Ashford General Hospital - Final Paper

6 Power and Conflict in Health Organizations

Learning Objectives

After reading this chapter, you should be able to:

• Identify the main theories and models of power in organizations.

• Articulate the role of politics in achieving and wielding power in health organizations.

• Discuss how gender and culture impact perceptions of power and behaviors in the health care workplace.

• Recognize uses and abuses of power in health organizations.

• Describe the types of conflict likely to occur in health organizations.

• Analyze sources of organizational conflict in health organizations.

• Describe management styles and the application of workplace conflict management strategies.

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Section 6.1Introduction to Power and Conflict in Health Organizations

The Grind: A Clinical Scenario One Health Control health system offers a full range of health care services, including urgent and emergency care; inpatient, outpatient, and rehabilitation services; as well as an array of ancillary support services for patients and their families. Professionals at One Health Control come from around the world, and the organiza- tion touts its cultural diversity in its public relations and marketing communications. The executive board is composed of an equal number of males and females, and approximately 60% of employees in the rest of the organization are female.

During a postsurgery check on a patient, the attend- ing physician, an American-born male in his 40s, requested that the assisting nurse, a foreign-born and foreign-educated female in her early 20s, stop what she was doing with the patient because it was wrong and could cause infection of the wound. The setting became tense while the nurse stopped her activity and struggled to maintain her composure. (The patient had drifted off to sleep.) The physician informed the nurse that she was treating the patient’s surgical wound incorrectly and that he planned to write her up for negligence. He added, “This is the United States. Here, we need to do things as we are trained in U.S. education systems.” The nurse replied that she had performed the treatment exactly as she had been trained both in her nursing program and by One Health Control. The physician told her again that she was wrong and to fix her care approach immediately or she would be written up and reported. The nurse later told a nonphysician colleague at One Health Control what had transpired. The colleague advised her to do whatever the physician had instructed her to do, because the physician had the ability to continue reporting her, which could lead to her termination.

Critical Thinking and Discussion Questions 1. Does this scenario exemplify abuse of power? 2. Does the physician have the right to threaten the nurse with corrective action? 3. How can this issue be approached and handled, and by whom? 4. Should upper management become involved, or can this be resolved between the two indi-

viduals subject to this conflict?

6.1 Introduction to Power and Conflict in Health Organizations

This chapter will review several theories and models of power and conflict. It shows how gender and culture can influence perception and behavior, since each relates to power and conflict. It also illuminates a number of issues for health care professionals about abuse of power, as well as how and by whom this issue can best be approached and handled.

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Is there a situation in which it is acceptable to question a doctor’s authority?

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Section 6.2Theories and Models of Power

These are important topics, because professionals entering the health care field need a strong understanding of power and conflict in order to deal with difficult and sometimes threatening dilemmas in the workplace.

6.2 Theories and Models of Power Power relationships are inherent in all organizations, but larger organizations feature many interdependent business units with varying degrees of importance; they therefore possess varying degrees of power and influence. Theories have paired power and influ- ence together to help explain behaviors and changes resulting from their use. These theo- ries are useful for analyzing behaviors in health organizations. Such behaviors are subtle and may go unnoticed, yet they have important and far-reaching repercussions. Not all concepts of power fit all types and settings of health organizations; however, sources of power can be found at various levels of health organizations and should be consid- ered in order to develop the appropriate strategy and tone of professional actions and communications.

Sources of Power

Power can be used in organizations to encourage individuals and groups to act in accor- dance with the company’s goals and objectives (Bewley, 2009). It is important for health professionals to know the individual and organizational domains of power and their respective components. By analyzing individual power bases, one can better identify the power players in an organization and understand how they leverage their power. Know- ing organizational structural power bases helps a health organization manager positively influence staff performance.

Individual Bases of Social Power French and Raven (1959) define power in terms of psychological relationships in which influence can change individual perceptions and behaviors. Their model is the foundation for the study of power in organizations and will be discussed in some detail. Its principal elements are the agent, who is the driving force behind the influence, and the recipient of the power and influence. In One Health Control, the physician is the driving agent, and the nurse is the recipient. The resulting psychological change derives from both the recipi- ent’s respect for the agent and her resistance to the use of power (Shafritz, Ott, & Yang, 2011). The key constructs of French and Raven’s model are five bases of social power, which occupy various structures of influence: coercive power, legitimate power, referent power, expert power, and reward power.

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Section 6.2Theories and Models of Power

Coercive power involves a dependent relationship between the driving agent and the recipient(s) of force. It derives from a threat (real or perceived) of punishment should the recipient of force not comply with the instructions or (actual or perceived) wishes of the driving agent. The degree of coercive power depends on the driving agent’s scope of power and the strength of the recipient’s perception that punishment can be avoided by conformity. For example, the physician at One Health Control threatened to continue reporting the nurse for negligence if she did not conform to his prescribed treatment method. His action could have a large negative impact on the nurse, especially if he were to report her repeatedly. The nurse could be considered inept or insubordinate. Although the nurse took notice of the threat from the physician, she may not consider his action as abuse of power nor be able to think of how to manage the conflict if she perceives the phy- sician as having the power to make or break her career at One Health Control.

Legitimate power derives from authority and social and cultural norms. It involves loyalty, social rank, and the organizational hierarchy, so that the influenced individual believes the driving force agent’s use of power is just and right. Cultural values strongly influence legitimate power. Some cultures, for example, hold firm that all males, elders, or higher ranked individuals must be respected and never questioned. These cultural values further shape the legitimate power agent’s ability to influence the recipient. In the case of One Health Control, the nurse could view the older male physician as possessing a justifiable right to reprimand and correct her. Both culture and gender could influence the nurse’s decision to change the scope of her practice according to the physician’s request.

Legitimate power, when exerted and not abused, can be mutually understood and respected. It reflects acceptance of the organization’s social structure, so that in health organizations physicians have more authority than nurses or administrators to make medical treatment decisions. It can also derive from designation by a legitimizing agent or process, such as when a nurse practitioner is authorized to prescribe medications through a scope of practice agreement or an individual is appointed or elected to a committee or office. The range of legitimate power may be specified formally in an organization’s poli- cies or an individual’s job description, or it may be derived informally from customary practice, which then becomes a de facto policy.

Referent power derives from the driving agent’s personal charisma and its effect on the recipient of influence; the recipient’s attribution of prestige to the driving agent leads to a desire to please or emulate the agent. The level of referent power reflects the level of respect for and the degree of prestige accorded to the driving agent by the recipient. Specific to the One Health Control scenario, the nurse may admire and seek to please the physician if she perceives him to be a prestigious member of the medical staff. Ott, Parkes, and Simpson (2003) caution against confusing referent power with other bases of power. For example, if the nurse were to conform to the physician’s orders only to avoid being reported, this would be coercive power. Should she conform because of his position as a doctor, it would be legitimate power. If she conformed because other nurses respected the physician and spoke highly of him, this would be an example of referent power.

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Section 6.2Theories and Models of Power

Expert power derives from the recipi- ent’s perception of knowledge pos- sessed by the driving agent of force. Its strength varies with the perceived extent of the agent’s knowledge. Examples of expert power are the relationships between attorneys and clients and between physicians and patients. In the case of One Health Control, the physician may have rec- ognized credentials (such as board certification) as well as extensive experience practicing medicine, and the nurse associates his education and experience with expert power.

