Healthcare Recurring conflict with the potential to negatively impact patient care

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Negotiation and Conflict Resolution Conflict can never be eliminated in organizations; however, conflict can be managed. Typically, conflict arises when people feel strongly about something. Conflicts may take place between individual staff, within a unit, or within a department. They may be inter-unit and interdepartmental, affect the entire organization, or even occur between multiple organizations, between or within teams or units, or between an organization and the community. Conflict is the “tension arising from compatible needs, in which the actions of one frustrate the ability of the other to achieve a goal” (Boggs, 2003, p. 366).

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Key Definitions There are three types of conflict: individual, interpersonal, and intergroup/organizational (Dessler, 2002). The most common type of individual conflict in the workplace is role conflict, which occurs when there is incompatibility between one or more role expectations. When staff does not understand the roles of other staff this can be very stressful for the individual and does affect work. Staff may be critical of each other for not doing some work activity when in reality it is not part of the role and responsibilities of that staff member, or staff members may feel that another staff member is doing some activity that really is not his or her responsibility.

Interpersonal conflict occurs between people. Sometimes this is due to differences and/or personalities, competition, or concern about territory, control, or loss.

Conflict also occurs between groups (e.g., units, services, teams, health care professional groups, agencies, community and a health care provider organization, and so on). When conflict occurs something is out of sync, usually due to a lack of clear understanding of one another’s roles and responsibilities. “Conflict can be overt or covert, and both can lead to problems as well as opportunities. However, covert conflict processes, obviously, tend to be fluid and difficult to describe. It is in behaviors between individuals and groups, as well as individual behaviors that are observable. These behaviors can be categorized as reactive, repressive, or avoidant. Reactive behaviors include high levels of competition, inefficiency, ‘yesing’ people with no real attempt to understand, whining, complaining, destructive behavior, counter organization moves, and passive-aggressive behaviors such as escapist drinking, irregular output, or frequent expression of low job satisfaction. In workplaces that are ripe with unacknowledged conflict, rumor mills flourish. Repressive behaviors include absenteeism, whereas avoidant behaviors can include withholding information, avoidance of contact with managers or other team members, or ‘hiding out’ on the job” (Clement, 2001, p. 212).

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Everyone has experienced covert conflict. It never feels good and increases stress quickly. Distrust and confusion about the best response are also experienced. Acknowledging covert conflict is not easy, and staff will have different perceptions of the conflict since it is not clear and below the surface. Overt conflict is obvious, at least to most people, and thus coping with it is usually easier. It is easier to arrive at an agreement when conflict is present and easier to arrive at a description of the conflict.

The common assumption about conflict is that it is destructive, and it certainly can be. There is, however, another view of conflict. “Despite its adverse effects, conflict is viewed by most experts today as potentially useful because it can, if properly channeled, be an engine of innovation and change. This view explicitly encourages a certain amount of controlled conflict in organizations because lack of active debate can permit the status quo or mediocre ideas to prevail” (Dessler, 2002, p. 315). In reality, staff really cannot avoid conflict because some conflict is inevitable. The following quote speaks to the need to recognize most conflict as opportunity. “When I speak of celebrating conflict, others often look at me as if I have just stepped over the credibility line. As nurses, we have been socialized to avoid conflict. Our modus operandi has been to smooth over at all costs, particularly if the dynamic involves individuals representing roles that have significant power differences in the organization. Be advised that well-functioning transdisciplinary teams will encounter conflict-laden situations. It is inevitable. The role of the leader is to use conflicting perspectives to highlight and hone the rich diversity that is present within the team. Conflict also provides opportunities for individuals to present divergent yet equally valid views that allow all team members to gain an understanding of their contributions to the process. Respect for each team member’s standpoint comes only after the team has

explored fully and learned to appreciate the diversity of its membership” (Weaver,

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2001, p. 83). This is a very positive view of conflict, which on the surface may appear negative. If one asked nurses if they wanted to experience conflict, they would say no. Probably behind their response is the fact that they do not know how to handle conflict and feel uncomfortable with it. However, if you asked staff, “Would you like to work in an environment where staff at all levels could be direct without concern of repercussions and could actively dialogue about issues and problems without others taking comments personally” then many staff would most likely see this as positive and not conflict. Avoidance of conflict, however, usually means that it will catch up with the person again, and then it may be more difficult to resolve. There may then be more emotions attached to it, making it more difficult to resolve.

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Causes of Conflict Effective resolution of conflict requires an understanding of the cause of the conflict; however, some conflicts may have more than one cause. It is easy to jump to conclusions without doing a thorough assessment. Some of the typical causes of conflict between individuals and between groups are “whether resources are shared equitably; insufficient explanation of expectations, leading to performance being questioned; unexplained changes that disturb routines and process and that team members are not prepared for; and to stress resulting from changes that team members do not understand and may see as threatening” (Finkelman & Kenner, 2010, p. 359). Other causes are ambiguous jurisdiction, conflict of interest, communication confusion, and unresolved conflicts (Hansten & Jackson, 2008).

Two predictors of conflict are the existence of competition for resources or inadequate communication. It is rare that a major change on a unit or in a health care organization does not result in competition for resources (staff, financial, space, supplies) so conflicts will arise between units or between those who may or may not receive the resources or may lose resources. As has been demonstrated in some of the examples, causes of conflict can be varied. An understanding of a conflict requires as thorough an assessment as possible. Along with the assessment, it is important to understand the stages of conflict.

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Stages of Conflict There are four stages of conflict that help describe the process of conflict development (Marquis & Huston, 2009).

Latent conflict . This stage involves the anticipation of conflict. Competition for resources or inadequate communication can be predictors of conflict. Anticipating conflict can increase tension. This is when staff may verbalize, “We know we are going to have a hassle with this” or may feel this internally. The anticipation of conflict can occur between units that accept one another’s patients when one unit does not think that the staff members on the other unit is very competent and yet they must accept orders and patient plans from them.

Perceived conflict . This stage requires recognition or awareness that conflict exists at a particular time. It may not be discussed but only felt. Perception is very important as it can affect whether or not there really is a conflict, what is known about the conflict, and how it might be resolved.

