Manage Conflict and Resolve Problems by Negotiating

Traditionally, conflict has been viewed as a destructive force to be ignored or silenced; today, many are redefining conflict as an opportunity. Once conflict is approached as a cooperative effort, nurses and other healthcare professionals can restructure trust to enhance professional relationships. By understanding the dynamics of negotiation in areas such as leadership, power, and conflict management, healthcare professionals will improve the quality of their professional practice, relationships and their working environment.

This article presents an overview of conflict resolution by introducing: Conflict management concepts and principles Strategies for effective negotiation Useful techniques for conflict management

Healthcare organizations, although extremely complex, have as their mission nothing less than improving the health of patients and their communities. Unfortunately, this lofty goal can be lost amid the conflicting agendas and value systems of individuals and disciplines within the healthcare system. This is, understandably, a frustration for many healthcare professionals. 

Working Together    

Professionals who are, or should be, working together to provide healthcare services for patients must develop a set of skills for effective communication. These skills include:

• Conflict management
• Consensus-building through collaboration
• Negotiation

These essential skills not only improve patient care, but are vital for personal, professional, and organizational success.

Collaboration—one method of conflict management—is a process by which people and groups work together to achieve a common goal. Collaboration works best when each person involved takes responsibility for his or her own working relationships and quality patient services. For example, imagine there is insufficient staff on a unit. By working collaboratively, nurses can prioritize patient care needs, pool available resources, and ultimately match those resources to achieve the mutually defined common goal of quality patient care.

Negotiation--Problems can arise, however, when healthcare professionals disagree on how to achieve that goal. This calls for another method for conflict management—negotiation. During negotiation, healthcare professionals must engage in honest communication, adjusting their differences to eventually reach consensus. Negotiation works best when the people involved in a conflict tell each other their goals, needs, and wants.(1)  Individuals  can then adapt their needs and wants so that the common goal can be achieved.

These processes take time to learn and practice. Even so, every healthcare professional has the power and responsibility to “step up to the plate” and negotiate disputes or differences of opinion, even while organizational decisions are being made. For some individuals, this might represent a new approach for professionally relating to others. Yet taking a chance—possibly even a risk—can be liberating and empowering.

Why Negotiate? We negotiate with others every day, usually without even thinking about it. Occasionally an impasse does occur, and then we realize that finding a solution isn’t always easy. This is especially true when people perceive the same thing differently, or if we are not sure what action   is expected from us or required of another. Examples abound. Do any of these sound familiar?

These situations can be emotionally draining. And, over time, our reactions to these situations intensify, creating an atmosphere of:

• Tension
• Frustration
• Anger
• Misperceptions
• Polarization of staff

Negative emotions and feelings start to affect a work group.  For example, we begin to see different staff members  as belonging to two or more work groups pitted against each other defining themselves as “we-they” in their communications. 

Once “we-they” positioning occurs, effective communication deteriorates. The stress level in the workplace escalates to the point that, ultimately, patient care is affected. (2,3) Until issues are addressed and collaborative agreements reached, the problem worsens, affecting more professional relationships and personal well-being.(4)
 
When conflict arises, professionals have the opportunity either to affect change by taking action or do nothing and maintain the status quo. This choice puts us in a powerful position to assist or obstruct the negotiating process and thereby expand or diminish our own potential.

If we choose, we can remain silent, feeling victimized, powerless, and pressured. Realize that taking no action is a decision—in essence, an act of avoidance. By giving away our voice, we give away our power. By staying caught in the middle, we lose our voice, our options, and the chance to make a positive difference. Regardless of the strategy used, effective professionals understand the connection between the choices we make and the results we live with.

Power

Most conflict involves power, either directly or indirectly. Here are a few basic thoughts on the nature of power:

Every relationship involves power issues on some level. Sometimes power issues are covert and hidden, and other times they are overt and clear to all. When we use our power for personal advantage, others are affected, either negatively or positively. Power is neither good nor bad. We tend to associate the idea of power with strength and ability. The purpose of power is to get another person or group to do what we want.

