Behaviors

Conflict Management in the HealthCare WorkplaceBy Allan F. Simpao, MD

In this article...

Recognition of conflict between health care teammembers and utilization of conflict managementstrategies is important to ameliorate conflict situationsand minimize their potential impact on the workplaceas well as patient care.

Conflict begins when one party perceives that anotherparty has negatively affected, or is about to affect nega-tively, something that the first party cares about.' Conflictcan occur in any setting where two or more people worktogether.

The initial personal response to a disagreement mani-fests as an emotional reaction, while conflict behavior is theaction that is initiated by an individual in order to expressemotion or interfere with another individual's needs.^

Interests are the needs that motivate people's actions.There are three themes that are common to most defini-tions of conflict:

1. Perceived incompatibility of interests

2. Some interdependence of the parties

3. Some form of interaction^

Conflict in the health care setting may not only impactthe productivity and morale of the disagreeing individuals(e.g., physicians, nurses, technicians, administrative staffmembers),"* but also negatively affect patients and theirfamily members if they interact with a demoralized or dis-enfranchised team member.

As a result, it is imperative for health care professionalsto identify and manage conflict when it arises in order toameliorate its potential impact on patient care and safety.

Sources of conflictConflict commonly implies fight, struggle or battle;

however, conflict in the workplace occurs along a continu-um of low-intensity minor disagreements to high-intensitysabotage, litigation and all-out war. In addition to stratifica-tion by intensity, workplace conflict can also be categorizedaccording to the duration (acute, sub-acute, chronic andinterminable) .5

Conflict often also involves an emotional dimensionthat signals a disagreement with another party. The emo-tions may be fear, sadness, bitterness, anger, hopelessnessor some combination. Thus, conflict can occur along vari-ous dimensions that often result in a non linear dynamicwith parties who are in conflict behaving and reacting indifferent, seemingly irrational ways.^

Bernard Mayer described five major sources of conflict:

1. Communication

2. Emotions

3. Values

4. Structure

5. History

Communication failures can occur due to imperfectionswith the sending or receiving of a message, particularly onethat concerns complex or emotional matters; this includeslanguage barriers. Emotions such as anger or jealousy canboth instigate and add intensity to a conflict.

Values (i.e., moral and ethical beliefs) guide one's deci-sions and actions; should values differ between individu-als, conflicts may arise. Structure consists of the elementsin the external framework constituting an issue, such asindividual experiences, the physical work environment andresources involved.

Conflicts resulting from structure issues include exam-ples such as disputes over resources due to overutilization

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by one group, or limited workspacefor too many coworkers. History inthe context of the health care work-place refers to the background ofthe individuals participating in theconflict as well as the environment.For example, a senior administra-tive assistant may balk at his bossinsisting that he assume menial filingduties when that role has been tradi-tionally handled by new hires.

Other causes of conflict exist.Disparate, desired goals for both indi-viduals and organizations may bringparties into conflict. One example isa young attending physician desir-ing an incentive-based compensationplan for overnight call whereas seniorattending physicians might prefer asystem with less call for seniormembers and no incentive-basedcompensation.

The effects of conflict com-monly extend beyond the partiesinvolved and affect others in theworkplace. When poorly managed,conflict can have an adverse impacton other workers or patients whenproductivity and attentiveness totasks is diminished. Conversely,well-managed conflict can actuallyhave a positive benefit when work-ers realize that there are systems inplace to properly handle disputes andconflicts.

Conflict management stylesConflict management consists

of the use of strategies and tactics tomove all disagreeing parties towardresolution, or at least containment ofthe dispute. There are five fundamentalapproaches to conflict management:

1. Competition

2. Avoidance

3. Compromise

4. Accommodation

5. Collaboration

Competition entails using what-ever power is available to pursueone's own concerns at some otherperson's expense. Although this styleis assertive and uncooperative, its usemay be appropriate in order to standup for one's rights, defend a posi-tion that is believed to be correct, orwhen the other party refuses to takeanything other than a competitiveapproach.^

Avoidance occurs when one doesnot pursue or address one's own con-cerns or those of the other party in

ACPE.ORG 55

Table 1Procedural steps for a typical negotiation process.

1. Identify and define the problem.

2. Get the facts (not the assumptions).

3. Generate possible solutions without criticism.

4. Evaluate possible solutions using logic and mature judgment.

5. Select solutions. A combination may be preferable.

6. Implement the solution(s) with clearly defined roles for both parties.

7. Evaluate the results.

the conflict. Avoidance is unassertiveand uncooperative, and may involvesidestepping issues or withdrawingfor a cool-down period before resum-ing conflict. Repeated avoidance mayresult in loss of self-esteem andconfidence.