Felt conflict . This occurs when individuals begin to have feelings about the conflict such as anxiety or anger. Staff feels stress at this time. If avoidance is used at this time, it may prevent the conflict from moving to the next stage. Avoidance may be appropriate in some circumstances, but sometimes it just covers over the conflict and does not resolve it. In this case, the conflict may come up again and be more complicated. Trust plays a role here. How much does staff trust that the situation will be resolved effectively? How comfortable do staff members feel in being open with their feelings and opinions?

Manifest conflict . This is overt conflict. At this time the conflict can be constructive or destructive. Examples of destructive behavior related to the conflict are (a) ignoring a policy, (b) denying a problem, (c) avoiding a staff member, or (d) discussing staff in public with negative terms. Examples of constructive responses to the conflict are (a) encouraging the group to identify and solve the problem, (b) expressing appropriate feelings, or (c)

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offering to help out a staff member (Figure 12-1 highlights the stages of conflict).

Figure 12-1 Stages of conflict.

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Prevention of Conflict Some conflict can be prevented so it is important to take preventive steps whenever possible to correct a problem before it develops into a conflict. A staff team or organization that says it has no conflicts is either not aware of conflict or prefers not to acknowledge it. Prevention of conflict should focus on the typical causes of conflict that have been identified in this chapter. Clear communication, known expectations, appropriate allocation of resources, and delineation of roles and responsibilities will go a long way toward preventing conflict. If the goal is to eliminate all conflict this will not be successful, because it cannot be done.

Since not all conflict can be prevented, staff and managers need to know how to manage conflict and resolve conflict when it exists. It is important to identify potential barriers that can make it more likely that a situation will turn into a conflict or will act as barriers to conflict resolution. First and foremost, if all staff makes an effort to decrease their tension or stress level, this will go a long way in preventing or resolving conflict. In addition to this strategy, it is important to improve communication, recognize team members as members with expertise, listen and compromise to get to the most effective decision given the available data, understand the roles and responsibilities of team/staff members, and be willing to evaluate practice and team functioning.

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Conflict Management: Issues and Strategies Conflict management is critical in any organization. When conflicts arise then managers and staff need to understand conflict management issues and strategies. The major goals of conflict management are as follows:

To eliminate or decrease the conflict1. To meet the needs of the patient, family/significant others, and the organization

To ensure that all parties feel positive about the resolution so that future work together can be productive

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Powerlessness and Empowerment

When staff experiences conflict, powerlessness and empowerment, as well as aggressiveness and passive-aggressiveness, become important.

Power and powerlessness When staff members feel that they are not recognized, appreciated, or paid attention to, then they feel powerlessness . What happens in a work environment when staff feels powerlessness? First, staff members do not feel that they can make an impact—they are unable to change situations that they feel need to be changed. Staff members will not be as creative in

approaching problems. They may feel that they are responsible for tasks and yet have no control or power to affect change with these tasks. The team community will be affected negatively, and eventually the team may feel it cannot make change happen. Staff may make any of the following comments: “Don’t bother trying to make a difference,” “I can’t make a difference here,” and “Who listens to us?” Morale deteriorates as staff feels more and more powerless. New staff will soon pick up on the feeling of powerlessness. In some respects, the powerlessness really does diminish any effort for change. As was discussed in Chapter 3 , responding to change effectively is very important today. In addition when staff feels powerless this greatly impacts the organizational culture. Power is about influencing decisions, controlling resources, and affecting behavior. It is the ability to get things done—access resources and information, and use it to make decisions. Power can be used constructively or destructively. The power a person has originates from the person’s personal qualities and characteristics, as well as the person’s position. Some people have qualities that make others turn to

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them—people trust them, consider their advice helpful, and so on. A person’s position, such as a team leader or nurse manager, has associated power. Power is not stagnant. It changes as it is affected by the situation. There are a number of sources of power. Each one can be useful depending on the circumstances and the goal. An individual may have several sources of power; for example, a team leader may have legitimate power due to the position held, expert power due to team members’ recognition of the team leader’s expertise in care of oncology patients, and persuasive power because the team leader is able to convince team members the best steps to take to solve a problem. The common sources of power include the following.

Legitimate power . This power is what one typically thinks of in relation to power. It is power that comes from having a formal position in an organization such as a nurse manager, team leader, or vice president of patient services. These positions give the person who holds one of them the right to influence staff and expect staff to follow requests. Staff members recognize that they have tasks to accomplish and job requirements. Reward power . A person’s power comes from the ability to reward others when they comply. Examples of reward power include money (such as an increase in salary level), desired schedule or assignment, providing a space to work, or recognition of accomplishment. Coercive power . This type of power is based on punishment when a person does not do as expected or directed. Examples of this type include denial of a pay raise, termination, and poor schedule or assignment. This type of power leads to an unpleasant work situation. Staff will not respond positively to coercive power, and this type of power has a strong negative effect on staff morale. Referent power . This informal power comes from others recognizing that an individual has special qualities and is admired. This person then has influence over others because they want to follow the

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person due to the person’s charisma. Staff feels valued and accepted. Expert power . When a person has an expertise the person can have power over others who respect that expertise. When this type of power is present, the expert is able to provide sound advice and direction. Informational power . This type of power arises from the ability to access and share information, which is critical in the Information Age. Persuasive power . This type of power influences others by providing an effective point-of-view or argument (Finkelman & Kenner, 2010). (Box 12-4 highlights the types of power.)

It is important to note that a leader must have legitimate power. “A mugger on the street may have a gun and power to threaten your life, but not qualify as a leader, because leading means influencing people to work willingly toward achieving your objectives. That is not to say that a little fear can’t be a good thing, at least occasionally” (Dessler, 2002, p. 212).

Box

12-4 Types Of Power Legitimate1. Reward2. Coercive3. Referent4. Expert5. Informational6. Persuasive7.

This is a critical concept to understand about leadership and power.

