Conflict Resolution Nursing Case Study
When analyzing the results obtained, it was identified that conflicts originating from interpersonal relationships were predominant. Thus, owing to their magnitude, two categories emerged: management of interpersonal conflicts and strategies for dealing with interpersonal conflicts.
Management of interpersonal conflicts
Problems in interpersonal relations were characterized as situations which made the nurse's leadership performance most difficult in the hospital environment, as shown in the statements below:
My greatest difficulty is dealing with conflict, seeing employees arguing with each other, not speaking or not collaborating, and then you have to call this to their attention, which I think is the worst part (E15).
[...]it's complicated when the relationship is not good. I always say to them that nobody is obliged to love anybody here, but we have to respect each other (E21).
One of the shifts is more complicated because there are people with strong personalities that do not accept opinions and criticism. So, it can be quite taxing (E25).
[...] it's complicated, because you can't make everyone happy, there will always be one person that's not content (OD2).
Interpersonal conflicts are those that have a relational nature, and may occur between people, between a group and a person, between an organization and a group, and so on(9). Furthermore, interpersonal relationships are considered as a potential stressor, as they involve various individual and group variables, making it unfeasible to find a measure capable of making everyone happy(6).
Given the complexity of healthcare work, conflicts also arise between various professionals. Misunderstandings between nurses and physicians are common in hospital environment. Interpersonal conflicts among these professionals tend to interfere in the progress of health work and consequently the performance and motivation of these workers, affecting the quality of the care to users. The participants' statements affirm these conflicts:
Nurses waste a lot of time arranging medical records and requests for exams and often stated they feel like secretaries of the physicians, as these professionals ask them for everything in terms of paperwork (O6).
I cared for a patient with tracheostomy complications [...] the physician was very angry and start to shout and argue with everyone. It's very complicated working with people sometimes, it makes you want to run off (E7).
[...] there's a lot of that here, the physicians here like to dominate, if you let them they'll dominate, they want to give orders and shout (E16).
The conflict instated between physician and nurse can be one of the main problems in health services. This conflict causes ethical problems that end up negatively affecting the relationship, prejudicing the care provided to the patient. As such, it is necessary to allocate efforts so that these problems can be avoided or minimized(13). It was noted that the organization of the work of health professionals in the hospital environment is permeated by greater valorization and dominance by physicians meaning that nurses are often led to solving problems outside of their scope.
In relation to the history of the organization of health professionals, there has been an institutionalization process centered on medicine as the legal holder of knowledge. Even with the relativity of medical control over such professionals, physicians still continue to hold legal power of healthcare. It is worth emphasizing that part of the conflict that occurs in organizations is derived from unequal distribution of power, requiring greater comprehension and negotiation from managers in order to resolve them(14). However, the physician-nurse relationship may generate conflicts that often concealed and presented as a discreet dispute for power, in which both which to confirm their role in the treatment of patients, i.e. who prescribes and who administers the medication(15).
A study has revealed that in the nursing area, when a worker witnesses a physician acting outside of their routine, they proceed in accordance with their hierarchical position. Therefore, a nursing technician will general allow the physician to act as they wish and subsequently inform the situation experienced to their supervisors. Frequently, nurses experiencing a problem will take action if the physician maintains their previous conduct, and will tend to take the problem to superior authorities(14). This result is seen as an advance given that nurses often adopt a position of conformism faced with routines and contractions of hospital activities resulting from the power relationship(15).
Conflicts involving the multi-professional team, especially physicians, represent a challenge for nurses. Thus, the cause of these conflicts should be uncovered in order to find solutions and strategies for dealing with them, as environments where conflicts are not handled interfere in performance, professional motivation and affect the quality of the care.
Lack of commitment by team members in relation to certain activities and prejudicing the continuity of the care and discomfort between workers was also experienced by participants in the study. The following statement shows this kind of conflict:
When the shift was handed over, the nurse became aware that one patient hadn't been prepped for surgery. The nurse called an employee and told her, and she angry with the situation, saying that the obligation for giving the patient a bath was for the night shift. After stating her opinion, the nursing technician went to help the patient to bathe (O6).
Conflicts between professionals in the nursing team are prominent for a large part of nurses. There is a lot of evidence that these professionals are divided between legalism and basic needs, emotion and applicability of standards, and ethical dilemmas and remaining in their position(10). These conflicts may be clearly expressed, represented by the increased in criticisms, implications or discussions between team members. On the other side, when not openly demonstrated, conflict may cause demotivation and dissatisfaction in the team, affecting the quality of the work(16), as well as suffering for the worker.
Difficulty for workers in providing continuity to team actions that came before them also emerged in the study as a problem in the hospital environment. Leaving an activity for another time is frequent and seen as a lack of commitment and responsibility, neglecting the progress of nursing activities and consequently the care provided. This problem is faced by the nurse-leader.
