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Nurses’ perceptions of conflict as constructive or destructive Wonsun (Sunny) Kim, Anne M. Nicotera & Julie McNulty Accepted for publication 17 March 2015
Correspondence to S. Kim: e-mail: [email protected] Wonsun (Sunny) Kim PhD Assistant Professor College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA Anne M. Nicotera PhD Chair Department of Communication, George Mason University, Fairfax, Virginia, USA Julie McNulty PhD RN CPHQ Francis Fellow in Bio-behavior Oncology College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
K I M W . , N I C O T E R A A . M . & M C N U L T Y J . ( 2 0 1 5 ) Nurses’ perceptions of conflict as constructive or destructive. Journal of Advanced Nursing 71(9), 2073– 2083. doi: 10.1111/jan.12672
Abstract Aims. The aim of this study was to examine nurses’ perceptions of constructive and destructive conflicts and their management among nurses. Background. Conflict among nurses is common and has been associated with lack of collaboration, lack of communication and disruptive behaviour, with the potential to have negative impact teamwork. However, unlike the broader social science literature, positive views of conflict are scarce in the nursing literature. Given the various functions of conflict and the high stakes of ineffective conflict management in nursing, it is necessary to examine how nurses understand both sides of conflict: constructive and destructive. Design. A qualitative descriptive design. Methods. Data were collected from 34 full time nurses as part of a conflict skills training course offered over 6 months beginning in October 2009. Each participant was asked to write a weekly journal about conflicts in his/her work place. Result. Data yielded 163 entries (82 classified as constructive and 81 as destructive). Results showed that quality patient care and cooperative communication contributed to the perception that conflict is constructive in nature. The central underlying themes in nurses’ perceptions of destructive conflict were time constraints, role conflict and power differences that are not managed through communication. Conclusion. This article helps to identify nursing perceptions of constructive and destructive conflict and to understand complexities nurses face during their interactions with other nurses, physicians and patients. The insight that constructive views are related to constructive processes provides an excellent opportunity for an educational intervention, so that we can educate nurses to analyse problems and learn how to manage conflict with effective collaborative processes. Keywords: constant comparative, construct conflict, destructive conflict, nurses
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Why is this research or review needed? • Social scientists have long argued that conflict is inevitable and, when managed productively, is an important source of critical thinking, good decision-making and innovation. • Although some nursing research has examined important conflict-related problems, nurses’ perception of the fundamental nature of conflict has not been well studied. • Given the various functions of conflict and the high stakes of ineffective conflict management in nursing, it is necessary to examine how nurses understand both sides of conflict: constructive and destructive.
What are the key findings? • Conflict interaction that maintains a central focus on quality patient care and cooperative communication contributed primarily to
a perception of the conflict as
constructive in nature. • The perception of conflict as constructive was rooted in the perception that the central issue was resolved through communication. • The central underlying theme in nurses’ perceptions of destructive conflict was rooted in the work environment and patient outcome. Issues such as time constraints, role conflict and power differences that are not managed with good communication arise as key contributors to destructive conflict.
How should the findings be used to influence policy/ practice/research/education? • Understanding nurses’ constructive and destructive perceptions of conflict should help shape questions to examine
source of critical thinking, good decision-making and innovation (Putnam & Poole 1987, De Dreu & Weingart 2003, Song et al. 2006, De Clercq et al. 2009). When not managed appropriately, however, conflict elicits negative and damaging behaviour. ‘Intimidating and disruptive behaviors’ have been reported across health professions (Joint Commission 2002, p 3). In a position statement, ‘Lateral Violence and Bullying in the Workplace,’ the Center for American Nurses (2008) claimed that disruptive behaviour ‘interferes with effective communication . . . and negatively impacts performance and outcomes’ (p. 2). These workplace climate factors have been linked closely to recruitment and retention problems for the nursing profession (Coomber & Louise Barriball 2007, Apker et al. 2009). The American Association of Critical Care Nurses Healthy Work Environment standards include skilled communication as a critical element and consider communication just as important as clinical skills (American Association of Critical-Care Nurses 2005). Successful management of conflict depends on two basic factors: the recognition that conflict is an opportunity for productive growth and the ability to fruitfully confront issues in a socially constructive manner (Gross et al. 2004). However, Mahon and Nicotera (2011) documented a tendency among nurses to be conflict-avoidant, including a belief that directly discussing conflict with the other person is ‘unprofessional’ (p. 160). Given the long history in social science and communication theory, which teaches precisely the opposite, examining nurses’ perceptions of conflict as constructive and/or destructive is warranted.
nurse-nurse relationships in depth in future research. • Educating nurses about more conceptually rich ways of defining conflict and more productive ways of managing it is imperative for promoting constructive conflict management.
Introduction Nursing professionals face numerous challenges, including cost constraints and concerns, patient and staff safety concerns and a wide range of nursing role conflicts and overload in the same practice setting. The nursing workplace is unpredictable, highly dynamic and complicated by the fact that a nurse often juggles multiple roles at once. Nurses must respond as all of these factors lead to conflicts within and between professions (Mahon & Nicotera 2011). Social scientists have long argued that conflict is inevitable and, when managed productively, is an important 2074
Background Conflict and communication Conflict is inevitable in any organization because of incompatible goals, needs, responsibilities and values, among other fundamental differences in perception. Conflict is conceptualized by communication scholars as ‘the interaction of interdependent people who perceive the opposition of goals, aims and/or values and who see the other party as potentially interfering with the realization of these goals’ (Putnam & Poole 1987, p. 552). Folger et al. (2005) argued that members in organizations engage in communication to deal with conflicts and accomplish their tasks through conflict. When conflicts are managed directly and constructively, they contribute to workers’ ability to accomplish tasks (Nicotera & Dorsey 2006). In organizational settings, a moderate amount of conflict, handled in a constructive manner, is necessary for attaining and keeping an optimum level of organizational effectiveness. When not handled con© 2015 John Wiley & Sons Ltd
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structively, conflict can increase stress and decrease productivity for employees and decrease the quality of services provided (Rahim 2001). Conflict in nursing Conflict among nurses is common and has been associated with lack of collaboration, lack of communication and disruptive behaviour, with the potential to have negative impact teamwork (Joint Commission 2002, Fontaine & Gerardi 2005). However, unlike the broader social science literature, positive views of conflict are scarce in the nursing literature. Conflict itself is generally described as negative in nursing (Kelly 2006, Hahn 2009, Milton 2009). Poor conflict outcomes are often a serious issue in any healthcare setting (Abrahamson et al. 2009, Azoulay et al. 2009). However, the conflation of conflict itself with poor conflict outcomes, is likely associated with ineffective conflict management, severely limits our understanding of conflict in nursing. In nursing research, conflict is most often illustrated as adversarial due to general differences (Hahn 2009), relationships between management/staff (Kelly 2006), nurse/physicians (Azoulay et al. 2009) or nurse/family (Abrahamson et al. 2009). These dichotomous perspectives perpetuate an ‘us vs. them environment where conflict resolution is attempted in an unalterably adversarial environment’ (Mahon & Nicotera 2011, p. 153). In addition, conflict is also frequently illustrated as a personality function (Northam 2009). These approaches hinder the opportunity for growth and critical issue resolution. McKenna et al. (2003) found that ‘overt interpersonal conflict’ (p. 93) was a common experience for RNs in their first year of practice. Overt interpersonal conflict was described by 34% of the first-year nurses; 38% reported ‘distress about conflict’ (McKenna et al. 2003, p. 94). The most common conflict management strategy used in nursing is avoidance or withdrawal (Kelly 2006, Northam 2009, Mahon & Nicotera 2011). Mahon and Nicotera (2011) found that such avoidance is directly related to a view of conflict as inherently negative. However, among communication theorists and other social scientists, conflict avoidance is widely regarded as ineffective and potentially damaging to interpersonal relationships. Constructive vs. destructive conflict Here, we take the stance that conflict is neither inherently positive nor negative; the distinction between constructive and destructive conflict lies in how the conflict is managed to produce positive or negative results. The constructive or destructive characterization of conflict can thus be made based on process or outcome. Constructive outcomes include innovation and growth; improved decision-making; discov© 2015 John Wiley & Sons Ltd
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ery of synergized solutions to common problems; enhanced individual and group performance; searching for new approaches by individuals and groups. Destructive conflict outcomes include job stress, burnout and dissatisfaction; reduced communication between individuals and groups; a climate of distrust and suspicion; damaged relationships and reduced job performance. These constructive and destructive outcomes result from constructive and destructive processes, respectively, not from the natural and inevitable occurrence of a conflict in itself (Deutsch 1973, Deutsch et al. 2011). According to Deutsch (1973), in a destructive conflict process, individuals compete, trying to defeat others and ultimately win. In a constructive conflict, individuals cooperate, are interested in reaching an agreeable outcome and maintain understanding of their ongoing interdependence. A cooperative process allows for the open and honest communicating that enables a meaningful and accurate description of the conflict. Individuals can combine information and reduce misunderstandings, confusion and mistrust. A cooperative process encourages the search for mutually beneficial solutions because the parties have a better understanding of each other’s needs and their interdependence.
