Conflict Management in Health Care Teams: A new paradigm - Safer care: Saving costs Dr Michael Goodyear Department of Medicine, Dalhousie University August 2006 Version 2.3 CONTENTS Introduction .................................................................................................................... 2 The Nature of Conflict ............................................................................................... 2 Social Conflict Theory ........................................................................................... 2 Attributes of Conflict ............................................................................................. 2 The origins of conflict ........................................................................................ 2 The forms of conflict ......................................................................................... 3 Conflict management ......................................................................................... 3 The Health Care Workplace........................................................................................... 3 Conflict in Health Care .................................................................................................. 4 Sources of Conflict in Interdisciplinary Teams ......................................................... 4 Building Conflict Management into Health Care ...................................................... 5 The Role of Organisational Culture ........................................................................... 6 Leadership .................................................................................................................. 7 Ambiguity .................................................................................................................. 7 Physicians and Conflict.............................................................................................. 8 Management and Prevention of Unproductive Conflict ................................................ 8 Dr Michael Goodyear Version 2.2 August 2006 Conclusions .................................................................................................................... 8 References ...................................................................................................................... 9 Introduction The Nature of Conflict Social Conflict Theory Conflict has been the subject of study since the time of ancient civilisation, and opinions have always existed as to whether conflict played both a constructive as well as destructive role in society.1 Formal examination of the role of conflict in society began in the eighteenth century, the earliest era of sociological thought, with the work of Adam Ferguson (17231816),2 while modern concepts of the nature of conflict can be traced to the work of Georg Simmel (1858-1918) at the beginning of the twentieth century. 3 Simmel recognised that conflict was pervasive, embedded in social structure, and potentially unifying.4,5 These ideas were further developed by later writers, most notably Coser6, who described how conflict contributes to the maintenance of social order. Drawing on functionalist theory, Coser distinguishes between conflict operating in open and rigid social systems. In open systems, provided the issues are not central to group existence, there is sufficient flexibility to allow conflict to contribute to relationships, social norms, and power balance adjustments, while controlling tension. In contrast inflexible systems inhibit expression of conflict and challenge basic values and goals, threatening consensus (Sands et al. 1990). Abramson7 sought to apply social conflict theory to health care interdisciplinary teams, in particular collective decision making and responsibility, and how team members deal with their individual moral agency with respect to group process. Abramson asked to whom is moral responsibility primarily due in the face of conflicting obligations. Attributes of Conflict The origins of conflict Conflict is both normative and requisite in human life, and is simply a recognition of, and expression of difference.8 Conflict is central to human relations9 and human interactions are based on conflict.10 Every human being represents an expression of values, meaning, attributes, perspectives, biases and roles.11 This is the basis for the uniqueness of human identity. This uniqueness then becomes the basis for expression and behaviour that emphasise individual separateness. Yet at the same time each individual identifies with groups both within and without the team or workplace, based on attributes such as race, culture, religion, values, experience and professional role, and injects these into the Dr Michael Goodyear 2 Version 2.3 August 2006 complex fabric of workplace interaction, leading to divided loyalties. The continuous and endless diversity that this complexity brings provides ample opportunity for conflict. At the same time this uniqueness results in creativity, energy, excitement, innovation and an array of expression and challenges.12 This is the richness of human life, the colour and the contours of social fabric that we should embrace and treasure. Recognising and accepting conflict forces us to acknowledge the centrality of diversity in human experience.13 Conflict is sustaining in human interaction, communication and decision making. The forms of conflict Historically conflict was considered destructive,14 was either punished or resolved. Conflict that is destructive is often rooted in work roles or organisational factors, when the values and intentions of others are perceived solely or mainly in terms of the individual’s own frame of reference.15 With the recognition that