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Conflict Management

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Chelsea Lambright

on 17 March 2014

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Transcript of Conflict Management

Conflict Management in Nursing
Nurse/Patient Conflict Management
Nurse/Nurse Conflict
"Lateral Violence"
Patient Predisposing Factors of Conflict
Conflict—Insufficient Collaboration
Unresolved conflict creates barriers between physicians and nurses

(Hendel, Fish, & Berger, 2007)
Majority of nurse-physician conflicts occur in response to general plan of care for patients and disposition of patients
(Nelson, King, & Brodine, 2008)
Conflict with doctors is the most harmful type of interpersonal conflict
(Tabak & Koprak, 2007)
Tabak and Koprak (2007)
determined that a correlation exists between a nurse’s choice of conflict management style and amount of stress
Nurse/Physician Conflict
Importance of Collaboration
better patient outcomes--leads to better HCAHPS scores
more positive work environment
helps limit errors in health care setting
decreased length of hospital stay
increased nurse autonomy and satisfaction
(Schmalenberg & Kramer, 2009)
Importance of Collaboration (cont)
Tschannen et al. (2011)
briefly described a previous study that revealed that higher collaboration between nurses and physicians led to decreased patient mortality rates by 41% of their predicted rates
So which style do I use to manage conflict with a physician?
Nurse/Physician Relationships
Collegial relationship (equal trust, power, and respect between physicians and nurses)
Collaborative relationship (mutual trust, power, and respect)
Student-teacher relationship
Friendly stranger relationship (say hello but do not talk much about patient care)
Hostile/adversarial relationship (anger or verbal abuse)
(Schmalenberg & Kramer, 2009)
Methods for Improving Relationships
“Patient is first” mindset
Constructive conflict resolution
Interactive and interdisciplinary collaborative patient rounds
Competent performance and confidence
(Schmalenberg & Kramer, 2009)
Conflict Response Study
Leever et al. (2010)
conducted a qualitative study regarding the collaboration between physician and nurses and discovered two responses to conflict:
ignoring the conflict
engaging in conflict
Engage or Ignore?
5 factors influence the decision
influence of oneself
influence of other
nature of conflict
context of conflict
personal motives
(Leever et al., 2010)
Conflict Management Styles
Integrating (high concern for self and other)
Obliging ( high concern for other)
Dominating (high self concern)
Avoiding (no concern for self or other)
Compromising (some concern for both self and other)
(Leever et al., 2010)
Hendel, Fish, and Berger (2007)
conducted a study to determine the type of conflict management style used most often by physicians and nurses in an acute care setting
Theoretical framework based on Thomas and Kilmann’s model of conflict resolution
Thomas & Kilmann's 5 Styles of Conflict Resolution
Avoiding (neither cooperative nor assertive)
Accommodating (cooperative & unassertive)
Competing (assertive & uncooperative)
Collaborating (assertive & cooperative)
Compromising (some cooperativeness & some assertiveness)
(Hendel, Fish, & Berger, 2007)
Study Results
Most frequently utilized conflict management style: Compromising
Second most frequently utilized style: Avoidance
Least frequently utilized style: Collaboration
Head Nurses
Most frequently utilized style: Compromising
Least frequently utilized style: Accommodating
Head nurses used the collaboration style much more frequently than the physicians
(Hendel, Fish, & Berger, 2007)
The conflict management style utilized depends on several factors in regard to the conflict at hand, the physician, and the nurse
No single conflict management style is fitting for every single conflict
Important to keep patient in mind (patient-centered care)
The conflict management style utilized can also depend on the amount of time available
What is lateral violence?
involves nurses "openly or discretely directing their dissatisfaction with the work setting at nurses of equal of lower levels within an organization"

(Coursey, Rodriguez, Dieckmann, & Austin, 2013, p. 101)
failing to respect privacy
using innuendo
verbal comments
withholding information

