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Journal of Nursing

Conflict Resolution
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by Antonie Hiemer MS RN

Tags: conflict resolution, tools, nursing, RN

Abstract
The nursing profession is one that is based on collaborative relationships with both colleagues and
patients. It requires individuals to work closely with others with varying backgrounds or cultures.
Individuals can hold diverse values, potentially affecting these relationships, which may result in
conflict. Good communication or conflict resolution skills can decrease the risk of conflict.
Conflict Resolution - Tools for Nursing Success
Introduction
Conflict is neither good, nor bad, it just is, (Marshall, 2006). It can occur at anytime and in any
place, originating between two individuals or groups when there is a disagreement or difference in
their values, attitudes, needs, or expectations (Conerly, 2004), miscommunication or lack of
information (Marshall, 2006). Over time individuals learn how to respond to conflict, making it an
unconscious process. Dealing with conflict properly requires the individual to develop conflict
resolution skills. This is a conscious effort to control the individuals behavior of poor communication
(Conerly, 2004).
Nurse-Patient Relationship
A therapeutic nurse-patient relationship is the foundation of nursing care. It contributes to both the
patients well-being and their health. Conflict can impede these collaborative relationships by not
allowing the nurse to fully support the patient in attaining his or her health goals (CNO, 2006). It
requires individuals to work closely with others who have varying backgrounds or cultures and, hold
diverse values that can potentially result in conflict. Good communication or conflict resolution skills
can decrease the risk of conflict.

Evolving Roles of the Nurse

Healthcare organizations are dramatically changing the way they operate due to initiatives to
increase productivity and the quality of services provided. These initiatives are forcing hospitals to
break down traditional hierarchal structures and move toward a team-managed environment. As a
result, nurses no longer function on nursing units in a typical subordinate role, but are finding
themselves in new roles. Nurses are participating members of a multidisciplinary team improving the
overall delivery of care (Baker, 1995).
Diversity can Lead to Conflict
Cultural diversity, combined with the stress of providing quality care, often results in conflict (Pettrey,
2003). According to the New York State Nurses Association (2005), unresolved conflict leads to
barriers for employees, teams, organizational growth, and productivity, which results in a cultural
breakdown within the organization. Conflict is a natural phenomenon (Kelly, 2006), and an inevitable
aspect of life (Kemp-Longmore, 2000). It is a disagreement between individuals who perceive a
threat to their needs, interests, and or concerns (Kelly, 2006). Improperly managed conflict can result
in the nurses inability to provide quality care, and can escalate into violence or abuse (CNO, 2006).
The Importance of Conflict Resolution
In general, nurses have difficulty in dealing with conflict in an open manner and avoid conflict,
harboring emotions that the conflict creates leading them to act out in covert ways. Nurses need to
achieve effective team building skills within nursing groups in order to deliver quality and productivity
required for the organizational structure. The decisions nurses make in team-managed environments
are more superior to decisions made in a hierarchal environment in terms of both quality and cost
effectiveness. Nurses must possess effective conflict resolution skills to be able to function
successfully in the evolving healthcare system (Baker, 1995).
The process of conflict resolution is an opportunity for growth and change in a work environment,
with great potential for a positive outcome. On an individual level, conflict resolution is important for
personal achievement. On an organizational level it is important for the bottom line and overall
success (Kemp-Longmore, 2000). Proper conflict management results not only in successful conflict
resolution, but also contributes to higher effectiveness, trust, and openness (Kelly, 2006).
Research has concluded that styles of conflict resolution are strong predictors of the level of morale,
burnout and job satisfaction of the nursing profession. The use of negative coping mechanisms,
such as confrontation and avoidance styles, result in increased negative outcomes, increased
burnout and occupational stress (Montoro-Rodriquez & Small, 2006). The use of avoidance as a
conflict resolution method results in ineffective and unproductive outcomes, since it only postpones
the conflict. By avoiding the conflict, individuals are neglecting their own needs, goals, and concerns,
while trying to satisfy those of others. This approach has an element of being self-sacrificing and
simply obeying orders or serving other people (Kelly, 2006).

Responses to Conflict
Individuals respond in five distinct ways to conflict. These include avoidance, competition,

accommodation, compromise, and collaboration (Marshall, 2006). Avoidance is the most overused
technique as a conflict resolution method by nurses (Baker, 1995). It results in not addressing the
conflict (lose-lose situation). Competition results in pursuing ones own goals at the expense of
another (win-lose situation). This may be appropriate when a quick or unpopular decision has to be
made. Accommodation results in meeting the goals of the other person (lose-win situation). This may
be appropriate when the issue or goal is more important than winning, the other individual is more
powerful, or when an individual is wrong. Compromise combines assertiveness and cooperation
(lose-lose situation). This may be effective when individuals are of equal power and an expedient
answer is needed. A match between the action and the nature of the conflict will most likely result in
a resolution with desirable outcomes. Collaboration results in finding a mutual agreeable solution
(win-win situation) (Leddy & Pepper, 1998).
Collaboration
Collaboration is the most desirable approach in resolving a conflict. It is an assertive and cooperative
approach that allows individuals to be creative and find a solution that satisfies all concerns and
goals to be achieved (Baker, 1995; Leddy& Pepper, 1998; Kelly, 2006). Collaboration is viewed as
the opposite of avoidance and competition. The goal is for both parties to win. The problem-solving
process continues until each individual is satisfied with the resolution. Although this process is
growth producing, it takes a considerable amount of time (Leddy & Pepper, 1998).
Game theory
According to Team Technology (2005), based on the game theory (see responses to conflict
diagram), most people are trying to receive or achieve a payoff or benefit in a conflict situation. The
payoff is called a win, and not getting a payoff is called a loss. These can range from the individual
being able to gain a sense of achievement from completing a worthwhile and quality job or obtaining
financial reward, or making a profit for the company. Other wins include getting the job done as
quickly as possible in order to go somewhere, having a feeling of self-esteem or self-worth, and
being recognized for ones efforts (Team Technology, 2005).
Responses to conflict
I dont win
I win
You win
Submission
Acquiescence
Collaboration
Assertiveness
You dont win
Withdrawal
Blocking/Sabotage
Aggression
Dominance
Adapted from Conflict resolution in the workplace, by Team Technology, 1995, retrieved from
www.teamtechnolgy.co.uk/conflictresolution.html
Effective communication

Nurses can prevent or manage conflict by improving their communication skills. It is important for the
nurse to try to understand the other party. The nurse can then focus on being understood. Typically
in conversation an individual is already trying to think of a response to give to a person instead of
just listening to what is being said (Marshall, 2006). Effective communication occurs only when the
message received is interpreted in the way it was intended (Piotrowski, 2005). Individuals must
actively listen to each other and, maintain appropriate eye contact without looking down. The nurse
needs to be aware of body language and tone, thus avoiding a mismatch of styles (quiet vs.
boisterous personalities). The individual needs to ask for clarification by asking open-ended
questions and not assuming what is being said. Paraphrasing is a good technique to be sure you
have understand the message. Most importantly the nurse must listen, and not interrupt the other
individual, for good communication to occur.