When conflict occurs in healthcare organizations, professionals respond according to their belief and understanding of how power is distributed. One’s strategy for managing conflict is often influenced by one’s understanding of who has the power and how they will probably wield it.

As healthcare professionals, we have a responsibility to not stop at simply understanding organizational power. We need to develop our own bases of power. Here are some resources various professionals have found helpful as they develop their own power bases:

• Reliable and trusted sources such as leaders and seasoned experts
• Participation in professional associations
• Participation in organizational projects or committees

In any industry, people can seek power by (5,6):

• Giving something of value to another
• Threatening negative consequences or disciplinary action
• Becoming experts in their field
• Developing inspirational personalities using charisma to influence others
• Acquiring formal positions of authority
• Obtaining support from others who have power
• Establishing autonomy and independence from others

As professionals seeking to manage conflict among coworkers, we can be strengthened by a variety of other resources within our organization, such as:

• Seeking out wise and seasoned persons who have demonstrated a commitment to balancing patient needs with organizational resources
• Forging alliances with persons or committees having similar goals
• Developing relationships with individuals with formal authoritive power to influence organizational resources and decisions

When we develop alliances with trustworthy resources, we begin to build a shared strength and power. By collaborating with these resources, we build credibility for ourselves and strengthen our own bases of power.

Clinical professionals such as nurses, physicians, and physical therapists working at the bedside have the power to influence decisions for patients, work units, and organizations by getting involved. Empowerment (a term frequently used in nursing) is defined as “giving individuals the authority, responsibility, and freedom to act on what they know and instilling in them belief and confidence in their own ability to achieve and succeed” (7). Self-empowerment includes learning about and participating in decision making. Taking responsibility for our own empowerment can transform us and our coworkers, patients, departments, organizations, nursing profession, and even society in general.

How Gender Affects Power and Conflict Management Style

Men and women tend to handle power differently.(8,9) Women define themselves through relationships and networking, whereas men define themselves by the tasks they accomplish. Men often see conflict as a means to engagement and competition whereas women experience this competition as threatening to relationships.  Although some men prepare for “battle,” some women prepare for “retreat.”(7,8) Conflict management styles among nurses are heavily influenced by the fact that many nurses are female, and females in our society are socialized to handle conflict in specific, sometimes negative ways.(9,4) As one researcher explained it, “Nurses are typically socialized to press for consensus, which may make them appear tentative. In contrast, physicians often focus on justice issues and are intent on ruling out alternatives.”(4)

Studies that focus on working relationships in healthcare settings reveal patterns of female aggression and bullying that consistently result in destructive and counterproductive influences on nurses and other females.(10) As one writer has explained, “Conflicts arise because women have behavioral expectations for other women [which] we do not have for men. Simply put, we make allowances for men being different from us, but when women are different, it makes us uncomfortable.”(11) Valuing each other’s differences is part of collaborating and negotiating for a common good.

At times, when a woman does decide to speak out and address concerns, she may be left to fend for herself, which can make her feel betrayed.  The conventional model for many women to remain quiet and not speak up has a silencing effect on others.(8)Yet, not all men are competitive; thus, stereotypical patterns of behavior that frustrate communication and damage teamwork must be addressed and redefined for both genders. The solution lies in raising awareness among both men and women and encouraging them to learn new ways of talking with each other.

Leadership

When conflict arises, we naturally look to leaders for resolution. Effective leaders, however, understand that their jobs are not merely to “fix things” but rather to equip others to creatively manage their own conflicts and thus develop their skills.(12) Leadership is more than a position on an organizational chart; it is a learned skill that is best developed when it is shared.

Shared leadership, also known as shared governance, tends to flatten the bureaucracy of an organizational chart, and helps employees become empowered stakeholders. When leaders are willing to share their power, followers learn to manage issues such as control, authority, and influence.(13) Professionals  who successfully practice shared governance have developed the following skills:

• Decision making about patient management issues
• Standards of practice knowledge
• Quality assurance abilities
• Excellent conflict resolution skills
• Excellent negotiation skills

A leader’s commitment to shared governance supports professionals as they seek to work and negotiate within all disciplines of their organizations. Distributed power can be one of the most inspiring and encouraging endorsements a healthcare professional can receive.