(Embree & White, 2010, p. 168)
Case Study Results
Verbal abuse @ work: from
90% to 76% (decrease)
Control over own practice: form
40% to 42% (increase)
Reported that "verbal abuse had impact on morale, workload, productivity, and potential for errors: from
42% to 63% (increase)

(Ceravolo, et al., 2012)
Evidence of Lateral Violence
*So common that it is often ignored*

(generally) experienced nurses

(generally) novice nurses

Study performed in SE United States
of nurses have witnessed
of nurses have been targeted

(Coursey et al., 2013, p. 101).
Alicia Danner

Jessica Calvert

Chelsea Lambright


WHY does this occur?
Conflict of opinions
Stressful nature of nursing
Different personality types
Common Effects/Problems
increased emotional health issues
increase staff turnover rate
decreased productivity
decreased teamwork amongst staff
negative affect on patient care

(Embree & White, 2010, p. 168)
Emotional Health
lowered self-esteem
lack of autonomy
may cause dysfunctional coping and/or lack of coping skills
increase in mental health strains
suicidal ideation has even been reported
Staff Turnover Rate
hostile work environment transferring to another unit/job location
"RN turnover costs up to two times a nurse's salary, and the cost of replacing one nurse is between
, geographic location and specialty area"

(Jones & Gates, 2007)
damaged relationships
(or lack of)
toxic work environment
lack of teamwork
loss of trust in co-workers
Patient Care
frustration in staff could be projected on to patients
"shortness" with patients
rushing patient care
teamwork is necessary in nursing for best patient outcomes
What can be done?
ANA (Section 6): "professional nurses are responsible for attaining and maintaining work environments consistent with professional vales"
Nurse leaders play a major role
trusting behaviors allow staff to feel supported
hold themselves accountable
Staff nurses should also hold self accountable
Provide resources to decrease stress & anxiety
Audit & feedback (i.e. charge nurses)

(Becher & Visovsky, 2012, p. 210)
Drug/Alcohol Abuse
Delays in Appointments/Treatments
Lack of Communication
Loss of Autonomy
(Rew and Ferns, 2005)
Nurse Predisposing Factors of Conflict
Negative environment
Personal Stress
Lack of sleep
Low EQ
Emotional Intelligence

Self Confidence/Self-esteem
Can be diminished when peers/management are not supportive/empowering
Communication skills: Verbal, Visual, Vocal
Lack of communication can escalate conflict into even bigger issues.
(Rew and Fern, 2005)
Hourly Rounding: improves and facilitates communication between nurse and patient.
*High individual emotional intelligence may help avoid conflicts between nurse and patient due to nurse being comfortable in his/her role which helps provide a trusting environment for patient

What to do when there is conflict

Intervene during early escalation
Intervene During Early Escalation
Attempt to verbally connect w/ pt.
Stay calm/use calm voice
Try to give patient choices to maintain autonomy
Try to emphathize
Stay out of power struggle/no ultimatums
(Johnson and Hauser, 2001)
Confront the situation
"You seem upset..."
Understand their position
Define the problem
Seek a solution
Agree a course of action
Factors &
Warning Signs
lack of self-esteem
suppressed anger
learned behavior
ex. witnessed this as a child
previous abuse
poor coping skills
learned helplessness

Target Audience:
Student Nurses

To educate student nurses on Conflict Management as it pertains to nursing

Date of Production:

