Conflict management: Importance and implications

Abstract

Conflict is a consistent and unavoidable issue within healthcare teams. Despite training of nurse leaders and managers around areas of conflict resolution, the problem of staff relations, stress, sickness and retention remain. Conflict arises from issues with interpersonal relationships, change and poor leadership. New members of staff entering an already established healthcare team should be supported and integrated, to encourage mutual role respect between all team members and establish positive working relationships, in order to maximise patient care. This paper explores the concept of conflict, the importance of addressing causes of conflict, effective management, and the relevance of positive approaches to conflict resolution. Good leadership, nurturing positive team dynamics and communication, encourages shared problem solving and acceptance of change. Furthermore mutual respect fosters a more positive working environment for those in healthcare teams. As conflict has direct implications for patients, positive resolution is essential, to promote safe and effective delivery of care, whilst encouraging therapeutic relationships between colleagues and managers.

Full text

C
onict, or at least the propensity for it, is considered
inherent to the human condition, therefore, it
is destined to be inevitable, particularly in the
dynamic arena of healthcare with its hierarchical
organisation and complex care issues and
dilemmas. The aim of this article is to highlight that positive
conict management, with favourable team leadership, can be
benecial. Positive management fosters mutual role respect,
improves working relationships, recovers sta retention and
sickness, and especially benets new members of sta who may
nd it dicult coming into long-established teams (Marquis
and Huston, 2014; Stanton, 2014). Moreover, if conict is not
managed eectively, it will have direct implications for the level
and quality of care that is delivered to patients. Poor delivery of
patient care threatens the integrity of the nurse, the profession,
and the health service as a whole.
Conflict management: importance
and implications
Laurie McKibben
ABSTRACT
Conict is a consistent and unavoidable issue within healthcare teams.
Despite training of nurse leaders and managers around areas of conict
resolution, the problem of staff relations, stress, sickness and retention
remain. Conict arises from issues with interpersonal relationships, change
and poor leadership. New members of staff entering an already established
healthcare team should be supported and integrated, to encourage mutual
role respect between all team members and establish positive working
relationships, in order to maximise patient care. This paper explores the
concept of conict, the importance of addressing causes of conict, effective
management, and the relevance of positive approaches to conict resolution.
Good leadership, nurturing positive team dynamics and communication,
encourages shared problem solving and acceptance of change. Furthermore
mutual respect fosters a more positive working environment for those in
healthcare teams. As conict has direct implications for patients, positive
resolution is essential, to promote safe and effective delivery of care, whilst
encouraging therapeutic relationships between colleagues and managers.
Key words: Conict ■ Patient care team ■ Work performance ■ Leadership
■ Nursing ■ Morale
Laurie McKibben, Registered Nurse, Belfast HSC Trust, Queen’s
University, Belfast, lturner12@qub.ac.uk
Accepted for publication: January 2017
The Nursing and Midwifery Council (2015) Code highlights
a nurses’ professional responsibility to work cooperatively and
use eective communication to resolve dierences between
colleagues when they arise. The nurse is legally accountable
for providing safe competent care, and is ethically bound to
the non-malecence principle to ‘do no harm’, therefore there
is a duty and obligation to adapt to challenging situations in a
professional manner, to prevent or resolve conict, and promote
the health and wellbeing of patients.
In respect to those in management positions, the Health
and Safety at Work Order (1978) identies that employers are
responsible for employee health, including mental wellbeing;
it is essential that nurse managers therefore also adhere to
their professional responsibilities, and implement eective
resolution techniques to minimise low morale, stress and illness
of teammembers.
Conict dened
In order to discuss positive approaches to managing conict, it
must rst be dened and its potential genesis acknowledged. There
are several denitions; it has been described as an interpersonal
disagreement, or discord between two or more individuals, owing
to dierence in opinion, competition, negative perceptions, poorly
dened role expectations or lack of communication (Ellis and
Abbott, 2011; Marquis and Huston, 2014).
Johansen (2012) provided a different perspective on
conict in healthcare, citing such is borne from a disparity
in an individual’s perceptions, in relation to patient care.
Prerequisites such as autocracy, hostility, disrespect, inequities,
hierarchy, low morale and absence of shared goals have been
suggested as precipitating factors (Barr and Dowding, 2012). In
presenting several denitions a wider perspective is provided
upon how we dene the larger, abstract concept of conict in
its complexity. The focus of positive resolution therefore lies in
addressing these root causes, for example, mending relationships,
improving communication, accepting change, all of which may
be facilitated via eective leadership and team management.
