Conflict Resolution

Reference for book :

Yoder-Wise, P. S., & Sportsman, S. (2023).  Leading and Managing in Nursing(8th ed.). Elsevier Evolve.

7: Gaining Personal Insight: Being an Effective Follower and Leader

Introduction

Approximately 4 million people in the United States are registered nurses. That number seems enormous when we think of the numbers in other healthcare disciplines. Because we are so large in numbers, we have additional obligations in healthcare. One of those obligations is to capitalize on the role of leading and following in any position so that quality care is rendered.

Leadership is a journey. It is an iterative process, one that may take twists and turns and always contributes to our learning if we exhibit intentionality in our approach to learning. It begins with being an effective follower, and it never ends. Our task is to continue to develop personally and professionally so that our talents match the tasks we need to address, which evolve over our careers.

All members of the healthcare team have worked in a follower role at one point or another within their careers. However, being in a follower role does not place people into a passive or submissive role in which their thoughts and ideas are not valued. Being an effective follower means that you courageously challenge or champion leaders based on complex situations that arise within the healthcare environment (Chaleff, 2017). The relationship between leaders and followers is extremely important in the effectiveness of the entire team. Effective followers develop into effective and authentic leaders and managers with the experiential knowledge of how to create a constructive and trusting environment.

Being proactive about learning is a key strategy to developing effective followership that may evolve into effective leadership. We have to be mindful of our actions and the motivations behind those actions. The follower can either advance the leader’s goals or divert and limit progress. As an example, some people think about leadership in terms of power, “being in charge,” and fame and glory. When someone exerts leadership from that perspective, the individual may have followers, but they commonly are not really engaged with the mission of the work they are doing. They may even behave very differently depending on the physical presence of the leader. An opposite example is when leadership derives from the desire to help others be their best. When leadership is exerted from that perspective, followers are engaged in the mission of their work and they behave consistently—with or without the formal leader being present.

Our task in leadership is to promote a focus on person-centered or population-centered care to provide the most accessible, inclusive, least costly, and highest-quality outcomes. To achieve that, we need the vision of each of us contributing something critical to the work at hand. In this view, leadership is shared. This means that one person may hold a title that conveys a position of ultimate authority, yet each person has the potential to step forward and lead when that person is the one most capable of supervising a particular element of work. Diversity in leadership can fuel healthcare organizations into caring for diverse populations within each community. This chapter explores established tools and strategies that will help you develop into an effective follower and leader.

Differences between Leading and Following

Leading and following can be visualized within any organization, especially within healthcare organizations. If we look into the behaviors of leaders and followers, we can dive into how they are used within nursing practice. We can see some differences and similarities in the characteristics of each one.

Leaders

When people think of leadership, they typically think of position. Those types of positions have official-sounding titles: president, chief executive, director, and the like. That type of leadership is positional and, therefore, formal. The assumption is that people in formal leadership roles exert influence over others and that they are “in charge.” Within healthcare organizations and nursing practice, the word leader describes a person who does so much more. A leader within this context guides and gives direction to those who are perceived to be subordinate or reliant on them. The nursing leader performs the courageous act of releasing control to create an active learning and engaging environment. This release of control allows leaders to share the accountability of decision-making with other people within their supervision (Alegbeleye & Kaufman, 2020). Sharing accountability fosters a partnership of trust between leaders and team members or followers. Leaders supervise by inspiring team members to speak up and voice their opinions and concerns. The leader can handle and adapt to the unknown. Different leadership styles emerge during different crises and everyday situations.

Followers

Within nursing, followers are often the direct care or frontline nurses who are trusted to think critically, ask probing questions about care, and advocate for the patient. When we think about leadership, we often think only of one element of the equation—the leader. Yet without the follower role, leadership does not actually exist.

Another term for follower is informal leader. Informal leaders are those individuals who influence others because they are engaged with those who listen to and follow the informal leaders. These individuals are often the “behind the scenes” and “go-to” people who motivate others to act (Heard, 2018). They are more accessible to their coworkers and provide critical thinking, innovation, and ideas that support their organizational goals (Heard, 2018). Wise formal leaders acknowledge that they do not have all the answers and, thus, look to their informal leaders or followers, whose talents may differ from their own.

Exercise 7.1

Name five characteristics of a great leader. Think about a nursing leader you have observed. Does that person match those characteristics? Now, name five characteristics of a great follower. Have you seen a follower exhibit those characteristics? How are the two sets of characteristics similar? How are they different?

Effective Followers

The phrase effective followers identifies engaged and participating team members who think for themselves. Effective followers identify the practical aspects of nursing, provide input when needed, and ask questions to clarify. They have positive attitudes and support the leaders within their organization. Effective followers need leaders who foster professional growth. In return, effective followers can also influence the leader by using intelligent and experience-driven suggestions to solutions about patient care (Falls & Allen, 2020). Effective followers are loyal to the organization, fostering partnerships and supporting leadership in every area of nursing. Followers have the ability to self-manage; have commitment to their organizations; and have competence, focus, and courage (Watters et al., 2019). The effective follower has the potential to not only influence the leadership but also influence coworkers within the healthcare organization. Positive attitudes can be contagious and increase the morale of the entire unit and team. Fostering this type of atmosphere will most likely increase productivity and patient outcomes.

Ira Chaleff describes the courage it takes to become an effective follower within an organization. In these circumstances, followers use their own self-awareness when they courageously question or challenge leaders. Chaleff developed a self-assessment for followers to explain these behaviors. The intent of the self-assessment is to identify behaviors among followers that encourage reflection. Chaleff (2017) stated that this is a way to develop followers and help them identify the style of follower they are in order to move into an effective follower role (see the Literature Perspective).

Literature Perspective

Resource: Chaleff, I. (2017). In praise of followership style assessments. Journal of Leadership Studies, 10(3), 45–48.

The roles of the leader and follower are not always static. Most team members will occupy both roles interchangeably or simultaneously within the organizational setting. Chaleff describes the ability to move fluidly into and out of these roles as an area in which self-assessment of behaviors should occur. These assessments can be oriented toward the individual, group, or culture. The result will help identify what is needed to know about followers and how they react within their environment.

Implications for Practice

To be effective in any teamwork, all members of the team must be effective at what they do. Additionally, because leadership is shared and fluid, a leader must be equally capable of transitioning into the role of follower as the follower is in transitioning into the role of leader.

Ineffective Followers

The term ineffective followers describes static team members who rely solely on leadership for all direction and guidance (Malak, 2016). They do not challenge or champion leadership and have a hard time voicing their opinions or concerns because of the traditional hierarchy. The way that ineffective followers communicate is through complaining and pointing fingers—they hardly ever offer solutions. Ineffective followers are not flexible, and their main concern is putting in only their required number of hours. Ineffective followers who have gained influence can alter the workplace culture, placing different demands on the team and leader (Watters et al., 2019).

Exercise 7.2

Think of a time when you were involved in a great work relationship. What made the relationship great? Was it hierarchical, in which one person was always the leader and the other was always the follower? Or was it “give and take” depending on the situation? What kind of trust was present? Were you afraid to voice your opinion? Did the other person value your opinion?

Leader–Follower Relationship

Great leadership requires great followership. For a long time within healthcare organizations, the hierarchy of leaders and followers did not permit the development of the leader–follower relationship. The leaders were the source of knowledge and power, and the followers were submissive. This was more like a dictatorship than a true working relationship. Fortunately, a shift in thinking occurred away from hierarchies because, within a successful healthcare team, all members are active and contribute to the leadership processes and behaviors. In modern healthcare today, the relationship between leaders and followers is a true partnership built on trust and accountability. Communication opens up the engagement, increases the trust, and increases the influence to and from both leaders and followers within this relationship (Varpio & Teunissen, 2021).

“All team members are leaders and followers; together collaborators create the relationships that enable (or inhibit) success” (Varpio & Teunissen, 2021, p. 5). Simplifying this statement, leaders can become followers and followers can become leaders depending on the situation and expertise and experience of the nurse. With this knowledge, the emphasis on understanding the leader–follower relationship is more important to create a cohesive and productive team. Trusting and cohesive partnerships between leaders and followers are necessary in creating a safe, team-based work environment. This understanding helps new graduates to develop the capacity for leadership as required by the 2021 American Association of Colleges of Nursing (AACN) baccalaureate essentials.

A cohesive relationship between leaders and followers can reduce skill-based errors because followers are not afraid to challenge leaders by asking questions and speaking up about possible mistakes or missed steps. When the formal leader and the follower(s), or informal leader(s), are in concordance, great outcomes can be produced. When these relationships do not exist, a lot of energy is expended on working around the other person(s) and creating an appearance of productivity rather than actually being productive. The path to authentic leadership starts with being an effective follower. Most of the strategies seen in authentic leaders are mirrored in the characteristics and strategies of an effective follower. Box 7.1 lists the characteristics of both authentic leaders (Rosler, 2018) and effective followers (Chaleff, 2017; Falls & Allen, 2020). From the information in Box 7.1, we can see how the characteristics among authentic leaders and effective followers complement each other within the workplace. We will learn more about becoming an authentic leader later in this chapter.

Box 7.1

Comparing Authentic Leader Characteristics and Effective Follower Characteristics

Leader Effective Follower

Knows what they stand for Understands values and principles

Understands strengths and weaknesses Understands strengths and weaknesses

Leads by example Leads by example

Is open and honest in communications Engages in open and honest communication

Is true to individual values Speaks up when ethical concerns arise

Admits when they do not know something Asks thought-provoking questions

Considers input from all viewpoints before making a decision Makes decisions based on the right thing to do

Is objective Faces the fear of rejection and ridicule to speak up for the right thing

Knows the right thing to do, then does it Knows the right thing to do, then does it

From Rosler, G. [2018]. Your journey to authentic leadership. American Nurse Today, 13(2), 40–41. https://www.myamericannurse.com/journey-authentic-leadership/; Chaleff, I. (2017). In praise of followership style assessments. Journal of Leadership Studies, 10(3), 45–48. https://doi.org/10.1002/jls.21490; Falls, A., & Allen, S. (2020). Leader-to-follower transitions: Flexibility and awareness. Journal of Leadership Studies, 14(2), 24–37. https://doi.org/10.1002/jls.21696.

The Core of Being a Leader

Personal leadership is an integration of you, your ideas, and your personhood into the path you set for your life. It is the ability to lead from your core values and beliefs. Leadership is not a part that you play to fulfill a role responsibility; rather, it is a role responsibility that comes to life because of who you are. Incorporating your unique qualities into the role of leader is a function of both living and learning. Fig. 7.1 suggests that being a nurse is integral to who we are as individuals and that being a leader overlaps both nurse and person because we can exert leadership in our personal and professional lives. We are the sum of our life experiences, bringing the fullness of our personhood to the other roles we fulfill. In this case, we are referring to the role of nurse and leader. Sometimes, all three elements intersect, indicating that all of the roles we assume in life are influenced by all others.

FIG. 7.1 Leadership integration.

