Interpersonal and Workplace Conflict in Nursing

Conflict may be simply the recognition of difference between two or more people, group or departments due to variation in attitudes, behaviors, values, beliefs or goals. In work place, conflict can be originated from two sources: staff to staff interaction and manager to staff interaction or some time both can be found in same timing. It may be external or internal in nature and can be positive or negative. Health professionals deal with internal and external conflicts every day. According to estimations, more than 20% of a manager’s time is devoted to conflict management (Kaitelidou et al., 2012). If conflict exists in health care setting, it can damage long term professional and interpersonal relationship which results to have a negative impact on patient care due to gap in communication to transfer accurate information. Conflict is a vast topic but the aim of writing this paper is to identify the issues related to interpersonal conflict and its impact on patient care and to find the strategies to its resolution.

An interpersonal conflict is a disagreement between two persons or subgroups of an organization involving significant bitterness and dissatisfaction. Interpersonal conflict usually develops due to altered interpersonal relationship among peers or coworkers. Relationship means being connected or related positively. So relationship plays significant role in causing and resolution of conflict in effective way. According to Martin and Dowson (2009) that relationships are a main source of pleasure and provide defense against stress and because of good relationships, individuals receive active help for difficult tasks and challenges in jobs, emotional support in their daily lives, and companionship in shared activities. On the other hand if there is no relationship or misunderstanding, obviously conflict will arise and outcome would be distress and ineffective working environment. Recently health care organizations have become complex due to recruitment, lack of resources and communication skills, and work overload. These are subjected to complex interpersonal dynamics among colleagues, and if policies are exist to identify and resolve these, then out come in terms of job satisfaction by employees and patient satisfaction through standard care will be improved. In 2009, the Center for American Nurses conducted a survey to identify challenges related to conflict encountered by the professional RN, that interpersonal conflict is the most common and problematic type of conflict experiencing in work place (Johansen, 2012). No one denies this fact but usually the manager pays less attention due to busy schedule and adopts avoidance style which result in poor work related attitudes and psychological states such as job dissatisfaction, organizational commitment, turnover intensions, negative emotions, and emotional exhaustion. Hence it is important for the nurse to identify the source of conflict which may terrible impact on patient care and to manage conflict by understanding the strategies for the effectiveness of health care setting.

Significance of the Issue

Johansen (2012) reports that workplace conflicts in the healthcare environment tend to be far more complicated because they often involve ongoing, complex relationships that are based in emotion. As in hospital one would interact with different human resources with diversity, including physicians, nurses, managers and personnel’s from same or other departments. However, some time nurses are working under difficult and stressful situation which can lead to negative interpersonal relationship with other co-workers, and they are so busy in their work to reflect upon and to resolve it. As a result patient care will be compromised and organization would lose its productivity. Health care professionals, who understand each other’s roles and can work effectively together, have been shown to provide higher quality care (Begley, 2009). Hence, to achieve out comes in patient care or education, it is essential to have good interpersonal relationship in terms of cooperation, collaboration, listen, and respect the values or positions of each other. It is usually observed in our context that physicians showing dominancy and lack of acceptance of role by nurses are the root causes of interpersonal conflict in health care settings.

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There are number of researches on conflict in health care, especially regarding nurses issues in clinical areas. The most important sources of conflict are deviating management style and staff perceptions, scarce resources in the unit resulting in higher levels of stress, differences in goals among work groups and competition (Vivar, 2006). Hence managerial style plays a vital role when conflict is arising either within group or with manager. However, stressful environment, difficulty in achieving the goal and misperceptions lead to conflict. In this regard lack of job satisfaction and lack of staff retention will result low work outcome and have direct effect on patient care. In our scenario the common causes of interpersonal conflicts are lack of managerial and communication skills by managers, lack of competency and misinterpretation by nurses. There are many skills those we should learn and practice to work together in a specific way, which may acceptable to all. These skills are not inherent but we learn through education and ongoing experiences. Grady (2003) argued that managers come across such conflicts which arise from these skills deficiencies more than any other reasons. The nurses usually when enter the patient care setting; they have fewer opportunities to get formal training regarding such skills. Conflict is the root cause for any mishap in patient care, these are medication error, improper communication, lack of respect, delay care, cultural and religious valves violation, which would have a direct impact on image of organization, as a result staff turnover and job dissatisfaction will be escalated. So it is essential for a nurse leader to identify the causes and sources of conflict, for which the leader should have specific skills to avoid it and improve the quality of patient care. The main objective of this paper is to find out such solutions to minimize negative interpersonal conflict among coworkers and to present strategies for the resolution of interpersonal conflict in education or patient care setting and to improve a healthy working environment.

