Keywords

FormalPara Key Points

  • Conflict occurs frequently within healthcare, and particularly in the operating room environment.

  • Conflict fosters decreased collaboration, employee satisfaction and patient safety, and can have significant institutional and individual implications.

  • The basic sources of conflict include failures in communication, the presence of disruptive behaviors, and differences in values or priorities.

  • Conflict evolves through different stages from participants not being fully aware of issues to overt manifestations of anger and stress.

  • Participants’ assertiveness and cooperativeness yield five distinct styles for responding to conflict: avoiding, accommodating, cooperating, compromising and collaborating. Collaborating produces the optimal results.

  • Analyzing the source of conflict, understanding the positions, acknowledging possible and preferred solutions and creating a plan that assigns roles and tasks can improve conflict resolution.

  • Conflict intensity, and their associated emotional states, can influence participants’ willingness and ability to achieve a solution.

  • The use of basic precepts during conflict resolution conversations can create a more open, communicative environment.

  • Lasting solutions to conflict require participants to trust the intentions and promises of the other party.

  • Conflict management skills can be learned and developed, and can be used to alter outcomes and relationships.

Introduction

Conflicts occur routinely in the healthcare environment. Your patient, armed with information obtained from the internet, insists that a different surgical approach would lead to a better outcome. The nurse refuses to draw the labs you ordered 6 hours ago because the requisition form was incomplete. The anesthesiologist delays your case until a cardiologist reviews what you perceive to be a normal electrocardiogram. Your surgical colleague jests that he contacted a malpractice attorney on your behalf regarding your complicated, just completed, operation.

Defined as a process in which perceived opposition between people or groups exists due to differences in interests, resources, beliefs, or values, (De Dreu and Gelfand 2008) conflict can lead to a number of outcomes. Personal or organizational growth can emerge from conflict, (Caudron 2000) particularly when the interaction is task oriented, and accomplished in a positive, trusting, environment (Tjosvold 2000).

However, conflict can also have dysfunctional, disruptive, or even destructive consequences, which can have significant implications to the involved individuals and institutions (Alper 2000). Alterations in productivity, work place or career satisfaction, job turnover and absenteeism, family well-being, and reputation in the medical (and legal) community can result (De Dreu 2010). Moreover, conflict can escalate in intensity, produce aggressive behavior, and lead into a spiral of unintended and unpredictable outcomes (Mikolic et al. 1997). Once promising surgical careers have ended due to poorly managed conflicts.

In observational studies of the surgical environment, an average of one to four conflicts occur among operating room teams during each operation (Booij 2007; Saxton 2012). Within health care teams, conflicts have lead to reductions in communication, collaboration, and ultimately, patient satisfaction and safety (Joint Commission).

The reduction of conflict is therefore valuable to individuals as well as institutions; objective evaluations of the quality of communication and relationships, deemed relational coordination, can alter clinical outcomes. In 878 patients undergoing total hip and knee arthroplasty at nine independent hospitals, variation in relational coordination between health care providers has been associated with significant differences in satisfaction, postoperative pain and function, and even length of stay (Gittell et al. 2000). Consequently, understanding the sources and methods for managing conflict are paramount to a successful surgical career.

Sources and Stages of Conflict

Recognizing the principal source(s) of conflict can be helpful in diminishing or resolving a situation. Although the genesis of conflict may seem trivial (e.g., “He changed the radio station without asking…at a key point in the surgery!”), the underlying issues often involve essential differences in values, perspectives or priorities, failures in communication, or the presence of disruptive behaviors.

Values represent our personal beliefs of right or wrong. Reflected in how and why we make decisions, values are a core feature of our belief system. Although it is often difficult to articulate or even recognize individual values, it is difficult to compromise when our basic system of beliefs is challenged (Harolds and Wood 2006). Conflicts can also stem from differences in perspectives (e.g., lack of clarity of role or jurisdiction, interpretations of existing workload), priorities (e.g., efficiency of patient throughput), or personality attributes (e.g., limited emotional intelligence, introversion).

Communication failures can amplify these differences, particularly when inadequate, incorrect, or excessive information is provided (Table 8.1) (Saltman et al. 2006). Ongoing or unresolved communication failures or prior conflicts with you or individuals in a role identical to yours (e.g., “You surgical residents are all the same!”) can lead to prejudiced initial viewpoints.