Nurses as Facilitators of Conflict Resolution

Nurses need to become proactive and learn how to effectively communicate with their patients, the
patients families and friends, as well as their colleagues (Pettrey, 2003). Good communication skills
(see effective communication table) allow the nurse to resolve his or her own conflicts or facilitate
conflict resolution between other individuals. As a facilitator, the nurse must protect each persons
self respect by focusing on the issue(s), and not the personality of the party involved. It is also
important not to blame the participants for the problem. This hinders open and complete discussion
of the issue. Encouraging discussion of both positive and negative feelings will increase the chances
of both parties expressing all of their concerns. Fostering active listening and understanding
enhances this. The facilitator must allow for equal time for all parties to participate expressing their
opinions. The nurse must summarize key themes in the discussion and assist in developing
alternative solutions to the issue. At a later date or time the facilitator must follow up on the progress
of the conflict resolution and give positive feedback to both parties related to the use of problem
solving skills (Leddy & Pepper, 1998).
Case Study
It has been an accepted practice at nurse Susies* healthcare organization to keep the narcotic
cupboard, syringe drawers, medication fridge, and medication cart unlocked during a nurses shift
and during shift change. So, imagine nurse Susies surprise when without warning nurse Betty
locked the narcotic cupboard, syringe drawers, medication fridge, and the medication cart. Nurse
Susie had learned to respond to conflict with retaliation, resulting in her deciding to act out her
frustration in covert ways. She decided to not only report to work late whenever she would receive
keys and report from nurse Betty, but also preceded to unlock and count everything in an
exaggerated slow manner.
It quickly became apparent to nurse Betty that nurse Susies attitude toward her had changed. Nurse
Susie decided to utilize her good communication skills, to resolve the possible conflict between
them. Nurse Susie told nurse Betty that since nurse Susie was locking everything on purpose, she
was retaliating and reporting late, unlocking and counting slow on purpose. The policy at nurse
Susies healthcare organization is that everything is to be locked when not in use; it had been
accepted practice to not lock anything. After a State inspection by the Commissioner, a citation was
issued for failure to comply with the policy.
Nurse Betty had decided to break the social norm and follow the policy, to prevent another possible
citation. She did not communicate her change in routine, because she thought that it was an obvious
response to the citation. Since she did not communicate this to her colleagues, she was perceived

as having locked everything on purpose, in retaliation for some unknown cause. By clarifying, and
asking open-ended questions nurse Betty was able to resolve the conflict between herself and nurse
Susie.
* names have been altered to protect the nurses identity

Conclusion
Nurses need to remember that the foundation of nursing care is the therapeutic nurse-patient
relationship, which contributes to the patients well-being and health. This therapeutic relationship is
threatened whenever there is conflict, either with the patient, the patients family, the patients
friends, or colleagues. It hinders communication, collaboration, and teamwork. Nurses need to
remember that they share the responsibility with their employers to create a healthy workplace
environment, ensuring that conflict does not negatively affect the patients health outcomes or the
relationships among colleagues (CNO, 2006). By becoming more accountable, nurses are able to
decrease, if not eliminate conflict in their organization by utilizing good communication skills and
assisting in facilitating conflict resolution between individuals.

Effective communication skills - DOs

DO maintain appropriate eye contact
Be aware of your own body language and tone
DO ask for clarification
DO ask open-ended questions
Paraphrase at the appropriate time
DO listen
Effective communication skills - DONTs
Do NOT look down
Do NOT mismatch your style
Do NOT assume
Do NOT interrupt

References

Baker, K. M. (1995). Improving staff nurse conflict resolution skills. Nursing Economic$, 13(5), 295317.
College of Nurses of Ontario. (2006). Conflict prevention and standard of care. Practice guideline, 116.
Conerly, K. (2004, Summer). What is your conflict style? Understanding and dealing with your
conflict style. Journal for Quality and Participation. Retrieved on October 18, 2007 from
www.findarticles.com/p/articles/mi_qa3616/is_200407/ai_n9425833/print
Kelly, J. (2006). An overview of conflict. Dimensions of Critical Care Nursing, 25(1), 22-28.
Kemp-Longmore, C. (2000). Conflict resolution in the workplace. The Black Collegian, 131-3.
Lancaster, J. (1999). Nursing issues in leading and managing change. New York: Mosby.
Leddy, S., & Pepper, J. M. (1998). Conceptual base of professional nursing (4th ed.). New York:
Lippincott.
Marcus, L. J., & Roover, J. E. (n.d.). Healing the conflict that divide us. Retrieved on January 18,
2007, from www.hcna.net
Marshall, P. (2006, May). Conflict resolution: what nurses need to know. Retrieved October 18, 2007
from www.mediatecalm.ca/pdfs/what%20nurse%20need%20to%20know.pdf
Montoro-Rodriquez, J., & Small, J. A. (2006, June). The role of conflict resolution styles on nursing
staff morale, burnout, and job satisfaction in long-term care. Journal of Aging and Health, 18(3), 385406.
NYSNA (2005). NYSNA position statements. Retrieved on January 18, 2007, from www.nysna.org
Pettrey, L. (2003). Who let the dogs out? Managing conflict with courage and skill. Critical Care
Nurse, 21-4.
Piotrowski, M. B. (2005, January/February). Are you listening? Tips on improving your
communication skills. Biomedical Instrumentation & Technology, 1-2.
Robin, D. (2004). A better workplace. Retrieved on January 18, 2007, from
www.abetterworkplace.com
Shortell, S. M., & Kaluzny, A. D. (2006). Health care management organization design and behavior
(5th ed.). New York: Thompson Delmar Learning.
Staneart, D. (2001). Workplace conflict resolution and anger management skills. Retrieved on
January 18, 2007, from www.leaderinstitute.com
Team Technology (1995). Conflict resolution in the workplace. Retrieved on October 18, 2007, from
www.teamtechnolgy.co.uk/conflictresolution.html
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American nurses association

Carefronting: An innovative approach to managing conflict

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Publication Date: October 2012 Vol. 7 No. 10

Author: Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Nick Chase is an emergency department (ED) charge nurse. He and Michelle Stanley have
worked together for the past 3 years. Their relationship has always been what Nick
describes as very rocky. Nick was given the charge nurse role 1 year ago with only 2
years of nursing experience. Although Michelle isnt interested in being in charge, she has
complained to others about Nicks lack of experience and immaturity. At times, Michelle
demonstrates bullying behaviors toward Nick and continually questions leadership
decisions that he makes while in his charge nurse role. Clinically, she is a very good nurse.
Nick relies on her expertise to care for very acutely ill ED patients. He had hoped that over
time he would gain Michelles confidence and respect but this hasnt happened. When Nick
and Michelle are scheduled to work shifts together, the atmosphere on the ED team is
tense. Nick has hesitated to discuss the situation with his nurse manager. He has felt that
as a leader, he should be able to manage the conflict and establish a better working
relationship with Michelle.

The dilemma that Nick is confronted with in the scenario above isnt uncommon. One of the
most significant challenges that nurses face in their work is the management of conflict. In
todays environment, nursing teams are composed of staff from different backgrounds with
divergent values, attitudes, and beliefs. These differences can and do lead to conflict. If not
managed well, conflict can become a patient-safety issue in healthcare environments.

Carefronting is an important competency for nurses that can help them to resolve conflict
and create healthier work environments.

Carefronting versus conflict management

The term carefronting was coined by David Augsburger, a professor of pastoral care, more
than 3 decades ago. Dr. Augsburger believes that conflict is to be expected. Its the way that
its managed that affects relationships. Too often in conflict management, situations become
confrontational. Respect and concern for the individuals involved arent considered, and
participants in conflict feel personally violated.
Carefronting takes a different approach to managing conflict. In carefronting, the overall
goal is to attain and maintain effective, productive working relationships. Carefronting is a
method of communication that entails caring enough about ones self, ones goals, and
others to confront conflict courageously in a self-asserting, responsible manner.

