HEALTH COMMUNICATION

2016, VOL. 31, NO. 7, 815–823

http://dx.doi.org/10.1080/10410236.2015.1007548

Conflict and Stress in Hospital Nursing: Improving Communicative Responses to

Enduring Professional Challenges
Jennifer J. Morelanda and Julie Apkerb
a
The Research Institute, Nationwide Children’s Hospital; bSchool of Communication, Western Michigan University

ABSTRACT
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Nurses function as central figures of health teams, coordinating direct care and communication between
team members, patients, and their families. The importance of nurses to health care cannot be
understated, but neither can the environmental struggles nurses routinely encounter in their jobs.
Organizational communication and nursing scholarship show conflict and stress as two visible and
ongoing challenges. This case study aims to (a) explore the ways conflict communication and commu-
nicative stress are experienced and endure in nursing and (b) understand how nurses discursively
(mis)manage conflict and stress. Open-ended survey comments from nurses (N = 135) employed at a
large teaching and research hospital were qualitatively analyzed. Weick’s model of organizing, specifi-
cally his notion of communication cycles, emerged as a conceptual lens helpful for understanding
cyclical conflict and stress. Results show that exclusionary communication, specifically nonparticipatory
and unsupportive messages, contribute to nurse conflict and stress. Nurses tend to (mis)manage conflict
and stress using respectful and disrespectful discourse. These communication patterns can facilitate or
prohibit positive change. Metaphorically, nurse communicative conflict and stress can be depicted as
fire. Relationships can go up in flames due to out-of-control fires in the form of destructive conflict.
However, conflict and stress, like fire, can be harnessed for positive ends such as organizational decision
making and innovation. Findings suggest conveying respect may help nurses manage and even avoid
flames of conflict and stress. Solutions are offered to mitigate the effects of conflict and stress while
developing respectful organizational cultures.

Qualified nursing professionals form the backbone of health This case study focuses on conflict and stress, two topics
care delivery in the United States. Nurses are most visible in considered in nursing scholarship. We draw upon organiza-
our nation’s hospitals and provide around-the-clock care to tional communication and nursing literatures to better under-
highly acute, complex patients. Nurses function as the most stand nurses’ cycles of work conflict and stress. This
frequent and consistent caregivers at the bedside, coordinat- scholarship shows the discursive complexities nurses’ experi-
ing care among health team members and connecting health ence as they provide care within interdependent relationships.
professionals with patients and their families (U.S.
Department of Health and Human Services [HRSA], 2010).
Nurse conflict and communicative stress
Nurses’ job environments consist of many communication
challenges affecting their quality of work life (Apker, Propp, & Contributions from nursing literature
Ford, 2005; Kreps, 2009; Nicotera & Clinkscales, 2010). For
Nursing practice involves working closely with other
instance, responses from HRSA’s 2008 National Sample
health care professionals, and, at times, such interdepen-
Survey of Registered Nurses identified the following commu-
dent work roles contribute to conflict. Scholars describe
nication problems as major factors in nurses’ decisions to
nurses’ work conflict as largely due to incompatible goals
leave their current jobs and employers: (a) lack of good
and recurrent, normative strife (Brinkert, 2010; Cox,
management/leadership; (b) lack of collaboration/communi-
2003). Common conflict sources include, but are not lim-
cation; and (c) interpersonal difficulties with colleagues.
ited to, patient care disagreements, insufficient time to
Regrettably, these difficulties have endured over time, contri-
manage patients’ and their families’ concerns, and diffi-
bute to decades of nurse conflict, stress, burnout, and turn-
culty working alongside individuals trained in different
over (Willard & Luker, 2007), and are associated with
capacities (Azouley et al., 2009). Nurses are often at the
significant human and financial costs. Turnover and shortages
center of health team conflict, as the responsibility for
negatively affect patient care by escalating medical errors and
managing patient care, once a physician makes a diagnosis
increasing recruitment and training expenses (Waldman,
decision, rests on nurses (American Nurses Association
Kelly, Arora, & Smith, 2010).
[ANA], 2013).

