What can you do about the powerlessness the nurses feel?

Points

This assignment is worth 200 points.

Directions

1. Read Finkelman (2016), Chapter 13: Improving Teamwork: Collaboration, Coordination, and Conflict Resolution, section on Negotiation and Conflict Resolution, pp. 324-333.

2. Observe nurses in a care delivery setting. Identify a recurring conflict with the potential to negatively impact patient care. Decide if delegation was an issue in the conflict. This should be from your practice setting or prelicensure experiences.

3. Provide details of what happened, including who was involved, what was said, where it occurred, and what was the outcome that led you to decide the conflict was unresolved.

4. Identify the type of conflict. Explain your rationale for selecting this type.

5. Outline the four stages of conflict, as described in our text, and how they relate to your example.

6. Propose strategies to resolve the conflict. Search scholarly sources in the library and the Internet for evidence on what may be effective.

7. Discuss if delegation was an issue in the conflict. Be specific.

8. Describe how you would collaborate with a nurse leader to reach consensus on the best strategy to employ to deal with the conflict.

9. Describe the rationale for selecting the best strategy.

10. Provide a summary or conclusion about this experience or assignment and how you may deal with conflict more effectively in the future.

1. Follow APA format. Consult your APA manual, and consider using the APA resources provided by Chamberlain.

2. Write a 5-7 page paper (not including the title or References pages) using APA format that includes the following.

a. Describe an unresolved (recurring) conflict that you experienced or observed. Identify the type of conflict.

b. Provide details of what happened, including who was involved, what was said, where it occurred, and what was the outcome that led you to decide the conflict was unresolved.

c. Outline the four stages of conflict, as described in Finkelman, and how the stages relate to your example. Decide if delegation was an issue in the conflict. Be specific.

d. Describe the strategies for conflict resolution and how you would collaborate with a nurse leader to resolve the conflict. Cites the course textbook and two scholarly sources.

e. Provide a conclusion or summary about this experience and how you may deal with conflict more effectively in the future.

f. Submit by the end of Week 3.

Read Finkelman (2016), Chapter 13: Improving Teamwork: Collaboration, Coordination, and Conflict Resolution, section on Negotiation and Conflict Resolution, pp. 324-333.

BELOW

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.

Gets Results 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):

1. 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.

2. 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.

3. 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?

4. 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:

1. To eliminate or decrease the conflict

2. To meet the needs of the patient, family/significant others, and the organization

3. 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

· Legitimate

· Reward

· Coercive

· Referent

· Expert

· Informational

· Persuasive

· 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).

Gender Issues

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.

Nurse-Physician Relationships

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).

· recognize strengths and limitations.

· respect individual responsibilities.

· maintain open communication.

Positive professional communication is critical. Both sides should initiate positive dialogue rather than adversarial positions. Cooperation and collaboration are also integral to the success of this relationship. A frequent question discussed in the literature is “Why is there conflict between nurses and physicians?” The structure of work is different for physicians and for nurses, and this has an impact on understanding, communicating, collaborating, and coordinating. This perspective identifies the key elements as sense of time, sense of resources, unit of analysis, sense of mastery, and type of rewards as described by the following:

· The nurse is focused on shorter periods of time, and time is usually short, with frequent interruptions. The physician’s sense of time focuses on the course of illness.

· If a physician gives a stat order, the physician has problems understanding what might interfere with the nurse’s making this a priority. There is a lack of understanding of the nurse’s work structure.

· Physicians often are not concerned with resources, though this is certainly changing as physicians recognize that there may be a shortage of staff as well as issues about costs and reimbursement for care. They, however, may not be willing to accept these factors as relevant when their patients need something. There are, of course, other resources such as equipment availability, supplies, and funds that can cause problems and conflicts. Nurses are typically more aware of the effect that these factors have on daily care and the work that needs to be done.

· Unit of analysis is another factor; for example, nurses are caring for groups of patients even though care is supposed to be individualized. Physicians may not have an understanding of this if they have only a few patients in the hospital.

· Physicians also do not have an understanding of nursing delivery models, and often nurses themselves are not clear about them. This affects nurses’ ability to explain how they work.

· The sense of reward is different. Nurses work in a task-oriented environment and typically get paid an hourly rate. Most physicians are not salaried and are independent practitioners, though some are employees of the organization (hospital, clinic, and so on).