Principles of carefronting
Betty Kupperschmidt, an associate professor of nursing at the University of Oklahoma
Health Sciences Center, has been a pioneer in bringing the concept of carefronting to

nursing practice. In her work, she describes seven basic tenets of carefronting. We will use
Nicks situation in his conflict with Michelle to provide an illustration of how these tenets can
be applied in the practice setting.

1. Truthing itA simplified speech style

Identifying truths from different viewpoints is important if conflict is to be managed

sensitively. When truthing it, Nick would need to demonstrate the willingness and ability to
listen to Michelles viewpoints with empathy and a desire to understand. This will take
courage and humility. Some of what he will hear may be hurtful. He needs to listen carefully,
so he hears accurately what Michelle tells him. Its also important that Nick is honest about
his own feelings and attitudes. Michelles bullying and lack of confidence in his leadership
have been stressful and are affecting staff teamwork. Throughout the discussion, Nicks
behavior needs to demonstrate that he cares about their relationship.
2. Owning angerLet both your faces show

Nick undoubtedly feels some anger toward Michelle for her unwillingness to accept him in
the leadership role. Michelle may feel angry about Nicks selection for the position and lack
of experience. Anger is a natural part of conflict. When acknowledged in a constructive way,
it can be a positive and self-affirming emotion. When one feels ignored or rejected, the
normal response is anger. Nick would want to let Michelle know that the situation has been
upsetting to him. Letting Michelle know this will make her more aware that Nick is a person
of worth and should be respected. Nick and Michelle both have to accept responsibility for
choosing how they have responded and reacted to one another during the conflict.
3. Inviting changeCareful confrontation

A key principle in carefronting is that those in the conflict are invited to participate in
changing the situational dynamic. Nick would invite Michelle to participate in changes that
could improve their relationship but he would not demand it. When leaders like Nick invite
change, they need to focus on the behaviors that they would like to see changed. This
should be presented based on observations, not conclusions. Nick needs to be specific in
his descriptions so they dont appear judgmental. Ideas for change should be presented for
discussion in a way that encourages the discussion of alternatives. Nick would want to
avoid statements such as, You need to improve your attitude. Change should be invited by
carefronting in a caring manner, one that is clear but gentle and constructive.
4. Giving trustA two-way venture

Trust is the foundation of effective relationships. High trust environments correlate positively
with high degrees of staff engagement, commitment, and organizational success. Trust is
essential in work relationships but can quickly erode in conflict situations. As a leader, Nick
needs to learn to confront situations openly, frankly, and responsibly. He should approach
this and other conflicts with the viewpoint that the other person will assume his or her
responsibility to be equally honest and frank. Although he may not feel a great deal of trust
in Michelle at this point, he will need to work hard to build a trusting relationship.
5. Ending blameForget whose fault the conflict is

Assigning blame in a conflict inevitably evokes resistance and resentment. Carefronting

ends the blame game. To move forward in conflict, Nick will need to put aside any feelings
that Michelle is responsible for the conflict. By ending the blame game, he can then talk with
Michelle and ask the following questions:

What is the respectful thing to do now?

Where do we go from here?

When do we start to discuss the conflictIf not now, when?

Who will end the blame and help work toward the professional practice environment
we all deserve?

6. Getting unstuckThe freedom to change

Getting unstuck means owning the responsibility for ones role in the conflict. It also involves
refusing to waste time assigning blame. Nick and Michelle have worked with each other for
3 years. Their conflict has a long and rocky history. The freedom for both of them to change
will only come if they are able to get unstuck from past behaviors and feelings. A release
from this toxic situation, and all of the negative feelings involved, could be quite liberating
for Nick and Michelle.
7. PeacemakingGetting together again

Nurse leaders who are peacemakers are caring people who take the risk to be present in
conflict no matter how difficult. This wont be an easy role for Nick to assume but its
important that he works to be a peacemaker in this conflict. To do this, he will need to value
Michelle and at the same time understand his own values. Conflict usually involves some
compromise. There are always multiple viewpoints in every conflict that need to be
appreciated.

Why carefronting matters

The use of carefronting is especially important in healthcare settings where team synergy
and interdependence are required for high quality and safe patient care. Relationships on
healthcare teams live within the contexts of conversations that team members have, or
dont have with one another. For Nick to create the type of teamwork that is needed in the
ED, he needs Michelle to support his leadership and open better lines of communication.
Will carefronting work in every situation? Probably not, but its worth trying. When it works, it
can lead to remarkable changes in relationships, which ultimately impact the quality of
patient care.
Rose O. Sherman is an associate professor of nursing and director of the Nursing
Leadership Institute at the Christine E. Lynn College of Nursing at Florida Atlantic
University in Boca Raton, Florida. You can read her blog
atwww.emergingrnleader.com.
Selected references
Augsburger D. Caring Enough To Confront. Ventura, CA: Regal Publications; 2008.

Kupperschmidt B. Addressing multigenerational conflict: mutual respect and carefronting as

a strategy. Online Journal of Issues in Nursing. 2006.
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/T
ableofContents/Volume112006/No2May06/tpc30_316075.aspx. Accessed September 6,
2012.
Kupperschmidt B. Carefronting: caring enough to confront. A reprint. The Oklahoma Nurs.
2006;51(2):22-23.
Kupperschmidt B. Conflicts at work? Try carefronting. J Christian Nurs. 2008;25(1):10, 17.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2793934/dealing With Conflict

All too often, people avoid dealing with conflict. If you are just starting oncology practice, you
may feel especially hesitant to confront conflicts. Exposing yourself as the one rocking the boat
is a little scary when you're first starting out, comments a young oncologist who has been in
practice just over a year, who asked not to have his name appear in this article. You feel you
don't have the authority. But it's just frustrating when everyone has just adapted to an
inappropriate situation and doesn't do anything about it. Indeed, the young oncologist's
sensitivity about having his name used is a further example of how issues related to conflict are
particularly difficult for those fresh out of fellowship.
Although confrontation is especially hard for those who are just starting out, or those who are not
in positions of authority, avoiding it is a common human trait. People are fearful of conflict,
explains California-based consultant Stanley Wachs, PhD, who has specialized in conflict
resolution for more than 25 years. We avoid confronting other people about difficult issues
because we have three or four basic fears.
Wachs describes the fears of confronting others as follows:

We're afraid confronting them will make the situation worsethat it will
become an angry or tearful discussion.

We're afraid confrontation will hurt the relationshipwe'll lose a friend or we

will not be liked by an associate.

We're concerned that we're not so clean ourselves. Because we have our own
faults, we fear the other party will attack us and switch the topic to our own
failingsWho are you to raise this with me?

We fear retribution in some wayIf I confront this the powers that be will
come down on me.