Conflict Conflict in the healthcare industry presents some unique challenges simply because there are so many people involved in the delivery of services, making it impossible for any one provider to have total control over decisions affecting patient care.(12) Because of this dynamic, conflicts surface, calling for negotiation skills. If managed well, the conflict can be resolved constructively. If not managed well, the conflict may result in disaster. Whether managed well or not, conflict changes things. It calls into question the status quo. We are motivated by the tension it creates to move from our current situations to the situations that we desire.

The Benefits of Conflict

What are the benefits of conflict? By courageously and honestly discussing conflict, nurses can:

• Increase awareness of problems
• Improve preparedness to cope with problems
• Initiate organizational change and adaptation
• Strengthen relationships and improve morale
• Promote awareness of self and others
• Enhance personal growth
• Encourage psychological development

Destructive Malfunctions with Unmanaged Conflict

The downside of conflict occurs when it is unmanaged. Then conflict can (14):

• Set in motion a win/lose approach
• Cloud the truth with misperception and bias
• Polarize coworkers
• Isolate us from those with differing opinions
• Blur the issues
• Magnify our differences instead of focus on our similarities
• Escalate the conflict 

Unmanaged conflict is costly and stressful. Research indicates that the single greatest cause of job stress is unhealthy workplace practices and conditions.(15) The real costs of healthcare conflict are the losses for each staff member in terms of (16):

• Effectiveness
• Morale
• Employee turnover/retention
• Absenteeism
• Meaningful professional relationships

These costs do not include the impact of compromised patient care. In addition, for the patient, a communication breakdown among caregivers results in a patient’s increased sense of vulnerability, anxiety over interrupted care, and health status.(17)

Listed below are the five basic styles of managing conflict.(18) Do you recognize yourself in any of them? Do you recognize any of your coworkers?

No single style for managing conflict is correct in all situations. Some personality types prefer one style; others prefer another. The style we choose is largely influenced by (9,19,20):

• Personality trait development
• Age
• Socialization
• Culture
• Gender factors

When conflict is approached as a cooperative effort, the goal becomes doing as much as possible for everyone involved, instead of engaging in destructive win/lose struggles.(21) What becomes important are the problem-solving and decision-making aspects of healthy negotiation.

Negotiation

People in conflict often think in terms of win/lose. This mindset is especially true when the issue involves something that people take a position on or have a belief about. If the issue only involves people’s interests, they will be more willing to compromise. But if their beliefs are at stake, they often hold tenaciously to their position. Under these circumstances, the conflict intensifies because one side wants something the other side opposes, or both sides want something that cannot be shared. Both sides then become further entrenched in their positions, moving further apart by making more extreme statements in an effort to win support from others. For example, the following debate is ongoing in healthcare: What is the correct number of staff caregivers need to provide quality nursing services? What should be the mix of RNs, LPNs, and NAs to provide safe quality services?  Who should decide the mix and what criteria should be used to influence the decision?

Nurses would probably argue this debate based on a belief that greater numbers of staff would make the difference in promoting safe quality patient care services, whereas administrators would possibly argue from a position based on their belief in limited financial resources. Both sides would believe they were correct, and, oftentimes, both sides would gather information to defend their positions. Defending one’s side, or position, is called positional bargaining, and eventually affects other people, departments, patients, and the organization because the focus is on defending a position instead of negotiating a solution.

Interest-based Bargaining

People view situations differently depending on:

• Experiences
• Background
• Education
• Situational specifics

Unlike positions or beliefs, interests are the reasons why people want something. When we understand why another person wants what he or she wants, we can recognize ourselves in the others. This recognition makes negotiating for a solution, or even a partial solution, much easier.

This ability to “walk in another’s shoes” is called interest-based bargaining. We negotiate by understanding the other person’s interests or why they want what they do. Understanding why someone wants something motivates us to find creative ways to work together. Interest-based bargaining brings out the human meaning behind the conflict.

