a result, many medical team

performance models were created: Anesthesia Crisis Resource Management (ACRM) and

Medical Team Training (MTM) as well as Team Oriented Medical Simulation (TOMS) and

others (Baker et al., 2003). In spite of these successful models, nothing has been widely accepted

as team communication and coordination training across hospitals in the US.

Team communication is still an issue in recent years. The Joint Commission (2008), in

their Sentinal Event Alert Issue 40 about behaviors that impact safety, cites that rather than

confront a safety issue, 40 percent of healthcare providers have kept quiet or remained passive

during patient care events. The Advisory Board’s (2014) Nurse Executive Center published data

which states nurses are more comfortable talking to doctors about errors rather than approaching

peers. Collaboration, teamwork, and communication are necessary components of providing a

safe patient care experience. It was important to understand current literature about conflict in

order to fully identify the problem.

Problem Identification

Understanding any problem is important in a thorough quality improvement program.

Evidence-based practice relies on the premise that the outcome of solving the PICO question will

drive implementation of new practices (Melnyk & Fineout-Overholt, 2011). Through process

analysis utilizing a fishbone diagram, possible gaps were identified. The fishbone diagram for

this EBP can be found in Appendix A. An important step in identifying gaps was through data

collection at Avera McKennan.

Internal Evidence

Internal data is information obtained at the HCO in order to answer the question

appropriately (Melnyk & Fineout-Overholt, 2011). Internal data may include items from a


healthcare record, managerial reports, quality data, or information obtained from occurrence

reports. Internal data should be specific to the question asked and relate directly to the variables,

or outcomes, in the PICO question.

An important component of instituting a conflict engagement strategy is to undergo

internal data collection via a conflict assessment. Scott and Gerardi (2011) provide a template for

internal data research into conflict assessment (p. 67). This template was modified and given to

the leadership at Avera McKennan to complete. Table 4 shows key questions related to historical

conflict engagement practices at Avera McKennan. Scott and Gerardi (2011) state a conflict

assessment should include four domains: resource issues, structural issues, relationships, and

unique organizational issues (p. 67). An organizational assessment should include questions from

all domains and be open-ended in nature.

Table 4

Organizational Conflict Assessment Survey Questions

Resource Issues Structural Issues Relational Dynamics Contextual IssuesWhat resources are

available for implementing a

conflict management process?

What is the current process for addressing conflict among staff?

How would you characterize the current

relationships among staff?

Are there any current significant

disputes among staff or within

groups that conflict could

impact the design process?

Who has sufficient conflict management

expertise to implement a process

for staff?

How effective is the current process?

Describe how conflict has been managed

respectfully in the past.

When conflicts are effectively

addressed, what has enabled them

to go well?

What are the most significant types of conflict that occur among the staff or

What works best for managing conflict among staff at this

organization?

How has retaliation been addressed in the past?

What strengths does staff possess that you can build

on?


division?

Do reoccurring patterns emerge from personalities or from

sensitive subject matters?

What aspects would an ideal process

include?

Are there particular individuals who are at the heart of most major

conflicts?

Have there been times when the

staff has worked well together?

Has the CNO set a tone or expectation

that there are no conflicts (and so they

may be festering below the surface)?

What is the time frame for developing the new process and

implementing it?

Do people deal with each other directly or look for ways to defer

addressing the conflict to others?

Are there any upcoming projects or organizational

changes that could escalate current

conflicts?

The results from the internal assessment indicated conflict engagement education was

needed. The resources available for implementing a conflict engagement strategy included

utilizing the Resource Nurses as they tend to be the front-line staff involved in conflicts

(personal communication, C. Ehlers, December 4, 2015). Additional resources included nursing

grand rounds and engaged senior leadership. C. Ehlers stated the only current process utilized

was 1:1 communication and Nurse Manager involvement (personal communication, December 4,

2015). These processes were used only as well as the Resource Nurses were comfortable with

direct communication. The feeling expressed from Ms. Ehlers was that direct conflict

communication was not used as widely as it should have been with the biggest barrier involving

individual confidence in having objective conversations with each other (personal

communication, December 4, 2015). The biggest sources of conflict in the Women’s and

Children’s Division were staffing related as well as patient flow or transferring patients. Themes

of unfairness emerged between units, and served as some of the foundation for educational case

studies (C.Ehlers, personal communication, December 4, 2015).


Beyond an organizational assessment, numerical data was also important internal

evidence to gather. When first meeting with the Director of Professional Practice, initial thoughts

were to utilize Avera Health’s National Database of Nursing Quality Indicators (NDNQI) results

(personal communication, C. Borchardt, October 8, 2015). Over 1,100 health care organizations

are currently using the NDNQI on a quarterly as well as annual basis to assess the quality of the

nursing care that is provided directly to the unit level and how it relates to patient outcomes.

Organizations that participate also have the opportunity to compare their outcomes to similar

units throughout the nation (Montalvo, 2007). However, after further review of the information,

it was discussed that the questions do not specifically relate to conflict.

A meeting was then held with the Director of the Women’s and Children’s Division who

determined that more accurate information relating directly to conflict would be obtained from

the Employee Opinion Survey (personal communication, C. Ehlers, October 15, 2015). One

question specifically related to how well conflicts are managed in the department; the responses

ranged from 1 to 5 with 5 being the highest (Employee Satisfaction and Engagement Research,

2015). Table 5 outlines the scores of the nursing units in the Women’s and Children’s Division.

Table 5

Avera McKennan Employee Opinion Survey

Work Group Question Work Group Mean

National Work Group Comparison

NICU How well are conflicts managed in your department?

2.36 3.13

Labor and Delivery

How well are conflicts managed in your department?

3.29 2.88

Post-Partum and Newborn Nursery


2.86 3.00

Pediatrics and PICU


2.60 3.13


NICU staff showed a rating of 2.36 with the national work group comparison being 3.13.

Identified variables in this score include a change in management and opening a new unit. There

were additional questions relating to communication, constructive feedback, and personal

recognition not displayed in Table 5. This NICU scored lower than the national work group

comparison on all of the additional questions as well.