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However, it takes more than power to be an effective leader and manager. “If you have the traits and you have the power, then you have the potential to be a leader” (Dessler, 2002, p. 212). All organizations experience their own brand of “politics.” Some staff and managers find themselves maneuvering to acquire power within the organization. This is directly influenced by the goals that people feel are important to them. These goals may come in conflict with the goals of others, and when this happens, holding greater power may make a difference in who “wins.” Political power maneuvering can become unpleasant for staff and managers and can also damage the organization’s culture. Trust may decrease, along with effective communication, coordination, collaboration, and resolution of conflicts. This is not to say that all political power in the organization is negative, but it is a slippery slope and needs to be carefully observed. Part of this process is the need to identify where the power is coming from and to learn how to access the power to meet goals (Marrelli, 2004). As has been said, power can be used negatively, and this can also lead to the unethical use of power or not doing the right thing with the power. Chapter 2 discusses examples of ethical issues. There is no doubt that there are managers who use their power to control staff, as well as staff who use power to control other staff, but this is not a healthy use of power. Rather, it is a misuse of power and does not demonstrate nursing leadership. A self-appraisal of a person’s personal view of power allows the individual to better understand how the person uses power and how it then affects the person’s decisions and relationships. This can lead to more effective responses to change during planning and decision making, coping with conflict, and the ability to collaborate and coordinate. Empowerment Empowerment is often viewed as the sharing of power; however, it is more than this. “To empower is to enable to act” (Finkelman & Kenner, 2010, pp. 108). Power must be more than words, but rather it must be demonstrated. Participative decision making empowers staff, but only if

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staff really do have the opportunity to participate and influence decisions. Recognizing that one’s participation is accepted makes a difference. True empowerment gives the staff the right to choose how to address issues with the manager. Should all staff be empowered? A critical issue to answer this question is whether or not staff can handle decision making. This implies that staff members need leadership qualities and skills to make sound decisions and participate together collaboratively. They need to be able to use communication effectively. When staff members are selected, all these factors become important. Empowerment is not gained just by being a member of the staff, but rather staff members become empowered because they are able to handle it. Management that wants to empower staff must transfer power over to the staff, but management must first feel confident that staff can handle empowerment. When staff is empowered some limits or boundaries need to be set or conflict may develop. Some of these boundaries are established by the organization’s policies, procedures, and position descriptions, education and experience, and by laws and regulations (for example, nurse practice acts). The manager must be aware of these boundaries and establish any others that may be required (for example, direct involvement of staff in the selection process for new equipment). If staff members are involved in the decision making, then they should first be given a list of several possible equipment choices that meet the budgetary requirements from which to choose. It is critical that the manager make clear

the boundaries, or staff members will feel like their efforts are useless if their suggestions are rejected because they were not given the boundaries. What does this mean? Roles and responsibilities need to be clearly described, and if they change, they need to be discussed. At the same time

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the nurse manager or the team leader must not control, domineer, or overpower staff. This type of response is usually seen in new nurse managers or team leaders who feel insecure. Ineffective use of empowerment can be just as problematic as a lack of empowerment. Although empowering one’s self may seem like an unusual concept, it is an important one. The amount of power a person has in a relationship is determined by the degree to which someone else needs what the other person has. Anger is related to expectations that are not met, and when these expectations are not met, the person may act out to gain power. It is the responsibility of the nursing profession to communicate what nurses have to offer to patient care and to the health care delivery system, but individual nurses also need to understand what they have to offer as nurses. To have an impact this communication and development must be ongoing. Empowerment can be positive if the strategies that are used to gain empowerment are constructive (for example, gaining new skills, speaking out constructively, networking, using political advocacy, increasing involvement in planning and decision making, getting more nurses on key organization committees, improving image through a positive image campaign, and developing and implementing assertiveness skill). There are many other strategies that can result in empowerment that improves the workplace and the nurse’s self-perception.

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Aggressive and Passive-Aggressive Behavior

Aggressive and passive-aggressive behavior can interfere with successful conflict resolution and might even be the cause of conflict. When staff members are hostile to one another, the team leader, or the nurse manager, anxiety rises. Hostile behavior can be a response to conflict. It is important to recognize personal feelings. The first response should be to get under control and communicate control to the hostile staff member. The nurse manager or team leader may be the one who is hostile, which makes it even more complex and requires assistance from higher level management. Hopefully, someone will recognize the need to bring the situation under control and try to move to a private place. Demonstrations of open conflict with hostility should not take place in patient or public areas. If the suggestion to move to a private area does not work and the situation continues to escalate, simply walking away may help set some boundaries. Cool down time is definitely needed.

There are many times when more information is really required before a response can be given. If this is the case, everyone concerned needs to be told that when information is gathered the issue or problem will then be discussed. No one should be pressured to respond with inadequate information as this will lead to ineffective decision making and may lead to further hostility. It is critical that after further assessment is completed that there be additional discussion and a conclusion. “Unless the behavior of a difficult person is physically threatening, try ignoring it. Deal only with the heart of the matter. Focus your attention on the issue and work at refocusing your ‘opponent’s’ attention. Repeatedly use his or her name. State and restate the problem. Try to defuse emotion—yours first, because ultimately the only person you really control is yourself” (Forman, 2001, p. 13). These are methods that can help move a negative situation into a positive one.

When there are problems with patients and families, what is the best way to cope? Many of the same strategies mentioned earlier can be used. Safety is the first issue, as it must be maintained. It is never appropriate to allow patients or families to demonstrate anger inappropriately. When this occurs, someone needs to set

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reasonable limits that are based on an assessment of the situation. There may be many reasons for anger and inappropriate behavior, such as pain, medications, fear and anxiety, psychosis, dysfunctional communication, and so on. Staff needs to avoid taking things personally, as this will interfere with thoughtful problem solving. When one gets defensive or emotional, interventions taken to resolve a conflict may not be effective. Active listening is critical to cope with emotions. If a different culture is involved, then this factor needs

to be considered (for example, some cultures consider it appropriate to be very emotional and others do not). In the long term, clear communication is critical during the entire process.

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How Do Individual Staff Members Cope With Conflict?

Not everyone responds to conflict in the same way, and individuals may vary in how they respond dependent upon the circumstances. Four typical responses to conflict are avoidance, accommodation, competition, and collaboration (Boggs, 2003).