Research question This qualitative descriptive study seeks to identify nurses’ perceptions of constructive and destructive conflict in the workplace. Research reports are rife with descriptions of various facets of nurses’ hostile work environments; perhaps this is due, in part, to their presumption that conflict is by nature a destructive force. Understanding how nurses perceive conflicts as constructive or destructive will help to shed light on this thorny problem. Thus, the following research question is advanced: What perceptions do nurses have about constructive and destructive aspects of conflict?
The study This study used the constant comparative approach to examine diary data gathered as part of a training course designed to help nurses gain skills in conflict management.
Aim The aim of this study was to examine nurses’ descriptions of conflicts that they characterize as ‘constructive’ and ‘destructive’, to more deeply understand common meanings for conflict and its management among nurses. Although some nursing research has examined important conflict2075
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related problems (Coomber & Louise Barriball 2007, Hutchinson et al. 2008), nurses’ perceptions of the fundamental nature of conflict has not been well studied.
Design This study was a descriptive, qualitative diary of conflict experiences in a work place and is part of a larger study that assessed troublesome outcomes in nursing communication and the effectiveness of the training course to reduce nursing workplace conflict. Data for the larger study were collected between September 2009–April 2010. (Nicotera et al. 2010, Nicotera & Mahon 2013, Nicotera et al. 2015).
Sample/participants All participants had been full-time hospital-based nurses for at least 1 year. Participants were recruited by distributing fliers in several healthcare systems and nursing school graduate-level courses in a major metropolitan area. Roles of participants included staff nurses, charge nurses and nurse managers from a variety of settings and specialties.
Data collection Five small groups of registered nurses (N = 34) each attended six monthly 90-minute sessions. Between the first and second monthly sessions, each participant was asked to write a weekly journal about conflicts in his/her work place. There were four specific questions: (1) describe a constructive conflict you have experienced in your work place this week; (2) what made it constructive?; (3) describe a destructive conflict you have experienced in your work place this week and (4) what made it destructive? The data were collected using a web-based survey program (surveymonkey.com). The survey yielded 163 replies (82 classified as constructive and 81 as destructive).
Ethical considerations This research was generated by an interdisciplinary research team at a large research university. The institution’s Human Subjects Research Board reviewed and approved the study. The university provided an internal grant for the training program’s development. Nurses enrolled in the course for no fee and were paid only for parking.
Data analysis Textual data from the journals were subjected to thematic analysis using the constant comparative method (Corbin & Strauss 2008). First, each response to each question was 2076
treated as a unique unit. These units were then divided into two groups, constructive and destructive. Each group of data was then subjected to open coding, ‘the process of breaking down, examining, comparing, conceptualizing and categorizing data’ (Strauss & Corbin 1990, p. 61). For the first stage, the researchers studied all responses to acquire familiarity with the text and gain understanding from the data without written notes. After that, the text was reread in the order as initially listed, without placement into categories. The researchers drew on tacit knowledge in making these initial judgments for early category formulation. The categories are then named and a description written for each. These categories (and their corresponding descriptions) are then compared in the same fashion to collapse the categories, repeating until no more reduction in categories can be accomplished. As the data analysis progressed, the researchers were able to easily combine and define categories based on overlying themes. Once the categories emerged, fewer modifications were required as more data were processed. Delimiting of the construction occurred as the data sources became saturated and the categories were integrated. The final conceptual definitions for each category are included in Tables 1 and 2. Once formed, the categories can be treated as codes applied to each individual unit of data.
Rigour Two qualitative researchers independently coded the units using the categories generated and determined if they arrived at the same codes. We compared the sets of codes that each coder assigned to each of the 163 responses. A response was considered to be coded the same only if both coders used the identical set of codes. The results showed that 98 (601%) of the 163 responses were coded the same by both coders. By discussing the reasons for their disagreements, the two coders were able to identify and correct
Table 1 Categories and definitions of constructive conflict. Category
Conceptual definition
Problem-solving Collaboration
Finding and solving the problem Collaborate with other teams or other nurses to resolve a conflict Manage schedule effectively Conveying messages, thoughts and information through the communication which is a way to gain understanding Increased patient care
Coordination Communication
Patient care
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Table 2 Categories and definitions of destructive conflict. Category
Conceptual definition
Poor conflict managementSubcategory: direct confrontation, lack of communication Medical outcome
Manage their conflict ineffectively Confront conflicts in front of other people (in public) Lack of communication Conflicts affect patients’ medical outcome Conflicts between nurses and patients or patients’ family Limited time or shortage of nurses Conflicts occurred due to some unresolved personal conflict or fairness with previous relationships Conflicts happened from working with different team members or unit people Power differences between different nurses or between nurses and doctors Incompatible role expectations
Patients or their family Time constraints Relationships
Teamwork
Power differences Role conflicts
problems with the codes. The reasons for the discrepancies included problems such redundant codes for the same belief, vague code definitions and lack of mutual exclusivity between codes. After resolving the discrepancies, the two coders recoded the same 163 responses a final time. The final level of agreement between the two coders showed substantial improvement with 89% agreement. The two coders resolved any remaining intercoder discrepancies and coding was finalized.
Findings Demographical characteristics The sample consisted of 34 nurses (33 females, 1 male; mean age 441 years; 21 European Americans, three African Americans, one Latina, six Asian, one African and two unspecified). Time in nursing ranged from 2–40 years (mean = 192); time in the current position ranged from 6 months to 31 years (mean = 56 years). A variety of specialties were represented, in 24 inpatient settings. Eight participants had current or past experience as a nurse manager.
Constructive conflict themes Five themes emerged from the 82 entries that reflected constructive conflict (Table 1). The frequency of responses in each category is presented in parentheses.
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Problem-solving (10) Participants in this study often used conflict as a way to understand a problem and find a solution. One of the participants responded that ‘nurses involved in the discussion were actually trying to come up with solutions that distributed the responsibility more fairly. Instead of just complaining about the acknowledged flaws in the current situation, they believed that there was a solution.’ In another example, a participant stated, ‘Instead of just complaining about the paediatrician, we took his concern to heart and came up with a solution.’ Collaboration (12) In some cases, nurses felt that collaboration helped to resolve a conflict, allowing the individuals to combine their information and to reduce the opportunity of misunderstandings, confusion and mistrust. A sample response was, ‘By working on the different units you had a different perspective and respect for what the nurses on that unit experience in their workplace.’ Coordination (10) Coordination was identified in several responses as crucial for resolving the conflict constructively. In some cases, there was a scheduling problem about assigning shifts and holidays for nurses in a way that both respected the constraints of the nurses and fulfilled the objectives of the hospital. One respondent said: ‘We have been understaffed the last few weeks and not had the proper RN coverage to make certain safety.’ ‘I have had less patient assignments in my area and have been able to make the appropriate safety and equipment checks for the other units.’ Communication (24) A popular response concerning constructive conflict expressly highlighted the importance of communication in resolving conflict. Nurses conveyed messages, thoughts and information through communication and specified that communication was a way to achieve understanding of other nurses doctors’ and patients’ perceptions. One of the respondents stated: ‘One RN (A) from night shift had been complaining about another RN (B). RN B was also complaining about RN A behind his/her back to other people. Finally, they did talk one-on-one and they cleared the misunderstanding.’ Patient care (26) Several conflicts were labelled as constructive, because it led to a positive outcome for patient care due to the centrality of patient care to the nursing role. For example: ‘My charge
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Nurses’ perceptions of conflict as constructive or destructive Wonsun (Sunny) Kim, Anne M. Nicotera & Julie McNulty Accepted for publication 17 March 2015
Correspondence to S. Kim: e-mail: [email protected] Wonsun (Sunny) Kim PhD Assistant Professor College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA Anne M. Nicotera PhD Chair Department of Communication, George Mason University, Fairfax, Virginia, USA Julie McNulty PhD RN CPHQ Francis Fellow in Bio-behavior Oncology College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
K I M W . , N I C O T E R A A . M . & M C N U L T Y J . ( 2 0 1 5 ) Nurses’ perceptions of conflict as constructive or destructive. Journal of Advanced Nursing 71(9), 2073– 2083. doi: 10.1111/jan.12672
Abstract Aims. The aim of this study was to examine nurses’ perceptions of constructive and destructive conflicts and their management among nurses. Background. Conflict among nurses is common and has been associated with lack of collaboration, lack of communication and disruptive behaviour, with the potential to have negative impact teamwork. However, unlike the broader social science literature, positive views of conflict are scarce in the nursing literature. Given the various functions of conflict and the high stakes of ineffective conflict management in nursing, it is necessary to examine how nurses understand both sides of conflict: constructive and destructive. Design. A qualitative descriptive design. Methods. Data were collected from 34 full time nurses as part of a conflict skills training course offered over 6 months beginning in October 2009. Each participant was asked to write a weekly journal about conflicts in his/her work place. Result. Data yielded 163 entries (82 classified as constructive and 81 as destructive). Results showed that quality patient care and cooperative communication contributed to the perception that conflict is constructive in nature. The central underlying themes in nurses’ perceptions of destructive conflict were time constraints, role conflict and power differences that are not managed through communication. Conclusion. This article helps to identify nursing perceptions of constructive and destructive conflict and to understand complexities nurses face during their interactions with other nurses, physicians and patients. The insight that constructive views are related to constructive processes provides an excellent opportunity for an educational intervention, so that we can educate nurses to analyse problems and learn how to manage conflict with effective collaborative processes. Keywords: constant comparative, construct conflict, destructive conflict, nurses
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Role conflict (5) Role conflict was simply defined as incompatible role expectations and was identified as an underlying cause for negative outcomes. One respondent stated: ‘The charge nurse felt that since there were more discharges, each nurse is ready to have an admission. The nurse felt that even though some of the patients have gone home, she is still busy with the rest of the patients. The charge nurse and the staff nurse did not have the same opinions.’
