Betsy has been a nurse manager and a team player in her organization for a very long time, but an issue has finally come up where she needs to go to the mat — she has been asked to reduce her nurse-patient ratio on her unit to a level where she doesn’t believe she can still provide quality patient care. She does have choices though: She can confront her administrators head on and compete for what she believes in; the problem is that if she loses, Betsy may have to abdicate her position and any chance to influence future change. She could just give up and accommodate whatever staff reduction she has been asked to make, or she could pretend that whatever is going on has nothing to do with her and avoid the confrontation altogether. Betsy could compromise and redirect her demands to other areas that may make compliance acceptable. Or Betsy could join the fray and try to collaborate with the hospital team to find new solutions that would be acceptable to everyone in a difficult healthcare market.

Conflict — a struggle between opposing or incompatible behaviors, needs, or feelings within one person or between two or more people — is a part of every healthcare organization. Arising from a perception of incompatibilities, it can range from a subtle lack of support or disagreement to sabotage and violence. In the past, conflict in the workplace was regarded as dysfunctional, representing a breakdown in communication that would either go away by itself or be resolved with someone winning and someone losing.

Today, conflict is no longer considered harmful or inherently bad; instead, it is expected in a dynamic organizational environment. Many experts view conflict as a normal aspect of interpersonal relations in organizations and believe that, when handled correctly, it can be managed and resolved to achieve beneficial outcomes. In fact, such friction can be a motivator for change and growth, a medium for airing problems, and a dynamic force for preventing stagnation. When managed from a positive perspective, conflict can hold an organization together. Still, it would be naïve to assume everybody comes to the table wielding an equal balance of power. The more powerful person, or group, in a conflict may have a vested interest in keeping the power unequal as a means of entitlement.¹ It’s been said that nursing is a “gender-structured, systematically exploited, and oppressed occupational group,”¹ therefore it follows that conflicted persons or groups would sometimes be seated unevenly at an table. Because sources of conflict are so diverse and its consequences so important to patient care, nurses need to be adept at both recognizing different types of conflict and employing appropriate strategies to resolve them.

Levels of conflict

Nurses who work in healthcare encounter three levels of organizational conflict — intrapersonal, interpersonal, and intergroup. A nurse can experience intrapersonal conflict when confronted with two or more incompatible demands. Examples of inner, job-related struggles include ethical dilemmas, role conflict, work overload, and uncertainty about job expectations. Intrapersonal conflict can also be related to organizational structure, supervisory style, and the actual position that the nurse occupies within the organization.²

Interpersonal conflict occurs between two or more people when one person perceives or values a situation differently than the other. This kind of conflict can happen when there is a clash between core work values, such as determining how a job should be done, or setting different priorities or expectations because of age, experience, sex, race, and other personal attributes.

Intergroup conflict occurs between two or more groups and may result from competition among departments within a single healthcare facility or from rivalry among several organizations.

Most organizational conflict in healthcare agencies emerges at the interpersonal and intergroup levels. Major sources include divergent management and staff perspectives; competition for limited resources, such as staff, space, equipment, and funds; difficulties arising from interdependence of work activities; and differences in values and goals among work groups.² Additionally, in today’s healthcare environment, change — new policies and procedures, employee layoffs, and rapid growth — or even the threat of change, contributes to conflict.

Common approaches to conflict resolution

Conflict produces winners and losers. Five common approaches to conflict resolution have been identified:

1. Competition is a “winner takes all” attempt at complete dominance. The focus is on forcing a particular outcome at all costs, resulting in a win-lose situation.
2. Accommodation, the opposite of competition, occurs when one person or group is willing to yield to the other. This conciliation or giving in results in a lose-win situation.
3. Avoidance is a lose-lose approach in which one side is uncooperative, denies that a problem exists, or withdraws from the situation so that there is no active resolution of the conflict. Personal gain is forfeited as well as any potential contribution to the working relationship with the other person. This may happen when a less powerful person involved in a conflict responds with accommodation and avoidance to avoid possible retaliation, even at the risk of sacrificing his or her interests or the interests of others.¹
4. Compromise involves negotiation, tradeoffs, and swapping. Each person gets something, but gives something else up in the process, creating a win-lose/win-lose situation for the two sides.
5. Collaboration occurs when each party meets the problem head on with equal concern for both the issues and maintenance of a working relationship. This approach allows everyone to win by identifying areas of agreement and differences, evaluating alternatives, and selecting solutions that have the full support and commitment of both parties.³

How a nurse processes conflict

Nurses who experience on-the-job conflict go through a series of identifiable stages —

1. Disbelief is often the first emotional reaction, particularly when others are disagreeing with values that are held in high regard.
2. Disconnectedness often follows the initial sense of shock, making the nurse feel bewildered.
3. Obsession with the situation soon develops as the nurse’s focus narrows. The nurse may spend much of the day thinking about the problem, and wake up at night wondering what to do.
4. Frenzied activity is a common way of dealing with the obsession and reducing the bitterness, frustration, and pain that may be evoked by the conflict. Suddenly, there is boundless energy as the nurse becomes determined to find the information needed to understand the situation. Meetings with one colleague, then another, are arranged, and the nurse rushes about in an attempt to define and redefine the situation. The nurse may become quite aggressive, taking on new tasks or simultaneously working on numerous projects.
5. As the whirlwind search for clues subsides, self-evaluation begins. This is a crucial turning point when the nurse either begins to recover a sense of balance or experiences symptoms of burnout — withdrawal, apathy, and depression. If the conflict has been intense, the nurse may have to fight a tendency to internalize negative attitudes about himself or herself.
6. Purposeful alienation — emotional space between the nurse and colleagues — is a temporary reaction to deep conflict that provides for self-preservation. A wariness is adopted and the nurse controls self-presentation and verbalization. This is a haven, a rest, for all of the involved parties.
7. Once the conflict is resolved, and if it is processed positively, the nurse may gain insight into personal shortcomings and gain experience for managing future conflict.⁴

Fitting the strategy to the situation

The ability to manage conflict is a critical organizational skill that nurses can use to be more productive. Whenever conflict develops, whether with a boss, subordinate, or peer, they need to choose a strategy that fits the situation. Unfortunately, nurses often select an approach that is more comfortable than effective. Of the five common approaches to conflict resolution, research indicates that we all tend to prefer the more comfortable, and often less effective choices of avoidance, accommodation, and compromise.³

Instead of trying to eliminate conflict or deal with it in a way that is most comfortable, nurses need to use whatever strategy is necessary to effectively and positively achieve beneficial outcomes.⁵

Although conflict in organizations is inevitable, it is generally resolvable. The important issue is not to engage in futile attempts to avoid conflict, but to seek resolution through actively applying the appropriate strategy — competition, accommodation, avoidance, compromise, or collaboration. Each method of conflict resolution can be appropriate in different situations.

Competition or a win-lose approach may be the only way to achieve necessary change when an emergency occurs and there is no time for discussion, when unpopular changes need to be implemented, or when other strategies for altering the status quo have failed. For example, there is no time to negotiate disagreements between code team members when a patient has a cardiac arrest; someone has to direct the team without discussion.

Accommodation, a lose-win strategy, is often used when preserving relationships, being reasonable, or encouraging others to express themselves and learn by their actions. Two team leaders could use this strategy when deciding which team should get the extra float nurse; one leader might concede to the other nurse, after listening to her rationale.

Appropriate use of a lose-lose technique or avoidance includes situations where others may resolve the conflict more effectively; both parties see the issue as minor; the negative impact of the situation will be too damaging or costly to both parties to attack it head on; if additional time is required; or if both parties need a chance to cool off and regroup. For instance, after a heated exchange with a physician, a nurse might ask a colleague to make rounds until there was time to calm down.