Avoidance occurs when a person is very uncomfortable and cannot cope with the anxiety effectively. This person will withdraw from the situation to avoid it. There are times when this may be the most effective response, particularly when the situation may lead to negative results, but in many situations this will not be effective in the long term. This response might occur when a staff member is in conflict with a manager and disagrees with the manager. The staff member must consider whether it is worth it to disagree publicly. Typically, avoidance occurs when one side is perceived as more powerful than the other. It is a helpful approach when more information is needed, or when the issue is not worth what might be lost. A second response is accommodation. How does this occur? The person tries to make the situation better by cooperating. The critical issue may not be resolved, or not be resolved to the fullest satisfaction. The goal is just to eliminate the conflict as quickly as possible. Accommodation works best when one person or team is less interested in the issue than the other. It can be advantageous as it does develop harmony, and it can provide power in future conflict since one party was more willing to let the conflict deflate. Later interaction may require that the other party cooperate. A third response is competition. How does this work? Power is used to stop the conflict. A manager might say, “This is the way it will be.” This closes further efforts from others who may be in conflict with the manager. Collaboration is the fourth response, which has been discussed in this chapter. This is a positive approach, with all parties attempting to reach an acceptable solution, and in the end both sides feel that they won something. Collaboration often involves some compromise, which is a method used to respond to conflict.

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Using the best conflict resolution style can make a difference in success. There are many ways that a conflict can be resolved. When conflict occurs each person involved has a personal perspective of the issue and conflict. Today there is more conflict in the health care delivery environment with increased workplace stress that may lead to misunderstandings, ineffective communication, and reduced productivity and dysfunctional organizations as noted in the Institute of Medicine reports (2001; 2004).

Gender Issues

Are there differences in the way that women and men negotiate? There are differences in how women and men approach leadership issues such as conflict (Caliper, 2004). Men tend to negotiate to win while women focus more on what is fair. It is believed that this is related to the way children play through sports and activities. Women will make an effort to reach win-win solutions. Men will test the limits that have been set more overtly than women, so it is important for women to ensure that limits are set and maintained. It is important, despite the differences described, to avoid stereotyping. (See Chapter 8 for additional gender differences.)

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Nurse–Physician Relationships

Though the nurse–physician relationship should be the strongest relationship that nurses have in order to meet the needs of the patient, it frequently is not. Both sides of the relationship play a role in the inadequacies of this relationship. Conflict does occur, and this conflict can act as a barrier to effective patient care. Literature about Magnet hospitals distinguishes between collegial and collaborative relationships and between nurses and physicians (Kramer & Schmalenberg, 2002). Collegial relationships are those where there is equality of power. This power is different but equal power and knowledge. In contrast,

collaborative relationships between nurses and physicians focus on mutual power, but the physician’s power is greater. The nurse’s power is based on the nurse’s extended time with patients, experience, and knowledge. In addition to power, this relationship requires respect and trust between the nurse and physician. Due to these factors, it is a complex relationship.

Nurses have long worked on teams, mostly with other nursing staff. However, the nurse–physician relationships have become more important in the changing health care environment with the greater emphasis on interprofessional teams. Nurse– physician interactions and communication have been discussed for a long time in health care literature.

A study that explored the impact of nurse–physician relationships on nurse satisfaction and retention, conducted by a physician, was reported in 2002 (Rosenstein, 2002). The results of the 1,200 nurses, physicians, and hospital executive survey “suggest that daily interactions between nurses and physicians strongly influence nurses’ morale (Rosenstein, 2002, p. 26). Overall, 96% of the nurses had witnessed or experienced disruptive physician behavior, including

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yelling or raising the voice, disrespect, condescension, berating colleagues, berating patients, and use of abusive language. The survey found 344 nurses who knew of other nurses who had left the hospital due to disruptive behavior. These nurses did not feel that the administration supported the resolution of conflict between nurses and physicians. This study recommended the following improvement strategies, which could apply to most health care organizations, which continue to be important strategies to improve the nurse–physician relationship.

Create more opportunities for collaboration and communication through open forums, group discussions, and collaborative relationships. Increase availability of training and educational programs for nurses and physicians that focus on improving teamwork and working relationships (for example, sensitivity training, assertiveness training, conflict management, time management, and phone etiquette, with emphasis on courtesy, respect, promptness, and preparation). Improve organizational processes by requiring administrators to take a more proactive approach to avoiding potential confrontations related to staffing, scheduling, and equipment. Establish a zero-tolerance policy for disruptive behavior, holding nurses and physicians more accountable for their actions. Disseminate code-of-conduct policies and reporting guidelines to both nurses and physicians, and apply policies consistently and quickly, providing feedback to all involved. Ensure appropriate nurse competencies. Have physicians sign a code-of-conduct policy when they are credentialed or re-credentialed. Appoint a physician leader who will take charge of training and education programs. Provide an ongoing forum to increase physician awareness of the issues addressed in this survey and raise awareness of other factors that increase nurses’ stress levels.

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Place physicians on nurse recruitment teams, enabling them to gain a better understanding and appreciation of the factors that are important to nurses as they consider employment opportunities. Provide a case study or conduct role-play exercises that allow physicians a firsthand understanding of nurses’ responsibilities and work flow (Rosenstein, 2002, pp. 32–33).

Other studies have examined work relationships and patient outcomes. Rosenstein and O’Daniel (2005) surveyed 1,500 nurses and physicians about the impact of disruptive behavior on job satisfaction and retention. Disruptive behavior included verbal abuse. In this study nurses were perceived as being disruptive as much as physicians. Nurses and physicians surveyed felt that disruptive behavior had a negative impact on stress levels, relationships, communication, collaboration, and transfer of information leading to problems with quality of care and patient satisfaction. Lower (2007) uses the following descriptors for disruptive behavior: verbal abuse, negative behavior, and physical abuse (e.g., profanity, innuendo, demeaning comments), reprimanding or insulting another in public, threatening, telling racial or ethnic jokes, undermining team cohesion, scapegoating, silence (not speaking to a team member), assaulting

another, throwing objects, and outbursts of rage. In a study of 20 medical and surgical residents nurse–physician relationships were reviewed from the perspective of relational coordination (Weinberg, Miner, & Rivlin, 2009), which is a theory that views high-quality relationships and communication among participants in the work process as important for effective outcomes (Gittell, 2001). The results of this qualitative study are disturbing though the study was small and had other limitations. Positive relationships depended on whether the resident viewed the nurse as cooperative and competent. Most communication was motivated by the need to tell the nurses something, not necessarily looking for professional

