Workplace Conflict in Nursing

Going to work should be a productive, fulfilling, and enjoyable experience since a great amount of time and energy is spent by each individual at their workplace. Within healthcare organizations nurses, physicians, and other health care professionals (HCP) put in long hours to provide quality health care for patients and family members, contributing to a healthy, productive, and sustainable population (Johnston, Phanhtharath & Jackson, 2009). Considering that the purpose of the health care environment is to provide sensitive, compassionate, and empathetic care, it is ironic that conflict and bullying persists in this sort of workplace (Sheridan-Leos, 2008). With the combination of workplace stressors and natural differences among staff perceptions, ideas, needs, and work ethics, conflict is unavoidable. If the required skills, support and management are not present conflict can persist within workplaces, impeding on the development of a healthy work environment. Understanding the complexities of nursing conflict is essential in successfully managing the challenge and extremely relevant in achieving a healthy workplace as outlined by the Registered Nursing Association of Ontario (RNAO, 2008).

A plethora of literature suggests that workplace conflict and bullying is widespread in nursing, and that it can render the workplace a harmful, fearful and abusive environment, indicating the importance and urgency of understanding the issue (Hutchinson, Vickers, Jackson & Wilkes, 2005). This paper will provide an in-depth analysis of this professional issue as it relates to the Comprehensive Conceptual Model for Healthy Work Environments; discuss the interplay between individual, organizational, and external systems; and propose strategies to overcome this workplace challenge (RNAO, 2008). Methods of Data Collection

The literature used in this paper was located using computerized searches of the world-wide web. Search words, phrases, and terms were focused on nursing conflict, horizontal violence, effects of nursing conflict, and nursing conflict management. The databases searched include PubMed, CINAHL, RNAO, CNO and OVID, in accordance to the hierarchy of Evidence-Based Practice. The period of 2002-2012 was chosen because it represented a reasonable length of time to detect changes in the conceptualization of conflict. Articles of high-quality were chosen based on relevance, credibility, and methodological rigor. Workplace Conflict and its relationship to the Comprehensive Model for Healthy Work Environments

Conflict can be defined as “an antagonistic state of opposition, disagreement or incompatibility between two or more parties” (Almost, 2010, p. 6). Within the nursing profession, it can manifest in several dimensions including nurse-to-nurse conflict, patient-nurse conflict, and conflict with inter-professionals and management (CNO, 2009). Interestingly, nurses report nurse-to-nurse conflict or horizontal conflict being the most distressing of them all (Johnston, Phanhtharath & Jackson, 2009). The various way in which conflict can present itself in the nursing profession can be found in Appendix A, Figure 1. It is important to note that conflict is not synonymous with an unhealthy work environment. In fact, conflict can often be a constructive and functional experience that can be catalytic to new ideas, progress and positive change and growth. Vivar explains that “conflict increases creativity and innovation, provides more energy for personal growth and healthier relationships, encourages self-examination and fosters reappraising of the situation” (2006, p.202). However, in order for conflict to transform into a positive learning experience and contribute to a healthy working environment, the appropriate skills and strategies are essential.

The Healthy Work Environments (HWE) Best Practice Guidelines (BPG) are designed by the RNAO to support health care organizations in creating and sustaining positive work environments. The RNAO states that a healthy work environment is defined as “a practice setting that maximizes the health and well-being of nurses, quality patient outcomes and organizational and system performance” (RNAO, 2008). The framework for HWE can be found in Appendix B (Figure 1), and illustrates that healthy workplaces are a product of the interdependence among individual, organizational, and external contexts. Moreover, the model suggests that there is a synergistic interaction between all levels and components of the model, indicating that interventions must be targeted across all areas. The professional issue of workplace conflict falls into two components of the model, both Professional/Occupational and Cognitive/Psycho/Socio/Cultural components; the latter component being the one explored in this paper (RNAO, 2008). Workplace conflict very suitably fits into this component of the HWE model, as conflict has a significant connection to social and cultural working norms, with resulting cognitive and psychological impacts on each level.