Organisational conict and dynamics
In relation to understanding organisational conict, it can
be benecial to apply a model or framework that may act
as explanatory or predictive. The Pondy (1992) framework
presupposed that conflict manifested from one of five
predisposing phases. The rst latent phase is when there is
unease and conict is imminent, the second perceived phase is
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where there is believed conict but it is minimised, and the third
felt phase is concerned with personalised conict, where there
is discomfort experienced. The nal two phases are manifest,
when conict is expressed, and the aftermath, and how this
aects the individuals and the team. Pondy viewed conict as
dynamic, and despite how or why conict arises, it can still be
inspected and managed using this framework.
Thomas’s (1992) model agreed that conict is dynamic
in that it is continuous, with the outcome of one episode
of conict leading to another. The model involves awareness,
thoughts and emotions, intentions, behaviour and outcomes.
Thomas suggests conict is a rolling issue that requires ongoing
management within organisations. Using the knowledge from
such frameworks and models as a predictor, and also as a tool to
manage, can be benecial in resolving such conict, whether
it is new or ongoing.
Organisational conict is classically considered to have
a negative impact on team functioning, weakening stability,
disrupting the status quo and impeding productivity (Barr
and Dowding, 2012). This compounds the earlier discussed
denitions of conict. To expand, types of specic team conict
have been shown to include tasks, relationships, and the processes
that enable tasks to be carried out. These conicts directly impact
on performance, however, the inuence of each varies (Jehn,
1997). Nevertheless, reduced performance will have a direct
impact on patient care and so these factors must be considered
to be precipitating for poor care.
Bradley et al (2013) agree the focus of conict in teams is
in terms of task and relationships, however acknowledge other
predisposing conditions such as the characteristics of the conict
or indeed the individuals. Barr and Dowding (2012) oer three
types of relationship-based conict; intrapersonal, interpersonal
and inter-group. Intrapersonal conict is internal discord and
conict occurring within the individual, which can manifest
from role confusion for example. Interpersonal conict arises
between two or more people with diering views or goals,
which may lead to harassment and stress, and intergroup conict
involves two or more teams who, for example, do not share
the same organisational goals. Common interpersonal conict
is relationship based with interpersonal frictions, tensions and
resentment occurring between two or more team members.
It is essential that this is identied and managed as it can have
a negative impact on team performance (Bradley et al, 2013).
Hierarchy may result in team members feeling dominated or
not having a voice, furthermore, process conict arising from
incompatible views on how work should be done, for example
distribution of the workload and task ordering, can also aect
individual job performance and overall team functioning (Jehn,
1997). It is therefore important that the conict is managed
carefully by the team manager, for example, through group
supervision or a forum for team communication, to allow for
shared discussion and problem solving.
Clinical team conict can equal growth or destruction
depending on how it is managed, importantly it is how a
team manages this that determines the end result (Marquis and
Huston, 2014). Dysfunctional outcomes of conict include stress,
sickness, reduced job satisfaction, poor communications, distrust,
suspicion, damaged inter-group relations, resistance and reduced
function (Marquis and Huston, 2014). Counterproductive
situations such as those mentioned above compromise patient
care and safety, one’s professional registration, and overall
reputation of the healthcare organisation.
Resolution
Eective resolution and conict management can be benecial
if managed practically. However, this is dependent on transparent
communication, listening, and understanding the perceived
focus of disagreement (Ellis and Abbott, 2011; Stanton, 2014).
Pondy (1992) stated that recognising the signs of conict
and sourcing the origins will determine the best means for
preventing it. Escalation can be prevented by recognising early
signs and acting on them (Stanton, 2014).
Ellis and Abbott (2011) recommended avoiding seven Cs
as ground rules before approaching conict: commanding,
comparing, condemning, challenging, condescending,
contradicting and confusing. Commanding by way of telling
people how to behave will induce resistance and comparing
the person or situation to other people and situations should
be avoided as each case is individual. Conict resolution seeks
to solve a problem, not the person, therefore condemning
individuals is not the solution. Challenging behaviour and
condescension may cause distress by reducing morale and
creating bad feeling, likewise, contradictory or confusing actions
may lead to uncertainty and frustration, all of which create bad
feeling and demonstrate lack of respect.