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feedback from the nurse. The physicians had limited knowledge of the various nursing degrees or which nurses had which degrees and also did not differentiate from RNs, LPNs, or unlicensed assistive personnel. Physicians, however, are not the only health care providers that nurses must work with while they provide care (for example, nurses work with other nursing staff, social workers, support staff, laboratory technicians, physical therapists, pharmacists, and many others). There are also other members joining the health care team such as alternative therapists (massage therapists, herbal therapists, acupuncturists, etc.), case managers, more actively involved insurers, and so forth. The future will probably bring other new members into the health care delivery system. Nurses need to develop the skills necessary to participate effectively on the team, which requires collaboration, communication, coordination, delegation, and negotiation. Communication and delegation are discussed in other chapters. It is difficult to practice today in any health care setting without experiencing interprofessional interactions such as nurse–physician. As teams work together, effective teams

Work together (collaborate). Recognize strengths and limitations. Respect individual responsibilities. Maintain open communication.

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Case Study A Verbal Explosion Leads to Confrontation of a Problem

As a nurse manager in a busy OR you have to ensure that all staff is collaborating and communicating well. In the last six months you have noticed more problems with poor communication between nurses and physicians, some of which have impacted the quality of care. Nurses are also frequently complaining that they are “second-class citizens” in the department. The number of last minute call-ins has increased by 25% over the last 6 months causing last minute staffing problems. Today was the last straw when a nurse and a surgical resident had a shouting match in the hallway. The nurse left the encounter crying, and the resident said he would not work with the nurse anymore. The nurse manager went into the OR medical director’s office. They have had a positive collaborative relationship over several years. She went in and said, “We have a problem!” As she described the problems, he said, “I was unaware there was so much tension and lack of collaboration. Why didn’t you tell me this earlier?”

Questions How would you respond to the medical director’s question?1. What do you and the medical director need to do?2. How can you avoid this being a “we–they” situation?3. How will you involve all staff?4. What can you do about the powerlessness the nurses feel?5.

Positive professional communication is critical. Both sides should initiate positive dialogue rather than adversarial positions. Cooperation and collaboration are also integral to the success of this relationship. A frequent question discussed in the literature is “Why is there conflict between nurses and physicians?” The structure

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of work is different for physicians and for nurses, and this has an impact on understanding, communicating, collaborating, and coordinating. This perspective identifies the key elements as sense of time, sense of resources, unit of analysis, sense of mastery, and type of rewards as described by the following.

The nurse is focused on shorter periods of time, and time is usually short, with frequent interruptions. The physician’s sense of time focuses on the course of illness. If a physician gives a stat order, the physician has problems understanding what might interfere with the nurse making this a priority. There is a lack of understanding of the nurse’s work structure. Physicians often are not concerned with resources, though this is certainly changing as physicians do recognize that there is a shortage of staff as well as issues about costs and reimbursement for care. They, however, may not be willing to accept these factors as relevant when their patients need something. There are, of course, other resources such as equipment availability, supplies, and funds that can cause problems and conflicts. Nurses are typically more aware of the effect that these factors have on daily care. Unit of analysis is another factor; for example, nurses are caring for groups of patients even though care is supposed to be individualized. Physicians may not have an understanding of this if they have only a few patients in the hospital. Physicians also do not have an understanding of nursing delivery models, and often nurses themselves are not clear about them. This affects nurses’ ability to explain how they work. The sense of reward is different. Nurses work in a task-oriented environment and typically get paid an hourly rate. Most physicians are not salaried and are independent practitioners though some are employees of the organization (hospital, clinic, and so on).

Conflict and verbal abuse are related. Verbal abuse occurs in health care settings between patients and staff, nurses and other nurses, physicians and nurses, and all other staff relationships. This abuse can consist of statements made directly to a

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staff member or about a staff member to others. A common complaint from nurses regards verbal abuse from physicians. “Some nurses, particularly new ones, allow physicians to verbally abuse them because they are insecure about their knowledge base” (Parks, 2001, p. 20MW). Verbal abuse affects turnover rates and contributes to the nursing shortage so it is has serious consequences. “Poor physician–nurse interaction also compromises patient care” (Stringer, 2001, p. 7).

How can this problem be improved? A critical step is to gain better understanding of each profession’s viewpoint and demonstrate less automatic acceptance of inappropriate behavior. This requires that management become proactive in eliminating negative communication and behavior. Some hospitals have tried a number of strategies to deal with verbal abuse. Some of these are (a) encouraging staff to report abuse by allowing anonymity, (b) using physician–nurse counseling teams to act as liaisons with employees, (c) encouraging staff to speak firmly and address abuse, and (d) introducing staff to new physicians and encouraging them to come for assistance (Stringer, 2001). The IOM recommends increased interprofessional approaches to care delivery and the need for increased interprofessional health professions education so that all health professions are prepared to work together on teams (2003). What can nurses do about this? One suggestion is to improve their own knowledge base and thus develop more self-confidence. “Remind yourself that you have many valuable skills, and you don’t deserve to be verbally abused. These efforts will help decrease the feelings of intimidation” (Parks, 2001, p. 20MW). Another problem is that nurses think they must resolve all problems and “make things” work correctly when this may not be realistic. The nurses then become scapegoats. Verbal abuse, no matter who is doing it, physician or nurse, should not be tolerated. Those involved need to be approached in private to identify the need for a change in behavior. Staff needs to be respected. The AONE Guiding Principles for Excellence in Nurse-Physician Relationships is found in Box 12-5 .

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Box

12-5 Aone Guiding Principles for Excellence in

Nurse–Physician Relationships

Introduction to the Guiding Principles Excellent working relationships between nurses and physicians are key to creating a productive, safe, and satisfying practice environment. The patient and the patient’s family benefit from care delivered by a team practicing within this environment.

