Improving Teamwork: Collaboration, Coordination, and Conflict Resolution
The American Nurses Association (ANA) defines collaboration as “recognition of the expertise of others within and outside the profession, and referral to those other providers when appropriate. Collaboration involves some shared functions and a common focus on the same overall mission” (2010b, p. 40). This is a critical competency required to practice in any healthcare setting today or to participate in any aspect of healthcare delivery—critical for effective patient-centered, quality care. The increased emphasis on using interprofessional teams to meet the patient’s needs across the continuum of care requires collaboration. Team members and different healthcare providers must be able to work together; recognize strengths and limitations; respect individual responsibilities and expertise; and maintain open, effective communication.
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Nurses who have long worked on teams should be familiar with teamwork. Despite this, there continues to be a separation between physicians and nurses, who often work in silos. Nurses and physicians need to work together to ensure that the patient receives the care that is required when it is required. Collaboration involves cooperative effort among all healthcare providers offering care for a patient. This will result in more effective decision making with healthcare professionals working together to accomplish identified outcomes. This is not easy to do. There are professional issues, territory issues, conflicting goals, inadequate communication, and multiple differences; however, despite all of this, effective and efficient care requires collaboration. The system is just too complex to function well without collaboration. The nurse is often the person who must lead the effort to ensure collaboration occurs.
Key Definitions Related to Collaboration
Collaboration is a cooperative effort that focuses on a win-win strategy. To collaborate effectively, each individual needs to recognize the perspective of others who are involved and eventually reach a consensus of a common goal(s). The ANA notes that collaboration involves recognition of expertise and some shared functions (2010a, 2010b). The ANA’s Nursing: Scope and Standards of Practice (2010b) and the Nursing Administration Scope and Standards of Practice (2009) also identify the need for collaboration, emphasizing that all nurses are expected to collaborate. The American Organization of Nurse Executives (AONE) also includes the need for collaboration in its descriptions of leadership competencies, as described in Appendix A.
Key concepts related to collaboration are partnership, interdependence, and collective ownership and responsibility. Considering these concepts helps in understanding the impact of collaboration. Collaboration is also a process. It is not stagnant but rather changes, which requires staff to make adjustments to collaborate with others as situations change. The American Association of Critical-Care Nurses’ nurse competencies in its Synergy Model™ states: “working with others (e.g., patients, families, healthcare providers) in a way that promotes/encourages each person’s contributions toward achieving optimal/realistic patient/family goals; involves intra- and interdisciplinary work with colleagues and the community” (American Association of Critical-Care Nurses, 2014). Most people can remember experiences when working with others where the work just seemed to flow with less stress and good communication. This probably means that the people working together were collaborating.
Collaboration should be a positive experience, but this is not always the case. If it is not positive, it will not be effective. If a group of nurses were surveyed, it would be surprising to get a consensus that collaboration was always a positive experience. Often attempts at collaboration mean struggle, conflict, and sometimes ineffective results. Some research has been conducted to assess the effectiveness of collaboration. The Institute of Medicine (IOM) recognizes the importance of collaboration in its rules to guide healthcare provider behavior in the 21st-century healthcare system (2001). The 10th rule, cooperation among clinicians, emphasizes, “cooperation in patient care is more important than professional prerogatives and roles” (p.93). To meet this rule, staff need to collaborate and use effective teamwork, which is weak in the healthcare delivery system.
The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011) includes collaboration in its content. For example, by noting that nursing leadership competencies need to be applied in “a collaborative environment” (p.8) and “future, primary care and prevention are central drivers of the healthcare system where interprofessional collaboration and coordination are the norm” (p.2). In its recommendations for priorities in research that focus on teamwork, the report lists “identification of the main barriers to collaboration between nurses and other healthcare staff in a range of settings” (p.275).
Barriers to Effective Collaboration
As noted by the IOM, working in isolation with concern for only your own profession is not effective; however, nursing also has much work to do to improve the image of nursing and nursing leadership. Salmon (2007) comments that “improvements in care quality and safety will simply not happen with nurses working by themselves. To take it a step beyond what may seem obvious, it can’t happen just by adding physicians to the equation. It’s going to take the partnered engagement of other clinicians, health administrators, and, ultimately, the public” (p.117). Given these issues, how does the nursing profession arrive at the right balance, one that focuses on nursing and its professional role and needs, while simultaneously developing nurses who can work collaboratively with others to meet positive patient outcomes? Collaboration requires an interactive process. If staff are not willing to interact or have any other barrier to interaction, collaboration cannot take place. Lack of understanding about the roles and responsibilities of others and lack of respect for what others have to contribute interferes with effective collaboration. How much do nurses know about what physicians or social workers or physical therapists or others do and vice versa? If there is distrust, collaboration is hindered because distrust affects willingness to share information, which is an integral component in the collaborative relationship. Collaboration has an impact on whether or not a team is effective or ineffective as team members need to work with each other to develop effective teams and also need to work with others external to the team. Conflict may arise as teams and individual staff work together. Conflict and conflict resolution are discussed in more detail later in this chapter. Although each nurse must develop individual expertise, this expertise must come together with others’ expertise. Few nurses really can work effectively in isolation. Nursing is a profession that requires contact with others—patients, other nursing staff, other healthcare professionals, families, community members, and so on.