Fostering a HWE on the Cognitive/Psycho/Socio/Cultural component from an individual nursing level requires nurses to demonstrate capabilities with respect to maintaining nursing roles, team relationships, emotional demands and effective coping and communication skills (RNAO, 2008). Having said that, if there is a deficiency in any of theses areas workplace conflict can arise. With the extensive amount of both intra- and inter- professional relationships that nurses must engage in, there are more windows of opportunity for conflict to arise. When a divergence of values, needs, opinions, goals or objectives exists between individuals, a nurse’s personality and conflict management skills play a significant role (Brinkert, 2010). The development and maintenance of respectful and collaborative professional relationships is the responsibility of each individual nurse and stated in The Standards of Practice for the CNO (College of Nurses of Ontario, 2009). Nurses who are well adjusted, positive, self- confident, and efficacious with a strong belief in themselves will bring a ‘positive frame’ to situations and, subsequently, will experience less conflict with others, less job stress and ultimately more job satisfaction (Almost, 2010).

Coping skills and having an understanding of professional roles is another vital component of the HWE model and can dictate how conflicts are handled. Brinkert explains that “basic differences in role-related perspectives between nurses and physicians and among nurses and other professional groups were shown to impede conflict resolution, if not an additional source of conflict”, illustrating the importance of having an accurate understanding of personal and inter-professional roles and responsibilities (2010, p.148). Upon knowing roles and expectations when collaborating with others, both parties can develop a sense of trust, dependability, and accountability to work effectively as a team. The ability to trust others in the workplace leads to less conflict, as colleagues are more likely to accept disagreements at face value and less likely to misinterpret behaviors negatively (Almost, 2005).

When dysfunctional and unresolved conflicts takes place at one’s workplace, there are significant negative outcomes for nurses that can disrupt one’s emotional, physical, and psychological well-being. Victims of conflict report diminished self-confidence, self-esteem, sense of worth, and belief in their competency. Physical effects include irritable bowel syndrome, migraines, hypertension, asthma, arthritis, and decreased immune response. Although emotional effects tend to be less obvious in appearance, workplace conflict can cause victims to have poor concentration, forgetfulness, loss of sleep, increased fatigue, indecisiveness, nightmares, and obsessive thinking about argumentative coworkers (Johnston, Phanhrharath & Jackson, 2009). Understandably, when conflict lingers and remains unresolved, the negative consequences experienced by nurses lends itself to the existence of an unhealthy workplace. Provided that nurses experience the previously mentioned outcomes, they will be unfit to carry out their professional role as a nurse, putting their emotional stability, coping skills and team relationships in jeopardy.

Organizational social factors are the second component of the HWE model and encompass an organization’s climate, culture, and values. “Included among these factors are organizational stability, communication practices and structures, labour/management relations, and a culture of continuous learning and support” (RNAO, 2008). The health care organization is a powerful organization that relies on tremendous amounts of collaboration amongst individuals on several levels of the system to deliver quality health care. The climate and culture in which individual organizations are built upon are crucial components to allow for healthy workplaces to evolve. In fact, the negative effects of persistent conflict are a major concern on an organizational level. As previously mentioned, workplace conflict has been linked to decreased work satisfaction and team performance in nursing. Extensive evidence suggests that persistent conflict results in higher turnover and absenteeism, lower collaboration and communication, damaged team morale, and decreased productivity. Negative, non-supportive, and uncooperative colleagues are barriers to positive unit morale and interpersonal relations (Brinkert, 2010).

The climate and cultural component of the model is extremely relevant to workplace conflict. If workplace conflict is present within an organization and remains unresolved, staff can come to believe that such behaviors are normal and acceptable within the organization’s culture. New staff may believe that this manner of relating to each other and interacting with other coworkers is ‘just how things are done around here’. As a result, nurses can become afraid to ask colleagues for help, leading to the obstruction of a healthy culture of learning and support as required by the HWE model (Sheridan-Leos, 2008).

When conflict is allowed to continue within a workplace, organizational stability is negatively affected. Nurses are more likely to leave a workplace if conflict is present, which lowers the organization’s retention of qualified staff and ultimately reflects in patient care. Moreover, if an organization develops a reputation for tolerating workplace conflict, their organization may become unappealing for the recruitment of new staff. Impaired collegial relationships among nurses hinders healthy communication practices that are vital in providing safe patient care, which is likely the core value of an organization. For example, in a recent survey of 2,000 healthcare providers by the Institute for Safe Medication Practices, about 40% of respondents reported that they accepted a medication order because they feared the intimidation by the prescriber (Sheridan-Leos, 2008). This illustrates that healthy working practices amongst staff are indispensable for delivering safe, quality patient care within an organization.