Table 8.1 Information patterns that lead to communication failures and conflict
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Finally, the work environment, including workload and stress, and organizational culture may engender conflicts between individuals or teams. Over time, dysfunctional experiences lead to adjusted behaviors that can negatively impact the relationships as well as the individuals involved (Song et al. 2000). Such behaviors, especially when emotionally charged, can become disruptive or destructive.

Conflict has been categorized into different stages (Table 8.2), which can be visualized as a bell shaped curve (Robbins and Judge 2014). When participant(s) first perceive conflict, resolution can be sought. However, conflicts typically build until a triggering event elicits the manifest stage during which enhanced discomfort leads to altered behavior and visible or obvious conflict (e.g., passive aggressive behavior, disruptive actions or activities, etc.).

Table 8.2 Stages of conflict
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Manifestations of conflict are often best mitigated if addressed earlier; however, the duration and movement through conflict stages is dependent on a number of variables. The ramifications of a missing surgical instrument, for example, would differ if an easily substitutable instrument was already present on the surgical tray.

Responses to Conflict

Although some organizations have processes to assist conflict management, the participants involved determine the initial, and often ongoing, actions and responses.

A number of variables, including personality, roles, presence of power or hierarchy, rewards, attitudes, perceptions, ethnicity, and gender, can influence responses to conflict. Psychosocial studies, especially those based on the Thomas Killman Conflict Mode Instrument, have validated the presence of five distinct styles in responding to conflict; the styles can be visualized on a matrix using two axes of assertiveness and cooperativeness (Thomas 1992; Fig. 8.1).

Fig. 8.1
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Conflict mode instrument. The four basic “modes” or styles of responding to conflict based on the elements of assertiveness or cooperativeness. The “compromising” style has features of two or more styles, but is not the most effective. The “collaborating” style yields the optimal outcomes for participants

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The five styles are avoiding, accommodating, competing, collaborating, and compromising. Avoiding, which is the most frequent response to conflict, is both unassertive and uncooperative; it allows the conflict to continue and possibly flourish. By contrast, collaborating is both assertive and cooperative, and represents a direct attempt to resolve the conflict; it is considered to be the optimal style. The collaborating style requires an open, non-threatening discussion of issues, an imaginative exploration of alternatives, and honesty and commitment; the style can merge insights from people on different “sides” of a problem, and result in commitment to the solution. This style is not to be confused with compromising, which has each interested party give up or trade desired elements; resulting solutions can often lead to agreements where no one is satisfied.

As individuals gain experience or leadership positions, there is a tendency to use more assertive, less cooperative methods (i.e., competing). Novice or less experienced individuals (e.g., intern) have a tendency to engage in less assertive, more cooperative methods (i.e., accommodating) (Slabbert 2004). Hierarchical organizations, such as surgical or medical environments, tend to embrace less cooperative methods at higher levels, reflecting the dominance-subservience patterns that often exist. However, individuals should still strive to be both assertive and cooperative (i.e., collaborative) to improve conflict resolution success.

A second model of conflict resolution defines negotiating styles in accordance with the extent to which the negotiator attempts to satisfy their own interests and consider the other party’s interests (Rahim 1995). These dimensions can be visualized on two axes yielding four pure categories (Fig. 8.2), with the fifth category “compromising” being a moderate position encompassing interests of self and others. Forcing is distinguished into direct fighting (i.e., uses result-oriented mechanisms such as threats, and physical or verbal violence) and indirect fighting (i.e., controls the process or resists considering the adversary’s issues) (Van de Vliert 1994). Not surprisingly, problem solving is the most successful option, as it enables both parties to consider a greater number of positions and counter-positions and places greater effort into satisfying underlying needs (Putnam and Wilson 1989) to reach a mutually satisfactory agreement (Medina and Benitez).