Competencies and Strategies to Achieve Effective Collaboration
The increased emphasis on interprofessional teams to meet the patient’s needs across the continuum of care requires effective use of collaboration. The very nature of a team implies that there is more than one idea or approach and not all can usually be accomplished. Decisions need to be made, and this is where collaboration comes into play. It is important to remember that collaboration is also a critical factor in the nurse-patient relationship. Nurses need to actively pursue patient collaboration to ensure that patients are involved in their own care—patient-centered care. The nursing profession has long emphasized patient participation in planning care and in patient education. Collaboration is also important in the development of effective management. To be effective in collaboration, staff require a number of skills:
Communication skills are critical. Verbal skills are the focus; however, in some instances written communication is also important when information and process are described in written format.
Staff members also need to be aware of their own feelings, as was discussed in some of the leadership theories such as emotional intelligence.
Staff need to be able to make decisions to solve problems effectively.
As is discussed in this chapter, coordination is also important when collaborating with others.
Conflicts will arise, which may interfere with collaboration. Staff need to develop negotiation skills to be used in resolving difficult conflicts.
Assessment skills are needed to collect and analyze information as collaborative relationships develop. Box 13-1 highlights these skills.
Collaborative care is central to the success of efficient, outcome-driven care. With the complex healthcare system, specialization of many healthcare professionals, variety of healthcare settings, complex reimbursement systems, technology, and new drugs, collaboration is the only way that patients will receive quality, cost-effective care. Today the healthcare system is an interdependent system with multiple settings and a variety of healthcare professionals, who are dependent on one another. Delivery of care in this complex system requires sharing of information, analysis, critical thinking, clinical judgment, reasoning, clear communication, and ability to use team problem solving. These activities are integral to successful care as the nurse works with many different healthcare providers, within many different healthcare settings, and with the patient and family to ensure quality, cost-effective care for the patient.
Collaborative planning recognizes that collaboration has a positive effect on achieving patient outcomes (Institute of Medicine, 2001). Collaborative planning requires that all parties agree on the mission and goals of the partnership so they have common expectations. All members
Box 13-1 Collaboration: Skills Needed
Awareness of personal feelings
Recognition of expertise: Self and others
of the collaborative effort need to commit to open and honest communication, which is essential to sharing. This can be difficult in some HCOs, components of an organization such as specific units or departments, and for some individuals. Those who fear competition and are concerned about power will struggle with the need to share.
Regular evaluation needs to be built into collaborative planning. This evaluation should not only focus on the content of the planning but also on the process—how the collaborative relationship is working. This is something that is often neglected. Power, which is discussed later in this chapter, is related to collaboration. Usually some of the partners in a relationship have more power than others. When partners work through the collaborative planning process, some issues, such as weak communication, level of commitment, expertise, and an understanding that working together is better than working against one another, may interfere with the process. Recognizing these potential issues should be a priority to prevent barriers to success. What can be done to prevent them? Clear communication about purpose, particularly identifying issues from the past that may affect the collaborative planning, can help to clear up misconceptions. Team members need to accept the importance of effort and commit to it. All efforts should be made to keep team members committed. Evaluation data about the collaborative effort can help to improve team functioning.
Application of Collaboration
What is gained from collaboration? The complex healthcare delivery system requires many competencies, and no one healthcare profession has all of the necessary competencies to provide all the care that is required. Effective interprofessional teams and collaboration are critical. The IOM report on nursing (2004) identifies practices that have an impact on the delivery system, and these practices require collaboration to be effective. The practices are to create and maintain trust throughout the organization, deploy staff in adequate numbers, create a culture of openness so errors are reported, involve staff in decision making pertaining to work design and work flow, and actively manage the change process.
How do healthcare professionals develop the skills necessary for effective collaboration? There is a great need to incorporate more interprofessional educational experiences in all healthcare professional education, including nursing (Interprofessional Education Collaborative, 2011; World Health Organization, 2010). Students from the various healthcare professions need to have some experiences learning together in the same classroom and participating in clinical experiences together. Learning separately makes it very difficult to expect that at the time of graduation new healthcare professionals will easily collaborate when they have had limited collaborative experience with other healthcare professional students or healthcare professionals. They do not understand or respect the knowledge and learning experiences of other students or their roles and typical communication methods and processes. They may not even value or respect what other healthcare professionals offer to the team and to the patient. This causes serious problems as new healthcare professionals begin to work and are then confronted with working with one another. In addition, nurses need to have a positive understanding of their own roles and responsibilities—what they have to offer is valuable—so they can approach collaboration while understanding that they have important knowledge and competencies to add to the collaboration. This, however, must be accomplished not from the perspective of “I am better than you” but rather “How can we bring our respective skills and knowledge together to provide comprehensive, consistent care?” (Chapter 20 discusses staff education in more detail.)