As discussed here, conflict is not simply disagreement, which can be a healthy and effective
characteristic of work groups. Disagreeingthe expression of differing opinions in open
discussionis not laden with negative emotions like those that accompany conflict. Indeed,
honest disagreement is often intellectually stimulating, and in effective work groups it is
encouraged.
Conflict, in contrast, is associated with negative emotions such as resentment, anger, impatience,
and bitterness. You may feel a conflict over a situation without expressing disagreement, and, in
fact, the other person may not even be aware of the conflict. Once you recognize that you have
an emotionally negative feeling about a situation, the road to resolving it is confronting the other
person, and that's the challenge.
Wachs notes, My clients always refer to the work I do as conflict resolution.' But I like to think
of it as knowing how to have discussions about difficult issues. This is easy to say, but how do
you do it?
Go to:

Steps for Confronting a Difficult Issue

Wachs teaches skills that are learnable and practicable to help people confront difficult issues.
Using these skills does not eliminate the fear of confrontation, he says, but people can learn the
skills to manage their own emotions, their own vulnerabilities. Having such a skill set can help
people stop avoiding confrontationand start those discussions that they need to. For
physicians, he draws a comparison to the skills learned during residency and fellowship training.
Physicians do things now that once frightened them, because they learned and practiced the
skills.
Wachs was asked to explain how he would advise confronting this real-life situation described by
an oncologist we'll call Susan:

At the weekly tumor board held at a community hospital, one particular pathologist is
chronically ill prepared. He's been there a long time and is basically not doing his job. He is
supposed to familiarize himself with the cases beforehand, but makes no effort whatsoever. He's
not helpful to the basic goals of a workable conference. When guest speakers attend, it's
embarrassing and affects our current initiative to develop an ongoing relationship with regional
specialists.
In confronting this issue, Susan has completed the first stepassessing the situation. These are
the subsequent steps Wachs advises to deal with this conflict:
1. Susan should make an appointment to meet privately with the pathologist. In
this face-to-face meeting, she should look him in the eye and say, I need to
talk with you about a difficult issue. Then she should pause briefly.
Wachs points out that these initial words are important. She is not saying
she wants to chat' with him; she is not saying he is a difficult person, or
suggesting that he is slacking off because he is near retirement; she is not
saying she is angry. She is simply saying she needs to talk with him about a
difficult issue.
2. After this initial statement, Susan should say what she sees. This step
includes stating in a factual way what she has observed. For example, You
come to the tumor board without having reviewed the specimens, and you
have been unprepared to discuss the cases. This is hurting our ability to
network with outside experts. Susan should again pause briefly after this
statement. Wachs notes that it's important to be forthright in describing both
the behavior and the impact of the behavior. Don't be judgmental or offer an
opinion about why he didn't come prepared. State your observations but do
assign motivations to the behavior you have observed.
3. The next step is for Susan to acknowledge her role in the situation or her
reservations about the topic. For example, I didn't bring this up before
because I thought the situation would change, or I held back from speaking
to you sooner because I was new to the hospital.
4. An optional step at this point is for Susan to state the good intentions of the
pathologist. For example, she might say, I know you want to contribute to
the reputation of the hospital within the region, or You are known for your
contributions to good patient care. If, however, Susan's honest view is that

the pathologist really doesn't care, or she can't make a positive statement in
good faith, she should skip this step.
5. Next, Susan should ask the pathologist for his thoughts. How do you see it?
or Do you see the situation differently? Wachs stresses that at this point it's
essential to be genuinely prepared to listen and understand the other's point
of view. She must not debate or argue, but hear his side fully, without
interrupting him. She must listen deeply and curiously, abandoning control
about how she sees it. He may be angry with her for bringing it up. He may
say he hasn't been well. He may say he's withdrawn because he's tired of
dealing with a bunch of incompetents. Susan doesn't know what he will say
and must not try to control it. Her job is to hear his emotions and his passions
as well as the content.
6. After the pathologist has stated his perspective, Susan should summarize
what she has heard and compare their two views of his behavior at the
cancer conferences.
7. Finally, Susan should ask the pathologist what it would take for him to
participate more fully at the tumor board. She should explore with him what
needs to change or what he needs in order to come to the meeting prepared.
Susan should work with him to create solutions that will address his needs
and her concerns.

The skills for confronting difficult situations like this can be learned, Wachs states.
Harvey Bichkoff, MPH, CEO of California Cancer Care, a 10-physician group in Northern
California, agrees. Bichkoff's group worked with Wachs in 2007 to develop conflict resolution
skills at the group's annual retreat. We learned a set of skills to deal with conflict, he says. On
the second day, after role playing and practice, we participated in a very constructive exercise of
confronting one another.
Bichkoff, who has been with California Cancer Care for 13 years, encourages those who report
to him to work out conflicts directly with each other. They're the ones who are going to have the
working relationship. The group's retreat on conflict resolution reinforced that approach, he
says. The take-home message is that confronting conflict is healthy. Dealing with it makes for
better relationships in the long run.
Go to:

Choose Words Carefully

The children's chant, Sticks and stones may break my bones, but words will never hurt me, is
far from the truth. A biting criticism or personal attack can stay vivid in one's memory for years.
In addressing a difficult issue, words take on special importance. Avoid making generalized or
absolute statements, such as You never finish your charts on time or This behavior is
destroying the office morale. Avoid the use of superlatives such as worst, most, or highest.
Instead, use moderating terms such as sometimes, often, a few times, and possibly.
Use of the word but is also a red flag in conflicts. For instance, telling your boss I really like
working here but I feel the call schedule should be changed is likely to elicit a defensive
response. Replace the word but with and by saying something like I really like working
here and hope the call schedule can be revised in some ways. Using and instead of but can
open the way to a constructive discussion and resolution without raising the other party's
defensiveness.
Be especially wary of labeling people, even in your private thoughts. It's common to categorize
or label certain people whom we consider difficult: Mariella is a whiner; Johnson's just dead
weight; Connelly's a real blowhard. Such labeling is a way we work to classify and organize
information, including people, but it can set up negative expectations and generalizations that
can be counterproductive. Work at broadening your own views of others to see them as a whole
person, not as an embodiment of a specific irritating behavior.
Go to:

Mediating Conflict Between Others

Whether in a private practice or a teaching environment, you may be called on to help others
resolve conflicts between them. Avoid the temptation to take responsibility for resolving the
conflict; as a mediator, your role is to help the parties in conflict explore acceptable options and
develop agreement. Even if one of the parties is a difficult personality whom you yourself have
had problems with, as a mediator you must demonstrate objectivity and fairness, giving the
parties equal time and attention, and sufficient time to express themselves.
Establish a Win-Win Approach to Resolution

Define your mediator role as one of supporting winning for both parties. A key to success is for
each individual to change from thinking of the other as an adversary to considering him or her a

partner in reaching a solution. When both people win, both are committed to the solution because
it actually suits them.
Model Good Conflict Management Behaviors

Remain neutral and be an active listener. Focus your full attention on the individual speaking.
Don't allow distractions or interruptions. Show that you are taking the situation seriously and are
committed to the problem-solving process.
Create a Constructive Foundation

Create an environment in which people feel safe to open up. Use caring language. Actively
discourage judgments about who is right and who is wrong. If necessary, set ground rules that
prohibit behavior such as put-downs, blaming, threats, bringing up the past, or getting even.
Let Your Communication Skills Help the Process

Slow down the conversation when needed. Keep your voice low and modulated, and use a
relaxed body language. For instance, folding your arms can be off-putting.
Define the Issue in Neutral Terms

Take personalities out of the definition of the problem. For example, state the problem in
objective terms, such as determining an equitable holiday call schedule rather than deciding if
Brent or Marsha should have a 3-day holiday. Be prepared to revise the statement of the issue as
your understanding of the conflict evolves. Be objective and resist advising. Your role is to steer
the process, not the content.
Help the Parties Communicate Clearly

