Using conflict resolution as a strategy within the clinical setting.

Key Words: conflict resolution * strategies for conflict management * family communication * perceptions between clients and nurses

SUMMARY

* Conflict on decision making in clinical settings is common.

* Conflict resolution is a skill that can be used to resolve conflicts.

* In order to manage a conflict, the sources of conflict must be well understood, and then appropriate conflict management strategies can be used to address and resolve the problem.

* Successful conflict resolution can remove frustration and promote trust between the patient's family and nurses. This helps to improve the quality of nursing care to both the patient and his or her family.

INTRODUCTION

A critical care setting is a complex environment due to the presence of advanced technological machines and the intensity of medical and nursing interventions. Patients as well as families may be overwhelmed with the stress of the environment and the high stress level may affect the he effectiveness of communication between health care professionals and families. Moreover, conflict is inevitable in any work environment due to onflict inherent differences in goals, needs, desires, responsibilities, perceptions and ideas (Van de Vliert, 1998). Conflict between patients or families and doctors about medical treatment decisions is commonly experienced by nurses (Almost, 2006).

Traditionally, having conflicts with other individuals indicated that the person had poor interpersonal relationships, therefore, having conflicts with others should be suppressed and avoided as much as possible (Nadler & Tushman, 1999). On the other hand, conflict can also be beneficial because conflicts may stimulate discussion, which will not only uncover differences in views but may also provide an opportunity to bring about change (Way et al., 2002). New solutions can be found through the problem solving process. Hence, better nursing care might be obtained (Almost, 2006). Conflict is a multidimensional construct, with both constructive and destructive effects depending on the type of conflict, the task at hand, and how the conflict was managed (Jehn, 1997). Therefore, conflict strategies are developed to eliminate the destructive effects and promote the constructive effects (Way et al., 2002).

Nowadays, nurses not only encounter patients but their families also. Studies have shown that there is a disconnection between patients' priority ion needs identified by nurses and the priority needs identified by patients and families (Jacono et al., 1990; Kosco & Warren, 2000). Conflict often rises during the interaction with families due to differences regarding the plan of care, visiting hours, access to equipment and supplies, placement of patients and so on (Gerardi, 2004). Nurses sometimes become increasingly frustrated when encountering difficulty while working with families (Tracy & Ceronsky, 2001). Consequently, a negative relationship between nurses and relatives may affect the patient care directly or s indirectly as the patient is part of a larger family system; things affecting the family may eventually affect the patient (Wilson, 1999).

The aim of this paper is to analyse a conflict between nurses and family members; ultimately, nursing care can be improved through conflict analysis. Firstly, a clinical situation of a conflict between a nurse and a family will be introduced. Then, the sources of the conflict and conflict resolution approach will be analysed. Finally, strategies to improve nursing care in such a situation will be discussed. In order to maintain patient confidentiality, the pseudonym Hill was used as the family name.

CLINICAL SITUATION

Mrs. Hill, aged 68, was hospitalised after a stroke. She sustained a right hemiplegia and suffered from slurred speech. Prior to her stroke she could walk unaided and take care of herself independently. The speech therapist assessed Mrs. Hill and suggested that oral feeding was temporarily stopped because of her dysphagia, to reduce the risk of aspiration. During visiting hours, Mr. Hill came to see his wife and, because she was mumbling for food, he decided to feed her some noodles. A nurse passed by the bedside and immediately stopped him feeding Mrs. Hill. Mr. Hill was informed that it was the doctor's decision to keep Mrs. Hill 'nothing by mouth', therefore, no food was allowed at the moment. However, before the nurse could provide further explanation, she was distracted by other tasks in the ward, which required her immediate attention.

An hour later, the nurse returned to find Mr. Hill again attempting to feed his wife. The nurse tried to stop him once more. However, Mr. Hill refused to follow her advice, claiming that the clinical staff were trying to starve his wife. Mr. Hill was very emotional and became agitated during the discussion and threatened to punch the nurse. The nurse decided to walk away from the incident at that moment. She subsequently documented the event in the integrated process notes.

SOURCES OF CONFLICT

Conflict can be classified into several different types. The three most common types of conflict are organisational, interpersonal and intrapersonal (Tomey, 1996). The conflict that arose between the nurse and Mr. Hill may be classified as an interpersonal conflict, which usually occurs between two or more persons when they hold different views and values. In order to resolve a conflict, the causes of a disagreement need to be well understood (Tomey, 1996). In Mr. Hill's case, the differences in perception between him and the nurse and their lack of communication were the two main issues, which were likely to be the main causes of the conflict.

