After you have completed the dominance, inducement, submission, compliance (DiSC) style assessment, identify two conflicts (

C onflict, 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 conflict management, with favourable team leadership, can be beneficial. Positive management fosters mutual role respect, improves working relationships, recovers staff retention and sickness, and especially benefits new members of staff who may find it difficult coming into long-established teams (Marquis and Huston, 2014; Stanton, 2014). Moreover, if conflict is not managed effectively, 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.

The Nursing and Midwifery Council (2015) Code highlights a nurses’ professional responsibility to work cooperatively and

Conflict management: importance and implications Laurie McKibben

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.

Key words: Conflict ■ Patient care team ■ Work performance ■ Leadership ■ Nursing ■ Morale

Laurie McKibben, Registered Nurse, Belfast HSC Trust, Queen’s University, Belfast, [email protected]

Accepted for publication: January 2017

use effective communication to resolve differences between colleagues when they arise. The nurse is legally accountable for providing safe competent care, and is ethically bound to the non-maleficence 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 conflict, and promote the health and wellbeing of patients.

In respect to those in management positions, the Health and Safety at Work Order (1978) identifies 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 effective resolution techniques to minimise low morale, stress and illness of team members.

Conflict defined In order to discuss positive approaches to managing conflict, it must first be defined and its potential genesis acknowledged. There are several definitions; it has been described as an interpersonal disagreement, or discord between two or more individuals, owing to difference in opinion, competition, negative perceptions, poorly defined role expectations or lack of communication (Ellis and Abbott, 2011; Marquis and Huston, 2014).

Johansen (2012) provided a different perspective on conflict 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 definitions a wider perspective is provided upon how we define the larger, abstract concept of conflict 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 effective leadership and team management.

Organisational conflict and dynamics In relation to understanding organisational conflict, it can be beneficial 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 first latent phase is when there is unease and conflict is imminent, the second perceived phase is where there is believed conflict but it is minimised, and the third felt phase is concerned with personalised conflict, where there

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is discomfort experienced. The final two phases are manifest, when conflict is expressed, and the aftermath, and how this affects the individuals and the team. Pondy viewed conflict as dynamic, and despite how or why conflict arises, it can still be inspected and managed using this framework.

Thomas’s (1992) model agreed that conflict is dynamic in that it is continuous, with the outcome of one episode of conflict leading to another. The model involves awareness, thoughts and emotions, intentions, behaviour and outcomes. Thomas suggests conflict 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 beneficial in resolving such conflict, whether it is new or ongoing.

Organisational conflict 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 definitions of conflict. To expand, types of specific team conflict have been shown to include tasks, relationships, and the processes that enable tasks to be carried out. These conflicts directly impact on performance, however, the influence 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 conflict in teams is in terms of task and relationships, however acknowledge other predisposing conditions such as the characteristics of the conflict or indeed the individuals. Barr and Dowding (2012) offer three types of relationship-based conflict; intrapersonal, interpersonal and inter-group. Intrapersonal conflict is internal discord and conflict occurring within the individual, which can manifest from role confusion for example. Interpersonal conflict arises between two or more people with differing views or goals, which may lead to harassment and stress, and intergroup conflict involves two or more teams who, for example, do not share the same organisational goals. Common interpersonal conflict is relationship based with interpersonal frictions, tensions and resentment occurring between two or more team members. It is essential that this is identified 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 conflict arising from incompatible views on how work should be done, for example distribution of the workload and task ordering, can also affect individual job performance and overall team functioning (Jehn, 1997). It is therefore important that the conflict 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 conflict 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 conflict 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 Effective resolution and conflict management can be beneficial 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 conflict 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 conflict: commanding, compar ing, 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. Conflict 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 conflict. This model suggests that groups work though sequential stages of evolution before performing in a cultivated and efficient manner. The forming stage incorporates group efforts to come together, storming exposes conflict and hostility, norming involves group settling, and performing concludes in optimum performance. The fifth 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 conflict still exists in many healthcare teams.

In order to minimise conflict or manage it effectively, 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 conflict management, identifying five 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 Conflict Mode Instrument (TKI) was developed to identify conflict style. The five styles were: collaborating, compromising, accommodating, competing and avoidance.

Collaborators meet everyone’s needs, compromising individuals implement problem solving to find a solution that satisfies the greatest number of people, while accommodators meet the needs of other team members while sacrificing 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 Abbott, 2011).

In understanding what kind of style a person adopts in

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relation to conflict we enhance our ability to manage it more effectively. 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 conflict positively. In order to manage conflict, the source must first be identified, including the type of conflict, 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 conflict, they should be encouraged to admit accountability (Ellis and Abbott, 2011; Johansen, 2012). This is in keeping with the collaborator or compromising conflict 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, defining transformational leaders as the most effective, 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 effectively 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 effective leadership will help prevent or resolve conflict positively, through harmonious team function and raised morale.

In contrast if a manager is too open, or adopts a poor TKI conflict 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 conflict, 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 conflict resolution must be processed upward within the organisation, or autonomous mediation may be required (National Health Service Improving Quality (NHSIQ), 2013).

Change Change and conflict are intertwined as one can precipitate the other. For example, unplanned change with poor

communication can be a cause of conflict 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-confidence, therefore, people management via effective leadership is implicit (Tavakoli, 2014). In this circumstance conflict 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 conflict will arise or not. If conflict 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 satisfies the criteria for a cohesive well-functioning team, which minimises the risk of negative conflict. This acknowledges that episodes of conflict in these circumstances are not necessarily negative, and that management of conflict 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 staff morale, thus reducing long-term issues such as high staff turnover and sickness levels (Ellis and Abbott, 2011).

Conflict as beneficial Weber (1947) and Fayol’s (1949) old theories argued a bureaucratic system of mechanistic structure to discourage and eliminate conflict 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 conflict, 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 conflict (Marquis and Huston, 2014; Stanton, 2014).

Conflict, when used positively, can stimulate and encourage change if team function has become stagnant, increase productivity, and inspire critical thinking. Pondy (1992) stated that conflict 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 that conflict status needs reassessed regularly, with ongoing management taking into account factors such as emotions, behaviours and outcomes.

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Conflict 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 conflicts 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 conflict, management style, conflict 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 conflict can promote an opportunity for growth in the clinical team, this can be constructive if there is a balance, as too much negatively affects 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 find mutually satisfactory agreements, this is beneficial 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 conflict 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 conflict 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 reflective practice, can enhance or develop conflict management styles (Johansen, 2012). Considerate management fosters an environment that minimises precursory conditions for future conflicts and organisational stasis (Marquis and Huston, 2014).

Even the best functioning teams will encounter conflict. 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). Conflict 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 ■ Conflict is inevitable within healthcare teams

■ Poorly managed conflict 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 beneficial conflict resolution and promote team function and harmony

■ In the dynamic area of health care, change should be expected, and any manifest conflict used as a driving force for positive change

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