All of the scores of the labor and delivery unit (L&D) showed above the national work

group comparisons. Their conflict management score is 3.29 and the national work group is 2.88.

The manager of L&D is well liked throughout her department and had high scores from her

employees on her performance review.

Post-Partum and Pediatrics also scored lower than the national average in conflict. This

unit does have high turnover; some of the nurses transfer to the OBGYN clinics due to clinic

hours and a work/life balance. Some of the scores on the additional questions demonstrated the

staff felt uncomfortable with communication on their unit. Many are new staff and may not be

involved with committees and may not be aware of ways to get involved on the unit. The

Pediatrics Unit recently went through a change in management as well as a new nurse educator

which may have been a reflection of the lower score. During a meeting held with the Director of

the Division she stated that they are satisfied with any type of an increase in the scores (personal

communication, C. Ehlers, December 3, 2015).

Management does become concerned when there is any type of decrease noted. The

lower scores demonstrated nursing staff did not feel comfortable in one on one conversations

with their colleagues or manager. The NICU, Post-Partum, and Pediatrics staff demonstrated that

conflict engagement education was needed to provide them with the tools to be confident in


having an uncomfortable conversation with a colleague. Education was targeted at all areas in

the Women’s and Children’s Division as almost all showed lower than average conflict scores

when compared to national averages.

The Graduate Student Team contact also met with a Human Resources (HR)

representative to determine if any metrics existed internally about conflict engagement. Most

conflict is handled directly by Nurse Managers. No official tracking exists within the hospital to

count specific conflict episodes. However, according to L. Flute, two tracking domains do exist

in which conflict issues could be generally counted: performance issues and behavior issues

(personal communication, November 10, 2015). Of the corrective action which HR was involved

in for the fiscal year 2014-2015, 30% of the involvement was for performance issues and 22%

was a result of behavior issues (personal communication, L. Flute, November 10, 2015).

Therefore, while HR is important in employee relations, no data was reported related to specific

conflict engagement activity throughout the hospital. It may be important for the HCO to track

these percents long term to note if conflict engagement education impacts either performance or

behavior HR involvement. It was also important to determine how internal surveys and HR data

related to known external evidence for a successful project implementation.

External Evidence

External evidence is generated through rigorous research of the literature. When

implementing external evidence from research, it is important to ask the question of whether

clinicians can achieve results in their own clinical practices that are similar to those derived from

a body of evidence (Melnyk & Fineout-Overholt, 2011, p. 4). Data has guided each aspect of this

project. Once the internal data indeed demonstrated a need for education, the three themes found

in the literature review were applied to the project at Avera McKennan.


First, it is important for staff to understand the concept of engagement. It may not be

possible for all conflicts to be resolved but it is important to engage with peers. Second, staff

should understand how resolving conflict will positively impact their experience as staff

members of the Women’s and Children’s Division at Avera McKennan. A direct correlation

exists for increased professional satisfaction when healthcare workers have been educated and

emotional intelligence raised. Finally, patient safety is important to include in this project. These

three topics were further explored as recommendations for this project.

Project Recommendations

Based on literature supporting conflict engagement, it was necessary to implement an

education program in the Women’s and Children’s Division as requested by administration to

address conflict engagement gaps among nurses. The change necessary to close the gap was to

enlighten the attitude and thought processes of nursing staff so that when situations mired in

conflict arise, they can be managed with strategic education and enhanced knowledge.

Two key components of this education were self-assessment of emotional intelligence and an

opportunity to engage in case study review and role playing with tips and strategies.

Role of Emotional Intelligence

While functional conflict may serve to generate new ideas, dysfunctional conflict is an

unhealthy focus on people and emotions rather than the work to be done (Nelson & Quick, 2013,

p. 473). Additionally, Abdallah and Ahuwalia (2013) state a lack of trust creates such high

barriers to successful team functioning that employees cannot adequately develop in their roles.

The unhealthy focus on emotion as well as distrust may be a result of amygdala hijacking.

Horowitz (2014) describes this phenomenon as a defensive biological response. The hallmarks

of an amygdala hijacking are a strong emotional reaction which is sudden in onset. Upon


reflection, people often realize comments made during an amygdala hijack were inappropriate

(Horowitz, 2014). The antidote to an amygdala hijacking is emotional intelligence (EI). Staff

members who display high EI get promoted more and are overall more effective at managing

conflict (Horowitz, 2014). Nelson and Quick (2013) also discuss the importance of EI in their

conflict engagement strategies. Borrowing on the research related to amygdala hijacking and the

importance of emotionally intelligent workers, Brinkert (2010) states, “high emotional

intelligence was associated with the desirable nursing conflict style of collaboration suggesting

intelligence surveys are useful in training programs” (p. 151). Therefore, the first

recommendation was to utilize a survey with an emphasis on emotional intelligence.

Educational Methodology

In order to incorporate the adult learner activities, it was important for the educational

trainer to be aware of the participants’ general ages, education levels, culture or ethnicity. Brady

(2013) states adults prefer to use audio and visual methodologies. Additionally, learning in a

social or group setting using logic and reasoning by incorporating case studies and critical

thinking is preferred (Brady, 2013). Most importantly, adult learners prefer the information

provided is related directly to them and that it is information which will be applied in practice

(Pappas, 2013).

Marshall and Robson (2005) specifically address how to educate nurses utilizing these

principles with conflict engagement strategies. First, the authors state training and education are

foundational efforts for providing conflict engagement skills because lack of education leads to

blame and under-reporting (Marshall & Robson, 2005). Since communication is at the root of the

engagement process, the training must include time for role-playing in groups. Role specific

patient safety scenarios were used for practice to increase comfort when a real conflict occurs.


Finally, Marshall and Robson (2005) recommend annual training brush-up sessions to renew

conflict engagement skills. This plan was endorsed by the sponsoring organization.

Project Implementation Plan

Conflict is a normative part of the human experience and present in every profession.