Conflict implies disorganization of all team members and causes incased stress owing to the lack of participation in decision making, lack of management support, overwork, and rapid technological changes. Furthermore, other factors collaborate to causing conflicts, including high turnover of professionals, disrespect for workers, lack of trust and professional devaluation (16). The issue of turnover is illustrated in the following statements:
The turnover doesn't help because you can't create a connection. I think it really doesn't help structurally, so it's negative for us (E11).
We see a large turnover on the technical level, with people staying one, two or three weeks, but they can't cope, because there're a lot of demands (E19).
There's a high turnover, we see it as the institution's fault because a lot of people leave the hospital because they're unhappy. A lot of people take the entrance exam, pass and then leave (E23).
Four people were off on Saturday, so I had to fill in using people from the general on call shift [...] I know it's horrible, nobody wants to leave their wing. There was rotation before but it had to be stopped (OD10).
The intense turnover of professionals at the units is understood as a prejudicial aspect that interferes in the quality of the care(17), as constant rearrangement of professionals prevents the formation of professional ties and building teamwork based on union and the establishment of clear and common objectives.
Another relevant result was being overloaded with work, which was also indicated as generating conflicts:
[...] if employees had less patients the quality would be higher (E8).
At present, being overloaded with work is a big challenge we're experiencing, as we have few employees. This has been very difficult (E12).
It is very difficult to be overworked, you end up saying: I'm going to run away, but I can't abandon my patients and my employees (E14).
[...] the weakness I find by being overworked is very strong, it's a very stressful routine and a large and complex ward (E22).
The issue of being overworked as experienced by the participants in the study may directly interfere in the satisfaction of the worker and consequently generate conflicts, affecting leadership and interfering in the care. Being overworked also usually causes fatigue and exhaustion in the professional and can lead to extreme situations such as mistreatment of the patient, an important problem in healthcare management.
I had problems with a nighttime employee that was very rude to patients. The patients complained every day. I wasn't extreme with him, as that's not my style, but I went to the management and ended up removing him from the sector (E5).
[...] sometimes employees mistreat a patient, they person has two or three jobs and comes here too, and they can't manage it all so they end up taking it out on someone, such as the patient (E17).
When witnessing this type of situation, the nurse cannot hesitate to take a stance or choose to take ownership of the situation, i.e. not expecting the team to resolve the problem. From the moment that care is neglected and the human being is exposed to risks it is indispensable that the nurse, as the legal person responsible for coordinating the actions by the nursing team reprehends the behavior and, if necessary, notifies the situation to their superiors.
Strategies for dealing with interpersonal conflicts
In relation to conflict management, some strategies have arisen that promote a better routing for solving them, including nurses adhering to a participatory and dialogical leadership style.
[...] very participative, very democratic leadership where I think that people in the team are able to achieve the best healthcare possible for the patient (E9).
I try to exercise this leadership in a participative manner. I remain very open because we are here to work for the patient's benefit (E13).
[...] I try to listen to others so that we can reach a conclusion on what's best to do together. So, my leadership is very participative (E20).
[...] everything requires conversation, and not imposing a situation without knowing what the team thinks, without the participation and consensus of all (E24).
The leadership style consists in the behavior adopted by the leader in order to influence their collaborators, which may be authoritarian, based on the use of power, or democratic, in which people have greater freedom to participate in decision making. The literature shows that the democratic style is closes to authentic leadership, which involves all members of the team not only in decision making processes but in the elaboration and planning of strategies for work and problem solving. Authentic leadership is centered on communication as an instrument to achieve the best results in health(18).
Participation emerges as an instrument that collaborates with cooperation and conflict solving. When admitting that conflict has an origin in organizational and individual factors, it is believed that the use of participative methods is an effective solution, as well as accommodation or equilibrium between people and divergent groups(14).
Authors mention listening, respect and dialog as strategies for dealing with conflicts that is, as a springboard for getting out of a problematic situation as a possibility for resolution(15). This was shown in the participants'' dialogs:
[...] I talk a lot with them. I've never needed more abrasive conduct and have always managed to resolve things by talking (E1).
I try to speak with the personnel a lot. I don't like to impose things, because I don't like them imposing anything on me (E3).
I always like to be more democratic, to talk and have dialog. I do not come with a closed mind; it doesn't need to be like that I think (E4).
[...] I've always been available to talk and discuss issues with the whole team so they feel at ease and can bring up problems for me to try and help resolve (E18).
For there to be participation it is necessary for dialogical interpersonal relations to flourish in the work environment. This means a new proposal for leadership, denominated dialogical leadership, which is based on establishing a horizontal communication process with the intention of potentiating autonomy, responsibility and valorization of team members and health service users, as well as helping in decision making, planning and implementation of care practices(19-20).