Discussion Participants’ perceptions of constructive conflict are all related to a central theme of constructive process. Conflict interaction that maintains a central focus on quality patient care and cooperative communication seems to contribute primarily to a perception of the conflict as constructive in nature, contributing to improved job satisfaction (De Dreu & Weingart 2003). This is consistent with Forsyth and McKenzie (2006) conclusion that nurses’ job satisfaction is highly correlated with their ability to provide comprehensive patient care. The results of the present analysis reveal that when nurses have a conflict that centres on patient care, they are more likely to view their conflict constructively or to express understanding of other persons. Mahon and Nicotera (2011) explained that nurses are taught to receive information and understand the patient’s situation. The existence of multiple roles in nursing has long been assumed to improve patient care, but this has not been demonstrated heretofore. Our data describe a work environment, where statistically significant power differentials are present and having a negative impact on patient care. Further exploration of how power differentials could be better managed to improve patient care is warranted. Many responses indicated that the perception of conflict as constructive is rooted in the perception that the central issue was resolved through communication. Deutsch (1973) argued that a cooperative process allows for open and honest communicating that enables the communicators to gain a more meaningful and accurate description of the conflict they are facing. This underscores the importance of open and direct communication in nursing communities. Collaboration and problem-solving, especially in interdepartmental conflict, are also consistent with an underlying © 2015 John Wiley & Sons Ltd
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theme of patient care as common concern and cooperative interaction for conflicts seen as constructive. As Rahim (2001) discussed, one of the constructive conflict outcomes is that alternative solutions to a problem may be found. Problem-solving involves identifying and removing the cause of the conflict to make the situation normal again. When nurses discover the problem and attempt to solve it through directly confronting conflict, this can minimize the likelihood of potential conflicts in the future. Last, time constraints emerge as a source of destructive conflict, with a constructive flip side. Nurses often experience extreme time demands and often work overtime (Shattell 2004, Lu 2008, Adriaenssens et al. 2015). However, when nurses are able to coordinate their schedules effectively through collaboration and cooperative communication, they consider their conflicts constructive. The central underlying theme in nurses’ perceptions of destructive conflict seems to be rooted in the work environment and patient outcomes. Issues such as time constraints, role conflict and power differences that are not managed with good communication arise as key contributors to destructive conflict. When these issues result in poor medical outcomes, such as a medication error, their destructiveness can be quite literal. When nurses label a conflict as related to a poor patient medical outcome, they are more likely to perceive such conflict as destructive. Lammers et al. (2003) described the dual hierarchy in hospitals: ‘Physicians are organized in one hierarchical staff and other hospital personnel – including nurses and other departments and staff – are organized in a second chain of command’ (p. 327). The dynamics of role negotiation are therefore ongoing and complex. The constant negotiation of power between a physician and nurse is one of many factors that can lead to organizational and/or interpersonal conflict. Programs such as TeamSTEPPS, which have been implemented in a variety of healthcare settings, have begun to address these issues through teaching strategies to manage interdisciplinary conflict and promote effective communication, thus increasing patient safety. One of the skills taught in the program is to encourage team members to speak up, when they are not comfortable with the plan of care for the patient (Agency for Healthcare Research & Quality 2013). In addition to power differences between doctors and nurses, power differences between nurses were other aspects of destructive conflict. Johnson (2009) argued that the most complex power differentials are between nurses. There is a cliche that nurses eat their young. This phrase refers to what researchers have identified as horizontal violence or bullying between nurses (Farrell 2001). In addition, con2079
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flicts with patients and/or their family members are complicated by the dynamics of that patient–provider relationship at the centre of multiple providers, all with relationships and power differentials among themselves. Davidson et al. (1997) found that associated problems, including low autonomy, poor communication and increasing workloads, are common sources of nurses’ conflicts. As Nicotera and Clinkscales (2003) described, nurses are often involved in negative communication exchanges, or conflicts, between a host of individuals including physicians, patients and peer nurses. Often these conflicts result in immobilization as nurses seek to satisfy each requirement placed on them (Nicotera et al. 2003). In working to fulfil competing job demands, nurses can find themselves unable to set or achieve attainable goals, thus continuing the negative spiral of conflict (Nicotera et al. 2003). Finally, poor conflict management was one of the aspects of destructive conflict. Conflicts perceived as destructive were rooted in workplace constraints that were not managed with cooperative communication and then resulted in poor medical outcomes. This is consistent with previous research identifying nurses as conflict avoidant (Mahon & Nicotera 2011).
Comparison of constructive and destructive conflict The analysis in this article revealed similar themes in both constructive and destructive conflict. First, patient care (medical outcomes) emerged as a theme in both. The distinction is that between process and outcome. As a constructive conflict characterization, patient care may be viewed as a process theme. Maintaining a focus on patient care as part of the conflict management process was present in the constructive and the destructive examples. The characterization of a conflict as destructive is described when there is a poor medical outcome for the patient. While these outcomes are also highly related to role demands, such as time constraints, it is not the process that nurses highlight in the patient care theme in perceptions of conflict as destructive, but the outcome, or what was viewed as having a negative impact on the patient. The themes coordination and time constraints also emerged in both constructive and destructive conflict. When they are able to coordinate effectively with peer nurses and nurse managers during the process of conflict management, nurses are more likely to view this conflict as constructive. When they cannot, the conflict is characterized as destructive. Farrell (2001) claimed that some of dysfunctional conflict can be attributed to nurses’ heavy workload, which requires that they complete several tasks within a certain 2080
timeframe. Nurses unable to complete their tasks in their shift may become unpleasant with coworkers. Last, communication was present in both characterizations, in an interesting interplay between process and outcome. Conflicts are seen as constructive when the communication process is viewed as resolving issues. However, validating the observation that nurses believe that directly communicating about conflicts is unprofessional (Mahon & Nicotera 2011), a lack of communication leading to a perpetuation of unresolved issues leads nurses to perceive these conflicts as destructive, deepening the perception that conflict is to be avoided. The data in the diaries used in this study clearly showed that the perception of conflicts as constructive or destructive is based not on the issues in dispute, but rather in how they are framed. Thus, it is important to examine how we might improve nurses’ perspectives about conflict in a positive way both in research and in practical settings.
Research implications It is important to study conflict from various disciplines such as communication and nursing to understand the various disciplinary presumptions. Researchers in communication and nursing view conflict quite differently. Most social science research on interpersonal health relationships focuses on physician-patient dyads; nursing research usually focuses on the nurse–physician relationship (Rosenstein 2002, Labrie & Schulz 2014). Little research has investigated the impact of conflict in nursing relationships/communication or the ways where that conflict is managed. Thus, it is necessary to examine nurse-nurse relationships in depth in future research.
Practical implications A nurse’s success depends on quality communication and successful conflict management. In nursing, communication theory education should be integrated in practice settings to generate a culture that recognizes constructive conflict and values direct communicative confrontations in conflict issues to achieve productive conflict management. Mahon and Nicotera (2011) suggested, however, that mere education does not change practice; practice is likely to change if nurses understand the theory behind the practice and have regular models of colleagues demonstrating the new behaviours. For instance, training involving simulated patients, reflective exercises and role-play may be useful. In future studies, nurses could be given case studies of conflict situations illustrating the destructive categories that we identi© 2015 John Wiley & Sons Ltd
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fied and be asked to work through what makes the conflict healthy vs. unhealthy. Thus, if training is offered in practice settings, nurses will be able to watch others work through conflict, thereby gaining an observation-based appreciation for the positive results of good conflict management. Educating nurses how to handle conflict is imperative for promoting constructive conflict management, at the same time dispelling the notion that conflict is negative by nature and fostering the opportunities for growth and critical thinking engendered by well-managed conflict. Nurses will benefit from understanding that conflict avoidance is poor conflict management that will likely serve only to perpetuate negativity. Thorough training in the nature of conflict as understood by social and organizational scientists may go a long way to creating a cultural shift in attitudes. Fostering open communication about the hardships of nursing (time constraints, role concerns, etc.) could encourage more successful group coping. Even when a mutually agreeable solution is not reached, a cooperative process builds the relationship and improves group functioning. These fundamental principles are the same as those that underlie Crucial Conversations (CC) training (Patterson et al. 2002), which is highly valued in nursing. CC teaches people to approach, rather than avoid, interactions on important issues and to focus on goals. A crucial conversation engenders strong emotions and divergent opinions. ‘Crucial conversations promote inclusivity, encourage broad participation, address emotional dimensions, create a safe environment and maintain respect for others’ emotions, beliefs and experiences. From a communication theory perspective, the benefits of CC training are well grounded’ (Nicotera et al. 2014, p. 256). However, the nursing literature has not drawn all the necessary connections between CC and how to best understand and manage conflict.