Reward power provides an incen- tive for the person on the receiving end of influence to change his or

her behavior, expecting to receive a reward or recognition. Reward power derives from an attraction from the recipient to the driving agent. For example, the One Health Con- trol physician might indicate to the nurse that if she follows his direct orders (regard- less of whether the orders are correct), he would cease reprimanding and instead praise her. Reward power relies on the driving agent to offer rewards within the scope of the agent’s power (Ott et al., 2003). The physician could not promise the nurse vacation time or increased pay, as these rewards are at the discretion of people in other roles at One Health Control. However, if the physician offered the nurse favorable future treatment for following his orders, and this offer influenced the nurse to change her behav- ior, this would be an example of reward power.

Structural Power Bases Health organization managers can also use three primary structural power sources within their organizations to achieve an individual or organizational purpose—resources, decision-making authority, and information (Bewley, 2009). The power to generate and direct organizational resources is the greatest source of organizational power, summed up in the “golden rule” of business: “He who has the gold, rules.” The greater the amount of resources an individual manager or executive controls, both absolutely and as a propor- tion of the organization’s total resources, the greater his or her level of resource power. For example, in most health organizations, a vice president can approve a higher expenditure figure than a director. Decision power is closely related to an individual’s level of author- ity within the organization; it can be a potent source of power for staff members who are influenced by the decision maker. In most health organizations only clinicians can make treatment decisions. Administrative decisions as such embarking on a new business ven- ture require executive-level authorization. Information power at the organizational level can be a strong foundation of influence when the information is highly desired by others

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Expert power is derived from knowledge or per- ceived knowledge.

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Section 6.2Theories and Models of Power

and is closely held or otherwise difficult to obtain. Executive assistants who manage their bosses’ calendars possess this type of power.

These individual and structural sources of power may be used separately or collectively by health administrators to improve business processes and enhance organizational performance. They are often interdependent, serving as levers of influence to generate desired actions.

Leadership and Power

Theories providing insight about the origination of power sources and bases for power are highly useful to organizational leaders. Also notable, and no less important, are ways that leaders and individuals in positions of responsibility handle themselves in turbulent times. Health organizations in the United States are subject to constant changes resulting from technological advances and public and private payers’ efforts to control costs while also improving quality and increasing access. To cope with the health system’s myriad challenges, health organization leaders must understand how to use power judiciously when making key decisions that ensure their organizations succeed.

Negative Views of Power Power has many negative connotations; calling someone power hungry or power driven conjures up images of ruthless, domineering, dictatorial behavior by leaders and sneaky, cunning, manipulative behavior by followers. Power can also be a force for good, both for the person wielding it and those whom it affects: “Power can be a source of personal efficacy. It is the ability to mobilize resources to accomplish productive work. People with power shape their environment, whereas the powerless are molded by theirs” (Whetten & Cameron, 2011, p. 284). People want to work for powerful bosses because they are more privy to important information and are able to obtain more resources for their staffs. Like- wise, followers perceive their own status in the organization as higher if they work for a boss with clout. Powerful managers not only teach their followers how to get things done more effectively, but they can also use their influence to promote or defend their employees and gain fast access to top decision makers and expeditious action on their requests. Power- less leaders, by contrast, are merely bossy and attract less capable followers (Kanter, 1979).

Leadership Power Styles In a classic Harvard Business Review article, Robert Tannenbaum and Warren H. Schmidt (1973) addressed the use of power by organizational leaders. They considered whether a manager should lead democratically; make decisions based on his or her knowledge, experience, and authority; or develop a leadership style that incorporates both staff par- ticipation and direct self-reliance to make decisions (Tannenbaum & Schmidt, 1973).

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Section 6.3Managing With Power

Tannenbaum and Schmidt (1973) present a continuum of leadership power behaviors. At one extreme is a domineering style, where man- agement assesses situations and decides for the organization with- out follower input. In this autocratic leadership style, a manager makes decisions and then informs the staff. The staff does not have input and must carry out the leader ’s dictum. At the other extreme, the manager with a democratic leadership style calls on the staff to analyze the prob- lems and recommend solutions for management’s consideration. Man- agement seriously considers and usually follows staff recommenda- tions, relying on the staff to provide accurate information and skilled analysis. Effective leaders find a comfortable balance by which autocratic and democratic leadership qualities blend together in order to effi- ciently assess critical situations. One of the democratic leader ’s most vital roles is to clearly communicate downward to the work group and upward to the senior organiza- tional executives or governing body.

Building on French and Raven’s bases of power theory and Tannenbaum and Schmidt’s delineation of leadership styles, Jeffrey Pfeffer (1992) noted that the level of importance a decision carries increases the level of power associated with the decision maker. As Pfeffer defines it, the source of a leader’s power consists of control over the organization and the ability to manage the organizational environment through that control.

6.3 Managing With Power Many management scholars consider the ability to effectively use power as the most critical leadership skill. Warren Bennis of the University of Southern California Marshall School of Business found that individuals nominated by peers as the most influential leaders in all industries and fields built a strong power base in the organizations they led, and, more importantly, used their own power to help colleagues and followers to achieve extraordinary results and accomplish exceptional tasks (Whetten & Cameron, 2011). They understood power and were not afraid to use it or share it. As a health care professional, understanding power and politics within an organization is vital for professional devel- opment and advancement to leadership positions.

Organizational Politics and Power

The oft-cited maxim “knowledge is power” is based on a statement by 16th-century Eng- lish philosopher Sir Francis Bacon: “Knowledge and human power are synonymous, since the ignorance of the cause frustrates the effect” (as cited in Forbes.com, 2014). Information

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Health organizational leadership can fall along a continuum of power behaviors.

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Section 6.3Managing With Power

Case Study: Acknowledging Transfusion-Transmitted AIDS

Soon after the American medical and public health community recognized AIDS as an emerging epidemic disease in the early 1980s, blood transfusions were implicated as a form of transmittal when several hemophiliacs and babies who received transfusions developed and died from the disease. Public health officials and leaders of the CDC called for amending blood donor screening protocols to include AIDS and hepatitis antibodies beginning in 1982 (Pfeffer, 1992).

The blood bank industry fiercely opposed the CDC’s recommendation. The American Red Cross denied that transfusions spread AIDS and suggested that the CDC was exaggerating the risk in order to increase its funding. After Stanford Hospital began testing blood for evidence of AIDS infection, blood industry representatives accused Stanford of trying to draw AIDS patients from San Francisco hospitals. In early 1984 the U.S. Department of Health and Human Services convened blood bank leaders and CDC officials to develop a screening policy, but the industry officials agreed only to form a task force to study the issue (Pfeffer, 1992). Not until 1985 did blood banks begin screening blood donors for AIDS (AIDS.gov, n.d). By then an estimated 12,000 people had become infected with AIDS from blood transfusions (Pfeffer, 1992).

Why were public health officials and medical researchers’ recommendations to protect public health ignored for so long? The scientists and the epidemiologists felt that the data were compelling, and they presented their case forcefully. Yet they lacked power to change U.S. Food and Drug Administration policies. Their opponents in the blood bank industry had vastly more resources (lobbyists and public relations experts), extensive contacts and allies in Congress and the media, and years of experience advocating and exerting influence with key decision makers in the Washington, D.C., establishment—especially the Red Cross. While the Red Cross’s mission statement describes the organization’s function as providing emergency relief, its principal business is selling blood: In the late 1980s more than half of the organization’s revenues derived from sales of blood and blood products (Gaul, 1989). The blood banks’ resistance to AIDS screening resulted in thousands of preventable cases of AIDS (Pfeffer, 1992).

