2

Where Does Conflict 

Come From?

Conflict is generally recognized as the existence of real or perceived differences within an individual (i.e., a nurse whose personal beliefs conflict with her professional beliefs), or between two or more individuals (e.g., two hospital departments in conflict over limited equipment, dollars), involving feelings, thoughts, resources, and actions.

Disagreement among staff members in relationships, groups, teams and organizations comes with the territory. It's common to hear:

u"What I dislike most about conflict and disagreements is the endless arguing and having to listen to someone else's stored up anger and resentment. Who needs it?"

u"We could be doing something a lot more productive than dancing around the conflict in this unit. It's a waste of time, resources and money, not to mention the effect it has on productivity and patient care."

u"Sure, I could be understanding and listen to why a staff member doesn't want to follow instructions and maybe even give some help or mentoring. But, all I'm going to get for my trouble is that others in the unit will start talking and questioning what I'm doing and then my manager will see me as weak. As far as I'm concerned, nice guys finish last."

Every encounter with someone whose views differ from our own offers the potential for friction, wasted time, bruised feelings, and looking foolish. Managing conflict and interpersonal differences isn't easy. Signs of mismanagement are everywhere, back-biting, rivalry, bickering coworkers and colleagues. Not resolving these differences can leave emotional scars, undermines morale and certainly diverts energy from taking care of the patient. No wonder so many people walk away from trying to resolve conflict.

Another factor to consider is the present state of the health care environment. It is a stressful environment because of the nature of work, which often involves life and death. The complexity of health and medical care requires that many people need to work closely together. Interdependence, particularly where there are limited resources, inevitably leads to conflict. Bernice Potter has outlined several definitions of conflict below:

¶ Conflict is a process that occurs whenever two or more parties experience incompatible goals or scarce resources.

¶ Conflict is a set of divergent aims, methods, or behavior. The degree of the divergence determines the severity and duration of the conflict.

¶ Conflict is a struggle of values or claims to status, power, and scarce resources.

¶ Conflict is an expressed struggle between at least two interdependent parties who perceive incompatible goals, scarce rewards, and interference from the other party in achieving their goals.

[Bernice Potter. From Conflict to Collaboration (Berkeley, California: Ronin Publishers, 1996), 91].

Taking a broader look at conflict and the characteristics of a conflict situation is described by Laurence Douglas:

¶ One individual, or two or more individuals or groups, involved in an interaction.

¶ A difference in goals or values exists or is perceived to exist.

¶ The interaction involves behavior that will defeat, reduce, or suppress one of the opponents or groups.

¶ Opposing actions and counteractions occur.

¶ Both sides attempt to gain the favored position.

[Laurence Douglas. Nursing Management and Leadership in Action (St. Louis: Mosby Publishers, 1995), 234].

There are numerous other sources that cause conflict, with the major one being, miscommunication. Other sources of conflict include: poor attitude, differences in values or goals, poor performance by staff members and distortion of facts. Often, regardless of the work environment, personalities can play a large role in conflict, along with lack of trust, politics, status and control issues, perceptions and uncertainty as to who is in charge.

When conflict progresses without effective intervention, others are drawn in, or tangled in, and it becomes difficult to determine how, why, and with whom the conflict began. How conflict is defined and subsequently approached can determine if its outcome is a positive growth-enhancing experience, or if it will have negative effects, determined to resurface, provoking further conflict.

Conflict itself is neither positive nor negative. It primarily serves as an alert to differences within or among individuals. How one responds to those differences determines the value ultimately ascribed to a conflict situation. Below is a case study to examine the many aspects of conflict.

Case Study

This case study takes place in a large operating room of a Community Hospital in the Midwest. The situation is as follows:

Tuesday 8 am

In preparing an operating room suite for a complex case, Sara (a nurse with just under one year of operating room experience) observed what she believed to be a break in sterile procedure made by Dr. Jackson's private technician, Tom. Sara called her observation to Tom's attention, matter-of-factly suggesting a new set-up. His response was a terse reminder of the difference in their years of experience. Nothing was changed, and the surgery was completed with the original set-up.