Conflict among nurses in the workplace has many negative outcomes associated with it and must

be attended to effectively in order to create a healthy, safe work environment. In health care

settings, the management of persistent conflict issues through strategic educational approaches

for nursing staff has been linked to increased job satisfaction and patient safety (Scott & Gerardi,

2011). The first step was to recognize and utilize a change theory.

Change Theory

To remain competitive, organizations must recognize and respond to the growing

complexity of the industry and understand that change is necessary for progress and a successful

future (Roussel, 2013). When change is made within the workplace, it naturally creates a sense

of uncertainty and emotional challenge that can derail efforts and inhibit sustainability (Bowers,

2011). Attempts at change most often fail due to an unstructured approach and a strong

resistance to movement from the comfort of the status quo (Mitchell, 2013). For sustainability of

this project, it was crucial to use a classic, structured, well-respected change model for plan

implementation that enlisted support from nurse participants. Therefore, Lewin’s Change Theory

was chosen for this project.

Lewin’s Change Theory, as illustrated in Appendix B, identified three stages for

implementing change. Unfreezing occurs when the need for change is identified. Moving is the

stage when the change is actually initiated. Refreezing, which is when equilibrium has been

established and accepted as the norm (Lewin, 1951; Mitchell, 2013). During the unfreezing stage


of this project, the sponsor organization indicated that due to a noted increase of communication

breakdown, there was a need for nursing staff to recognize and improve communication and

conflict engagement skills. Poor conflict engagement led to decreased staff satisfaction and

patient safety issues (Rosenstein, Dinklin, & Monroe, 2014; Roussell, 2013). There were no

conflict engagement educational opportunities or tools in place for the Women’s and Children’s

Division at the sponsor organization. However, recent Culture of Safety education initiatives

have been adopted and leadership requested this project expand upon this initial work. To move

the project, the plan included a pre-education survey, an original educational program, and a

post-survey. Based on the results of the post-assessment surveys, the effectiveness of the

program was to be evaluated. The results determined the establishment of a new way of

addressing conflict engagement and a refreezing of new communication strategies and behaviors

(Mitchell, 2013).

While Lewin’s classic change model provided a structured framework for the project, it

was just as important to address concerns from the participating nurses and reinforce their

contributive efforts to the project (Rosenstein, Dinklin, & Monroe, 2014; Roussel, 2013). In

addition to these initiatives, it was crucial to have a strong commitment from leadership to round

out mutual understanding, support, and cultural endorsement (Rosenstein, Dinklin, & Monroe,

2014; Roussell, 2013). Once a change theory was identified, key stakeholders of the project were

evaluated.

Key Stakeholders

Innovative, quality health care should be at the forefront of every nurse administrator’s

mind who seeks to remain competitive in the industry. HCOs are shaped by the needs and

demands of stakeholders who have a direct professional, personal, regulatory, or financial


interest in the organization’s success (White & Griffith, 2010). “Organizational excellence

begins with and is measured by stakeholder satisfaction” (White & Griffith, 2010, p. 6).

The stakeholders who were directly involved with the project and received educational

benefit were the staff nurses, specifically the Resource Nurses. The purpose of the project was to

educate nurses with information and techniques that increased their peer-to-peer communication

abilities, as well as their conflict intelligence and engagement skills. The educational initiatives

were put in place to combat the disruptive attitudes and behaviors that lead to emotional distress,

burnout, absenteeism, job dissatisfaction and staff turnover (Brinkert, 2010).

Managers spend a reported 20% of their time dealing with conflict; however, it is believed

that number is actually much higher (Scott & Gerardi, 2011). Conflict engagement education at

the clinical level benefitted not only middle management, but also executive leadership and the

Avera McKennan organization as a whole. By reducing the amount of time used to manage

conflict, more time is now available to spend on creating, managing, and advancing innovative

future-oriented projects, and improving patient care services at the bedside that will grow the

organization (Brinkert, 2010). In addition, a reduction in the costs of problematic conflict issues

reduces nurse turnover rates (Brinkert, 2010). This is a long-term project goal, and outside the

scope of this EBP project, however it was important to make Nursing Leadership aware of this

benefit.

Patients have the most to gain from conflict engagement in the nursing environment.

Failures in communication, lack of teamwork and trust, as well as purposeful information

withholding, disrespect, bullying, and other disruptive behaviors all increase the likelihood of

deficient care, errors, and poor patient outcomes (Rosenstein, Dinklin, & Monroe, 2014). While

a collaborative, supportive, teamwork environment is what nurses desire, quality and safety are


what is most important to patients. This is shown by the following priority concerns listed in

order of importance: do not harm me, heal me, respect me, be nice to me (Nationwide

Children’s, 2015). These same concerns should be a priority for interpersonal colleague

collaboration as well.

The complex, unpredictable healthcare environment can make collaboration among

nursing teammates volatile, but utilizing evidence-based practice to implement conflict

engagement education strategies will create safe, quality environments for all stakeholders

involved (Roussel, 2013). For nurses, leaders and patients to benefit, it was important to study

barriers and drivers of change next.

Barriers and Drivers of Change

It was crucial to understand both potential barriers as well as drivers of change.

Education was provided to an adult, almost exclusively female, population. The staff is

multigenerational which may represent different learning preference styles. Since most adults

are self-directed, it was important to include them in the learning process and provide them with

the knowledge that can be directly and immediately applied to their role (Pappas, 2013). This

approach also improved adults’ skills as well as boosted confidence levels. Pappas (2013) notes

adult learners may be less open-minded and more resistant to change which could be related to

their experience and age. Educators needed to provide adult learners with the “why” and

promoted the need to explore and learn new things.

Additional barriers included a lack of time, lack of confidence in one’s self or skill level,

problems with schedules, lack of motivation by the learner and also lack of the information

regarding the learning opportunity (Russell, 2006). Adult learners have many responsibilities


and are caught in a juggling act. These adult learning barriers were overcome with careful

educational planning.