conflict can be resolved into two distinct forms,16 a way was found to manage conflict constructively. Conflict theory distinguishes between two forms of conflict. Cognitive conflict addresses ideas and approaches, as opposed to affective conflict that is interpersonal, including inter group relationships.17 While well managed cognitive conflict has the potential to improve performance and satisfaction, affective conflict is likely to be wholly destructive. Unfortunately without high levels of awareness, one tends to merge into the other. All too often the personality becomes confused with the issue. By refocusing on the issues, and separating them from the people, management and resolution are possible. Affective conflict, focussing on anger or resentment, rapidly leads to hostility, distrust, cynicism, avoidance and apathy.18 The role of cognitive conflict in group judgement and decision making is dealt with in a separate document.19 Conflict management Conflict management represents a paradigm shift from the more traditional approaches based on the concept that conflict should be avoided at all costs, and when present, resolved or eliminated. Indeed Porter-O’Grady (2004a) argues that conflict should be embraced20 rather than feared. Well managed conflict is the key to effective strategic decision making.21 Conflict management must be proactive rather than reactive, and therefore mediation strategies should be in place a priore.22,23 Assumptions and differences need to be openly acknowledged and, in health care, negotiations based around a patient focus.24 Not all manoeuvres to limit conflict result in improved effectiveness. For instance in joint decision making, limiting conflict decreases participation and acceptance of outcomes,25 as opposed to a more facilitative approach26. The Health Care Workplace Health care has a prominent place in society, and as an environment mandated to serve and care for its community and to promote the overall physical, psychological and social health has a special responsibility to create a healthy workplace. Not only Dr Michael Goodyear 3 Version 2.3 August 2006 does the health of the providers impact on those they serve, but there is a responsibility to be an exemplar in work relationships. Addressing the normal relationships of working life in a healthy way is therefore a fundamental responsibility of health care systems. Conflict in Health Care Conflict and diversity are inherent in health care and in team function and conflict in interdisciplinary teams is natural and inevitable.27,28,29 While the natural tendency is to treat conflict as threatening, for group decision-making, conflict is desirable (Margolis and Fiorelli 1984). By examining a variety of different perspectives, distinguishing substantive from personal issues, and identifying underlying tensions, conflict becomes a vehicle for growth.30 Recognition of the normative role of conflict is the first step in managing conflict. As part of the establishment of a healthy workplace, the normal conflicts of life and relationships need to be addressed. Conflict can be a source of both creativity and destruction, and diversity needs careful and skilled management.31 Conflict in teams reflects not just the differing perspectives of its members but its interactions with the system in which it lies and with its clients.32,33 Handled appropriately, the development of conflict enables teams to draw inferences about its roles in relations to providers, clients, institution and society: “Disagreements that are internal can be negotiated within the team; disagreements that are a reflection of institutional priorities require group efforts at system changes, not interprofessional blaming and name calling” (Nason 1983) Conflict also reflects the developmental stage of team development and may be a necessary step in its maturation and focus. Lowe and Herranen (1981)34 describe the evolutionary stages of a team from emotional repression and turf guarding, through conflict avoidance, the emergence of conflict, and finally commitment. Similarly Germain35 describes how teams move from “fragmented thinking…based on disciplinary specialization” to a more holistic view of the patient and their environment. In Lowe and Herranen’s model, the higher the developmental level the more fluid the boundaries and more flexible the roles, its decisions being driven by client needs as opposed to interdisciplinary rivalry. Sources of Conflict in Interdisciplinary Teams Key contributors in health care conflict are the diversity of roles and functions, and the high levels of stress, much greater than in the general work force resulting in profound opportunities for conflict. Consequently conflict is embedded in health care services.36 In interdisciplinary teams there is the potential for overlapping roles to lead to the perception of competition.37,38 Other sources are differences in professional values, socialisation, philosophy and theoretical perspective.39,40 These may be manifest in the interfaces between those who see their professional roles as primarily advocacy as Dr Michael Goodyear 4 Version 2.3 August 2006 opposed to establishing evidence based best practices, or caring as opposed to technology based practice (Nason 1983, Sands 1990). Perceived differences in disciplinary status provide another source of conflict and interfere with democratic team functioning,41 requiring high levels of collaboration, consensus,42 egalitarianism, cohesion, group based problem solving and shared responsibility. Disciplines with a perceived lower status may feel a greater pressure to conform (Nason 1983, Sands 1990), however concepts of authority within groups is also dependent on legally delegated powers, demographics and