3.3 Conflict Resolution

Managing Conflict

Conflict is not uncommon on interprofessional teams, especially when there are diverse perspectives from multiple staff regarding patient care.

When conflict occurs, the DESC tool can be used to help resolve conflict by using “I statements.” DESC is a mnemonic that stands for the following^[1]:

• D: Describe the specific situation or behavior; provide concrete data.
• E: Express how the situation makes you feel/what your concerns are using “I” statements.
• S: Suggest other alternatives and seek agreement.
• C: Consequences stated in terms of impact on established team goals while striving for consensus.

The DESC tool should be implemented in a private area with a focus on WHAT is right, not WHO is right. Read an example of a nurse using the DESC tool in the following box.

Conflicts are inevitable when working on a team composed of members with different personalities, roles, and responsibilities. It is essential for all nurses to develop conflict resolution skills.

Common Sources of Interpersonal Conflict

Common sources of interpersonal conflict in health care settings are passive-aggressiveness, horizontal aggression, defensiveness, peer informer behavior, and victimization behaviors.^[3]

Passive-Aggressiveness

Passive-aggressiveness is a behavior that shows disconnection between what a person says and does. Many times, a passive-aggressive person will agree with another person’s request, but later express feelings of frustration or anger to others and not comply with the request.

As an example, a charge nurse informs the team of RNs in a team meeting that a new policy requires bedside rounding. A nurse responds enthusiastically during the meeting but then complains to others about the policy and refuses to do it. The best method of managing passive-aggressive behavior is to confront it calmly and directly. For this example, it would be helpful for the charge nurse to say, “I was disappointed to hear you are upset about the new bedside rounding policy because you didn’t express any concerns directly to me. It would be helpful for you to directly communicate concerns to me so we can discuss them and make a plan for going forward.”^[4]

Horizontal Aggression

Horizontal aggression refers to hostile behavior among one’s peers. It is not acceptable and should be directly confronted in a constructive manner or it will get worse. A suggested approach to a peer displaying horizontal aggression is to respond calmly and sincerely, “I value your expertise and experience and am looking for your help and support.” If the negative behavior continues after an attempt to address the individual directly, the nurse supervisor should be notified according to the agency’s chain of command.^[5]

Defensiveness

It can be difficult to receive negative feedback. Some people respond by becoming defensive. Defensiveness puts the blame for one’s shortcomings on another person to make oneself appear better.

As an example, a nurse addresses a surgical tech about forgetting to open a required supply for a surgical procedure. The tech responds defensively by inaccurately blaming others, stating, “The preference card is unclear about what to open.” It is helpful to confront defensiveness by restating the facts in a calm manner and redirecting the conversation to the problem, its resolution, and the risk of jeopardizing patient safety. For example, the nurse could reply, “In this situation, it is your responsibility to ensure all supplies are opened. If you are uncertain it is important to ask someone.”^[6]

Peer Informer Behavior

Peer informer behavior is similar to gossip. Peer informers relay information about fellow team members to the nurse leader, and this information often lacks objective evidence. It is often best to respond to the informer by asking them to speak to their team member directly about their concerns unless it is an urgent matter that must be dealt with immediately. However, keep in mind that if concerns are shared about a staff member by more than one team member, it may be a pattern of behavior, and the nurse leader should follow up with that staff member.^[7]

As an example, a nurse approaches the charge nurse and says, “Everyone is concerned about how much time Nancy is spending in the room with her patients. She gets behind in her work and the rest of us have to make up for it.” The charge nurse could reply, “Have you addressed your concerns directly with Nancy?” If the nurse replies, “No,” then the charge nurse could state, “Please talk to Nancy directly with your concerns first.” However, if another nurse shares a similar concern with the charge nurse, then the charge nurse should address this pattern of behavior with Nancy and obtain her perspective.

Victimization

Victimization occurs when a team member feels they are being singled out unfairly or held to higher expectations than their peers. Comments may include, “Why am I getting called out on this when other people are doing this and aren’t getting in trouble?” or “I was never told this; why am I always the last to know?” Team members who feel victimized should be reminded by the leader they are held to the same standards as the other members. .^[8]

Conflict Management

Individuals manage conflict differently. During conflict, a person’s behavior is typically driven by their commitment to their goals or their commitment to relationships^[9]:

• Commitment to goals: The extent to which an individual attempts to satisfy their personal concerns or goals.
• Commitment to relationships: The extent to which an individual attempts to satisfy the concerns of another party or maintain the relationship with the other party.

Most people use different methods to resolve conflict depending on the situation and what strategy best applies. One approach is not necessarily better than another, and all approaches can be learned and used effectively with practice. However, to effectively manage conflict, it is important to first analyze the situation and then respond accordingly.