Drivers of change are regulatory and quality related. The Joint Commission (2015) is

focused on improving healthcare for the public. It encourages Avera McKennan to strive to

provide the highest quality health care by awarding accreditation and certification. Avera

McKennan is a Magnet™ designated hospital, which is a program recognizing health care

organizations for excellence in nursing, high quality patient care and innovative and professional

nursing practice (American Nurses Credentialing Center, 2015). The designation is awarded to

health care facilities that empower nurses with strong transformational nursing leadership,

involve nurses in organizational decision-making and support advanced education and exemplary

practice (American Nurses Credentialing Center, 2015). Not only are The Joint Commissions

and Magnet drivers of change, they are also important to the business of the organization.

Business Impact

One approach to determining business impact was to engage in an environmental scan.

Finkler, Jones, and Kovner (2013) describe an environmental scan as a common-sense review of

the likely impact of the economic environment on the organization. In addition to The Joint

Commission and Magnet, patient safety is impacted by unresolved conflict.

First, this hospital recently received its fourth consecutive Magnet™ designation. During

the decade of the 1980’s, hospitals sought to determine how a few specific hospitals were not

experiencing labor shortages that others were experiencing (Abraham, Jerome-D’Emilia, &

Begun, 2013). The commonality between these hospitals helped define the 14 Forces of

Magnetism seen today. The thirteenth of these forces of magnetism is interdisciplinary

relationships, a part of the exemplary professional practice component (Forces of Magnetism,


2015). Conflict engagement is an important component of professional practice. Forces of

Magnetism (2015) states that to be in compliance, “Conflict management strategies are in place

and are used effectively, when indicated.” Therefore, the first business implication for this HCO

was to comply with the Forces of Magnetism to ensure the Magnet status is retained. A formal

conflict engagement training program helped achieve this business goal.

Secondly, The Joint Commission (TJC) has many standards and sentinel event alerts

which address conflict and communication. As of 2011, fifteen standards and three alerts dealt

with disruptive communication behaviors (Scott & Gerardi, 2011). The very first standard Scott

and Gerardi (2011) list is Standard LD 01.03.01.EP7 which is “conflict among individuals

employed within the organization” (p. 61). Even though the suggested Joint Commission

standard is clearly written, it may not be an actual skill in practice within HCOs. Collaboration is

key and includes aspects of skill building and engagement in the process. Compliance with TJC

standards was a second key business strategy for this HCO.

Finally, Scott and Gerardi (2011) state a clear link exists between managing conflict and

patient safety outcomes. Brinkert (2010) asserts one cost of conflict which affects patients is

absenteeism. However, additional costs related to medication errors, injuries, and even death are

much greater. Gerardi (2004) states there are direct and indirect costs related to conflict that an

HCO must consider: litigation, employee turnover, increased care to manage adverse outcomes,

damaged morale, and lack of staff engagement. When one considers both the direct and indirect

cost of conflict for an HCO, the case for instituting conflict engagement strategies is undeniable.

A healthcare organization’s business is most certainly impacted when outcomes are diminished

by conflict. Following Magnet principles, The Joint Commission's standards, and focusing on


patient safety contributed to the effect of implementing a formal conflict engagement program at

Avera McKennan.

Organizational Planning

Because the literature is clear that both patient safety and staff satisfaction are impacted

by conflict, organizations need to create a strategic plan for conflict engagement. Scott and

Gerardi (2011) state, “developing a proactive mindset and aligning effective conflict

management approaches with the overall mission of the organization are the first steps in

addressing conflict and its impact on the organization” (p. 59).

Working closely with the organization to determine their needs and wants in this project

was a successful organization planning strategy. A letter of support from the organization can be

found in Appendix C. Just like University of Mary, Avera McKennan hospital is founded upon

Benedictine values. These rules guide the overarching mission, vision, and values of this HCO.

As Avera’s website states, the mission is to truly impact the lives and health of their customers

utilizing Christian values (Mission, Vision, Values, 2015). Additionally, Avera follows the

Ethical and Religious Directives for Catholic Health Care Services. These directives emphasize

ethical standards in behavior (Mission, Vision, Values, 2015). Treating others as one would treat

him or herself plays strongly into the organizational values. Resolving conflict respectfully by

creatively and consciously engaging in discussions with others followed the mission, vision, and

values at Avera McKennan.

The importance to the organization was to determine staff nurses’ perceptions related to

conflict engagement. In consultation with the HCO, five primary goals were identified (personal

communication, J. Blauwet, September 10, 2015). The first was to improve communication

strategies between staff members. The second was to view an increase in one to one


conversations when conflicts arise. The organization also wanted to implement an education

process as part of this project directed at targeted groups in the HCO. The fourth goal related to

improving patient outcomes as evidenced by the literature. Finally, this hospital’s long-term goal

was to implement this education beyond the Women’s and Children’s Division with a potential

to publish the strategies utilized. With these goals in mind, as well as utilizing the Benedictine

values, attention was focused toward implementation.

Implementation Plan

After a meeting with the Director of the Women’s and Children’s Division, it was

determined that the education would be provided by the Graduate Student Team contact at the

Division Wide Resource Meetings which were planned for February of 2016. See Appendix D

for a sample agenda. Resource nurses, a role similar to charge nurses, deal with conflict on a

daily basis as they are collaborating with multiple departments, staff members, patients and

family members. It was a benefit to start with this group as they are the front line for the unit.

Training may then move forward with the remaining staff as part of the handoff plan (personal

communication, C. Ehlers, October 8, 2015).

In order to successfully implement this project, an action plan was developed. Various

tools, decision-making models, and problem-solving grids exist to aid in the implementation of a

project. Avera McKennan utilizes the PDSA model. Taylor, McNichols, Darzi, Bell, & Reed

(2014) state the PDSA cycle is made of four key steps: Plan, Do, Study, and Act. These steps,

like a problem-solving process, mimic the scientific method. The PDSA cycle was first found in

industry and was based on Deming’s work in Japan (Taylor et al., 2014). PDSA can occur as

one independent cycle or sequenced cycles based on what is found thereby linking many cycles


together. The Graduate Student Team completed a PDSA cycle worksheet with timelines and

responsible parties. The completed action plan can be found in Appendix E.

Per the request of the Division Manager, an educational power point presentation was to

be developed by the Graduate Student Team. After the presentation the nurses were to be given

scenarios to discuss within small groups. The scenarios related to issues in the division. After

small groups, the plan was to conclude with a large group discussion reflecting on the scenarios.