Senior leadership in health care organizations must support the development of excellent relationships and, more importantly, create an environment that sustains and nurtures these critical relationships.

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Guiding Principles for Excellence in Nurse–

Physician Relationships Institutions that are committed to establishing and maintaining environments that promote excellence in the nurse–physician relationship adhere to the following principles.

Interprofessional collaborative relationships are promoted, nurtured, and sustained.

This requires that practitioners be proficient in communication skills, leadership skills, problem solving, conflict management, utilizing their emotional intelligence, and functioning within a team culture.

Excellence in relationship building begins with hiring, continues with learning and developing together, and is reinforced over time.

The organization has specific systems for reward, recognition, and celebration.

The organization supports the “Platinum Rule” with a specific Professional Code of Conduct that includes a system to support it. A “No Tolerance” standard exists for those unable to adhere to the Code.

The organization creates and supports a “Just & Fair” environment.6. The work of all professional caregivers is seen as interdependent and collegial.

Cross-discipline job discovery is supported and encouraged.8. Patient-focused care and better patient outcomes are the organizing force behind creating a collaborative environment.

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Implementation Guidelines Interprofessional collaborative relationships are promoted, nurtured, and sustained.

Nurses and physicians are given formal training in communication skills, leadership development, problem solving, conflict management, development of emotional intelligence, and team functions. Education and training is provided to nurse–physician teams and is not discipline specific.

Specific education is provided in team building.2. Organization-governing bodies and committees have representative members from all disciplines.

Nurse–physician leadership teams are identified to lead the work at the unit level (Microsystem Management).

All organizational task forces include representatives from those stakeholders closest to the issue.

Interprofessional collaborative relationships are assessed, unit-by-unit. Each unit has a development and improvement plan for continued growth of the relationship.

Teams develop common values for their interprofessional collaboration.

Teams develop common language for their interprofessional collaboration.

Nurse–physician collaborative champions are identified at the hospital and unit level.

Excellence in relationship building begins with hiring, continues with learning and developing together, and is reinforced over time together and is reinforced over time.

Nurses and physicians work collaboratively to identify the behaviors that they want in team members.

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Employees, both nurse and physician, are hired using behavioral interviewing to ascertain a good fit with the organization, teams, values, culture, and behavioral expectations.

Nurses and physicians do 360-degree performance reviews.3. Credentialing criteria includes behavioral attributes and expectations, as well as clinical skills.

The Graduate Medical Education competencies are used as hiring criteria and for performance review.

Education and team training is done in work teams, as described in the Institute of Medicine reports.

Personal accountability for demonstrating team behaviors is rewarded.

The organization has specific systems for reward, recognition, and celebration.

There is alignment of purpose among the disciplines regarding reward, recognition, and celebration.

Mechanisms for reward and recognition are easy to access.

Performance appraisal is linked to patient satisfaction measurements.

Awards, recognition, and celebration are public and visible and across disciplines and teams. Example: Physicians identify the Nurse of the Year; Nurses identify the Physician of the Year.

Rewards and Recognition programs promote team accomplishments.

The organization supports the “Platinum Rule” with a specific Professional

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Code of Conduct that includes a system to support it. A “No Tolerance” standard exists for those unable to adhere to the Code.

The Golden Rule states: “Do unto others as you would have them do unto you.” The Platinum Rule states: “Do unto others as they would have you do for/unto them.” Thus, this principle speaks to treating others as they want to be treated, not necessarily how you would want to be treated.

Code of Conduct Guidelines/Policies exists for all professionals that outline behavioral expectations.

Work improvement plans and measures hold the team accountable, not just individual.

Individual professional codes of ethics/conduct are known and honored.

Contacts and processes/procedures for the impaired professional are easily accessible to all staff.

There are identified coaches and mentors for the professionals on site in the hospital to help with performance issues.

All professionals receive team training that focuses on communication skills and processes.

Processes exist to identify and address conflict situations before they become a crisis and/or deteriorate.

The organization creates and supports a “Just & Fair” environment.

There is a systems approach to management and decision making.1. Internal trends and reporting processes are multidisciplinary.2. Language for reporting and safety is analyzed to assure that it is “Just & Fair.”

Processes exist for multidisciplinary critical incident debriefing.4. Decision-making tools are used that support the “Just & Fair” processes, such as the “Just Model.”

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The processes outlined in the patient-safety literature that creates cultures of safety are used as blue prints for culture changes.

Remedial training is offered when needed.7.

The work of all professional caregivers is seen as interdependent and collegial.

The culture of team includes all disciplines providing care on a unit.1. Behavioral expectations are defined for all disciplines.2.

Cross-discipline job discovery is supported and encouraged.

All disciplines are educated in the role/responsibility of their colleagues.

Opportunities for shadowing different professions are encouraged.2.

Patient-focused care and better patient outcomes are the organizing force behind creating a collaborative environment.

Work is directed toward identifying and measuring those outcomes that are sensitive to the function of collaboration.

Patients and families are appointed to internal committees.2. Patient-centeredness is a key focus for processes.3.

Source: American Organization of Nurse Executives. Guiding Principles for

Excellence in Nurse-Physician Relationships. Chicago, IL: Author. Reprinted with

permission.

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Application of Negotiation to Conflict Resolution

Negotiation is the critical element in making conflict a nightmare or an opportunity. Negotiation can be used to resolve a conflict, and some types of negotiation, such as mediation, can be very structured. When two or more people or organizations disagree or have opposing views about a problem or solution, a conflict exists. To resolve the conflict, the involved people need to discuss resolution in a manner that is acceptable to all of those involved. Although it does not have to

take long, in some cases it may be very long, such as what might occur in a union– employer negotiation for a contract. Conflict resolution includes the use of a variety of skills and strategies. Key skills and strategies are communication, listening, and respecting different points-of-view. Four needs are clarification, performance, questioning, and expectations (Marrelli, 2004). As the process begins it is important to clarify all of the issues and parties who are involved in the conflict. Performance or potential outcomes should be established early in the process. Questioning is important throughout resolution. For example, it is important to ask about behaviors that started the conflict and how to avoid them in the future. Management needs to be clear about expectations and provide these in writing, which helps to decrease conflict over critical issues.