A long-standing conflict resolution model created by Thomas and Killmann describes five approaches to dealing with conflict: avoiding, competing, accommodating, compromising, and collaborating. Each of these steps is further described in the following sections.^[10]

Avoidance Approach

An avoidance approach to conflict resolution demonstrates a low commitment to both goals and relationships. This is the most common method of dealing with conflict, especially by people who view conflict negatively. See Table: Avoidance Approach below for types of avoidance, potential results, and situations when this strategy may be appropriate.^[11]

Table 3.4: Avoidance Approach^[12]

Application to Healthcare

In a clinical setting, there may be times when it is appropriate to avoid confrontation. For example, on a particularly busy day in the emergency department, a patient in a life-threatening condition was recently received. The attending physician shouts orders to the nurse in a disrespectful manner. The nurse avoids addressing the conflict until after the patient has been stabilized and then shares their concerns. However, if the physician continues to bark orders to nursing staff in nonemergency situations, avoidance is no longer appropriate, and the conflict must be addressed to establish a positive and respectful working environment.^[13]

Competitive Approach

A competitive approach to conflict management demonstrates a high commitment to goals and a low commitment to relationships. Individuals who use the competitive approach pursue their goals at other individuals’ expense and will use whatever power is necessary to win. A competitive approach may be displayed when an individual defends an action, belief, interest, or value they believe to be correct. Competitive approaches may also be supported by infrastructure (agency promotion procedures, courts of law, legislature, etc.).^[14] See Table: Competitive Approach for types of competitive approaches, potential results, and appropriate uses.

Table 3.5: Competitive Approach^[15]

Application to Healthcare

A competitive approach to conflict resolution may be appropriate in a clinical setting if a nurse leader realizes a nurse has made an error while preparing to administer IV medication to a patient. The nurse leader may stop the nurse from inaccurately administering the medication and take over completing the procedure. In this case, the goal of patient safety outweighs the commitment to the relationship with that nurse. However, after patient safety is maintained, it would be inappropriate to continue the competitive approach when debriefing the nurse about a simple human error. Debriefing should focus on educating the nurse about policy and procedures to improve their performance. However, if it is determined the nurse was acting recklessly and disciplinary measures must be instituted by a manager, then the competitive approach may be appropriate.^[16] This approach to responding to errors is often referred to as “Just Culture.”

Accommodating Approach

An accommodating approach to conflict management demonstrates a low commitment to goals and high commitment to relationships. This approach is the opposite of the competitive approach. It occurs when a person ignores or overrides their own concerns to satisfy the concerns of the other party. An accommodating approach is often used to establish reciprocal adaptations or adjustments, but when the other party does not reciprocate, conflict can result. Accommodators typically do not ask for anything in return but can become resentful when a reciprocal relationship isn’t established. If resentment grows, individuals relying on the accommodating approach may shift to a competitive approach from a feeling of “being used” that can lead to conflict.^[17] See Table 3.6: Accommodating Approach for types of the accommodating approach, potential results, and appropriate uses.

Table 3.6: Accommodating Approach^[18]

Application to Healthcare

It may be appropriate to use an accommodating approach when one of the members on your team has a challenging patient who is taking up a lot of time and effort. By being situationally aware and noticing the team member has been involved in that patient’s room for a long period of time, you offer to provide task assistance in an effort to provide mutual support. You are aware this will increase your workload for a short period of time, but it will assist your colleague and promote a strong team. However, the accommodating approach is no longer appropriate if the team member continues to expect you to cover their tasks after the situation has been resolved.^[19]

Compromising Approach

A compromising approach to conflict resolution strikes a balance between commitment to goals and commitment to relationships. The objective of a compromising approach is a quick solution that will work for both parties. It typically involves both parties giving up something in return for something, thereby “meeting in the middle.”^[20] See Table 3.7: Compromising Approach for types of compromising approaches, potential results, and appropriate uses.

Table 3.7: Compromising Approach

Application to Healthcare

Compromise is an appropriate approach to conflict in many clinical settings. For example, you are working with a team member who rarely assists other team members. The team member asks you for assistance with a blood draw for a patient. You hesitate because you are busy addressing your own responsibilities. You end up asking your colleague to help with your responsibilities while you complete their request for assistance with a blood draw. It would be inappropriate to refuse to assist the team member based on their reputation because this could impact safe, effective care for the patient.^[21]

Collaborative Approach

The collaborative approach to conflict resolution demonstrates a high commitment to goals, as well as a high commitment to relationships. The collaborative approach attempts to meet the concerns and priorities of all parties, but trust and willingness for risk are required for this approach to be effective.^[22] See Table 3.8: Collaborative Approach for types of collaborative approaches, potential results, and appropriate uses.