Clarifying Values

Values are at the core of most conflicts, which can be a problem because values can be hard to articulate.  Everyone at times struggles between contending values such as truthfulness, fair-mindedness, and autonomous self-directed behavior.  Individual values and beliefs about conflict affect behavior.  Many beliefs are deep-seated in a culture and period of time. Generational and gender differences also exist about the behavior that is acceptable in conflict. Values also affect how direct one can be about concerns, feelings, hopes, and ideas. By clarifying values, each party is given an opportunity to identify and appreciate the similarities with and differences from other parties. Usually the values that underlie personal or professional interests, although not easily detectable, emerge during open discussion and negotiation.(5) By simply asking the question: “Help me understand what this means to you?” opens the door to values clarification.

Framing the Problem

To effectively begin negotiation, individuals in conflict must separate the problem from the person. They must also agree to temporarily suspend judgment on who is right and who is wrong. This allows people to set aside distractions and anger and to enter into direct dialogue and negotiation.

Setting these distractions aside requires awareness and participation on the part of everyone involved. Preparing to negotiate, also called framing the problem, sets the stage for constructive negotiation.

Listed below are seven strategies for framing problems (22):

1. Try to see the situation from the other party’s perspective. Although you do not have to agree with another’s perception, it is important to understand what others think and feel and why they do so. Listen.
2. Try to not operate from a suspicious assumption. Operating from suspicion makes it more difficult to accurately distinguish another’s real intentions or openly begin dialogue. Don’t jump the gun.
3. Avoid the blame game. Blame, even if deserved, will only make your opponent defensive, and worse, your opponent may attack you in response. Blame is counterproductive. Be respectful of the other person.
4. Openly discuss each other’s perceptions. Take your time to explicitly discuss perceptions to gain a greater understanding. Such discussions may reveal shared perceptions and goals. By acknowledging shared perceptions, you will facilitate collaboration. It is OK to respectfully disagree.
5. Use the element of surprise in a positive way. By changing your opponent’s worst beliefs and expectations about you, you can begin to set the stage for mutual agreement.
6. Give the other party(ies) a stake in the outcome. Make sure all participate in the negotiation process. Investment in the outcome requires involvement in the process.
7. Make the proposals consistent with the principles of self-image. All parties to a negotiation need to feel the agreement is consistent with their own personal and professional principles of integrity. Proposals consistent with all parties’ principles are more likely to be accepted.

When negotiation takes place in a safe, respectful setting, individual strengths and abilities emerge, and people work together. In essence, “Each healthcare professional has information the other needs to possess in order to practice successfully.”(5) Rather than engaging in power struggles, nurses can negotiate from positions of strength when they recognize the substantial power they possess, remain confident in their abilities, and believe in the meaningful contributions they can make.

Summary

Hospitals are complex structures with overriding missions to improve the health care of patients and community. Personal, professional, and organizational success requires:  

• Core nursing skill competencies of leadership
• Negotiation
• Consensus building
• Conflict management

Power used constructively is crucial for survival and success for healthcare professionals and organizations. Traditionally, conflict has been viewed as a destructive force to be ignored or silenced; today, many are redefining conflict as an opportunity. Once conflict is approached as a cooperative effort, nurses and other healthcare professionals can rebuild trust and create a future of enhanced professional relationships.