Interprofessional relationships and activities can result in positive, collaborative outcomes; however, it is not easy to establish these relationships and maintain them over time. It takes time to develop an effective interprofessional environment. Other recommendations are to set realistic goals with commitment from all involved professionals, negotiate the means to meet the goals, avoid battles that serve only as barriers such as turf battles, and measure success based on established goals.
The IOM identifies care coordination as one of the critical priority areas of care that need be monitored and improved. The purpose of care coordination is “to establish and support a continuous healing relationship, enabled by an integrated clinical environment and characterized by a proactive delivery of evidence-based care and follow-up” (Institute of Medicine, 2003b, p. 49). Patient-centered care is discussed in Chapter 9; however, patient-centered care is an important theme throughout this text. There needs to be greater attention on how care is coordinated across people, functions, activities, and sites to provide effective and efficient care that leads to the patient’s specific desired outcomes. Coordination requires that the nurse understands patient needs and the resources that are available to meet these needs. An awareness of the association of costs and services is part of coordinating patient care. The healthcare delivery system has become more complex, which has made communication and coordination more complex, all of which leads to increased risk of errors. There is greater need for interprofessional teams. Team members may not always view the patient, problems, or priorities in the same way, yet it is critical that the team find a way to work collaboratively to provide coordinated patient care. Team members need to have a better understanding of individual responsibilities and stress to appreciate each other and develop more realistic working relationships. As noted by the IOM healthcare core competency, all healthcare professionals need to know how to work in interprofessional teams (Institute of Medicine, 2003a). Recognizing this will make coordination less frustrating.
Key Definitions Related to Coordination
Coordination is the process of working to see that “the pieces and activities fit together and flow as they should” (Finkelman & Kenner, 2016, p. 328). Effective coordination requires working across services that are complementary—across clinicians or settings—to ensure quality care across patient conditions, services, and settings over time (Institute of Medicine, 2001). Examples might be physicians, nurses, social workers, pharmacists, informatics specialists, and administrators working together to improve documentation through an electronic medical record or staff from a hospital and an ambulatory care center working together to coordinate better care for patients. Coordination is related to collaboration, and in fact, it is very difficult to do one without the other. When considering patient care, however, there is a critical difference between the two. Collaboration with a patient requires a direct interaction with the patient. Coordination of care usually takes place before or after patient care is provided, or it is interwoven in the care process. In the latter situation, a nurse may ensure that all the plans for the patient’s discharge are complete or that the various treatment and exam procedures are scheduled appropriately for the patient’s needs. Coordination does not mean that the patient is not involved because patient input is critical to achieve patient-centered care, but the nurse may do the coordination such as calling for supplies or making sure a treatment is scheduled when not in the presence of the patient or while providing direct care. Both coordination and collaboration are also found daily in staff-to-staff interactions. Collaboration focuses on solving a problem with two or more people working toward this goal. Coordination is done to ensure that something happens such as the provision of services. The ANA Nursing Administration Scope and Standards of Practice (2009) includes a standard on coordination recognizing the need for nurses in administration/management to be competent in coordination, which is needed for planning and implementation of plans, implementation of the management functions, teamwork with other nurses and interprofessional teams, and is part of effective communication with staff and patients/families/significant others. The ANA supports the need for care coordination as an important component of improving the quality of care and providing for efficient and effective use of resources. Care coordination needs to be a critical competency that all registered nurses demonstrate (American Nurses Association, 2012).
Barriers to Effective Coordination
As HCOs and services become more complex and use more interprofessional teams, team members may not always have the same view of the patient, problems, or priorities. It is, however, critical that the team find a way to work collaboratively to provide coordinated patient care and prevent errors, disorganized care, and care that does not reach effective outcomes. Team members need to have a better understanding of individual responsibilities and their own stress to appreciate each other and develop more realistic working relationships. Coordination is also more effective when involved staff have a better understanding of their respective roles and work stresses. Recognizing this will make coordination less frustrating. If resources are not available
Applying Evidence-Based Practice Evidence for Effective Leadership and Practice
American Academy of Nursing. (2012, March 5). The imperative for patient, family, and population centered interprofessional approaches to care coordination and transitional care. Policy Brief 126.96.36.199. Retrieved from http://www.aannet.org/assets/docs/PolicyResources/aan_care%20coordination_3.7.12_email.pdf
The American Academy of Nursing (AAN) praises the Centers for Medicare & Medicaid Services (CMS) for its support of evidence-based care coordination and transitional care, which has been applied to Medicare and Medicaid services. The AAN recommends that the CMS consider the framework it will use to implement care coordination and the evidence to support that framework.
This paper from AAN suggests various models and measurement methods to assist CMS in the implementation of greater use of care coordination, which requires an interprofessional team approach.
What are the guiding principles recommended by the AAN?
Why is this change important?
What models are described? How is measurement included?
Analyze the recommendations made by the AAN.
when and in the manner required, this will act as a barrier to coordination. Staff who are not willing to listen and include others will find that coordination may not be as successful as planned. Other barriers are a lack of interprofessional understanding, lack of resources, and inadequate communication. Ineffective problem solving is also a critical barrier. Coordination needs to include the patient and, when appropriate and agreeable with the patient, the family. If patient engagement is not present, it is a major obstacle to care.