Limitations Despite gaining valuable knowledge about conflict issues that happen between and among nurses, physicians, patients and their family, this study has some limitations. First, the sample is not representative of the diverse nursing workplace as it represents mostly White nurses and only one male nurse. Second, the sample was a convenience sample of nurses enrolled in a continuing education course about nurses’ conflict, so they may personally have a greater interest in conflict than the general nursing population. Although the nurses did represent a range of specialties, the findings have limited generalizability. © 2015 John Wiley & Sons Ltd
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Conclusion This article helps to identify nursing perceptions of constructive and destructive conflict and to understand complexities nurses face during their interactions with other nurses, physicians and patients. The insight that constructive views are related to constructive processes provides an excellent opportunity for an educational intervention. Nurses in this study framed conflict positively based on process and negatively based on outcome. Despite some limitations, this paper presents valuable information to integrate communication perspectives in nursing, so that we can improve the nurses’ ability to analyse problems and learn how to manage conflict with effective collaborative processes. Hence, we may be able to effect a culture change that allows nurses to perceive that conflict can be healthy and even beneficial when managed productively.
Funding This study was funded by the Mason-Inova Partnership Initiative and by the American Organization of Nurse Executives.
Conflict of interest The authors declare that they have no conflict of interest.
Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:
• •
substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.
References Abrahamson K., Jill Suitor J. & Pillemer K. (2009) Conflict between nursing home staff and residents’ families: does it increase burnout? Journal of Aging and Health 21, 895–912. Adriaenssens J., De Gucht V. & Maes S. (2015) Determinants and prevalence of burnout in emergency nurses: a systematic review of 25 years of research. International Journal of Nursing Studies 52(2), 649–661. Agency for Healthcare Research and Quality (2013) TeamSTEPPS: National Implementation. Retrieved from http://teamstepps. ahrq.gov/about-2cl_3.htm on 31 July 2014. American Association of Critical-Care Nurses (2005) AACN standards for establishing and sustaining healthy work 2081
W. Kim et al. environments: a journey to excellence. American Journal of Critical Care 14, 187–197. Apker J., Propp K.M. & Zabava Ford W.S. (2009) Investigating the effect of nurse–team communication on nurse turnover: relationships among communication processes, identification and intent to leave. Health Communication 24, 106–114. Azoulay E., Timsit J.F., Sprung C.L., Soares M., Rusinova K., Lafabrie A., Abizanda R., Svantesson M., Rubulotta F., Ricou B., Heyland D., Joynt G., Francßais A., Azeivedo-Maia P., Owczuk R., Benbenishty J., de Vita M., Valentin A., Ksomos A., Cohen S., Kompan L., Ho K., Abroug F., Kaarlola A., Gerlach H., Kyprianou T., Michalsen A., Chevret S. & Schlemmer B. (2009) Prevalence and factors of intensive care unit conflicts: the conflicus study. American Journal of Respiratory and Critical Care Medicine 180, 853–860. Center for American Nurses (2008) Lateral Violence and Bullying in the Workplace. Retrieved from http://web.archive.org/web/20 081003022807/http://www.centerforamericannurses.org/display common.cfm?an=1&subarticlenbr=32 on 31 July 2014. Coomber B. & Louise Barriball K. (2007) Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature. International Journal of Nursing Studies 44, 297–314. Corbin J. & Strauss A. (2008) Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage, Newbury Park, CA. Davidson H., Folcarelli P.H., Crawford S., Duprat L.J. & Clifford J.C. (1997) The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses. Medical Care 35, 634–645. De Clercq D., Thongpapanl N. & Dimov D. (2009) When good conflict gets better and bad conflict becomes worse: the role of social capital in the conflict–innovation relationship. Journal of the Academy of Marketing Science 37, 283–297. De Dreu C.K.W. & Weingart L.R. (2003) Task versus relationship conflict, team performance and team member satisfaction: a meta-analysis. Journal of Applied Psychology 88, 741–749. Deutsch M. (1973) Conflicts: productive and destructive. Conflict Resolution through Communication 25, 155. Deutsch M., Coleman P.T. & Marcus E.C. (2011) The Handbook of Conflict Resolution: Theory and Practice. John Wiley & Sons, New York, NY. Farrell G.A. (2001) From tall poppies to squashed weeds*: why don’t nurses pull together more? Journal of Advanced Nursing 35, 26–33. Folger J.P., Poole M.S. & Stutman R.K. (2005) Working through Conflict: Strategies for Relationships, Groups and Organizations, 5th edn. Allyn & Bacon, New York, NY. Fontaine D.K. & Gerardi D. (2005) Healthier hospitals? Nursing Management 36, 34–44. Forsyth S. & McKenzie H. (2006) A comparative analysis of contemporary nurses’ discontents. Journal of Advanced Nursing 56, 209–216. Gross M.A., Guerrero L.K. & Alberts J.K. (2004) Perceptions of conflict strategies and communication competence in task-oriented dyads. Journal of Applied Communication Research 32, 249–270. Hahn J. (2009) Effectively manage a multigenerational staff. Nursing Management 40, 8–10.
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Hutchinson M., Wilkes L., Vickers M. & Jackson D. (2008) The development and validation of a bullying inventory for the nursing workplace. Nurse Researcher 15, 19–29. Johnson S.L. (2009) International perspectives on workplace bullying among nurses: a review. International Nursing Review 56(1), 34–40. Joint Commission (2002) Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Retrieved from http://www.jointcommission.org/NR/rdonlyres/5C138711-ED764D6F-909F-B06E0309F36D/0/health_care_at_the_crossroads.pdf on 04 December 2007. Kelly J. (2006) An overview of conflict. Dimensions of Critical Care Nursing 25, 22–28. Labrie N. & Schulz P.J. (2014) Does Argumentation matter? A systematic literature review on the role of argumentation in doctor–patient communication. Health Communication 29, 996–1008. Lammers J.C., Barbour J.B. & Duggan A.P. (2003) Organizational forms of the provision of health care: an institutional perspective. In The Handbook of Health Communication (Thompson T., Dorsey A., Miller K. & Parrott R., ed.) Mahwah, NJ, pp. 319– 345. Lu J.L. (2008) Occupational hazards and illnesses of filipino women workers in export processing zones. International Journal of Occupational Safety and Ergonomics 14, 333–342. Mahon M.M. & Nicotera A.M. (2011) Nursing and conflict communication: avoidance as preferred strategy. Nursing Administration Quarterly 35, 152–163. McKenna B.G., Smith N.A., Poole S.J. & Coverdale J.H. (2003) Horizontal violence: experiences of registered nurses in their first year of practice. Journal of Advanced Nursing 42, 90–96. Milton C.L. (2009) Leadership and ethics in nurse-nurse relationships. Nursing Science Quarterly 22, 116–119. Nicotera A.M. & Clinkscales M.J. (2003) Understanding Organization Through Culture and Structure: Relational and Other Lessons from the African-American Organization. LEA, Mahwah, NJ. Nicotera A.M. & Dorsey L.K. (2006) Individual and interactive processes in organizational conflict. In The Sage Handbook of Conflict Communication: Integrating Theory, Research and Practice (Oetzel J. & Ting-Toomey S., ed.), Thousand Oaks, CA, pp. 293–325. Nicotera A.M. & Mahon M.M. (2013) Exploring the impact of structurational divergence in nursing. Management Communication Quarterly 27, 90–120. Nicotera A.M., Clinkscales M.J. & Walker F.R. (2003) Understanding Organization through Culture and Structure: Relational and Other Lessons from the African American Organization. Routledge, Mahwah, NJ. Nicotera A.M., Mahon M.M. & Zhao X. (2010) Conceptualization and measurement of structurational divergence in the healthcare setting. Journal of Applied Communication Research 38, 362–385. Nicotera A.M., Mahon M.M. & Wright K.B. (2014) Communication that builds teams: assessing a nursing conflict intervention. Nursing Administration Quarterly 38, 248–260. Nicotera A.M., Zhao X., Mahon M.M., Peterson E., Kim W. & Conway-Morana P. (2015) Structurational divergence theory as
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Rosenstein A.H. (2002) Nurse-physician relationships: impact on nurse satisfaction and retention. AJN The American Journal of Nursing 102(6), 26–34. Shattell M. (2004) Nurse–patient interaction: a review of the literature. Journal of Clinical Nursing 13, 714–722. Song X.M., Dyer B. & Thieme R.J. (2006) Conflict management and innovation performance: an integrated contingency perspective. Journal of the Academy of Marketing Science 34, 341–356. Strauss A. & Corbin J. (1990) Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Sage Publications, Newbury Park, CA.