The Tuckman (1965) model has been used for decades in
health care in understanding conict. This model suggests
that groups work though sequential stages of evolution before
performing in a cultivated and ecient manner. The forming
stage incorporates group eorts to come together, storming
exposes conict and hostility, norming involves group settling,
and performing concludes in optimum performance. The fth
stage, adjourning, occurs if the team demobilises and members
move on to other duties. The model provides insight into team
dynamics, however, an unhealthy level of conict still exists in
many healthcare teams.
In order to minimise conict or manage it eectively, it is
useful to understand the person, or people at the centre of it.
Thomas and Kilmann’s (1974) theory provides an alternative
method of conict management, identifying ve varying
styles of management in relation to scope of assertiveness
and cooperativeness. The theory argues that individuals favour
a particular style and acknowledge certain styles were more
useful. The Thomas-Kilmann Conict Mode Instrument (TKI)
was developed to identify conict style. The ve styles were:
collaborating, compromising, accommodating, competing
and avoidance.
Collaborators meet everyone’s needs, compromising
individuals implement problem solving to nd a solution that
satises the greatest number of people, while accommodators
meet the needs of other team members while sacricing
their own. A competing style is operated from a position
of authority, and avoiders simply do not solve the problem,
which can make problems worse in the long term (Ellis and
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Abbott, 2011).
In understanding what kind of style a person adopts in
relation to conict we enhance our ability to manage it more
eectively. In understanding styles we must also understand
and respect roles within the clinical team; this encourages
collaborative practice. Collaboration in a multidisciplinary team
impacts on shared decision making and patient involvement,
it is therefore essential for increased patient satisfaction and
outcomes (Aston et al, 2010).
Leadership
There is leadership responsibility from nurse managers in
acknowledging and managing conict positively. In order to
manage conict, the source must rst be identied, including
the type of conict, and how and why it has arisen (Pondy,
1992; Barr and Dowding, 2012). A good leader will encourage
negotiations and a level of compromise, and when particular
team members are central to the conict, they should be
encouraged to admit accountability (Ellis and Abbott, 2011;
Johansen, 2012). This is in keeping with the collaborator or
compromising conict styles posited by the TKI (Thomas and
Kilmann, 1974).
Doody and Doody (2012) stated that a transformational leader
shows good leadership qualities and will inspire and motivate
other team members, thus enhancing morale and team function.
Burns (1978) introduced the concept of transformational versus
transactional leadership, dening transformational leaders as
the most eective, as transactional leaders simply tell people
what to do and cause increased tensions. Transformational
leaders, however, wish to resolve disagreements in order to push
forward. Individual views are explored enabling commonalities
to be built upon. It is clear that decades later the qualities of
a transformational leader remain widely regarded and actively
promoted in nursing.
Good leadership entails someone who displays qualities such
as honesty, resilience, good communication and assertiveness. A
good leader is approachable and can eectively delegate, escalate
concerns, they will be competent and innovative, and seek to
improve collaboration through education and training (Barr
and Dowding, 2012; Sullivan and Garland, 2013). These are all
qualities in keeping with a transformational style that Burns
(1978) spoke of, qualities that also incorporate the avoidance of
behaviours such as the seven Cs suggested by Ellis and Abbot
(2011). In essence eective leadership will help prevent or
resolve conict positively, through harmonious team function
and raised morale.
In contrast if a manager is too open, or adopts a poor
TKI conict style such as that of an avoider, it can lead to
problems when exerting discipline or authority; this results in
reduced respect for authority and diminishment of boundaries.
This poor leadership style can aggravate conict, or in some
occasions be the root cause (Barr and Dowding, 2012). In
cases where the problem is top down and management cannot
be approached, then conict resolution must be processed
upward within the organisation, or autonomous mediation
may be required (National Health Service Improving Quality
(NHSIQ), 2013).
Change
Change and conict are intertwined as one can precipitate
the other. For example, unplanned change with poor
communication can be a cause of conict due to resistance,
negative perceptions, uncertainties and lack of understanding.
Individuals are responsible more so than the situation or
objectives of the team, and this is dependent on psychological
self-condence, therefore, people management via eective
leadership is implicit (Tavakoli, 2014). In this circumstance
conict may be intrapersonal, interpersonal, or both (Barr and
Dowding, 2012).
Change can induce stress if one cannot adapt, for example,
entering a new team is a change for the new member and existing
members; it is how this situation is managed by each individual
and the team manager that determines whether potential
conict will arise or not. If conict arises in this instance, if it
is acknowledged and managed through practical avenues such
as group supervisions, increased one to ones, plans of action or
communication forums, this will promote longer term resolution.