Kouzes and Posner (2017) developed one of the most widely used models for considering leadership (see the Theory Box). Although this model is used widely in other fields, the key for us is that it is used widely in nursing and healthcare. The five elements of their model begin with modeling the way. This means that if we want others to be civil, we must be civil to others. Inspire a shared vision is an expectation of a formal leader, yet effective followers contribute to this by taking such actions as translating a big-picture vision to the practicalities faced by team members. Members of the team, any of whom may exhibit leadership, have the obligation to challenge the process. We can all do this by asking questions or posing scenarios to help clarify how something is possible across a wide range of situations. Enable others to act refers to how we help others find the conditions that allow them to do their best. Finally, encourage the heart is about creating a positive work environment and self-renewal. Think for a moment about the feedback you receive. We expect feedback from those “above” us, such as team leader, manager, or clinical director. The question is: Do you provide that same type of feedback to your leader? People in leadership positions are in “the middle” between those they are accountable for and those they are accountable to. They receive feedback from those to whom they report. An opportunity to exert leadership is to provide feedback to those individuals who seldom receive input from those to whom they are accountable. How powerful you can be if you take this model to heart!

Theory Box

Theory/Contributor Key Ideas Application to Practice

Kouzes and Posner: The Leadership Challenge (2017) Model the way.

Inspire a shared vision.

Challenge the process.

Enable others to act.

Encourage the heart. This approach to leadership provides a view of how to lead and develop others and how to remain personally relevant in leadership.

How do we enhance our current leadership competency? The answer begins with understanding one’s self.

At the core of both effective followership and leadership is self-awareness. In his classic text, The Four Agreements (1997), Don Miguel Ruiz presents a set of agreements we can make with ourselves to enhance personal growth and awareness. These agreements focus on how we present ourselves to self and others and how we act in and interact with the world around us. They also can serve as the core of who we are as leaders (Table 7.1).

Table 7.1

Application of Ruiz Four Agreements

Ruiz Four Agreements (1997) Effective Follower and Leader Implications

Be impeccable with your word.

• Listening and engaging in discussion are vital trust-building activities.

• Being honest with yourself and others is foundational to developing trust and reliability as an effective follower and leader.

Don’t take anything personally.

• Personalizing every comment or action others make disrupts critical thinking.

• Realizing opinions are not about you but are rather a reflection of the person voicing those views frees you from self-imposed judgment.

Don’t make assumptions.

• Overcoming assumptions requires asking deeper questions to get the needed clarity.

• Avoiding misunderstandings in healthcare is vital because of the risk to the health and safety of human life.

Always do your best.

• Committing to always doing your best acknowledges your humanness.

• Doing your best enhances group performance by acknowledging where we are in our performance.

Be impeccable with your word means to always speak with integrity about yourself and others. As leaders, we must use language that reinforces integrity of practice and honors humanity. We demonstrate leadership when we speak in truth and follow through on our words. One of the most difficult agreements to master is don’t take anything personally. What others say is reflective of their reality, not yours. You will encounter numerous opinions about you, your work, your ideas, your philosophies, and so forth. Deliberately destructive communications can be found in toxic environments where incivility is tolerated. Although personally based, these communications actually say more about the originator than the target.

In conversations, having the willingness to ask clarifying questions leads to success in the third agreement, don’t make assumptions. Assumptions are created by your imagination when clear communication fails. Asking clear follow-up questions and listening with a desire to understand fills in the gaps where assumptions take hold. The fourth and final agreement is to always do your best. Numerous factors influence how you feel from day to day and even hour to hour. Yet you can commit to doing your best in each circumstance. You are able to release any looming self-judgment because you have put forth your best effort. In other words, you have good days, bad days, and in-between days. On each of those days and, indeed, in varying moments throughout the day, your best will vary. Yet, at the end of the day, you want to be able to say, “I did my best.” Does that mean we would tolerate “I’m doing my best” (and having a bad day) as rationale for subpar performance? Of course not! The intent of this agreement is to strive to do our best every day.

Gaining Insight into Self

Many organizations and educational programs address the task of developing leaders. Although we encourage you to explore and select those that meet your personal needs, our attempt here is to use broad concepts plus readily available, and least costly, strategies to help develop your insight into self. You may choose to use any of these strategies that fit your needs. The key point is that resources exist to help you understand who you are; capitalizing on the information those resources provide can enrich your talents as a leader.

Reflection and Reflective Practice

Developing leadership comes from knowing and understanding your authentic self (Kouzes & Posner, 2017). Learning from experience is a critical skill in developing your potential for leadership. Reflection, exploring the thoughts you have about your experiences, actions, and reactions, is an active process you can use to strengthen your ongoing professional growth. In his foundational work, Schön (1983) described reflection from two different perspectives: thinking-in-action and thinking-on-action. Thinking-in-action occurs when an individual employs existing knowledge to guide behaviors as a situation develops. Thinking-on-action is a recounting of the situation, inviting self-evaluation (Schön, 1983). We often think-in-action as we provide nursing care. We are not as diligent about thinking-on-action afterward (debrief or reflection). Adding this strategy can create new insights and lead to more effective performance.

Consider a cardiac arrest event in an acute care setting. The decision-making occurring in the midst of cardiopulmonary resuscitation (CPR) is an example of thinking-in-action. A post-CPR debriefing, reviewing all aspects of the event after the fact, is thinking-on-action—giving thoughtful consideration to individual and group performance as well as to any technical issues influencing the outcome. The same type of thinking occurs when you are in a situation in which you think harm may occur and you intervene immediately. How you decided to act and what you decided to do are thinking-in-action. After the fact, you consider the many factors leading up to the situation, what else you might have done (or done differently), and what you will do the next time such an event occurs. That is an example of thinking-on-action.

Reflection helps you assess the effect your choices have on both yourself and on those around you. Numerous models have been developed to guide reflection and reflective practice. Fig. 7.2 identifies four basic stages that are common to most reflective practice models: reflection, value, knowledge, and action.

FIG. 7.2 The impact of reflection.

The thinking-on-action type of reflection starts when you begin to think about the activities of the day. You may choose to take a broad view or focus on a single specific event. The list of questions in Exercise 7.3 is not exhaustive. However, you will notice that each experience you have invites other deeply personal questions as you explore the core of who you are as a leader.

Exercise 7.3

Think of what you did yesterday. You may have been in a clinical setting, at a religious service, out to dinner with friends, or at a meeting. As you do so, consider asking questions of yourself to guide the reflection: What happened? Why did I respond the way I did? What precipitated my behavior? Were my values in conflict with others? Did I honor the view of others?

In contemplating and grappling with probing questions, you release yourself to value specific aspects of each experience. Understanding develops about why you felt the way you did in the moment. You have the freedom to study the sources of input that influenced your behavior. You can contemplate different choices that might yield other outcomes. Over time, awareness is raised of your own conduct and you begin to distinguish more effective patterns for interaction.

Awareness is essential; however, successful leaders go well beyond being aware. Building on self-awareness, leaders cultivate personal insight and new knowledge. A key question at this stage of reflection is: What have I learned about myself and how can I take this knowledge into the future? Leaders embrace new knowledge, making sense of the events of the past and present to develop a plan of action for the future. For example, if you accept that learners learn in different ways, you do not simply tell your team something collectively. You find ways to provide something from the key senses to engage each member in gaining the knowledge you are sharing. You may use a graph to show progress of a new intervention. You may talk with your team about the importance of this work. You might even ask them to manipulate equipment to develop the sensation of a psychomotor skill.

The ultimate goal of reflection is to bolster your leadership acumen. The final stage of the process is action—putting what you have learned into practice. The action stage of reflection is where you test the new knowledge you have gained about yourself. You may discover only incremental improvement toward the desired outcome. If this is the case, you need not worry. With each cycle of reflection, you increase your understanding of the leader within. Reflection as part of leadership development is a lifelong iterative process. After you act, you recycle through the process again to learn more about what your values are, what knowledge you gained, and what action modifications or replacements you will test next.

A common outcome of reflection in your early stages of development is to focus on what not to do. Actively considering what to do is equally beneficial and often more reinforcing to us. For example, think about when we started telling people to stop smoking. We did not tell them what to do, just what not to do. As a result, some people who smoked assumed the habit of using chewing tobacco. The point about the harmful effects of tobacco was lost in the focus on what to stop. The incorporation of reflection on a regular basis, however, allows us to move from a narrow thinking of what not to do to the broader thinking about possibilities and what fits with our values.

Reflection occurs through a variety of formats. The cognitive and emotional benefits of writing down our thoughts are well known. Thus, journaling, also known as reflective journaling, is a method to support self-confidence, critical thinking, and resilience (Horton et al., 2021). Journals allow you to retrace your thinking and to see improvements in your thinking actions over time.

Because journaling is an individual exercise, you have flexibility to write in your journal at any time. You may choose a simple notebook or an e-journal. You might also choose from a variety of guided journals that contain focused themes and questions designed to help direct your thinking. Writing in a journal may feel unnatural at first. Box 7.2 describes basic considerations for an individual who is just beginning to journal.

Box 7.2

Tips for Creating a Personal Journal

1. Determine whether you are going to use a hard copy journal or whether you are going to do this electronically.

2. Consider finding a space that is comfortable—a place where you can concentrate.

3. Create an entry as soon as possible after an important event so you can remember details, including how you felt.

4. Write in the first person—it is your journal. And don’t worry about spelling, etc. Be sure to use abbreviations that are clear to you.

5. Focus on lessons learned. After you make an entry, you need to answer two questions: So what? and What if? “So what” asks whether this was life-changing (or practice-changing) and what you will do. “What if” addresses the idea of alternative thinking so you consider different contexts, players, outcomes, and other ideas.

Regardless of the way that you choose to practice reflection, by committing time and energy to this practice you allow yourself an opportunity to grow in clarity around your own beliefs and values and your philosophies about nursing and the core of leadership. You become more adept at integrating the person you are into the professional role of nurse and leader. Reflection is a foundational skill needed to move each of us along the path from individual thought leader to nursing thought leader. Think about it!

Exercise 7.4

Conduct an Internet search about methods and tools for reflection or reflective practice. Explore what resources are available. What strategy for reflection made sense to you? Consider how routine reflective practice might be used to enhance your individual leadership ability.

Emotional Intelligence

For years, we have focused on test scores, the most common being intelligence tests. Those tests, such as the GRE (Graduate Record Examination) or SAT (Scholastic Assessment Test), are typically used to determine a person’s ability to be successful in a graduate program or undergraduate program, respectively. Emotional intelligence (EI, or EQ as it is known by some) tests or assessments, however, are typically used by an individual, and to a lesser extent by an organization, to understand what aptitude people have in understanding themselves and others. Furthermore, EI can improve—thus, it is a flexible view of your ability to relate to self and others (Bradberry, n.d.).

Emotional intelligence can be defined as understanding and managing our own emotions with the added social awareness of discerning the emotions of others. Knowing how to identify and use emotions to guide personal behavior and engagement with others is essential for effective followers and leaders. The core elements of EI, as described in the now classic work, Emotional Intelligence 2.0 (Bradberry & Greaves, 2009), consist of understanding and then managing yourself (you) and social awareness and how to manage relationships (others). Why is this important to know? Several answers are possible; one of the most important is that people with better EI scores are viewed as more successful. EI is viewed as the basis for numerous skills we use every day as humans, nurses, and leaders. EI is the “single biggest predictor of performance in the workplace and the strongest driver of leadership and personal excellence” (p. 21). Although some of us, at least at some point in our careers, may deny interest in being a leader, who of us would not want to be our personal best? Therefore, knowing one’s EI would be of great value. The even better news about EI is that it can be improved.

Being self-aware does not require a process of psychoanalysis. Rather, self-awareness refers to our ability to consider who we are as people. What would we say we do well? What makes us respond with a proverbial “knee jerk” response? What makes us feel confident? Thinking about our “good” and “bad” insights and responses is not geared to categorizing ourselves. It is geared to helping us understand who we are and what we do.

