Managing Conflict in a Nurse Leader Role

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The following course content

Introduction

Every organization will experience some degree of conflict at one time or another; healthcare is no exception. Uniquely, conflict can create serious issues regarding care delivery, patient safety, and patient outcomes. Other end results include cost impacts related to staff turnover in an already understaffed industry, regulatory fines, and even law suits due to errors; more serious results include psychological impacts on staff members. Characteristics, leadership styles, and the ability to handle conflict are vital to those fulfilling a nurse leader role. This educational course will help you to identify conflict, the components of conflict, reasons for conflict in healthcare as well as management strategies. Conflict management is not just the responsibility of one in a nurse leader role, but that of all team members, especially the registered nurse. "Conflict management helps foster stronger relationships horizontally between employees and vertically between employees and management by increasing awareness and understanding of different points of view and educating staff about how to avoid conflict in the first place" (1). 

Conflict 

Conflict is defined as an internal discord resulting from differences in ideas, values, or feelings between two or more parties. Evoking feelings of hostility, anxiety, and stress can be extremely disruptive to a unit or department's functioning. Another definition includes a disagreement through which the parties involved perceive a threat to their needs, interests, or concerns. Workplace conflicts in the healthcare environment tend to be far more complicated because they often involve ongoing, complex relationships that are based on emotion (1). 

Stages

Conflict has different stages, and for those fulfilling a nurse leader role, it is useful to become aware of these so you can develop stage-appropriate interventions. The stages of conflict include: 

• Latent: At this point, the participants are not even aware of the conflict. Differences exist; perhaps, something has happened. 
• Perceived: The participants have become aware of the conflict. 
• Felt: The stress and anxiety of the conflict are being felt. 
• Manifest: The conflict is open and observable. 
• Aftermath: The result of the conflict, which can be either negative or positive (2).  

The earlier the conflict is identified, the less time it may remain open. Preserving the safe and efficient functionality of the unit or department is one reason why early management is important.

Types

Healthcare and nursing present a unique environment, which can lead to different types of conflict. We all bring our values, ideas, thoughts, and education to this work environment.  The types of conflict most identified within the healthcare environment includes a nurse-to-nurse, nurse-to-outside departments, physician-to-nurse, and generational differences. Let’s break these down.  

Nurse-to-Nurse Conflict (Horizontal)

Nurses often work closely with other teams where there are different values, opinions, and ages; the environment can be emotionally charged. Oftentimes, conflict resolution skills are not taught in school. The conflict can be staff nurse-to-staff nurse or staff nurse-to-nurse leader. 

 Nurse-to-Outside Department (Interdisciplinary)

The nurse is often the leader of the interdisciplinary team. Again, this is an area where there is little if any conflict training. Each department tends to be loyal and supportive of their department when there is conflict. This type of conflict often is between the physician and nurse.   

Generational Differences

Unprecedented, the nursing workforce currently spans five different generations, each with different characteristics and work ethics. The different generations are described as follows: 

• Silent Generation: Born between 1922 – 1946. They are known as traditionalists.  Characteristics include respect for authority, hardworking, and sacrifice for work. This generation values loyalty and may delay retirement (3). 
• Baby Boomers: Born between 1947 – 1964. Characteristics include a belief that workers need to pay their dues. Oftentimes, the generation includes workaholics with traditional learning styles; rewards are expected for hard work (3). 
• Generation X: Born between 1965 – 1977. Characteristics include independence, self-reliance, and skepticism of authority. This generation tends to work better with flexibility (3). 
• Millennials (or Generation Y): Born between 1978 – 1991. Characteristics include team-oriented, technological, entrepreneurial, and the need for quick feedback. This generation wants to be coached and mentored (3).  
• Generation Z born after 1991. Although there is a lot we do not know yet about this generation, some of their characteristics include tech-savviness, being a self-starter, and pragmatic (3).  

Most of you are familiar with the phrase, "nurses eat their young." This is not a new concept, and despite the valiant efforts of organizations, this type of conflict has persisted. Usually, horizontal, nurse-to-nurse bullying with the older generations makes the new generations feel unwelcome, incapable, and unwilling to help when asked (4). However, it is important to note that the opposite is also a workplace issue. Younger, newer nurses are perceived as faster, able to utilize technology at lightning speed, and can cope better with variable shifts than older nurses. This gives the newer nurse a perceived power gradient over the older nurse and can be used as a form of bullying (4). 

Leadership 

Qualities 

Leadership requires many qualities; this should begin with relational intelligence.  Relational intelligence revolves around the idea of how you positively navigate through relationships with others. For one fulfilling a nurse leader role, this skill is absolutely necessary for your team’s success (5). Although nurse leaders are looked to when there is conflict, it is not solely their responsibility to resolve it, but that of all team members (5).  