CONTACT Jennifer J. Moreland jenniferjmoreland@gmail.com The Research Institute at Nationwide Children’s Hospital, 700 Childrens Drive, Columbus, OH
43205.
© 2016 Taylor & Francis
 816 J. J. MORELAND AND J. APKER
Nursing scholars have identified ways in which nurses
communicate conflict. For instance, some nurses “eat their
young” by engaging in destructive displays of conflict to teach
power, authority, and status to newcomers (Hippeli, 2009, p.
186). Other nurses engage in conflict avoidance that allows
problems to fester and/or permits harsh behaviors to continue
unchecked (Mahon & Nicotera, 2011). Nurses also may find
themselves experiencing conflict in forms of passive-aggres-
siveness, purposeful violations of practice standards, backstab-
bing, and bullying (Dellasega, 2011). These behaviors not only
decrease nurse morale, increase job dissatisfaction, and reduce
work performance (Cox, 2003), but also go against the ANA
(2001) Code of Ethics for Nurses, a guide for nurses’ profes-
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sional conduct and ethical obligations.
The topic of conflict figures prominently in nursing
and allied health literature as a major stressor for nurses.
For example, some sources of conflict (e.g., lack of con-
trol, failure to involve nurses) also are known factors that
exacerbate nurses’ stress and burnout (Rosenstein, 2009).
Nurses who routinely experience negative job strain are
more likely to engage in conflict with other health team
members (Chang, Hancock, Johnson, Daly, & Jackson,
2005). Lacking support to cope with stress may even
encourage nurses to fall back on dysfunctional behaviors,
making conflict with others spiral, creating more stressful
working conditions (Maslach & Leiter, 2008).
Although nursing and allied health scholarship calls atten-
tion to conflict and stress in the nursing profession, this
literature lacks full consideration of the importance of com-
munication (Mahon & Nicotera, 2011). We turn to organiza-
tional communication literature for a more complete
understanding of conflict and stress. We argue that the pair-
ing of research from both disciplines, particularly given com-
munication researchers’ multifaceted approach to interaction
and conflict communication, provides a foundation for ana-
lyzing nurse conflict and stress.
Contributions from organizational communication
literature
Organizational communication scholars argue that conflict
and stress are inherently communicative and have relational,
transactional, and meaning-centered qualities. Such an asser-
tion demonstrates how conflict and stress are evolving, rela-
tionally dependent processes that are open to the
interpretations of involved parties. For instance, research
shows that conflict enables individuals to identify shared
difficulties together, which can often lead them to mutual
problem solving (Nicotera & Dorsey, 2006). Furthermore,
experiencing stress encourages people to use coping strategies
and seek and/or give support (Miller & Considine, 2009).
Putnam and Poole (1987) offered a seminal definition of
conflict still useful for exploring nurse conflict. They define
conflict as, “the interaction of interdependent people who per-
ceive the opposition of goals, aims, and (/or) values, and who see
the other party as potentially interfering with the realization of
these goals (aims, or values)” (p. 552). Putnam and Poole’s and
Nicotera and colleagues’ (Mahon & Nicotera, 2011; Nicotera &
Clinkscales, 2010) research show how communication
transforms human agency and organizational structures during
times of conflict. Competent discourse has the potential to stop
or reduce negative conflict, whereas dysfunctional communica-
tion can promote destructive interaction cycles.
Organizational communication research shows nurses
experience multiple, communication-based stressors in
their jobs. Studies reveal nurses encounter intense and
wide-ranging emotional interactions, perform a diverse
repertoire of communication skills with multiple constitu-
encies, and experience high communication load (Miller &
Considine, 2009). Chronic, negative interactions create phy-
sical, emotional, and cognitive strain that contributes to
nurse burnout (Kreps, 2009). Nicotera and Mahon (2013)
found recurrent conflict relates to nurse role stressors,
burnout, and depression. Organizational communication
researchers have also found that workplace communicative
stressors produce conflict for nurses and contribute to how
they cope/manage stress (e.g., Apker, 2012). For example,
Real and Poole (2011) found that issues, such as different
professional orientations to care and a hierarchy which limits
decision-making from lower-status team members (i.e., non-
physicians), can cause turbulent interactions. Such turbulent
interactions can ultimately lead to dysfunctional stress for
nurses and all team members involved. Building on this
research literature, the current study aims to (a) explore the
ways conflict and communicative stress are experienced and
endure in nursing and (b) understand how nurses discursively
(mis)manage conflict and stress.
Method
Host hospital and participant characteristics
Participants were nurses (N = 135) from a large,
Midwestern teaching and research hospital. This institution
has been awarded the national honor of Magnet Status for
years and serves diverse regional, national, and interna-
tional populations. The main hospital houses 1,400+ inpa-
tient beds and is a quaternary (i.e., highly specialized) care
center. Nurses were by majority White/Caucasian (92.5%),
female (93.3%), and registered nurses (RNs) (95.6%). They
were practicing nurses for an average of nearly 19 years
(M = 18.96, SD = 13.31) and had worked nearly 13½ years
(M = 13.63, SD = 11.23) in their current role (i.e., as a nurse
manager, nurse practitioner, staff nurse, etc.). Nurses
worked for their current employer, on average, for
10 years (M = 10.12, SD = 8.95), with almost 7 of these
years (M = 6.98, SD = 8.08) in/on their current unit,
hospital floor, or team. Participants’ average age neared
46 years (M = 45.66, SD = 11.79), and 61.9% possessed at
least a bachelor’s degree. With regard to hierarchy, 71.9% of
nurses were staff nurses, 10.4% were administrators or
managers, and 4.4% were advanced practice nurses (e.g.,
nurse practitioners).
Data collection and analytic method
Data in the present study are derived from a larger survey
project aimed at exploring nurse identity, communication,
 HEALTH COMMUNICATION 817