Self-management requires that we act independently for ourselves to strengthen those things we do well and to alter our approach to things we do not do so well. Although we may appreciate someone else pointing out something we need to do differently, our real source of making change is within us. Just knowing how we are is insufficient. We need to determine whether we are going to adjust or whether we want to maintain our current state. This aspect of EI is really about aligning ourselves with our goals and sometimes delaying certain actions or satisfactions to advance toward our goals.

Social awareness now turns the awareness toward others. Gaining the perspective of another person is what that person lacks and what is critically important to working with others. Our observational and listening skills predispose us to being capable of determining what others are experiencing.

Relationship management pulls the first aspects (understanding and managing self and social awareness) together so that you can be effective at responding to people, being clear in expressing your personal assessment of a situation, and creating connections with others that allow you together to be more effective in the work you need to do. Being able to know yourself and others and then manage your own personal reactions allows you to direct energy toward managing a relationship. While nursing requires technical competency, EI adds a skill required of today’s clinicians. Further, research supports how the relationship between EI and mindfulness as a protective factor for healthcare professionals (see the Research Perspective).

Research perspective

Resource: Jimenez-Picon, N., Romero-Martin, M., Ponce-Blandon, J. A., Ramirez-Baena, L., Palomo-Lara, J. C., & Gomez-Salgado, J. (2021). The relationship between mindfulness and emotional intelligence as a protective factor for healthcare professionals: A systematic review. International Journal of Environmental Research and Public Health, 18, 5491. https://doi.org/10.3390/ijerph.18105491.

Using the Joanna Briggs Institute criteria, the researchers performed a systematic review of the literature spanning the years 2010 and 2020. The inclusion criteria were—the article was published in English or Spanish, a quantitative methodology was used, the study population was healthcare professionals or students; and the focus was related to mindfulness and emotional intelligence. Ten studies met the criteria and showed a positive relationship between mindfulness and EI. Additionally, the researchers found an increase in personal resilience who had undergone mindfulness training, and as a result have been able to reduce emotional exhaustion, increase their commitment to their work and improve their performance when facing challenge at work (p. 10 of 14).

Implications for Practice

Practicing mindfulness enhances the potential for emotional intelligence and limits the potential impact of emotional exhaustion. Based on the strains placed on health care today, serious consideration should be given to supporting the benefits of mindfulness practices as a strategy to aid in developing and strengthening healthcare professionals’ ability to enhance their emotional intelligence and lessen their chances of emotional exhaustion.

Research Perspective

Resource: Echevarria, I. M., Patterson, B. J., & Krouse, A. (2017). Predictors of transformational leadership of nurse managers. Journal of Nursing Management 25, 167–175.

This study utilized a predictive correlation design to explore relationships between education, leadership experience, and emotional intelligence as predictors of transformational leadership in 148 nurse managers from various healthcare settings. Transformational leadership is one of several positive relationship styles that incorporate elements of EI. Consistent with previous research, this study found that EI was a strong predictor of transformational leadership. The findings were also consistent with an American Nurses Association position paper supporting EI as a required nurse manager skill.

Implications for Practice

EI is not just a good idea. It is important for nurses who desire a formal leadership role. Nursing leadership job descriptions may include EI as a required skill, supporting the need for ongoing self-reflection and education.

Exercise 7.5

Conduct an Internet search using the term emotional intelligence assessments. What types of assessments are available? Did they identify reliability and validity information? What was the cost range? Were any that seemed useful available online? What could you do with the results of such an assessment?

Exercise 7.6

Go tohttps://hbr.org/2015/06/quiz-yourself-do-you-lead-with-emotional-intelligence and complete this online assessment of your EI. Print or save your results. What did you learn about yourself?

Moral Courage

As a leader or effective follower, having the ability to speak up or provide input and/or feedback is a skill that requires courage. Speaking up for or against issues within the team requires taking a moral stand. This type of courage can also be called moral courage. Moral courage is defined as “standing up for what is right” (Rainer & Schneider, 2020, p. 349). Leaders and effective followers have an obligation to be aware and take ownership of their professional values to make ethical decisions when the need to speak up arises regardless of the fear of rejection or ridicule by their peers (Gibson, 2019). Rainer and Schneider (2020, p. 349) stated that nurses not speaking up is concerning for three reasons:

• Nurses not speaking up can result in patient harm.

• Nurses are in a key position to speak up for patients.

• Nursing as a profession has a strong moral and ethical imperative for patient advocacy.

Healthcare organizations should strive to create an environment where leaders and effective followers feel empowered to speak up, putting their principles into action. As partners within healthcare teams, supporting the discussion of concerns and confronting issues head on is a courageous act.

Exercise 7.7

You are the nurse in an emergency department. You are taking care of a patient who is having a right-sided myocardial infarction (MI). The provider orders metoprolol 5 mg IVP × 3 doses. Incorporating your knowledge about right sided MIs and the contraindications of metoprolol, you confirm the order with the provider. The provider insists that the order is correct. Would you have the courage to speak up and advocate for your patient’s safety and well-being? What would you say as an effective follower? What would you say as a leader? Are they different?

Strengths

One of the most widely used self-assessment tools is StrengthsFinder 2.0 (Rath, 2007). Because it has been used worldwide, in numerous cultures, and across all sorts of personal characteristics, this is one of the most tested tools to help people determine their talents for developing strengths. The Research Perspective provides greater detail about the analyses of this tool. If you complete this assessment by yourself, you are given your top five strengths, or talents, out of the possible 34 themes. If you complete this assessment with others, you can identify how various themes contribute to the whole of a project or a relationship. Imagine if everyone in your group were deliberative, which is one of the 34 themes. This theme is described as careful, private, and cautious. What would the work look like? Likely, few timelines would be met and very little would be accomplished. However, what was done would have withstood multiple tests of thinking. Now, imagine that everyone in your group were competitive. This group would be great to enter into tournaments to represent your organization. However, because they are so driven by the need to compete, these individuals might dim others’ prospects of participating. In addition, we might wonder whether they could ever really reach agreement on a course of action or whether their competitiveness kept them focused on making their own individual points. Fortunately, this tool provides your top five strengths rather than only focusing on one. The authors point out that we can develop any of the strengths. However, our natural tendency is to respond in any given situation with just one of our strengths.

The key with strengths is to capitalize on those that are your talents and to surround yourself with people with other talents that “fill in” the total set of talents needed to accomplish work. No single strength is better than another except as it relates to some specific activity and goal. You always must meet the minimum performance expectations for any position in your career. How you will be deemed successful, however, typically derives from practicing and honing your talents so that they become great assets. Leaders need to help their followers develop their talents to their best potential. As a result, their followers are focusing on what is positive about themselves and not on what is not among their best talents.

Exercise 7.8

Conduct an Internet search using the term personal strengths assessments. What types of assessments are available? Did they identify reliability and validity information? What was the cost range? Were any that seemed useful available online? What could you do with the results of such an assessment?

Becoming an Authentic Leader

Earlier, we discussed various leadership theories and models, some of which tend to be more applicable in situations in which a person holds a formal title (see Chapter 1). To begin a solid advancement in leadership, one of the most direct models is that developed by George (2003). That model is authentic leadership. Although developing leadership competence is a lifelong journey, being authentic is a good introduction to thinking of oneself as a leader.

Authentic leadership (Raso, 2019) focuses on building honest relationships by remaining true to personal values and honoring all relationships (think of Ruiz’s statement about being impeccable with your word). How those relationships are formed may be artificial—you are assigned to an organizational task, know none of the people, and have a time frame to accomplish specific goals. In other words, at this point, you are not an organized whole; you are a group. Valuing what each person brings helps others develop trust in you and increases your potential for trusting the others in the group (think of Ruiz’s statement about not making assumptions). Exploring with each other what values you hold, how you see the assigned task unfolding, and who has what strengths and talents to contribute to the task are examples of how to build a cohesive team. Yet if we are not authentic in our approach, trust will be at a minimum.

Being truthful and open is critical to developing as an authentic leader. As George (2003, p. 11) said when he created this view of leadership, “It’s being yourself; being the person you were created to be.” He goes on to contrast this view of leadership with the idea of creating an image of what a leader is. Thus, no matter what list of characteristics you might read, if they are not the real you, trying to adopt those only makes you look fake. That does not mean you should not explore those characteristics or styles. It simply means you will not look as genuine in leading as you would if you are being the real you. Being the real you, however, is built on a true caring for others and a desire to help everyone maximize talents so that any group effort is as powerful as possible. As an example, being an authentic leader relies on having a true passion for people and the work in which they engage. Being able to respond to situations in an authentic manner promotes people’s personal values. Although this may seem somewhat concerning because some people do not necessarily have values that fit a mission or task, authenticity quickly filters people into those who can achieve a particular goal and those who cannot.

George (2003) developed the concept of authentic leadership having five dimensions: purpose, values, heart, relationships, and self-discipline. The corresponding developments are passion, behavior, compassion, connectedness, and consistency, as Table 7.2 illustrates. Think, as an example, of someone who does not have real compassion. We say that person does not have heart or that person’s heart is not in the work.

Table 7.2

Behaviors and Developments of Leading Authentically

Dimensions Corresponding Developments

Purpose Passion

Values Behavior

Heart Compassion

Relationships Connectedness

Self-discipline Consistency

Data from George, B. (2003). Authentic leadership: Rediscovering the secrets to creating lasting value. San Francisco, CA: Jossey Bass.

If all we developed as a skill was awareness of self, think of the potential for further explorations of who we are and the actions we could take to be more—for our patients and ourselves.

National Academy of Medicine: Future of Nursing 2020–2030

Nurses have always contributed to the health and well-being of the populations they serve by advocating for improved outcomes. The report conducted by the National Academy of Medicine (formerly known as the Institute of Medicine [IOM]) and the Robert Wood Johnson Foundation (RWJF) expanded the reach of nursing practice to assist with the need from the public for healthcare. This initiative included ideas such as nurses practicing to the full extent of their training and education and becoming full partners with physicians and other healthcare professionals in redesigning healthcare to provide improved access and promote health equity (Flaubert et al., 2021).

This initiative expands the view of the development of effective followership. Educated and well-trained professionals in nursing with limited experience can feel the weight of the hierarchy ladder on their shoulders. Becoming an effective follower in a learning institution and workforce organization elevates your position by acknowledging your strengths among your team. Ultimately, your voice is given merit—increasing your ability to speak up and be heard. The National Academy of Medicine calls for the nursing workforce to partner with providers and other healthcare professionals. This partnership changes the clinical ladder to a clinical roundtable where nurses and providers can listen and engage in discussions to address the social determinants of health and health inequities facing communities today.

Quintuple Aim

Nurses in leader or effective follower roles are expected to fulfill the expectations of the Quintuple Aim. The Institute for Healthcare Improvement (IHI) developed the Triple Aim in 2008 (Berwick et al., 2008). The Triple Aim’s ultimate goal is to improve the health of the communities in which each healthcare organization serves (Bodenheimer & Sinsky, 2014). The specific actions necessary to meet the goal included the following:

• Enhancing patient experience

• Improving population health

• Reducing costs

The aims were expanded to include another: to decrease the incidence of healthcare provider burnout (Bodenheimer & Sinsky, 2014). Guiding healthcare professionals to achieve the Quintuple Aim will help achieve the goal of improved health while keeping the providers engaged and decreasing turnover through improving the work life of care providers. The addition of the fifth aim, advancing health equity, reflects the concern for the inequities in health care (IHI, 2022).