Reflection Questions: 1. What type of power did the American Red Cross exercise to oppose AIDS screening? 2. How did lack of power limit the CDC’s ability to fulfill its mission of protecting the

public’s health? 3. How did the Red Cross risk its future survival as an organization by its actions?

can become knowledge, so an individual can gain power by having access to informa- tion. Pfeffer (1992) uses this chain of logic to describe how an individual with access to information can make successful decisions and strategically manipulate his or her way through an organization to a position of more power.

There are four facets of what Pfeffer (1992) refers to as the politics of information analysis:

1. Organizations rely on information to make informed decisions. 2. Not all decisions are clear-cut, so rendering a determination is difficult. 3. An individual in a position of power with access to information can identify use-

ful data to render the decision very carefully. 4. Because access to information can be associated with power and decisions can

be made by use of such accessible information, individuals who use power for internal political gains or as weapons within an organization may be witnessed by others and frowned on.

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Section 6.3Managing With Power

Political Influence Strategies in Health Organizations Specific to successful management processes in hospitals and other health care organiza- tions, Lee Bewley (2009) indicates that collectivism of departments and staff is a critical success factor in organizations in which hundreds of employees work together, from top executives down to support staff. By understanding organizational politics and using power, managers of health care organizations are able to mold and influence how the organization’s staff performs. The more managers can positively influence the organiza- tion’s relationships and output, the more successful the organization can be. Bewley claims that health care organizations whose managers are unable to exert power and influence in this way have negative outcomes and lack employee spirit, which detracts from the health organization’s ability to fulfill its mission and achieve its goals. The higher the level of power associated with the manager, the greater the influence will be on the follower (Bewley, 2009).

Considering the opening vignette about One Health Control, the nurse taking direction from the physician may associate the physician with a high level of power, and he would thereby have a stronger influence on the nurse. The physician may be attempting to flex power and influence on the nurse in the hope that the same influence would permeate to other nurses on the staff. Over time, such occurrence and manipulation could provide the physi- cian more power conducive to his own goals, which may not be aligned with the goals of the organization. Bew- ley (2009) describes this process as politics in business, which can lead to an abuse of power and adversely affect the organization.

The study of organizational politics is grounded in Pfeffer’s (1981) central principle, which asserts that power is relative, not absolute. An individual is only powerful in relation to others, and only when these others accept the distribution of power as legitimate. To achieve their preferred outcomes, members of organizations must often make conscious efforts to overcome opposition or resistance to their ideas (Crossman, n.d.). These efforts often involve behind-the-scenes actions to obtain and use information from and culti- vate relationships with individuals and groups within and external to the organization. For example, a marketing director facing opposition to his proposed social media plan from the organization’s board of directors might elicit information from the secretary who records board minutes about who opposed the plan and why. The director could use this information to craft a strategy to overcome the opposition. He or she could also network with colleagues in other organizations and professional associations to learn how they may have handled similar situations.

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Like a functional cardiac rhythm, an organization’s collective efforts generate consistent productivity.

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Section 6.3Managing With Power

Political Games Henry Mintzberg (1983, 1985) developed an elaborate model of organizational behavior as a series of political games and players (“influencers”) that represent different external and internal interest groups seeking to control the organization’s decisions and actions. Table 6.1 describes how these games might be played by professionals in health organizations.

Table 6.1: Mintzberg’s power game

Game Health organization example

Insurgency: Individuals or groups of follow- ers resisting authority

Nurses leak information to the press about planned staff reductions that they say will endanger patient safety.

Counterinsurgency: Leaders fighting back to defend against insurgency

The CEO prohibits anyone other than the designated organizational spokesperson from speaking to the media.

Sponsorship: Junior staff seeking patronage from powerful leaders

The financial analyst asks the chief financial officer to serve as her mentor.

Alliance building: Leaders building power through peer networks

Hospital department heads form coalitions and establish norms for mutual support and cooperation.

Empire building: Leaders accumulating resources to build their power bases

When the head of an HMO coding unit resigns, the claims department manager sug- gests incorporating the coding unit into his department.

Budgeting: Managers’ striving to increase their unit’s budget

The hospital compliance manager inflates estimates of staff hours and consultant time needed for Joint Committee accreditation review.

Expertise: Expert employing his or her power for personal benefit

The doctors in a community clinic refuse to allow nurse practitioners to prescribe medi- cines.

Lording: Flaunting authority The hospital chief of medical staff repeatedly tells the chief nursing officer that medical treatment decisions are made by physicians.

Line versus staff: Conflicts between manag- ers with and without line authority

The chief information officer refuses to enforce the company dress code for the infor- mation technology staff and ignores requests by the vice president of human resources to meet and confer.

Rival camps: Organizational factions blam- ing and disparaging each other

Two health plans merge, and employees from each organization compete for power by insisting that their company’s business process is better.

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Section 6.3Managing With Power

Game Health organization example

Strategic candidates: Individuals or groups advocating for selection of a specific indi- vidual for a key position or office

When the CEO of a large community health center system announces his plans to retire, trustees and executives promote various internal successors and oppose the use of an executive search firm.

Whistle-blowing: Reporting damaging information about an individual or the organization

The hospital controller reports to the CMS that the CEO authorized payments to the hospital’s contracted travel agency for luxury vacation packages for physicians admitting a certain number of patients.

Young Turks: Employees or junior leaders attempting to buy the company or take over its leadership

Hospital nursing unit managers demand replacement of the long-tenured and dictato- rial director of nursing.

Sources: Mintzberg, H. (1983). Power in and around organizations. Englewood Cliffs, NJ: Prentice Hall; Mintzberg, H. (1985). The organization as a political arena. Journal of Management Studies, 22, 133–154.

Health professionals in organizations where these games are played have several courses of action. They can ignore the games, in effect leaving the playing field to the gamers, and dedicate their energies to performing well. They can get out of the game entirely by seeking a job in another organization. Or they can play to win; some of the games can be useful strategies for success. The key task is to analyze what is going on in order to make these choices.

Transforming Power Into Influence

Having the knowledge and skills necessary to succeed within a company does not auto- matically translate into a promotion, pay raise, or acquisition of more responsibility. The challenge is garnering knowledge from prior education, research, and experience, and then performing when the moment is opportune. Management does not always explicitly acknowledge who is influencing the company or which associates’ work products are rec- ognized as outstanding. The definition of power in organizations is shifting from having authority and control over others to the ability to get things done (Whetten & Cameron, 2011). To get things done and to be recognized and rewarded for this ability, health pro- fessionals need to develop strategies for gaining organizational power throughout their careers, and using that power wisely and constructively.

Power Signals One way to gauge whether management is receptive to use of knowledge and influence is through nonverbal communication. Wall Street Journal columnist Sue Shellenbarger (2013) reported on a study demonstrating that eye contact is significant in any type of in-person communication exchange. The more time a superior maintains eye contact with

Table 6.1: Mintzberg’s power game (continued)

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Section 6.3Managing With Power

an associate during business meet- ings, the more influence an associate may have, and the more attentive the superior is to the associate. Gender differences can influence how eye contact is made in business meet- ings. Female leaders shared eye con- tact more evenly than male leaders when in group meetings, regardless of the participants’ status. Female leaders also made more eye contact than male leaders to establish their presence in meetings (Shellenbarger, 2013). Engaging others with insight- ful information and using nonverbal communication such as eye contact can express motivation and confi- dence, and inspire trust.