The attendees were to be given a survey to complete immediately prior to the education session

on one colored paper and the same survey immediately after the session on a different colored

paper. The survey was to assess nurses’ perception of their self-awareness in regards to conflict

engagement.

No matter the tool utilized, if repeated communication is not a key factor the project will

have less success. Allowing opinions to be heard with as much transparency as possible

provides a recipe for successful implementation. While the primary intervention was the

education of the Resource Nurse group, secondary interventions aided in a successful

implementation as well. With cooperation of the Division Director, secondary initiatives

included incorporating brief submissions for staff newsletters related to conflict engagement as

well as posters with tips and strategies placed in high traffic staff areas.

Project Measurement Plan

For this project, measurements were developed using the SMART criteria. First, Duncan

(2015) states specificity is important when developing the goals. Secondly, the plan needs to be

measurable. It is also important for goals to be attainable and realistic (Duncan, 2015). Finally,

all projects must be planned with timeframes in mind. Therefore, the SMART goals stand for


Specific, Measurable, Attainable, Realistic, and Time-Oriented (Duncan, 2015). The SMART

goals for this project are found in table 6.

The Graduate Student Team nurse contact will provide conflict engagement education to

Resource Nurses in the Avera McKennan Women’s and Children’s Division. The participants

will be given the Conflict Intelligence Self-Assessment tool prior to, and after, providing the

conflict engagement education program, to determine the nurses’ perception of conflict

intelligence improvement. The specific goal is to increase nurses’ self-perceived conflict

engagement intelligence through educational strategies.

Table 6

Conflict Engagement Project SMART Goals

Specific Increase nurses’ self-perceived conflict engagement intelligence through

educational strategies

Measureable Conflict Intelligence Self-Assessment from CINERGY™

Attainable 15% increase from pre to post assessment scores

Realistic Resource Nurses only

Time-Oriented

Completed by March 2015

The Conflict Intelligence Self-Assessment is a measurement tool developed by and

offered courtesy of CINERGY™, an international conflict management-coaching firm based in

Toronto, Canada (CINERGY™, 2015). A sample of the tool can be found in Appendix F with

permission to use the tool in Appendix G. Participants use 20 questions to rate their current level

of conflict intelligence, from 1 being the lowest score and 4 being the highest score for each

question (Conflict Intelligence Self-Assessment, 2015). A range of 20-80 will be totaled for

placement into four categories: conflict intelligent (70-80), conflict intelligent with some work to

do (55-69), more work to do (35-54), and lots of work to do (20-34) (Conflict Intelligence Self-


Assessment, 2015). The measurement will be the difference between pre and post self-

assessment scores. A 15% increase in conflict intelligence assessment scores is an attainable

project goal. However, in discussion with the CNO at this facility, she stated she would be

pleased with any amount of increase in assessment scores (personal communication, L. Popkes,

December 1, 2015).

Per the organization’s request, conflict management education strategies were provided

to Resource Nurses by the Graduate Student Team nurse contact during two separate sessions in

February 2016. Eventually nurse educators may become involved as this initiative rolls division-

wide after the completion of this project. At that time, the educators will administer the Conflict

Intelligence Self-Assessment tool to staff nurses, then provide the conflict engagement education

program, and re-administer the tool for a final assessment immediately following the education.

Additionally, nurse educators would be utilized for new hire education as well as annual

refreshers about conflict engagement. Therefore, to be realistic for the purposes of this project,

just the Resource Nurses were utilized with education for the Resource Nurses provided by the

Graduate Student Team nurse contact person.

The CINERGY™ survey tool was administered prior to an education presentation in

February on conflict engagement and immediately after the education is completed. The project

was completed by March 2016, within the time frame established by University of Mary Service

and Seminar courses. This allowed for an assessment of the difference in scores that determined

the change in participants’ perception of their conflict intelligence.

As experts in conflict engagement, the Graduate Student Team served as consultants to

the nursing leadership at Avera McKennan Hospital and University Health Center. While the

leadership only requested the Graduate Student Team to evaluate nurses’ perception of conflict


intelligence, other benefits may be seen long-term. The team impressed upon leadership that

increase in conflict scores on internal surveys may be noted after education. Additionally, HR

involvement in behavioral issues may decrease. It is possible the activities of this EBP project

may affect the well-being of the staff. Utilizing conflict engagement strategies successfully,

along with possessing increased conflict intelligence, may impact patient and staff satisfaction

and staff engagement (Gerardi, 2015). This project may impact patient safety. When nurses

engage in conflict, rather than avoid it, outcomes are improved and patient satisfaction may be

positively impacted. Poor communication between healthcare providers is a leading cause of

error A decrease in medication errors and improvement in nurse-sensitive outcomes, such as

found in the National Database of Nursing Quality Indicators® (NDNQI®) are seen when nurses

address conflict (The Joint Commission, 2008; Baker, Gustafson, & Beaubien, 2003). The

organization may benefit with improved conflict intelligence by staff. Both The Joint

Commission and Magnet™ organizations have standards for conflict resolution in facilities they

regulate. This organization may also see cost benefits: lower nurse turnover rates and increased

reimbursement by CMS for meeting safety outcomes.

Even though no patients will be surveyed, it was still important to protect the rights of the

staff who will be participating. This was accomplished in collaboration with the HCO’s Internal

Review Board (IRB) as well as University of Mary’s IRB.

Human Subject Protection Statement

The Graduate Student Team submitted a proposal to the IRB at Avera McKennan

Hospital and University Health Center as well as the University of Mary IRB for review. It was

the responsibility of both IRBs to ensure the project and Graduate Student Team members

proceeded with the highest ethical integrity and kept the risk of harm to the participants at a


minimum (Polit & Beck, 2012). To fulfil University of Mary’s IRB requirements, a four part

document was prepared outlining the names of the Graduate Student Team and purpose of the

project. Additionally, the risks, benefits, and informed consent was also explored. Since this was

an EBP project, as opposed to primary research, informed consent was not necessary. The

completed IRB proposal can be found in Appendix H. This approved IRB proposal was shared

with the host facility’s IRB committee. At that time, a presentation was also given to the Nursing

Leadership at Avera McKennan. Approval was given by the host facility’s IRB committee

allowing the project to proceed as planned (personal communication, C. Ehlers, December 8,

2015).

