Managing RN/RN and RN/MD Conflict in the ICU
Managers are in a pivotal position to decrease conflict. By their response, or lack of response, they informally create the code of behavior for the unit. Staff are always watching: What did the manager do when the physician yelled at the nurse? What action did the manager take after a nurse complained that a coworker was sabotaging his or her reputation? The way these challenges are addressed on a daily basis not only forms the code of behavior, but essentially governs the way staff address conflict on the unit.
Significant research exists to confirm the damage caused by relationship conflict in healthcare; particularly aggression, verbal abuse, and horizontal hostility among nurses. Relationship conflict affects morale, satisfaction and quality of care. Nurses who report the highest degree of conflict also experience the highest degree of burnout (Hillhouse). This data is no surprise to managers who spend 30-40% of their workday dealing with some form of workplace conflict (Thomas). Because resolving the quarrels that result from poor relationships can be exhausting and time consuming, many managers tend to ignore nurse-to-nurse conflict, or act like a third party and negotiate compromise in order to end an energy-draining situation quickly. But neither of these strategies is effective. What is the best way to manage nurse-to-nurse and nurse-to-physician conflict in the ICU?
Horizontal behaviors can be overt or covert and are extremely hurtful. Gestures such as raised eyebrows, cliques, sarcasm and eye-rolling have a profound and detrimental effect on teamwork, retention, quality, safety and satisfaction and are the source of much conflict. Unfortunately, in the culture of nursing, these behaviors are viewed as “normal”. Nurses simply do not recognize the tremendous impact of hostile behaviors on their self-esteem or performance - nor do most nurses possess the skill set necessary to confront each other.
Since the most common communication style of nurses is passive-aggressive, and the most common way nurses deal with conflict is avoidance (Forte), nurse-to-nurse conflict is seldom resolved in the workplace. Instead, it runs underground – undermining the very relationship bonds that are the foundation of a healthy workplace. Therefore, the responsibility to constructively deal with conflict falls to the unit manager to demonstrate and create the healthy relationships that are mandatory in today’s complex and fast paced healthcare setting. In addition, when workplace pressure escalates, people tend to revert back to their old styles of communicating – even if they have been given the tools to communicate effectively. Monitoring the conversational health of the unit requires constant vigilance.
One of the most vulnerable populations is new nurses, of which up to 60% leave their first position within the first 6 months specifically because of some form of lateral violence. In a global nursing shortage, this statistic is particularly disheartening. However, research shows that knowledge of horizontal hostility allows new grads to depersonalize the attack and continue to learn (Griffin). The key is awareness.
Solutions to Reduce Nurse-to-Nurse Conflict
The first step in creating healthy work place relationships is to point out the behaviors that are unacceptable to staff. In order to successfully change the culture of a unit, the manager must set a new standard and then hold staff accountable to that standard. It’s not easy to pay attention, act upon, and follow-up with staff who roll their eyes, make sarcastic comments (or otherwise alienate co-workers) when you’re juggling so many other priorities. And it takes time and consistency to alter the current nursing culture. But “unmanaged conflict results in the high costs of personnel turnover, absenteeism, loss of productivity, and in some instances, loss of life” (Haraway). Clearly, investing in a campaign to end negative and destructive behaviors has a tremendous payoff: retention, healthy relationships, and cohesive teams.
What works? Managers who encourage nurses to resolve their own issues and who provide education on communication and confrontation skills will find that the investment far exceeds their expectations. A major cause of conflict is a sense of powerlessness (“That’s the way it is around here”, “Nothing will change” attitude). Consistent with the oppression theory, staff who lack authority or power will act out their frustrations toward each other. In response, the most important action a nurse manager can take is to empower staff to take care of their own relationships, as well as the quality and safety of the workplace.
To do this, nurses will need assertive communication skills. Because managers are not omnipresent, it is critical to first ensure that head nurses possess the skills and tools they need to feel confident in confronting conflict on the unit before initiating staff education. Then, provide education on conflict-management and assertive communication for staff (or incorporate these classes as part of a staff education day.) Post a flyer which defines horizontal hostility and reminds staff of the behaviors that are unacceptable. If a staff member comes to you for help in resolving an issue, offer to role-play the conversation and provide coaching – but set the expectation that THEY will be solving the problem and that your role is supportive. Another proven strategy is to ask staff to develop a unit based philosophy which clearly states unit behavioral standards. No where is guidance more needed than in leading staff to realize that they themselves have the power and ability to create a work environment where every single team member is valued, appreciated and acknowledged.