11:30 am

During lunch with Anita, Jose and Lois, three other staff members, Sara described her encounter with Tom that morning. Jose and Lois both shared conflicts they had had with Tom in the past, and Jose recalled that he was scheduled to work with Tom on a case later that afternoon. He then made a mental note to watch Tom set up closely.

12:45 pm

Tom and Jose worked separately, but beside each other, to prepare an operating suite without incident. Tom noticed Jose watching him throughout the set-up and preparation.

3:30 pm

Tom noticed Jose and Sara talking quietly and glancing at him. He later made a point to discuss his concerns about Sara's competence with Dr. Jackson.

Wednesday 6:30 am

Dr. Jackson arrived at the operating room nurse manager's office

unexpectedly to discuss his concerns about the competency of one of the staff members, Sara. The nurse manager had difficulty obtaining specific details from Dr. Jackson, but clearly understood that he felt uncomfortable with Sara's ability. The manager then adjusted the schedule for the week to ensure that Sara would not be involved in any of Dr. Jackson's cases and quietly asked another circulating nurse to watch Sara more closely. She also made a note to tell herself to discuss Dr. Jackson's concerns with Sara during her upcoming annual evaluation.

10:30 am

Dr. Jackson's surgical patient (from Sara's and Tom's 8:00am case Tuesday) began to run a high temperature, and was placed on aggressive intravenous antibiotic and pulmonary therapy.

10 days later

The surgical patient was discharged, 4 days later than anticipated, on oral antibiotics. The operating room nurse manager was unaware of the patient's experiences, but she had heard from the surgical unit nurse manager that Dr. Jackson had made comments about his patients not doing very well in her operating room suite. Both nurse managers then expressed concern that Dr. Jackson might move some of his business to another facility.

Recognizing the importance of his business to their organization, the nurse managers begin to develop a plan to increase their services to him. The nurse manager of the operating room also made a mental note to discuss with her staff her impression that things have been more tense than usual over the past week among staff during some procedures.

Discussion

In this situation, conflict was directly experienced by Tom and Sara, and then spread to encompass, Jose, Lois, Anita, the patient, Dr. Jackson, and two nurse managers. To understand the source of the conflict, attention must be focused on Tom and Sara. Perhaps Tom was uncomfortable with issues related to formal power and autonomy (Tom is a surgical technician employed as an assistant by the physician, and Sara is an RN employed by the organization), or to a professional value system that strongly emphasizes experience (he had much more experience with the procedure than Sara).

Conversely, perhaps (as an RN) Sara felt primary responsibility for the case and, therefore, for the set-up. Both may have experienced some degree of concern over job security and a sense of needing to protect their relationship with Dr. Jackson. Sara also perceived that a break in sterile procedure had been made and Tom perceived that one had not been made. Resolution could have occurred through their discussion of what each perceived, and the development of a mutually agreed upon solution. Instead, both began to feel the conflict on a personal level.

It also seems clear that both Tom and Sara shared their perception of the situation with others and added implications of the situation of competence to their discussions. This, in turn, began a snowball of additional actions by others. The situation was no longer a simple misunderstanding between two individuals. It had

escalated to the perception of the potential loss of a key physician's business, the questioning of a nurse's competence, the decreased willingness of the operating room staff to work with an experienced technician, and a lost opportunity to identify a situation that might lead to inferior patient care.

This example encompasses many aspects of conflict. It also shows the far reaching impact of a relatively simple conflict. Many opportunities in the described interactions existed for constructive conflict resolution to occur, but were not acted upon. To do so would have required at least one of the members of the situation to have an understanding of conflict as well as to have the ability and desire to effect various resolution options.

In many cases, the understanding and ability are lacking, and it is here where managers, interested in decreasing the conflict in the environment, should begin. Defining conflict and recognizing its many sources is the first step in understanding it.

Another defense the manager could have used is to facilitate an environment where there is a focus on education of conflict resolution skills for the staff members. If accomplished, the potential conflict situations are minimized and those that occur are resolved early in the process in a constructive manner.