and conflict themes.1 The data analyzed here consist of open-
ended responses to the prompt, “In the following space, please
feel free to write about your identity, communication prac-
tices, and conflict experiences as a nurse.” In total, 135 nurses
responded, for an 18.4% response rate of 734 eligible nurses.
Responses were imported into to NVivo v. 10.0 qualitative
analysis software.
We used a grounded, inductive process consisting of
several analytic stages (Lindlof & Taylor, 2011; Tracy,
2013). First, we independently reviewed data without mak-
ing notes. Second, we identified 12 overarching themes/
codes to develop and refine a codebook (Moreland,
Krieger, Hecht, & Miller-Day, 2013). Third, we indepen-
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Along with the Weickian perspective on communicative
cycles, fire emerged as an apt metaphor useful for under-
standing the data. Items—and relationships—can go up in
flames due to communication conflict and stress. When fire,
or conflict/stress, is not properly harnessed (or extinguished,
should it become completely out of hand), it smolders and
damages the surrounding environment (and relationships).
Alternatively, fire can provide light and heat and draws indi-
viduals to it; likewise, conflict and stress can signal the need
for change in an environment. Small conflict and/or stressor
sparks may bring about ideas for harnessing fire and improve
work surroundings. A flame in the proper context also lights
the way for constructive change

dently coded 50% of the data and discussed codes wherein

discrepancies reached above 15% (Saldana, 2013). We
resolved differences through consensus and repeated this Theme 1: Exclusionary communication behaviors
process until theoretical saturation was achieved. Fourth, Conflict and communicative stress are cyclical phenomena
we developed and refined memos for each code2 through that endure over time. Messages of exclusion stemming
discussion. from multiple sources function as an accelerant, intensify-
ing and/or speeding up dysfunctional cycles of conflict and
stress. Exclusionary communication disrupts nurse interde-
Results and interpretations pendencies and weakens team, unit, and organizational
cohesion (Table 1).
Upon completion of thematic coding, we decided Wieck’s
(1979) model of organizing, specifically his conceptualization
Nonparticipatory communication. Nurses feel excluded
of communication cycles, fit the data. Communication cycles
when others, particularly hospital leaders, unclearly and/or
are established patterns of discursive behavior used repeatedly
inconsistently communicate policies, don’t solicit nurses’
by organizational members in uncertain environments (Kreps,
feedback, and fail to involve nurses in decision making.
2009). In highly ambiguous circumstances, such as times of
Findings indicate a destructive, cyclical effect in which exclu-
stress and conflict, organizational members introduce and
sion creates nurse stress and conflict, which, in turn, height-
respond to ideas to reduce ambiguity. Nurses’ responses indi-
ens nurses’ disengagement. This corresponding lack of
cate that conflict and communicative stress feed off each other
engagement exacerbates conflict and chronic, negative stress.
in a cycle that contributes to destructive, equivocal working
Comments such as “It doesn’t feel like upper management
conditions. They engage in communication to make sense of
listens to us” were commonly identified as stressors and
the ambiguity. Further, conflict and stress have multiple
sources of conflict, especially regarding matters of scheduling
sources and varied outcomes profoundly affecting nurses
and staffing shortages. For instance, an assistant nurse man-
and their institutional employers. Conflict and stress function
ager said she experiences stress and conflict when “[I’m] often
independently in nurses’ lives, but these forces also interrelate,
stuck delivering all the bad news (changes, discipline, staffing
with conflict contributing to stress and vice versa.
decisions, etc.) and having nearly no authority. Often, it

Table 1. Examples of Exclusionary Communication Behaviors as Contributors to Conflict and Stress in Nursing.
Behavior Description Data examples
Nonparticipatory Discourse that excludes nurses from decisions, such as when others “I am told to use my nursing judgment and then when I do, I feel
communication unclearly and inconsistently communicate policies and don’t solicit that some of my decisions are found to be wrong even though the
nurses’ feedback. people making the judgments about my decisions were not in the
situation and having to make the decisions. I do not feel that my
organization recognizes my contribution or the contribution of my
coworkers to this organization. I am not as happy in my position as I
was even 6 months ago.”
Unsupportive Interactions that indicate a failure of others, such as leaders and peers, “Most conflict arises from when our unit RN’s do not feel our
communication to support nurses’ needs. Includes talk that shows insider-outside management is looking out for the unit’s best interest, but rather
status, avoidance, and unfair, preferential treatment. trying to please their higher ups.”

