Dimensions of Critical Care Nursing

(C) 2006 Lippincott Williams & Wilkins, Inc.

Volume 25(1), January/February 2006, pp 22-28
An Overview of Conflict
[Leadership DIMENSION]
Kelly, Jacinta RN
Jacinta Kelly, RN, is currently a nurse lecturer at the Department of Nursing
and Midwifery, Brookfield Health Sciences Complex, University College Cork,
Ireland.
Address correspondence and reprint requests to: Jacinta Kelly, RN, Nurse
Lecturer, Department of Nursing and Midwifery Brookfield Health Sciences
Complex, University College Cork, Ireland (Amnesia104@hotmail.com).
Abstract
Conflict is found in all aspects of society and nursing is not immune. Conflict
is also found in critical care units. However, conflict within the nursing
profession has traditionally generated negative feelings and many nurses use
avoidance as a coping mechanism. This article will provide an overview of
conflict, conflict management, and conflict resolution.
---------------------------------------------INTRODUCTION
Conflict is an integral part of the fabric of a postmodern society which is
litigious, competitive, complex, and alienating.1 Subsequently, modern-day
intensive care environments are exposed to many of these conflicts which are
compounded by increased demands on an ever-limited staffing supply, a decrease
in available resources, and a profound period of change. These complexities and
tensions in modern intensive care settings will undoubtedly continue, and even
escalate, providing fertile ground for conflict among healthcare professionals.2
However, conflict within the nursing profession has traditionally generated
negative feeling. It has been seen as draining energy, reducing focus, and
causing discomfort and hostility.3 It is, therefore, not surprising that
intensive care nurses are more known for their use of avoidance, as opposed to a
more open acknowledgment of the factors contributing to the issues causing the
conflict.4
Valentine 5 argued, however, that the use of avoidance as a conflict management
strategy produces unsuccessful results and that it only ensures that conflict is

postponed. This article will examine the subject of conflict in the contemporary
intensive care environment and the circumstances that predispose intensive care
nurses to adopt avoidance as a management strategy when conflict arises.
DEFINING CONFLICT FOR NURSES
Although a generally accepted definition of conflict does not exist, Walton 6
defined conflict as processes occurring within a group in any of several forms,
such as hostility, decreased communications, distrust, sabotage, verbal abuse,
and coercive tactics. However, this definition engenders a negative and
inflammatory approach to conflict. Marquid and Huston 7 defined conflict less
malignantly as the internal discord that results from differences in ideas,
values, or feelings between 2 or more people. Although this definition
recognizes the existence of interpersonal and interorganizational conflict, it
does not acknowledge the conflict that can develop within a person or the
intrapersonal conflict. The discipline of intensive care nursing needs to
establish a definition of conflict that is both positive and comprehensive so
that conflict in the critical care area can be better understood and more
constructively approached within the workplace.
CONFLICT MANAGEMENT STRATEGIES
Conflict management can achieve successful conflict resolution and also remove
frustration, which can lead to higher effectiveness, trust, and openness.8 Lewis
9 identified various conflict resolution strategies such as compromising,
competing, accommodating, avoiding, and collaborating. Goodman 10 maintained
that, in general, avoidance behavior or suppression is the most common reaction
to an emerging conflict. Cavanagh 4 and Valentine 11 maintained that nurses in
the intensive care setting commonly use avoidance as they feel they need to
prevent open conflict, preserve relationships, and be exemplary role models for
students. However, the causative factors, which contribute to the use of
avoidance as a conflict management strategy in the intensive care setting, are
more far reaching. Observably, stereotypical and gender behavioral expectations,
issues of nurses' self-esteem together with management and leadership styles
predispose nurses in the intensive care environment to adopt avoidance as the
primary conflict management strategy.
Stereotypical Perspective
"Nice" Nurses Avoid Conflict:
Although caricatured images of the nurse as the starched to the core battleaxe,
the control freak, the naughty nurse, or the doctor's handmaiden are evident,
the overriding perception of the nurse in the public domain is one of ministering
angel who is gentle and caring.12 Subsequently, there is almost a stereotypical
expectation that nurses should not engage in conflict as people prefer nurses to