Types of Conflict

Robert Brinkman states there are 6 major types of conflict:

Intrapersonal conflict includes psychological conflicts within one's self because of conflicting demands related to motivation, choice, or allegiances.

Interpersonal conflict is a frequently occurring interactional conflict between two or more individuals that generally arises from personal values or interests.

Intragroup conflict is a conflict that exists within a group, frequently related to roles and relationships.

Intergroup conflict exists between groups, usually related to differences in role expectations, value systems, and communications.

Organizational conflict is a by-product of changing dynamics in a structure, with the following reasons: the change process, reorganization, conflicting goals and objectives, limited resources and the domino effect.

Hierarchical conflict results from the structure of the organization.

[Robert Brinkman. Dealing with People You Can't Stand (New York: McGraw-Hill Publishers, 1996) 110].

To take a further look at one type of conflict, read the case study below:

Case Study

Smith Laboratories, the premier maker of IV tubing, wanted to introduce a new line of tubing to ten home health care agencies for use on their chemotherapy patients. The sales director for Smith Laboratories promised his employees an all- expense-paid trip to Disney World if IV sales increased by 15% next quarter. The home health care agency nursing directors were contacted and started inservicing their nursing staff immediately on the new product. The nursing staff then informed their patients that a new, and improved IV tubing would cut down on their infection rate and be simpler to use.

Sales of the new tubing went up, and the employees at the lab were excited about the trip to Disney World that they were planning to make. No one told the production line at the IV tubing company of the change and they fell behind in their orders.

Shipping was late and the nursing staff was not able to use the product and had to inservice their patients again, on the old method. The nursing directors at the home health care agencies were frustrated that they had gone to a lot of effort to introduce a new product for improved patient care, and it was not as readily available as promised. Where was the conflict?

Discussion

This was an example of an organizational conflict. It had components of the change process taking place, by introducing a new IV tubing. It also demonstrated poor communication throughout the process by not informing the production line making the tubing, thus resulting in a limited resource of the tubing available for patients. It showed how the domino effect can influence all levels from the sales director, lab employees, nursing directors, nursing staff and down to the patients.

This conflict could have had a different result if a better planning effort had taken place. A phased-in strategy for the use of the new tubing with communication at all levels may have eliminated the frustration and domino effect.

Communication Styles and Personalities

We choose how we relate to other people. Inside each of us are four basic personalities that communicate in different ways our needs, desires, and concern to others. The four personality types are:

1. Assertive. This individual communicates openly and honestly. Takes into account the needs of others and their feelings. He or she states the needs and wants, and doesn't wait for others to "read my mind." This individual also takes charge and is responsible for his life and destiny. He's true to himself and expects others to treat him with respect and dignity. Assertive individuals do not listen to other people.

2. Passive. This staff member or individual avoids conflict or confrontation at all costs, and could actually be a manager, boss or supervisor. Such individuals do not express their needs and feelings. They can't say "no" without feeling guilty. The passive person avoids hurting others because it makes him feel guilty and avoids making others angry because it makes him feel uncomfortable.

3. Aggressive. This individual needs to be in control of all things_ people, themselves and situations. Uses hurt and anger to manipulate others into feeling guilty and thus giving in. Does not take "no" for an answer. Will use abuse, sarcasm, humiliation, put downs, whining, complaining and threats to get what he wants.

4. Passive-Aggressive. This person wants to get even. Uses trickery, seduction and manipulation to get his way. They are usually not as open as the aggressive individuals. Will often be nice to your face and use behind-the-back techniques to get even. Get control by using silent treatment, withdrawal of affection and attention, gossip, tattling and refusing to cooperate. When asked what's wrong, they often say "oh nothing."