Power Base Development An individual’s power in an organization derives from two basic factors: personal charac- teristics and position. The importance of each factor varies greatly among organizations, depending on their type and culture (Whetten & Cameron, 2011). For example, in gov- ernment, military, and highly traditional private organizations, one’s position and title are closely tied to the amount of power wielded by the position holder. In many other organizations, membership in a specific group (Ivy League college alumni, members of a particular ethnic group, or followers of a particular religion) and personal or family connections with powerful individuals or stakeholders are key determinants of power. Regardless of the organization, there are some general strategies to develop a personal power base that health care professionals are well advised to employ.

Blend Images/SuperStock

Eye contact reveals confidence, trust, ability, under- standing, and respect.

Theory in Action: Building a Personal Power Base

• Look beyond titles: Focus on the opportunities embedded in a position or job rather than its level of authority. Can you produce outstanding results and be recognized for them? Can you learn new skills and forge new relationships with individuals and external stakeholders that will be useful to you in the future?

• Demonstrate, modestly, your expertise: “Expertise, or work-related knowledge, is the great organizational equalizer because it can come from formal education, self-directed learning, or on-the job experience” (Whetten & Cameron, 2011, p. 289). If you know more than your boss about a particular topic (such as regulatory agency reporting requirements), make your knowledge available in a way that makes your boss look good and respects his or her authority. However, be careful to avoid being typecast as a particular type of expert with knowledge in a very narrow area if you aspire to a general management or executive position.

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Section 6.3Managing With Power

Theory in Action: Building a Personal Power Base (continued)

• Show a positive personality: Research demonstrates that leaders of high-performing organizations are more likely to be characterized as charismatic (Allinson, Armstrong, & Hayes, 2001), and that likable individuals make more effective persuasive arguments and receive more favorable treatments from their bosses (Huston, 1974). Making eye contact, saying hello, paying appropriate compliments, expressing appreciation for others’ efforts and assistance, and courteous behavior all demonstrate warmth and interest in other people.

• Look as good as you can: Attractive people are more successful because they are perceived as having more positive characteristics; their work products and their performance receive more favorable evaluations as well (Hosoda, Stone-Romero, & Coats, 2003). While you cannot transform all aspects of your physical appearance, you can improve others’ perceptions of your attractiveness by dressing professionally and maintaining high standards of personal cleanliness and grooming. Look like the holder of the job you want.

• Work hard: Demonstrate that you can be counted on to do whatever it takes to get the job done. In addition to demonstrating your work ethic, you will often benefit by increasing your knowledge about the work involved and therefore increasing your expert power. If you consistently perform at a level above and beyond what is expected, your boss will likely seek to reduce the cognitive dissonance he or she experiences by increasing your scope of work or level of responsibility. Under promise and over deliver.

• Build and nurture strong positive relationships with colleagues throughout the organization: Develop both horizontal networks of people in positions with similar levels of authority and vertical networks with people in positions with different levels of authority. For those at higher levels, promote these relationships within protocol, respecting hierarchical relationships. Make time to get to know and keep in touch with people beyond the inner circle of your coworkers: Socialize at breaks or lunch, volunteer or ask to be appointed to interdepartmental work groups, and seek out positions that require working with other departments. Offer to write an article for the employee or the professional association newsletter. Effective leaders and managers develop and cultivate a broad base of organizational contacts to build and maintain a strong internal network.

• Increase your visibility: LinkedIn (http://www.linkedin.com) bills itself as “the world’s largest professional network,” claiming more than 250 million registrants. It is a valuable tool for establishing one’s professional identity online and for networking. Have a LinkedIn profile, establish and grow your professional online network, and join groups in your area of interest. Post and respond to comments on topics in your field—but be sure that you do not reveal any confidential or proprietary information from your company. Participate actively in a professional development organization by volunteering for at least one committee. For example, members of a program or events committee are involved in recruiting speakers for organizational events and facilitating their presentations. This affords an opportunity to invite high-level people in your organization to be speakers as well as to meet influential leaders in other organizations and industry sectors.

The following is a list of just a few of the many professional organizations for health administrators. Join at least one that is best aligned with your career focus. The best time to join is as a student for discounted rates—and be sure to renew just before you graduate!

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Section 6.3Managing With Power

Uses of Power

Seemingly common and purposeful, using power to make a positive influence can change lives, and even the faces of organizations. Psychiatrist turned management consultant Dr. Mark Goulston and UCLA School of Management Professor Dr. John Ullmen advocate using connected influence to forge genuine and powerful connections with others to gain buy-in and achieve outstanding results. In contrast is disconnected influence, or getting people to do what the manager or leader wants. While these manipulative techniques may create short-term gains, in the long run they are counterproductive, since people do not like being used in this fashion. “In short, disconnected influence is about getting what you want. Connected influence is about leading others to better results” (Harrin, 2013, p. 1).

Constructive Use of Power The first step in using connected influence is to create a believable vision of a great out- come, to positively influence the employee to be the best he or she can be. Jim Sinegal, the cofounder and former CEO of Costco, experienced this type of positive influence when he was a troubled teenager working as a bagger at the original warehouse store, FedMart. Sol Price, the company founder and CEO, saw that Sinegal had a knack for the business and gave him increasingly challenging assignments. Price’s vision of a great outcome for his company—exceptional customer value combined with caring treatment of employees—allowed him to positively influence Sinegal. Sinegal went on to found his own warehouse company, Costco, which later merged with Price’s company and then became the nation’s dominant warehouse store (Goulston, 2013).

Theory in Action: Building a Personal Power Base (continued)

American College of Healthcare Executives

http://www.ache.org

American Health Information Management Association

http://www.ahima.org

American Society for Healthcare Human Resources

http://www.ashhra.org

Asian Health Care Leaders Association

http://www.ahcla.org/i4a/pages/index.cfm pageid=1

Healthcare Financial Management Association

http://www.hfma.org

Healthcare Information and Management Systems Society

http://www.himss.org

Medical Group Management Association

http://www.mgma.com

Society for Healthcare Strategy & Market Development

http://www.shsmd.org

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Section 6.3Managing With Power

Goulston and Ullmen explain that an effective leader can positively influence employees by identifying a great outcome that they can buy into. In doing so, the employees will also gain the ability to positively influence others in the organization as exemplary workers and top performers. This use of constructive power can lead organizations to success by engaging employees to share that vision and continue to achieve great results.

Destructive Use of Power Power can also be used in a destructive way, resulting in negative outcomes. The importance of identifying destructive uses of power in an organization is illustrated by the experience of a physician practice where revenues increased by 30% in the year following the departure of a grouchy nurse whose negative behaviors impacted both staff and patients. Although professionally competent and hardworking, this nurse was seldom happy and other staff habitually apologized to patients for her rude behavior. Remarkably, she continued to work at the practice for 20 years (Gandolf, 2013). This type of destructive power can weigh heavily on a health organization. In this case, a 30% increase in practice revenues over 20 years would have allowed the physician to retire comfortably. Allowing this problem to continue for 2 decades meant that the doctor could not afford to retire when he would have liked to do so.

Power, Gender, Culture, and Discrimination in Health Organizations

Health organizations and their employees are products of their environment. Thus, both are influenced by the geographical, social, technological, economic, and political forces from which they emanate and in which they operate. Men and women of diverse cultures can influence organizational leaders, and diverse leaders can influence organizations and their employees. An effective leader is receptive to input from both men and women across cultures. An effective leader employs both social influence and psychological understanding in order to exert power and to accomplish tasks at hand through learning from the organizational environment (Pfeffer, 1992).