personality (Mailick and Ashley 1981). Building Conflict Management into Health Care The problem of workplace conflict is immense. In the US the Equal Employment Opportunity Commission received more than 80,000 complaints in 2003 and recovered $236 million in damages from the private sector alone.43 Early engagement can avoid many unnecessary and costly measures taken later. Despite an overall increasing litigation climate, alternative dispute resolution continues to grow while litigation is declining as an approach to conflict.44,45 At the same time the number of organizations implementing conflict management programmes continues to rise.46 A study conducted by the American Arbitration Association demonstrated that those organizations that were ‘Dispute-wise’ in conflict management demonstrated stronger relationships with customers, suppliers, business partners and employees, lower legal costs and better utilisation of legal resources.47 This study was endorsed by the Association of Corporate Counsel as making good business and legal sense in utilization of organisational risk management resources.48 Other research into the implications and outcomes of well organised conflict management programmes have identified many positive findings. These include an improved workplace atmosphere, reduced stress,49 reduced health problems,50 improved job satisfaction,51,52,53 improved behaviour,54 and reduced aggression.55,56 In totality the evidence points to organised conflict management resulting in improved outcomes for both individuals and organisations. Although now relatively well established in the service and industry sectors these concepts are still relatively new in health care. Health care is a humanistic enterprise and requires high levels of relationship and functional interaction and has a high propensity for conflict. Conflict management needs to be incorporated into personal skill sets as a fundamental problem solving tool, along with other basic skill requisites for health care workers. Essential elements of such a programme should include the concepts of human nature, diversity, interaction and conflict, the dynamics of conflict and the elements of resolution, the organizational conflict policy and structure and a clear understanding of systematic approaches to addressing conflict as part of everyday business.57 Dr Michael Goodyear 5 Version 2.3 August 2006 This should address issues between organization and employees, management and employees, and between employees. Issues include productivity, performance, conduct, collegiality, absenteeism, coverage, quality of work life, harassment and bullying, discrimination, discipline and termination procedures. These tend to be the situations in which much of conflict arises. Conflict resolution needs to be part of an overall conflict management programme and should address structural and process issues in both organisational and interpersonal conflict. It should be an integral part of human resource policy and be adequately resourced including ensuring that the requisite mediator skills are in place and distributed throughout the system, and must be equally available to all. Adequate conflict management processes may require major system-wide realignment of policies, process and dynamics within the organisation. Existing structures may be in conflict with any new programme because it shifts the locus of decision making and problem solving closer to the point of service or point of conjunction and moves power balances in favour of employees. This will require a complete review of grievance, compliance and disciplinary policies, processes and practice. In essence employees develop ownership of their own problem solving. Mediation should be conducted at the level of the individuals experiencing conflict. Employees become accountable for issues that belong to them. When the concept, structures, resources, and programme are in place, employees increase investment in the work environment.58 This investment in problem solving in turn reaps benefits for the organisation including identification of important issues (Constantino and Merchant 1996). In turn leadership must be prepared to embrace staff derived solutions to organisational problems. A critical structural element is timeliness. Conflict is a dynamic, and deepens and expands if not dealt with effectively and in a timely manner. The Role of Organisational Culture Conflicts arise within the broader context of organisations and therefore become a collective responsibility and require an organisational commitment to management.59,60 Embracing the normative role of individual and organizational conflict must flow down from the highest levels to every individual in the system.61 This must be evident not only in the personal commitment of leadership by example as well as dictate, but in the provision of conflict management, resolution and mediation programmes, including regular evaluation and adjustment. Similarly performance assessment will incorporate assessment of knowledge, attitude and application of conflict management skills as a fundamental competency. Mechanisms need to be in place for early diagnosis and engagement. As PorterO’Grady (2004a) states; Dr Michael Goodyear 6 Version 2.3 August 2006 “Effective conflict management processes are one of the most articulate ways to reflect to the larger community the healthy management of human relationships among health care providers and the people they serve.” Leadership As the person often entrusted with dealing with conflict in a team, effective leaders require strong conflict management skills62 and recognition of the fundamental principle that elimination of conflict is neither possible nor desirable.63 Indeed to attempt to eliminate