The human subjects involved in the activities for this project were identified as staff

nurses fulfilling a Resource Nurse position. The Graduate Student Team contact at Avera

McKennan administered the Conflict Intelligence Self-Assessment tool to determine nurses’

perception of conflict intelligence improvement to the nursing staff. The tool provided to the

participants prior to education strategies was printed on green paper and the post education

assessment was on yellow paper to ensure good management of data collection. Submission of

the self-assessment was completely voluntary and no subject identifiers were requested or

present on the tool. The collected data was then delivered to the Graduate Student Team nurse

contact member for collaborative analysis with the Graduate Student Team.

Implementation and Measurement

Perhaps the most crucial part of an evidence-based practice project is the planning phase.

With a clear guide in place, implementation flows more smoothly. This proved to be true for the

Graduate Student Team during implementation and measurement of the conflict engagement


EBP. The elements of the implementation plan were to develop the course content, hold two

sessions, administer the conflict intelligence tool, and evaluate the results.

Implementation

The Graduate Student Team prepared for implementation by creating the actual

education session. Research was conducted and information gathered with two primary goals.

First, teach the learners about the importance of emotional intelligence. Second, provide

strategies for engaging in conflict.

Emotional Intelligence. Helping the learner understand emotional intelligence was an

important aspect of the educational presentation. Emotional intelligence is the ability to identify,

assess, manage and control self and reactions to others (Children’s Mercy Hospitals and Clinics,

n.d.). The elements of high emotional intelligence include caring and consideration, trusting

one’s intuition, taking feedback well, and knowing one’s own emotions and sensing the emotions

of others. Self-awareness of these elements assists in determining where one can strengthen their

emotional intelligence.

The educational session assisted learners to focus on using phrases which assisted in

engaging in conflict rather than creating environments of anxiety, fear and distrust. Conversation

starters that engage in conflict include phrases that seek to understand, encourage team work,

discuss collaboration, utilize acknowledgement and affirmation, and never point blame.

Incorporating these phrases into routine communication can assist in better outcomes with

conflict engagement. Healthcare settings are demanding work environments and it is reasonable

to propose that emotional intelligence is an appropriate vehicle for improving conflict

engagement and well-being among nurses.


Engagement Strategies. Conflict engagement strategies are important to understand and

practice before real conflict occurs. Strategies can be generic or more specific. Two very

common general tips when engaging in conflict are using “I” statements as well as monitoring

one’s own non-verbal behaviors. The principles of emotional intelligence can also be thought of

as general strategies: considering others views, active listening, and keeping an open mind

(Children’s Mercy Hospitals & Clinics, n.d.). Two other general strategies are leaving personal

baggage out of the conversation as well as not avoiding conflict. Conflict and tensions will only

get worse over time if the necessary conversations are avoided (Children’s Mercy Hospitals &

Clinics, n.d.). These general strategies were presented to the learners in the session.

In addition to general strategies, four specific strategies are useful to remember during

conflict engagement. The use of mnemonic devices assists one to remember processes better; it

is a common learning principle utilized in education arenas for many topics. Almost all of the

strategies presented utilized a mnemonic device. These four specific strategies are reflected

below.

Table 7

Specific Engagement Strategies

Make it L.A.S.T Listen, Apologize, Solve, Thank

(Children’s Mercy Hospital’s & Clinics, n.d.)

Strive for

P.E.A.C.E.

Pause, Express, Assess, Choose, Enact

(Stone, Patton, & Heen, 2010)

D.E.S.C. for Success Describe, Explain, Share, Collaborate

(Pocket Guide TeamSTEPPS 2.0, 2013)


Tend and Befriend Focus on understanding the thoughts and feelings of the other person

(Children’s Mercy Hospital’s & Clinics, n.d.)

During the engagement educational sessions, the general principles were shared as well

as the specific strategies. When specific strategies are used in case scenarios, this allows the

learner to be more comfortable when a real conflict situation occurs. The learners were

encouraged to use several strategies during practice as each individual may gravitate to one over

another, and none is better or worse. Each strategy can be used in varying situations, therefore it

was important for the Resource Nurses to understand several different approaches depending on

the conflict as it arises in day to day nursing practice. The educational lesson is found in

Appendix I.

Conflict Engagement Education Sessions. Two education sessions were held for

division-wide Resource Nurses and the Nursing Leadership team on Wednesday, February 3rd,

2016 and Thursday, February 11th, 2016. The sessions were held in the Prairie Center in the

Benedictine Room. As luck would have it, a major snow storm blanketed Sioux Falls the day

before each session was held as well as the day of the sessions. Tuesday, February 2nd, was

actually considered a blizzard. Schools were closed for that day and had a late start the day of

the session on February 3. The Graduate Student Team had reservations that the conflict

engagement education session would be cancelled, however, the organization contact, Ms.

Ehlers, assured the team she would not let a little snow get in the way of such important

educational content.

Twenty-two participants attended the sessions, which was slightly lower than anticipated.

However, it was determined that number was approximately 40% of the eligible participants.


The Director was pleased with this turnout. The Graduate Student Team, along with Nursing

Leadership, felt the attendance numbers were smaller because of the unexpected snow. Attendees

were asked to complete a self-awareness survey immediately pre and post the education session.

The sessions started with the power point presentation. The participants were broken into small

groups and were provided scenarios. The scenarios were obtained from the Nurse Managers of

the units and were based on actual conflicts the Managers had witnessed. The groups were given

approximately fifteen minutes to discuss the scenarios in their small groups. Participants were

observed to be animated in their discussions and interested in the topic and scenarios. After

discussions the groups were brought back together and each scenario was discussed. All of the

attendees participated in both the small and large group sessions. Many positive comments were

received from each group. Ms. Ehlers, the Division Manager, also expressed her satisfaction

with the education session.