What strategies might be used to resolve specific conflicts?

Help involved parties settle their differences themselves whenever possible rather than stepping in and taking over. Maintain an objective approach. Communicate trust to the staff members and communicate that it is believed that they can resolve problems.

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Avoid criticizing or denying feelings. Use a problem-solving approach. Provide privacy for sensitive discussions. Identify staff members who chronically complain and work with them to adapt their behavior as this behavior can increase the risk of conflict and interfere with resolving it when it does occur. Listen with understanding rather than judgment. This is important throughout the resolution process and can also assist with prevention of conflict. Provide opportunities for all staff members to improve their problem-solving and communication skills (Marrell, 2004).

Since conflict is inevitable, all staff nurses will encounter it. Knowing how to manage conflict will be of great benefit to the individual nurse as well as improve the working environment and ability to better reach patient outcomes.

Why is negotiation identified as a critical skill for nurses in the health care environment? Patients should not become part of staff or organizational conflicts, and there is risk that this may occur. These conflicts need to be resolved or patient care may suffer negative consequences. Consider these examples:

The interprofessional team cannot agree on a treatment approach and must do this by the end of the team meeting. A patient’s insurer refuses to allow the patient to stay two more days in the hospital. As the hospital’s nurse case manager you must work with the insurer representative to reach a compromise. Staffing in a hospital is being reduced, and the nurses are convinced that the new staffing level will be unsafe for patients. Something must be done to resolve this issue. A home health care agency has learned that the Medicare contract has decided that specific patients will receive fewer visits.

How can these examples be resolved satisfactorily so that the quality of care does

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not suffer? Finding a mentor to discuss the process as well as vent feelings may be very helpful. Developing negotiation skills makes conflicts easier to handle and less stressful. Nurses who become involved in unions will find that negotiation skills are also very important. If negotiation is not used effectively, all of these conflict examples can lead to major problems for the patient and/or staff.

When approaching conflict resolution, it is important to recognize that both sides contributed to the conflict. One side cannot have a conflict by itself; it takes at least two. Consider how each side has contributed to the conflict. Another critical issue is to carefully consider if this is the time and place to address the conflict. When the environment is too emotional, conflict resolution will be difficult. Stepping back or taking a break may be the best position to take. The following are strategies that can be used to effectively negotiate.

Negotiate for agreements—not winning or losing. Clearly state that your desire is to find a solution and to work together. Separate people from positions. Establish mutual trust and respect. Avoid one-sided or personal gains. Allow time for expressing the interests of each side/party. Listen actively during the process, and acknowledge what is being said; avoid defending or explaining yourself. Use data/evidence to strengthen your position. Focus on patient care interests. Always remember that the process is a problem-solving one, and the benefit is for the patient and family. Clearly identify the priority and arrive at common goal(s). Avoid using pressure.

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Identify and understand the real reasons underlying the problem. Be knowledgeable about organizational policies, procedures, systems, standards, and the law, applying this knowledge as needed. Try to understand the other side, and ask questions and seek clarification when unsure or uncertain; understanding the other side first before explaining yours increases effectiveness. Avoid emotional outbursts and overreacting if the other party exhibits such behavior; depersonalize the conflict. Avoid premature judgments, blame, and inflammatory comments. Be concrete and flexible when presenting your position. Be reasonable and fair (Gebelein et al., 2000).

Mediation There are some conflicts that will require a third-party negotiator to reach a more effective resolution. This is needed when there is no opportunity for cooperative problem solving and objectivity is required. “Mediation is a form of dispute resolution that has been used in many cultures throughout history…. Mediation is a problem-solving process in which a neutral third party (who has no stake in the outcome of the process) helps people who have a disagreement or dispute reach a mutually satisfactory resolution.” (Gebelein, p. 56, 2000). Mediators are facilitators, not decision makers (as in the case of arbitrators). In mediation, the people with the dispute have an opportunity to tell their story and to be understood, as well as to listen to and understand the story of the other party. A key factor in mediation is the need for all parties to willingly participate in the process. The mediator guides the process and discussion. Certain guidelines are established for the discussion that all parties must follow throughout the process (for example, allowing each party time to speak and complete a statement without interruption, calling for a break when needed, enforcing time limited meetings, substantiating comments with facts, and so on). With these guidelines and the presence of a mediator, this type of negotiation can result in positive outcomes. It provides protection for both sides.

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Applying Leadership and Management

My Hospital Unit When you arrive at work today you are confronted with staff members that are upset that work is not being done effectively, particularly with other departments. Successful coordination requires identification of barriers and strategies to resolve barriers to coordination. Coordination also requires collaboration. Identify the barriers to effective coordination and collaboration. Clearly describe them. Then consider what strategies could be used to prevent the barriers or to decrease the barriers on your unit. Your strategies need to be applicable to your unit as you have designed it. Use the virtual unit site found on the textbook website to record the work that you do as the role of nurse manager for your unit.

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Critical Thinking Questions and Activities

What do nurses in practice think? Select one of the following issues to discuss with RNs. Students should not all choose the same questions so that when data are discussed there will be different issues described. (1) Is collaboration with other health care professionals part of your practice? If so, describe some examples. If not, why do you think collaboration does not exist? (2) How is coordination used in your practice? (3) How might you and others where you work improve coordination? (4) Describe your worst experience with conflict at work and how it was resolved or not resolved. (5) What were the long-term consequences of conflict? (6) Do you feel empowered at work? Why or why not? How do you think the situation could be improved?

The examples of strategies to improve nurse–physician relationships are broad. What do you think about them? Divide into teams and have each team take one of the strategies. Discuss the advantages and disadvantages of the strategy. How would you respond to the strategy? Have you experienced or observed any abusive behavior among staff or with you? Do you think one of these strategies might prevent this type of behavior? Each team should explore the strategy. How would it work? Would it be offensive to staff (nurses or physicians)? It is important to look at both sides, nurses’ and physicians’.

Conflict is complex and yet there are guidelines for understanding it. Select an example of a conflict, which can be one you experienced or observed. Describe the conflict, identify the type of conflict, and explain your rationale for selecting the type. Apply the four stages of conflict described in the chapter to your example. What resulted from the conflict?