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Nurses’ perceptions of conflict as constructive or destructive Wonsun (Sunny) Kim, Anne M. Nicotera & Julie McNulty Accepted for publication 17 March 2015
Correspondence to S. Kim: e-mail: [email protected] Wonsun (Sunny) Kim PhD Assistant Professor College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA Anne M. Nicotera PhD Chair Department of Communication, George Mason University, Fairfax, Virginia, USA Julie McNulty PhD RN CPHQ Francis Fellow in Bio-behavior Oncology College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
K I M W . , N I C O T E R A A . M . & M C N U L T Y J . ( 2 0 1 5 ) Nurses’ perceptions of conflict as constructive or destructive. Journal of Advanced Nursing 71(9), 2073– 2083. doi: 10.1111/jan.12672
Abstract Aims. The aim of this study was to examine nurses’ perceptions of constructive and destructive conflicts and their management among nurses. Background. Conflict among nurses is common and has been associated with lack of collaboration, lack of communication and disruptive behaviour, with the potential to have negative impact teamwork. However, unlike the broader social science literature, positive views of conflict are scarce in the nursing literature. Given the various functions of conflict and the high stakes of ineffective conflict management in nursing, it is necessary to examine how nurses understand both sides of conflict: constructive and destructive. Design. A qualitative descriptive design. Methods. Data were collected from 34 full time nurses as part of a conflict skills training course offered over 6 months beginning in October 2009. Each participant was asked to write a weekly journal about conflicts in his/her work place. Result. Data yielded 163 entries (82 classified as constructive and 81 as destructive). Results showed that quality patient care and cooperative communication contributed to the perception that conflict is constructive in nature. The central underlying themes in nurses’ perceptions of destructive conflict were time constraints, role conflict and power differences that are not managed through communication. Conclusion. This article helps to identify nursing perceptions of constructive and destructive conflict and to understand complexities nurses face during their interactions with other nurses, physicians and patients. The insight that constructive views are related to constructive processes provides an excellent opportunity for an educational intervention, so that we can educate nurses to analyse problems and learn how to manage conflict with effective collaborative processes. Keywords: constant comparative, construct conflict, destructive conflict, nurses
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Why is this research or review needed? • Social scientists have long argued that conflict is inevitable and, when managed productively, is an important source of critical thinking, good decision-making and innovation. • Although some nursing research has examined important conflict-related problems, nurses’ perception of the fundamental nature of conflict has not been well studied. • Given the various functions of conflict and the high stakes of ineffective conflict management in nursing, it is necessary to examine how nurses understand both sides of conflict: constructive and destructive.
What are the key findings? • Conflict interaction that maintains a central focus on quality patient care and cooperative communication contributed primarily to
a perception of the conflict as
constructive in nature. • The perception of conflict as constructive was rooted in the perception that the central issue was resolved through communication. • The central underlying theme in nurses’ perceptions of destructive conflict was rooted in the work environment and patient outcome. Issues such as time constraints, role conflict and power differences that are not managed with good communication arise as key contributors to destructive conflict.
How should the findings be used to influence policy/ practice/research/education? • Understanding nurses’ constructive and destructive perceptions of conflict should help shape questions to examine
source of critical thinking, good decision-making and innovation (Putnam & Poole 1987, De Dreu & Weingart 2003, Song et al. 2006, De Clercq et al. 2009). When not managed appropriately, however, conflict elicits negative and damaging behaviour. ‘Intimidating and disruptive behaviors’ have been reported across health professions (Joint Commission 2002, p 3). In a position statement, ‘Lateral Violence and Bullying in the Workplace,’ the Center for American Nurses (2008) claimed that disruptive behaviour ‘interferes with effective communication . . . and negatively impacts performance and outcomes’ (p. 2). These workplace climate factors have been linked closely to recruitment and retention problems for the nursing profession (Coomber & Louise Barriball 2007, Apker et al. 2009). The American Association of Critical Care Nurses Healthy Work Environment standards include skilled communication as a critical element and consider communication just as important as clinical skills (American Association of Critical-Care Nurses 2005). Successful management of conflict depends on two basic factors: the recognition that conflict is an opportunity for productive growth and the ability to fruitfully confront issues in a socially constructive manner (Gross et al. 2004). However, Mahon and Nicotera (2011) documented a tendency among nurses to be conflict-avoidant, including a belief that directly discussing conflict with the other person is ‘unprofessional’ (p. 160). Given the long history in social science and communication theory, which teaches precisely the opposite, examining nurses’ perceptions of conflict as constructive and/or destructive is warranted.
nurse-nurse relationships in depth in future research. • Educating nurses about more conceptually rich ways of defining conflict and more productive ways of managing it is imperative for promoting constructive conflict management.
Introduction Nursing professionals face numerous challenges, including cost constraints and concerns, patient and staff safety concerns and a wide range of nursing role conflicts and overload in the same practice setting. The nursing workplace is unpredictable, highly dynamic and complicated by the fact that a nurse often juggles multiple roles at once. Nurses must respond as all of these factors lead to conflicts within and between professions (Mahon & Nicotera 2011). Social scientists have long argued that conflict is inevitable and, when managed productively, is an important 2074
Background Conflict and communication Conflict is inevitable in any organization because of incompatible goals, needs, responsibilities and values, among other fundamental differences in perception. Conflict is conceptualized by communication scholars as ‘the interaction of interdependent people who perceive the opposition of goals, aims and/or values and who see the other party as potentially interfering with the realization of these goals’ (Putnam & Poole 1987, p. 552). Folger et al. (2005) argued that members in organizations engage in communication to deal with conflicts and accomplish their tasks through conflict. When conflicts are managed directly and constructively, they contribute to workers’ ability to accomplish tasks (Nicotera & Dorsey 2006). In organizational settings, a moderate amount of conflict, handled in a constructive manner, is necessary for attaining and keeping an optimum level of organizational effectiveness. When not handled con© 2015 John Wiley & Sons Ltd
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structively, conflict can increase stress and decrease productivity for employees and decrease the quality of services provided (Rahim 2001). Conflict in nursing Conflict among nurses is common and has been associated with lack of collaboration, lack of communication and disruptive behaviour, with the potential to have negative impact teamwork (Joint Commission 2002, Fontaine & Gerardi 2005). However, unlike the broader social science literature, positive views of conflict are scarce in the nursing literature. Conflict itself is generally described as negative in nursing (Kelly 2006, Hahn 2009, Milton 2009). Poor conflict outcomes are often a serious issue in any healthcare setting (Abrahamson et al. 2009, Azoulay et al. 2009). However, the conflation of conflict itself with poor conflict outcomes, is likely associated with ineffective conflict management, severely limits our understanding of conflict in nursing. In nursing research, conflict is most often illustrated as adversarial due to general differences (Hahn 2009), relationships between management/staff (Kelly 2006), nurse/physicians (Azoulay et al. 2009) or nurse/family (Abrahamson et al. 2009). These dichotomous perspectives perpetuate an ‘us vs. them environment where conflict resolution is attempted in an unalterably adversarial environment’ (Mahon & Nicotera 2011, p. 153). In addition, conflict is also frequently illustrated as a personality function (Northam 2009). These approaches hinder the opportunity for growth and critical issue resolution. McKenna et al. (2003) found that ‘overt interpersonal conflict’ (p. 93) was a common experience for RNs in their first year of practice. Overt interpersonal conflict was described by 34% of the first-year nurses; 38% reported ‘distress about conflict’ (McKenna et al. 2003, p. 94). The most common conflict management strategy used in nursing is avoidance or withdrawal (Kelly 2006, Northam 2009, Mahon & Nicotera 2011). Mahon and Nicotera (2011) found that such avoidance is directly related to a view of conflict as inherently negative. However, among communication theorists and other social scientists, conflict avoidance is widely regarded as ineffective and potentially damaging to interpersonal relationships. Constructive vs. destructive conflict Here, we take the stance that conflict is neither inherently positive nor negative; the distinction between constructive and destructive conflict lies in how the conflict is managed to produce positive or negative results. The constructive or destructive characterization of conflict can thus be made based on process or outcome. Constructive outcomes include innovation and growth; improved decision-making; discov© 2015 John Wiley & Sons Ltd
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ery of synergized solutions to common problems; enhanced individual and group performance; searching for new approaches by individuals and groups. Destructive conflict outcomes include job stress, burnout and dissatisfaction; reduced communication between individuals and groups; a climate of distrust and suspicion; damaged relationships and reduced job performance. These constructive and destructive outcomes result from constructive and destructive processes, respectively, not from the natural and inevitable occurrence of a conflict in itself (Deutsch 1973, Deutsch et al. 2011). According to Deutsch (1973), in a destructive conflict process, individuals compete, trying to defeat others and ultimately win. In a constructive conflict, individuals cooperate, are interested in reaching an agreeable outcome and maintain understanding of their ongoing interdependence. A cooperative process allows for the open and honest communicating that enables a meaningful and accurate description of the conflict. Individuals can combine information and reduce misunderstandings, confusion and mistrust. A cooperative process encourages the search for mutually beneficial solutions because the parties have a better understanding of each other’s needs and their interdependence.
Research question This qualitative descriptive study seeks to identify nurses’ perceptions of constructive and destructive conflict in the workplace. Research reports are rife with descriptions of various facets of nurses’ hostile work environments; perhaps this is due, in part, to their presumption that conflict is by nature a destructive force. Understanding how nurses perceive conflicts as constructive or destructive will help to shed light on this thorny problem. Thus, the following research question is advanced: What perceptions do nurses have about constructive and destructive aspects of conflict?
The study This study used the constant comparative approach to examine diary data gathered as part of a training course designed to help nurses gain skills in conflict management.