Project Outcome Measurements

Success of a project is not only measured on the qualitative feedback received from the

Director and participants, but also must be quantitative in nature. The results were compiled and

evaluated with assistance of Jason Douma, Associate Professor of Mathematics at University of

Sioux Falls in Sioux Falls, South Dakota. This proved to be a valuable and important piece of the

implementation and results phase for the Graduate Student Team.

Results. The Mann-Whitney U test is utilized when comparing two population means

that originate from the same population, as well as for testing whether there is equality between

two populations or not (Statistics Solutions, 2016). It is a non-parametric alternative to the

independent sample t-test for testing the median of two populations, and it is primarily applied

when the data is ordinal (Statistics Solutions, 2016). While the Mann-Whitney U test is


applicable in every field, it is more frequently used in nursing, psychology, medicine and

business, particularly when comparing attitude, behavior, and preferences (Statistics Solutions,

2016). Hence, the usefulness of the Mann-Whitney U test for comparing the perception scores of

the participants from two groups of nurses with both groups originating from Avera McKennan

Hospital prior to conflict engagement education and their perception after the education session

was completed.

Since the study data are not matched pairs (that is, each post-intervention survey is not

linked to a particular pre-intervention survey), it was treated as a comparison of two independent

samples (pre-intervention ratings versus post-intervention ratings). For the comparison of the

individual survey items one through twenty see Appendix J. The statistician also completed a

hypothesis test study related to the questions. Results of that study can be found in Appendix K.

Because the data is ordinal and discrete with only three values actually used, the data

cannot reasonably be treated as scale measurements, let alone normally distributed scale

measurements (J. Douma, personal communication, March 17, 2016). Therefore, it was strongly

recommended that the nonparametric Mann-Whitney U-test be used for these items. For the total

scores, a pre-intervention mean of 58.6 (s = 7.6, n = 22) was observed, and a post-intervention

mean of 65.5 (s = 5.8, n = 22) was noted. This was a statistically significant difference (p = .004,

Mann-Whitney U-test). According to J. Douma, the results yielded a 6.9% increase in perception

(personal communication, March 17, 2016). The plot grid can be found in Table 8.


Table 8

Plot Grid Results

While the Graduate Student Team was hopeful for a full 15% increase, senior nursing

leadership at Avera McKennan Hospital and University Health Center were pleased with the

results. Key stakeholders, such as Magnet™, look for any amount of increase. Therefore, while

the percent increase was less than what the Graduate Student Team had hoped, the project was

deemed a success.

Recommendations and Hand-off Plan. A formal hand-off occurred with Courtney

Ehlers, MSN, RN, CPN Director of Women’s and Children’s Division at Avera McKennan


Hospital and University Center on Wednesday April 20, 2016. The entire process of the project

was reviewed culminating with the results of the surveys. This presentation can be found in

Appendix L. While Ms. Ehlers expressed extreme satisfaction at the outcome of the project, the

Director was eager to hear how the project could be improved moving forward. The Graduate

Student Team representative discussed further recommendations.

Because the Graduate Student Team administered the post-intervention surveys on site

immediately following the education session, the response/compliance rate was considered

outstanding. However, the very tight time frame did make it a bit more difficult to interpret the

meaning of the post-intervention survey responses. The language of the survey items referred to

how the respondents act/react/behave. If the post-intervention survey had been administered

three to six months after the education session, it would be much more reasonable to interpret the

responses as a self-evaluation of how the respondents actually behaved in the scenarios being

described. Since the survey was administered at the end of the session, and thus the respondents

hadn’t really encountered any actual conflict situations since their training, the post-intervention

survey responses represented something different; however, it is not quite clear how best to

articulate that difference. While it would be ideal to administer the post-intervention survey a

few months after the education session, unfortunately, the time constraint for the project did not

allow for that intervention. Therefore, the major recommendation to nursing leadership at Avera

McKennan Hospital and University Health Center would be to re-survey the Resource Nurses

three to six months after the session rather than immediately post education. While this would

result in a decreased return rate, the scores may better reflect true integration of learning.

Another broad recommendation would be to implement conflict engagement education in

nursing school. This lack of preparation has been cited as one of the main reasons why new


graduate nurses feel unprepared to approach others when errors occur (Brinkert, 2010). Since the

reality of impacting this change is difficult, the Graduate Student Team is recommending

placement of this education in the new graduate nurse residency program. This program is

mandatory for all new graduate RNs entering Avera, therefore inclusion of this important

education early in a nurse’s career may have longstanding positive benefits related to patient

safety, satisfaction, and retention. Additionally, a further recommendation was to present this

content to the Strategic Council for inclusion into house-wide education, not only with new

graduate nurses.

A Successful Conclusion

Melnyk and Fineout-Overholt (2011) state in order to embark upon a clinical

practice project, the need must be clear. It is not enough to reproduce evidence already

generated. Clinicians must strive to further the knowledge base about a topic. The external data

linking conflict engagement to staff satisfaction and patient safety is clear. However the internal

data from Avera McKennan indicated improvement could be found with enhanced

communication. Therefore, targeted education about conflict engagement will yield important

benefits for staff, leaders, and most importantly patients.

The project implemented at Avera McKennan incorporated a conflict intelligence survey

based on Brinkert’s (2010) literature review which found enhanced emotional intelligence

among nurses renders a better conflict engagement environment. Additionally, the project

targeted adult learning principles including case scenarios and group work as recommended by

Marshall and Robson (2005). With support and approval from the organization’s IRB and

University of Mary’s IRB, the project was implemented and completed in the first quarter of

2016. Success of the project was indicated with statistically significant improvement results,


generating administrative praise and nods for future, permanent placement among organizational

education programs.

Evidence based practice models have made it possible for staff nurses to impact practice

changes. The process improvement began with asking a question about how nurses perceive their

level of conflict intelligence pre and post education. By incorporating this evidence, staff nurses

can make a difference in patient care and staff engagement at Avera McKennan. Better

communication practices and increased safety are attainable. Nurse leaders only need to look at

the evidence to take the first step.


