Navigating conflict: a model for nursing home social workers.
THE CONFLICT DYNAMICS OF NH SOCIAL WORK
Conflict is triggered when one party perceives its interests as being blocked by another or when both parties covet something that they cannot see how to share. Three factors specific to NHs aggravate conflict: (1) fundamentally competing care-related ideologies and priorities, (2) factors emerging from the NH's organizational and regulatory structure, and (3) the mental and emotional status of the residents and their families (Nelson, 2000; Nelson & Cox, 2004).
Research has confirmed that NH social workers are assigned the greatest responsibility for resolving conflicts at a rate that exceeds that for nurses (Vinton & Mazza, 1994). In fact, one study revealed that directors of nursing formally manage irate family members in only about 6 percent of the cases, whereas social workers intercede 43 percent of the time (Vinton, Mazza, & Kim, 1998). Social workers also mediate a good deal of interstaff conflict. In a study assessing 20 areas of the NH social workers' core influence, social workers ranked "settling staff disputes" fourth overall, trailing only "making changes in care plans," "planning resident care," and "deciding resident transfer issues" (Kruzich & Powell, 1995, p. 219). However, social workers' capacity to advocate for residents is inherently limited by their status as facility employees. This often creates a conflict of interest between residents' informed preferences and the facility's efficiency needs (Nelson, Netting, Huber, & Borders, 2001a). Such rifts lead to hierarchical conflict between the social worker and management or functional conflict between the social worker and coworkers.
During a normal day, social workers may coordinate admissions, facilitate resident councils, develop care plans, work out financial resources, arrange for transportation, and purchase personal items (Kruzich & Powell, 1995). Although these tasks seem innocuous, almost any of them could lead to conflict, and others virtually guarantee hostility. Consider how social workers must intervene in problematic sexual affairs or may have to prohibit or limit smoking by lifelong smokers. Here, social workers' "people-changing responsibilities" (Lauffer, 1984) invite resistance, especially when the social worker strives to do what is best for the resident, but that conflicts with the resident's desire for autonomy.
Social workers often stand alone in the middle of heated ethical controversies about providing intimate care within a very rigid health-business model (Neuman, 2000). Still, social workers are more likely to achieve their diverse goals as they "stimulate the various other staff members to participate" (Allen, 1997, p. 124). Effective social workers build partnerships that are based on open communication, which is critical if the team is able to examine focal problems cooperatively from perspectives of shared interests. Effective social workers influence decisions to optimize resident preferences while getting their teammates to understand the sociopsychological implications of treatment regimens and to accept, at some point, the resident's right to noncompliance. Persuasive confrontation is sometimes necessary to flush out the real barriers to optimizing residents' interests (Mayer, 1995).
RESIDENT-AND FAMILY-ENGENDERED CONFLICT
NH social workers are often solely responsible for handling feuds and fights among residents, staff, and involved families (Hegland, 1992). Resident-to-resident conflicts are pervasive. Fortunately, much of this low-intensity bickering is easily soothed by appeasement, attention, diversion, or separating residents from one another (Shield, 1988). Family-engendered conflict, on the other hand, arises in part from the incongruence between families' sometimes unrealistic hopes for their loved ones' care and the facility's inability to meet those needs (Vinton & Mazza, 1994; Vinton et al., 1998). These frustrations are often intensified by the family's guilt about the resident's placement. Families may also bring long-standing family dysfunctions with them into the facility, where old wounds easily erupt when triggered by the stress and strains that are associated with life in an institution (Nelson, 2000).
Family--staff conflict is exacerbated when family members hold biased perceptions of caregivers and vice versa (Sudberry, 2002). Research has suggested that bias often amplifies feelings when an opponent's interests are diametrically opposite one's own (Thompson & Hastie, cited in Thompson, 1995). Sudberry stressed use of psychodynamic insight, such as recognizing how transference influences the client's perception of the social worker's role (Irvine, cited in Sudberry). Consequently, family members may perceive aides as uncaring and slothful; for their part, aides tend to view "involved family members as meddlesome, unrealistic, and demanding" (Savishinsky, cited in Nelson, 2000, p. 48).
MODELS FOR HANDLING NH CONFLICT
A number of models can be used to build knowledge and skills. For long-term care, Nelson and colleagues' (2001a) resident-centered process model offers strategies to address client needs. Four dimensions are considered in the face of potential conflict: (1) the resident's socioemotional or physical needs, (2) the quantity and quality of evidence verifying the urgency of the resident's need, (3) the strength of any legal and ethical mandates that may bear on the case, and (4) the likely strength of the staff and management resistance to the social worker's advocacy effort.
When facing potential conflict, the social worker must analyze all of these factors to assess options that are both effective and realistic, given the host system's dynamics. Facility resistance or receptivity determines the degree of confrontational "force" that may be needed to promote change. This will be assessed against the strength of the resident's needs, the evidence that the problem is real, any standards that may lawfully or ethically compel the social worker to action regardless of other considerations and the target's resistance. The confluence of the model's four dimensions results in five conflict-resolution strategies: (1) avoidance, (2) conciliation, (3) compromise, (4) problem solving, and (5) forcing (Thomas & Killiman, 1974).