Gender and Power A critical consideration regarding power in health organizations is gen- der neutrality: Leaders must under- stand and address gender-specific influences and concerns, but must not favor one gender over another. Health care organizations employ both male and female workers, managers and leaders, yet the proportion of men and women varies tremendously by orga- nizational level (Chase, 2012). Women constitute

Chaos/GettyImages

Data shows few women hold high-level leadership positions in health care organizations.

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Section 6.3Managing With Power

• 73% of medical and health service managers, • 47% of medical school graduates, • 32% of physicians and surgeons, • 19% of hospital CEOs, • 14% of boards of directors at health care companies, • 4% of health organization CEOs, and • 0% of CEOs of Fortune 500 health care companies (RockHealth, 2012, 2013).

RockHealth surveyed 100 women in health organizations and found that three of the top five reasons that women left their previous positions were subject to control by the company: company culture, lack of managerial support, and salary. To encourage and promote more female leadership in health organizations, these conditions must be addressed and changed.

Diversity, Culture, and Power Sometimes the best way for a health organization manager to gain power is by empow- ering followers. For example, if a manager in a health organization desires to improve communications with limited English proficiency (LEP) patients, the leader’s willing- ness and ability to increase the organization’s level of cultural awareness is important for both the community and the staff’s morale. Empowering staff members who speak the patients’ languages to strategize and collectively integrate linguistically and culturally appropriate information into the health organization’s communications with LEP patients benefits both the leader and the organization. Such a practice not only demonstrates the leader’s confidence in the staff. It also decreases communication barriers for LEP patients and family members and thus enhances the quality of care the organization provides.

Clinical health professionals have highly portable and valued skills that enable many to obtain jobs in the United States. From their experiences, a body of research has emerged on how culture and gender often are seen as potential limitations to upward mobility within U.S. health organizations. Internationally born immigrant professionals who speak heavily accented English often experience discrimination in all types of large U.S. organizations—especially those with low-status accents (African, Asian, or Hispanic). In contrast, immigrants with high-status accents (western European, Australian, or New Zealand) experience much less discrimination. As few organizations recognize or address this type of discrimination, these foreign-accented immigrant speakers may be considered an invisible minority (Akomolafe, 2013).

This situation is particularly germane to health organizations where a substantial pro- portion of clinical professionals are immigrants born and educated outside of the United States. It is important for health organization leaders and managers to understand how integral all health care professionals in the workforce are to the community’s health needs, regardless of their speaking accents. Although language may seem a communication bar- rier, delegitimizing a professional’s abilities based on culturally influenced spoken lan- guage is a larger barrier, in itself, to the organization’s ability to serve the needs of a diverse community.

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Section 6.4Conflict

6.4 Conflict While the absence of organizational conflict is often considered a sign of good leadership, it can actually signal that management is out of touch with significant changes in the mar- ketplace (Argenti, 1976). As evidenced in the opening vignette of the physician and nurse, conflict can and does occur within organizations. Also, as discussed in Chapter 4, having work teams at all organizational levels openly and vigorously debate their ideas is a form of healthy conflict that produces both stronger team relationships and better work outcomes.

The case at One Health Control, however, involved verbal conflict with a strong discrimi- natory tone and was more of a one-way admonishment than a dialogue between profes- sionals. Understanding workplace conflict and knowing how to handle it are extremely important managerial skills, and health care organizations are no exception. If unhealthy conflict arises within an organization and is not addressed, it can create internal turmoil, reduce productivity, and increase turnover.

There are numerous types of conflict and a variety of approaches to conflict management. Ledlow (2009) defines conflict as the result of varying goals among interdependent individuals in situations with limited available resources—most commonly, staff and money. In the context of health orga- nizations, conflict most often takes place when two or more individuals have different intentions about a par- ticular clinical or business process or how to resolve a particular problem. Conflict resolution strategies involve establishing or restoring communica- tion, interpersonal relationships, cul- tural competence, empathy, and trust.

Relationship Conflicts

Relationships within a health organization are vital to success. There are relationships between nurse managers, frontline nurses, senior physicians, technicians, division and unit managers, and many types of support staff. There are numerous types of operational relationships: between individuals (interpersonal); within groups (intra-organizational); and between organizations (inter-organizational). Inter-organizational, and to a certain extent intra-organizational, relationships involve different stakeholder groups. Given the wide variety of personality types, there is the potential for both healthy and unhealthy conflict at every level. Therefore, managers need to understand and effectively manage conflict within these relationships in order to foster organizational success.

Blend Images/ERproductions Ltd/Getty

Conflict is inevitable, but an organization that expe- riences healthy conflict can grow more stable and strong.

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Section 6.4Conflict

Interpersonal Conflict There are two main types of interper- sonal conflict, depending on the focus. Issue-focused conflicts in business are generally rational negotiations about how to allocate scarce resources where the participants recognize the need to reach an agreement that is acceptable and perceived as reasonable to all par- ties. People-focused conflicts are more about what transpires, or has previ- ously transpired, between the parties. When this conflict becomes intense, the level of emotion is high and the nega- tive repercussions can be long lasting. Healthy conflict refers to issue-based conflict; when a dispute becomes per- son focused, it is much more difficult to resolve since it is more emotional than rational (Eisenhardt, Kahwajy, & Bourgeois, 1997).

Difficult personalities within an organization can create communication barriers and con- flict with other employees. People who are negative, overly sensitive or dramatic, nar- cissistic, or blamers may often have other desirable attributes such as integrity, values, commitment to teamwork, a strong work ethic, and desirable skills. However, their bad attitudes make them difficult to work with and for and can negatively affect or drive out the people they work with. While a manager cannot change an employee’s fundamen- tal personality traits, by focusing on the facts and behaviors, managers can enable these difficult employees to become more effective and productive (Murphy, 2013b). Table 6.2 displays the fact-focused solutions recommended by Leadership IQ CEO Mark Murphy for dealing with various types of difficult personalities.

Table 6.2: Fact-focused managerial solutions for dealing with difficult employees

Personality type Fact-focused solution

Negative personalities: People who always look on the dark side and have multiple rea- sons why any new idea will not work

Stay focused on facts to force negative employees to critically analyze their negativ- ity and consider the possibility of a positive outcome.

Drama kings & queens: People who crave attention and provoke others to get it

Insist on facts, not stories and calm, not emotion.

Narcissists: Individuals with an exaggerated sense of self-importance, which obstructs the work of the team

Acknowledge their intelligence, challenge them to use it constructively.

Thomas Northcut/Digital Vision/Thinkstock

Positive interpersonal professional relationships foster communication and cohesiveness in health organizations.

(continued)

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Section 6.4Conflict

Personality type Fact-focused solution

Blamers: People who believe an issue or problem is always the fault of someone else

Redirect (repeatedly if necessary) the discus- sion back to the facts of their actions.

Overly sensitive: “Touchy” individuals who require handling with care

Provide positive reinforcement of their potential, then challenge them to live up to it.

Source: Murphy, M. (2013b, May 21). 5 difficult personalities you can do something about. Retrieved June 3, 2013, from the Leadership IQ website: http://www.leadershipiq.com/5-difficult-personalities-you-can-do-something-about

Focusing on facts when personalities present themselves in employees saves time and pro- vides clarity. The goal is not to change an employee’s personality; it is to remain focused on the organization’s goals and operations. Facts and data help leaders in health organiza- tions resolve interpersonal conflicts created by talented employees with various types of difficult personalities (Murphy, 2013b).