Labour and management practices are essential in producing healthy work environments, as outlined by the HWE model. The support provided by nursing managers has been identified as one of the key factors in a positive work environment, as nurses often look to their managers in times of conflict within an organization. In efforts to achieve a HWE, it is essential that organizations recruit management that is skilled in conflict management, approachable and supportive for staff, motivates development of self-confidence, provides adequate staffing, and promotes group cohesion. A cohesive and supportive team can be created through the recognition that each person is important, valued, and necessary to the team, and subsequently reduce the amount of conflict on that team (Dellasega, 2009).

The last component in achieving a healthy workplace according to the HWE model is the systems level of external socio-cultural factors. Factors include consumer trends, changing care preferences, changing roles of the family, diversity of the population and providers, and changing demographics- all of which influence how organizations and individuals operate (RNAO, 2008). The social and cultural roots in which the nursing profession originated is linked to subordination and oppression of the nursing profession that continues to prevail in society and in the health care system. When looking at nursing conflict, the theory of oppression is frequently noted in the literature and suggests that nurses are oppressed in two significant ways-through gender and medical dominance.

As a consequence of oppression, nurses are socialized into a system of historical hierarchal structures and unequal power relations that are maintained by not only colleagues, but society as a whole (Hutchinson, Vickers & Jackson, 2005). Cherished nursing characteristics, such as sensitivity and caring are viewed as less important or even negative when compared to those of medical practitioners, who are often seen as the central and most important component in health care. Consequently, feelings of powerlessness, lack of control, and subordination can prevent nurses from confronting issues, leading them to express their frustration on other nurses lateral to them (Sheridan-Leos, 2008). This ideology indicates that HWE are significantly reliant on societal views and perspectives of the nursing profession within the health care system.

Within the external socio-cultural factors of the HWE model, demographics such as age, sex, length of service, culture and educational background are additional contributors to workplace conflict. Differing demographic characteristics amongst individuals increases the potential for differing opinions and values, heightening opportunity for disagreement and potential conflict. In nursing, it is not uncommon to hear the expression “nurses eat their young”, attributing the continued presence of generational conflict within the nursing profession. Generational diversity and having differing years of experience leads to conflict in nursing working environments as each generation of nurses brings its own set of values, beliefs, life experiences and attitudes to the workplace (Johnston, Phanhtharath & Jackson, 2009). The origin and historical context in which the health care system and nursing was based on is a significant contributor in the persistence of workplace conflict, inevitably resulting in the continuation of unhealthy work environments. Salient Points of Workplace Conflict

Workplace conflict is an extremely relevant issue that continues to persist within the health care system and can have severe negative consequences on a nursing, organizational and systems level. Although conflict can be functional and constructive in nature, the appropriate tools and strategies are required in the prevention and management of conflict in the workplace. Health care professionals are frequently engaged in high-stress environments with long working hours and heavy workloads, making the health care system particularly vulnerable to experiencing workplace conflict (Vivar, 2006). The HWE framework provided by the RNAO illustrates the important interplay of the various components that must be present in achieving an overall healthy work environment. As stated by the RNAO, a healthy work environment is one that maximizes the health and well-being of nurses, quality patient/client outcomes, organizational performance and societal outcomes (2008). Managing workplace conflict and creating healthy workplaces is critical in recruiting and retaining nurses, reducing occupational stress and injury, increasing job satisfaction and collaboration, and optimizing the future of the health care system (RNAO, 2008). Strategies to Overcome Workplace Conflict

While conflict cannot be eliminated from the workplace, developing effective strategies to both prevent and manage conflict is imperative in working towards a HWE. Nurses are at the forefront of witnessing and experiencing workplace conflict, thus play an integral role in setting the standards of healthy working relations and stopping the cycle of workplace conflict. It is a required national competency held by the CNO that all nurses use basic conflict resolution strategies to transform situations of conflict into healthier interpersonal interactions (CNO, 2009). The CNO outlines several realistic strategies for nurses such as: modeling professional behaviors, mentoring, supporting, and integrating new staff members, reflecting on personal attitudes and beliefs, and managing personal stress. When nurses encounter a situation of conflict, it is important to address the issue quickly and directly rather than avoiding or postponing its resolution (CNO, 2008).