Other qualities needed include integrity, critical thinking, communication, dedication, self-awareness, and professionalism. There is not an adequate or inadequate strategy to deal with conflict. However, early detection of conflict and adoption of the most effective conflict resolution behavior is essential in organizations as soon as possible (6). How these qualities are learned is an important issue. Many nurse leaders have little training to prepare them for the responsibility of conflict resolution. However, unresolved or unmanaged conflict may end with work disruption, poor work performance, tardiness, absenteeism, low staff morale, low staff productivity, increased psychological distress, and burnout (6). It can affect the productivity of the organization. 

Another important quality to develop at all levels of nursing especially for those in a nurse leader role is communication skills; including both how the message is sent, and how the message is received. Listening skills is a vital aspect of nursing and oftentimes, we are moving at a fast pace and already thinking about an answer before the person finishes speaking; with that being said, misunderstandings are easy to cause but not always so easy to fix.  

For nurse leaders, it is important to recognize and engage in managing conflict. Many times, there are barriers, including time constraints, fear of retaliation, and fear of exclusion. Of course, no one wants conflict, and sometimes this results in an attempt to soothe and prematurely place a solution. Those in the nurse leader role must learn how to positively engage in conflict resolution and stay engaged to promote collaboration and effective care. Being successful includes dialogue, coaching, the identification of the potential conflict, education, and training. 

Styles 

Leadership styles are the set of management thoughts and behaviors related to your personality, communication preferences, strengths, weaknesses, and values (7). Styles can develop over time or be influenced by the organization. The most common styles leadership styles are (7):  

• Democratic: The democratic style is team-oriented and involves openness in conversations and management. Although the leader has the final say, the opinions of others are valued; this style tends to be successful. 
• Autocratic: The autocratic style is the opposite of the democratic style; where the leader has their way and does not consider or consult team members. This style does not tend to be successful.   
• Transformational: The transformational style has defined goals, a clear direction, and looks at the big picture. Those in the leadership role share their vision with staff and thinks outside the traditional path; this style tends to be successful. 
• Coaching: The coaching style is similar to the transformational style and involves mentoring to bring the team closer. Having the nurse leader walk the direct care nurse through a variety of conversations to resolve a dispute or disagreement provides the opportunity for alternative solutions to be considered; this also tends to be a successful style.  
• Lassiez-Faire: The lassiez-faire style is casual and laid back; meaning there is little leadership. In fact, authority is turned over to the staff. Generally, this style does not want to deal with conflict and is not successful.  
• Situational: The situational style is used when instant change is needed for safety or regulatory reasons. Often the style is used to respond to an event and is not always accepted by staff. 

While developing a style, it is important to allow for the expression of multiple viewpoints and how to build better relationships (8). The absentee leader does little to communicate, mentor, and plan. The incompetent leader has little involvement in planning and faces serious moral issues. If the environment is not maintained and cohesive, job satisfaction and performance can be impacted negatively.   

Regulatory Issues and Conflict 

In 2008, The Joint Commission released a sentinel event alert addressing disruptive behaviors and provided recommendations as to how organizations should address their relational issues and conflicts. The defined behaviors recognized more of the physician-to-nurse issues, but placed all disruptive behavior on its radar. Identified behaviors included: verbal outbursts, physical threats, uncooperative attitudes, and cooperation refusal (i.e. not taking pages or answering calls). Other behaviors include condescending language and refusing to complete tasks (9). Disruptive behaviors often go unreported, and therefore unaddressed for several reasons. Whether that is fear of retaliation and the stigma associated with "blowing the whistle" on a colleague, or a general reluctance to confront an intimidator, it all contributes to underreporting of intimidating and/or disruptive behavior (9). Part of the sentinel event has given guidance on what defines behaviors and required resolutions. Organizations are required within this mandate to develop a specific ‘Code of Conduct’ that outlines acceptable and disruptive behaviors as well as the processes managing these behaviors. Additionally, organizations are to develop policies and procedures that clearly state zero tolerance and provide training and education; this includes physicians.    

Regarding nurse-to-nurse (horizontal) disruptive behavior, the American Nurses Association (ANA) Code of Ethics for Nurses includes interpretive statements outlining that nurses are required to "create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect," (10). Similarly, nurses must be afforded the same level of respect and dignity as others; thus, the nursing profession should no longer tolerate violence of any kind from any source. As someone who is fulfilling a nurse leader role, it is essential that you refer to the ANA Code of Ethics for Nurses when managing conflict within the workplace.  

Nurse Leader Role: Conflict Strategy 

As one involved in a nurse leader role, in order to effectively eliminate or manage conflict, it cannot be ignored. Engagement must be an ongoing process. To be successful, one must learn to not only engage in conflict, but remain engaged to promote collaboration and effective care coordination (11). The earlier conflict is identified, the better, as dysfunctional patterns can take place and can potentially define the culture of the department.   

