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Introduction

Management of workplace conflict is critical if teams and organizations are to continue to grow and accomplish their core missions. The nature of healthcare systems is increasingly complex and everyday work done around patient care, personnel management, and payment reform creates tension across all the key stakeholders. Conflict in this environment is inevitable and leadership in academic surgery demands the ability to feel comfortable with conflict and the ability to come to successful resolution. By nature of the skills needed to manage conflict, elements of management principles, tenets of communication and difficult conversations, and negotiation are woven into this review and discussion.

There are four major types of conflict: relationship, task, process, and status [1]. Conflicts can have elements of more than one type and rarely do major conflicts fit squarely into a single category. Identifying a root cause may help with conflict management and resolution. Relationship conflicts are simply defined as “a clash of personalities,” or a personal disagreement. This type of conflict can be hard to manage when egos and a desire for control lead to parties feeling disrespected and hurt. More subtle causes include personal insecurity which can have an extreme manifestation as habitual victimization. Relationship clashes at work [2] range from denial (“I don’t see any issue here”) to aggression (bullying behavior) and can also encompass many variations of passive-aggressive behaviors.

Efforts to increase self-awareness, coupled with empathy and compassion in the workplace are examples of effective tools for dealing with relationship conflicts. When members of the same team have a long history of disagreement or dislike, that dysfunctional relationship needs to be addressed in order for the team to succeed. Strategies for resolution include giving the parties an opportunity to hear each other’s point of view. Possible pitfalls include ensuring that such actions to unite do not have unintended consequences of worsening the situation by either worsening the divide or by worsening how the conflict is perceived or managed by leadership.

Beyond personal disagreements, there are three other types of well-defined workplace conflict. Task conflict is a common source of disagreement at work and typically results from a dispute over a task or project. Different agendas and different goals (or even the perception of different goals) exacerbate these types of task conflict. Process conflicts are disagreements about how things are getting done, rather than what the work is. There can be overlap with task conflict, but one distinguishing characteristic is whether the conflict is over the outcome (task conflict) or how the decisions are made (process conflict). Status conflicts commonly manifest over who is “in charge” or who deserves credit for work being done.

Causes of Conflict

Causes of conflict can be attributed to opposing positions, competitive tensions, or emotion (e.g., egos, power struggles). There may be a tendency to think of conflict in very stark terms: enemies and allies. This mental mindset, in and of itself, speaks to emotion as one of the major underlying causes of conflict. In many so-called rivalries, emotion can trump data and reason, making even small gaps seem like large chasms. Further, gaps in communication can cause and/or exacerbate conflict.

Why It Is Important to Manage Conflict

In practical terms, non-relationship conflicts arise with power struggles (titles, money, resources) as well as status (influence, credit or attention) despite the relatively hierarchical structure of surgery departments and health systems. The disruption that accompanies such conflict may have implications for access and productivity, quality of patient care, revenue, workplace dynamics, and the ability to perform cutting-edge research at academic medical centers.

Conflict Management Styles

Conflict Avoidance

Lack of conflict management is tantamount to doing nothing [1]. Avoiding conflict, especially over a long period of time, leads to conflicts that fester, eventually growing to resentment. Employees often withdraw and confidence in leadership erodes. Unfortunately, this outcome is not only avoidable, but also potentially very difficult to detect because these employees or groups are not usually in crisis. A common scenario is one in which the team or teams underperform. Conflicts appear to be resolved but they are merely dealt with on a very superficial level, with a shiny veneer masking real issues. Occasional attempts at resolution, ironically, can be met with unease because of disruption of a stably unstable environment.

Not managing conflicts may not be disruptive in the short term, and in fact, many leaders who tend to avoid conflict may be competent, well-liked and highly collaborative. However, managers who “do not manage” eventually have to deal with problems of accountability and underperformance [3]. Ultimately, the desire to be well-liked and a so-called team player can lead to ineffectiveness and possibly heighten team tensions because trying to make everyone happy often backfires. Learning to be comfortable with conflict is often coupled with understanding that few people actually like conflict, but leaders must be willing to deal with conflict and have difficult conversations rather than skirting major issues.