The importance of achieving the Quintuple Aim can be emphasized with the engagement of the leader–follower relationship. The outcomes from promoting the leader–follower relationship can be seen in Table 7.3.

Table 7.3

How Leaders and Effective Followers Achieve the Quintuple Aim

Quintuple Aim Guidelines Leader Effective Follower Outcomes

1. Enhancing patient experience

Sets the tone on the unit

Trusts in the follower’s instincts

Listens actively to concerns

Guides decision-making

Creates trust

Sees the practical

Identifies risks

Voices concerns

Advocates actively for patients

Grows and learns

Builds trust

Decreases errors

Improves quality of care

Improves patient outcomes

Engages patients

2. Improving population health

Provides an environment that advocates for high-quality care delivery

Uses open communication

Encourages participation

Delivers high-quality care to every patient

Educates the patient and family

Gains the patient’s trust to ask questions

Informs populations of patients to return to their communities healthier and more engaged

3. Reducing costs

Promotes a more productive team

Commits to increasing productivity

Reduces waste from nonproductive leaders and followers

4. Improving the work life of care providers

Reduces stress by trusting followers

Delegates tasks effectively without overloading followers

Reduces stress by increasing autonomy

Commits to the organization

Feels accomplished and important because the follower has a voice

Reduces turnover

Increases retention

Increases production

Results in an effective unit

5. Advancing health equity Creates plans for services to address inequities Identifies inequities in care for population served Results in outcomes comparable across differing groups

Conclusion

No matter where you are in your leadership trajectory, being complacent is not an option. Seeking new insights, using established tools (such as journaling), and wanting to do one’s best and what is right are lifelong habits that allow each of us to develop our full potential. If leadership is a journey expressed as a skill, each of us has the potential to contribute to the needed changes in healthcare by starting with a solid knowledge of and value for who we are and what we can become.

The Solution

Amy McCarthy

I decided to report this issue to the manager of our unit and to advocate for the purchase of hospital-grade thermometers for every room while removing the generic thermometers from our stock room. When I brought the issue to my manager, she was hesitant at first to make a sweeping change. In an effort to demonstrate how widespread the issue was, I asked for several other nurses to begin using both thermometers to measure infant temperatures. Within days, they all started to report the same results—the generic thermometers were contributing to unnecessary interventions in our infants. With this evidence at the table, my manager agreed to remove the generic thermometers and required the use of the hospital-grade ones, eventually purchasing larger quantities so that all nurses could have one during their shift.

While it can be intimidating to be the first one to speak up, I always tell myself that as a nurse, I am my patient’s advocate. In many cases, our insights can lead to better processes and safer environments for our patients.

Would this be a suitable approach for you? Why?

Reflections

Taking on the role of the effective follower and leader is a continuous task. It involves all of the characteristics described in this chapter, including active listening, open communication, trusting your own knowledge and instincts, and have the courage to speak up and voice any questions or concerns you may have in any situation. How effective are you in each role?

What are one or two first steps you can take to ensure you are developing as an effective follower and leader? What do you need to learn about yourself? How do you think others perceive you as an effective follower and leader? How will you intentionally use reflection to enhance your leadership competence to be the best nurse possible?

Best Practices for Effective Following and Leading

• Participate in self-assessments and reflect on the results.

• Know that the journey to effective following and leading is a journey rich with discovery of self and others.

Tips for Effective Following and Leading

• Stay up-to-date on evidence-based care.

• Engage in open communication.

• Take an active role within your organization.

• Practice reflection daily

• Allow what you learn from your reflections to guide your next steps

• Trust in your knowledge and instincts.

• Do not be afraid to ask questions.

• Have the courage to voice any concerns

Ch 8 : Communication and Conflict

Introduction

In today’s complex practice environment, communicating effectively and resolving conflict are more important than ever to provide optimal patient care and to consistently meet the six competencies identified by Quality and Safety Education for Nurses (QSEN): patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (QSEN Institute, n.d.). To achieve these competencies and to reduce the likelihood of miscommunication that leads to healthcare errors, nurses must effectively communicate with patients and families, nurse colleagues, and other members of the healthcare team. The Literature Perspective of a concept analysis describes how effective communication promotes high-quality nursing care, positive patient outcomes, and patient and nurse satisfaction (Afriyie, 2020).

Interprofessional communication is effective when healthcare providers communicate with each other and with patients and their families in an open, collaborative, and respectful manner. Conflict is a disagreement in values or beliefs within oneself or between people that causes harm or has the potential to cause harm. Conflict is a catalyst for change and has the ability to produce either detrimental or beneficial effects. Conflict, when used positively, can stimulate stagnant teams and increase productivity. If properly understood and managed, conflict can lead to positive outcomes and practice environments. If it is left unattended, it can have a negative impact on both the individual and the organization. Good leadership—combined with positive team dynamics, effective communication, and successful conflict management practices—promotes shared problem solving and acceptance of change (Fowler & Robbins, 2021). In professional practice environments, unresolved conflict and miscommunication among nurses is a significant issue resulting in job dissatisfaction, absenteeism, and turnover. Effective healthcare team communication may strengthen nurses’ engagement within their organizations and improve nurse retention. Patient satisfaction is lower in hospitals in which nurses are frustrated and burned out, which signals a problem with quality of care (White et al., 2019). Communication and conflict management are two key competencies of professional practice, as identified by the American Association of Colleges of Nursing (AACN, 2021), and they need to be mastered to be an effective leader.

Successful organizations are proactive in anticipating the need for interprofessional education about communication, conflict resolution, and teamwork—they enact innovative and integrated conflict resolution strategies and communication programs. Structured shadowing and cross-training across interprofessional departments may lead to improved teamwork and communication between units, which improves patient safety (Sarver et al., 2020). Conflict should not be avoided; it can be a strategic tool when leveraged appropriately to promote teamwork and collaboration (Fowler & Robbins, 2021). Some of the first authors on organizational conflict (e.g., Blake & Mouton, 1964; Deutsch, 1973) claimed that a complete resolution of conflict might, in fact, be undesirable because conflict also stimulates growth, creativity, and change. Seminal work on the concept of organizational conflict management suggested that conflict was necessary to achieve organizational goals and cohesiveness of employees, facilitate organizational change, and contribute to creative problem solving and mutual understanding. Moderate levels of conflict contribute to the quality of ideas generated and foster cohesiveness among team members, contributing to an organization’s success. An organization without conflict is characterized by no change. In contrast, an optimal level of conflict will generate creativity, a problem-solving atmosphere, a strong team spirit, and motivation of its workers. Conflict in an interdisciplinary team can result in better patient care when collaborative treatment decisions are based on carefully examined and combined expertise. Nursing leaders must focus on healthy work environments to promote effective communication in stressful situations to promote successful teamwork and increase patient safety. Positive patient and staff outcomes are associated with a leader who exhibits communication competence. For example, nurses’ intent to stay and their job satisfaction are impacted by a consistent and systematic method to provide praise and recognize accomplishments (Fowler & Robbins, 2021).

The complexity of the healthcare environment compounds the impact that ineffective communication, caregiver stress, and unresolved conflict have on patient safety. Conflict is inherent in clinical environments in which nursing responsibilities are driven by patient needs that are complex and frequently changing and in practice settings in which nurses have multiple professional roles. Healthcare providers are exposed to high stress levels from increased demands on a limited and aging workforce, a decrease in available resources, a more acutely ill and underinsured patient population, and a profound period of change in the practice environment. Interventions aimed at promoting nurses’ psychological well-being can promote a better practice environment, improved patient safety, and better nursing outcomes (Lee et al., 2019). Conflict among healthcare providers is inevitable and is compounded by employee diversity, high patient-to-nurse ratios, pressure to make timely decisions, and status differences. Nurses employed in better care environments report more positive job experiences and fewer concerns about quality care (White et al., 2019). Interprofessional collaboration has been characterized by effective communication and is a key factor in reducing error and improving patient outcomes. Further, being competent in using communication technology and systems within any given organization is important to facilitate effective communication and promote patient safety. Moreover, hospitals with good nurse–physician relationships are associated with better nurse and patient outcomes, making collaboration and conflict resolution among nurses and physicians crucial in promoting quality of care outcomes.

An important factor in the successful management of stress and conflict is a better understanding of its context within the practice environment. The diversity of people involved in healthcare may stimulate conflict, but the shared goal of meeting patient care needs provides a solid foundation for conflict resolution. Because nursing remains a predominately female profession, this may contribute to the use of avoidance and accommodation as primary conflict handling strategies. The stereotypical self-sacrificing behavior seen in avoidance and accommodation is strongly supported by the altruistic nature of nursing. Avoidance may be appropriate during times of high stress; however, when overused, avoidance threatens the well-being of nurses and retention within the discipline. To illustrate, a correlation exists for nurses who experience job stress and emotional exhaustion and who use avoidance to handle conflict (Lee et al., 2019).

Effective communication within healthcare settings

Effective communication between a healthcare provider and other members of the healthcare team promotes optimal patient outcomes. Equally important is making certain that the communication occurring between healthcare providers and patients and their families ensures quality care and patient safety and satisfaction. When communicating with populations who speak different primary languages, using language-interpreting services enhances communication with patients and their families, reduces health disparities, and promotes safe nursing care (Boruff, 2020). Although the communication within healthcare settings is often complex and chaotic, understanding the basic principles of the communication process is essential (Fig. 8.1). The Joint Commission (TJC, 2020) recognizes that breakdown in communication is the root cause of sentinel events, which are unexpected occurrences that result in death or serious injury. Communication when the patient is handed over from one provider to another or from one setting to another is especially problematic. Not surprisingly, each of the National Patient Safety Goals (see TJC for the current goals, https://www.jointcommission.org/standards_information/npsgs.aspx) is directly or indirectly related to communication.

FIG. 8.1 Basic communication model.

Literature perspective

Resource: Afriyie, D. (2020). Effective communication between nurses and patients: An evolutionary concept analysis. British Journal of Community Nursing, 25(9), 438–445.

Communication is a complex phenomenon and is an essential element of building trust as well as promoting clinical reasoning and advancing the nursing process to individualize care. Effective communication is bidirectional; both the nurse and patient must work together to achieve their desired outcomes, including the patient’s satisfaction with care and the nurse’s ability to provide the best care. Effective communication promotes high-quality nursing care, positive patient outcomes, and patient and nurse satisfaction.

Implications for Practice

Effective communication is a key component of nursing practice and must be prioritized in nursing education and practice. It must be intentional in nature and can be improved through direct actions taken by the nurse. Engaging nurses in professional education and offering continuing education training focused on communication skills will empower them to communicate effectively with their patients.

Exercise 8.1

Access The Joint Commission website (https://www.jointcommission.org/standards_information/npsgs.aspx) for the current National Patient Safety Goals. Identify how each goal is affected by communication.

Because adverse patient outcomes commonly are a result of communication failures, TJC’s National Patient Safety Goals added standardization of handoff communication, the verbal and written exchange of pertinent information during transitions of care. Handoff communication occurs during nurse change-of-shift reports, transfer of patients between units or facilities, and reports between departments and between disciplines. Effective communication is also important when nurses are describing changes in a patient’s condition to other members of the healthcare team. Common language for communicating critical information, such as during huddles or rounding, can help prevent misunderstandings. Bedside handoffs have the added benefit of increasing direct patient contact, increasing the possibility of patient participation, and enhancing patient safety (Malfait et al., 2018). Healthcare providers need to allow sufficient time to ask and respond to questions. Reading back information also helps identify any miscommunication and ensures that the information received is accurate. Intimidating and disruptive behaviors affect communication and must not be tolerated in healthcare settings because both employee satisfaction and patient safety can be affected.