1
A three-part recruitment method was employed to obtain participation in the survey. To begin, the first author announced the study at an all-hospital
nurse managers’ meeting and flyers were distributed to these nurses. Soon after, the administrative associate to the chief nursing officer (CNO) of the
hospital sent all nurses (LPNs and RNs of all statuses) active in the human resources system an e-mail inviting them to participate in the study. Three
groups received the survey invitations: (a) nurses at the main campus of the hospital system; (b) nurse managers at an ambulatory clinical institute; and
(c) nurse managers in regional medical practices.
2
Memos consisted of the codes’ description and definitional properties (inclusionary and exclusionary criteria), illustrative examples, antecedent conditions,
consequences, relationships to other codes, and evolving hypotheses.
 818 J. J. MORELAND AND J. APKER
doesn’t feel like upper management listens to us or the front-
line employees!” One way to deal with the cycle is to disen-
gage, but disengaging promotes a lack of performance control
(Rosenstein, 2009). Her comments are reinforced by a neona-
tal nurse, who lamented how leaders do not share control over
shift scheduling, which negatively impacts her work–family
balance:
Many RNs here have been here for many years and want no
changes. Scheduling is an issue that makes working in this unit
very hard because there are no alternatives to allow me to spend
time I with my family. Options to help with scheduling are often
dismissed.
These comments illustrate how lack of participation in con-
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troversial issues contributes to a cycle of conflict and stress.
Not being involved may threaten nurses’ role autonomy, an
identified job stressor, and may spark a conflict, pitting nurses
against each other for more desirable shifts, and so on. Nurses
in this study reported feeling helpless and frustrated when
they don’t have control over their work. In addition, exclud-
ing nurses specifically in scheduling decisions can limit their
work–life balance. Experiencing such job pressures may
reduce nurses’ ability manage conflict competently (Nicotera
& Mahon, 2013) and may promote unhealthy competition. In
turn, conflict produced by insufficient decision-making invol-
vement can heighten nurses’ experience of negative stress.
Nurse participants also identified lack of involvement in
patient care decisions as a contributor to conflict and stress. A
charge nurse said, “I am told to use my nursing judgment and
when I do, my decisions are found to be wrong even though
the people making the judgments about my decisions were
not in the situation.” When nurses shut down or avoid offer-
ing expertise, they may experience conflict with others and a
lack of a sense of personal accomplishment—both of which
are indicators of stress and burnout (Propp et al., 2010).
Participants said that many physicians undervalue nursing
and do not invite nurse collaboration. A clinical nurse spe-
cialist explained that conflict occurs when she asserts her
professional view:
The greatest conflicts arise when physicians believe to know more
regarding certain areas of my expertise than I. It does occur
frequently as I can support my position with experience and
evidence . . . unfortunately the casualty of battle is the patient.
Study data also indicate that not only do nurses feel
excluded from participating in job-related decisions, they
are criticized by nurse leaders, hospital administration,
and physicians when slowdowns or work inefficiencies
occur. An emergency department nurse explained, “The
work is physically and mentally difficult; we hardly ever
get to take a break to eat in a 12-hour shift, and expected
to manage everything . . . everything is blamed on the
nurse if it doesn’t get done.” Her quote aligns with factors
promoting the co-occurrence of conflict and stress: (a)
intense work, (b) work overload with little down time,
and (c) messages faulting nurses for conditions potentially
outside their control (Apker, 2012; Chang et al., 2005).
Unsupportive communication. Nurses also encounter
exclusionary communication when supervisors or other
colleagues fail to support them. Findings indicate that
inadequate or nonexistent supportive communication
heightens nurse conflict and stress and may create a
cycle in which little or no social support is provided
during difficult times. For some, the presence of unit
cliques and communication demarcating some nurses as
insiders and others as outsiders contributed to their experi-
ences of conflict and stress. A quote from a palliative care
staff nurse demonstrates this view: “My floor is very cliquey
and I feel that even though I’ve worked here for almost an
entire year it is hard to make friends and feel like I
‘belong.’” Other nurses commented on how cycles of dys-
functional communication were created when they brought
job stressors and conflicts to supervisors’ attention, only to
experience lack of support and isolation from management.
The following quote from an intensive care unit nurse
exemplifies this view:
If you address any issues with a supervisor, you are put in the hot
seat of ways that “you” should have handled the situation and
then get treated like an outcast by the fellow co-worker and their
“crew” for several days/weeks dependent upon the issue that was
addressed regardless of the impact on the patient care.
Rather than ignoring problems and/or conflict, this nurse
sought out her supervisor for conflict management. She
experienced exclusion instead of a resolution. The super-
visor offered no emotional or information support and
returned the problem to the nurse. At the same time, the
nurses’ peers ostracized her for confronting conflict
directly. Thus, the nurse was cut off from two sources of
workplace social support, which is critical to nurses’ cop-
ing abilities (Wright, Banas, Bessabarova, & Bernard,
2010). Besides receiving no suggestions or help in creating
a remedy, the lack of social support and ostracization
from peers added fuel to this conflict flame.
The anecdote above demonstrates how unsupportive
communication reinforces conflict avoidance as an
accepted (or at least tolerated) norm in nursing (Mahon
& Nicotera, 2011). Some respondents reported frustration
with coworkers and supervisors who either avoid conflict
completely or fail to support conflict management efforts.
For these nurses, avoidance does little to smooth over
conflict; rather, avoiding allows disputes to spiral, fester,
and become job stressors. A senior wound care staff nurse
said, “Conflict within my unit has not been dealt with
directly, leading to an unhealthy and frustrating work
environment.” Her comments were echoed by a urology
nurse, who explained, “[There] always will be conflict in
nursing, always. It is the nature of the job . . . It can make
your job more difficult and challenging.” For some nurses,
unresolved conflict and unaddressed stress create cycles of
dysfunction that are difficult to manage or reduce.
Finally, nurses perceive a lack of supportive communi-
cation when their immediate supervisors display inequita-
ble behaviors when managing subordinates and fail to
advocate for nurses’ work needs and interests. For exam-
ple, some responses described nurse managers as “playing
favorites” due to age and seniority (younger nurses
believed bias favored older nurses and vice versa). Such