Competencies and Strategies to Achieve Effective Coordination
For staff to provide effective coordination, they need to make decisions to solve problems, plan, use the abilities of other staff, identify resources required, communicate, and be willing to collaborate. Delegation often is required, so delegation skills are important. (See Chapter 15 for more discussion on delegation.) The nurse also needs to develop evaluation skills to determine if outcomes are met as well as when to change course or make adjustments. The skills required for coordination are the same ones required for collaboration, with the primary goal of working together to reach agreed-upon goals. Box 13-2 highlights the skills needed for effective coordination.
Application of Coordination
Coordination is integral to daily operations, short- and long-range planning, and the daily care process. All of these activities require coordination of clinical and administrative resources. The following strategies are helpful in improving coordination (Finkelman & Kenner, 2016):
All staff need to understand the importance of coordination.
All staff should have a clear understanding of purpose and goals.
All staff should have knowledge of policies and procedures with an understanding of what has to be done, by whom, and how it will help to facilitate coordination.
Improved organizational performance will depend on coordination at all levels in the organization.
Communication needs to be clear and timely. (See Chapter 14.)
Orientation and staff development programs should emphasize the importance of coordination and how to use it.
Box 13-2 Coordination: Skills Needed
Use abilities of others
Identify needed resources
Coordination requires effective communication and collaboration.
Staff/team members need to appreciate the expertise of other team members.
Delegation should be used as needed. (See Chapter 15.)
Health care uses many tools that focus on coordination of care to ensure patient-centered care. Some of these are case management, clinical pathways, practice guidelines, and disease management. To be successful and meet expected outcomes, these tools or methods also require collaboration with the patient, patient’s family and significant other, and other healthcare staff, and they are very useful when coordination is required. With insurers emphasizing more effective and efficient care, coordination plays a major role in reaching this goal. Coordination requires that the nurse understand patient needs and the resources that are available to meet these needs. An awareness of the association of costs and services is part of coordinating patient care. In addition, coordination is a very important part of management within the healthcare delivery system. This system has become more complex, which has made communication and coordination more complex. Coordination is required to get resources, schedule staff, plan work activities, implement quality improvement, and perform all types of management functions. With the growth of informatics in documentation and decision-making tools, additional methods are now available and new ones will be developed. (See Chapter 19.) Figure 13-1 describes one view of competencies needed to get results
Negotiation and Conflict Resolution
There may be conflict between professions, but there is also conflict within the nursing profession and with coworkers. In these situations, staff members may attack one another by asserting their position or by criticizing ideas. In some cases, they attack one another personally. Collaboration is used frequently to reach an agreement during a conflict. This is often true with nurse-physician collaboration, though ideally collaboration should be part of all of their interactions. Nurse-physician relationships are complex. There is overlapping focus in that both are concerned about the patient, though each may come from different points of view, which is not always understood or appreciated. There is also some confusion about roles, which can lead to problems. In some cases there is a certain amount of competition, which really is a sad statement; the goal should be focused on what is best for the patient and not what is best for individual staff or individual professions.
Conflict can never be eliminated in organizations; however, conflict can be managed. Typically conflict arises when people feel strongly about something. Conflicts may take place between individual staff, within a unit, or within a department. They may be interunit and interdepartmental, affect the entire HCO, or even occur between multiple organizations, between or within teams or units, or between an HCO and the community. When people disagree, this may lead to conflict—having views that are different and do not seem to be easy to resolve (MindTools®, 2014a).
Key Definitions Related to Conflict
There are three types of conflict: individual, interpersonal, and intergroup/organizational (MindTools®, 2014a).
Individual conflict. The most common type of individual conflict in the workplace is role conflict, which occurs when there is incompatibility between one or more role expectations. When staff do not understand the roles of other staff, this can be very stressful for the individual and affects work. Staff may be critical of each other for not doing some work activity when in reality it is not part of the role and responsibilities of that staff member, or staff members may feel that another staff member is doing some activity that really is not his or her responsibility.
Interpersonal conflict. This conflict occurs between people. Sometimes this is due to differences and/or personalities; competition; or concern about territory, control, or loss.
Intergroup/organizational conflict. Conflict also occurs between teams (e.g., units, services, teams, healthcare professional groups, agencies, community and a healthcare provider organization, and so on). Sometimes this is due to competition, lack of understanding of purpose for another team, and lack of leadership within a team or across teams within an HCO.
A leader’s ultimate purpose is to accomplish organizational results. A leader gets results by providing guidance and managing resources, as well as performing the other leader competencies. This competency is focused on consistent and ethical task accomplishment through supervising, managing, monitoring, and controlling of the work.
Prioritizes, organizes, and coordinates taskings for teams or other organizational structures/groups
Uses planning to ensure each course of action achieves the desired outcome.
Organizes groups and teams to accomplish work.
Plans to ensure that all tasks can be executed in the time available and that tasks depending on other tasks are executed in the correct sequence.
Limits overspecification and micromanagement.
Identifies and accounts for individual and group capabilities and commitment to task
Considers duty positions, capabilities, and developmental needs when assigning tasks.