Table 3.8: Collaborative Approach^[23]

Application to Healthcare

An example of appropriately using the collaborative approach in conflict management in a clinical setting is when discussing vacation time off with team members. During a team meeting, time is available to discuss and focus on what is important and a priority for each member of the team. However, the collaborative approach to conflict management would be inappropriate when discussing the implementation of a new agency policy if the team has little influence in making adjustments.^[24]

All approaches to conflict can be appropriate for specific situations, but they can also be inappropriate or overused. When conflict occurs, take time to consider which approach is most beneficial for the situation. Keep in mind that using wrong approaches can escalate conflict, damage relationships, and reduce your ability to effectively meet team goals. Correct conflict management approaches build trust in relationships, accomplish goals, and de-escalate conflict.^[25]

Everyone has the capacity to use any of these approaches for managing conflict and can shift from their natural style as needed. We tend to react with our most dominant natural style when under stress, but other approaches can be learned and applied with practice and self-awareness. When dealing with others who have not developed their capacity to shift from their natural style of conflict management, it is important to consider their underlying needs. By understanding individuals’ needs existing beneath the surface of the conflict, you can work with the other person toward achieving a common goal.^[26]

Addressing Individual Needs and Approaches

There are times when other individuals take an approach that is not helpful to resolving the conflict. It is important to remember the only person you can control during a conflict is yourself. Be flexible with your approach according to the situation and the team members with whom you are working. If someone is taking an approach that is not beneficial to resolving conflict, it can be helpful to try to understand the needs that underlie their decision to take that approach.^[27]

Here are some examples of needs underlying their approaches to conflict and suggested ways to address them^[28]:

• People using the avoidance approach may need to feel physically and emotionally safe. Take the time to reassure them that their needs will be heard.
• People taking the competitive approach often feel the need for something to be accomplished to meet their goals. It may be helpful to say, “We will work out a solution, but it may take some time to get there.”
• People using the accommodating approach may need to know that no matter what happens during the conversation, your relationship will remain intact. It may be helpful to say, “This decision will not affect our relationship or how we work together.”
• People using the compromising approach may need to know that they will get something in return. It may be helpful to say, “We will do Action A first, and then we will do Action B for you.” However, be sure to be true to your word.
• People using the collaborative approach may need to know what you want before they are comfortable sharing their needs. It may be helpful to say, “I need this, this, and this…What do you need?”

Escalating and De-Escalating Conflict

An approach taken to manage conflict can escalate (increase) or de-escalate (decrease) the conflict. Conflict on a team can take a life of its own and escalate beyond reason if not managed appropriately by nurse leaders. When conflict is not managed appropriately, negative consequences within the team often occur, and patient safety can be compromised. Increased rates of absenteeism and turnover may also occur.^[29]

Conflict tends to escalate under the following conditions^[30]:

• There is an increase in emotions like anger, frustration, etc.
• An individual feels that they are being threatened (i.e., the fight-or-flight response is triggered).
• Other people get involved and choose sides.
• The individuals were not friendly prior to the conflict.
• The individuals desire to engage in conflict.

However, conflict can be de-escalated under the following conditions^[31]:

• Attention is focused on solving the problem.
• There is a decrease in emotion and perceived threat.
• The individuals were friendly prior to the conflict.
• The individuals desire to reduce conflict.

Read an example of escalating conflict in the following box.

There are positive steps to take to de-escalate conflict with another individual before it gets out of control. See Figure 7.9^[33] for steps to de-escalate conflict and implement change.

Conflict Management Tips

Healthcare workers must develop their own tool kit to manage conflict in a productive, positive way. . See Table 3.9: Conflict Management Tips for tips on managing conflict constructively.^[34]

Table 3.9: Conflict Management Tips^[35]

Dealing With Conflict

Health care professionals provide personal care at integral times in the lives of patients. The demands of caregiving and the associated rapid decision-making process can create stress for health care team members, patients, family members, and other loved ones. Managing care and making decisions can cause conflict among all involved. As a healthcare worker, it is important to be aware of your role and responsibility when managing conflict.

Family members and other supports may have concerns about the plan of care for a patient. This may be due to lack of medical knowledge, little experience with the procedures of health care facilities, or a feeling of helplessness in regard to their loved one’s situation. The healthcare worker should listen to and acknowledge these concerns. Following confidentiality guidelines, the healthcare worker should only disclose information when they have confirmed the patient has permitted disclosure. It may be beneficial for family members or others involved to discuss concerns with the charge nurse or unit supervisor and possibly schedule a care conference with the health care team to resolve their concerns. In this instance, the healthcare worker should understand that any anger directed at them may be a result of the situation rather than a reflection of anything they have personally done.

Conflicts among coworkers can also be addressed with assertive communication techniques. As discussed in the “Communication Styles” subsection, using assertive communication is the best approach to address workplace conflict and a respectful way to make one’s viewpoints known. Communication should start between the two parties that have the conflict before involving other staff. It is best to think about the situation and develop a potential solution before approaching the coworker. Frame the situation from your perspective using “I” messages. If the situation is especially tense, it may be beneficial to allow some time between the experience and the discussion to reduce stress and think more logically about the conflict. A typical time frame is to wait one day to think logically about a conflict before addressing it, often referred to as the “24-hour Rule.” If you have discussed your concerns with the coworker and offered a potential solution without any resolution in the situation, it is appropriate to notify your supervisor for additional assistance at that time. See an example of conflict resolution in the following box.

Attribution

This section contains content taken from Nursing Management and Professional Concepts 2e by Chippewa Valley Technical College and is licensed under a Creative Commons Attribution 4.0 International License.