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Appendix A

Fishbone Diagram

Fishbone Diagram


Appendix B

Lewin’s Change Model


Appendix C

Host Organization Letter of Support


Appendix D

Agenda for Conflict Engagement Assessment and Education Session

0800 - 0805 Introductions

0805 - 0810 Administration of Pre-Survey

0810 - 0835 PowerPoint Presentation/Education Session

0835 - 0845 Scenario Discussion in Small Groups

0845- 0855 Large Group Reflection/Discussion

0855- 0900 Administration of Post-Survey


Appendix E

PDSA Cycle Action Plan Worksheet

TEAM:_Conflict Engagement Graduate Student Team____

DATE:_Nov 2015___ PDSA CYCLE # ___1____

Aim: What are you trying to accomplish with this project? The Aim includes a numerical goal, timeframe, and patient population and system to be improved. Aims may require multiple smaller tests of change. Write your aim here: The purpose of the project is to assist Avera McKennan Hospital and University Health Center with improving nurses’ perception of how they engage in conflict. Goals for the project include improved communication between the staff, staff are willing to engage in one on one conversations, staff educated about conflict are aware of the benefits of conflict engagement, as well as improved communication between staff which will aid in an improvement in patient outcomes. An interactive education session which will include a power point presentation as well as group discussions with actual conflicts that occur on the units in the division has been planned for all resource nurses in the division. The education sessions have been scheduled for February, 2016. At this time the Director of the Division will be satisfied with any improvements in the scores and no specific percentage is required. No patients will be utilized in this PDSA cycle.

Measure: How will you know that a change is an improvement? Write your measure here: The Graduate Student Team has chosen a Conflict Intelligence Self-Assessment tool which was developed by, and used with permission of, CINERGY™. Attendees of the education session will be administered the assessment tool immediately pre and post education sessions to determine if there is an increase in their self-assessment and conflict intelligence.

PlanDescribe your first (or next) process improvement cycle

Person Responsible

When to be done

Where to be done

Conflict Engagement education sessions will be provided to all resource nurses in the Women’s and Children’s Division who attend the February meetings.

Sandi Thorson Wednesday, February 3rd and Thursday, February 11th, 2016

Avera McKennan Hospital and University Center, Women’s and Children’s Division.

List the tasks needed to set up this test of change

Person Responsible

When to be done

Where to be done

1 – Complete Internal and External Research related to conflict engagement

Graduate Student Team

Dec 4, 2015 Each Graduate Student Team member will complete sections of the education and


2 – Create an implementation plan based on best evidence available3 – Buy in from the Leadership team. A Power Point presentation will be provided in regards to the needs for the project.

4 – The dates of the education sessions need to be communicated to resource nurses in the division

5 –Development of the education session

Graduate Student TeamSandi Thorson

Lana Shogren, Administrative Assistant

Graduate Student Team

Dec 4, 2015

December 7, 2015

By December 15, 2015

By Jan 20, 2016

conference calls will be held ongoing with the team

As above

Avera McKennan Hospital and University Center, Pediatric Conference Room

Via email at Avera McKennan

Graduate Student Team collaboration activity

Predict what will happen as a result of this process improvement cycle

What measures will help you determine if the prediction succeeds.

1 – Improved communication between staff members on all units

2 – staff are willing to be involved in one on one conversations with colleagues3 – an increase in awareness of conflict by staff members

4 –improved patient outcomes

5 – improved staff satisfaction

1 – results from self-assessment tool and future employee opinion survey2 – results from self-assessment tool and future employee opinion survey3 – results from self-assessment tool and future employee opinion survey4 –future HCAHPS results

5 – future internal staff surveys

…at this point. You have planned your cycle and will not be able to complete the Do-Study-Act portion until you run the test.

Do: Describe what actually happened when you ran the test

Study: Describe the measured results and how they compared to the predictions and what you learned from the cycle.

Act: Describe modifications for the next cycle based on what you learned


Appendix F


Appendix G

Permission granting the use of the CINERGY™ Assessment Tool

Via email received November 5, 2015-

Hello and thank you for asking about permission to use this assessment.

As the author of this tool, you hereby have my written permission to use

this document as described provided the copyright line at the bottom remains

intact as is including the website.

Wishing you all the best,

Cinnie Noble

CINERGY™ Coaching

Phone: 416-686-4247 | Toll free: 1-866-335-6466 | Skype: cinnie.noble

Email: [email protected] | Web: www.cinergycoaching.com


Appendix G

Institutional Review Board Application


Appendix I

Education Presentation


Appendix J

Statistical Comparison

Group Statistics

PrePost N Mean Std. Deviation

Std. Error Mean

Q1

Pre-Intervention 22 2.82 .501 .107

Post-Intervention

22 3.32 .568 .121

Q2


Post-Intervention

22 3.50 .598 .127

Q3


Post-Intervention

22 3.09 .526 .112

Q4


Post-Intervention

22 3.23 .528 .113

Q5


Post-Intervention

22 3.23 .685 .146

Q6


Post-Intervention

22 3.45 .671 .143

Q7


Post-Intervention

22 3.64 .492 .105

Q8


Post-Intervention

22 3.14 .468 .100


Q9


Post-Intervention

22 3.14 .468 .100

Q10


Post-Intervention

22 2.95 .575 .123

Q11


Post-Intervention

22 3.45 .510 .109

Q12


Post-Intervention

22 3.41 .503 .107

Q13


Post-Intervention

22 3.18 .664 .142

Q14


Post-Intervention

22 3.27 .631 .135

Q15


Post-Intervention

22 3.55 .510 .109

Q16


Post-Intervention

22 3.18 .588 .125

Q17


Post-Intervention

22 3.27 .550 .117

Q18


Post-Intervention

22 3.09 .526 .112


Q19


Post-Intervention

22 3.23 .612 .130

Q20


Post-Intervention

22 3.18 .733 .156

Total

Pre-Intervention 22 58.6364 7.58787 1.61774

Post-Intervention

22 65.5000 5.80435 1.23749


Appendix K


Appendix L

Leadership Presentation

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