One of the most effective strategies in dealing with nurse to nurse conflict has been to teach staff about the role of the “silent witness”. As one nurse recently realized, “I’ve never said anything bad about another nurse in my whole career, but on the other hand, I stand there and listen while one nurse is talking badly about another. I’ll never do that again.” When staff witness gossip or backstabbing, the psychological safety of the workplace is in jeopardy. A culture of horizontal hostility can only occur when you have secrecy, shame and a silent witness. As managers, we can take away the secrecy and shame by openly discussing damaging behaviors, stopping the pretense that these behaviors are harmless and can be ignored, and setting the expectation that it is not only unprofessional to stand by and be a silent witness while another nurse is being criticized, but extremely damaging.
Because the quality of nurse-physician relationships has been directly linked to patient mortality (Baggs), both physicians and nurses have an ethical obligation not to tolerate anything other than collegial relationships. In addition, poor physician-nurse relationships are a significant contributor to horizontal hostility because any group made to feel inadequate and powerless will always act out their frustrations towards each other. Interestingly enough, while a significant number of nurses report witnessing disruptive situations (92.5% Rosenstein); a very small percentage of physicians cause a disproportionate amount of damage. Attempts at improving physician-nurse communication and collaboration in the past have failed because the education failed to acknowledge that both assertiveness skills and courage are required to speak up to physicians. Manager intervention in holding physicians accountable for their behavior is crucial because the damage is exponential and insidious. Poor MD/RN relations inhibit communication and are detrimental to patient safety, teamwork and satisfaction.
Solutions to address nurse-physician conflict
Begin by garnering commitment from the chief physician for the unit. Clearly state the impact of any poor relationships as well as the benefit of collegial relations (use specific examples). Building collegial relationships begins with the relationship the manager has with the chief physician. Communicate weekly with the chief, providing an update on your concerns and proposed solutions and arrange monthly standing meetings.
Empower staff to stand up for themselves and never make excuses for destructive or negative behaviors. Even the smallest of condescending mannerisms have a profound impact on the team. If staff cannot approach a physician directly, stand ready to approach the physician on their behalf. Physicians respond very positively to the words: “May I speak to you for a moment in private?” State the specific behavior (e.g. raised voice) and the impact while redirecting the conversation to our common goal: safe, quality, patient care. In every single case of disruptive physician behavior I have heard or witnessed, the physician truly does not realize the impact of his/her behavior on staff and apologizes immediately. These unconscious learned behaviors are the antithesis of teamwork and can not be ignored because MD/RN collaboration has been directly linked to patient outcomes (Baggs).
A long history of power imbalance and inadequate communication skills in the healthcare culture manifests itself nurse-to-nurse and nurse-physician conflict. But managers are in a pivotal position to change history. Insist on professional behaviors at all times from the entire team. By refusing to let conflict go underground and empowering staff to resolve their own conflicts, managers have a powerful opportunity to create a new culture - one that is respected and acknowledged for its healthy collegial relationships.
Baggs, J.G. et al 1999. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Critical Care Medicine Sep: 27(9): 1991-8.
Bartholomew, K. 2006. Ending nurse to nurse hostility. HCPro, Marblehead, MA
Forte, P. S. 1997. The high cost of conflict. Nursing Economics 15 (3): 119-25.
Griffin, M. 2004. Teaching cognitive shield as a shield for lateral violence: an intervention for newly licensed nurses. The Journal of Continuing Education in Nursing 35(6).
Haraway, D. L. and William M. Haraway III. 2005. Analysis of the effect of conflict management and resolution training on employee stress at a healthcare organization. Hospital Topics: Research and Perspectives on Healthcare. Vol. 83. no. 4 Fall
Hillhouse, J. and C. Adler 1997. Investigating stress effect patterns in hospital staff nurses: results of a cluster analysis. Social Science and Medicine 45(12):1781-1788.
Rosenstein, A. 2002. Nurse-physician relationships: impact on nurse satisfaction and retention. Advanced Journal of Nursing 102(6):26-34.
Thomas, R. 2002. Conflict management systems: A methodology for addressing the cost of conflict in the workplace. http://www.mediate.com/articles/thomasR.cfm?nl=8. accessed June 26, 2007