Behavior Patterns

No one individual will display characteristics of one behavior pattern exclusively. Often, staff members may demonstrate a primary behavior pattern that may cause conflict in the work place. Defining a person's observable and dominant pattern of behavior can help structure your communication with him or her, and possibly prevent a conflict from occurring. Let's examine a few patterns and examples of responses below:

v Dominance. Persons who have this style usually want authority, challenge, prestige, and freedom from controls and supervision. They like varied activities, difficult assignments, and opportunities for individual accomplishment. They have high standards and expectations, which may cause stress for themselves and others around them. Dominant persons tend to be decisive, and act quickly. Persons with this style are often energetic, sometimes overschedule themselves, and frequently fail to consider others when making decisions. When working with someone who has high dominance behaviorism you can improve your communication with them and try to avoid a conflict if you remember to provide direct, concise answers. It may also help to outline possibilities that will get results, not just discuss them, and agree or disagree with the facts, not the person.

If you are a charge nurse or manager and have high dominance behavioral patterns, you will have more effective working relationships if you attempt to pace yourself and verbalize reasons for actions to help others. Make an effort to be more of a team player and resist overstepping authority and prerogatives. You may also want to rely more on others, delegate more, and attempt to eliminate tendencies to be critical and fault-finding.

v Influencing. This pattern describes individuals who are very articulate, and who like to be the center of attention, and enjoy being with other people. These persons are usually popular and can motivate individuals and groups. Those who have these behavioral tendencies are usually happy and successful. Individuals with this type of pattern may have difficulty controlling their time, and sometimes make spontaneous decisions without essential information. Influencing individuals tend to be disorganized and lack consistent followthrough.

Individuals with influencing behavior pattern need public recognition, freedom and opportunities to be with other people. They also need encouragement to concentrate on tasks. If this is not accomplished, it may set up a conflict situation. They work best if others provide the organization and objectivity they lack. If you have influencing behaviors, you may be more successful by managing time more effectively. If you are a supervisor or manager, you may need to speak more assertively and formally to others. This will be especially important if there are unpopular or controversial matters to discuss with the staff, or there is a need to make decisions based on logic and fact.

v Steadiness. Individuals who have steadiness behavior patterns want the status quo and usually take longer than others to adjust to change. This can potentially be a catalyst for numerous conflict situations, especially if the department or organization is undergoing a lot of changes, reorganization or downsizing efforts.

They also enjoy security and are loyal to their position, friends and family. They can be depended upon to perform in an accepted manner. They are patient and effective listeners who usually have a calming effect on excited patients.

They also can be content doing specialized kinds of work requiring minimal activity and involvement. These types of individuals usually make better followers than leaders, like routine kinds of work, and are supportive of their coworkers. Steady individuals rarely initiate tasks and can be possessive of their territory and belongings. They further tend to avoid growth situations, are slow to delegate to others, and often resist becoming involved with other persons and activities. Persons who are dominant or influencing may find spending much time with steady people confining and nonstimulating.

If you work with someone of this behavior pattern, expect that they will support you and your ideas as long as they have time to adjust. It is a good idea to give steady persons reinforcement or reassurance, placing them on teams and encouraging them to "stretch" out to others in job tasks and responsibilities. If you have a steadiness pattern, recognize that you are capable and valuable to yourself and staff members. You might be more successful by extending yourself to try new things and giving yourself more credit.

v Compliance. Those who have a compliant behavior style usually follow directions and standards with concentration and details. They often worship sacred cows (the way it's always been done, or no, we tried that before and it didn't work)! They enjoy working under controlled standards, are diplomatic with others but may have difficulty with the change process and ideas. They are good at checking for accuracy, complying with authority, and being involved in critical thinking and work performance evaluations.

Compliant staff members enjoy work situations that have standard policies and procedures, involve no sudden or abrupt changes and like plenty of personal attention and reassurance. They prefer not to be in charge of or responsible for others. Compliant individuals have difficulty stating unpopular opinions or positions. They tend to compromise, rather than confront situations and have difficulty dealing with conflict. As perfectionists, they set high standards for themselves and others.

In working with individuals who are compliant, it is important to give them precise work to do and plenty of personal attention and explanation. If you are compliant, try to think more about people and place less emphasis on rules, standards and policies. Let's examine a case study of a compliant behavior pattern, by a less than perfect interaction in the operating room.