Intra-organizational Conflict It is not uncommon for conflict to occur regarding a wide range of measures within health organizations because of their complexity and size. Interdependence of departments within an organization can lead to conflict, often grounded in differing professional train- ing and different measures of departmental success. Financial pressures almost always produce intra-organizational conflicts, such as when an organization is on the verge of laying off employees and individuals are vying to keep their jobs. Intra-organizational conflict can and does also occur during good times. When a small community hospi- tal received a multimillion dollar endowment donation to build and operate an urgent care center, the directors of the emergency and ambulatory care service departments each argued that the urgent care center should be under their control.

Health organizations have intricate management systems with rules encompassing a wide variety of practices that occur on a daily basis. As Ledlow (2009) describes, knowledge and education can lead to conflict, as individuals become aware of their own and others’ goals and how these goals can vary across a health organization. Yet conflict is integral for an organization to change and survive. Varying perspectives are good for debating ideas and the means for accomplishing goals. Some conflict is inevitable in these debates. Addressing and constructively managing that conflict in a way that builds or maintains team cohesiveness is among the most important managerial skills.

Table 6.2: Fact-focused managerial solutions for dealing with difficult employees (continued)

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Section 6.4Conflict

Inter-organizational Conflict Inter-organizational conflict that occurs between organizations with interdependent members almost always involves competition for resources or control. For example, when a health plan announces a rate increase, almost immediately the plan’s contracting hospi- tals and medical groups will compete with each other for a larger share of the increased revenues; within the medical groups, primary care physicians and each specialist unit will clamor for what they consider their fair share of the additional funding. In a more overtly political inter-organizational conflict, the California Medical Association successfully lob- bied in 2013 to defeat proposed legislation allowing nurse practitioners to practice with- out the direct supervision of a physician (Mason, 2013).

As authorized by the 2010 Affordable Care Act, health organizations are increasingly form- ing alliances, networks, and other forms of integrated organizational delivery systems, such as accountable care organizations. These integrative arrangements bring together a variety of different types of health care provider organizations whose ability to coor- dinate patient care to meet cost and quality standards determines their ability to realize economic gain through a shared savings program. Conflicts among these organizations inevitably occur as integration levels and financial stakes increase (Borkowski, 2011).

Conflict Management

Health service conflict emanates from health care organizations’ distinct culture that includes a stressful “life or death” environment; many people with intense, type A person- alities; and often conflicting values operating in a complex and highly regulated industrial arena.

Interpersonal conflict is an everyday challenge for health care workers as they strive to change minds, stall competition, dominate resources, or sim- ply react to contrary opinions or misunderstanding. . .. Like a fever, it can be uncomfortable, and even dangerous, but when diagnosed accurately and treated appropriately, it can be a healing mechanism that is crucial to supervisory success, patient safety, and organizational wellness. (Nelson, 2012, pp. 178–179)

There is no one best way to manage conflict; rather, there are a range of conflict manage- ment styles that health care professionals can employ depending on the situational con- text. Personality, gender, and culture all influence how an individual or group perceives and reacts to conflict, as will be discussed in this section.

Conflict Management Styles Ledlow and Coppola (2014) identify six styles of conflict management that synthesize the work of several management scholars, noting that the best style to use depends on the

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Section 6.4Conflict

situation but suggesting some conditions associated with each conflict management style. Table 6.3 offers a definition of each style and the situational conditions associated with it.

Table 6.3: Conflict management styles and when to use them

Style Definition Situational context

Accommodating Satisfying the other party’s concerns, neglecting one’s own interests

To demonstrate reasonable- ness and flexibility, to create political capital, or an obli- gation for future support on an issue of importance to the accommodating individual, and when the chances for winning the conflict are low.

Avoiding Sidestepping conflict or postponing a decision, neglecting both parties’ interests

Wisest approach with trivial issues, when the risk of disruption outweighs the benefits of resolution, when others can more effectively resolve the conflict, or when it is important for subordi- nates to reach agreement on their own.

Competing Satisfying one’s own needs at the expense of the other party

Sometimes necessary to (a) fight for an issue the individual considers vital to company welfare or against an action that she believes will have disastrous consequences or is morally wrong, (b) make vital deci- sions quickly, and (c) avoid being taken advantage of by aggressive adversaries who react to reasonableness as weakness.

Compromising Seeking partial satisfaction for both parties, requesting each to make sacrifices for a common gain

Advised with equally pow- erful opponents who have mutually exclusive goals, to achieve a temporary settle- ment of a complex issue, to reach agreement in a timely manner, and when the cost of competing outweighs the benefits.

(continued)

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Section 6.4Conflict

Style Definition Situational context

Collaborating Attempting to fully meet the needs of both parties

Enables the opposing par- ties to find an integrative solution that satisfies both and to gain commitment by achieving consensus, but it is often a labor-intensive and time-consuming process.

Problem solving Identifying a broad range of strategies and selecting the most feasible one

The ideal style, with many important benefits—but for it to work, both parties need to be flexible, realistic, issue-focused, and outcome oriented.

Source: Ledlow, G. R., & Coppola, M. N. (2014). Leadership for health care professionals: Theory, skills, and applications (2nd ed.). Burlington, MA: Jones & Bartlett.

Table 6.3: Conflict management styles and when to use them (continued)

Web Field Trip: What’s Your Conflict Management Style?

Take the TWO conflict management style quizzes to determine your conflict management style:

1. http://academic.engr.arizona.edu/vjohnson/ConflictManagementQuestionnaire /ConflictManagementQuestionnaire.asp.

2. http://www.agrisk.umn.edu/conference/uploads/CTerhune0790_02.pdf.

Compare the results. How consistent are they? Do you agree with the test results? What might explain any differences you find in results from the two assessments?

Gender and Conflict Management Nurses in health care organizations often are frontline experts delivering direct, hands-on patient care, whereas physicians play more of an administrative role as they diagnose, make a prognosis, recommend a course of treatment (which may involve an interventional procedure or surgery), and monitor patients’ progress toward recovery. Given the dynam- ics of the nurse-physician relationship, it is advantageous for nursing staff to understand conflict management.

Research on conflict management within health care organizations finds some common- alities among nurses and differences among health professionals. One Canadian study on conflict management from a gender perspective found that a majority of North Ameri- can women nurses use compromise and avoidance as conflict management styles. The authors concluded that nurses are often in less powerful roles, or at least the female nurses perceive themselves as less powerful and prefer not to take a stand for their positions

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Section 6.4Conflict

when managing conflict (Valentine, 2001). Sportsman and Hamilton (2007) conducted a study with 126 undergraduate and graduate students in multiple allied health profes- sions. The authors found no statistically significant differences in conflict management styles across professional health discipline or level of education, nor between women and men. Their results suggest that conflict management style, at least for students, is more closely associated with personality than gender, education, or profession. As in the study of Canadian nurses (Valentine, 2007), the most common conflict management style for nursing students was compromise, followed by avoidance. For allied health students, the prevalent style was avoidance, followed by compromise and accommodation (Sportsman and Hamilton, 2007). More than 1,000 health care professionals in Cyprus, 75% of whom were women, reported spending an average of 90 minutes each day in conflict resolution. Avoidance and collaboration were the most commonly used conflict management styles (Pavlakis et al., 2011).