Conflict and verbal abuse are related. Verbal abuse occurs in healthcare settings between patients and staff, nurses and other nurses, physicians and nurses, and all other staff relationships. This abuse can consist of statements made directly to a staff member or about a staff member to others. A common complaint from nurses regards verbal abuse from physicians. In addition to impacting quality care, verbal abuse affects turnover rates and contributes to the nursing shortage, so it is has serious consequences.

How can this problem be improved? A critical step is to gain better understanding of each profession’s viewpoint and demonstrate less automatic acceptance of inappropriate behavior. This requires that management become proactive in eliminating negative communication and behavior. Some hospitals have tried a number of strategies to deal with verbal abuse. The IOM recommends increased interprofessional approaches to care delivery and the need for increased

Case Study A Verbal Explosion Leads to Confrontation of a Problem

As a nurse manager in a busy operating room (OR), you have to ensure that all staff are collaborating and communicating well. In the past six months, you have noticed more problems with poor communication between nurses and physicians, which had an impact on the quality of care. Nurses are also frequently complaining that they are “second-class citizens” in the department. The number of last-minute call-ins has increased by 25% over the past six months, causing staffing problems. Today was the last straw when a nurse and a surgical resident had a shouting match in the hallway. The nurse left the encounter crying, and the resident said he would not work with the nurse anymore. The nurse manager went into the OR medical director’s office. They have had a positive collaborative relationship over several years. She went in and said, “We have a problem!” As she described the problems, he said, “I was unaware there was so much tension and lack of collaboration. Why didn’t you tell me this earlier?”

Questions:

1. How would you respond to the medical director’s question?

2. What do you and the medical director need to do?

3. How can you avoid this being a we/they situation?

4. How will you involve all staff?

5. What can you do about the powerlessness the nurses feel?

interprofessional education among health professions so all health professions are prepared to work together on teams (2003a). What can nurses do about this? One suggestion is to improve their knowledge base and thus develop more self-confidence. Another problem is that nurses think they must resolve all problems and “make things” work correctly when this may not be realistic. The nurses then become scapegoats. Verbal abuse, no matter who—physician or nurse—is doing it, should not be tolerated. Those involved need to be approached in private to identify the need for a change in behavior. Staff needs to be respected. The AONE Guiding Principles for Excellence in Nurse-Physician Relationships is found in Box 13–4.

Application of Negotiation to Conflict Resolution

Negotiation is the critical element in making conflict a nightmare or an opportunity. Negotiation can be used to resolve a conflict, and some types of negotiation, such as mediation, can be very structured. When two or more people or organizations disagree or have opposing views about a problem or solution, a conflict exists. To resolve the conflict, the involved people need to discuss resolution in a manner that is acceptable to all involved. Although it does not have to take long, in some cases it may be very long, such as what might occur in a union-employer negotiation for a contract. Conflict resolution includes the use of a variety of skills and strategies. As the process begins, it is important to clarify all of the issues and parties who are involved in the conflict. Performance or potential outcomes should be established early in the process. Questioning is important throughout resolution. For example, it is important to ask about behaviors that started the conflict and how to avoid them in the future. Management needs to be clear about expectations and provide these in writing, which helps to decrease conflict over critical issues. Since conflict is inevitable, all staff nurses will encounter it. Knowing how to manage conflict will be of great benefit to the individual nurse as well as improve the working environment and ability to better reach patient outcomes.

Patients should not become part of staff or organizational conflicts, and there is risk that this may occur. Consider these examples:

· The interprofessional team cannot agree on a treatment approach and must do this by the end of the team meeting.

· A patient’s insurer refuses to allow the patient to stay two more days in the hospital. As the hospital’s nurse case manager, you must work with the insurer representative to reach a compromise.

· Staffing in a hospital has been reduced, and the nurses are convinced that the new staffing level will be unsafe for patients. Something must be done to resolve this issue.

· A home healthcare agency learned that the Medicare contract has changed and specific patients will receive fewer visits.

How can these examples be resolved satisfactorily so the quality of care does not suffer and staff still work together collaboratively? Finding a mentor to discuss the process as well as vent feelings may be helpful. Developing negotiation skills makes conflicts easier to handle and less stressful. Nurses who become involved in unions will find that negotiation skills are also very important. If negotiation is not used effectively, all of these conflict examples can lead to major problems for the patient and/or staff.