Case Study

Nurse Compliant is a charge nurse who prides herself on her perfectionism. She is quiet, believes she is tactful by never confronting others with their "incompetence" and "careless" habits. She wonders why staff members avoid her, and why some have requested not to work with her. She appears an unlikely candidate for creating a stressful working atmosphere where conflict is constantly brewing. But her method of communicating nonverbal messages to those who have attempted to carry out her assignments is causing conflict.

Nurse Compliant told a staff nurse that Dr. King wants his patient positioned in a lateral position with the left side up. He also wants chest instruments available. Later, she walked into the operating room, went to the anesthetized patient who was positioned as instructed, and removed the carefully placed and folded towels and sandbags.

She then proceeded to refold and reposition the towels and sandbags. Then she rearranged the instruments, put several back into the instrument cabinet and added several different ones. Her coworkers report that she habitually repositions the surgical instruments and moves the cautery machine and other equipment.

The nonverbal communication is a hot bed for conflict! It makes the staff nurses feel inadequate, frustrated and angry. After attempting to carry out Nurse Compliant's instructions and not understanding or not being told what is wrong with the way he or she performed, the staff nurse feels so much stress that he or she becomes rebellious, hostile, and uncooperative.

Discussion

Nurse Complaint needs to loosen up a bit and communicate a lot more! She also needs encouragement to be more independent, help in confronting unpleasant situations and more tolerance for other people's work performance. She may need assistance at being more flexible and tolerant of other people's styles of behavior.

Your value system influences how you relate to and act toward other people. The better we know our values, the better we will understand how we relate to others. Many of the conflicts and disagreements that occur in interactions with others come from a lack of understanding of how we really think, feel, and act. These value judgments, decisions and opinions that are constantly shared with coworkers are the basis for most of the stress incurred, during our attempts to communicate with others.

The stress occurs because we form impressions of others, and they form impressions of us, considering the way we dress, talk, and behave. Future communications are based on the accuracy of the perceptions. If our perceptions are fairly accurate, then we will form meaningful and productive relationships. 

If we misjudge others, we will encounter stress, confrontations, misunderstandings and conflict. People are different. We have different strengths, needs, and motivation. When these differences are forgotten, problems in working together occur. We treat others the way we want to be treated, and communicate with them based on our needs, strengths, and goals.

But our method of relating and communicating can be stressful and irritating to others because they have different styles. Effective listening, knowledge of one's values, and understanding of communication styles can help to take the stress out of communication in the work arena. Therefore, good working relationships may depend on how accurately we interpret behavior styles.

Stages

Some conflicts appear to come out of nowhere, but most conflicts have some history. Many conflicts develop from minor problems that have not been handled well. Eventually the small problems become the source of a major conflict. John Wisinski describes three stages of typical conflicts and appropriate ways to handle conflict situations at each stage.

u Stage 1: Conflicts in daily events

Conflicts at stage 1 are usually minor. At Stage 1, people are still cooperative, optimistic, and willing to negotiate a resolution to the conflict. At this early stage people are still willing to look at both sides of the issue. The three conflict resolution strategies for stage 1 would include:

    ü Keep people looking at both sides of the issue.

 ü Brainstorming alternative solutions.

    ü  Encourage people to express their feelings. 

u Stage 2: Win/Lose

Unresolved conflicts from stage 1 often escalate into Stage 2. In Stage 2, people are less focused on the issues and more focused on winning or losing. stage 2 conflicts foster competition. People in stage 2 use phrases such as, "you always, he or she never," and "you should." It becomes difficult to talk about problems without talking about people. The four conflict resolution strategies for Stage 2 would be:

    ü Try to transition back to Stage 1.

    ü Establish group accountability for resolving conflict.

    ü Focus the discussion on facts. Be hard on the facts, but soft on the people.

    ü Discourage black/white thinking by challenging extreme positions. Remind people that they are responsible for resolving the conflict and that extreme positions are not realistic.

u Stage 3: Conflicts to inflict harm

The goal of conflict at this stage is to intentionally inflict harm on the other party. People begin to choose sides. Attempts are made to exclude some people from the problem-solving process.