Visit the website http://www.mapnp.org/library/grp_skll/grp_dec /grp_dec.htm and read about decision making and teams. How might you use this information?

Visit the website http://www.livestrong.com/article/14683-handling-5.

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conflict/and learn more about handling conflicts. How might you use this information? Visit the website http://www.cnr.berkeley.edu/ucce50/ag-labor/7labor/ 13.htm and explore conflict management skills. How might you use this information?

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Media Links

URL: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ ANAPeriodicals/OJIN/TableofContents/Volume102005/No1Jan05/ tpc26_416011.aspx Nurse–physician collaboration URL: http://www.accel-team.com/ Team Building: Tools for building strong teams, plus useful links and articles URL: http://www.au.af.mil/au/awc/awcgate/ndu/strat-ldr-dm/pt3ch10.html Strategic Leadership and Decision Making: Read about how to create and manage teams URL: http://www.ihi.org Institute for Health Improvement: Teams

URL: http://teamstepps.ahrq.gov/ Agency for Healthcare Research and Quality: TeamSTEPPS URL: http://www.mindtools.com/pages/article/newLDR_81.htm MindTools: Conflict Resolution URL: http://www.mindtools.com/pages/article/newTMM_53.htm MindTools: How to Be a Good Team Player URL: www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/ CommunicationCollaborativeSurveyPhysicianAttitudes.htm Institute for Health Improvement Communication/Collaboration Survey

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Pearson Nursing Student Resources

Find additional review materials at nursing.pearsonhighered.com

Prepare for success with additional NCLEX -style practice questions,

interactive assignments and activities, Web links, animations and videos, and more!

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References

American Nurses Association. (ANA). (2003). Nursing’s social policy statement. (2nd ed.). Silver Springs, MD: Author. American Nurses Association. (ANA). (2004). Nursing: scope and standards of practice. Silver Springs, MD: Author. American Nurses Association. (ANA). (2009). Nursing administration scope and standards of practice. Silver Springs, MD: Author. American Association of Critical-Care Nurses. (2005). AACN standards for establishing and sustaining healthy work environments. Aliso Viejo, CA: Author. Boggs, K. (2003). Resolving conflict between nurse and client. In E. Arnold & K. Boggs (Eds.), Interpersonal relationships: Professional communication skills for nurses (4th ed., pp. 368–388). Philadelphia: W.B. Saunders Company. Caliper. (2005). The qualities that distinguish women leaders. Princeton, NJ: Author. Clement, J. (2001). The leadership imperative: Managing conflict and resolving disputes creatively. Seminars for Nurse Managers, 9(4), 211–217. Cody, W. (2001). Interdisciplinarity and nursing: “Everything is everything,” or is it? Nursing Science Quarterly, 14(4), 274–280. Dechairo-Marino, A., Jordan-Marsh, M., Traiger, G., & Saulo, M. (2001). Nurse/physician collaboration. Journal of Nursing Administration, 31(5), 223–232. Dessler, G. (2002). Management: Leading people and organizations in the 21st century. Upper Saddle River, NJ: Prentice Hall. Disch, J. (2001). Strengthening nursing and interdisciplinary collaboration. Journal of Professional Nursing, 17(6), 275. Finkelman, A. & Kenner, C. (2010). Professional nursing concepts. Competencies for quality leadership. Boston: Jones and Bartlett Publishers. Forman, H. (2001). Difficult people? What’s the problem? Nursing Spectrum

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Metro Edition, August, 12–13. Gebelein, S., et al. (2000). Successful manager’s handbook. Minneapolis, MN: Personnel Decisions International Corporation. Gittell, J. (2001). Supervisory span, relational coordination, and flight departure performance: A reassessment of postbureaucracy theory. Organizational Science, 12(4), 468–483. Hansten, R. & Jackson, M. (2008). Know how to resolve conflict: Getting coworkers to work together as a team. In R. Hansten & M. Jackson (Eds.) Clinical delegation skills (pp. 255–284). Boston: Jones and Bartlett Publishers. Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academies Press. Institute of Medicine. (2003a). Priority areas for national action. Washington, DC: National Academies Press. Institute of Medicine. (2003b). Health professions education. Washington, DC: National Academies Press. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press. Kramer, M., & Schmalenberg, C. (2002). Staff nurses identify essentials of magnetism. In M. McClure & A. Hinshaw (Eds.), Magnet hospitals revisited. Attraction and retention of professional nurses (pp. 25–59). Washington, DC: American Nurses Publishing, Inc. Marquis, B. & Huston, C. (2009). Leadership roles and management functions in nursing. Philadelphia: Lippincott Williams & Wilkins. Lower, J. (September 2007). Creating a culture of civility in the workplace. American Nurse Today, 2(9), 49–52. Marrelli, T. (2004). The nurse manager’s survival guide. St. Louis, MO: Mosby-Year Book, Inc. Parks, S. (2001, August). Silence verbal abuse. Nursing Spectrum Metro Edition, 20MW–21MW. Puetz, B., & Shinn, L. (2002). Strategic partnerships. Journal of Nursing Administration, 32(4), 182–184.

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Rosenstein, A. (2002). Nurse–physician relationships: Impact on nurse satisfaction and retention. American Journal of Nursing, 102(6), 26–34. Rosenstein, A. H., & O’Daniel, M. (2005). Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing, 105, 1, 54–64. Salmon, M. (2007). Guest editorial: Care quality and safety: Same old. Nursing Outlook, 55(3), 117–119. Stringer, H. (2001). Raging bullies. Nursing Week, 1(2), 6–7. Tahan, J. (2001). A story from the bedside: The primary nurse as an integral health care team member. Seminars for Nurse Managers, 9(2), 68–72. Weaver, D. (2001). Transdisciplinary teams: Very important leadership stuff. Seminars for Nurse Managers, 9(2), 79–84. Weinburg, D., Miner, D., & Rivlin, L. (2009). ‘It Depends’: Medical residents’ perspectives on working with nurses. AJN, 109(7), 34–43. Wyatt, D. (2000). Negotiation savvy: Level the playing field by understanding sex differences. Dimensions of Critical Care Nursing, 19(1), 43–45.

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