Conflicts and miscommunication between nurses and other healthcare providers, including physicians, may be intensified because of the overlapping nature of their professional domains and lack of clarification between roles. Differences in nursing and medical school training have caused differences between nurses and physicians in communication styles and approaches to handling conflict (Vandergoot et al., 2018). Differences in power can also affect communication and create conflict. While effective communication between nurses and physicians is essential, communication between nurses and unlicensed assistive personnel is also foundational for good patient outcomes (Campbell et al., 2019). Use of common language, such as SBAR, when communicating critical information helps prevent misunderstandings and promotes a culture of quality and safety. SBAR, which stands for situation, background, assessment, and recommendation (Institute for Healthcare Improvement, 2021), has become a best practice for standardizing communication between healthcare providers. Research suggests that if nursing students modified SBAR to ISBAR to include an introduction, the consistent practice with this standardized communication approach could improve communication with healthcare providers, which would lead to reduced threats to patient safety and improve patient care (Foronda et al., 2021). The fast pace, frequent interruptions, and stress present in healthcare settings interfere with effective communication (Rhudy et al., 2019). The term VUCA describes today’s healthcare environment: volatility, uncertainty, complexity, and ambiguity. Each of these elements increases the potential for miscommunication. Clear, complete, and accurate communication among healthcare providers directly affects the quality and safety of care. Nurses have a responsibility to provide quality care; thus, they must serve in leadership roles to ensure effective communication and conflict resolution.

Types of conflict

The recognition that conflict is a part of everyday life suggests that mastering conflict management strategies is essential for overall well-being and personal and professional growth. A need exists to determine the type of conflict present in a specific situation because the more accurately conflict is defined, the more likely it will be resolved. Conflict occurs in three broad categories: intrapersonal, interpersonal, and organizational. A combination of types can also be present in any given conflict.

Intrapersonal conflict occurs within a person when confronted with the need to think or act in a way that seems at odds with one’s sense of self. Questions often arise that create a conflict over priorities, ethical standards, and values. When a nurse decides what to do about the future, conflicts arise between personal and professional priorities—for example, “Do I want to accept the job in the city with more cultural opportunities or remain in my hometown and be close to my family?”. Some issues present a conflict over comfortably maintaining the status quo—for example, “I know my newest charge nurse likes the autonomy of working nights. Do I really want to ask him to move to days to become a preceptor?”. Taking risks to confront people when needed can produce intrapersonal conflict and, because it involves other people, may lead to interpersonal conflict—for example, “Would recommending a change in practice that I learned about at a recent conference jeopardize unit governance?”. Many nurses expressed this type of conflict during the COVID-19 pandemic in 2020. Standards of care deteriorated for many reasons and nurses experienced unprecedented levels of conflict, resulting in burnout, turnover, and staffing gaps (Business Wire, 2021).

Interpersonal conflict is the most common type of conflict. It transpires between and among patients, family members, nurses, physicians, and members of other departments. Conflicts occur that focus on a difference of opinion, priority, or approach with others. A manager may be called upon to assist two nurses in resolving a scheduling conflict or issues surrounding patient assignments. Members of healthcare teams often have disputes over the best way to treat particular patient concerns or disagreements over how much information is necessary for patients and families to have about their illness. Yet, interpersonal conflict can serve as the impetus for needed change and can strengthen the practice setting.

Organizational conflict arises when discord exists about policies and procedures, personnel codes of conduct, or accepted norms of behavior and patterns of communication. Some organizational conflict is related to hierarchical structure and role differentiation among employees. Nurse managers, as well as their staff, often become embattled in institution-wide conflict concerning staffing patterns and how they affect the quality of care. Complex ethical and moral dilemmas often arise when profitable services are increased and unprofitable ones are downsized or even eliminated.

A major source of organizational conflict stems from strategies that promote more participation and autonomy of direct care nurses. Increasingly, nurses are charged with balancing direct patient care with active involvement in the institutional initiatives surrounding quality patient care. A growing number of standards set by TJC target improving communication and conflict management. Specifically, TJC requires that healthcare organizations have a code of conduct that defines acceptable and inappropriate behaviors and that leaders create and implement a process for managing intimidating and disruptive behaviors that undermine a culture of safety. Standards pertaining to medical staff also include interpersonal skills and professionalism (TJC, 2020). The Magnet Recognition Program® of the American Nurses Credentialing Center (ANCC) identifies effective interdisciplinary relationships as one of the 14 Forces of Magnetism necessary for Magnet® designation (American Nurses Credentialing Center, n.d.). Specifically, collaborative working relationships within and among the disciplines are valued, demonstrated through mutual respect, and result in meaningful contributions in the achievement of shared clinical outcomes. Magnet® hospitals must have conflict management strategies in place and use them effectively when indicated. The following are examples of “forces” contained within the 5 Model Components that are particularly germane to communication and conflict in the practice environment:

• Organizational structure (nurses’ involvement in shared decision-making)

• Management style (nursing leaders who create an environment that supports participation, encourage and value feedback, and demonstrate effective communication with staff)

• Personnel policies and programs (efforts to promote nurse work–life balance)

• Image of nursing (nurses effectively influencing system-wide processes)

• Autonomy (nurses’ inclusion in governance, leading to job satisfaction, personal fulfillment, and organization success)

Exercise 8.2

Recall a situation in which conflict between or among two or more people was apparent. Describe verbal and nonverbal communication and how each person responded. What was the outcome? Was the conflict resolved? Was anything left unresolved?

Before moving further ahead in discussing conflict, we might want to think about how easily conflicts occur. Misunderstandings occur frequently because of diminished hearing, different meanings attributed to words, different accents or languages, cultural or even regional meanings of words, potential or actual religious meanings to words, and probably countless other factors. The Theory Box provides one option for considering a way to manage conflict from a cultural perspective.

Theory box

Cultural Brokering in Conflict Management

Key Contributor Key Ideas Application to Practice

Jezewski (1995): Evolution of a Grounded Theory: Conflict Resolution through Culture Brokering Twelve attributes of a cultural broker in health care were identified. The purpose of cultural brokering is resolution of conflict and is defined as “bridging, linking or mediating between groups or persons of different cultural systems for the purpose of reducing conflict or producing change.” (p. 20) This theory can be applied to prevent conflict, as in when a nurse suspects a patient misperceives information or to correct misspoken information, as in when a nurse manager misstates a policy and another nurse provides the correct information to a staff member.

Stages of conflict

The classic view of conflict is that it proceeds through four stages: frustration, conceptualization, action, and outcomes (Thomas, 1992). The ability to resolve conflicts productively depends on understanding this process (Fig. 8.2) and successfully addressing thoughts, feelings, and behaviors that form barriers to resolution. As one navigates through the stages of conflict, moving into a subsequent stage may lead to a return to and change in a previous stage (Fig. 8.3). To illustrate, the evening shift of a cardiac step-down unit has been asked to pilot a new hand-off protocol for the next 6 weeks, which stimulates intense emotions because the unit is already inadequately staffed (frustration). Two nurses on the unit interpret this conflict as a battle for control with the nurse educator; a third nurse thinks it is all about professional standards (conceptualization). A nurse leader/manager facilitates a discussion with the three nurses (action). They listen to the concerns and present evidence about the potential effectiveness of the new hand-off protocol. All agree that the real conflict comes from a difference in goals or priorities (new conceptualization), which leads to less negative emotion and ends with a much clearer understanding of all of the issues (diminished frustration). The nurses agree to pilot the hand-off protocol after their ideas have been incorporated into the plan (outcome).

FIG. 8.2 Stages of conflict.

A cyclic flowchart for antecedents leading to conflict concept analysis and followed by consequences which lead back to antecedents shows the components as follows: • Antecedents: Individual characteristics: Value differences and demographic dissimilarity; interpersonal factors: Lack of trust, injustice or disrespect, and inadequate or poor communication; and organizational factors: Interdependence and changes that result from restructuring. • Conflict concept analysis: Individual conflict management style leads to perceived conflict. • Consequences: Individual effect: Job stress, job dissatisfaction, absenteeism, intent to leave, increased grievances, psychosomatic complaints, and negative emotions; interpersonal relationships negative: Negative perception of others, hostility, and avoidance; interpersonal relationships positive: Stronger relationships and team cohesiveness; and organizational effects: Reduced coordination and collaboration and reduced productivity.

FIG. 8.3 Antecedents and consequences of conflict.

Frustration

When people or groups perceive that their goals may be blocked, frustration results. This frustration may escalate into stronger emotions, such as anger and deep resignation. For example, a nurse may perceive that a postoperative patient is noncompliant or uncooperative, when, in reality, the patient is afraid or has a different set of priorities at the start from those of the nurse. At the same time, the patient may view the nurse as controlling and uncaring because the nurse repeatedly asks whether the patient has used his incentive spirometer as instructed. When such frustrations occur, it is a cue to stop and clarify the nature and cause of the differences.

Similarly, frustration intensified during the COVID-19 pandemic because so little could be controlled and threats to personal safety were amplified. Initially, that frustration centered around the lack of personal protective equipment. Later, that frustration related to inadequate staffing levels in many organizations and disruptions in the practice environment due to so many temporary personnel.

Conceptualization

Conflict arises when different interpretations of a situation occur, including a different emphasis on what is important and what is not, and different thoughts about what should occur next. All involved develop an idea of what the conflict is about, and their views may or may not be accurate. Conclusions may be instant or developed over time. Everyone involved has an individual interpretation of what the conflict is and why it is occurring. Most often, these interpretations are dissimilar and involve the person’s own perspective, which is based on personal values, beliefs, and culture.

Regardless of its accuracy, conceptualization forms the basis for everyone’s reactions to the frustration. The way that individuals perceive and define the conflict has a great deal of influence on the approach to resolution and subsequent outcomes. For example, within the same conflict situation, some individuals may see a conflict between a nurse manager and a direct care nurse as insubordination on the part of the latter and become angry at the threat to the leader’s role. Others may view it as trivial complaining, may voice criticism (e.g., “We’ve been over this new protocol already; why can’t you just adopt the change?”), and withdraw from the situation. Such differences in conceptualizing the issue block its resolution. Thus, each person must clarify “the conflict as I see it” and “how it makes me respond” before all of the people involved can define the conflict, develop a shared conceptualization, and resolve their differences. The following are questions to consider:

• What is the nature of our differences?

• What are the reasons for those differences?

• Does our leader endorse ideas or behaviors that add to or diminish the conflict?

• Do I need to be mentored by someone, even if that individual is outside my own department or work area, to successfully resolve this conflict?

Action

A behavioral response to a conflict follows the conceptualization. This may include seeking clarification about how another person views the conflict, collecting additional information that informs the issue, or engaging in dialog about the issue. As actions are taken to resolve the conflict, the way that some or all parties conceptualize the conflict may change. Successful resolution often stems from identifying a common goal that unites (e.g., quality patient care, good working relations). People are always taking some action regarding the conflict, even if that action is avoiding dealing with it, deliberately delaying action, or choosing to do nothing. The longer ineffective actions continue, though, the more likely people will experience frustration, resistance, or even hostility. The more the actions appropriately match the nature of the conflict, the more likely the conflict will be resolved with desirable results.