have warm, kind, and sympathetic personalities.13 Indeed, intensive care nurses
are considered by the public to be "nice" people and that "nice" people avoid
conflict, accommodate other people above themselves, and adapt their behavior to
match what they think people expect of them.14 However, Fisher et al 15
maintained that in conflict management it is necessary to concentrate on the
problems and not on the personalities.
Serve People Assertively:
Yoder-Wise 16 advised that when avoiding conflict, people neglect their own
needs, goals, and concerns while trying to satisfy those of others and this
approach has an element of being self-sacrificing and simply obeying orders or
serving other people. Indeed, this stereotypical self-sacrificing behavior is
strongly supported by the altruistic philosophy of nursing. Although this
approach may, on the surface, appear laudable, nurses as a result display a lack
of assertive behavior in conflict management, preferring instead to take a
passive role.17 However, assuming a passive role in the contemporary intensive
care setting is a recipe for low morale among intensive care nurses and
ultimately serves poorly the needs of critically ill patients.18 On the other
hand, assertiveness can be a means of expressing feelings honestly and directly,
while still showing respect to the other person.19 Assertive behavior could,
therefore, provide intensive care nurses with the potential to actively improve
communication and achieve goals, which would ultimately serve the needs of
patients in the intensive care unit more usefully.
My Way or the Highway!:
Although the underdevelopment of assertive behavior in critical care nursing may
be just dismissed as stereotypical behavior of the "nice" or "sympathetic"
nurse, anecdotal evidence also suggests that unassertive behavior may well
originate from the temporary nature of the nurses' employment in many acute care
settings in Ireland. Many nurses may be reticent to engage in conflict, such as
opposing traditional and ritualized approaches to nursing care, as the
"offending" practitioners may be viewed as agitators or conspirators and may
fear imposed relocation to other clinical areas. More permanent positions are
offered to staff nurses within the acute hospital setting. However, it could be
argued that opportunities for permanent staff nurse posts specifically in the
intensive care setting continue to be scarce and that this problem needs further
attention if open and fruitful exchange of views are to take place without fear
of recrimination.
Horizontal Violence:
Alternatively, McKenna et al 20 asserted that staff nurses, regardless of their
employment position, should not be sanctioned for expressing an opinion.
Although bullying is commonly acknowledged as the persistent, demeaning, and

downgrading of humans through vicious words or cruel acts that gradually

undermine confidence and self-esteem, Rayner 21 also cautioned that denial of
access to opportunity also constitutes horizontal violence or bullying. This
form of interpersonal conflict can be deleterious in the intensive care
environment as it is known to be a potential source of organizational problems
such as absenteeism, mistakes, and poor quality assurance.4 Therefore, intensive
care nurses should advocate confronting conflict openly and respectfully, which
in turn would promote dignity and prevent violence in the workplace.
Think Conflict, Think Critically:
Cavanagh 4 believed that avoidance of conflict could be of benefit during times
of high stress, frequently encountered in the intensive care setting, where
being able to put to one side interpersonal difficulties becomes very important.
By example, it may be expected that the stereotypically sympathetic and kind
nurse ignore the temper tantrums of an intensivist stressed with the responsibility
of attending to acutely ill patients. "Nice" nurses should overlook or indulge
other healthcare providers' difference of opinion for the sake of peace and
quiet in the unit. However, Lee 22 argued that conflict is a fact of life in any
interpersonal relationship and that conflict only grows in intensity when
ignored. When managed constructively through better communication, conflict can
lead to stronger and more satisfying interactions. Furthermore, in progressive
intensive care facilities, the welfare of the critically ill patient is not
interpreted as the sole responsibility of the intensivist. Instead, the critical
thoughts and contribution of each member of the multidisciplinary team are
acknowledged as a vital link in the chain of quality patient care.23 Therefore,
nurses in the intensive care setting should embrace conflict as a medium for
reconstituting the stereotypical attributes of the critical care nurse to
include critical thinking and good communication.12
Gender Perspective
Sexism:
Women favor peaceful coexistence in the workplace and do not engage in
confrontational behavior as much as their male counterparts.11 As nursing today
still figures predominantly as a female occupation, this undoubtedly contributes
to the use of avoidance as the chief conflict management strategy in intensive
care nursing.24 Observably, nursing suffers from an inherent sexism, which keeps
men outside the profession. Indeed, the very name of nursing should be changed
because descriptions of people looking after ill people have always been female
oriented such as "nurse" or "sister."25 Possibly, then the recruitment of a more
healthier gender mix to intensive care nursing would promote more open
confrontation as opposed to avoidance of workplace issues, and indeed, improve
staff retention in the intensive care setting.26