A sense of "holy mission" develops on the part of some people. There ceases to be any area of common ground, and people begin to feel that the conflict has no end in sight. The conflict resolution strategies for Stage 3 would be:

    ü Gather as much information as possible regarding the opposing perspectives.

    ü Set a time limit for resolving the conflict.

    ü Get commitments from each party to stick to the limit.

    ü Assess if resolution of the conflict is possible.

    ü If resolution is possible, get a third party to intervene.

Conflict can quickly escalate from a relatively minor problem to a major crisis. Learning to observe the stage of a crisis will help you decide how to handle it.

[John Wisinski. Resolving Conflicts on the Job (New York: Baum and Sons Publisher, 1996). 211].

Characteristics

Conflict can be one of the least understood of all human behaviors. In the early years of mankind, humans "resolved" conflict through some form of dominance. Unfortunately, this technique is often still used today. When two parties face conflict, one party usually feels frustrated. The feelings of frustration could be caused by a number of factors. Perhaps they were insulted, they had to fight for what they wanted, or maybe they believed they were cheated.

The frustration may lead one party to attempt to get what they want, regardless of whether others get what they want. If the frustrated party then does something else, then the second party responds.

And so goes the interaction of conflict. The tension between the parties increases because of what happens during the interaction. The tension created by the initial frustration is heightened by the parties' efforts to reduce the tension.

Communication breakdowns may occur. The parties may form stereotypes, which usually take the form of the other party being labeled wrong, bad, or even evil. Usually, parties interact, then separate and have time to think about the interaction. While thinking about the conflict, the tension can grow even though nothing has happened. Tension may continue to grow until one or both parties reach the tolerance threshold, at which time they will try to end the conflict.

Conflict can end in several ways. One party may walk away, one may give in, or they may reach a compromise. As we learn more about human psychology, we understand that there really is only one successful outcome of conflict, both parties must be truly satisfied. If one or both parties believe that the outcome is less than satisfactory, the conflict will be back, probably as part of some other conflict.

The outcome must not leave residual tension, a "ghost" to haunt later interaction. Therefore, in order to conquer conflict, the resolution must result in outcomes that are mutually satisfactory to both parties if the resolution is to be long lasting.

The characteristics of a conflict, as described by Alan Filly are paraphrased as follows:

v One individual, or two or more individuals or groups, involved in an interaction.

v A difference in goals or values exists or is perceived to exist.

v The interaction involves behavior that will defeat, reduce, or suppress one of the opponents.

v Opposing actions and counteractions occur.

v Both sides attempt to gain the favored position.

[Alan Filly. Interpersonal Conflict Resolution (Glenview, Illinois:Scott Foresman Publishers, 1995) 79].

Environmental Factors

Just as there are many sources of conflict, there are many environmental factors that influence conflict as well. Some of them include the following:

¶ Individuals or groups that work in proximity (such as the nurse and scrub technician in an operating room setting), or who depend on each other to per- form their jobs, are more likely to experience conflict.

¶ Groups that work closely together, they may dress together, work together, take breaks and lunch together. Then car pool home together and even socialize together.

¶ Persons with varying cultures, age spans and experience levels.

¶ Situations where individuals from many different specialties who all share responsibility for outcomes (such as a pharmacist, physician, social worker and nursing case manager) increase the potential for different viewpoints and, therefore, conflict.

¶ Groups that include large number of individuals increase the likelihood for perceived or real differences and the likelihood for misunderstandings, thus leading to a greater potential for conflict.

¶ Organizations that have tall hierarchical structures increase the potential for conflict (especially through distorted communication and incompatible depart- mental goals). This is also true in areas where there are many different levels of nursing staff working together.

¶ Organizations or areas within organizations experiencing significant changes, such as mergers, delivery system restructuring and personnel layoffs, are ripe for conflict.

¶ Areas with a poor infrastructure for communication (individually and within groups) and limited options for socialization (getting to know each other) allow many opportunities for misunderstanding and inaccurate perceptions.

¶ Organizations where there is not a clear investment in a primary goal or vision leave openings for individual interpretation and thus increased conflict.