By stimulating relationships based on dialog, it is believed that nurses can manage conflicts arising in the work environment in a more coherent manner. This dialog, which is different from empty conversation, values the prior knowledge of the participants as historical and social beings, which can awaken people's capacity to become a political actor, i.e. a professional that defends their convictions, is ready to act, has coherence between what they do and what they say, and is a reference point at the units, as well as in the health service.
Conflict in the workplace is a fact of life, and dealing with it is never easy. Sometimes it seems easier to ignore it and hope it will take care of itself. But in healthcare organizations, that’s not a good strategy. Unresolved conflict almost always leads to poor communications, avoidance behavior, and poor working relationships—which can easily affect patient safety and quality of care.
Much has been written about horizontal hostility and bullying among nurses and the impact on employee morale, performance, and satisfaction. But what happens when the conflict is with someone to whom you report, such as a nurse supervisor? Or perhaps it’s another higher-up—someone you don’t report to directly but who can influence your job and career; for instance, a physician who’s a department chair or a hospital administrator. In such cases, the power differential can pose an added challenge to confronting conflict, making it harder for you to do your job. Although intimidation can be outright, sometimes it’s more subtle. Examples include being left out of meetings, receiving a less desirable schedule, or not being given important information that the rest of the team has. In smaller communities where coworkers are more likely to have social relationships outside of work, the threat or reality of gossip or smear tactics may arise.
As research shows, fears of confronting conflict can affect nurses no matter where they work. In the United Kingdom, a 2013 survey of 8,262 nurses found that almost one-fourth had been discouraged or warned about raising concerns around patient safety. What’s more, 46% had tried to raise such concerns in the previous 6 months; of those nurses, 44% said fear of victimization or reprisal would make them think twice about reporting such issues again.
It’s no wonder many nurses view dealing with conflict directly as risky. They fear retaliation or even job loss for addressing conflicts with a manager or other higher-up. For patients, the downstream effects of conflict avoidance can be catastrophic. Conflict also can cause:
- poor team dynamics
- nothing getting resolved
- breakdown of trust
- need for work¬arounds
- misplaced aggression (as when nurses “eat their young”).
Addressing conflict constructively
While dealing with conflict can be risky, you have to weigh the risks of confronting it against those of avoiding it—for your patients and your own psychological well-being. We recommend a direct approach. For one thing, your leader may be unaware of your concerns or how you’ve been affected by workplace conflict. You need to bring these forward to make her or him aware of conflict and have the chance to address it constructively.
Another reason to bring concerns forward is to preserve your personal integrity. Without an opportunity to speak up, you can easily become passive, discouraged, and cynical and let negative feelings build. This approach compromises your job performance and team unity.
If your concern relates to an isolated or immediate incident, wait to cool down before approaching your leader so you can present the issue in a coherent, professional way. Doc¬ument your concerns in advance to help you express them more articulately and discern any behavior patterns. Request a time and place to talk that allow privacy and are convenient for all involved. If you expect an emotionally charged conversation, consider including a union representative or someone from the human resources department or employee assistance program (EAP), to bring objectivity and help diffuse tension.
When sharing your concerns, remain professional. Be friendly but direct. Present the facts and demonstrate respect. Make sure to speak for yourself by using “I” statements, not “you” statements. Here are examples of how to present concerns in a constructive way.
Sample statement #1:
“Yesterday when I was with patient X, I felt you wanted me to rush to finish up. Do you remember that? I felt embarrassed and flustered, and I don’t think those are good feelings to have when I’m working. It seemed like the task you needed me for could have waited. But perhaps I’m missing something. Am I?…I would have appreciated your waiting patiently for me. I know you’re busy and have a lot going on, but it would have meant a lot to me.”
Sample statement #2:
“The last few times I was in your office talking with you, I felt somewhat diminished when you took phone calls, as if our conversation wasn’t important. Were you even aware of that happening? I was thinking you might not be, and that’s why I wanted to bring this up. I know you have a lot of demands on your time and are dealing with important matters, but it would mean a lot to me and my working relationship with you if I had your full attention when we meet.”
After you’ve shared your concerns, listen closely to your leader’s response—and don’t argue. If you can’t resolve the issue, inform the other party that you’ll need to go to his or her supervisor. (See Case studies in conflict management.) If you decide to do that, stay calm, state your concerns objectively, and be clear on what kind of resolution you want and the actions you’d like that person to take. Before the conversation ends, make sure you’re both clear on the next steps and their timing.
Royal College of Nursing. Nurses need support when raising concerns. April 24, 2013. http://thisisnursing.rcn.org.uk/public/updates/nurses-need-support-when-raising-concerns. Accessed October 29, 2013.
The authors work at Midwest EAP Solutions in Minneapolis, Minnesota. Pam Bowers is a nurse peer coach. Liz Ferron is a senior EAP consultant.