Use open-ended questions such as By difficult you mean and Help me to understand what
you mean by . Be aware of nonverbal cues and point out the triggers that are escalating
emotion or being used to avoid discussing the issue. For example, if someone points a finger or
rolls his or her eyes, calmly mention this behavior and explain that such body language is
counterproductive.
Identify Underlying Needs

Invite both parties to state their impression of the problem at hand. Find out what matters to
them. Ask thoughtful questions about what they want and what is important to them. Focus on
the why, not the what. An individual's position is usually based on a deeper interest or need,

so listen carefully to explore the hidden or underlying assumptions of each party. The better you
understand why something matters to individuals, the better you will be able to explore options
that will satisfy their real interests.
Probe Feelings

If they do not express their feelings, solicit the information: How did that affect you? or How
did you feel about that? Assess nonverbal cues as well as what is actually articulated.
Collect Information

In addition to finding out about the individuals' needs and concerns, obtain background
information. Be sure the facts are all out in the open. Ask questions about details that haven't
been expressed: How much will it cost? What happens when the informed consent is not
signed? How often does this happen? If someone makes a general statement such as I
thought it was out of line, ask for specifics about to what aspects he or she objects.
Check Understanding

Paraphrase what you hear the parties saying, and at various points ask each to state what he or
she heard the other one say. Sometimes individuals are surprised when they hear their
perspective articulated by someone else.
Engage Them in Problem Solving

Invite the parties to suggest ways to reach agreement. Ask them to list their choices and the
consequences of each.
Add Objectivity

Focus on the issue, not on personalities. Reinterpret an attack on a person to focus it on the issue.
This will help individuals not to be defensive. Where possible, turn to outside sources for
guidance or data. Using objective resources can also sometimes make it possible for individuals
to back down without feeling humiliated, by justifying a change in their opinion or their position
because of new information.
Reach Consensus

Identify the solutions that seem to have the greatest potential to address the interests of all
parties. Lay out the solutions for discussion, watching for cues from all parties about which

options are most appealing. The parties must believe the agreement is fair and recognize that
they have gained something.
Go to:

Take Steps to Resolve Conflict

Returning to our example at the beginning, what if you are that oncologist who has been with the
group just 6 months, and the promised health care coverage has not come through? You've
followed up with the office manager several times already, but you are afraid to confront the
group president about it. You have several fears about talking to him. Maybe the partners aren't
really happy with your work. Also, he's very aloof and a little brusque, and you've always felt ill
at ease around him. Finally, he might think all you care about is your compensation package
instead of focusing on the patients.
Presented with this scenario, Wachs goes right to the protocol outlined for starting a difficult
discussion. It's the same approach whether you are equals or not, he says. You start the
discussionI need to talk to you about a difficult issue.' You admit your reservations and
explain why you are doing it anyway: I hesitated to bring this up because I felt it was just a
paperwork problem and I felt anxious about bringing a trivial thing to your attention. I'm
mentioning it now because I feel the lack of insurance is putting my family at risk.' You state the
facts and ask how he sees it.
Wachs admits that it really takes courage to confront difficult issues. We do feel vulnerable and
anxious about conflict. But we have to find the compelling reason within ourselves to do it
anyway, despite the fear. We say to ourselves, I'm finding the alternative so unbearable, or so
inappropriate, I don't want to live like this.' It's really about affirming ourselves as people.
Using I Messages
Use I messages when you talk to someone about a problem. I messages state a problem
without blaming someone for it. This makes it easier for the other person to help solve the
problem without having to admit that he or she was wrong. For example, say, I felt my
suggestions were brushed off rather than You didn't even listen to what I had to say.
You messages suggest blame and encourage the recipient to argue. Responses to a you
statement such as No, I didn't, or Well, you were way off-base are likely to escalate emotions
and are not conducive to resolving the situation.

Using I messages takes practiceit's a skill that has to be learned. Use of I statements
doesn't come naturally, because we aren't used to talking about our feelings. In addition, it's a
normal response to see a conflict as the fault of the other person. Thus, expressing the problem in
terms of a you message just feels more natural, because it's more consistent
with our perspective about the problem.
But it's worth the effort to change our language. Using I messages not only diminishes the
negative responses of the other person, it helps reframe the way we think about the conflict
ourselves, thereby increasing the likelihood that a resolution can be found.
More Strategies for Career Success!
Deciding About Practice OptionsJuly 2006, page 187
The Interview: Make It Work for YouSeptember 2006, page 152
Employment Contracts: What to Look forNovember 2006, page 308
Joining a Practice As a ShareholderJanuary 2007, page 41
Principles and Tactics of NegotiationMarch 2007, page 102
Professional Advisors: They're Worth ItMay 2007, page 162
Building and Maintaining a Referral BaseJuly 2007, page 227
Malpractice Insurance: What You Need to KnowSeptember 2007, page 274
Develop Effective Communication SkillsNovember 2007, page 314
Go to:

Additional Resources
1. Wachs Stanley R.: Wachs Associates (www.wachs.com): wachs@wachs.com
2. Weeks D: The Eight Essential Steps to Conflict Resolution: Preserving
Relationships at Work, at Home, and in the Community. New York, NY,
Tarcher/Putnam, 1994

3. Dana D: Managing Differences: How to Build Better Relationships at Work and

Home, (ed 4), Mission, KS, MTI Publications, 2005
4. Lancaster LC, Stillman D: When Generations Collide: Who They Are. Why They
Clash. How to Solve the Generational Puzzle at Work. New York, NY,
HarperCollins Publishers, 2003

Source: http://www.nursingcenter.com/journalarticle?
Article_ID=593915

NursingCenter
AACN Advanced Critical Care
June 2004, Volume :15 Number 2, page 182- 195
Join NursingCenterto get uninterrupted access to this Article

Keywords
conflict, healthy work environments, mediation, working relationships

Authors

Gerardi, Debra RN, MPH, JD

Abstract
Healthcare organizations must find ways for managing conflict and developing effective working
relationships to create healthy work environments. The effects of unresolved conflict on clinical
outcomes, staff retention, and the financial health of the organization lead to many unnecessary
costs that divert resources from clinical care. The complexity of delivering critical care services
makes conflict resolution difficult. Developing collaborative working relationships helps to manage
conflict in complex environments. Working relationships are based on the ability to deal with
differences. Dealing with differences requires skill development and techniques for balancing
interests and communicating effectively. Techniques used by mediators are effective for resolving
disputes and developing working relationships. With practice, these techniques are easily
transferable to the clinical setting. Listening for understanding, reframing, elevating the definition of
the problem, and forming clear agreements can foster working relationships, decrease the level of
conflict, and create healthy work environments that benefit patients and professionals.

Article Content
As care of critically ill patients has advanced over the past few decades, there has been a
tremendous evolution in the development of technology, advances in less invasive therapies,
miraculous drugs for fighting infections and enabling organ transplantation, and an increased
knowledge of physiology and genetics. The growth in the scientific aspects of care has enabled
patients to receive treatment with fewer complications and better outcomes. The dramatic advances
have changed the system of care delivery and will continue to expand the options for critically ill and
injured patients. Unfortunately, healthcare organizations have not evolved as quickly as clinical
advances, and the environment of care has evolved into a difficult and complex setting filled with
poor communication, unclear policies, role confusion, turf battles, and stressful interpersonal
conflicts. 1

Creating a healthy work environment is as important, and perhaps more important, as mastering the
newest technology. The challenge of how to develop solid working relationships in a complex and
hectic clinical setting is the next step in the evolution of healthcare delivery. To address this
challenge, it is beneficial to understand the costs of conflict, the effects of organizational complexity,
the barriers to managing conflict, and techniques for effective resolution of disputes. Integrating
collaborative conflict management strategies into the daily activities of clinical care can improve

patient outcomes, improve retention of nursing staff, and create an environment that optimizes
scientific advances through enhancement of effective working relationships. 2 Incorporating the skills
and techniques used by mediators can facilitate collaborative working relationships and create
healthy work environments. This article provides an overview of factors impacting management of
clinical conflicts and an introduction to techniques used by mediators to resolve conflicts, foster
collaboration, and prevent dispute escalation.

