"Blessed are the peacemakers, for they will be called children of God." - Jesus (Matthew 5:9 NIV)
In the case study given by Finkelman the first question asked is: How would you respond to the medical director’s question?
As a nurse manager, I would have to own my mess. I would have to tell the director that I had made a mistake by not advising him of the deteriorating situation sooner. I would admit that I was wrong in allowing the communication between him and me to falter and pledge to work to make sure that it did not happen again.
From the scenario that was given, it was apparent that this breakdown in communication and collaboration had been going on “in the past six months.” (Finkelman, 2016, pg. 331)
This cannot happen.
Finkelman rightly underscores that “management [must] become proactive in eliminating negative communications and behavior.” (Finkelman, 2016, pg. 331) Research shows that “managers, including those in nursing environments, may spend much of their time resolving employee conflicts…[and] if conflict is not dealt with properly, it may significantly affect employee morale, increase turnover…ultimately affecting the overall well-being of the organization.” (Iglesias & Vallejo, 2012, pg. 73)
So, there is a problem in this scenario that must be resolved so that these break-downs in communication, staff conflicts and unprofessional behavior do not negatively impact the effectiveness of the unit.
To solve this problem, as the nurse manager, I must ask: What do I and the medical director need to do? How can I avoid this being a "we/they" situation? How will I involve all staff? What can I do about the powerlessness the nurses feel?
To solve the internal strife in the unit and address the questions raised by Finkelman, there needs to be program put into place to formulate real communication between members of the staff, foster productive collaboration and facilitate constructive ways to resolve conflicts.
Is Conflict a Bad Thing?
First off, there is reason to believe that “positive conflict management, with favorable team leadership, can be beneficial…[it] fosters mutual role respect, improves working relationships, recovers staff retention and sickness, and especially benefits new members of the staff who may find it difficult coming into long-established teams." (McKibben, 2017, pg. 100)
So I and the medical director can look at addressing this situation as a positive initiative that will only help to improve the hospital. Conflict can “equal growth or destruction depending on how it is managed.” (McKibben, 2017, pg. 101)
In order to be sure that this situation does not polarize the staff between nurses and physicians – something that it appears is already taking place – Finkelman argues “a critical step is to gain better understanding of each profession’s viewpoint.” (Finkelman, 2016, pg. 331)
McKibben also points out that “hierarchy may result in team members feeling dominated or not having a voice…[and contributes to] conflict arising from…[differing] views on how work should be done.” (McKibben, 2017, pg. 101) Another study finds “that most of the time physicians, nurses, and UAPs (unlicensed assistive personnel) operate as separate healthcare providers who barely speak to each other.” (Lancaster, Kolakowsky-Hayner, Kovacich, & Greer-Williams, 2015, pg. 275)
At the root of our conflict is a break down in communication and collaboration.
It will be imperative that the physicians and nurses in this surgery unit develop better communication and commit to working together as a team.
Lancaster et al write that “collaboration occurs when providers with different knowledge and skills interact to synergistically and constructively influence patient care…[and] collaboration involves direct and open communication, respect for different perspectives, and mutual responsibility for problem solving.” (Lancaster, Kolakowsky-Hayner, Kovacich, & Greer-Williams, 2015, pg. 276) Communication and collaboration between nurses and physicians directly impacts patient care and can even lower patient mortality by as much as 41%. (Putnam, Ikeler, Raup, & Cantu, 2014, pg. 10)
Between myself and the medical director, we would first seek to implement a conflict resolution plan, using the nurse and surgical resident from this situation as a starting point. The program that I would recommend using is called “The Exchange,” which is covered in an October 2014 issue of Nursing Management. In this program, “leaders learn a common language and structured methodology, which enables them to safely engage team members in all elements of a conflict.” (Rosenstein, Dinklin, & Munro, 2014, pg. 37)
Here are the steps in “The Exchange” program:
Step 1: Either the medical director or myself (preferably myself, since I work more closely with the parties involved in this conflict) would meet with the nurse and the surgical resident individually, “to determine the nature of the conflict, bring to the surface the emotional impact each individual feels, and discover the needs or interests of each party that must be met to react a resolution.” (Rosenstein, Dinklin, & Munro, 2014, pg. 38) Research also shows that “nurse managers are uniquely positioned to assume leadership roles in developing, monitoring, and establishing collaborative nurse-physician teams…[working] closely with the chief nursing officer and chief medical officer.” (Sherrod, Collins-McNeil, & Sharpe, 2013, pg. 46)
In this first step it is crucial for the facilitator to be an impartial party, working as a neutral mediator.
Understanding and validating the emotional factors of the conflict are important. If emotions are not considered, this “can negatively impact patient safety, and may also contribute to the creation of victimization…[and] teach leaders to tolerate chronic conflict behavior.” (Rosenstein, Dinklin, & Munro, 2014, pg. 37) It seems from the scenario that emotions are already a factor since “nurses are also frequently complaining that they are ‘second class citizens’ in the department.” (Finkelman, 2016, pg. 331)
Step 2: After the initial interviews, then I would work with the nurse and the surgical resident to establish a common ground to move forward from. At this point in “The Exchange” the leader seeks to start the conversation on a “positive note” and introduces a topic that provides common ground for the two parties. Meeting with both parties, I might ask each to tell me why they chose a career in healthcare. Research shows that doing this allows these people to begin to “see each other as human beings rather than enemies.” (Rosenstein, Dinklin, & Munro, 2014, pg. 38)
The nurse and the surgical resident might begin to see that they are not so very different after all.