Compromise involves a trade-offfor the conflicting parties, with theresult being an expedient, mutuallyacceptable solution that partiallysatisfies both. Concessions may beexchanged or both parties may agreeto a middle-ground position.

Accommodation consists ofdeferring one's personal intereststo satisfy the concerns of the otherperson. This style is unassertive yetcooperative, and may be exhibited inthe form of selfless charity, yieldingto another's point of view, or to settleminor conflicts when a major conflictis anticipated.

Collaboration is the attempt byconflicting parties to work togetherto find a solution that fully satisfiesthe concerns of both. Collaborationrequires a commitment of time andinterpersonal energy, yet it is a keystrategy for many major conflictsin health care because it buildsunderstanding of complex issuesand interdependent systems.

Conflict management inhealth care

Health care workers face recur-rent conflicts with demanding physi-cians, feuding co-workers, disgrun-tled patients, over-extended nursesand many other people. The healthcare setting is usually defined by ahierarchical structure, and disputescan occur with peers, supervisees orauthority figures.

Furthermore, the health careworkplace is often hectic and requiresstaff members and care providersto multi task. This setting makesconflict management challenging,and most physicians and other healthcare providers have little or no train-ing in conflict management. In a busyhealth care work environment, manyindividuals may choose to "deal withit" by avoidance rather than expendthe resources necessary to collabo-rate or compromise.

Individuals in the health careprofession often employ more thanone conflict management style. Thisis an important skill, as constructiveconflict management requires select-ing the appropriate style based on thecharacteristics of the conflict.

Although collaboration is usuallythe ideal method of conflict manage-

ment in the health care workplace,compromise also can be an importantcomponent. Negotiation is integral tocompromise and collaboration, andconsists of efforts to manage the giveand take between two conflicting par-ties to either a partially satisfying (i.e.,compromising) or fully satisfying (i.e.,collaborative) solution. A typical nego-tiation consists of a series of steps, asoutlined in Table l.̂

Negotiation in health care work-place conflicts should always bebased on substantive issues. Becauseof the implications of disgruntled ordissatisfied workers on patient care,negotiations in health care shouldfocus on solving problems and sat-isfying needs, with safe, effectivepatient care being the ultimate goal.

Objective criteria should be usedto discuss issues in a conflict, andone's position in the hierarchy (e.g.,attending physician) should not obvi-ate the arguments and interests ofsubordinates. Indeed, during nego-tiation, it is essential to recall andappreciate the interdependence of thecare providers with administrativeand support staff members.'

Additional strategies for man-aging conflict in the health careworkplace have been reported in theliterature.'"

1. Slow down. Because health careworkers tend to be action-orient-ed, they may move too quickly toresolve a situation without gather-ing the appropriate information.

2. Involve only those most closelyassociated with a conflict when itfirst arises to ensure that the direct-ly pertinent information is available.

3. If a committee is formed to solvea conflict, clarify the roles andexpectations of all committeemembers to minimize additionalconflict.

4. Involve the appropriate parties indecisions affecting their areas ofresponsibility.

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5. Address the issue at the appropri-ate level. Taking concerns directly"to the top" may escalate a con-flict to the point where it becomesmore difficult to resolve.

6. Confront the issue if at all pos-sible. In a busy health care set-ting, avoidance may be the easiestoption, but it is rarely the bestoption.

There can be significant costsinvolved with a failure to manageconflict appropriately in the healthcare setting. Direct costs of conflictinclude: litigation costs; managementproductivity losses due to conflictresolution rather than performingmanagerial duties; turnover costs fortraining new staff to replace disgrun-tled workers; disability/stress claims;as well as sabotage, theft and damageto facilities by those involved withthe conflict.

Indirect costs of conflict includediminished team morale, decreasedcustomer/patient satisfaction, thetarnished reputation of the organi-zation and health care profession-als, and emotional costs for thoseinvolved in the conflict."

ConclusionConflict in the health care work-

place can have significant financialand emotional costs that potentiallyimpact not only the employees, butalso the patients and the organizationas a whole. So it is imperative for con-flicts to be recognized early and man-aged appropriately.

Collaboration and compromiseare essential when working in thehealth care setting, as institutionsand departments within an institu-tion comprise myriad interdependentstakeholders, including administrativeand support personnel, nurses, tech-nicians, therapists, assistants, physi-cians, and management.

Strategies for managing conflictin the health care workplace should

be reviewed and utilized in order toincrease the likelihood of an asser-tive, cooperative solution to conflictsshould they arise.

Allan F. Simpao, MD, is assistant pro-fessor of anesthesiology and critical careat Perelman School of Medicine at theUniversity of Pennsylvania and The Children'sHospital of Philadelphia, Philadelphia, PA.

simpaoa@emaiLchop.edu

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