Outcomes

Tangible and intangible consequences result from the actions taken and have significant implications for the work setting. Consequences include (1) the conflict being resolved with a revised approach, (2) stagnation of any current movement, or (3) no future movement.

Constructive conflict results in successful resolution, leading to the following outcomes:

• Growth occurs.

• Problems are resolved.

• Groups are unified.

• Productivity is increased.

• Commitment is increased.

Unsatisfactory resolution is typically destructive and results in the following:

• Negativity, resistance, and increased frustration inhibit movement.

• Resolutions diminish or are absent.

• Groups divide, and relationships weaken.

• Productivity decreases.

• Satisfaction decreases.

Assessing the degree of conflict resolution is useful for improving individual and group skills in resolutions, including more effective communication. Two general outcomes are considered when assessing the degree to which a conflict has been resolved: (1) the degree to which important goals were achieved and (2) the nature of the subsequent relationships among those involved (Box 8.1).

Box 8.1

General Outcomes in Conflict Management

Assessing the Degree of Conflict Management

I. Quality of decisions

A. How creative are planned solutions?

B. How practical and realistic are they?

C. How well were intended goals achieved?

D. What surprising results were achieved?

II. Quality of relationships

A. How much understanding has been created?

B. How willing are people to work together?

C. How much mutual respect, empathy, concern, and cooperation have been generated?

Modified from Hurst, J., & Kinney, M. (1989). Empowering self and others. Toledo, OH: University of Toledo.

Categories of conflict

Categorizing a conflict can further define an appropriate course of action for resolution. Conflicts arise from discrepancies in four areas: facts, goals, approaches, and values. Sources of fact-based conflicts are external written sources and include job descriptions, hospital policies, standards of nursing practice, and TJC mandates. Objective data can be provided to resolve a disagreement generated by discrepancies in information. Goal conflicts often arise from competing priorities (e.g., desire to empower employees vs. control through micromanagement). Frequently, a common goal (e.g., quality patient care) can be identified and used to frame conflict resolution. Even when all agree on a common goal, different ideas about the best approach to achieve that goal may produce conflict. For example, if the unit goal is to reduce costs by 10%, one leader may target overtime hours and another may eliminate the budget for continuing education. Values, opinions, and beliefs are much more personal; thus, they generate disagreements that can be threatening and adversarial. Because values are subjective, value-based conflicts often remain unresolved. Therefore, a need to find a way for competing values to coexist is necessary for effective communication and conflict management.

Modes of conflict management

Understanding the way the healthcare providers respond to conflict is an essential first step in identifying effective strategies to help nurses constructively handle conflicts in the practice environment. Five classic approaches can be used in conflict resolution: avoiding, accommodating, competing, compromising, and collaborating (Thomas & Kilman, 1974, 2002). These approaches can be viewed within two dimensions: assertiveness (satisfying one’s own concerns) and cooperativeness (satisfying the concerns of others). Most people tend to employ a combined set of actions that are appropriately assertive and cooperative, depending on the nature of the conflict situation (Thomas, 1992). See the conflict self-assessment in Box 8.2.

Box 8.2

Conflict Self-Assessment

Directions: Read each of the following statements. Assess yourself in terms of how often you tend to act similarly during conflict at work. Place the number of the most appropriate response in the blank in front of each statement. Put 1 if the behavior is never typical of how you act during a conflict, 2 if it is seldom typical, 3 if it is occasionally typical, 4 if it is frequently typical, or 5 if it is very typical of how you act during conflict.

________1. Create new possibilities to address all important concerns.

________2. Persuade others to see it and/or do it my way.

________3. Work out some sort of give-and-take agreement.

________4. Let other people have their way.

________5. Wait and let the conflict take care of itself.

________6. Find ways that everyone can win.

________7. Use whatever power I have to get what I want.

________8. Find an agreeable compromise among people involved.

________9. Give in so others get what they think is important.

________10. Withdraw from the situation.

________11. Cooperate assertively until everyone’s needs are met.

________12. Compete until I either win or lose.

________13. Engage in “give a little and get a little” bargaining.

________14. Let others’ needs be met more than my own needs.

________15. Avoid taking any action for as long as I can.

________16. Partner with others to find the most inclusive solution.

________17. Put my foot down assertively for a quick solution.

________18. Negotiate for what all sides value and can live without.

________19. Agree to what others want to create harmony.

________20. Keep as far away from others involved as possible.

________21. Stick with it to get everyone’s highest priorities.

________22. Argue and debate over the best way.

________23. Create some middle position everyone agrees to.

________24. Put my priorities below those of other people.

________25. Hope the issue does not come up.

________26. Collaborate with others to achieve our goals together.

________27. Compete with others for scarce resources.

________28. Emphasize compromise and trade-offs.

________29. Cool things down by letting others do it their way.

________30. Change the subject to avoid the fighting.

Conflict Self-Assessment Scoring

Look at the numbers you placed in the blanks on the conflict assessment. Write the number you placed in each blank on the appropriate line below. Add up your total for each column and enter that total on the appropriate line. The greater your total is for each approach, the more often you tend to use that approach when conflict occurs at work. The lower the score is, the less often you tend to use that approach when conflict occurs at work.

Collaborating Competing Compromising Accommodating Avoiding

1. ________ 2. ________ 3. ________ 4. ________ 5. ________

6. ________ 7. ________ 8. ________ 9. ________ 10. ________

11. ________ 12. ________ 13. ________ 14. ________ 15. ________

16. ________ 17. ________ 18. ________ 19. ________ 20. ________

21. ________ 22. ________ 23. ________ 24. ________ 25. ________

26. ________ 27. ________ 28. ________ 29. ________ 30. ________

Total ________ Total ________ Total ________ Total ________ Total ________

From Hurst, J. B. (1993). Conflict self-assessment. Toledo, OH: Human Resource Development Center, University of Toledo.

Exercise 8.3

Self-assessment of preferred conflict-handling modes is important. As you read and answer the 30-item conflict survey in Box 8.2, think of how you respond to conflict in professional situations. After completing the survey, tally and reflect on your scores for each of the five approaches. Consider the following questions:

• Which approach do you prefer? Which do you use least?

• What determines whether you respond in a particular manner?

• Considering the reoccurring types of conflicts you have, what are the strengths and weaknesses of your preferred conflict-handling styles?

• Have others offered you feedback about your approach to conflict?

Throughout the rest of this section are descriptions of each approach and related self-assessment and commitment-to-action activities. Use your totals from Box 8.2 to stimulate your thinking about how you do and how you could handle conflict at work. Most important, consider whether your pattern of frequency tends to be consistent or inconsistent with the types of conflicts you face. That is, does your way of dealing with conflict tend to match the situations in which that approach is most useful?

As you read the rest of this section, use this pattern of scores and your reflections to examine the appropriate uses of each approach, assess your use of each approach more extensively, and commit to new behaviors to increase your future effectiveness.

Avoiding

Avoiding, or withdrawing, is very unassertive and uncooperative, because people who avoid neither pursue their own needs, goals, or concerns immediately nor assist others to pursue theirs. Avoidance as a conflict management style ensures that conflict is only postponed, and conflict has a tendency to escalate in intensity when ignored. That is not to say that all conflict must be addressed immediately; some issues require considerable reflection and action should be delayed. The positive side of withdrawing may be postponing an issue until a better time or simply walking away from a “no-win” situation (Box 8.3). The self-assessment in Box 8.4 will help you recognize your own avoidance behaviors and use them more effectively.

Box 8.3

Appropriate Uses for the Avoiding Approach

1. When facing trivial and/or temporary issues, or when other far more important issues are pressing

2. When there is no chance to obtain what one wants or needs, or when others could resolve the conflict more efficiently and effectively

3. When the potential negative results of initiating and acting on a conflict are much greater than the benefits of its resolution

4. When people need to “cool down,” distance themselves, or gather more information

Box 8.4

Avoidance: Self-Assessment and Commitment to Action

If you tend to use avoidance often, ask yourself the following questions:

1. Do people have difficulty getting my input and understanding my view?

2. Do I block cooperative efforts to resolve issues?

3. Am I distancing myself from significant others?

4. Are important issues being left unidentified and unresolved?

If you seldom use avoidance, ask yourself the following questions:

1. Do I find myself overwhelmed by a large number of conflicts and a need to say “no”?

2. Do I assert myself even when things do not matter that much? Do others view me as an aggressor?

3. Do I lack a clear view of what my priorities are?

4. Do I stir up conflicts and fights?

Commitment to Action

What two new behaviors would increase your effective use of avoidance?

1.

2.

Accommodating

When accommodating, people neglect their own needs, goals, and concerns (unassertive) while trying to satisfy those of others (cooperative). This approach has an element of being self-sacrificing and simply obeying orders or serving other people. For example, a coworker requests that you cover her weekends during her children’s holiday break. You had hoped to visit friends from college, but you know how important it is for her to have more time with her family, so you agree. Box 8.5 lists some appropriate uses of accommodation.

Box 8.5

Appropriate Uses of Accommodation

1. When other people’s ideas and solutions appear to be better or when you have made a mistake

2. When the issue is far more important to the other person or people than it is to you

3. When you see that accommodating now “builds up some important credits” for later issues

4. When you are outmatched and/or losing anyway; when continued competition would only damage the relationships and productivity of the group and jeopardize accomplishing major purpose(s)

5. When preserving harmonious relationships and avoiding defensiveness and hostility are very important

6. When letting others learn from their mistakes and/or increased responsibility is possible without severe damage

Individuals who frequently use accommodation may feel disappointment and resentment because they “get nothing in return.” This is a built-in by-product of the overuse of this approach. The self-assessment in Box 8.6 asks you to examine your current use of accommodation and challenges you to think of new ways to use it more effectively.

Box 8.6

Accommodation: Self-Assessment and Commitment to Action

If you use accommodation often, ask yourself the following questions:

1. Do I feel that my needs, goals, concerns, and ideas are not being attended to by others?

2. Am I depriving myself of influence, recognition, and respect?

3. When I am in charge, is “discipline” lax?

4. Do I think people are using me?

If you seldom use accommodation, ask yourself the following questions:

1. Am I building goodwill with others during conflict?

2. Do I admit when I have made a mistake?

3. Do I know when to give in or do I assert myself at all costs?

4. Am I viewed as unreasonable or insensitive?

Commitment to Action

What two new behaviors would increase your effective use of accommodation?

1.

2.

Competing

When competing, people pursue their own needs and goals at the expense of others. Sometimes, people use whatever power, creativeness, or strategies that are available to “win.” Competing may also take the form of standing up for your rights or defending important principles, as when opposition to mandatory overtime is voiced (Box 8.7).

Box 8.7

Appropriate Uses of Competing

1. When quick, decisive action is necessary

2. When important, unpopular action needs to be taken or when trade-offs may result in long-range, continued conflict

3. When an individual or group is right about issues that are vital to group welfare

4. When others have taken advantage of an individual’s or group’s noncompetitive behavior and now are mobilized to compete about an important topic

People whose primary mode of addressing conflict is through competition often react by feeling threatened, acting defensively or aggressively, or even resorting to cruelty in the form of cutting remarks, deliberate gossip, or hurtful innuendo. Competition within work groups can generate ill will, favor a win-lose stance, and commit people to a stalemate. Such behaviors force people into a corner from which there is no easy or graceful exit. Use Box 8.8 to help you learn to use competing more effectively.