Aim The aim of this study was to examine nurses’ descriptions of conflicts that they characterize as ‘constructive’ and ‘destructive’, to more deeply understand common meanings for conflict and its management among nurses. Although some nursing research has examined important conflict2075
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related problems (Coomber & Louise Barriball 2007, Hutchinson et al. 2008), nurses’ perceptions of the fundamental nature of conflict has not been well studied.
Design This study was a descriptive, qualitative diary of conflict experiences in a work place and is part of a larger study that assessed troublesome outcomes in nursing communication and the effectiveness of the training course to reduce nursing workplace conflict. Data for the larger study were collected between September 2009–April 2010. (Nicotera et al. 2010, Nicotera & Mahon 2013, Nicotera et al. 2015).
Sample/participants All participants had been full-time hospital-based nurses for at least 1 year. Participants were recruited by distributing fliers in several healthcare systems and nursing school graduate-level courses in a major metropolitan area. Roles of participants included staff nurses, charge nurses and nurse managers from a variety of settings and specialties.
Data collection Five small groups of registered nurses (N = 34) each attended six monthly 90-minute sessions. Between the first and second monthly sessions, each participant was asked to write a weekly journal about conflicts in his/her work place. There were four specific questions: (1) describe a constructive conflict you have experienced in your work place this week; (2) what made it constructive?; (3) describe a destructive conflict you have experienced in your work place this week and (4) what made it destructive? The data were collected using a web-based survey program (surveymonkey.com). The survey yielded 163 replies (82 classified as constructive and 81 as destructive).
Ethical considerations This research was generated by an interdisciplinary research team at a large research university. The institution’s Human Subjects Research Board reviewed and approved the study. The university provided an internal grant for the training program’s development. Nurses enrolled in the course for no fee and were paid only for parking.
Data analysis Textual data from the journals were subjected to thematic analysis using the constant comparative method (Corbin & Strauss 2008). First, each response to each question was 2076
treated as a unique unit. These units were then divided into two groups, constructive and destructive. Each group of data was then subjected to open coding, ‘the process of breaking down, examining, comparing, conceptualizing and categorizing data’ (Strauss & Corbin 1990, p. 61). For the first stage, the researchers studied all responses to acquire familiarity with the text and gain understanding from the data without written notes. After that, the text was reread in the order as initially listed, without placement into categories. The researchers drew on tacit knowledge in making these initial judgments for early category formulation. The categories are then named and a description written for each. These categories (and their corresponding descriptions) are then compared in the same fashion to collapse the categories, repeating until no more reduction in categories can be accomplished. As the data analysis progressed, the researchers were able to easily combine and define categories based on overlying themes. Once the categories emerged, fewer modifications were required as more data were processed. Delimiting of the construction occurred as the data sources became saturated and the categories were integrated. The final conceptual definitions for each category are included in Tables 1 and 2. Once formed, the categories can be treated as codes applied to each individual unit of data.
Rigour Two qualitative researchers independently coded the units using the categories generated and determined if they arrived at the same codes. We compared the sets of codes that each coder assigned to each of the 163 responses. A response was considered to be coded the same only if both coders used the identical set of codes. The results showed that 98 (601%) of the 163 responses were coded the same by both coders. By discussing the reasons for their disagreements, the two coders were able to identify and correct
Table 1 Categories and definitions of constructive conflict. Category
Conceptual definition
Problem-solving Collaboration
Finding and solving the problem Collaborate with other teams or other nurses to resolve a conflict Manage schedule effectively Conveying messages, thoughts and information through the communication which is a way to gain understanding Increased patient care
Coordination Communication
Patient care
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Table 2 Categories and definitions of destructive conflict. Category
Conceptual definition
Poor conflict managementSubcategory: direct confrontation, lack of communication Medical outcome
Manage their conflict ineffectively Confront conflicts in front of other people (in public) Lack of communication Conflicts affect patients’ medical outcome Conflicts between nurses and patients or patients’ family Limited time or shortage of nurses Conflicts occurred due to some unresolved personal conflict or fairness with previous relationships Conflicts happened from working with different team members or unit people Power differences between different nurses or between nurses and doctors Incompatible role expectations
Patients or their family Time constraints Relationships
Teamwork
Power differences Role conflicts
problems with the codes. The reasons for the discrepancies included problems such redundant codes for the same belief, vague code definitions and lack of mutual exclusivity between codes. After resolving the discrepancies, the two coders recoded the same 163 responses a final time. The final level of agreement between the two coders showed substantial improvement with 89% agreement. The two coders resolved any remaining intercoder discrepancies and coding was finalized.
Findings Demographical characteristics The sample consisted of 34 nurses (33 females, 1 male; mean age 441 years; 21 European Americans, three African Americans, one Latina, six Asian, one African and two unspecified). Time in nursing ranged from 2–40 years (mean = 192); time in the current position ranged from 6 months to 31 years (mean = 56 years). A variety of specialties were represented, in 24 inpatient settings. Eight participants had current or past experience as a nurse manager.
Constructive conflict themes Five themes emerged from the 82 entries that reflected constructive conflict (Table 1). The frequency of responses in each category is presented in parentheses.
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Problem-solving (10) Participants in this study often used conflict as a way to understand a problem and find a solution. One of the participants responded that ‘nurses involved in the discussion were actually trying to come up with solutions that distributed the responsibility more fairly. Instead of just complaining about the acknowledged flaws in the current situation, they believed that there was a solution.’ In another example, a participant stated, ‘Instead of just complaining about the paediatrician, we took his concern to heart and came up with a solution.’ Collaboration (12) In some cases, nurses felt that collaboration helped to resolve a conflict, allowing the individuals to combine their information and to reduce the opportunity of misunderstandings, confusion and mistrust. A sample response was, ‘By working on the different units you had a different perspective and respect for what the nurses on that unit experience in their workplace.’ Coordination (10) Coordination was identified in several responses as crucial for resolving the conflict constructively. In some cases, there was a scheduling problem about assigning shifts and holidays for nurses in a way that both respected the constraints of the nurses and fulfilled the objectives of the hospital. One respondent said: ‘We have been understaffed the last few weeks and not had the proper RN coverage to make certain safety.’ ‘I have had less patient assignments in my area and have been able to make the appropriate safety and equipment checks for the other units.’ Communication (24) A popular response concerning constructive conflict expressly highlighted the importance of communication in resolving conflict. Nurses conveyed messages, thoughts and information through communication and specified that communication was a way to achieve understanding of other nurses doctors’ and patients’ perceptions. One of the respondents stated: ‘One RN (A) from night shift had been complaining about another RN (B). RN B was also complaining about RN A behind his/her back to other people. Finally, they did talk one-on-one and they cleared the misunderstanding.’ Patient care (26) Several conflicts were labelled as constructive, because it led to a positive outcome for patient care due to the centrality of patient care to the nursing role. For example: ‘My charge
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Nurses’ perceptions of conflict as constructive or destructive Wonsun (Sunny) Kim, Anne M. Nicotera & Julie McNulty Accepted for publication 17 March 2015
Correspondence to S. Kim: e-mail: [email protected] Wonsun (Sunny) Kim PhD Assistant Professor College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA Anne M. Nicotera PhD Chair Department of Communication, George Mason University, Fairfax, Virginia, USA Julie McNulty PhD RN CPHQ Francis Fellow in Bio-behavior Oncology College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
K I M W . , N I C O T E R A A . M . & M C N U L T Y J . ( 2 0 1 5 ) Nurses’ perceptions of conflict as constructive or destructive. Journal of Advanced Nursing 71(9), 2073– 2083. doi: 10.1111/jan.12672
Abstract Aims. The aim of this study was to examine nurses’ perceptions of constructive and destructive conflicts and their management among nurses. Background. Conflict among nurses is common and has been associated with lack of collaboration, lack of communication and disruptive behaviour, with the potential to have negative impact teamwork. However, unlike the broader social science literature, positive views of conflict are scarce in the nursing literature. Given the various functions of conflict and the high stakes of ineffective conflict management in nursing, it is necessary to examine how nurses understand both sides of conflict: constructive and destructive. Design. A qualitative descriptive design. Methods. Data were collected from 34 full time nurses as part of a conflict skills training course offered over 6 months beginning in October 2009. Each participant was asked to write a weekly journal about conflicts in his/her work place. Result. Data yielded 163 entries (82 classified as constructive and 81 as destructive). Results showed that quality patient care and cooperative communication contributed to the perception that conflict is constructive in nature. The central underlying themes in nurses’ perceptions of destructive conflict were time constraints, role conflict and power differences that are not managed through communication. Conclusion. This article helps to identify nursing perceptions of constructive and destructive conflict and to understand complexities nurses face during their interactions with other nurses, physicians and patients. The insight that constructive views are related to constructive processes provides an excellent opportunity for an educational intervention, so that we can educate nurses to analyse problems and learn how to manage conflict with effective collaborative processes. Keywords: constant comparative, construct conflict, destructive conflict, nurses
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JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE nurse is older and always has to have it her way. She proceeds to leave promptly at 3 pm regardless. She has done nothing and I need to take over from her work. Maybe I need to find a new job?