Costs and Consequences of Conflict

The consequences of unresolved conflict are serious and greatly impact retention of qualified staff,
clinical outcomes of patients, the satisfaction of patients and their families, and an organization's
financial success. 2-4 The direct and indirect costs of ongoing conflict organizationally include:
diversion of resources to litigation, workman's compensation and disability claims; employee
grievances, increased turnover, decreased morale, clinical errors, diversion of management time,
unwelcome publicity, and disruption of professional relationships. 5-7Table 1 outlines several of the
direct and indirect costs associated with organizational conflict.

Costs of Unmanaged Conflict

Patients and their families are often aware of the level of teamwork and collaboration within a unit
and are dependent upon the ability of the nursing staff to respond to their concerns. 4 Energy that is
put into managing a dysfunctional environment is energy that is unavailable for addressing the
concerns and needs of patients and families. 5 Clinically, outcomes are directly affected by the extent
of collaboration and coordination of care. 8-10 Coordinating care of critically ill patients requires clear
communication and effective teamwork. The culture of the unit impacts the effectiveness of the team.
Units in which staff members accept poor communication as status quo expose patients to errors
and bad outcomes. 11 A negative culture that perpetuates a "blame and shame" response to
adverse events further contributes to an unsafe care environment. 12 Additionally, once a negative
culture develops, recruitment and retention of qualified nurses becomes difficult. 1,2 Loss of
experienced staff contributes to the stress and unit dysfunction.

Barriers to Managing Conflict

Due to the unique culture of healthcare delivery, there are many barriers that prevent effective
resolution of disputes. These barriers include: time constraints, inadequate access to information,
poor communication structures, unclear roles, conflicting policies, diversity of education/experience
of clinicians, power imbalances, practice variations, high stakes, emotionally charged situations, and
fatigue. 13-16 Additionally, competing clinical and operational priorities prevent consistent focus on
the management and prevention of conflict situations. 15 For many nurses and physicians, there is
little training or skill development in negotiation, listening, communication, or conflict
resolution. 13,14 With limited training and with little priority placed on the importance of developing
collaborative working relationships, there are few mentors or role models for modeling effective skills
and techniques. 13,14There may be an expectation of collaboration and team-work, but there is
rarely a clear definition of collaboration, and perceptions vary across clinical
disciplines. 2,17,18 Feedback within hierarchical organizations as to appropriate communication and
professional interactions is skewed. 19Additionally, nurses have a tendency to avoid addressing
conflict directly. 20 With organizational barriers, skill-based deficiencies, few role-models,
inconsistent feedback, and avoidant behaviors, it is little wonder that conflict has become an integral
part of the clinical setting. The goal for successful collaboration is to overcome these barriers and
stay engaged in resolving the issues.

Organizational Complexity
Assessing the complexity of the clinical environment can help to focus the way in which conflict is
managed. Throughout each day, patient care relies on a complex series of interactions to coordinate
scheduling, resources, information, and people. Within complex systems, it is common for patterns to
form. What may appear from the outside to be chaotic, is actually a patterned network of loose
linkages between multiple components of the system. 21 These patterns are familiar to those who
work within these complex environments.

The basic routine in an intensive care unit (ICU) is quite similar from hospital to hospital. There are
parallels in how clinical orders are written and transcribed, how medications are obtained, how
treatments are scheduled, and how procedures are conducted. An experienced traveling nurse or
float nurse can learn what he or she needs to know to care for patients with just a few minutes of
orientation as to location of medications, use of phones, and access to physicians and supplies.
Additionally, communication flow and behavioral norms exhibit patterns that become familiar over

time and constitute the culture of the organization. 22 These patterns are learned through
experience, observation, and sharing of information from person to person. Most nurses can
navigate the clinical environment by asking questions and learning from others. The reliance on
information sharing and relationships with coworkers allows clinicians to make sense of the
environment and do the work of caring for patients. Making sense of a chaotic environment is a basic
skill for those working within complex systems. 21 Fostering collaborative relationships is the key to
ensuring success for professionals working within complex environments and serves as a foundation
for dealing with differences when they arise.21,23

The complexity of delivering critical care makes conflict management difficult and often the
complexity prevents resolution of underlying causes of conflict. 24 Quick fixes have become a
common mode of problem solving as staff and managers feel overwhelmed by what it takes to
achieve true issue resolution. Frequently, problems arise that become a tangled web of related
issues that make it routinely difficult to develop sound comprehensive solutions that can be
implemented throughout the unit or organization. For example, examining the repeated difficulty of
obtaining a particular medication can result in discovery of related issues such as a shortage of
pharmacy technicians, Drug Enforcement Agency or other regulatory restrictions, policy changes,
vendor back-orders, or outdated medication profiles. These issues are not easily addressed and with
typical management structures are definitely not within the realm of control of the staff nurse or staff
pharmacist who is attempting to collaborate to meet the patients' needs. This cascade of complex
problems can result in poor working relationships between the nursing unit and the pharmacy, which
can lead to unresolved conflicts that resurface repeatedly and cause burn-out, frustration, apathy,
and disengagement. 25 The continued exposure to systemic conflict taxes the emotional resources
of staff and contributes to the development of toxic environments. 19 Over time, it becomes easier to
walk away or to stop trying to resolve the constant stream of difficulties than invest energy in events
that distract from patient care. This disengagement can fuel further frustration, decreased morale,
loss of trust in the organization, and a lesser tendency toward giving colleagues the benefit of the
doubt when difficulties arise. 19,20

Interdependencies and Working Relationships

Complex systems have distinct interdependencies that enable coordination of resources and
information. These interdependencies exist among departments, professional groups,
administrators, and clinicians. 21 Nursing relies on the pharmacy to procure medications for the unit

on time. Pharmacy relies on the physicians to write the correct orders for medications. Unit staff
depend on management to secure resources and provide information. Patients depend on
practitioners, clinicians depend upon support personnel, and the list goes on. These
interdependencies make it essential that there be strong working relationships for care to be
delivered within these complex systems.

The presence of poor working relationships leads to operational and social hassles that impact the
staff's ability to provide quality care and affects recruitment and retention of nursing
staff. 25Adequacy of qualified staff directly impacts patient safety. 5 Additionally, the inherent stress
associated with delivering care to critically ill patients can foster inappropriate disruptive behavior that
further affects retention, morale, and quality of care. 26 Understanding the components of effective
working relationships and intentionally integrating techniques for improving collaboration helps to
manage conflict by developing the capacity to deal with differences.