The win-lose/win-lose strategy of compromise is best suited to cases where there is a need to reach agreement between equally empowered sides that seek to attain competing goals in complex matters or under time restraints. Here, conflict is resolved by finding common ground to achieve a temporary settlement that at least partially satisfies each party’s objectives while preserving the relationship. For example, a day-shift nurse volunteers to work extra evening hours to cover the assignment of a nurse who has called out sick if another colleague will come in early to work during the last part of the evening shift.

Collaboration is a win-win approach that preserves objectives that are at odds with each other, but can’t be compromised. This method maintains the relationship of the involved factions by merging their experiences and feelings to explore creative alternatives that each side may not have thought of on their own. Collaboration can often solve previously irreconcilable and long-standing problems. For example, a manager might deliberately assign two feuding nurses to work together to solve a chronic unit problem with shift-to-shift complaints.

Successful resolution

Whatever strategy is used, successful conflict resolution starts by identifying the problem and the desired behavior or outcome, and then confronting the conflict. Timing and location can be crucial. Individuals should not attempt to resolve a problem when emotions are out of control and a fight could be provoked. In most cases, a private setting is best for confrontation.

In addition, it is helpful for the nurse to have a clear understanding of the terms that may be bantered about by involved persons. For instance, nurses hear the word ‘team player’ all the time. And generally nurses understand what that term means within the context of their healthcare institution or their unit. In one setting, the term can refer to the unspoken agreement to go with the flow and not make waves, or allow others to take credit and not speak up. Or it can refer to a commitment to work toward a common goal with each team member making a concession or sacrifice toward the common good – usually patient care.⁶

Critical to successful conflict resolution is active listening. The temptation to listen passively, while mentally constructing what to say next, is a huge misstep toward a positive resolution. Instead, nurses need to actively listen to the other person and hear his or her words — strive first to understand and respond with empathy. In addition to being empathetic, nurses need to display credibility; consistent verbal and nonverbal messages must be established with a self-confident tone and manner. Nurses can establish credibility by being fair and consistent in interpersonal relations.

Nurses need to avoid responding automatically or reactively to other individuals during a confrontation. Self-examination is one way to gain insight about your own customary methods of conflict resolution and “hot buttons” that are likely to trigger inappropriate responses. Take a mental inventory of three personal characteristics most admired in the way others handle conflict, such as assertiveness, persistence, or competitiveness. After completing the list, develop another that includes three personal characteristics that you dislike. The first list will probably reveal traits that you possess and share with individuals whom you can easily confront. The second list will probably uncover traits that you do not possess or favor — characteristics in individuals that are likely to elicit inappropriate reactions from you during confrontation. By knowing these traits beforehand, you can avoid responding inappropriately.⁷

As professionals, nurses usually should seek to resolve conflict through collaboration with other professionals. The procedure for win-win conflict resolution consists of the following steps:

1. Identify the root problem and clarify issues surrounding values, purposes, and goals.
2. Encourage a free exchange of ideas, feelings, and attitudes, and cultivate an atmosphere of trust. Focus on the problem, not the personalities.
3. Search for alternative ways to resolve the problem.
4. Ask for help from outside sources as needed.
5. Set up a means for evaluation of possible solutions.
6. Keep interacting until all parties agree to a solution.

A collaborative approach requires willing participation from both parties, an atmosphere of acceptance, and open and honest communication. Encourage full expression of positive and negative feelings.³ Nurses can improve their ability to communicate clearly and appropriately and flex their negotiation muscles in instances of workplace conflict by practicing in their personal lives first. For practice it’s better to choose situations, such as a conflict over service at a restaurant or a returned purchase, where the stakes aren’t as high or emotionally charged.

Nurses can anticipate that conflict will characterize their practice in every work setting. Knowing how to choose and apply appropriate strategies will allow them to successfully manage and resolve conflict, and achieve their professional goals and those of their organizations and patients.