When approaching conflict resolution, it is important to recognize that both sides contributed to the conflict. One side cannot have a conflict by itself; it takes at least two. Consider how each side has contributed to the conflict. Another critical issue is to carefully consider if this is the time and place to address the conflict. When the environment is too emotional, conflict resolution will be difficult. Stepping back or taking a break may be the best position to take. The following are strategies that can be used to negotiate effectively (MindTools®, 2014b):

· Negotiate for agreements—not winning or losing. Clearly state that your desire is to find a solution and to work together.

· Separate people from positions.

· Establish mutual trust and respect.

· Avoid one-sided or personal gains.

· Allow time for expressing the interests of each side/party.

· Listen actively during the process, and acknowledge what is being said; avoid defending or explaining yourself.

Box 13-4 Aone Guiding Principles for Excellence in Nurse-Physician Relationships

Introduction to the Guiding Principles

Excellent working relationships between nurses and physicians are key to creating a productive, safe, and satisfying practice environment. The patient and the patient’s family benefit from care delivered by a team practicing within this environment.

Senior leadership in healthcare organizations must support the development of excellent relationships and, more importantly, create an environment that sustains and nurtures these critical relationships.

Guiding Principles for Excellence in Nurse-Physician Relationships

Institutions that are committed to establishing and maintaining environments that promote excellence in the nurse/physician relationship adhere to the following principles.

1. Interdisciplinary collaborative relationships are promoted, nurtured and sustained.

2. This requires that practitioners be proficient in communication skills, leadership skills, problem solving, conflict management, utilizing their emotional intelligence, and functioning within a team culture.

3. Excellence in relationship building begins with hiring, continues with learning and developing together and is reinforced over time.

4. The organization has specific systems for reward, recognition, and celebration.

5. The organization supports the “Platinum Rule” with a specific Professional Code of Conduct that includes a system to support it. A “No Tolerance” standard exists for those unable to adhere to the Code.

6. The organization creates and supports a “Just & Fair” environment.

7. The work of all professional caregivers is seen as interdependent and collegial.

8. Cross-discipline job discovery is supported and encouraged.

9. Patient-focused care and better patient outcomes are the organizing force behind creating a collaborative environment.

Implementation Guidelines

Interdisciplinary collaborative relationships are promoted, nurtured and sustained.

10. Nurses and physicians are given formal training in communication skills, leadership development, problem solving, conflict management, development of emotional intelligence, and team functions. Education and training is provided to nurse/physician teams and is not discipline specific.

11. Specific education is provided in team building.

12. Organization governing bodies and committees have representative members from all disciplines.

13. Nurse/physicians leadership teams are identified to lead the work at the unit level. (Microsystem Management)

14. All organizational task forces include representatives from those stakeholders closest to the issue.

15. Interdisciplinary collaborative relationships are assessed, unit-by-unit. Each unit has a development and improvement plan for continued growth of the relationship.

16. Teams develop common values for their interdisciplinary collaboration.

17. Teams develop common language for their interdisciplinary collaboration.

18. Nurse/physician collaborative champions are identified at the hospital and unit level.

Excellence in relationship building begins with hiring, continues with learning and developing together and is reinforced over time together and is reinforced over time.

19. Nurses and physicians work collaboratively to identify the behaviors that they want in team members.

20. Employees, both nurse and physician, are hired using behavioral interviewing to ascertain a good fit with the organization, teams, values, culture, and behavioral expectations.

21. Nurses and physicians do 360 degree performance reviews.

22. Credentialing criteria includes behavioral attributes and expectations, as well as clinical skills.

23. The Graduate Medical Education competencies are used as hiring criteria and for performance review.

24. Education and team training is done in work teams, as described in the Institute of Medicine reports.

25. Personal accountability for demonstrating team behaviors is rewarded.

The organization has specific systems for reward, recognition, and celebration.

26. There is alignment of purpose among the disciplines regarding reward/recognition & celebration.

27. Mechanisms for reward and recognition are easy to access.

28. Performance appraisal is linked to patient satisfaction measurements.

29. Awards, recognition and celebration are public and visible and across disciplines and teams—Example: Physicians identify the Nurse of the Year; Nurses identify the Physician of the Year.