The bystander effect has been described as a contributing factor to why some longstanding conflicts remain “open secrets.” Employees who observe problems were far less likely (and possibly less willing) to speak up if they thought their peers observed the same issues. A set of studies [4] on the impact of the psychological phenomena of the bystander effect were conducted. When employees believed they were the only ones privy to an issue, they were 2.5 times more likely to raise the issue. The “diffusion of responsibility” among a group appears to morph into individual responsibility, and importantly, these findings were robust even when controlling for factors such as psychological safety (safety to speak up) and perception of whether speaking up would have an impact. These results have several implications for leaders. They emphasize the need to encourage open communication since leaders may, by nature of the position, be somewhat removed from the everyday discussions and be “in the dark” about issues unless they are specifically brought forward. Assumptions may be made that “everyone knows,” when that is in fact not the case. Specific to leadership in clinical departments and hospitals (especially with leaders in new roles) are important issues around clinical competency, substance abuse or other health problems, and harassment.

Escalation of Conflict

Elements of self-management are necessary when taking on leadership roles. Employees expect leaders to lead and model courageous behavior, especially in times of conflict. There are times when “picking your battles” may be appropriate and a decision to avoid a minor issue is made. To be sure, harmony in the workplace should be valued, but there are times when conflicts surface and must be addressed. To that end, disagreement and debate may be favorable, though clearly, fighting is not.

While fighting certainly increases tension in the workplace, harboring tensions, emotions and misunderstandings also create tension, and ultimately leads to isolation, hopelessness, and burnout at the individual level. The balance between conflict avoidance and conflict seeking [1] must be calibrated. Escalation of conflict is the end result if conflict is not managed/resolved. Unwillingness to address conflict, or conflict avoidance, creates a true negative energy expenditure which is associated with a less productive, less effective workforce.

Elements of Healthy Conflict

On the other end of the spectrum, it is important to note that conflict can be a favorable characteristic of high performing organizations, and managing conflict in this context can actually strengthen collaboration and increase creativity and innovation. In fact, strong leaders do not fear conflict and see the positive side of conflict. Many understand the inevitability of conflict and seek it out, possibly to recognize and better understand the various stakeholder perspectives of a complex organization.

Healthy conflict must be rooted in a healthy environment, one in which parties do not have fear of criticism or penalty when engaging in honest conversation. Lack of trust in a work environment creates a lack of psychological safety and potentially controversial ideas are never surfaced. This is a missed opportunity for learning, discussion and constructive feedback.

In the current healthcare environment, teams are increasingly deployed to address complex problems, whether it be interprofessional teams around patient care (e.g., disease site management teams in a cancer center) or physician-administrator dyads or workgroups for the daily management of clinical operations. A misdiagnosis of why teams underperform often leads to efforts that are actually workarounds to managing the root cause of why collaborative efforts fail—unresolved conflict. Such workarounds, or even deliberate actions to improve collaborations such as team restructuring efforts, can actually increase points of conflict.

Further, recent efforts to improve employee engagement in organizations may have the unintended consequence of exacerbating conflict avoidant behavior with downstream consequences of decreased productivity and, ironically, increased employee burnout. Davey [5] posits that conflict becomes “a dirty word” in the modern workplace and is viewed as antithetical to teamwork, engagement and a positive culture at work. As a result, so-called “conflict debt” builds up because difficult decisions are deferred.

Principles of Conflict Management

Tools that allow for the effective management of conflict can be transformative not only for morale but for productivity, moving conflict from the liability column to the asset column. It bears stating that urgent situations call for an entirely different approach and there may be times when negotiation principles are not appropriate when conflict arises. Leaders need to be prepared to make quick decisions (e.g., crisis management) when there are life-threatening, legal, or other critical moral/ethical imperatives.

Assessing the Situation

There a several key steps to take when analyzing conflict, ideally prior to taking any action [1]. First, seek to understand the involved parties (including yourself), including management styles and how styles may or may not match. This may be a particularly relevant step if the conflict is outside the department or with unfamiliar parties. Then, identify the type of conflict to help understand the underlying cause of the conflict. Determining your goal or what you hope to accomplish helps to determine the final step, which is to decide how to act.