Emotional Women:
Women are more reluctant than men to engage in conflict as they feel they may be
dismissed as "emotional women."7 Oakley 27 maintained that women avoid conflict
because if they complained about a situation or a system they would be liable to
be called ill, neurotic, menopausal, premenstrual, or in need of some curative
relationship with a man. Indeed, in traditional nurse training programs, nurses
were trained to conceal their emotions and to display more rational thought.28
Undoubtedly, emotions of anger make conflict or rational problem solving
difficult in the workplace.16 However, Fuimano 29 affirmed that emotions of
empathy and compassion should not be suppressed in nursing, otherwise intensive
care nursing care would be unmotivated, robotic, and detached. Instead of
avoiding conflict, nurses in the intensive care setting should therefore be
provided with emotional intelligence training so that rational thought
(cognition) and emotional response (affect) could be used in harmony to deal
with conflict more openly and competently.30
Conflict is Caring:
Astoundingly, Lee 22 maintained that many women avoid conflict because they have
been brought up to believe that they are not to be involved in conflicts,
express negative communications, or to have an opinion regarding most matters.
Farrell believed that if nurses' behavior does not comply with either mother
earth (nurturing and caring), they are cast as "iron maiden-tough, dangerous,
and unfeminine."31 Nurses are presumably therefore expected to preserve their
feminine or "ladylike" image and submit to the other's perspective. Valentine 5
suggested that intensive care nurses, consequently, avoid confronting crucial
issues and solutions are frequently arrived at by default. However, it would be
remiss of nursing professionals to rely on "default" to solve the complex issues
in the contemporary intensive care environment. Instead, the ability to confront
problems positively and to offer an opinion should in fact be promoted as a very
caring and honorable trait in the intensive care nurse where intraprofessional
and interprofessional cross-pollination of views is essential for the common
good of the critically ill patient.
Girl Power:
Women are often considered to be a subordinate and powerless group within
society in general and the healthcare arena in particular.5 Farrell 32 perceived
nursing as a discipline that is "oppressed" by men. Davidhizar and Cramer 33
maintained that the health sector has a disportionately high number of men in
senior nursing management positions in relation to their percentage of the
nursing workforce. Most physicians, administrators, and nurse mangers are men
who use power or competing to resolve conflict, whereas nurses who are mainly
women tend to be coerced into a compromise.34 However, competition and
compromise, like avoiding, are inadequate approaches to conflict resolution in