Fig. 8.2
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Conflict mode instrument based on interests. The four basic “modes” or styles of responding to conflict based on elements of self- or other’s- interests. The “compromising” style has features of two or more styles, but is not the most effective. The problem solving style yields the optimal outcomes for participants

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Management of Conflict

Conflict should be addressed, particularly when the possibility of real or potential injury exists (e.g., a participant’s psychological health or a patient’s outcome) or a high likelihood of affecting subsequent behavior is present. Although soliciting a third party to resolve conflict has some appeal, such an approach is not realistic for many common issues; moreover, organizations, as well as individuals not personally involved, can have difficulties in managing conflict constructively and resulting delays can diminish memory of important provoking or contributing elements (Slabbert 2004). As importantly, conflict management skills are essential to achieving personal growth and development, and improving the workplace environment.

Initiating a conversation to resolve conflict requires preparation, including analyzing the source(s) and intensity of the conflict, understanding the positions (including yours), acknowledging the possible and preferred solutions, and creating a plan that assigns roles and tasks.

Runde and Flanagan (2010) describe five levels of conflict intensity between two or more participants with different perspectives (Table 8.3). The intensity of the situation, with its associated emotional states, can influence the participants’ willingness to approach and achieve a solution. Addressing conflict should ideally occur when the acute sensations of anger, frustration or hurt have somewhat dissipated, but the triggering or situational factors can still be recalled. Mitigating emotional states can lead to calmer and clearer discussions; tension reduction has been achieved by creating awareness of behaviors that provoke emotional responses and reframing perspectives from an alternative, generally more positive viewpoint.

Table 8.3 Conflict intensity levels
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In the presence of conflict escalation, certain behaviors, mostly related to accommodation, can assist in diffusing tension. “Influence tactics” include acknowledging their principle concerns, convincing the other individual(s) that your opinion of them is positive, which facilitates relations and increase trust (Wayne 1997), and making public concessions, which obliges the other party to consider or make concessions as well (Osgood 1962). For example, if a patient is vocally aggressive and agitated with clinic schedule delays in the waiting room, having someone approach them, agree that the clinic has not been punctual, acknowledge the value of their time, and offer the option of their going for a walk and receiving a text message at the appropriate time, will likely benefit all parties involved. Such accommodations can then facilitate a fuller, later conversation to potentially evaluate root causes for the conflict and diminish future similar encounters.

The use of basic precepts and mindsets can foster a more open, sharing environment for communication to occur (Table 8.4). As negotiations begin, the quality of the process and outcome depend on the frequency, as well as the distribution, of a given strategy; constructive resolutions most often occur when a negotiator is firm and resilient in the early phases, but flexible and creative in later stages (Medina and Benitez 2011). Conversely, ineffective influence tactics are often based on the use of demonstrable force, including launching personal attacks and trivializing the other party’s issue; adopting soft styles of avoidance and servility are also not effective in creating lasting solutions (Munduate et al. 1999). Finally, being firm and inflexible late in the negotiations process often leads to negotiation failure.

Table 8.4 Tips for engaging a conflict resolution conversation
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Understanding the differences inherent to the conflict include evaluating the background factual basis and data, anticipating the contrasting viewpoint’s arguments, achieving clarity on what defines desirable and undesirable outcomes, and considering reasonable concessions. The greatest potential for a workable solution exists when both parties understand the value of a long-term relationship and achieve an outcome that satisfies or exceeds their anticipated gain. An optimal outcome is one that encompasses mutual understanding and benefit; ideally, it is a solution whereby additional benefits for one party cannot be achieved without reducing those for the other party.

In seeking a lasting solution, participants must believe that they will be respected and treated fairly. The participants must trust in the intentions of the other party, with an expectation that confidentiality for disclosed information will be maintained, and promises tendered will be honored. Such a solution has roles and tasks that each party fulfills as an indicator of actively incorporating the agreement as well as strengthening the relationship.

Following conflict, further relationship building acknowledges the need for acknowledging a mutual purpose or goal, identifying and solving problems, and seeking opportunities for ongoing communication to resolve misunderstandings or irritations to the relationship.

Conclusion

Conflicts occur frequently in the healthcare environment, and can stem from failures in communication, the presence of disruptive behaviors, and differences in values or priorities. A collaborative approach to conflict resolution, which focuses on an open, non-threatening exploration of issues and alternatives, creates optimal outcomes for interested parties. Conflict intensity can alter the participants’ willingness to achieve a solution, and communication strategies should honor those emotions, while creating a neutral environment where dialogue can occur. Conflict management skills can be learned, and effectively employed for institutional and individual benefit.