Culture and Conflict Management Cultural background as well as personality influences conflict management styles, since cultural values are present during workplace conflicts. Kim-Jo and colleagues (2010) con- ducted a study of methods for conflict management among European American, Korean American, and Korean undergraduate students in a Southern California university and a South Korean university. The researchers concluded from their sample that Korean Ameri- can participants shared characteristics of both European American and Korean participants in conflict management: Korean American participants were aggressive in nature similar to European American participants and also avoidant similar to Korean participants.

Turner and Shuter (2004) examined work conflict and resolution attitudes among Afri- can American and European American women workers. The authors found that African American women’s attitudes toward workplace conflict were more negative, more pas- sive, less focused on resolution, and less optimistic about a positive resolution; European American women were more optimistic about managing conflict and achieving a positive outcome. Since African American and European American women view conflict from dif- ferent perspectives, the authors suggested that they are likely to approach conflict differ- ently. A manager might address this discrepancy by exploring with the African American women the reasons for their more pessimistic attitudes, encouraging them to be more active participants in the conflict resolution process and providing examples of positive outcomes achieved in the organization. Managers need to understand how race, culture, and gender shape both perceptions of and approaches to conflict management in order to develop optimally effective methods for conflict resolution. Diversity training and appre- ciation programs can help managers learn about and deepen their understanding of the influence of race, culture, and gender in conflict management.

Conflict Resolution

Providing high-quality patient care must be the number one goal in a health organization, regardless of internal interrelationship conflict. Community members rely on health care professionals to diagnose and treat medical conditions, not to argue or consume time trying to resolve conflict. When conflicts consume health care professionals, patients can get caught in the crossfire, which can negatively affect their treatment as well as erode their confidence

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Section 6.4Conflict

in the treatment team. Conflict management is an extremely important skill to understand, and not all individuals are equipped with the same competencies for conflict resolution.

Time is valuable, especially in health care. It is inevitable that conflict will arise, but strat- egizing and knowing beforehand how to approach conflict resolution is beneficial for not only individuals, but also the health care organization as a whole. Managing conflict is not innate; it is learned—through trial and error from experience and from formal training in educational programs or organizational systems.

Strategies Dean Tjosvold (1993) proposes a cooperative conflict model, which recognizes that the way people perceive their goals in relation to the goals of others influences their behavior toward either cooperation or competition. When people perceive their goals to be posi- tively related to those of others, they believe that their individual achievement depends on others achieving their goals. In contrast, when people believe that their goals are com- petitive with the goals of others, they reason that if others succeed they will fail. The lead- ership challenge is to get people to realize that their goals are interrelated, even though they may have very different ideas about how best to achieve them. With this recognition, people can manage their conflicts productively. They can speak freely, vigorously (but respectfully) disagree with each other, exchange information, and arrive at win-win solu- tions that resolve the problem and strengthen the relationships among the parties. Con- flict is not always a negative event. Positive aspects of conflict resolution can be achieved and should be a goal for conflict resolution.

Brad Spangler (2003), writing for the Beyond Intractability Project, part of the Conflict Information Consortium at the University of Colorado, proposes a similar approach to conflict resolution that he calls integrative or interest-based bargaining. This is a negotia- tion strategy with a goal of developing mutually beneficial outcomes that create joint value. Instead of fighting for a bigger piece of the pie, opposing parties seek to enlarge the pie so that everyone gets more of what they want. The key to this approach is to first discern the true interests of the parties in order to understand the reasons behind their demands and to analyze the potential consequences of an opponent’s position from the opponent’s perspective. When both parties know who wants what and why, they can work together to make the joint value (the pie) as large as possible and therefore easier to divide.

Michael Porter, long recognized as a thought leader in competitive strategy, echoes Spangler’s theme in his classic article on redefining competition in health care by noting that health care competition has become zero sum: Instead of increasing value, health care system partici- pants divide it by (a) shifting rather than fundamentally reducing costs, (b) pursuing greater economic bargaining power instead of striving to provide better care, (c) restricting choice and access to care rather than increasing its efficiency, and (d) settling disputes through legal action instead of negotiation or collaboration. Porter advocates for positive-sum competi- tion, where players compete to provide the best value instead of to shift a greater share of the costs of delivering care to others (Porter & Teisberg, 2004).

Forbes columnist Keld Jensen (2013) argues that cooperative problem-solving approaches are seldom effective, primarily as a result of people’s unwillingness to trust each other.

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Section 6.4Conflict

While acknowledging the soundness of Fisher and Ury’s concept of entering negotiations with a best alternative to a negotiated agreement, Jensen insists that successful negotia- tion requires a different mentality. The negotiator must not only act openly, honestly, and collaboratively but must also educate and persuade the other party to behave that way.

Theory in Action: How to Avoid Playing Umpire on Your Team

Fred Kofman, a professor of leadership and coaching, warns managers not to become involved in situations in which one employee calls on the manager to mediate a conflict with another. Discussing the problem separately with each employee wastes time, creates hostility and suspicion among team members, and fosters an unhealthy group dynamic where employees make the manager responsible for resolving staff disagreements. Kofman (2013a) recommends the following rules to resolve conflicts among a manager’s direct reports:

1. Information is free. Everyone can speak to anyone else about any issue he or she considers relevant.

2. If two people have a conflict they must first try to solve it among themselves through interest-based bargaining.

3. If they can’t reach an agreement, they must bring the problem to their manager together. (If they don’t report to the same manager, they must call a meeting and present the problem to the two managers together.)

4. They must present the disagreement as a shared narrative with alternative resolutions, highlighting the trade-offs they cannot resolve without the man- ager ’s help.

5. If one of the parties (e.g. Sally) refuses to escalate jointly, the other must inform her that he’ll do it alone and invite her, once again, to bring the matter “up” together.

6. If the reluctant party continues to refuse, the other can then escalate unilaterally.

To support this process, the manager must refuse to listen to any argument brought to her unilaterally unless the employee provides an affirmative answer to the fol- lowing questions:

1. “Have you and your colleague tried to resolve this problem using constructive negotiation?” If the answer is “no,” then, “Please try that first.”

2. “Have you invited your colleague to come escalate the problem with you?” If the answer is “no,” then, “Please invite him first.”

3. “Have you told your colleague that if he didn’t come with you, you would bring the problem to me alone?” If the answer is “no,” then, “Please tell him first.”

If the manager gets three yeses, she should call the missing colleague and ask him to attend. This sets a cultural norm: It is not acceptable to refuse to escalate jointly. (Kofman, 2013a)

Conflict Mediation When opposing individuals or parties are unable or unwilling to resolve a dispute between or among themselves, the manager or a third party will be called in to act as a mediator. When conflicts occur between a manager and subordinate, the mediator will be a human

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Section 6.5Summary and Resources

resources professional or an outside consultant. Whetten and Cameron (2011) offer the following guidelines for managers serving as mediators.

1. Acknowledge the conflict as a serious problem for the participants, even if you do not regard it as such, and establish a problem-solving framework.

2. Determine whether to first meet with the participants individually or jointly. As Kofman (2013a) recommends, meeting jointly with participants is preferable. However, separate fact-finding meetings may be necessary and useful when the parties have a long series of recurring disputes or if they have profound differ- ences in values, personality characteristics, and communication styles.

3. Respect both parties’ points of view and maintain a neutral posture. Ensure that both parties have a chance to tell their stories, focusing on facts and actions rather than perceptions of attitudes or intentions.