Major options for action range from doing nothing (or walking away) to taking action (including indirect or direct action). Assessing the situation allows time for preparation and preparation often includes consideration of multiple strategies which may be important if the situation is very fluid or potentially highly emotionally charged.

Preparing for Conversations

Some conflicts need to be resolved expeditiously. If a situation is likely to fester, then more immediate resolution allows for a more proactive and less reactive approach. Some particularly egregious situations demand attention and even a notice of intent to have a conversation will set expectations and prevent rapid de-escalation while allowing all parties to “take a (much needed) breath.”

When time allows, preparation for potentially difficult conversations can lead to better management of emotions and set expectations for conflict resolution. In fact, having upfront discussions about communications styles can be helpful even in advance of have a more conscious approach to conversations. For example, leaders with a very direct communication style may want to convey that early on in work relationships in order to avoid unintentional miscommunication.

Preparation for any potentially difficult conversation takes stakeholder perspective and organizational context into account. Anticipating different scenarios may be particularly helpful in managing one’s emotional response to conflict and ensuring that the conversation does not get derailed because of emotions or because a relationship conflict is allowed to compete with or take precedent over a critical issue. Additionally, taking communication tips into account can help maintain a fluid conversation.

Approaches to Conflict

When conflicts arise, it is easy to fall back on personal managerial styles, which may either be linked to a fierce desire to win (“hard positional bargaining”) or a desire to maintain the relationship at any cost (“soft positional bargaining”) [6]. When those taking the hard line are in negotiation with those pursuing a soft bargaining position, an agreement is often reached, but the result is often not the most optimal outcome, though likely most favorable for the hard positional bargainer who has dominated the conversation with threats and demands for concessions. The scenario with two soft negotiators is likely to result in resolution since a premium is placed on building and maintaining relationships, offering concessions and avoiding confrontation. However, the outcome may also not be the most optimal, as illustrated by the O. Henry allegory “The Gift of the Magi” in which the characters Jim and Della each sell their most treasured asset in order to buy a gift for the other, with Della selling her hair to purchase a chain for her husband’s gold watch while Jim sells his watch in order to buy beautiful combs for his wife’s hair.

One can imagine the scenario with two “hard liners” as the most difficult to manage and as the one in which resolution may not come to be. A better route to conflict resolution is needed. Decades of work from the Harvard Negotiation Project and the classic “Getting to Yes” book [6], which focuses on principled negotiation methods. The underlying basis of this approach can be summarized in four basic points: (1) separate the people from the problem; (2) focus on interests, not positions; (3) invent multiple options looking or mutual gains before deciding what to do; and (4) insist that the result be based on some objective standard. Mutual respect and understanding become the focus and this may be particularly applicable when there is time for a cooperative approach. This approach leverages overarching principles such as valuing relationships, managing emotions, active and emphatic listening to identify interests and options. These tactics can inform approaches to conflict resolution (Table 11.1).

Table 11.1 Negotiation skills can translate to conflict resolution
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Indeed, emotions do drive decisions and often result in getting entrenched in positions. This is why positional negotiation so often leads to unresolved conflict. Managing the emotional aspects of conflict is critical, especially in forming a needed basis of trust. Just as redirecting from personal tensions to the conflict at hand (separating people from the problem) serves as an effective strategy, turning the focus away from positions to interests can move key stakeholders beyond an impasse. Understanding the root cause of a conflict may require precisely defining the issues around which there are conflict. Once the issues are clear, it is important to separate the positions from interests.

Positions are “stands” that are taken on issues while interests are those underlying concerns which can be affected by how the conflict gets resolved. Many unresolved conflicts end at an impasse because positions are viewed as irreconcilable differences. However, positions (“this is what we stand for”) do not always mirror a party’s interests. Conversations that seek to understand and reconcile underlying interests create value and opportunities for successful resolution of the conflict. Key components include (1) taking time to ask “why” in order to help get focus on interests and not positions and (2) expressing and discussing strong emotions in order to increase understanding of all stakeholders’ perspectives.

Communication Tips to Encourage Resolution

Two aphorisms come to mind when the topic of effective communication is raised. Commonly, it is not what you say, it is how you say it. And, secondly, it is often not what’s said, but what’s heard.