Scenario

After completion of my diploma in nursing, I joined intensive care unit in one of the hospital in Karachi. It was ten bedded unit, and in each shift there were three staff nurses, one medical officer and one manager for the floor. The nurses’ turnover was more than any other employees and the reasons were poor communication among coworkers, physician’s attitude towards nurses, lack of cooperation, pulling legs of each other, lack of acceptance, emotional exhaustion, and lack of respect by colleagues. As a result patient’s were suffering and delaying in their care and dissatisfaction. One day in my duty, the physician came on round for follow up of his female patient presently complaining of urinary tract infection and known case of diabetic mellitus. He started shouting that why his patient is not catheterized in early shift as it was advised during patient admission. The patient insulin dose was also missed by the nurse. The nurse who did this had some issues with the physician and with nurses on duty. The patient condition became worse and deteriorated due to conflict among health care workers and she was admitted for ten days. Whenever there was complain from any staff regarding interpersonal problems, the manager ignored and adapted avoidance strategy which worsened the situation. The nurse manger had autocratic style while dealing with staff members and never listened issues but only disregarded them. In the same month after the incidence three staff nurses left the job including me.

Analysis of the Issue

A good interpersonal relationship is of crucial importance in any organization for productivity and to achieve the desire goals. In the above scenario there are multiple issues in regard to conflict among coworkers, and physician. The end result is a severe impact on patient care, as in the scenario, the patient suffered because of interpersonal conflicts in the unit. However, not only patients but the employees also leaving the job due to lack of job satisfaction and managerial style while dealing the issues. There are few studies on the prevalence of interpersonal conflict in health care organizations. Guidroz, Wang, and Perez (2011) discussed that in workplace the nurses reported two most distressing events, those are violent language or non-supportive behavior by a physician (24.4% prevalence) or by a colleague or supervisor (23.4% prevalence). Which highlighted the importance of the issue but it can be observed from different perspectives. Looking at the scenario that the situation is uncertain and it is difficult for anyone to cope in this type of environment. Nurses with conflict to the physicians have a negative impact on their profession, including increased feeling of exhaustion, lack of job satisfaction and also have greater intensions to left the nursing profession. Conflict in any sense either among coworkers or with supervisor both can be linked to personal and organizational outcomes. In the situation as the manager has avoidance strategy towards conflict, it is non-strategic style in case of altered interpersonal relationship among coworkers. It is the best strategy when to prevent some issues, to protect self-valves, to manage the situation and to enhance interpersonal relationship. Conflict among nurses has a negative impact on the retention of qualified staff and patient outcomes, and the shortage of nurses due to job dissatisfaction as a result of work place conflict creating a stressful and unpleasant environment (Almost, Doran, Hall, & Laschinger, 2010).

The missing of dose of the patient is alarming sign for a leader because it shows that the situation is out of control and immediate skillful strategies should be identified and implemented accordingly, to prevent further damage. The most crucial components for any organization are to have good relationship and communication skills among coworkers, which in our context is poor, which are the main sources of conflict. Dana (2005) reported that 60 – 80 % of conflict occurs in any organization due to poor relationship and 25 – 40% of time spends in resolving conflict. Reddin developed 3D- Theory of Situational Analysis of Management to analyze the situation through model of management behavior. It showed that managerial behavior can be positive or negative in specific situation. The three dimensions of the theory are; the first one is task orientation, in which the manager directs the subordinates’ efforts to achieve the goal in term of organizing, planning and controlling. Second is relationships orientation, in which the manager has personal job relations in regard to mutual trust, respect for employees and feelings for their concerns. Effectiveness is the third dimension, in which the manager achieves the output requirements of his/her position; managerial style may effective or less effective depending upon the situation. A manager may adapt the third dimension of effectiveness by matching the management style according to the situation. In the scenario, as the manager moved along with only one style and did not change her style according to the need of situation. If one style is less effective, then suitable style of management should be used to overcome the situation.

Strategies to Resolve Interpersonal Conflict

Today health care settings face more challenges as compare to past decades because of competition, downsizing, restructuring, cost control and new technology; these changes are likely to develop conflict in organization. There are many strategies to resolve conflict effectively to minimize its negative impacts. Organization and organizational leaders typically play a role in resolving conflict among the employees. Romer, Rispens, Giebels, and Euwema (2012) proposed a research model of “Leaders’ Third-Party Conflict Management Behaviors” which is neutral and resolving the conflict in three ways, which are problem solving, forcing, and avoiding. Problem solving is to identify the concerns of both parties and to find a suitable solution which addresses their concerns. Forcing is the imposing of decision by leader to resolve the conflict. Avoiding is the strategy when the leader does not want to involve in the conflict. These three components are suggested to resolve interpersonal conflict among coworkers. Problem solving behavior allowing the individuals to show their goals and point of view, they take it positively as the leader showing interest in their concerns. Hence, when the employees perceive their importance; so, their feelings of controlling the stressful situation enhance, and therefore negative impact of conflict decreases. This indicates participatory leadership style in which employees are given the opportunity to participate in the decision making process, which minimizing feeling of stress. According to Maboko (2011), involving subordinates in resolving the problems leads to team spirit, which produces job satisfaction, cost effectiveness and better solutions. Furthermore, if there is conflict, the authorized leader should ensure that it is fruitfully solved. On contrast forcing behavior has negative impact on employee but based on leader’s interest, and would increase stress rather than resolve the conflict in healthy way. However, conflict may be resolved to some extent as the employees expected the leader to be authoritative and obliged to obey. Furthermore avoiding behavior may cause frustration in the employees because the leader fails to resolve the conflict and thus conflict will be escalated. Avoiding strategy is better but if the employees perceive it positively, otherwise as in the scenario the situation was worsened.