4. Be a facilitator, not a judge. More important than what happened is how the par- ties will work together in the future.

5. Focus on the issues, not personalities. Limit the discussion to the actual behavior, the consequences of the behavior, and the impact on others of those consequences.

6. Examine the interests behind the opposing positions. Look for areas where inter- ests meet and where they clash. Point out areas of agreement as initial steps on the path to reconciliation.

7. Explore options for resolution. Encourage disputants to suggest other solutions for resolving the problem in addition to what they are proposing (or demanding).

8. Agree and document an action plan, ensure that all parties fully understand and support the plan, and propose a way to monitor it. Establish a means by which parties can in good faith modify the agreement to allow for changing circum- stances or unforeseen difficulties implementing the plan.

9. Consider a subsequent meeting to celebrate successful resolution of the dispute and to reinforce the lessons learned about resolving conflict.

Mercy Hospital and Medical Center in San Diego, California, has adopted a shared gov- ernance model in which nursing staff more actively manage their work units. For effec- tive shared governance, managers need to help nursing staff constructively address and resolve conflicts.

6.5 Summary and Resources

Chapter Summary Professionals entering the health care field need a strong understanding of power and conflict in order to deal with difficult and sometimes threatening dilemmas in the work- place. Managerial power can be used constructively to influence actions and groups to act in alignment with organizational goals and objectives. It can also be used destructively to further an individual or group’s personal agenda or economic interests. Both gender and culture can influence perception and behavior because each relates to power and conflict.

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Section 6.5Summary and Resources

Power and conflict are inevitable in health care organizations. Understanding power the- ory constructs a framework for behavior identification. Effective health organization man- agers can recognize and interpret the bases of power as well as the organizational politics and political games of their organizations. The primary bases of social power are reward power, coercive power, legitimate power, referent power, and expert power. Organiza- tional power sources are resource power, decision power, and information.

Although power has many negative connotations, power enables managers to attract well-qualified, ambitious staff and get things done with and through them. Effective use of power involves knowing when to use a democratic leadership style and when a more authoritarian approach is justified. Health care administration professionals can and should develop a personal power base with people and groups within and external to the organizations in which they work.

As with power, conflict is inevitable in health organizations and can be beneficial and productive when it concerns issues rather than personalities. There are numerous types of conflict and a variety of approaches to conflict management. Whether the conflict is between individuals, groups, or organizations, managers need to understand and know how to deal with it. The best conflict management style to use depends on the situa- tional conditions, and managers need to strategically consider the importance of the issue, the prospects for success, and the long-term consequences of the outcome when using a particular style. Gender and culture also greatly influence conflict in health care organi- zations, as do perceptions of professional roles and status. To achieve a cooperative or integrative conflict resolution, leaders need to help opposing parties see that their goals are related, if not aligned, and then facilitate a frank and vigorous debate of the issues involved to achieve mutually satisfying and beneficial outcomes.

Health care managers need to understand and manage conflict. Avoiding conflict may seem like the easiest course of action but will likely only prolong or exacerbate it.

Critical Thinking and Discussion Questions 1. What types of power described by French and Raven do you exercise, with

whom, and in what circumstances? 2. Although most people prefer a democratic leadership style, others do not. Can a

leader be too democratic? 3. Cite some examples of political games that you have observed in your workplace

or in other situations. Develop an action plan to build your personal power base. What are your top three priority actions?

4. Why is it important for health care professionals to understand how gender and culture influence perceptions of power?

5. Describe (a) a situation when you were in a conflict that was resolved success- fully, and (b) a situation when you were in a conflict that was not resolved successfully. How have you used or will you use what you learned from these experiences as a health organization administrator?

6. How does your preferred conflict management style resemble or differ from the styles used by colleagues and superiors where you work or have worked?

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Section 6.5Summary and Resources

Key Terms

accommodating A conflict management style of accepting all or part of an oppos- ing party’s demands.

agent (French and Raven) An individual who is the driving force of power that influences another.

autocratic leadership style (Tannenbaum and Schmidt) A style of leadership in which the leader makes decisions solely based on his or her knowledge, experience, and authority, with minimal input from or influence by staff.

avoiding A conflict management style of not appearing to recognize or ignoring or refusing to become involved in a conflict.

coercive power (French and Raven) The perception by the recipient of influence that he or she will be punished if the influencer’s explicit demands or perceived expectations are not met.

collaborating A conflict management style in which opposing parties work together to find a solution that satisfies both.

collectivism (Bewley) The alignment of individual and organizational goals result- ing in concerted collaborative action to achieve them.

competing A conflict management style characterized by arguing strongly for one’s position.

compromising A conflict management style in which one party makes conces- sions contingent on the opposing party making concessions of approximately equal value.

connected influence (Goulston and Ullmen) Using one’s influence to form positive relationships with others, which fosters the pursuit of common goals and higher performance.

constructive power Leaders positively influence employees to perform at a high level by identifying a great outcome that benefits both the organization and the employee.

cooperative conflict (Fisher and Ury, Tjosvold) A conflict management model in which opposing parties recognize that they have related goals and cooperate to find a means by which parties can realize their goals.

decision power The ability to make deci- sions on behalf of or for an organization.

democratic leadership style (Tannen- baum and Schmidt) A style of leadership in which the leader makes decisions based on information and input from staff.

destructive power Influence that nega- tively impacts the organization.

disconnected influence (Goulston and Ullmen) The process of persuading staff to do what the leader wants, in a manipula- tive manner.

expert power (French and Raven) Power derived from the perception by the recipi- ent of influence that the agent of influ- ences possesses valuable and specialized knowledge.

fact-focused solutions (Murphy) A mana- gerial approach for resolving conflicts presented by individuals with difficult personalities in which the leader limits the discussion to facts, observed behaviors, and data.

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Section 6.5Summary and Resources

healthy conflict An issue-oriented, straightforward, respectful disagreement among people who work together that often produces better results and strength- ens team relationships.

information power (French and Raven) A source of organizational influence accruing to individuals who have or have access to information that is valued and difficult to obtain.

integrative or interest-based bargaining (Spangler) A negotiation strategy designed to create joint value for the opposing par- ties by developing mutually beneficial outcomes.

invisible minority (Akomolafe) Foreign- accented, immigrant English speakers, who may experience discrimination because of their speaking style.

legitimate power (French and Raven) Power derived from authority of social rank or position.

limited English proficiency (LEP) The inability to understand, speak, read, or write English well.

mediator A third party, assumed to be objective, who assists two disputants to resolve a conflict.

politics in business (Bewley) Individual efforts to further one’s personal goals rather than to achieve organizational goals.

politics of information analysis (Pfeffer) The use of information to gain power in an organization.

problem solving A conflict management style in which both parties agree on the facts and nature of the problem and the need to resolve it.

recipient (French and Raven) An indi- vidual who is on the receiving end of influence.

referent power (French and Raven) The attribution of prestige by the recipient of influence to the influencing individual.

resource power The ability to generate and control organizational assets, staff, equipment, and funds.

reward power (French and Raven) An incentive that influences the recipient of influence to change his or her behav- ior, with the expectation of a reward or recognition.

structural power source Powers derived from leadership or ownership positions in organizations.

unhealthy conflict Disagreements between individuals or groups that focuses on personalities, perceptions and interpretations rather than on issues and behaviors, that is often highly emotional and disruptive to relationships within an organization.

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