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

Dr Michael Goodyear Version 2.2 August 2006

CONTENTS
Introduction....................................................................................................................3
The Nature of Conflict...............................................................................................3
Social Conflict Theory...........................................................................................3
Attributes of Conflict.............................................................................................3
The origins of conflict........................................................................................3
The forms of conflict..........................................................................................4
Conflict management.........................................................................................4
The Health Care Workplace...........................................................................................4
Conflict in Health Care..................................................................................................5
Sources of Conflict in Interdisciplinary Teams..........................................................5
Building Conflict Management into Health Care......................................................6
The Role of Organisational Culture...........................................................................7
Leadership..................................................................................................................8
Ambiguity..................................................................................................................8
Physicians and Conflict..............................................................................................9
Management and Prevention of Unproductive Conflict................................................9
Conclusions....................................................................................................................9
References....................................................................................................................11

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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 (1723-
1816),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
complex fabric of workplace interaction, leading to divided loyalties. The continuous
and endless diversity that this complexity brings provides ample opportunity for
conflict.

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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
does the health of the providers impact on those they serve, but there is a
responsibility to be an exemplar in work relationships.

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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
opposed to establishing evidence based best practices, or caring as opposed to
technology based practice (Nason 1983, Sands 1990).

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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

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

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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 Porter-

O’Grady (2004a) states;

“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.”

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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
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

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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.

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. Organisational commitment to

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problem solving has the potential to increase the level of service at lower cost. To that
end it is crucial that health care systems actively recognise the need for, and build in
conflict management skills and systems.

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