Role conflict (5) Role conflict was simply defined as incompatible role expectations and was identified as an underlying cause for negative outcomes. One respondent stated: ‘The charge nurse felt that since there were more discharges, each nurse is ready to have an admission. The nurse felt that even though some of the patients have gone home, she is still busy with the rest of the patients. The charge nurse and the staff nurse did not have the same opinions.’
Discussion Participants’ perceptions of constructive conflict are all related to a central theme of constructive process. Conflict interaction that maintains a central focus on quality patient care and cooperative communication seems to contribute primarily to a perception of the conflict as constructive in nature, contributing to improved job satisfaction (De Dreu & Weingart 2003). This is consistent with Forsyth and McKenzie (2006) conclusion that nurses’ job satisfaction is highly correlated with their ability to provide comprehensive patient care. The results of the present analysis reveal that when nurses have a conflict that centres on patient care, they are more likely to view their conflict constructively or to express understanding of other persons. Mahon and Nicotera (2011) explained that nurses are taught to receive information and understand the patient’s situation. The existence of multiple roles in nursing has long been assumed to improve patient care, but this has not been demonstrated heretofore. Our data describe a work environment, where statistically significant power differentials are present and having a negative impact on patient care. Further exploration of how power differentials could be better managed to improve patient care is warranted. Many responses indicated that the perception of conflict as constructive is rooted in the perception that the central issue was resolved through communication. Deutsch (1973) argued that a cooperative process allows for open and honest communicating that enables the communicators to gain a more meaningful and accurate description of the conflict they are facing. This underscores the importance of open and direct communication in nursing communities. Collaboration and problem-solving, especially in interdepartmental conflict, are also consistent with an underlying © 2015 John Wiley & Sons Ltd
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theme of patient care as common concern and cooperative interaction for conflicts seen as constructive. As Rahim (2001) discussed, one of the constructive conflict outcomes is that alternative solutions to a problem may be found. Problem-solving involves identifying and removing the cause of the conflict to make the situation normal again. When nurses discover the problem and attempt to solve it through directly confronting conflict, this can minimize the likelihood of potential conflicts in the future. Last, time constraints emerge as a source of destructive conflict, with a constructive flip side. Nurses often experience extreme time demands and often work overtime (Shattell 2004, Lu 2008, Adriaenssens et al. 2015). However, when nurses are able to coordinate their schedules effectively through collaboration and cooperative communication, they consider their conflicts constructive. The central underlying theme in nurses’ perceptions of destructive conflict seems to be rooted in the work environment and patient outcomes. Issues such as time constraints, role conflict and power differences that are not managed with good communication arise as key contributors to destructive conflict. When these issues result in poor medical outcomes, such as a medication error, their destructiveness can be quite literal. When nurses label a conflict as related to a poor patient medical outcome, they are more likely to perceive such conflict as destructive. Lammers et al. (2003) described the dual hierarchy in hospitals: ‘Physicians are organized in one hierarchical staff and other hospital personnel – including nurses and other departments and staff – are organized in a second chain of command’ (p. 327). The dynamics of role negotiation are therefore ongoing and complex. The constant negotiation of power between a physician and nurse is one of many factors that can lead to organizational and/or interpersonal conflict. Programs such as TeamSTEPPS, which have been implemented in a variety of healthcare settings, have begun to address these issues through teaching strategies to manage interdisciplinary conflict and promote effective communication, thus increasing patient safety. One of the skills taught in the program is to encourage team members to speak up, when they are not comfortable with the plan of care for the patient (Agency for Healthcare Research & Quality 2013). In addition to power differences between doctors and nurses, power differences between nurses were other aspects of destructive conflict. Johnson (2009) argued that the most complex power differentials are between nurses. There is a cliche that nurses eat their young. This phrase refers to what researchers have identified as horizontal violence or bullying between nurses (Farrell 2001). In addition, con2079
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flicts with patients and/or their family members are complicated by the dynamics of that patient–provider relationship at the centre of multiple providers, all with relationships and power differentials among themselves. Davidson et al. (1997) found that associated problems, including low autonomy, poor communication and increasing workloads, are common sources of nurses’ conflicts. As Nicotera and Clinkscales (2003) described, nurses are often involved in negative communication exchanges, or conflicts, between a host of individuals including physicians, patients and peer nurses. Often these conflicts result in immobilization as nurses seek to satisfy each requirement placed on them (Nicotera et al. 2003). In working to fulfil competing job demands, nurses can find themselves unable to set or achieve attainable goals, thus continuing the negative spiral of conflict (Nicotera et al. 2003). Finally, poor conflict management was one of the aspects of destructive conflict. Conflicts perceived as destructive were rooted in workplace constraints that were not managed with cooperative communication and then resulted in poor medical outcomes. This is consistent with previous research identifying nurses as conflict avoidant (Mahon & Nicotera 2011).
Comparison of constructive and destructive conflict The analysis in this article revealed similar themes in both constructive and destructive conflict. First, patient care (medical outcomes) emerged as a theme in both. The distinction is that between process and outcome. As a constructive conflict characterization, patient care may be viewed as a process theme. Maintaining a focus on patient care as part of the conflict management process was present in the constructive and the destructive examples. The characterization of a conflict as destructive is described when there is a poor medical outcome for the patient. While these outcomes are also highly related to role demands, such as time constraints, it is not the process that nurses highlight in the patient care theme in perceptions of conflict as destructive, but the outcome, or what was viewed as having a negative impact on the patient. The themes coordination and time constraints also emerged in both constructive and destructive conflict. When they are able to coordinate effectively with peer nurses and nurse managers during the process of conflict management, nurses are more likely to view this conflict as constructive. When they cannot, the conflict is characterized as destructive. Farrell (2001) claimed that some of dysfunctional conflict can be attributed to nurses’ heavy workload, which requires that they complete several tasks within a certain 2080
timeframe. Nurses unable to complete their tasks in their shift may become unpleasant with coworkers. Last, communication was present in both characterizations, in an interesting interplay between process and outcome. Conflicts are seen as constructive when the communication process is viewed as resolving issues. However, validating the observation that nurses believe that directly communicating about conflicts is unprofessional (Mahon & Nicotera 2011), a lack of communication leading to a perpetuation of unresolved issues leads nurses to perceive these conflicts as destructive, deepening the perception that conflict is to be avoided. The data in the diaries used in this study clearly showed that the perception of conflicts as constructive or destructive is based not on the issues in dispute, but rather in how they are framed. Thus, it is important to examine how we might improve nurses’ perspectives about conflict in a positive way both in research and in practical settings.
Research implications It is important to study conflict from various disciplines such as communication and nursing to understand the various disciplinary presumptions. Researchers in communication and nursing view conflict quite differently. Most social science research on interpersonal health relationships focuses on physician-patient dyads; nursing research usually focuses on the nurse–physician relationship (Rosenstein 2002, Labrie & Schulz 2014). Little research has investigated the impact of conflict in nursing relationships/communication or the ways where that conflict is managed. Thus, it is necessary to examine nurse-nurse relationships in depth in future research.
Practical implications A nurse’s success depends on quality communication and successful conflict management. In nursing, communication theory education should be integrated in practice settings to generate a culture that recognizes constructive conflict and values direct communicative confrontations in conflict issues to achieve productive conflict management. Mahon and Nicotera (2011) suggested, however, that mere education does not change practice; practice is likely to change if nurses understand the theory behind the practice and have regular models of colleagues demonstrating the new behaviours. For instance, training involving simulated patients, reflective exercises and role-play may be useful. In future studies, nurses could be given case studies of conflict situations illustrating the destructive categories that we identi© 2015 John Wiley & Sons Ltd
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fied and be asked to work through what makes the conflict healthy vs. unhealthy. Thus, if training is offered in practice settings, nurses will be able to watch others work through conflict, thereby gaining an observation-based appreciation for the positive results of good conflict management. Educating nurses how to handle conflict is imperative for promoting constructive conflict management, at the same time dispelling the notion that conflict is negative by nature and fostering the opportunities for growth and critical thinking engendered by well-managed conflict. Nurses will benefit from understanding that conflict avoidance is poor conflict management that will likely serve only to perpetuate negativity. Thorough training in the nature of conflict as understood by social and organizational scientists may go a long way to creating a cultural shift in attitudes. Fostering open communication about the hardships of nursing (time constraints, role concerns, etc.) could encourage more successful group coping. Even when a mutually agreeable solution is not reached, a cooperative process builds the relationship and improves group functioning. These fundamental principles are the same as those that underlie Crucial Conversations (CC) training (Patterson et al. 2002), which is highly valued in nursing. CC teaches people to approach, rather than avoid, interactions on important issues and to focus on goals. A crucial conversation engenders strong emotions and divergent opinions. ‘Crucial conversations promote inclusivity, encourage broad participation, address emotional dimensions, create a safe environment and maintain respect for others’ emotions, beliefs and experiences. From a communication theory perspective, the benefits of CC training are well grounded’ (Nicotera et al. 2014, p. 256). However, the nursing literature has not drawn all the necessary connections between CC and how to best understand and manage conflict.