Conducts initial assessments when beginning a new task or assuming a new position.
Designates, clarifies, and deconflicts roles
Establishes and employs procedures for monitoring, coordinating, and regulating subordinates’ actions and activities.
Mediates peer conflicts and disagreements.
Identifies, contends for, allocates, and manages resources
Allocates adequate time for task completion.
Keeps track of people and equipment.
Allocates time to prepare and conduct rehearsals.
Continually seeks improvement in operating efficiency, resource conservation, and fiscal responsibility.
Attracts, recognizes, and retains talent.
Removes work barriers
Protects organization from unnecessary taskings and distractions.
Recognizes and resolves scheduling conflicts.
Overcomes other obstacles preventing full attention to accomplishing the mission.
Recognizes and rewards good performance
Recognizes individual and team accomplishments; rewards them appropriately.
Credits subordinates for good performance.
Builds on successes.
Explores new reward systems and understands individual reward motivations.
Seeks, recognizes, and takes advantage of opportunities to improve performance
Asks incisive questions.
Anticipates needs for action.
Analyzes activities to determine how desired end states are achieved or affected.
Acts to improve the organization’s collective performance.
Envisions ways to improve.
Recommends best methods for accomplishing tasks.
Leverages information and communication technology to improve individual and group effectiveness.
Encourages staff to use creativity to solve problems.
Makes feedback part of work processes
Gives and seeks accurate and timely feedback.
Uses feedback to modify duties, tasks, procedures, requirements, and goals when appropriate.
Uses assessment techniques and evaluation tools (such as AARs) to identify lessons learned and facilitate consistent improvement.
Determines the appropriate setting and timing for feedback.
Executes plans to accomplish the mission
Schedules activities to meet all commitments in critical performance areas.
Notifies peers and subordinates in advance when their support is required.
Keeps track of task assignments and suspenses.
Adjusts assignments, if necessary.
Attends to details.
Identifies and adjusts to external influences on the mission or taskings and organization
Gathers and analyzes relevant information about changing situations.
Determines causes, effects, and contributing factors of problems.
Considers contingencies and their consequences.
Makes necessary, on-the-spot adjustments.
Figure 13-1 Competency: Gets results and associated components and actions
Source: U.S. Army. (2006). Army leadership: Competent, confident, and agile. Retrieved from http://fas.org/irp/doddir/army/fm6-22.pdf
When conflict occurs, something is out of sync, usually due to a lack of clear understanding of one another’s roles and responsibilities. Sometimes conflict is open and obvious, and sometimes it is not as obvious; this latter type may be more destructive as staff may be responding negatively without a clear reason. Everyone has experienced covert conflict. It never feels good and increases stress quickly. Distrust and confusion about the best response are also experienced. Acknowledging covert conflict is not easy, and staff will have different perceptions of the conflict since it is not clear and below the surface. Overt conflict is obvious, at least to most people, and thus coping with it is usually easier. It is easier to arrive at an agreement when overt conflict is present and easier to arrive at a description of the conflict.
The common assumption about conflict is that it is destructive, and it certainly can be. There is, however, another view of conflict. It can be used to improve if changes are made to address problems related to the conflict. The following quote speaks to the need to recognize that conflict can be viewed as an opportunity.
When I speak of celebrating conflict, others often look at me as if I have just stepped over the credibility line. As nurses, we have been socialized to avoid conflict. Our modus operandi has been to smooth over at all costs, particularly if the dynamic involves individuals representing roles that have significant power differences in the organization. Be advised that well-functioning transdisciplinary teams will encounter conflict-laden situations. It is inevitable. The role of the leader is to use conflicting perspectives to highlight and hone the rich diversity that is present within the team. Conflict also provides opportunities for individuals to present divergent yet equally valid views that allow all team members to gain an understanding of their contributions to the process. Respect for each team member’s standpoint comes only after the team has explored fully and learned to appreciate the diversity of its membership.
(Weaver, 2001, p. 83)
This is a positive view of conflict, which on the surface may appear negative. If one asked nurses if they wanted to experience conflict, they would say no. Probably behind their response is the fact that they do not know how to handle conflict and feel uncomfortable with it. However, if you asked staff, “Would you like to work in an environment where staff at all levels could be direct without concern of repercussions and could actively dialogue about issues and problems without others taking comments personally?” many staff would most likely see this as positive and not conflict. Avoidance of conflict, however, usually means that it will catch up with the person again, and then it may be more difficult to resolve. There may then be more emotions attached to it, making it more difficult to resolve.
Causes of Conflict
Effective resolution of conflict requires an understanding of the cause of the conflict; however, some conflicts may have more than one cause. It is easy to jump to conclusions without doing a thorough assessment. Some of the typical causes of conflict between individuals and between teams/groups are “whether resources are shared equitably; insufficient explanation of expectations, leading to performance being questioned; unexplained changes that disturb routines and processes and that team members are not prepared for; and stress resulting from changes that team members do not understand and may see as threatening” (Finkelman & Kenner, 2016, p. 336).