Strategies associated with nursing self-evaluation and reflection is frequently noted in the literature to manage conflict. Nurses who have higher levels of core self-evaluation and are positive, self-confident, and efficacious with a strong belief in themselves can manage the stress from conflict situations more effectively and ultimately reduce the amount of conflict with others. This includes being self-aware of personal behaviors and how these behaviors effect others. In order to achieve self-awareness and reflective practice, learning to understand and reflect on one’s own personal attitudes, motivators, values and beliefs that affect relationships with colleagues is essential (Almost, 2010). Additionally, it is vital for nurses to implement collaborative practice strategies such as buddy systems or team huddles in effort to strengthen group cohesion, trust, and teamwork. Organizational strategies that incorporate communication and collaboration in a designated timeframe such as daily team huddles, brings conflict to the forefront of everyone’s attentions, placing importance and consciousness on the issue (Brinkert, 2010). Upon collaborating with others and prioritizing workplace conflict as an essential challenge in achieving a HWE for all, colleagues can generate creative strategies that can be personal and unique to their workplace.

There are several strategies that can be implemented on an organizational level in managing conflict. As previously mentioned, management staff plays a key role in fostering a supportive, collaborative and cohesive team that is communicative when conflict arises. Having said that, hiring knowledgeable and approachable management staff who are trained in conflict management is an integral strategy for organizations to adopt. Additionally, organizational strategies should be focused on the development of policies and procedures in managing, reporting, following-up, and monitoring of conflict within the organization (Brinkert, 2010). Creating policies such as an open-door policy or no tolerance policy allows staff to feel comfortable in voicing concerns without fear or intimidation, and ensures that staff members are supported when conflict arises (Johnston, Phanhtharath, Jackson, 2009). Moreover, strategies that incorporate the transfer of conflict management skills and education to staff is vital. Educating staff through interactive workshops or focus groups for instance, gives staff the opportunity to learn about conflict, identify their conflict styles, and learn appropriate conflict resolution methods (Sheridan-Leos, 2008).

Strategies aimed at the systems level focus primarily on uprooting pre-existing notions of the hierarchal health care system, challenging the status quo, and developing a demographically diverse population of HCPs. As previously mentioned, the oppression theory is frequently attributed to workplace conflict within nursing and is largely based on a hierarchal perspective of health care workers that many people still hold today. Instituting strategies within the health care system that aims to gain equal respect and value to each member of the health care team, despite their professional role is a stepping stone in breaking down this paradigm. Changing the required nursing education from a college diploma to a university degree was a systems strategy which not only resulted in an increased readiness to practice, but an increased intolerance to patriarchal subservient healthcare systems (Wolff, Pesut & Regan, 2010). Strategies which expand the scope of practice for nurses allows nurses to have more control and power over their practice environment, and subsequently shifts the societal views of nursing roles. Extensive evidence suggests that nurses be involved in policy and strategy development, allowing the profession with greater autonomy by participating in decision-making and allowing opportunity for professional development (CNO, 2008).

Lastly, systems strategies should be aimed to increase awareness and development of cultural competency and intergenerational working forces. Initiating ‘awareness weeks’ or holding interactive workshops with staff members contributes to a system which recognizes and appreciates the value of everyone’s unique demographics to the overall system. ‘National Nursing Week’ is celebrated and observed by patients, consumers, providers, and HCPs which allows communities to designate time to appreciate the roles of nurses. Celebration strategies designates time to reflect on who nurses are as professionals, who nurses are as individuals, who nurses are as a team, and ultimately who nurses are in healthcare (Johnson, Phanhtarath & Jackson, 2009). Conclusion

As the findings of this paper have suggested, positive interpersonal relationships and respectful communication can reduce the amount of conflict among nurses. As stated by the CNO National Competencies, “Entry‐level registered nurses are beginning practitioners whose level of practice, autonomy and proficiency will grow best through collaboration, mentoring and support from registered nurse colleagues, managers, other health care team members and employers” (CNO, 2009, p.4). The implementation of innovative and effective strategies is critical in working towards a HWE, as outlined by the RNAO framework. With the aging nursing workforce and nursing shortage, creating work environments emphasizing positive relationships that will retain nurses is important. While conflict is inevitable, frequent conflict is detrimental to the quality of nurses’ work environments, clinical outcomes and patient satisfaction, highlighting the importance of the issue (Almost, 2010).