While it may be too simplistic to simply say that a change in tone would solve all communication problems, it is important to remember that perceptions of tone are exceedingly difficult to discern with nonverbal communication. Email correspondence, so common in the current work environment, is a good reminder that words do not always translate to the same message when written vs. when spoken. Indeed, being heard is not the same as writing a long email and expecting that the entire message, while memorialized, is read and properly interpreted. Further, those who have difficulty with phone conversations (again due to the paucity of nonverbal communication (specifically body language and eye contact) that is lost even though elements of a party’s tone is retained) are advised to meet in person if possible.

Having a productive conversation is hard when it starts with language that can be perceived as an attack [7]. Conversations that begin with a perceived accusation often never really become a true conversation because the response starts in a defensive mode, essentially preventing either party from focusing on the issue at hand and possibly creating escalation. Effective “nonviolent communication” skills emphasize “honestly expressing” and “empathetically listening” as the two major components of the model. Nonviolent communication places a focus on better communication [8].

There are four steps of the model: observations, feelings, needs and requests (Table 11.2). Articulating observations of the conflict should be done without judgment or evaluation. Stating how the observation makes one feel leads to needs that are connected to the identified feelings. Feelings should include very specific behaviors can be acted upon whereas statements about hard personality traits tend to be less actionable, especially in the workplace. The last component is a very specific request related to the observation.

Table 11.2 Communication strategies for conflict resolution
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The model is a two-way conversation, with the other party poised to consciously receive the information in the same four pieces. In this manner, elements of the conversation are more likely to foster compassion rather than conflict. Intentional listening skills help to mitigate feelings of under-appreciation that can trigger strong emotions as well as lead all parties to be acknowledged during the conversation.

Many other conflict resolution models or tips can be applied. While out of scope, there are specific strategies for dealing with frequently seen scenarios involving passive-aggressive behavior, deep-seated anger, and bullies. It may be helpful to discuss several pitfalls in conflict management and review possibly helpful solutions [1].

As a leader dealing with a conflict, your team may become upset and disengage (or in a worst case scenario, they mutiny). Understanding the underlying cause, and acknowledging it, is the first step in resolving and repairing the relationship. Ultimately, the group’s confidence will need to be earned back. Conversely, there may be a situation in which a conflict arises with one’s boss. Because of the reporting relationship, the resultant emotions of anger and fear are at odds. Consider the following steps: cool down, show respect, focus on business, and clearly explain intent (or the issue at hand) when discussing the conflict.

Understanding the Impact of Management and Conflict Resolution Styles

Rather than strictly dealing with or managing emotions, which tend to fluctuate with environment/context, understanding how managerial styles impact conflict resolution styles may provide a more effective framework for improving communication and engaging in more effective conflict resolution. What individuals’ managerial styles help codify are strengths and weaknesses, as well as a better understanding of what motivators and stressors are. A very effective use of this is a better understanding of how your style tends to interact, either synergistically or at odds, with others’ styles.

Recall the stark contrast between conflict seekers and conflict avoiders (Table 11.3). In this example [1], anticipation of conflict styles and directed consideration of stakeholder perspective can help the parties prepare for the conversation and work toward resolution. One can imagine that the tactics around a conversation between two conflict seekers would be quite different than if it were two conflict avoiders. Further, a greater appreciation of one’s own management and communication style leads to greater self-awareness and improved self-management. Those who value relationships and collaboration will need to be better about infusing objectivity and confronting conflict when working with those who are motivated by action and results. The latter can seek to be more patient and empathetic in order to improve discussions with the former. Team engagement exercises that include style inventories can create a better work environment and, ultimately, set the stage for better identification and management of conflicts.

Table 11.3 How conflict approach styles interact
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Conflict Resolution

As stated, results or decisions must be based on objective criteria. Successful resolution of a conflict results in (1) satisfying as many interests as possible, (2) a result that feels fair and reasonable to stakeholders, and (3) ends with intact relationships among the parties.

Once a resolution is in place and executed, it may be sensible to “make rounds” or do regular check-ins to ensure sustainability. Borrowing the Plan-Do-Study-Act (PDSA) cycle from healthcare improvement scientists [9], the “study” phase of the PDSA cycle includes close observation and learning from the consequences of the “plan” itself. Notably, further modifications (“act”) to the plan itself may be necessary to document and maintain change.