As observed clinically, conflict surrounding decision-making in clinical settings is common due to different perceptions between health care professionals and clients. It was noted that Mrs. Hill's family had a different perception of her condition than that of the healthcare professionals. Mrs. Hill's family might be too optimistic, continuing to view Mrs. Hill as someone who was full of energy, even though she was bed-bound and had a serious physical disability. At this critical period of time, without effective communication, it was likely that the family and the staff would continue to see things differently. As a result, the family might lose its confidence in the healthcare professionals and might become agitated more easily.

In Mr. Hill's case, he held an inappropriate expectation about his wife's physical condition due to the fact that he was provided with insufficient knowledge about the disease process and its management. Thus, he was unaware of the true extent of his wife's illness and, not surprisingly, viewed Mrs. Hill's condition differently to that of the healthcare staff. As a direct result of his poor knowledge of his wife's condition, Mr. Hill did not realise that his acts of attempting to feed her--which he clearly felt was for her benefit--might cause harm to his wife.

Conflicts arise when individuals perceive a problem or issue differently and receive different information (Tomey, 1996). An important element in effective communication is the skill to present and clarify information to others. Family members need to be well-informed and should be provided comprehensive information, according to their ability to process it, regarding the patient's condition, so that unrealistic requests are minimised (Way et al., 2002). However, many nurses believe that they should not be the one providing information to families even if they are the healthcare professionals who have the closest contact with them (Appleyard et al., 2000). Zaforteza et al. (2005) conducted research into the way nurses provided information to families in an intensive care unit. Their observations of fourteen nurses and families revealed that nurses tended to ignore or did not pay attention to families during the visiting hours. In addition, most nurses preferred to spend time performing routine duties rather than communicating with family members. Delgado (2000) pointed out that even though nurses sometimes do inform the family about the patient's condition, in general they do not communicate detailed information to the family. Nurses tend to have a brief exchange about insignificant issues (Zaforteza et al., 2005).

CONFLICT RESOLUTION

Conflict management is a skill that can be used to resolve conflicts. Successful conflict resolution can remove frustration and promote trust (Van de Vliert, 1998). Hence, the quality of nursing care, as well as patient satisfaction, may be enhanced.

Five common approaches or strategies to conflict resolution have been identified within the literature: accommodation, avoidance, collaboration, competition and compromise (Thomas 1976; Rahim & Magner, 1995). It is critical to select the appropriate approach for each conflict situation, as different strategies may lead to different outcomes. For example, using competition as a conflict resolution strategy is a win-lose approach (Vivar, 2006). It designates a situation in which one person or group attempts to acquire complete dominance. This strategy is appropriate when quick decisions are vital and there is no time for discussion, such as an emergency (Vivar, 2006).

In Mr. Hill's case, the avoidance approach was the only tactic used by the nurse. Avoidance is often employed to deny the person, issue or the situation; and people using this approach will ignore the existence of a problem (Vivar, 2006). Cavanagh (1991) found that nurses tend to overuse the technique of avoidance. However, avoiding a situation until more information is available and an analysis of the problem has been made could be an appropriate approach to temporarily handle conflict. Long-lasting avoidance may be dysfunctional, as it prevents recognition of an existing problem (Vivar, 2006). The unsolved problem may have a he diminishing effect on the effectiveness of nursing care.

The avoidance approach is characterised by ignorance and withdrawal (Tomey, 1996). In most cases it creates a 'lose-lose' situation as no problem solving activities are involved. In Mr. Hill's case, although the tension may have been reduced because the nurse removed herself from the conflict, her actions could have resulted in harm to Mrs. Hill because she had failed to stop Mr. Hill's attempts to feed his wife.

The ethical principle of non-maleficence--to do no harm to the patient --should always be considered foremost when nurses determine the best conflict management approach. Effective conflict management can help nurses to focus on problem solving rather than causing harm to others (Gerardi & Morrison, 2005). Therefore, the collaborative approach is considered to be the most effective method of conflict resolution as it produces a 'win-win' situation in most cases. Using this approach, both parties involved in the conflict should co-operate assertively with each other in order to identify the problems and to determine a mutually satisfying solution (Tomey, 1996). However, this approach can be time consuming and requires a high level of cooperation from both parties.