biased behavior pits nurses on the same unit against each
other, contributing to conflict-ridden and stressful work
environments. Nurses also report stress and frustration
when their immediate supervisors use one-way, downward
communication to please “higher ups.” A cardiac surgery
nurse commented, “Most nurses who I work with feel our
managers are not advocates for us,” whereas an intensive
care nurse said her supervisors don’t “stand up to the
crowd” to enforce rules and protocols. A cardiothoracic
nurse went a step further, blaming her manager for per-
vasive nurse–nurse conflicts and corresponding stress:
The manager is pulling us apart. She is more concerned with
herself and how she must have done things on her old unit even
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though it is not policy and says “well that’s how you’re expected to
do things even if it’s not written that way.” Everyone is unhappy
with the way she manages and we are all talking about leaving
because of HER!
This cyclical pattern of responses is unfortunate because
research literature indicates how nurse managers play impor-
tant communicative roles for staff nurses (e.g., developing
unit cohesion, coordinating care; Brinkert, 2010). Further,
nurse managers serve as vital boundary spanners between
nurses and nurse/hospital executives (e.g., conveying upward
feedback, communicating changes, and explaining policies).
Managers who display such exclusionary practices can shut
down two-way interaction between multiple levels of organi-
zational hierarchy.
Theme 2: Nurses’ discursive (mis)management of conflict
and stress
Nurses (mis)manage conflict and stress through respectful
and disrespectful communication. Disrespectful communica-
tion among nurses to one another fuels the flames of frustra-
tion and discord, making productive conflict management
difficult. In contrast, data show how respectful management
of conflict and stressful situations can manage or even extin-
guish destructive flames. In contrast, disrespectful communi-
cation heightens nurse stress and conflict. Respectful and
disrespectful conflict (mis)management in the workplace can
take either explicit (e.g., going straight to the source) or
implicit (e.g., skirting an issue and avoiding) forms. These
results complement and extend existing health communica-
tion research about social support (Wright et al., 2010) and
reinforce the importance of respectful communication in nur-
sing (Willard & Luker, 2007). Further, results may provide
hospital and nurse leaders with ideas to improve nurses’
communicative working conditions and add to nurses’ reper-
toire of communication solutions to stress and conflict
(Tables 2 and 3).
Explicit, respectful forms of managing conflict. Explicit and
respectful forms of conflict management refer to direct,
visible attempts to convey value and admiration for others.
In conflict situations, respectful communication means
approaching conflict, disagreements, or difficulties with
others in a manner displaying fairness, honesty, mutual
understanding, and directness. Displaying respect in the
HEALTH COMMUNICATION 819
face of stress and/or conflict extinguishes the growing flames
of conflict. Going to the source and managing conflict
quickly, efficiently (as opposed to letting the conflict fester
or gossiping), and fairly exemplify nurses’ explicit manage-
ment of conflict in the hospital environment. For example, a
newer cardiothoracic staff nurse asserted,
I am typically non-confrontational, but do well with conflict
resolution. I am very calm and patient and tend to listen to all
perspectives before engaging. I truly love my job, and love my
unit. Everyone on this unit works well as a team for the benefit of
the patient.
A pulmonary assistant nurse manager reported, “My commu-
nication style is straight forward. I do not sugar coat things. I
do speak honestly. My staff feels I am fair.” These quotes,
along with several others, demonstrate how some nurses
explicitly employ respectful communication tactics to manage
conflict situations. Other nurses noted that they made an
effort to get along, tried to help others when needed, and
mentioned they actively promote positive work environments.
These nurses thus reported acting out the ANA (2001) Code
of Ethics: Nurses are to extend respect not only to patients,
but to other colleagues and professionals, and develop “caring
relationships” with them.
Implicit respectful forms of managing conflict . Along with
the aforementioned explicit communicative disruption
management techniques, some nurses reported choosing
more implied and indirect ways. For instance, in conflict,
some nurses mentioned the usefulness of presenting dis-
agreements in a calm, assertive, and caring style, excluding
harsh confrontation and aggression. Such implicit tactics
prevented conflict flames from growing to an unmanage-
able size. Nurses reported that attentiveness and empa-
thetic listening—values inherent to nursing—aided them
in working through difficult situations (ANA, 2001).
Attentiveness and empathetic listening serve to contain
conflict fire, much like a fireplace does; the conflict exists
and is worthy of discussion, but such person-centered
conflict management skills encourage mutual understand-
ing. While they did not specifically mention communicat-
ing it to others, nurses noted possessing mutual respect
and admiration for their peers. This no doubt created a
supportive and functional organizational system. A staff
nurse commented, “I truly enjoy working with the nurses
on my unit, they are caring and intelligent and I feel very
lucky to have such strong support.” In a more global
statement, a nurse glowed, “I respect nurses in all fields
and everywhere. We are an amazing group of people.”
The preceding comment also demonstrates how pride
and the valuing of others in this stressful environment can
help nurses manage conflict communication situations.
Conflict is not as detrimental and lasting to the relation-
ships between nurses when mutual respect is demon-
strated. The nurses in this study who reported
management having a high opinion of nurses seemed
more supported in their role. Furthermore, nurses impli-
citly demonstrated respect by helping their peers, promot-
ing a positive work environment, and exemplifying
 820 J. J. MORELAND AND J. APKER