the sources of conflict is to create an environment that is flat and colourless (Porter-O’Grady 2004). The wise leader identifies the elements, processes and opportunities early in every transaction and moves interactions through conflict towards outcomes that benefit all.64,65 Leadership style and skills are now recognised as key components to conflict management and effective group decision making.66 Well managed conflict actually leads to an overall reduction in workplace conflict (Porter-O’Grady 2004). Leaders must recognise that conflict arises from misunderstandings of role, relationship and function not from failure to carry out directions. Conflict management in the health care team will depend critically on the leaders’ insight into their and to a lesser extent others’ reactions to conflict. The leader’s reaction to conflict will be one of the most critical influences on organisational response and handling of conflict. Leaders create the context for organisational behaviour and process. For instance effective leadership facilitates the work interactions of others to include anticipation, recognition and management of conflict at all levels. Leaders frequently attempt to deal with conflict away from its source, without engagement and in an authoritarian manner. This creates the ideal conditions for extending and intensifying conflict as unresolved issues fester. In the alternative model the leader gathers the information in a safe environment and acts as facilitator and if necessary, mediator.67 Leaders therefore have a responsibility to ensure an organisational mindset that incorporates conflict management into ordinary daily practice and to create an organizational culture that is not conflict adverse, which is no simple undertaking. Responsibilities of leadership include the creation of a safe and positive environment for clinical practice. Inherent in this is both the personal application of a high level of conflict management skills as well as the creation of an expectation of such skills at all levels. Ambiguity Several authors have identified ambiguity as one of the root causes of conflict.68,69 Key elements of ambiguity are historical attitudes, structure, leadership, information and direction. When ambiguity exists in the context of complexity, the potential for conflict and error are exceptionally high. It is just this intersection that characterises Dr Michael Goodyear 7 Version 2.3 August 2006 much of health care, therefore minimising ambiguity is an integral element of managing the work environment. Ambiguity in information and direction hinges around leadership structures. Health care, like the military, has traditionally relied on hierarchical decision making processes. Yet in practice multiple interacting decisions need to be made throughout the system. The complexity of clinical decision making makes it impossible for any individual provider to posses the necessary insight, knowledge and capacity to manage all aspects of care. Enlightened health professionals recognise that they make a large number of decisions both individually and interdependently in a mosaic that represents care. Traditional authority lines are no substitute for solid intersection of individual decision making in delivering effective care. Effectively it is the resonance between the actions of providers, not authority that provides safe quality patient care.70 Physicians and Conflict Physicians have a high predisposition to conflict arising from role and identity. This has its roots in traditional views of the physician as authoritarian, superordinate, autonomous and a privileged guest amongst employees. Role conflicts most frequently arise at point-of –care and need to be addressed at that site by engaging the stakeholders within a time and contextual frame. All too often these role conflicts are removed from the site of origin and taken to administrators thereby minimising the possibility of resolution. One of the commonest mistakes is for leaders to seek resolution without full engagement of participants and issues inevitably setting the scene for more intense conflict. Optimal conflict resolution requires the ownership of all participants. Identity conflict arises from individuals’ perception of role and relationships within the wider context,71 and requires a much broader organization based approach gathering the perceptions of the involved groups and identifying common ground. This is particularly so when conflicts arise at the aggregate level (departments, disciplines). Management and Prevention of Unproductive Conflict In addition to inbuilt organisational structures, awareness and training in conflict management, incorporation of these attributes at the work group level are needed. These require the development of an interdisciplinary perspective with common values, language and conceptual framework.72,73 (also Abramson 1984), transcending boundaries and hierarchies. These provide for the recognition of diverse viewpoints as opportunities for growth, and exploring the assumptions that inform them, rather than unsatisfying compromise and incomplete solutions. Conclusions Conflict is a normative expression of human diversity and is a necessary component of team and programmatic function. Dr Michael Goodyear 8 Version 2.3 August 2006 The ultimate goal of health care teams is the care of patients. Focussing on common values and frameworks, as opposed to imposing diverse perspectives brought to the table, and committed and skilled leadership are key elements to effective team function and delivery of care. It is essential that lessons learnt from the application of organised conflict management in industry be applied in health care. 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