Box 8.8

Competing: Self-Assessment and Commitment to Action

If you use competing often, ask yourself the following questions:

1. Am I surrounded by people who agree with me all the time and who avoid confronting me?

2. Are others afraid to share themselves and their needs for growth with me?

3. Am I out to win at all costs? If so, what are the costs and benefits of competing?

4. What are people saying about me when I am not around?

If you seldom compete, ask yourself the following questions:

1. How often do I avoid taking a strong stand and then feel a sense of powerlessness?

2. Do I avoid taking a stand so that I can escape risk?

3. Am I fearful and unassertive to the point that important decisions are delayed and people suffer?

Commitment to Action

What two new behaviors would increase your effective use of competition?

1.

2.

Compromising

Compromising involves both assertiveness and cooperation on the part of everyone and requires maturity and confidence. Negotiating is a learned skill that is developed over time. A give-and-take relationship leads to conflict resolution, with the result that each person can meet one’s most important priorities as much of the time as possible. Compromise is very often the exchange of concessions, as it creates a middle ground. This is the preferred means of conflict resolution during union negotiations, in which each side is appeased to some degree. In this mode, nobody gets everything, but a sense of energy exists that is necessary to build important relationships and teams.

Negotiation and compromise are valued approaches. They are chosen when less accommodating or avoiding is appropriate (Box 8.9). Compromising is a blend of both assertive and cooperative behaviors, although it calls for less finely honed skills for each behavior than does collaborating. Compromise supports a balance of power between self and others in the workplace. The compromising mode is a common conflict-handling mode used in nurse–physician interactions. A need exists to strengthen a healthy professional alliance that relies on collaborative practice to ensure favorable patient outcomes. Effective communication with other members of the healthcare team positively influences teamwork and staff satisfaction and improves quality of patient care and safety.

Box 8.9

Appropriate Uses of Compromise

1. When two powerful sides are committed strongly to perceived mutually exclusive goals

2. When temporary solutions to complex issues need to be implemented

3. When conflicting goals are “moderately important” and not worth a major confrontation

4. When time pressures people to expedite a workable solution

5. When collaborating and competing fail

Negotiating is more like trading—for example, “You can have this if I can have that” as in “I will chair the unit council task force on improving morale if you send me to the hospital’s leadership training classes next week so I can have the skills I need to be effective.” Compromise is one of the most effective behaviors used by nurse leaders because it supports a balance of power between themselves and others in the work setting. The self-assessment in Box 8.10 will help you become more aware of your own use of negotiation and compromise and improve it.

Box 8.10

Negotiation and Compromise Self-Assessment and Commitment to Action

If you tend to use negotiation often, ask yourself the following questions:

1. Do I ignore large, important issues while trying to work out creative, practical compromises?

2. Is there a “gamesmanship” in my negotiations?

3. Am I sincerely committed to compromise or negotiated solutions?

If you seldom use negotiation, ask yourself the following questions:

1. Do I find it difficult to make concessions?

2. Am I often engaged in strong disagreements or do I withdraw when I see no way to get out?

3. Do I feel embarrassed, sensitive, self-conscious, or pressured to negotiate, compromise, and bargain?

Commitment to Action

What two new behaviors would increase your compromising effectiveness?

1.

2.

Collaborating

Collaborating, although the most time-consuming approach, is the most creative stance. It is both assertive and cooperative, because people work creatively and openly to find the solution that most fully satisfies all important concerns and goals to be achieved. Collaboration involves analyzing situations and defining the conflict at a higher level where shared goals are identified and commitment to working together is generated (Box 8.11). Collaboration demonstrates relationship-centered approaches with patients and with others because both parties are concerned with their relationship with the other person, not just with the issue at hand. When nurses use cooperative conflict management approaches, decision-making becomes a collective process in which action plans are mutually understood and implemented. An organizational culture that supports collaborative communication and behavior among nurses and other members of the team is needed to merge the unique strengths of all professions into opportunities to improve patient outcomes. For example, when nurses and physicians work together, they can collaborate by asking, “What is the best thing we can do for the patient and family right now?” and “How does each of us fit into the plan of care to meet their needs?” This requires discussion about the plan, how it will be accomplished, and who will make what contributions toward its achievement and proposed outcomes. Use the self-assessment in Box 8.12 to determine your own use of collaboration.

Box 8.11

Appropriate Uses for Collaboration

1. When seeking creative, integrative solutions in which both sides’ goals and needs are important, thus developing group commitment and a consensual decision

2. When learning and growing through cooperative problem solving, resulting in greater understanding and empathy

3. When identifying, sharing, and merging vastly different viewpoints

4. When being honest about and working through difficult emotional issues that interfere with morale, productivity, and growth

Box 8.12

Collaboration Self-Assessment and Commitment to Action

If you tend to collaborate often, ask yourself the following questions:

1. Do I spend valuable group time and energy on issues that do not warrant or deserve it?

2. Do I postpone needed action to get consensus and avoid making key decisions?

3. When I initiate collaboration, do others respond in a genuine way, or are there hidden agendas, unspoken hostility, and/or manipulation in the group?

If you seldom collaborate, ask yourself the following questions:

1. Do I ignore opportunities to cooperate, take risks, and creatively confront conflict?

2. Do I tend to be pessimistic, distrusting, withdrawing, and/or competitive?

3. Am I involving others in important decisions, eliciting commitment, and empowering them?

Commitment to Action

What two new behaviors would increase your collaboration effectiveness?

1.

2.

At the onset of conflict, involved collaborating individuals can carefully analyze situations to identify the nature and reasons for conflict and choose an appropriate approach. For example, a conflict arises when a direct care nurse and a charge nurse on a psychiatric unit disagree about how to handle a patient’s complaints about the direct care nurse’s delay in responding to the patient’s requests. At the point that they reach agreement that it is the direct care nurse’s responsibility and decision to make, collaboration has occurred. The charge nurse might say, “I didn’t realize your plan of care was to respond to the patient at predetermined intervals or that you told the patient that you would check on her every 30 minutes. I can now inform the patient that I know about and support your approach.” Or the direct care nurse and the charge nurse might talk and subsequently agree that the direct care nurse is too emotionally involved with the patient’s problems and that it may be time for her to withdraw from providing the care and enlist the support of another nurse, even temporarily. Discussion can result in collaboration aimed at allowing the direct care nurse to withdraw appropriately. Another less desirable choice could be to compete and let the winner’s position stand—for example, “I’m in charge; I’m going to assign another nurse to this patient to preserve our patient satisfaction scores” or “I know what is best for this patient; I took care of her during her past two admissions.”

Differences in conflict-handling styles among nurses

An increased emphasis has been placed on effective communication and appropriate conflict management styles in healthcare. Avoidance and accommodation are often the predominant choices for direct care nurses, and the prevalent style for nurse managers is frequently compromise despite the benefits placed on collaboration as an effective strategy for conflict management. Nursing students and new graduates may be unprepared to handle conflict in the practice environment and may experience a number of barriers, such as fear of causing conflict (Vandergoot et al., 2018). Speaking up as a patient advocate is difficult for novice nurses. This highlights the need to develop delegation strategies, including conflict-handling skills, to adapt to the evolving professional role. A prevalent conflict management style for nursing students and new nurses is avoidance and accommodation. Nurses who successfully manage disruptive workplace conflict reported a deliberate approach that included delaying confrontation, approaching the colleague calmly, and acknowledging the colleague’s point of view. Nurses may need to adapt communication and conflict management strategies to respond to diverse patient populations and the unique mix of interprofessional colleagues. See the Research Perspective, which describes early-career hospital nurses’ experiences with verbal abuse in the workplace.

Research perspective

Resource: Cho, H., Pavek, K., & Steege, L. (2020). Workplace verbal abuse, nurse-reported quality of care and patient safety outcomes among early-career hospital nurses. Journal of Nursing Management, 28, 1250–1258.

The differences between early-career nurses’ verbal abuse experiences and the relationship to patient care quality and safety outcomes were examined. Nurses’ gender and age and the type of unit on which they work predispose early-career nurses to verbal abuse, including yelling and cursing at work. Male nurses reported more verbal abuse from patients and families than female nurses. Nurses in their 20s reported more verbal abuse from physicians than older nurses, while nurses in their 30s reported more incivility from disciplines other than nurses in their 20s. Nurses working on step-down units and on general units reported more verbal abuse than those working in intensive care units. Early-career nurses who experienced verbal abuse reported lower ratings of quality of care and patient safety, regardless of age, perpetrator, or unit.

Implications for Practice

Managing verbal abuse is important to promote a safe and healthy workplace and, in turn, improve patient quality and safety. Leaders should monitor unit culture and schedule regular meetings with new graduate nurses and early-career nurses to discuss any concerns about bullying, lateral violence, or incivility. Nurse managers can collaborate with other leadership structures such as unit councils to implement changes in the practice environment to reinforce a zero-tolerance culture and provide bystander intervention training. Education about how to effectively confront workplace disruptions should begin in nursing school and continue into orientation and nurse residency programs.

The role of the leader

Encouraging positive working relationships among healthcare providers requires effective conflict management as part of a healthy working environment. The role of the nurse leader is to create a practice environment that fosters open communication and collaborative practices for achieving mutual goals that enable nurses to use constructive approaches to conflict management. Specifically, leaders must adopt a strategic proactive approach that aligns conflict management approaches with the overall mission of the organization. The training of nurse managers as conflict coaches shows promise in creating a positive practice environment when integrated with other conflict intervention processes. By modeling open communication and acknowledging each team member’s viewpoint, the nurse manager can coach staff to independently and effectively resolve future conflicts themselves.

With the aging workforce and current nursing shortage, practice environments must be designed to retain nurses and prevent premature departure from the discipline. How to preserve the wisdom that experienced nurses have is a critical challenge. Moreover, nurse leaders need to help challenge the stereotypical gender behavioral expectations and self-esteem issues frequently associated with a female-dominated profession and model effective management and leadership styles. One way to promote a positive work setting is to promote conflict prevention and ensure conflict management. The Literature Perspective highlights the results of an integrative review of publications about teamwork, delegation, and communication among registered nurses and nursing assistants. Nurse leaders must provide the best example of advocacy and empowerment to their staff by coaching newer nurses to think strategically about a mode of conflict handling that is appropriate for the situation. Poor communication often creates conflict that jeopardizes patient safety, whereas inadequate leadership appears to be a contributing factor to adverse patient outcomes. Nurse managers need to support their staff’s use of effective conflict management strategies by modeling open and honest communication, including staffing decision-making, and securing resources whenever possible that meet the staff’s needs in delivering quality care. Providing education about conflict management could empower nurses to use these newly acquired skills in negotiation and creative problem-solving techniques. One example is nurse leaders using an interprofessional education program designed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ) called TeamSTEPPS to reduce stress and conflict because it focuses on evidence-based strategies to enhance teamwork and communication (AHRQ, 2018). Healthcare providers do not always voice concerns about patients and often avoid conflict in clinical settings.

Literature perspective

Resource: Campbell, A. R., Layne, D., Scott, E., & Wei, H. (2019). Interventions to promote teamwork, delegation and communication among registered nurses and nursing assistants: An integrated review. Journal of Nursing Management, 28, 1465–1472.