References

1. Anastakis D. Negotiation skills for physicians. Am J Surg. 2003;185:1-8.
2. Donald A. Alternative dispute resolution: Managing upsets and keeping people safe. Evidence-based Healthcare and Public Health. 2004; 8(6):412-413.
3. Baggs J, Norton S, Schmitt M, Sellers C. The dying patient in the ICU: role of the interdisciplinary team. Crit Care Clinics. 2004;20:525-540, xi.
4. Lindeke LL, Sieckert AM. Nurse-physician workplace collaboration. Online Journal of Issues in Nursing. vailable at: http://nursingworld.org/mods/mod775/nrsdrfull.htm. Accessed November 5, 2005.
5. Huber D. Leadership and Nursing Care Management. Philadelphia: WB Saunders; 1996.
6. Coleman P. Power and conflict. In: Deutsch M, Coleman P, Eds. The Handbook of Conflict Resolution: Theory and Practice. San Francisco: Jossey-Bass; 2000.
7. Tannen D. You Just Don’t Understand: Women and Men in Conversation. New York: Morrow; 1990.
8. Moynahan B.  Managing issues of resistance and sex stereotyping when conducting gender awareness workshops. In: Brown C, Snedeker C, Sykes B, Eds. Conflict and Diversity. Cresskill, NJ: Hampton Press; 1997.
9. Wood J. Gendered Lives: Communication, Gender, and Culture. 4th ed. Belmont, CA: Wadsworth Thomson Learning; 2001.
10. Briles J. The Briles Report on Women in Healthcare: Changing Conflict to Collaboration in a Toxic Workplace. San Francisco: Jossey-Bass; 1994.
11. Duff C.  When Women Work Together: Using Our Strengths to Overcome Our Challenges. Berkeley, CA: Conari Press; 1992.
12. Porter-O’Grady T. Embracing conflict: building a healthy community. Health Care Management Rev. 2004;29:181-187.
13. Hess R. From bedside to boardroom: Shared governance. Online Journal of Issues in Nursing. Available at: http://nursingworld.org/mods/mod680/govfull.htm. Accessed November 5, 2005.
14. Lewicki RJ, Litterer JA, Minton JW, et al. Negotiation. 2nd ed. Boston: Irwin; 1994.
15. National Institute of Occupational Safety and Health. Working with stress. Available at: http://www.cdc.gov/niosh/docs/video/stress1.html. Accessed August 8, 2005.
16. Joint Commission on Accreditations of Healthcare Organizations. Health care at the crossroads: strategies for addressing the evolving nursing crisis. Available at http://www.jcaho.org/about+us/public+policy+initiatives/health_care_at_t.... Accessed November 5, 2005.
17. Marcus LJ, Dorn B, Kritek PB, et al. Renegotiating Health Care: Resolving Conflict to Build Collaboration. San Francisco: Jossey-Bass; 1995.
18. Thomas K. Toward multidimensional values in teaching: The example of conflict behaviors. Academy of Management Review.1997;2:484-490.
19. Sandy S, Boardman S,  Deutsch M. Personality and conflict. In: Deutsch M, Coleman P, Eds. The Handbook of Conflict Resolution: Theory and Practice. San Francisco: Jossey-Bass; 2000.
20. Opotow S. Aggression and violence. In: Deutsch M, Coleman P, Eds. The Handbook of Conflict Resolution: Theory and Practice. San Francisco: Jossey-Bass; 2000.
21. Weitzman E, Weitzman P. Problem solving and decision making in conflict resolution.  In: Deutsch M, Coleman P, Eds. The Handbook of Conflict Resolution: Theory and Practice. San Francisco: Jossey-Bass; 2000.
22. Fisher R, Ury W, B Patton. Getting to Yes: Negotiating Agreement Without Giving In. 2nd ed. New York: Penguin; 1991.

Glossary

Collaboration
An attempt to work with others to find a solution that satisfies the concerns of both or all involved parties.

conflict
A disagreement or incompatibility.

conflict management
The study and practice of methods used to prevent or resolve disputes.

empowerment
To give people power, authority, or confidence in themselves.

framing the problem
Strategies used to prepare for negotiation.

interest-based bargaining
A style of negotiation that begins with understanding why other people want what they want.

negotiation
A process of digging into an issue to identify underlying individual concerns and find alternatives that meet most or all sets of concerns.

positional bargaining
In a conflict, both sides argue their positions by making extreme statements in an effort to win support from others.

power
To act or exert force in negotiation and the associated capacity to influence the behavior of others.

shared governance
A leadership style that emphasizes the delegation of power, authority, and influence among followers.

“we-they” positioning
Seeing people or organizational members working against or competing with each other.