Two predictors of conflict are the existence of competition for resources and inadequate communication. It is rare that a major change on a unit or in an HCO does not result in competition for resources (staff, financial, space, supplies), so conflicts arise between units or between those who may or may not receive the resources or may lose resources. Causes of conflict can be varied. An understanding of a conflict requires as thorough an assessment as possible. Along with the assessment, it is important to understand the stages of conflict.
Stages of Conflict
There are four stages of conflict that help describe the process of conflict development (MBA, 2014):
Latent conflict. This stage involves the anticipation of conflict. Competition for resources or inadequate communication can be predictors of conflict. Anticipating conflict can increase tension. This is when staff may verbalize, “We know this is going to be a problem,” or may feel this internally. The anticipation of conflict can occur between units that
Figure 13-2 Stages of conflict
accept one another’s patients when one unit does not think that the staff members on the other unit are very competent yet must accept orders and patient plans from them.
Perceived conflict. This stage requires recognition or awareness that conflict exists at a particular time. It may not be discussed but only felt. Perception is very important as it can affect whether or not there really is a conflict, what is known about the conflict, and how it might be resolved.
Felt conflict. This occurs when individuals begin to have feelings about the conflict such as anxiety or anger. Staff feel stress at this time. If avoidance is used at this time, it may prevent the conflict from moving to the next stage. Avoidance may be appropriate in some circumstances, but sometimes it just covers over the conflict and does not resolve it. In this case the conflict may come up again and be more complicated. Trust plays a role here. How much do staff trust that the situation will be resolved effectively? How comfortable do staff members feel in being open with their feelings and opinions?
Manifest conflict. This is overt conflict. At this time the conflict can be constructive or destructive. Examples of destructive behavior related to the conflict are ignoring a policy, denying a problem, avoiding a staff member, and discussing staff in public with negative comments. Examples of constructive responses to the conflict include encouraging the team to identify and solve the problem, expressing appropriate feelings, and offering to help out a staff member. (Figure 13-2 highlights the stages of conflict.)
Prevention of Conflict
Some conflict can be prevented, so it is important to take preventive steps whenever possible to correct a problem before it develops into a conflict. A staff team or HCO that says it has no conflicts is either not aware of conflict or prefers not to acknowledge it. Prevention of conflict should focus on the typical causes of conflict that have been identified in this chapter. Clear communication, known expectations, appropriate allocation of resources, and delineation of roles and responsibilities will go a long way toward preventing conflict. If the goal is to eliminate all conflict, this will not be successful because it cannot be done.
Since not all conflict can be prevented, managers and staff need to know how to manage conflict and resolve it when it exists. It is important to identify potential barriers that can make it more likely that a situation will turn into a conflict or will act as barriers to conflict resolution. First and foremost, if all staff make an effort to decrease their tension or stress level, this will go a long way in preventing or resolving conflict. In addition to this strategy, it is important to improve communication, recognize team members as members with expertise, listen and compromise to get to the most effective decision given the available data, understand the roles and responsibilities of team/staff members, and be willing to evaluate practice and team functioning.
Conflict Management: Issues and Strategies
Conflict management is critical in any HCO. When conflicts arise, then managers and staff need to understand conflict management issues and strategies. The major goals of conflict management are as follows:
To eliminate or decrease the conflict
To meet the needs of the patient, family/significant others, and the organization
To ensure that all parties feel positive about the resolution so future work together can be productive
Powerlessness and Empowerment
When staff experience conflict, powerlessness and empowerment, as well as aggressiveness and passive-aggressiveness, become important. When staff members feel that they are not recognized, appreciated, or paid attention to, then they feel powerless. What happens in a work environment when staff feel powerless? First, staff members do not feel they can make an impact; they are unable to change situations they think need to be changed. Staff members will not be as creative in approaching problems. They may feel they are responsible for tasks yet have no control or power to effect change with these tasks. The team community will be affected negatively, and eventually the team may feel it cannot make change happen. Staff may make any of the following comments: “Don’t bother trying to make a difference,” “I can’t make a difference here,” and “Who listens to us?” Morale deteriorates as staff feel more and more powerless. New staff will soon pick up on the feeling of powerlessness. In some respects, the powerlessness really does diminish any effort for change. As was discussed in Chapter 3, responding to change effectively is very important today. In addition, when staff feel powerless, this greatly impacts the organizational culture.
Power is about influencing decisions, controlling resources, and affecting behavior. It is the ability to get things done—access resources and information, and use them to make decisions. Power can be used constructively or destructively. The power a person has originates from the person’s personal qualities and characteristics, as well as the person’s position. Some people have qualities that make others turn to them—people trust them, consider their advice helpful, and so on. A person’s position, such as a team leader or nurse manager, has associated power.
Power is not stagnant. It changes as it is affected by the situation. There are a number of sources of power. Each one can be useful depending on the circumstances and the goal. An individual may have several sources of power. The common sources of power include the following:
Legitimate power. This power is what one typically thinks of in relation to power. It is power that comes from having a formal position in an organization such as a nurse manager, team leader, or vice president of patient services. These positions give the person who holds the position the right to influence staff and expect staff to follow requests. Staff members recognize that they have tasks to accomplish and job requirements. It is important to note that a leader must have legitimate power. This is a critical concept to understand about leadership and power. However, it takes more than power to be an effective leader and manager. The leader must also demonstrate competency.