An integrative review of publications focusing on interventions to promote teamwork, delegation, and communication among registered nurses (RN) and unlicensed assistive personnel (UAP) revealed strategies to strenghten the RN-UAP dyad to promote patient safety and positive patient and staff outcomes. Of the seven articles included in the review, four measured patient outcomes, including patient falls, hospital-acquired pressure injuries, and patient satisfaction. With improved RN-UAP relations, three studies reported decreased falls, two described increased patient satisfaction, and one reported a reduction in hospital-acquired pressure injuries. Five of the studies reflected improved teamwork and communication and two studies reported improved job satisfaction. Team building is essential for enhancing team unity, improving communication, and building mutual respect and trust. The organizational impact of ineffective communication and negative conflict management includes reduced productivity and ineffective teamwork, which can lead to adverse patient outcomes. The need to build a foundation of trust and respect and to engage in effective communication was evident across all studies.

Implications for Practice

Although emphasis is frequently placed on improving nurse–physician relations, the need to foster effective relationships between registered nurses and nursing assistants is also essential. Providing quality patient care requires collaborative working relationships punctuated by effective communication and conflict resolution. Interprofessional handoffs or rounding could include unlicensed nursing personnel to promote teamwork. Healthcare leaders must model effective communication, conflict management, and appropriate delegation to promote an organizational culture of quality and safety. Nursing leaders should focus educational efforts on nursing care that requires RN-UAP coordination, including turning, ambulating, feeding, hygiene, emotional support, documentation, and surveillance.

Exercise 8.4

Review the educational program TeamSTEPPS. Identify two strategies you can incorporate into your practice. State your rationale for selecting those and create an action plan to incorporate those strategies into your practice.

Healthcare leaders and managers who promote effective conflict resolution skills and who discourage the use of avoidance as a strategy have the potential to reduce employee stress and burnout as well as promote higher job satisfaction. Effective conflict resolution enhances team performance, increases patient safety, and improves patient outcomes (Fowler & Robbins, 2021).

Nurse conflict, stress, burnout, and turnover must be reduced to positively transition new graduate nurses into the workforce and retain experienced nurses. Organizations must support nurses by reducing role stress through reasonable workloads, clear expectations, and providing opportunities to be mentored, including in communication and conflict resolution (Hallaran et al., 2021). The nature of the differences, underlying reasons, importance of the issue, strength of feelings, and commitment to shared goals all have to be considered when selecting an approach to resolving conflict. Preferred and previously effective approaches can be considered, but they need to match the situation. Sometimes, a third party may be introduced into a conflict so that mediation can occur. Mediation is a learned skill for which advanced training or certification is available. Principled negotiation can produce mutually acceptable agreements in every type of conflict. The method involves separating the people from the problem; focusing on interests, not positions; inventing options for mutual gain; and insisting on using objective criteria. The mediator is usually an impartial person who assists each party in the conflict to better hear and understand the other. In society, for example, much focus is on who can control whom and on who is the “winner.” The successful individual involved in conflict resolution and negotiation often moves beyond avoidance, accommodation, and compromise. In nursing practice, added difficulty occurs in negotiating conflicts when at least one of the parties is on an unequal or uneven playing field. This disadvantage is made even worse when the other party to the conflict does not even acknowledge the disparities involved.

Managing incivility, lateral violence, and bullying

An expression of conflict may be incivility, lateral violence, or bullying. In nursing, they are prevalent in all settings. Incivility is one or more rude, discourteous, or disrespectful actions, which can range from gossiping to refusing to assist a coworker. A significant source of interpersonal conflict in the workplace stems from lateral violence—aggressive and destructive behavior or psychological harassment of nurses against each other. Nurses are particularly vulnerable because lateral or horizontal violence involves conflictual behaviors among individuals who consider themselves peers with equal power—but with little power within the system. Bullying is closely related to lateral or horizontal violence; however, a real or perceived power differential between the instigator and recipient must be present in bullying. Bullying (defined as repeated, unwanted harmful actions intended to humiliate, offend, and cause distress in the recipient) is a very serious issue that threatens patient safety, nurse safety, and the nursing profession as a whole.

Understanding the sources of intraprofessional conflict in the practice environment is essential. Nurses are in positions to identify and intervene on the part of their colleagues when they see or experience horizontal violence or bullying, which is referred to as bystander intervention in the workplace. With increased awareness and sensitivity, nurses may be better able to monitor themselves and to assist their peers to recognize when they are participating in negative behaviors. Identifying and understanding particular incidences (e.g., heavy workload, short staffing) when nurses are most vulnerable and apt to engage in negative behavior and establishing performance expectations has the potential to reduce lateral violence in the workplace (Crawford et al., 2019). Incorporating workplace civility in nursing orientation programs and modeling professional behaviors provides a foundation to promote a healthy work culture. Nursing students and new graduates often lack the confidence and skill set to prevent interpersonal conflict and must rely on experienced nurse leaders to reduce the likelihood of incivility, horizontal violence, or bullying. The actions of nurse leaders will determine not only the future of professional nursing practice but also how the public views the nursing profession (Crawford et al., 2019). Nurse educators have a similar responsibility to develop nursing curricula that educate and encourage dialogue about incivility and horizontal violence to increase awareness, communication, and conflict resolution skills.

In hostile work environments, the ability to provide quality patient care is compromised. TJC (2020) acknowledges that unresolved conflict and disruptive behavior adversely affect safety and quality of care. The vulnerability of newly licensed nurses as they are socialized within the nursing workforce and deal with interpersonal conflicts is a significant challenge (Cho et al., 2020). Lateral violence affects newly licensed nurses’ job satisfaction and stress. It also affects their perception of whether to remain in their current position and in the profession. Similarly, nursing students are particularly vulnerable to lateral violence and bullying in the transition to becoming a nurse. This could lead to nursing students questioning their long-held belief that nurses are caring and supportive professionals and can negatively affect quality of care and patient safety outcomes (Cho et al., 2020).

Lateral violence may be a response to the practice environment, in which ineffective leadership may exacerbate the problem. Incivility and disruptive behavior that intimidates others and affects morale or staff turnover can be harmful to patient care. It mandates that organizations have a code of conduct defining acceptable, disruptive, and inappropriate behaviors and that leaders create and implement a process for managing these conflictual situations. Ignoring the importance of informal communication and informal social networks can be detrimental to employee satisfaction, patient outcomes, and organizational goal attainment. Managing the rumor mill, the grapevine, or the gossip chain will assist in decreasing incivility and improve the work environment (Prestia, 2021). One-on-one conflict resolution must be encouraged, but a mechanism for confidential reporting is also necessary. Training on conflict management that includes how to recognize and defend against lateral violence is necessary to ensure a positive professional practice environment. Senior-level leaders and nurse managers are responsible for ensuring that appropriate policies are in place to confront negative workplace behaviors, including lateral violence and bullying. The ANA Position Statement on Incivility, Bullying, and Workplace Violence (American Nurses Association, 2015) remains relevant today. It states that the nursing profession will not tolerate violence of any type from any source and directs nurses and nurse leaders to collaborate to create a culture of respect.

Exercise 8.5

Consider a conflict you would describe as “ongoing” in a clinical setting. Talk to some people who have been around for a while to get their historical perspective on this issue. Then, consider the following questions:

• What are their positions and years of experience?

• How are resources, time, and personnel wasted on mismanaging this issue?

• What blocks the effective management of this issue?

• What currently aids in its management?

• What new things and actions would add to its management in the future?

Conclusion

Communication is impossible to avoid. Even when we say nothing, we are communicating. The complexity of healthcare and its delivery have created specific approaches to safeguard how information is transmitted to prevent, as much as possible, harm occurring to patients.

Conflict is inevitable within healthcare environments. The major issue of miscommunication and unresolved conflict in nursing is that patients could suffer. Knowing how to respond appropriately in conflictual situations helps the entire healthcare team focus on quality and safety rather than disagreements and disruptions.

Unresolved conflict in the professional practice environment results in negative outcomes for nurses and other healthcare professionals, organizations, and patients. Incivility, bullying, and lateral violence are toxic to the profession through the negative impact on the retention of staff and on detrimental outcomes for patients. Registered nurses must work in an effective and collaborative manner with other members of the healthcare team to enhance retention and eliminate incivility, lateral violence, and bullying from the workplace. Incivility, bullying, lateral violence, and all forms of disruptive behaviors have a negative effect on the retention of nursing staff and the quality and safety of patient care. Nurses must enhance their knowledge and skills in managing conflict, communicating clearly, and promoting workplace policies to eliminate bullying and lateral violence. Nurse leaders must eliminate hostile work environments, workplace intimidation, reality shock for new graduates, and the acceptance of inappropriate professional interactions.

The solution

Elia Nava

I apologized to the patient about not having the dressings changed earlier and changed them immediately. I was really upset that this had happened. I knew this was not right, for both the patient’s quality of care and the dishonesty from the nurse. I did not want to be the nurse who points out other’s mistakes or who created conflict. I knew I had to speak up, because not only was this not the first time this happened with that nurse, but also because we need to prevent this from happening again because it affects patients’ quality of care. I spoke with the charge nurse about the situation, and I was relieved when she said she was ecstatic about me speaking up about this, since not many new graduate nurses would feel comfortable doing so. I felt proud of myself for communicating these concerns. I felt heard and understood, and I realized that it does not matter that you are a new graduate nurse; if you see something wrong, you have to say something, because in the end you are your patient’s advocate.

Would this be a suitable approach for you? Why?

Reflections

How will you use the material from this chapter to promote effective communication and reduce conflict with the patients for whom you provide care as well as with interprofessional coworkers? How do healthcare environments compound the complexity of communication and contribute to conflict? Write a one-page summary including specific examples with an emphasis on how you can be more effective in managing conflict.

Best practices

Civil work environments promote patient safety and favorable patient and staff outcomes. Because communication is such a critical element in patient care, all members of the interprofessional team must employ effective strategies and speak up when care can be compromised. Effective communication contributes to positive patient care.

Tips for effective communication and addressing conflict

• Develop common language for critical information for handoff communications and communication of changes in a patient’s condition.

• Use a communication tool such as SBAR to standardize communication.

• Use a standardized format for change-of-shift report and handoff communication.

• Use a standardized format for report when patients are transferred to other units or facilities.

• Provide the opportunity for questions and confirmation of understanding of communication.

• Have face-to-face communication when possible.

• Read back all healthcare provider orders or other pertinent information.

• Create a culture of patient safety that has zero tolerance for intimidating and disruptive behavior.

• Work in interprofessional teams to develop common language.

• Develop skills in assertive communication and conflict management.

• Recognize that conflict is a necessary and beneficial process typically marked by frustration, different conceptualizations, a variety of approaches to resolving it, and ongoing outcomes.

• Assess the work environment to see what behaviors are endorsed and fostered by the leaders. Determine whether these behaviors are worthy of imitation.

• Determine any similarities and differences in facts, goals, methods, and values in sorting out the different conceptualizations of a conflict situation.

• Assess the degree of conflict resolution by asking questions about the quality of the decisions (e.g., creativity, practicality, achievement of goals, breakthrough results) and the quality of the relationships (e.g., understanding, willingness to work together, mutual respect, cooperation).

• Remind yourself of your preferences for resolving conflict (e.g., which of the five approaches do you not use often enough and which do you overuse?) and assess each situation to match the best approach for that type of conflict regardless of which is your favorite approach.

• Assist others around you in assessing conflict situations and determining how they can best approach them.