As part of the Harvard Negotiation Project, Fisher and Brown 24 conducted seminal research on the
qualities that ensure a good working relationship. The researchers defined a working relationship as
having the ability to deal with differences. Having a good working relationship depends upon
balancing reason and emotion, understanding the other's needs and interests, fostering good
communication, being reliable, using persuasion rather than coercion, and mutual
acceptance. 24 These collaborative relationships can serve as the foundation for responding to more
difficult conflicts and create an atmosphere where common differences are prevented from
escalating into protracted disputes. Mediators are frequently called upon to assist with conflict
situations and help establish functional working relationships. Developing skills in each of these six
areas is important for improving clinical negotiations and in managing conflict situations. Providing
staff training is one method for developing collaborative skills. Skill development can occur through
formalized training programs as well as through modeling of mediator techniques in daily clinical
practice. Incorporating the techniques used by mediators is an effective way to teach collaborative
skills and create functional working relationships.

What Is Mediation?
Mediation is a conflict resolution process in which a neutral person facilitates communication, the
development of understanding, and the generation of options for creative dispute

resolution. 27 Unlike a judge or jury, the mediator does not decide the outcome of a dispute. A
mediator's role is to help participants surface issues, to create a safe space to discuss issues that
may be emotionally or psychologically difficult, and to foster agreement as participants seek options
that could move them forward toward workable solutions. Mediation is a useful process to use when
the goal of preserving the working relationship is as important as resolving the substantive problems.
Unlike litigation or arbitration, mediation allows the participants in the dispute to remain in control of
the process and to contribute to the outcomes. 27 Through facilitated dialogue, the participants are
able to identify what is important to them and what they need to reach a solution. Mediation is
voluntary and relies on the good faith participation of the people involved in the process. One of the
fundamental tenets of mediation is confidentiality. To encourage honest and open communication
among participants, all conversations associated with the mediation process remain confidential. As
a process, mediation can be used within and external to the clinical setting and requires the use of a
trained "neutral" or mediator. With sufficient training and practice, anyone can serve as a mediator
provided they have no stake in the outcome of the dispute.

In the critical care setting, many conflicts arise in the normal course of care delivery. Common
examples include conflicts related to end-of-life decision-making, differences regarding plan of care,
scheduling and assignment making, visiting hours, access to equipment and supplies, and
placement of patients. More serious disputes can arise when a medical error or adverse outcome
occurs or when a patient's family is in conflict with the clinical team. Often these conflicts are
managed at a cursory level, addressing obvious or expressed needs but frequently leaving
underlying causes of the conflict unaddressed.23,27

It is uncommon for people to clearly identify what is driving their discomfort, whether it be a need for
control, fear, perceptions of mistreatment, or allegations of injustice or unfairness. 27 In a busy
critical care unit, it is particularly unlikely that someone will identify their emotional or psychological
needs. Generally, healthcare organizations value being in control; asking to have your emotional
needs met can foster fears of appearing weak. 28 The inability to express needs directly can also be
seen with patient's family members. The following is an example observed in an intensive care unit:

Patient's Husband: What is the hematocrit level? Has it come back yet? Why is her blood pressure
so low? It was higher when I was in here before. Will I be able to come back in to see her if I leave to
get something to eat? Last time I left, I wasn't able to get back in for 2 hours. Have you taken care of

her before? She had a really good nurse yesterday. When will the doctor be here for rounds? Has he
seen her scans yet? Do you know when she will be scheduled for her procedure?

Observed Needs: Information

Possible Unspoken Psychological Needs: Control, reassurance, to appear responsible.

Possible Unspoken Emotional Needs: Fear, worry, frustration, guilt.

Addressing the husband's need for information meets one of his needs. Failure to assess and
address the unspoken needs can lead to a continued barrage of questions that can result in
frustration by both the nurse and the family member. Failure to acknowledge them does not lessen
unspoken needs or make them disappear. Continuing to discount or ignore them can lead to
stressful interactions that may result in a conflict situation.

All too often, when faced with frequent or recurring demands for information, the nurse or physician
will repeatedly provide further explanation of clinical physiology, or reiterate unit policies that only
serve to cause further anxiety for the family member or patient whose underlying fears remain
unacknowledged. Table 2 provides examples of "symptoms" of conflict and common underlying
needs and interests. Accurate assessment and avoidance of premature assumptions (Table 2) can
facilitate resolution of clinical conflicts. Mediation techniques are very effective at surfacing
underlying needs and interests and helping people communicate their interests in a supportive
environment.

Assessing the Conflict*

Mediation Techniques
Mediators use several techniques that are effective at resolving conflicts. Not every situation requires
a mediator, and frequently differences can be managed early and directly by those involved in the
situation. Mediation techniques can be integrated into clinical care to assist nurses in recognizing
issues and addressing the actual needs of patients, families, and coworkers in order to prevent
escalation of conflicts, to address underlying motivations, and to save time and resources by solving
the correct problem. These techniques can be integrated into routine clinical care situations.

Effective techniques for improving collaboration and resolving conflicts include listening for
understanding, reframing, elevating the definition of the problem, and creating clear agreements.
Use of these techniques helps to manage conflict by fostering understanding and acceptance,
surfacing and acknowledging underlying interests or needs, identifying common ground, and
communicating clearly regarding future actions that enable each person to feel that his or her needs
have been addressed. Table 3 summarizes these four techniques; exercises for practicing each of
these techniques appear below.

Mediation Techniques

The Role of the Advanced Practice Nurse

The advanced practice nurse (APN) can play a role in creating a healthy work environment by
fostering collaborative relationships. 29 Components of the APN's role include educating staff,
serving as a role model, developing and working in collaborative and interdependent relationships,
negotiating resources, and establishing effective linkages to accomplish goals. 29 Incorporating
mediation techniques into the daily work of the APN allows nursing and physician colleagues to
observe effective conflict management strategies, helps meet the needs of patients and families in a
nonadversarial manner; and minimizes the consequences of unresolved conflict within the unit.

Exercises for Learning Mediation Techniques

The systematic management of conflict makes use of a broad continuum of complementary
techniques and processes for addressing differences. Just as clinical care includes alternative
treatment modalities, the process of conflict management also has a range of alternatives for

preventing, addressing, deescalating, and resolving disputes. Effective conflict management requires
a combination of skills and processes for meeting the needs and interests of various stakeholders.
Integrating these techniques into the clinical environment can effectively reduce the level of conflict
and prevent a unit from becoming dysfunctional. The techniques listed below are but a few of the
complementary tools that are useful in managing healthcare conflicts.

Technique 1: Listening for Understanding

Listening for understanding is more than just receiving information, it is a multilayered technique that
entails listening without judgment, without planning a response, and without devising solutions or
offering advice. Truly attempting to understand what is occurring for another person requires
centering, focus, and presence. Taking in information that includes facts, emotions, body language,
and context enables the listener to develop an understanding of the needs, interests, and values of
the speaker. Listening at this level enables the listener to fully assess the problem before diagnosing
or treating the situation. In a busy critical care environment, there is often a perception that there is
insufficient time for this level of interaction. However, this technique can be applied to every
interaction without an additional commitment of time. Additionally, achieving an understanding of the
underlying issues enables the listener to address the correct problem rather than solve the wrong
problem, which results in long-term time savings. A method for practicing this technique is described
below.

Exercise: Listening for Understanding

Exercise 1: Pair up with a coworker. One person is the listener and the other the speaker. For 60
seconds, tell the listener about your favorite teacher from school, a preceptor, a mentor, or a family
member. The listener should listen for insight into what is important to this person. What made this
person choose this story to tell? What do the characteristics of the teacher described in the story tell
you about the speaker's interests or values? Validate your observations with the speaker. Now switch
roles and repeat the exercise. What level of understanding were you able to gain by listening in this
fashion? Was it more time consuming to listen in this way for 60 seconds than it would have been if
you were just listening to the facts of the story?