In Mr. Hill's situation he was angry and held a misconception about the healthcare staff. He did not understand that the 'nothing by mouth' order was made to prevent his wife choking and to prevent further complications developing; rather than intentionally starving her. Providing further information to Mr. Hill at the time that he was upset might not have been helpful, as the information given might have been distorted or only partially received by him due to his emotional state. Furthermore, at this time, because Mr. Hill was angry, it would have been difficult to develop a cooperative relationship with him. Therefore, the avoidance approach was initially useful to defuse the situation and reduce the tension. However, without providing valid information to Mrs. Hill's family, the benefit of not feeding Mrs. Hill would not be understood and the intervention would not be supported. Therefore, at this point, the nurse could also have contacted other family members to explain the situation. Other family members could have been encouraged to come and sit with Mr. Hill in a quiet environment, such as an interview room within the unit. This would help by removing Mr. Hill from the immediate vicinity of his wife and preventing possible harm to her. Additionally, it might have helped to calm him after the conflict. Once he had calmed down it would then have been a better time to attempt a more collaborative conflict management strategy to explore solutions and alternatives.

CONFLICT RESOLUTION IN PRACTICE

In Mr. Hill's case, lack of communication and differences in perception were the main sources of conflict. There are several strategies that can be used in such situations to address these issues and to prevent further conflict.

Arranging a meeting with family and the multi-disciplinary team

Through multi-disciplinary meetings, both the patient and/or family are likely to have a clearer idea about treatment goals and treatment options, as well as the patient's diagnosis and prognosis. By improving communication through discussion, most conflicts can be resolved and unrealistic requests by families can be minimalised. In addition, the family's level of understanding about the disease and prognosis can be validated and clarified immediately. In this way misconceptions can be dispelled and corrected. The family can also be invited to participate actively in discussing the choice of treatment and rehabilitation strategies. For example, the insertion of a nasopharyngeal tube for feeding might have been suggested to Mrs. Hill's family as an alternative way forward. All the difficulties and concerns that families have can be discussed with healthcare professionals in order to achieve mutual agreement about nursing care and medical treatment.

Improving communication between nurses and families

Nursing staff should be encouraged to communicate with the family during visiting hours. The family needs to be informed about tests, procedures and it is important to use simple, non-patronising language so that their anxiety and the perceived distance between nurses and families can be reduced (Kelly, 2005). As the nurse is the healthcare professional who usually has the closest contact with the relatives, she can provide up-to-date information about the patient's progress and treatment. When concise and clear information is provided to families, it can greatly reduce their stress (Tomey, 1996). If nurses are distracted by other clinical tasks during visiting hours, they could ask the relatives to wait for a short while and then return to them as soon as possible. As communication is not only a process of exchanging information but also feelings, nurses can also encourage family members to express their feelings in order to better manage their anxiety.

As discussed previously, some nurses may feel that they are not adequately trained to give information to families. Therefore, provision of educational programmes on techniques of emotional self-control and communication skills should be provided by hospitals for nurses. De Lucio et al. (2000) found that nursing communication skills and self-control ability improved significantly through the training in social communication skills and emotional self-control techniques. Moreover, nurses who received training had a significant improvement in their skills of listening, emphasising, interrupting and coping with emotions (De Lucio et al., 2000).

Encourage family participation in daily activities

Nurse-family relationships can be improved by employing a collaborative approach to meet the patient's needs (Potter & Perry, 2005). To invite family members to participate in the daily care of the patient may be helpful in building up the rapport and relationship between families and nurses. From clinical experience, educating and facilitating family members in the performance of passive range-of-motion exercises, turning the patient, helping them to provide assistance to the patient when using the bedpan, and assisting the patient to dress are all possible caring activities that families can be involved in order to promote the nurse-family relationships.

By involving families in the daily care activities, their sense of helplessness may be reduced and their perception of the patient's condition is more likely to be realistic. Had this been the case with Mr. Hill, he may have had a better understanding of his wife's physical condition, especially when comparing her current status to her previous norms. This would help him to understand better and come to terms with her stroke-induced disabilities.

CONCLUSION

Conflict happens daily in our nursing professional life. It can be constructive or destructive depending on the type of conflict and how the conflict is managed (Jehn, 1997). Nursing care provided to both patient and families can be improved through the conflict resolution process. In order to manage a conflict, the sources of conflict must be well understood, and then appropriate conflict management strategies can be used to address and resolve the problem. However, regardless of what nurses do, it is not always possible to totally avoid conflict. But if conflicts between families and nurses are resolved effectively, frustration and stress arising from the conflict can be reduced.

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On Ying Pang RN; BN, Staff Nurse, Alice Ho Miu Ling Nethersole Hospital, Hong Kong 

Sek Ying Chair RN; MBA, PhD, Assistant Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong

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