"Cost" of Turnover
Staff member transfers
Overtime for current employees
HR representative to hire new nurse
6 weeks training (where double is paid)
Case Study
Who: 5 integrated hospitals; over 2,000 nurses
children's hospital
2 urban hospitals
2 suburban hospitals
Place: NE area of US
Time: 2008-2011
Background: in years prior to study, turnover rate was 11.5%, costing almost $19 million/year
40% of turnover had been employed <1 year
(Ceravolo, Schwartz, Foltz-Ramos, Castner, 2012)
Case Study (cont'd.)
Research had indicated that lateral violence was the source of this turnover rate
Initial survey completed
3 years, 203 workshops, 60-90 minutes in length
Main topic: Conflict Resolution
Follow-up survey completed following 3 year training period
(Ceravolo, et al., 2012)
Potential Effects of Conflict
Impaired work performance
May require psychological help
Loss of confidence/self-esteem
Burn out
Increased Turnover
Added stress
Additional Conflict
(Rew & Ferns, 2005)
Reducing Conflict
Training in conflict management:e-learning situations to risk assess and resolve conflict
Know predisposing factors of conflict
Address issues before they become conflicts.
Becher, J., & Visovsky, C. (2012). Horizontal violence in nursing. MEDSURG Nursing, 21(4), 210-214.
Ceravolo, D. J., Schwartz, D. G., Foltz-Ramos, K. M., & Castner, J. (2012). Strengthening communication to overcome lateral violence. Journal of Nursing Management, 20(5), 599-606. doi:10.1111/j.1365-2834.2012.01402.x
Crigger, N. (2009). Towards understanding the nature of conflict of interest and its application to the discipline of nursing. Nursing Philosophy, 10(4), 253-262. doi:10.1111/j.1466-769X.2009.00412.x
Coursey, J., Rodriguez, R., Dieckmann, L., & Austin, P. (2013). Successful implementation of policies addressing lateral violence. AORN Journal, 97(1), 101-109. doi:10.1016/j.aorn.2012.09.010
Davis, C. (2007). Keeping the peace. Nursing Standard, 22(12), 18-19.
Embree, J., & White, A. (2010). Concept analysis: Nurse-to-nurse lateral violence. Nursing Forum, 45(3), 166-173. doi:10.1111/j.1744-6198.2010.00185.x
Guidroz, A. M., Wang, M., & Perez, L. M. (2012). Developing a model of source-specific interpersonal conflict in health care. Stress & Health: Journal of the International Society for the Investigation of Stress, 28(1), 69-79. doi:10.1002/smi.1405
Hendel, T., Fish, M., & Berger, O. (2007). Nurse/physician conflict management mode choices: Implications for improved collaborative practice. Nursing Administration Quarterly, 31(3), 244-253.

Johnson, M., & Hauser, P. (2001). The practices of expert psychiatric nurses: accompanying the patient to a calmer personal space. Issues in Mental Health Nursing, 22(7), 651-668.
Leever, A., Hulst, M., Berendsen, A., Boendemaker, P., Roodenburg, J., & Pols, J. (2010). Conflicts and conflict management in the collaboration between nurses and physicians - A qualitative study. Journal of Interprofessional Care, 24(6), 612-624. doi:10.3109/13561820903550762
Milstead, J., Furlong, E. (2006). Handbook of nursing leadership: Creative skills for a culture of safety. Sudbury, MA: Jones and Bartlett Publishers.
Nelson, G., King, M., & Brodine, S. (2008). Nurse-physician collaboration on medical-surgical units. MEDSURG Nursing, 17(1), 35-40.
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Schmalenberg, C., & Kramer, M. (2009). Nurse-physician relationships in hospitals: 20,000 nurses tell their story. Critical Care Nurse, 29(1), 74-83. doi:10.4037/ccn2009436
Tabak, N., & Koprak, O. (2007). Relationship between how nurses resolve their conflicts with doctors, their stress and job satisfaction. Journal of
Nursing Management, 15(3), 321-331. doi:10.1111/j.1365-2834.2007.00665.x
Tschannen, D., Keenan, G., Aebersold, M., Kocan, M., Lundy, F., & Averhart, V. (2011). Implications of nurse-physician relations: Report of a successful intervention. Nursing Economic$, 29(3), 127-135.

(Davis, 2007)

~Nurse brings in all scheduled medication for pt, but he refuses and is uncooperative/rude to nurse.
Confront: "You seem upset, can you tell me what i
"A situation becomes a conflict because of people's reactions to the circumstances or actions of others."

(Rew and Fern, 2005)
(Rew and Fern, 2005)
"Conflict is not necessarily always a negative thing. It can generate many positive outcomes and be a motivator for change."

(Rew and Fern, 2005)
Involve Chain of Command when necessary
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