Application to Clinical Practice

Do this exercise with a new staff nurse. Consider the information that you obtain. Are the needs or
interests you identified a match with the type of preceptor with whom he or she has been? Is the way
orientation is structured compatible with what matters to this person? For example, a nurse
describes a teacher who took the time to encourage her to explore many different ways of solving a
particular problem, and she describes the happiness she felt upon being able to problem solve on
her own. Is a very structured and compulsive preceptor a good fit for this individual?

Exercise 2: Practice this with a patient's family member who has a concern or with a coworker who
has a problem at work: Listen for 90 seconds without interrupting, asking questions, or offering
advice. Listen as you did in Exercise 1 for what is important, for what needs or interests you hear
identified. Are there points in the story in which the individual seems more upset? What is the person
discussing when there is more energy in his or her speech? Are any words or themes being
repeated? While you are listening, be aware of yourself. Are you planning a response? Are you
preparing mentally with a solution to the problem? Have you decided you know what the problem is
before the speaker finishes talking? What does it feel like to listen without the obligation of replying?

Application to Clinical Practice

Assume that in doing Exercise 2, a patient's family member expressed the following concerns:"No
one has come to talk to us today. We don't know what is going on with him. Isn't there a doctor we
could talk to? When will he be taken off the ventilator and transferred to the other unit? We thought
he would be extubated yesterday and he is still here. He doesn't like the ventilator; can't you do
something to make him more comfortable? The nurse last night gave him medication to help him
sleep. Why can't you do that? We have been here for a week and there is never the same nurse. Will
you be here tomorrow or will there be someone else? We have other family who would like to see
him. When will he move out of the ICU?"

What is this family really requesting? What do they need? Would it be difficult to listen to this string of
questions without interrupting or becoming frustrated? What would be your response to this family?
What sentence could reflect what you hear and summarize what is important for the family member,
such as: "It must be frustrating to not have the information you need to make decisions," or "You

sound like you are concerned that he is not getting the attention he needs." Would these statements
have a different effect than trying to answer each question or giving detailed clinical explanations of
why the patient cannot have sedatives during vent weaning?

Technique 2: Reframing
Listening for understanding provides information as to what is happening for someone and helps to
surface the issues. The next step is deciding how to respond to the information. The response
should let the speaker know that you have heard what he or she is trying to say. Additionally, if the
person is emotionally upset, it is difficult for them to hear any response. Deescalating a person who
is upset allows him or her to better hear your comments. Reframing the statements as you respond
is one way of surfacing the issues while helping the patient or family member stay engaged and hear
your message. Reframing accomplishes many functions. Through reframing, it is possible to remove
inflammatory language, acknowledge or clarify the underlying issues, inform the speaker that you
understand what he or she is saying, and redirect the conversation from a confrontational mode into
a problem-solving mode.

Reframing is a technique that requires practice, particularly for those who are uncomfortable when
an individual's words feel like an attack or an insult. Mediators frequently use reframing to create a
safe space for individuals to have difficult conversations. Reframing strong language while
acknowledging the emotion helps people stay in the dialogue. Too frequently, a confrontational
statement elicits a "fight or flight" response that can lead to a caustic reply, withdrawal, or walking
away. Practicing the technique of re-framing allows the others to stay in the conversation in order to
work toward solving the problem. Often, the person who is upset will make a strong statement that
places blame on someone who is not present. Reframing helps to focus the conversation back on
the speaker and away from the person who is not present. This helps to create a space for surfacing
the issues and for removing blame from the conversation.

There are four steps in reframing a statement:

* acknowledge the emotion

* remove the inflammatory language

* restate the problem or issue

* request or wait for clarification or validation from the speaker.

Several examples of reframing, and a re-framing exercise, are listed below:

Examples of Reframing
Statement 1: "Doesn't anyone know what they are doing around here?"

Reframed: "You seem to be frustrated, what information would be helpful to you?"

Statement 2: "He is the most incompetent doctor I have ever seen!!"

Reframed: "You sound upset. What would help you feel assured that your dad is receiving good
care?

Reframing Exercise
There are many variations in crafting a re-framed statement. Reframe the following statements:

Statement 1: "I can see you have to be a friend of who's in charge to get a decent assignment
around here!!"

Statement 2: "You know, any first-year resident would know the dosing for digoxin; this guy must be
some kind of idiot!!"

Journal of nursing managementonlinelibrary.wiley.com ... Vol 14 Issue 3

by CG VIVAR - 2006 - Cited by 84 - Related articles

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Putting conflict management into practice: a nursing case study
1.

CRISTINA GARCA VIVAR BSc, MSc, RGN

Article first published online: 14 MAR 2006
DOI: 10.1111/j.1365-2934.2006.00554.x
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Journal of Nursing Management

Volume 14, Issue 3, pages 201206, April 2006

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Keywords:

conflict;

conflict management;

nursing case study

Aim This paper is intended to put knowledge in conflict management into practice through reflecting on a nursing
case study.
Background Nursing organizations are particularly vulnerable to conflict as the context of nurses work may be
difficult and stressful. Power conflict is argued to be an important source of tension within nursing units. Learning to
manage conflict at an early stage is therefore crucial to the effective functioning of nursing organizations.
Evaluation A nursing case study that illustrates power conflict in an oncology nursing unit is displayed and reflection
on conflict management from the case is provided.
Key issues There is no appropriate or inappropriate strategy to deal with conflict. However, detecting initial
symptoms of conflict and adopting the most effective behaviour to conflict resolution is essential in nursing units.
Conclusion Further nursing education in conflict management for staff nurses and nurse managers is greatly
needed.
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Ranking: 2014 SJR (SCImago Journal Rank) Score: 0.242 | 7/10 Research and Theory (Scopus)

Conflict management styles used by nurses in Jordan

1.

Zaid Al-Hamdan
Assistant Professor, Faculty of Nursing, Jordan University of Science and Technology, Jordan
Peter Norrie
1.
Principal Lecturer and Senior Research Fellow, School of Nursing and Midwifery, De Montfort
University, UK
Peter Norrie, School of Nursing and Midwifery, De Montfort University, Bosworth House, Leicester LE1
5RR, UK. Email: pnorrie@dmu.ac.uk
Denis Anthony
1.
Professor of Nursing, School of Nursing and Midwifery, De Montfort University, UK
1.

1.
1.
1.

Abstract
Aim: This paper is a report of a study of conflict management styles used by nurses in Jordan.
Background: There are five main styles used to deal with conflict. At present research into their utilisation is
dominated by reports from Western countries. This research is the second to investigate their use by nurses in
an Arab country and it illustrates similarities with the earlier work, allowing an initial profile to be constructed
which may be applicable to the larger Arab world of healthcare.
Methods: Cross-sectional quantitative survey of nurses in Jordan using the Rahim Organisation Conflict
Inventory (ROCI II) questionnaire.
Results/Findings: The nurses were most likely to prefer an integrating style of conflict management, followed
in rank order by compromising, obliging, dominating and avoiding.
Conclusion: A tentative model of the styles which nurses in Arab countries prefer to manage conflict is
proposed, which suggests that they are likely to provide stable workplaces.

Arab countries

conflict management

Jordan

nursing

nurses organisational behaviour

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