Step 3: Now that communication is taking place in a positive direction, I would begin to help the two individuals work through the conflict, “specifically getting each party to state the emotional impact the conflict has had…then [having] the other party restate that impact to demonstrate understanding and empathy.” (Rosenstein, Dinklin, & Munro, 2014, pg. 38)
In this step we are also addressing the powerlessness that nurses can feel (as directed in Finkelman's questions) as well as moving away from a polarized environment (that “we/they situation”) and moving toward mutual understanding and constructive communication.
Both parties have a voice. Both parties are heard. Communication is taking place.
Step 4: At this point I would take what each person has learned about the other in the previous two steps and help move the two people toward coming up with a resolution together. In “The Exchange” process, this underscores “empathetic buy-in, mutual understanding, and respect.” (Rosenstein, Dinklin, & Munro, 2014, pg. 38)
The goal of this process is “to determine the underlying issues, decide on the solutions and then document the decision in written form.” (Rosenstein, Dinklin, & Munro, 2014, pg. 38)
This system of conflict resolution also helps in building communication between staff members and increases collaboration.
Research on using "The Exchange," indicates that “99.1% said they used the learned communication skills to care for patients, 43.5% stated that conflict negatively affecting productivity decreased, and managers spent 25.4% less time managing disruptive behaviors.” (Rosenstein, Dinklin, & Munro, 2014, pg. 38)
As the need for more nurses increases and collaborative approaches to healthcare are used with greater frequency, there will be a need for greater communication between doctors (who stand to have less autonomy) and nurses (who will gain more authority).(Rosenstein, Dinklin, & Munro, 2014, pg. 39)
As a nurse leader it will be imperative to work toward “improving nurse relationships…[and] improving efficiency in communication and collaboration.”(Rosenstein, Dinklin, & Munro, 2014, pg. 39)
It will be those “healthcare institutions that promote these skills…[who] transform leadership and improve healthcare efficiency, reduce preventable medical errors…and foster a culture where loyal, committed providers will want to be employed.” (Rosenstein, Dinklin, & Munro, 2014, pg. 39)
Finally, as stated before, it is the nurse manager who is uniquely positioned to formulate real communication between members of the staff, foster productive collaboration and facilitate constructive ways to resolve conflicts.
It is her job to help develop relationships between team members – making sure to involve physicians in the events that are held for the nurses, such as birthdays, weddings, etc. She can also foster respect by asking physicians to “address nurses by their names…[and] demonstrate respect for each other by not criticizing or questioning care decisions or actions in front of patients, family members, or other members of the healthcare team.” (Sherrod, Collins-McNeil, & Sharpe, 2013, pg. 47)
It is also important to “increase opportunities for sharing about the differences between the work of the nurse and the physician, using that knowledge to create a collaborative common ground.” (Crawford, Omery, & Seago, 2012, pg. 549)
As a nurse manager, I would also work to develop orientation/training materials for the unit which would focus on the need for collaboration. This staff development would focus on “establishing mutual support, trust, and respect [as well as] developing shared goals and knowledge.” (Sherrod, Collins-McNeil, & Sharpe, 2013, pg. 47)
By implementing across-the-board orientation and training in conflict resolution, communication and collaboration, nurse managers are being proactive in helping staff members before a problem arises. Teams are more cohesive when everyone is working with the same set of ideals, goals, expectations and guidelines.
Work at living in peace with everyone, and work at living a holy life, for those who are not holy will not see the Lord. (Hebrews 12:14 NLT)
Crawford, C., Omery, A., & Seago, J. A. (2012). The Challenges of Nurse-Physician Communication. Journal of Nursing Administration, 42(12).
Finkelman, A. (2016). Leadership and Management for Nurses: Core Competencies for Quality Care (3rd ed). Upper Saddle River, NJ: Pearson.
Iglesias, M., & Vallejo, R. (2012). Conflict Resolution Styles in the Nursing Profession. Contemporary Nurse, 43(1).
Lancaster, G., Kolakowsky-Hayner, S., Kovacich, J., & Greer-Williams, N. (2015). Interdisciplinary Communication and Collaboration among Physicians, Nurses, and Unlicensed Assistive Personnel. Journal of Nursing Scholarship, 47(3).
McKibben, L. (2017). Conflict Management: Importance and Implications. British Journal of Nursing, 26(2).
Putnam, J., Ikeler, S., Raup, G. H., & Cantu, K. (2014). There's No "I" In Team: Evaluating Nurse-Physician Collaboration. Nursing Management, 45(1).
Rosenstein, A. H., Dinklin, S. P., & Munro, J. (2014). Conflict Resolution: Unlocking the Key to Success. Nursing Management, 45(10).
Sherrod, D., Collins-McNeil, J., & Sharpe, D. (2013). Practical Tips for Nurse-Physician Collaboration. Nursing Management, 44(8).