Limitations Despite gaining valuable knowledge about conflict issues that happen between and among nurses, physicians, patients and their family, this study has some limitations. First, the sample is not representative of the diverse nursing workplace as it represents mostly White nurses and only one male nurse. Second, the sample was a convenience sample of nurses enrolled in a continuing education course about nurses’ conflict, so they may personally have a greater interest in conflict than the general nursing population. Although the nurses did represent a range of specialties, the findings have limited generalizability. © 2015 John Wiley & Sons Ltd
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Conclusion This article helps to identify nursing perceptions of constructive and destructive conflict and to understand complexities nurses face during their interactions with other nurses, physicians and patients. The insight that constructive views are related to constructive processes provides an excellent opportunity for an educational intervention. Nurses in this study framed conflict positively based on process and negatively based on outcome. Despite some limitations, this paper presents valuable information to integrate communication perspectives in nursing, so that we can improve the nurses’ ability to analyse problems and learn how to manage conflict with effective collaborative processes. Hence, we may be able to effect a culture change that allows nurses to perceive that conflict can be healthy and even beneficial when managed productively.
Funding This study was funded by the Mason-Inova Partnership Initiative and by the American Organization of Nurse Executives.
Conflict of interest The authors declare that they have no conflict of interest.
Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/recommendations/)]:
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substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.
References Abrahamson K., Jill Suitor J. & Pillemer K. (2009) Conflict between nursing home staff and residents’ families: does it increase burnout? Journal of Aging and Health 21, 895–912. Adriaenssens J., De Gucht V. & Maes S. (2015) Determinants and prevalence of burnout in emergency nurses: a systematic review of 25 years of research. International Journal of Nursing Studies 52(2), 649–661. Agency for Healthcare Research and Quality (2013) TeamSTEPPS: National Implementation. Retrieved from http://teamstepps. ahrq.gov/about-2cl_3.htm on 31 July 2014. American Association of Critical-Care Nurses (2005) AACN standards for establishing and sustaining healthy work 2081
W. Kim et al. environments: a journey to excellence. American Journal of Critical Care 14, 187–197. Apker J., Propp K.M. & Zabava Ford W.S. (2009) Investigating the effect of nurse–team communication on nurse turnover: relationships among communication processes, identification and intent to leave. Health Communication 24, 106–114. Azoulay E., Timsit J.F., Sprung C.L., Soares M., Rusinova K., Lafabrie A., Abizanda R., Svantesson M., Rubulotta F., Ricou B., Heyland D., Joynt G., Francßais A., Azeivedo-Maia P., Owczuk R., Benbenishty J., de Vita M., Valentin A., Ksomos A., Cohen S., Kompan L., Ho K., Abroug F., Kaarlola A., Gerlach H., Kyprianou T., Michalsen A., Chevret S. & Schlemmer B. (2009) Prevalence and factors of intensive care unit conflicts: the conflicus study. American Journal of Respiratory and Critical Care Medicine 180, 853–860. Center for American Nurses (2008) Lateral Violence and Bullying in the Workplace. Retrieved from http://web.archive.org/web/20 081003022807/http://www.centerforamericannurses.org/display common.cfm?an=1&subarticlenbr=32 on 31 July 2014. Coomber B. & Louise Barriball K. (2007) Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature. International Journal of Nursing Studies 44, 297–314. Corbin J. & Strauss A. (2008) Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Sage, Newbury Park, CA. Davidson H., Folcarelli P.H., Crawford S., Duprat L.J. & Clifford J.C. (1997) The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses. Medical Care 35, 634–645. De Clercq D., Thongpapanl N. & Dimov D. (2009) When good conflict gets better and bad conflict becomes worse: the role of social capital in the conflict–innovation relationship. Journal of the Academy of Marketing Science 37, 283–297. De Dreu C.K.W. & Weingart L.R. (2003) Task versus relationship conflict, team performance and team member satisfaction: a meta-analysis. Journal of Applied Psychology 88, 741–749. Deutsch M. (1973) Conflicts: productive and destructive. Conflict Resolution through Communication 25, 155. Deutsch M., Coleman P.T. & Marcus E.C. (2011) The Handbook of Conflict Resolution: Theory and Practice. John Wiley & Sons, New York, NY. Farrell G.A. (2001) From tall poppies to squashed weeds*: why don’t nurses pull together more? Journal of Advanced Nursing 35, 26–33. Folger J.P., Poole M.S. & Stutman R.K. (2005) Working through Conflict: Strategies for Relationships, Groups and Organizations, 5th edn. Allyn & Bacon, New York, NY. Fontaine D.K. & Gerardi D. (2005) Healthier hospitals? Nursing Management 36, 34–44. Forsyth S. & McKenzie H. (2006) A comparative analysis of contemporary nurses’ discontents. Journal of Advanced Nursing 56, 209–216. Gross M.A., Guerrero L.K. & Alberts J.K. (2004) Perceptions of conflict strategies and communication competence in task-oriented dyads. Journal of Applied Communication Research 32, 249–270. Hahn J. (2009) Effectively manage a multigenerational staff. Nursing Management 40, 8–10.
2082
Hutchinson M., Wilkes L., Vickers M. & Jackson D. (2008) The development and validation of a bullying inventory for the nursing workplace. Nurse Researcher 15, 19–29. Johnson S.L. (2009) International perspectives on workplace bullying among nurses: a review. International Nursing Review 56(1), 34–40. Joint Commission (2002) Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Retrieved from http://www.jointcommission.org/NR/rdonlyres/5C138711-ED764D6F-909F-B06E0309F36D/0/health_care_at_the_crossroads.pdf on 04 December 2007. Kelly J. (2006) An overview of conflict. Dimensions of Critical Care Nursing 25, 22–28. Labrie N. & Schulz P.J. (2014) Does Argumentation matter? A systematic literature review on the role of argumentation in doctor–patient communication. Health Communication 29, 996–1008. Lammers J.C., Barbour J.B. & Duggan A.P. (2003) Organizational forms of the provision of health care: an institutional perspective. In The Handbook of Health Communication (Thompson T., Dorsey A., Miller K. & Parrott R., ed.) Mahwah, NJ, pp. 319– 345. Lu J.L. (2008) Occupational hazards and illnesses of filipino women workers in export processing zones. International Journal of Occupational Safety and Ergonomics 14, 333–342. Mahon M.M. & Nicotera A.M. (2011) Nursing and conflict communication: avoidance as preferred strategy. Nursing Administration Quarterly 35, 152–163. McKenna B.G., Smith N.A., Poole S.J. & Coverdale J.H. (2003) Horizontal violence: experiences of registered nurses in their first year of practice. Journal of Advanced Nursing 42, 90–96. Milton C.L. (2009) Leadership and ethics in nurse-nurse relationships. Nursing Science Quarterly 22, 116–119. Nicotera A.M. & Clinkscales M.J. (2003) Understanding Organization Through Culture and Structure: Relational and Other Lessons from the African-American Organization. LEA, Mahwah, NJ. Nicotera A.M. & Dorsey L.K. (2006) Individual and interactive processes in organizational conflict. In The Sage Handbook of Conflict Communication: Integrating Theory, Research and Practice (Oetzel J. & Ting-Toomey S., ed.), Thousand Oaks, CA, pp. 293–325. Nicotera A.M. & Mahon M.M. (2013) Exploring the impact of structurational divergence in nursing. Management Communication Quarterly 27, 90–120. Nicotera A.M., Clinkscales M.J. & Walker F.R. (2003) Understanding Organization through Culture and Structure: Relational and Other Lessons from the African American Organization. Routledge, Mahwah, NJ. Nicotera A.M., Mahon M.M. & Zhao X. (2010) Conceptualization and measurement of structurational divergence in the healthcare setting. Journal of Applied Communication Research 38, 362–385. Nicotera A.M., Mahon M.M. & Wright K.B. (2014) Communication that builds teams: assessing a nursing conflict intervention. Nursing Administration Quarterly 38, 248–260. Nicotera A.M., Zhao X., Mahon M.M., Peterson E., Kim W. & Conway-Morana P. (2015) Structurational divergence theory as
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JAN: ORIGINAL RESEARCH: EMPIRICAL RESEARCH – QUALITATIVE explanation for troublesome outcomes in nursing communication. Health Communication 30, 371–384. Northam S. (2009) Conflict in the workplace: Part 1. The American Journal of Nursing 109, 70–73. Patterson K., Grenny J., McMillan R., Switzler A. & Covey S. (2002) Crucial Conversations, Tools for Talking when Stakes are high. Tata McGraw-Hill Education. McGraw-Hill, NY, New York. Putnam L.L. & Poole M.S. (1987) Conflict and negotiation. In Handbook of Organizational Communication (Jablin F.M., Putnam L.L., Roberts K.J. & Porter L.W., eds), Sage, Newbury Park, CA, pp. 549–599. Rahim M.A. (2001) Managing Conflict in Organizations, 3rd edn. Quorum Books, Westport, CT.
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Rosenstein A.H. (2002) Nurse-physician relationships: impact on nurse satisfaction and retention. AJN The American Journal of Nursing 102(6), 26–34. Shattell M. (2004) Nurse–patient interaction: a review of the literature. Journal of Clinical Nursing 13, 714–722. Song X.M., Dyer B. & Thieme R.J. (2006) Conflict management and innovation performance: an integrated contingency perspective. Journal of the Academy of Marketing Science 34, 341–356. Strauss A. & Corbin J. (1990) Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Sage Publications, Newbury Park, CA.
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