Reward power. A person’s power comes from the ability to reward others when they comply. Examples of reward power include money (such as an increase in salary level), desired schedule or assignment, providing a space to work, and recognition of accomplishment.
Coercive power. This type of power is based on punishment initiated when a person does not do what is expected or directed. Examples of punishment may include denial of a pay raise, termination, and poor schedule or assignment. This type of power leads to an unpleasant work situation. Staff will not respond positively to coercive power, and this type of power has a strong negative effect on staff morale.
Referent power. This informal power comes from others recognizing that an individual has special qualities and is admired. This person then has influence over others because they want to follow the person due to the person’s charisma. Staff feel valued and accepted.
Expert power. When a person has expertise in a particular topic or activity, the person can have power over others who respect the expertise. When this type of power is present, the expert is able to provide sound advice and direction.
Box 13-3 Types of Power
Informational power. This type of power arises from the ability to access and share information, which is critical in the Information Age.
Persuasive power. This type of power influences others by providing an effective point of view or argument (Finkelman & Kenner, 2016). (Box 13-3 highlights the types of power.)
All HCOs experience their own politics, and this usually involves some staff trying to gain power, hold on to power, or expand power. As has been said, power can be used negatively, and this can also lead to the unethical use of power or not doing the right thing with the power. Chapter 2 discusses examples of ethical issues. There is no doubt that there are managers who use their power to control staff, as well as staff who use power to control other staff, but this is not a healthy use of power. Rather, it is a misuse of power and does not demonstrate nursing leadership.
A self-appraisal of a person’s personal view of power allows the individual to better understand how the person uses power and how it then affects the person’s decisions and relationships. This can lead to more effective responses to change during planning and decision making, coping with conflict, and the ability to collaborate and coordinate.
Empowerment is often viewed as the sharing of power; however, it is more than this. “To empower is to enable to act” (Finkelman & Kenner, 2016). Power must be more than words; it must be demonstrated. Participative decision making empowers staff but only if staff really do have the opportunity to participate and influence decisions. Recognizing that one’s participation is accepted makes a difference. True empowerment gives the staff the right to choose how to address issues with the manager.
Should all staff be empowered? A critical issue to consider when answering this question is whether or not staff can effectively handle decision making. This implies that staff members need leadership qualities and skills to make sound decisions and participate together collaboratively. They need to be able to use communication effectively. When staff members are selected, all these factors become important. Empowerment is not gained just by being a member of the staff, but rather staff members become empowered because they are able to handle it. Management who want to empower staff must transfer power over to the staff, but management must first feel confident that staff can handle empowerment.
When staff are empowered, some limits or boundaries need to be set, or conflict may develop. Some of these boundaries are established by the HCO’s policies, procedures, and position descriptions; education and experience; standards; and laws and regulations (for example, state nurse practice acts). The manager must be aware of these boundaries and establish any others that may be required (for example, direct involvement of staff in the selection process for new equipment). If staff members are involved in the decision making, then they should first be given a list of several possible equipment choices that meet the budgetary requirements and criteria to use in the evaluation process. It is critical that the manager make clear the boundaries, or staff members will feel like their efforts are useless if their suggestions are rejected because they were not given the boundaries. Setting staff up by not giving them full information leads to poor choices and is not effective. What does this mean? Roles and responsibilities need to be clearly described, and if they change, they need to be discussed. At the same time, the nurse manager or the team leader must not control, domineer, or overpower staff. This type of response is usually seen in new nurse managers or team leaders who feel insecure. Ineffective use of empowerment can be just as problematic as a lack of empowerment.
Although empowering oneself may seem like an unusual concept, it is an important one. The amount of power a person has in a relationship is determined by the degree to which someone else needs what the other person has. Anger is related to expectations that are not met, and when these expectations are not met, the person may act out to gain power. It is the responsibility of the nursing profession to communicate what nurses have to offer to patient care and to the healthcare delivery system, but individual nurses also need to understand what they have to offer as nurses. To have an impact, this communication and development must be ongoing. Empowerment can be positive if the strategies that are used to gain empowerment are constructive (for example, gaining new competencies, speaking out constructively, networking, using political advocacy, increasing involvement in planning and decision making, getting more nurses on key organization committees, improving image through a positive image campaign, and developing and implementing assertiveness). There are many other strategies that can result in empowerment that improves the workplace and the nurse’s self-perception.
Aggressive and Passive-Aggressive Behavior
Aggressive and passive-aggressive behavior can interfere with successful conflict resolution and might even be the cause of conflict. When staff members are hostile to one another, the team leader, or the nurse manager, anxiety rises. Hostile behavior can be a response to conflict. It is important to recognize personal feelings. The first response should be to get emotions under control and communicate control to the hostile staff member. The nurse manager or team leader may be the one who is hostile, which makes it even more complex and requires assistance from higher-level management. It is hoped someone will recognize the need to bring the situation under control and try to move to a private place. Demonstrations of open conflict with hostility should not take place in patient or public areas. If the suggestion to move to a private area does not work and the situation continues to escalate, simply walking away may help set some boundaries. Cool down time is definitely needed.