Post Test

1. Conflict is the same as discomfort.
   a.  True
   b.  False
2. Conflict is always a destructive force.
   a.  True
   b.  False
3. The best style for managing conflict is to “accommodate” so the other party will know you are giving them something
   a.  True
   b.  False
4. One type of power is based on role relationships and the ability to deliver something of value.
   a. True
   b. False
5. You are a staff nurse on a busy unit. The nurse manager approaches you and asks you about a medication error “you committed.” You are embarrassed, given the question and her tone of voice, because coworkers and physicians are close enough to hear the conversation. You should: 
   a.  Step into the hallway to discuss the question. 
   b.  Admit the error (you are pretty sure you did it) and walk away. 
   c.  Stay in the area to listen and discuss the concern with the nurse manager. 
   d.  Negotiate with the nurse manager—even if she seems to resist—to meet at a later time or at the end of the shift to discuss the problem.
6. Which choice is not a benefit of conflict? 
   a.  Organizational change and adaptation 
   b.  Promotion of awareness in self and others 
   c.    Receipt of more bargaining chips 
   d.    Improving preparedness to cope with problems
7. If not handled constructively, conflict can be destructive and do all of the following except:  
   a.  Create a win/lose situation 
   b.  Put you in the driver’s seat 
   c.    Polarize individuals 
   d.    Blur the issues
8. Nurses Sally and Jeremy disagree on the best way to deal with a patient who is combative and difficult. Jeremy has the most hands-on time with the patient and believes his strategy would be most effective. Sally thinks that Jeremy is a know-it-all. Their conversation is getting louder, and they talk over each other. Sally and Jeremy might find it helpful if they: 
   a.  Reported the other to administration 
   b.  Complained to the rest of the staff 
   c.    Listened to understand what the other thinks and feels 
   d.    Avoided the conversation
9. When two parties are in the middle of a conflict, it is easier to reach a win/win outcome by: 
   a.  Using whatever power you have to make the other party feel inferior 
   b.  Avoiding the blame game 
   c.    Talking as loud as you can 
   d.    Disagreeing firmly when views differ
10. Nurse manager Meredith wants her staff to take part in a study on streamlining care on the unit. The staff are grumbling that it’s just one more thing to do on an impossibly long to-do list, with less and less resources to do it with. Meredith knows that the study could positively impact the workload of the staff, but she needs to get them on-board first. To do this she needs to: 
    a.  Ease the staff’s mind by telling them they have no stake in the decision.   
    b.  Make her proposal consistent with the staff’s personal principles. 
    c.    Tell them they have no choice. 
    d.    Keep the amount of time staff has to discuss the study to a minimum.

Answers and Rationales

1. Correct: b. Discomfort is an individual’s feeling in response to conflict. Each person reacts to conflict differently depending on his or her personal perspective, experience, values, and opinions on the issue.
2. Correct: b. When managed constructively, conflict energizes others—including management—to address concerns or issues. Managed conflict helps people speak their concerns and includes all interested parties in the resolution. Effective conflict management also helps individuals recognize and benefit from differences with others.
3. Correct: b. There is no “best” style. Effective conflict modes depend on the individuals involved and issues at hand. Accommodation—giving in to others—sometimes to the extent that one person compromises, can be dissatisfying. Usually this approach tends to worsen over time, causing inner conflict to increase.
4. Correct: a. When a person sits in a certain valued/respected position holding something another person values, the ability to reward may help decrease conflict. When a significant difference in status exists, recognition—as a reward—can be very powerful, given the value the person with less status has for the person with greater status.
5. Correct: d. To be questioned in a public place is embarrassing and places you in a vulnerable position to be defensive and possibly reactive. By asking/negotiating to discuss the problem later allows you the time to prepare for discussion and reflect on:
   • Your feelings about the public confrontation
   • The medication error
   • Your professional responsibility to stay calm and receptive to discussing the problem with the nurse manager
   • Additional information you may have on the reported error so that you can be more objective
6. Correct: c. Organizational change and adaptation, promoting and awareness in self and others, and improving preparedness to cope with problems are some of the six positive functions of conflict.
7. Correct: b. Conflict handled poorly can result in an ‘us’ and ‘them’ type of thinking.
8. Correct: c. Jeremy and Sally don’t need to agree, but the conflict may be resolved more easily and more effectively if they really hear the other person.
9. Correct: b. Even if the other party is deserving of blame, the end result is that it only puts people on the defensive.
10. Correct: b. Making the proposal consistent with the staff’s principles (deliver good care and enhance the quality of their own care) makes the study a more positive experience.