Common Strategies (11):

• Safe Space: It is important that staff feel they are meeting in a safe space, and that there is privacy and support. 
• Coaching: Coaching can be in either group or individual settings. Coaching sessions are confidential (unless otherwise agreed upon), must follow a consistent format, and include a written summary of the session. 
• Facilitation: There is usually a defined agenda. You will need someone neutral who can see past the fireworks or walls of silence and assist the group with arriving at the core problems or issues. 
• Dialogue: The importance is to have a discussion that addresses the issue and clears the air; avoid saying “always” and “never.” Nursing leaders and direct care nurses need to engage in dialogues that address conflict and conflict management behavior as a first step in creating a healthy work environment (1).  
• Collaborative: Collaborative works with the group problem solving together.  
• Storytelling: Storytelling works with traditional stories that are told to help move from personal experiences to broader, helping to negotiate group conflict.  
• Mediation: Can be formal or informal. 
• Education and training: Nurses need to be educated on conflict and conflict management strategies that address and effectively resolve conflict. Learning conflict management strategies empowers nurses to resolve conflict early and influence the work environment in which they deliver patient care. "The training should not be limited to the handling of interpersonal conflicts; it should include all types of conflict commonly encountered in the healthcare setting. Additionally, individuals who have a propensity for managing conflict well should be identified and developed” (1). Education and training should also include communication skills.  

"Leaders can change the climate in the workplace and promote better collaboration among workers by interrupting a group's dysfunctional behavior patterns," (12). Adding the skills of self-awareness and emotional skills helps to bring a team together. Relational ethics emphasizes the importance of mutually respectful relationships. People work to improve their awareness of how their choices and actions help shape their conversations and social interactions. The relational approach addresses conflict as it unfolds – just as a relationship evolves and unfolds over time. It incorporates the essential qualities that form the core of human relationships. It is hard to imagine an approach to conflict that excludes consideration of integrity, respect, identity, compassion, humility, shame, trust, fear, hope, pride, acceptance. Love, joy, and other human dynamics are at the heart of most conflicts (12). 

Emotional and social intelligence are defined as "skills that enable an individual to understand the impact of emotions on behavior and thinking, to regulate emotions and behavior, to understand the importance of emotions in others, and to understand social interactions and engage in adaptive ways with others in social situations," (12).  

An Example of Failed Conflict Management from a Nurse Leader Role 

This story is based on a true example experienced by the author; names and locations have been changed. 

Looking back to the 1980s, the nursing profession was struggling with shortages and how to produce more nurses quickly. During this time, the entry-level for nursing was either a three-year hospital diploma program or a BSN. Many times, nurses were made managers without experience. In a small California Neonatal Intensive Care Unit (NICU) in the mid-1980s, this unit called ‘neonatal’ was staffed by only nurses. The original manager was a diploma graduate who had newborn experience for many years, but not in the NICU specialty; however, she was beloved. Over the next two years, there were four different managers who did not work out. To be honest, the staff did not want it to work out but were weary and wanted some leadership.  The next nurse manager, Mary, was a BSN graduate with little NICU experience and no management experience; she immediately made several changes that completely divided the staff. During this time, one staff nurse, Jane, was undergoing some extreme personal issues.  She and Jane absolutely did not get along. Jane had been a nurse in this unit for over ten years and was an excellent clinician, but she had become a nightmare to work with. She was mean to her colleagues and had become a bully. Additionally, she would never help others, except for the few in her circle.  

Human Resources offered no help.  

The morale was dismal, and staff began to leave. During this time, to the horror of the staff, Jane committed suicide. The note she left cited personal issues, but also included the horrible work relationship she had with Mary as part of her reason. Staff felt responsible and guilty; they completely divided, making work a nightmare. Few resources were given to help with the situation, and many staff members left within the year; perhaps, an experienced manager may have been able to diffuse the situation differently.  

This is an extreme example but one that illustrates what can happen without leadership at both the unit and senior management level. In situations of conflict, the most powerful weapon we have is control over our own behavior.  If there is a single contributory factor that reduces and eliminates negative conflict, it is trust. Our ability to trust each other greatly impacts our working lives, family interactions, and achievement of personal and organizational goals. To create trust, it is necessary to avoid aggressive behaviors and at the same time develop supportive behaviors where people are respected for what they are or what they believe in and are treated equally without bias or prejudice. If a conflict develops at any level, it should be resolved with mutual benefit in mind (12).   

Conclusion 

Those with a nurse leader role have large responsibilities. They need to understand the definitions of conflict and how to manage it as soon as possible. They need to acknowledge the responsibilities of conflict resolution. Part of this responsibility is understanding the type of conflict, leadership qualities and styles, regulatory issues, and the ramifications of poor management. These ramifications can result in serious medical errors, patient safety concerns, poor patient outcomes, and psychological manifestations for staff.  

Not every nurse is a leader, but part of their role should understand conflict and conflict management. "Nursing professionals must use constructive conflict management approaches rather than destructive conflict management approaches when dealing with conflict situations. It is necessary to avoid aggressive behaviors and at the same time develop supportive behaviors where people are respected for what they are or what they believe in and are treated equally without bias or prejudice," (14). 

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