For teams, the ability to learn from conflict resolution itself should be considered. Proverbially, “don’t waste a good crisis”) and reap the benefits of the process of conflict resolution (including increased understanding; self-awareness/insight; team dynamics and cohesiveness). Having a retrospective look at the points of tension can lead to more efficient and proactive behaviors going forward.

Non-resolution of the Conflict

What if there is a failure to resolve the conflict? There may be severe consequences when conflicts are not resolved. From a business perspective, there may be a loss of productivity and downstream impact on access to care and net revenues. More broadly, organizations may experience increased barriers to collaboration as trust issues go unresolved. There may be a stifling of creativity and innovation, with impact on the effectiveness of the team and possibly of the composition of the team itself if employee retention becomes an issue as a result of a changing or unsupportive work environment.

Re-exploring options is critical at this juncture. Consideration of asking for a “third” position or mediator may lead to success if there is agreement to ask for and use help and if there is an agreement to consciously work together toward resolution. Forcing the use of a third party, especially if it invokes the reporting structure (organizational chart), may only serve to exacerbate a conflict and may create downstream consequences in an academic setting. If there is a deliberate determination to “walk away,” that intent needs to be clearly stated. If there is a need to “cool down,” making this a temporary hold, all parties need to recognize the potentially volatile issues leading to such an exit. If there is truly an impasse, take the time to commit to exploring other possible solutions (e.g., going from a win-win scenario to the so-called BATNA, or best alternative to a negotiated agreement) [6]. If the conflict continues to escalate, avoid cycles of action and reaction. In other words, remain calm and avoid escalation by refusing to react.

Can Conflict Be Prevented?

Some tenets for preventing or decreasing conflict include strategies such as setting expectations (communication) for acceptable behavior. Leaders may seek to recognize and understand various stakeholders’ perspective. Unearthing productive conflict can reap big rewards. In healthcare, many missions of a medical center appear to be at odds with each other: Value vs. volume. Standardization vs. innovation. Actually working through these tensions is not only necessary, but can result in improved productivity for the department and health system.

Looking for conflict is not the same a picking a fight. Preemptively “looking for” conflict can often serve as a litmus of the workplace environment and can help decrease gossip and resentment. A buildup of resentment has heavily detrimental effects in the long term so earlier detection and proactive resolution can pre-empt bigger problems downstream. Being on the lookout for conflict can actually help with early recognition of issues before they bubble up to the surface. This may be particularly true if there is concern that the work environment has not engendered enough of a “safe community” to allow for such conversations.

Preserving and encouraging productive conflict allows people to speak honestly, express disagreements, negotiate different viewpoints, and work under a certain amount of pressure. Conflict in this light is positive, fostering innovation and creativity, disrupting complacency, and actually instilling a sense of accomplishment [10].

Generational Conflicts

“Generational issues” in the workplace are often discussed in the context of cross-generational differences and conflicts [11]. While differences across generations are a known entity, Millennials (born between 1981 and 1996) are most frequently discussed because this group comprises the vast majority of medical students, trainees, and (now increasingly) junior faculty in academic Departments of Surgery. Interestingly, what examinations of the workplace have demonstrated is that Millennials on a team are different from one another. Avoiding the pitfall of pigeonholing or stereotyping Millennials on the basis of age is the first step to decreasing generational conflict. In fact, that same pitfall holds true for aging surgeons as well, remembering that there is no rationale for misunderstanding an entire generation. Principles for addressing conflict apply across generations, recognizing that age and rank in an organization does not necessarily inform a single approach to conflict management. The commonality across generations is a true need to feel valued on the job and a desire to contribute to the organization and its mission despite less flattering characterizations that Millennials switch jobs frequently, desire a flat work environment, and a better work-life balance than their older colleagues.

Conclusion

Conflict in the workplace is inevitable and are categorized into four main types: relationship, task, process, and status. Some degree of conflict can actually be beneficial to organizations by disrupting complacency and by fostering innovation and creativity. Conflict management is a key leadership skill and demands the ability to feel comfortable with conflict. Specific skills are helpful when managing conflict, and include elements of management principles, tenets of communication and difficult conversations, and negotiation.