30. Rewards and Recognition programs promote team accomplishments.

The organization supports the “Platinum Rule” with a specific Professional Code of Conduct that includes a system to support it. A “No Tolerance” standard exists for those unable to adhere to the Code.

31. The Golden Rule states: “Do unto others as you would have them do unto you.” The Platinum Rule states: “Do unto others as they would have you do for /unto them.” Thus, this principle speaks to treating others as they want to be treated, not necessarily how you would want to be treated.

32. Code of Conduct Guidelines/Policies exists for all professionals that outline behavioral expectations.

33. Work improvement plans and measures hold the team accountable, not just individual.

34. Individual professional codes of ethics/conduct are known and honored.

35. Contacts and processes/procedures for the impaired professional are easily accessible to all staff.

36. There are identified coaches and mentors for the professionals on site in the hospital to help with performance issues.

37. All professionals receive team training that focuses on communication skills and processes.

38. Processes exist to identify and address conflict situations before they become a crisis and/or deteriorate.

The organization creates and supports a “Just & Fair” environment.

39. There is a systems approach to management and decision-making.

40. Internal trends and reporting processes are multidisciplinary.

41. Language for reporting and safety is analyzed to assure that it is “Just & Fair”.

42. Processes exist for multidisciplinary critical incident debriefing.

43. Decision-making tools are used that support the “Just & Fair” processes, such as the “Just Model”.

44. The processes outlined in the patient-safety literature that creates cultures of safety are used as blue prints for culture changes.

45. Remedial training is offered when needed.

The work of all professional caregivers is seen as interdependent and collegial.

46. The culture of team includes all disciplines providing care on a unit.

47. Behavioral expectations are defined for all disciplines.

Cross-discipline job discovery is supported and encouraged.

48. All disciplines are educated in the role/responsibility of their colleagues.

49. Opportunities for shadowing different professions are encouraged.

Patient-focused care and better patient outcomes are the organizing force behind creating a collaborative environment.

50. Work is directed toward identifying and measuring those outcomes that are sensitive to the function of collaboration.

51. Patients and families are appointed to internal committees.

52. Patient-centeredness is a key focus for processes.

Source: From AONE Guiding Principles For Excellence In Nurse–Physician Relationships. Copyright © 2005 by American Organization of Nurse Executives. Used by permission of American Organization of Nurse Executives.

· Use data/evidence to strengthen your position.

· Focus on patient care interests.

· Always remember that the process is a problem-solving one, and the benefit is for the patient and family.

· Clearly identify the priority and arrive at common goal(s).

· Avoid using pressure.

· Identify and understand the real reasons underlying the problem.

· Be knowledgeable about organizational policies, procedures, systems, standards, and the law, applying this knowledge as needed.

· Try to understand the other side, and ask questions and seek clarification when unsure or uncertain; understanding the other side first before explaining yours increases effectiveness.

· Avoid emotional outbursts and overreacting if the other party exhibits such behavior; depersonalize the conflict.

· Avoid premature judgments, blame, and inflammatory comments.

· Be concrete and flexible when presenting your position.

· Be reasonable and fair.

There are some conflicts that require a third-party negotiator to reach a more effective resolution. This is needed when there is no opportunity for cooperative problem solving and objectivity is required. “Mediation is an informal and confidential way for people to resolve disputes with the help of a neutral mediator who is trained to help people discuss their differences. The mediator does not decide who is right or wrong or issue a decision. Instead, the mediator helps the parties work out their own solutions to problems” (U.S. Equal Employment Opportunity Commission, 2014). Mediators are facilitators, not decision makers (as in the case of arbitrators). In mediation, the people with the dispute have an opportunity to tell their story and to be understood, as well as to listen to and understand the story of the other party. A key factor in mediation is the need for all parties to willingly participate in the process. The mediator guides the process and discussion. Certain guidelines are established for the discussion that all parties must follow throughout the process (for example, allowing each party time to speak and complete a statement without interruption, calling for a break when needed, enforcing time-limited meetings, substantiating comments with facts, and so on). With these guidelines and the presence of a mediator, this type of negotiation can result in positive outcomes. It provides protection for both sides.