When resident's needs are low and the chance of coworker irritation or opposition is high, then avoidance may be the preferable strategy. The social worker may even work sub rosa to improve the situation through education, subtle suggestions, or building better working relationships. Consider, for example, how "looking the other way" might be ethically permissible if a resident is found assisting the staff in a clerical or housekeeping exercise, more for the well-being of the resident than to serve some type of financial benefit for the facility (Nelson et al., 2001 a, p. 39).
In cases in which the facility seems cooperative but the resident's position is erroneous, has no legal or ethical basis, or is not objectively important or even real, conciliation is advised. Nelson and associates (2001b) suggested building relationships in instances when families or residents have unrealistic expectations or have used threats to get their points across. For example, misguided perceptions, such as how a family feels about a roommate's condition that may be believed to interfere with the health of their loved one, might call for conciliation. Furthermore, the social worker often is faced with having to work out misdirected anger toward her or his role. Here, the social worker can help the resident best by smoothing relationships, repairing trust, and re-opening lines of communication (Nelson, 2000) and drawing from social work values, such as empathy and respect of individuals and using contracting skills and active listening with disgruntled residents.
Compromise is an expedient that is justified only when the resident's need, the facility's resistance, and the legal/rule applicability is moderate. These cases may involve a resident with a compromised physical status who strongly desires to smoke. The facility may be a nonsmoking environment, and medical professionals may hold steadfastly to the position that a resident's smoking is contraindicated. The resident may express a need for smoking as a social release, making the resident feel like a person with choices. It would be unreasonable to restrict the resident completely, adding to anger and frustration, yet allowing the resident to smoke freely is impracticable and will fuel the anger of other residents and staff. Through compromise, the resident might be allowed to smoke occasionally outside with a staff member or other residents who smoke, given that each party recognizes the risks. In this case, an action has been taken in which concessions have been made by all parties--each side gives something to get something.
When resident needs are high, but management's resistance is low, problem solving can be used through the enactment of fair negotiation, classic mediation and other forms of bargaining, and issue exploration. In these collaborative encounters, both sides seek to understand the problem's basal causes and must be willing to explore each other's needs, values, desires, and fears as they pursue common ground. Although classic mediation requires neutrality, the social-worker-as-mediator can ensure fairness by channeling information to the resident, ensuring sufficient time to respond and comfort with the process and the participants, and articulating his or her rights (Nelson et al., 2001a). Problem solving would be required in a situation in which a mentally incapable resident cries loudly and relentlessly, angering both residents and staff. A quick but illegal fix would be to transfer the resident out, passing the problem to another facility. But enlightened social workers will problem solve with other staff to formulate reasonable alternative solutions such as improving pain management, eliminating environmental stressors or other sources of anxiety, or perhaps providing some soothing stimulation, or it may take a more formal geriatric assessment to solve the problem.
When resident need urgency is high, rule applicability is high, evidence is high, and coworkers or other actors are resistant to a plea for help, then forcing may be necessary. Flagrant rights violations, negligence, and abuse may require social workers to confront those acting in ways inconsistent with the resident's informed choice or contrary to the mentally incapable resident's best interests. In such cases, confrontation requires that the social worker present clear and convincing evidence of the resident's compelling need. These claims or arguments may be ethically or legally based and often point out the facility's violation of some standard or resident right.
However, forcing may involve risks for the social worker and may even threaten job security. In these instances, social workers may want to contact an outside resource, such as the long-term care ombudsman, anonymously as a surrogate advocate. Activating these allies can be risky for facility social workers who want to keep their jobs (Nelson et al., 2001b).
Knowing how to deal with conflict from a resident-centered perspective is difficult in NH settings, given the interface of power dynamics and the complexities of the social work role. The ultimate intent of the conflict model is to achieve two main goals: (1) to reduce unproductive conflict and increase productive conflict and (2) to promote social work effectiveness by building interpersonal problem-solving skills. Collaborative work cultures are built by promoting environments of trust where opposing views are handled by a range of flexible tactics that lead to situationally appropriate solutions. With adequate training, social workers are not only able to identify and resolve conflict, but can even prevent unproductive conflict (Keefe & Koch, 1999; Nelson et al., 2001b).
Properly handled, conflict can be a productive force critical for the social worker in promoting change and improving care quality and in systems growth (Keefe & Koch, 1999). Given the NH social worker's lack of time, resources, and institutional support, models such as the resident-centered model described here can provide the necessary tools to enhance the preparation of future social workers and aid existing ones.
Original manuscript received March 15, 2005
Final revision received October 20, 2005
Accepted November 16, 2005
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Priscilla D. Allen, PhD, MSW, is assistant professor, School of Social Work, Louisiana State University, 311 Huey P. Long Fieldhouse, Baton Rouge, LA 70808; e-mail: email@example.com.
H. Wayne Nelson, PhD, FGSA, is associate professor. Health Sciences Department, Towson University, Towson, Maryland. F. Ellen Netting, PhD, MSSW, is professor, School of Social Work, Virginia Commonwealth University, Richmond. Virginia.
Donna M. Cox, PhD, is associate professor, Health Sciences Department, Towson University, Towson, Maryland.
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|Title Annotation:||PRACTICE FORUM|
|Author:||Allen, Priscilla D.; Nelson, H. Wayne; Netting, F. Ellen; Cox, Donna M.|
|Publication:||Health and Social Work|
|Date:||Aug 1, 2007|
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