Conceptual Framework

Nurses do not have enough time for research and analysis specified for formalizing processes through scientific method, so many problems need immediate action to find the solution. Sullivan and Decker (2004) developed seven-step process, practical strategy to resolve a problem or conflict, which are the most beneficial steps for nurse leader to be more effective in difficult situations. The first step is to identify the problem, the most important part for a leader to resolution of an interpersonal conflict. The problems should be in descriptive statement rather than judgmental or conclusive, and premature interpretations must be avoided by using thorough inquiry of issues as in the scenario, so that to avoid further mishaps. Accurate assessment of conflict among the coworkers need achieve long term goals rather than to just a stopgap measure. After the leader reaches to the root of the problem, then he/she should generate possible solutions. This step will give opportunity to a leader to develop more accurate solutions in regard to specific situations. The leaders once set the solutions; then evaluate the suggested solutions by keeping the subordinates and crisis in mind. Choose the best solution to resolve the issues, which is feasible, satisfactory and acceptable by subordinates and higher management. Now it is the time to implement the solution after a detail plan and practical in term of time consuming and effective. More often the employees usually cooperate with such solution which fit into their favor, while few resist. Then the nurse leader should initiate step to educate the staff to comply with the solution. In this situation participative management style is more perfect, which help to identify acceptable solutions to problems. If problem resolved among the co-workers, keep the problem solving process on continue basis. If the leader evaluates the outcome to ensure that conflict has been resolved and build on that experience, it becomes an expert skill that he/she can use throughout the career. The final step of the process depend upon the succession or failure of the resolving the problem, which if conflict does not resolve then repeat the process.

Leadership Theory

Strong and effective leadership styles are key components to any health care success. There are certain situations which demand different leadership approaches. Historian and Burns in 1978 developed transformational leadership theory, which emphasizes the importance of interpersonal relationship (Johnson et al., 2012). This theory covers Maslow’s higher level of needs which promote self esteem and elevate self actualization in terms of achievement, respect, confidence, creativity, problem solving and acceptance. Leaders need to develop a vision, create strategies to overcome conflicts, and to accomplish the changes required to reach the vision. Nurse leaders often face challenges when motivating the staff to function beyond self interest. A thorough knowledge and skills required if the subordinates refuse to participate. Tomey (2004) defines the need of knowledge for effective leadership while moving in the direction of transformational leadership style is: Knowing oneself, knowing the job, knowing the organization, knowing the business, and knowing the world. Furthermore, Ellis and Hartley (2012) argue that “effectively implementation of transformational leadership result in agreements about priorities, shared valves, perceived common goals and meaningful purposes”. So, one can see that it would be the most effective and desirable in a health care environment. Moreover, transformational leaders’ regular highlighting on team goals is likely to bring about appropriate use of rewards for cooperative behaviors. When confronting disagreement, team members are motivated to consider and incorporate opposing views of co-workers and integrate the most reliable information and the best ideas (Zhang, Cao, & Tjosvold, 2011).

If we review all leadership theories, there is no one best leadership style to adapt. One cannot say that leaders are totally people or task oriented. Leadership effectiveness is influenced by leader, followers and situation, leaders should be aware of their own behaviors and influence on followers, individual differences, group characteristics, motivation, task and situational variables (Tomey, 2004). Leaders may adjust their style according to the situation and require adaptive behaviors.

Recommendations

Conflict management is a complex process, which demands time and energy. The management and the subordinates must be concerned and devoted to resolving conflict among co-workers by being willing to listen and to find accurate solutions. Sullivan and Decker (2009) and Tomey (2004) suggested helpful strategies for mediating interpersonal conflict for nurse leaders are following.

• Be a role model.
• Be supportive of each individual’s needs within the group.
• Do not blame anyone for the problem.
• Focus on the issues, not the personalities.
• Give equal time to each party.
• Help to develop alternate solutions, select a mutually agreeable one and develop a plan.
• Summarize key points and plans.
• Follow up the plans and give positive feedback to participants regarding in resolving the conflict.
• Facilitate further problem solving as necessary.

It is important for individuals to maintain a healthy working environment and avoid stressful situation by respecting the co-workers, values and beliefs, good communication skills and have enough knowledge to work in a multicultural organization.

Conclusion

Conflict is inevitable in nature. It is a significant issue within health care organizations all over the world. To overcome interpersonal conflict in the health care setting requires accurate knowledge and skills for health care professionals to reduce the occurrence of conflicts. This paper has implications for nurse leaders and organizations who seek to manage conflict among employees to reduce its negative consequences on working environment and organization productivity. Learning to manage conflict may help nurses feel more job satisfaction and obviously have positive impacts on patient care. In addition, nurses are more concerns how they are treated. If they are treated with respect and dignity by colleagues and manager and are working with positive relationship and morale, they will experience a positive working environment with less conflict.