There are many times when more information is really required before a response can be given. If this is the case, everyone concerned needs to be told that when information is gathered, the issue or problem will then be discussed. No one should be pressured to respond with inadequate information as this will lead to ineffective decision making and may lead to further hostility. It is critical that after further assessment is completed there be additional discussion and a conclusion.
When there are conflicts with patients and families, what is the best way to cope? Many of the same strategies mentioned earlier can be used. Safety is the first issue, as it must be maintained. It is never appropriate to allow patients or families to demonstrate anger inappropriately. When this occurs, someone needs to set reasonable limits that are based on an assessment of the situation. There may be many reasons for anger and inappropriate behavior, such as pain, medications, fear and anxiety, psychosis, dysfunctional communication, and so on. Staff need to avoid taking things personally as this will interfere with thoughtful problem solving. When one gets defensive or emotional, interventions taken to resolve a conflict may not be effective. Active listening is critical to cope with emotions. If a different culture is involved, then this factor needs to be considered. (For example, some cultures consider it appropriate to be very emotional, and others do not.) In the long term, clear communication is critical during the entire process.
How Do Individual Staff Members Cope With Conflict?
Not everyone responds to conflict in the same way, and individuals may vary in how they respond dependent on the circumstances. Four typical responses to conflict are avoidance, accommodation, competition, and collaboration (MindTools®, 2014a).
Avoidance occurs when a person is very uncomfortable and cannot cope with the anxiety effectively. This person will withdraw from the situation to avoid it. There are times when this may be the most effective response, particularly when the situation may lead to negative results, but in many situations this will not be effective in the long term. This response might occur when a staff member is in conflict with a manager and disagrees with the manager. The staff member must consider whether it is worthwhile to disagree publicly. Typically avoidance occurs when one side is perceived as more powerful than the other. It is a helpful approach when more information is needed or when the issue is not worth what might be lost.
A second response is accommodation. How does this occur? The person tries to make the situation better by cooperating. The critical issue may not be resolved or not resolved to the fullest satisfaction. The goal is just to eliminate the conflict as quickly as possible. Accommodation works best when one person or team is less interested in the issue than the other. It can be advantageous as it does develop harmony, and it can provide power in future conflict since one party was more willing to let the conflict deflate. Later interaction may require that the other party cooperate.
A third response is competition. How does this work? Power is used to stop the conflict. A manager might say, “This is the way it will be.” This closes further efforts from others who may be in conflict with the manager.
Collaboration is the fourth response, which has been discussed in this chapter. This is a positive approach, with all parties attempting to reach an acceptable solution, and in the end, both sides feel they won something. Collaboration often involves some compromise, which is a method used to respond to conflict.
Using the best conflict resolution style can make a difference in success. There are many ways that a conflict can be resolved. When conflict occurs, each person involved has a personal perspective of the issue and conflict. Today there is more conflict in the healthcare delivery environment with increased workplace stress that may lead to misunderstandings, ineffective communication, and reduced productivity and dysfunctional organizations, as noted in the Institute of Medicine reports (2001, 2004).
Are there differences in the ways in which women and men negotiate? There are differences in how women and men approach leadership issues such as conflict (Greenberg, 2005). Men tend to negotiate to win, while women focus more on what is fair. It is believed that this is related to the way children play through sports and activities. Women will make an effort to reach win-win solutions. Men will test the limits that have been set more overtly than women, so it is important for women to ensure that limits are set and maintained. It is important, despite the differences described, to avoid stereotyping.
Though the nurse-physician relationship should be the strongest relationship that nurses have to meet the needs of the patient, it frequently is not. Both sides have a role in the inadequacies of this relationship. Conflict does occur and this conflict can act as a barrier to effective patient care. Collegial relationships are those where there is equality of power and knowledge. In contrast, collaborative relationships between nurses and physicians focus on mutual power, but typically the physician’s power is greater. The nurse’s power is based on the nurse’s extended time with patients, experience, and knowledge. In addition to power, this relationship requires respect and trust between the nurse and physician. Due to these factors, it is a complex relationship.
Nurses have long worked on teams, mostly with other nursing staff. However, the nurse-physician relationships have become more important in the changing healthcare environment with the greater emphasis on interprofessional teams. Nurse-physician interactions and communication have been discussed for a long time in healthcare literature.
Physicians, however, are not the only healthcare providers nurses must work with while they provide care. (For example, nurses work with other nursing staff, social workers, support staff, laboratory technicians, physical therapists, pharmacists, and many others.) There are also other members joining the healthcare team such as alternative therapists (massage therapists, herbal therapists, acupuncturists, etc.), case managers, more actively involved insurers, and so forth. The future will probably bring other new members into the healthcare delivery system. Nurses need to develop the skills necessary to participate effectively on the team, which requires collaboration, communication, coordination, delegation, and negotiation. Communication and delegation are discussed in other chapters. It is difficult to practice today in any healthcare setting without experiencing interprofessional interactions such as nurse to physician. Effective teams:
work together (collaborate).