Table 2. Nurse Perceptions of Respectful Workplace Communication.

Behavior Description Data examples
Respectful Demonstrations of appreciation, admiration, and value for
communication nurses personally and professionally. Expressions of pride
and self-respect.
Explicit ● Communicating with others in a manner displaying “Fairness and gathering as much information to obtain the full picture
fairness, honesty, mutual, understanding, and of the occurrence is paramount in aid to a conflict resolution.”
directness. “I do not believe in allowing things to fester. It is better to talk it over
● Managing decisions and/or conflict quickly and effi- and move on, do not continue to beat an old horse.”
ciently while displaying empathy
● Making an effort to get along and help

Implicit ● Communicating in a calm, assertive, caring style rather “Every nurse has a very high standard in delivering patient care,
than aggressive confrontation. everyone has the same goals, and conflicts are resolved with mutual
● Attentive, empathetic listening. understanding and agreement. At the end of the day, everyone cares
about each other.”
“I am very calm and patient and tend to listen to all perspectives
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before engaging.”

Table 3. Nurse Perceptions of Disrespectful Workplace Communication.

Behavior Description Data examples
Disrespectful Symbolic displays perceived by nurses as purposeful
communication demonstrations of negative regard, whether or not the
sender intended disrespect.
Explicit forms ● Not listening to opinions, rudeness, gossiping, “Management on my floor plays favorites and is sometimes not
mocking. encouraging but demeaning.”
● Going behind backs of people in conflict. “Nurses can be very mean people, there are many nurses who
● Going over a person’s head to boss. can’t wait for you to screw up, and the lack of support on my
● Minimizing professional contributions. unit with fellow nurses and management is appalling!”

Implicit forms ● Perceived lack of support.
● Ignoring/denying existence of problems.
● Passively accepting explicit disrespectful behaviors
as the norm.
● Taking for granted nurse contributions.
● Attending to the needs of others considered more
powerful/higher in status rather than those lacking
power/status.
“Sometimes talking to MD’s, I feel frustrated to not be taken
seriously.”
“I have never seen such basic lack of respect for others as a
person, much less a patient, as I have here by the medical team
. . . no one will step up and enforce making them comply.”