Where possible change should be planned, as it then satises
the criteria for a cohesive well-functioning team, which
minimises the risk of negative conict. This acknowledges that
episodes of conict in these circumstances are not necessarily
negative, and that management of conict using a framework
such as that proposed by Pondy (1992) can be constructive
for the team overall. As a result group unity and dynamics
will increase, which creates a feeling of identity. Moreover,
this positive working environment will augment sta morale,
thus reducing long-term issues such as high sta turnover and
sickness levels (Ellis and Abbott, 2011).
Conict as benecial
Weber (1947) and Fayol’s (1949) old theories argued a
bureaucratic system of mechanistic structure to discourage and
eliminate conict altogether, and to maintain harmony within
the organisational team. However, these theories are outdated
and to date have not been successful in their application to
teamwork or team dynamics in clinical practice. These theories
are based upon and suited to an organisational framework in
which there is minimal change, and an environment whereby
management are not questioned by subordinates. Whereas
sources such as Jehn (1997), Aston et al (2010) and Doody
and Doody (2012) have argued the issues with hierarchy within
organisations remain a source of conict, and actively promote
collaboration, communication, teamwork and transformational
leadership within management. Clinical practice is dynamic
and must employ the application of more suitable approaches
to conict (Marquis and Huston, 2014; Stanton, 2014).
Conict, when used positively, can stimulate and encourage
change if team function has become stagnant, increase
productivity, and inspire critical thinking. Pondy (1992) stated
that conict involving varying perspectives and ideas carries
the potential to be positive, this includes improved team
performance and innovation (Jehn, 1997). Negotiation and
problem solving, with manager mediation, can be successful
in preventing escalation (McConnon and McConnon, 2010).
Thomas (1992) supports this with his model that proposed
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that conict status needs reassessed regularly, with ongoing
management taking into account factors such as emotions,
behaviours and outcomes.
Conict highlights diversity and divergent, but equally
important, viewpoints, it promotes mutual respect for one
another, encourages dialogue and negotiations, and improves
understanding of roles. This is pertinent where there is
generational divide within a team for example, hence there
is a necessity for compromise (McConnon and McConnon,
2010; Moore et al, 2016).
The NHSIQ (2013) concur that conicts are more about
people than the problems, hence team members’ views and
goals should be valued to support team-based delivery of care.
In order to manage successfully certain factors must be taken
into account, such as type of conict, management style, conict
style and overall approach (Thomas and Kilmann, 1974; Pondy,
1992; Ellis and Abbott, 2011; Barr and Dowding, 2012).
An agreed solution equals resolution, where all parties see
themselves as winners; a positive consequence. When approached
positively conict can promote an opportunity for growth in
the clinical team, this can be constructive if there is a balance,
as too much negatively aects performance and compromises
patient care (Barr and Dowding, 2012; Sullivan and Garland,
2013). Shared problem solving cultivates a climate of mutual
respect and motivation to nd mutually satisfactory agreements,
this is benecial for trust, satisfaction and fairness, facilitating
better outcomes for the team and for patients (Posthuma, 2011).
Conclusion
There are legal, professional and ethical responsibilities to deliver
the best standard of patient-centred care, hence conict must be
managed and utilised positively as failure to do so puts patient
safety, care and satisfaction in jeopardy (Johansen, 2012; Nursing
and Midwifery Council, 2015). Clinical governance within
organisations is in place to ensure risk is managed, therefore
risk such as conict must be regulated, or managed, to minimise
near misses or serious adverse events involving patient care
(Marquis and Huston, 2014).
Professional development for nurses and nurse managers, via
reective practice, can enhance or develop conict management
styles (Johansen, 2012). Considerate management fosters an
environment that minimises precursory conditions for future
conicts and organisational stasis (Marquis and Huston, 2014).
Even the best functioning teams will encounter conict. If
it is managed well it can be a positive transforming force for
change and a conduit for innovation, growth and productivity
(McConnon and McConnon, 2010). Conict management
and positive resolution encourages mutual role respect among
nurses and the wider healthcare team, advocates the wellbeing of
team members, facilitates optimum team function and ultimately
promotes the delivery of high-quality care to patients. BJN
Declaration of interest: none
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KEY POINTS
■Conict is inevitable within healthcare teams
■Poorly managed conict impacts negatively upon staff and, importantly,
patient care
■All team members are responsible for promoting resolution and
implementing shared problem solving
■Nurse managers with reputable leadership qualities will foster benecial
conict resolution and promote team function and harmony
■In the dynamic area of health care, change should be expected, and any
manifest conict used as a driving force for positive change
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