camaraderie with one another. For instance, a cardiology
staff nurse stated,
I feel like my fellow staff nurses all act as a team and promote a
positive work environment. I don’t believe I would have stayed on
this floor for so long if it weren’t for the people I work with. We
do our best to keep negativity down & help each other.
Explicit, disrespectful forms of (mis)managing conflict
communication. Nurses discussed many forms of disrespect-
ful conflict communication, and this disrespect came in both
explicit and implicit manners. Nurses mentioned individuals
at all levels of the hospital organization conveying disrespect
via explicit means, like not listening to viewpoints, rudeness,
incivility, gossiping, and mocking; going behind others’ backs
rather than seeking out the source in response to conflict;
going over a person’s head to his or her boss rather than
working with the source; and minimizing professional con-
tributions. Such explicit disrespectful displays were sometimes
done in public, making the confrontation or disagreements
especially heinous. The following quote from a staff intensive
care unit (ICU) nurse exemplifies many of these subthemes:
Conflicts are becoming more regular with no resolution, not
only between our co-workers but also with the residents and
interns. We are shown no support by our supervisors other than
offering the “shoulder to cry on” but when it comes time to
stand up for the rules and protocol, they appear to be afraid to
stand up to the crowd.
Implicit disrespectful forms of (mis)managing conflict
communication. Finally, nurses in this study encountered
disrespectful, implicit means of managing communication
with individuals at all levels of the hospital. They reported
nurse peers, managers, and physicians diminishing and/or
ignoring work-related concerns, avoiding seeking out
others’ input, and attending to the needs of others con-
sidered more powerful/higher in status rather than those
lacking power/status. Several nurses felt nursing managers
took their contributions for granted. Nurses believed their
environment suffered from a lack of transparency from
management and felt supervisors and physicians ignored
them. Metaphorically, these management members
ignored the smoke coming from underneath the door. A
veteran neurological nurse stated: “Despite contacting
upper management with unit concerns, nothing has chan-
ged. A meeting was held with a formatted speech about
the concerns, but it is apparent that nothing will be
addressed or solved.” Even though this nurse spoke out
—going against nursing’s conflict avoidance norm—she

was punished via another individual’s choice to avoid
issues.
Quite egregiously, some nurses in this study noted their
peers passively accepted disrespectful communication
actions as the norm. For instance, several nurses reported
frustrations centered on a perceived lack of support from
peers. Nurses in this study reported times when they did
not have, but wanted another nurse to “have my back.” In
this way, nurses displayed implicit techniques for (mis)
managing conflict communication. For example, a surgical
telemetry staff nurse lamented:
I do not trust anyone in the new management nor do I think they
“have my back,” or support me, as the past management team did.
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Staff turnover is unbelievable. I no longer know anyone; too many
new faces; and these new nurses don’t stay very long either. I am
looking to get off this floor; no loyalty whatsoever!!
Related to a perceived lack of support, some nurses men-
tioned that peers and/or the organization itself ignored, dis-
missed, and/or denied the existence of unit and/or
organizational problems. When nurses expressed concern
over personal or organizational structural issues, peers and/
or management implicitly disrespected them. One nurse
stated:
I am new to a NICU [neonatal ICU] unit where there has been
many changes between old and new practices, staff doctors, and
overall affiliation between hospitals. There is much conflict and
discord with management and hospital policies due to these
changes. Many RNs her[e] have been here for many years and
want no changes.
The nurses in this study discussed several ways by which
individuals mismanaged conflict by sidestepping issues rather
than dealing with confrontation directly and constructively.
This finding is consistent with past research results indicating
nurses prefer to not confront conflict directly (Mahon &
Nicotera, 2011). Such reactions allow conflict and stress to
ignite rather than subside and to extinguish rather than kindle
key relational interdependencies.
Considerations for theorizing and practice
Implications for research
Weick’s model of organizing provides a conceptual frame-
work well-suited to understanding the complex communi-
cation dynamics comprising health organizations (Kreps,
2009). Rather than studying conflict and stress as linear
processes, Weick’s (1979) notion of communicative cycles
highlights the interrelated nature of conflict and stress and
the combined pressures conflict and stress put on indivi-
duals. Nurses in our study commonly said conflict is stress-
ful and their day-to-day responsibilities functioned as job
stressors, which cycled into conflict with others. These
dynamics are unfortunate in most organizations, but are
particularly problematic in hospitals, as nurses and other
health workers require holistic teamwork to provide opti-
mal patient care. Rather than promoting positive change,
findings indicate conflict and stress weaken mutually
dependent relationships that are at the center of health
care delivery.
HEALTH COMMUNICATION 821
Participants’ comments support prior organizational com-
munication research. The emotional work of health care
delivery may weaken nurses’ communicative abilities to cope
with stress and conflict (Wright et al., 2010)—thus, nurses
perpetuate the emotion-laden conflict cycle. Additionally,
stress and conflict endure in nursing as these forces act in
concert and, when handled poorly, produce ongoing, uncom-
fortable feelings (Mahon & Nicotera, 2011). When managers
choose to employ avoidance or disrespectful communication,
they perpetuate destructive interaction cycles. In contrast,
showing respect appears to break the cyclical forces of conflict
and stress by validating others’ worldviews and displaying
positive regard through perspective-taking (Apker, 2012;
Milton, 2005).
Implications for practice
Results of this study present a number of practical insights for
health communication and nurse scholars and practitioners.
To begin, many nurses should seek to return to the founda-
tions of nurses—mutual respect and caring—and continue to
build relationships with not just patients, but each other
(ANA, 2001, 2013). Such relationship building will further
promote communication between nurses at all system levels.
Hospital organizations can facilitate such relationship build-
ing via informal and informal social gatherings, mentoring
programs, and social media platforms (e.g., Intranet discus-
sion boards, Facebook groups). Nurses displaying respect to
one another will bolster each other in difficult duties and may
even encourage administrators and physicians to do the same
(Kupperschmidt, 2006).
Additionally, health communication scholars should seek
to develop interventions aimed at getting nurses to not view
conflict as such an abnormality, given that nurses face
repeated conflict and stress cycles inside the hospital environ-
ment. To date, few interventions have been designed to fully
utilize the power of conflict “fire” in the nursing environment
(for an exception see Nicotera, Mahon, & Wright, 2014).
Nurses can positively reframe communicative and environ-
mental frustrations such that conflict is viewed as an oppor-
tunity for change. Interventions, such as communication
training, should teach nurses how to avoid isolation and side-
stepping and create a culture of respect. Such education
should begin in undergraduate and graduate nursing pro-
grams and include experiential learning techniques. Conflict
and stress reduction skills need to be introduced in the class-
room long before nurses enter clinical rotations or their
career. Conflict management, communication, and perspec-
tive-taking skills will go a long way in helping nurses expand
their array of techniques to cope with stress and burnout, in
addition to managing conflict constructively.
Some hospital systems in the United States have turned to
Crucial Conversations (Patterson, McMillan, Grenny, &
Switzler, 2002), a popular literature offering practical conflict
management solutions. The authors encourage professionals
to examine their own motivations and create shared meaning
in conflict situations. However, the authors neglect to provide
tactics for managing cyclical conflict situations and those
times wherein professionals, like nurses, face repeated
 822 J. J. MORELAND AND J. APKER
disrespect and hostility. We argue that this book could be a
reference tool, but the authors’ tips should be partnered with
theoretically grounded communication principles that explain
the nuances of and reasons for conflict and stress resolution
(Critchfield, 2010). Hospital systems should tie communica-
tion and conflict management training programs to the results
of employee engagement reviews and patient satisfaction
surveys.
Our final recommendation is for nurse and hospital leaders
to collaborate with staff nurses and middle managers to adopt
a systemwide culture more supportive of conflict discussion.
Two strategies could be instrumental: (a) communication
between nurses and other health team members should pro-
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mote shared mental models (Haig, Sutton, & Whittington,
2006), wherein individuals come to view system issues con-
structively in order to confront conflict and make changes;
and (b) both health leaders and nonleaders should adopt
policies aimed at reinforcing prosocial behavior, rather than
a punitive culture (Reason, 2000).
Strengths, limitations, and directions for future research
A number of strengths and limitations point to the need for
continued research in this complex communication context.
First, the open-ended survey methods employed in this study
allowed nurses an opportunity to privately speak their mind
regarding communication, stress, and conflict concerns.
Obtaining such comments from busy professionals is a diffi-
cult yet worthy task. Furthermore, we subjected study data to
multiple iterations of analysis and continuously evaluated
themes and subthemes for consistency and rigor. We advocate
continued use of such methods to yield a rich, thick descrip-
tion of today’s nursing role. Our study also presents some
limitations. The nurses in this study (highly educated and
mostly Caucasian) are fairly homogeneous. Although these
characteristics are not too unlike those of the national popu-
lation of nurses (U.S Department of Health and Human
Services [HRSA], 2010), future studies would benefit from
involving participants from diverse nurse groups with a
broader range of ethnicity, age, and tenure. Such studies
may reveal how positional, generational, and cultural differ-
ences contribute to varied communication perceptions and
skills. Another limitation is the case-study focus on one hos-
pital. In the future, research should examine nurse conflict
and respect in varied hospital and health care systems.
Conclusion
Hospital nurses are expected to provide exceptional qual-
ity care while facing numerous communicative and rela-
tional difficulties. Guided by Weick’s conceptualization of
communication cycles, study findings show that stress and
conflict function cyclically in the nursing environment.
Exclusionary communication practices contribute to dys-
functional cycles of conflict and stress that are difficult for
nurses and nurse/hospital leaders to manage construc-
tively. The ways in which nurses discursively (mis)manage
conflict and stress, using respectful and disrespectful com-
munication, facilitates or prohibits positive relational and
organizational transformations. Fire provides an apt meta-
phor for considering conflict and stress and their effects.
Respectful communication can extinguish the fire, whereas
disrespectful discourse fans the flames. Likewise, respectful
conflict management can lower stress, and conflict sparks
can be harnessed for light or ideas signalling the need for
change. Given the centrality of nursing to health care
delivery, combined with the ongoing problems of nurse
burnout, turnover, and shortage, more research into
nurses’ management of stress and conflict is necessary.
Acknowledgments
We thank the nurses of Cleveland Clinic for their time and partici-
pating in this study. We also thank Nancy Albert, PhD, RN, CCNS,
for her advice and facilitation of data collection at Cleveland Clinic,
Cleveland, OH.
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