the intensive care setting because they are selfish and positional approaches,
but also because they can generate ill will, a win-lose stance, and a commitment
to inaction within groups.7 Evidently, intensive care nurses avoid conflict as
they feel perhaps that a win-lose outcome is a foregone conclusion in such an
oppressed discipline as nursing. Alternatively, there is a need for more
proportionate representation of women in executive positions in healthcare so
that intensive care nurses are imbued with a sense of empowerment to engage in
more productive conflict management strategies.
Independent Thought:
Intensive care nurses lack autonomy, accountability, and control over their
practice, as medicine, which is predominantly male, is the dominant culture.
Nurses in intensive care settings therefore rely heavily on hierarchical systems
and rule following.35 Within such professional practice confines, the nurse has
limited opportunity to develop independent thought, and engagement in conflict
is difficult and possibly therefore avoided. Furthermore, it is more exerting
and taxing for nurses to exercise independent thought and to articulate
alternative and informed opinions. Autonomy brings with it enormous commitment
and initiatives, and aspiring to having control over one's practice as a nurse
in the intensive care environment demands substantial challenges, responsibilities,
and increased accountability. Indeed, Kafka 36 observed that it is safer to be
in chains than to be free.
However, the development and growth of the discipline of intensive care nursing
would resultantly stagnate and the discipline of intensive care nursing would
not be allowed to advance to meet the contemporary needs of the critically ill
patient. Alternatively, autonomy and accountability need to be promoted in
intensive care nursing so that nurses can mobilize their faculty for independent
thought and be equipped with the means to engage competently in conflict
management. Subsequently, the ability to find innovative solutions, to extend
beyond their boundaries of comfort, and to test new ways of doing things, will
move nursing further into the center of the arena of the new healthcare
services.37
Self-Esteem
Nightingale's Legacy:
Florence Nightingale in 1881 remarked that nursing was done by those who were
too old, weak, drunken, or stolid or could not do anything else.38 It is
therefore not surprising that nursing has historically been viewed as a
low-status and inferior profession within the healthcare system and that it has
traditionally wrestled with low levels of professional esteem and low self-image.39
Evidence suggests that nurses in intensive care settings continue to be held in
low esteem.40 Doctors continue to make intensive care nurses feel that their

contribution is not valued by not waiting for nurses to join decision-making or

discussions on unit rounds. Self-esteem is generally considered to be a major
predictor of behavior.41 Hall 42 maintained that this lack of professional
esteem creates a submissive culture in critical care environments. Subsequently,
nurses lack confidence and self-assuredness when challenging authority figures
or confronting conflict in the intensive care setting.
Educated Conflict:
Mannahan 43 maintained that professional development is viewed as key for
intensive care nurses to increase their self-esteem. Admittedly, attempts have
been made to effect parity of esteem with other members of the multidisciplinary
team through undergraduate degree programs and postgraduate critical care
courses. However, McCarthy 44 believed that many nurses who wish to be treated
as esteemed professionals are still educationally unprepared. Although, An Bord
Altranais 45 specified that nurses must maintain and develop competencies
through continuous education and professional development, the nursing
profession in Ireland continues to labor under deficiencies in continuing
educational programs with regard to conflict management. Although assertiveness
and conflict management educational sessions may be offered in major cities,
provincial hospitals are observably, poorly served. Perhaps, nurse managers feel
threatened by the prospect of providing a subordinate with assertiveness and
conflict management skills and may accordingly be disinclined to authorize
financial support and study leave. However, gaps in professional development
need to be addressed to elevate the esteem of intensive care nurses and to imbue
nurses with the confidence and knowledge to engage competently and actively in
conflict management strategies when conflict arises.
Career or Conflict:
Farrell 31 maintained that because nursing is a low-status profession within the
healthcare system, nurses wish to align themselves with groups that are
perceived to be of high status, such as doctors, nurse managers, and administrators.
Kelly 46 concurred that nurses in contemporary intensive care settings view the
experience and education of critical care nursing as a springboard to perceived
higher positions such as clinical nurse specialist, advanced nurse practitioner,
or nursing manager. However, it could be argued that this predisposes intensive
care nurses to avoid conflict with doctors or managers as they may feel that
engaging in conflict may jeopardize their career advancement. Consequently,
intensive care nurses continue to reproduce a system that values medical/interventionist
care and managerial positions at the expense of marginalizing "basic" nursing-a
prejudice that will unintentionally ensure nurses remain assistants and
subservient to the biomedical model.47 However, instead of poaching the esteem
of medicine, intensive care nurses should defend the worthiness and privilege of
their own profession and, if necessary, engage in respectful conflict to develop
and illustrate their professional and holistic identity and expertise.

Management and Leadership

Collaboration Impossible:
Smith-Trudeau 26 maintained that if conflict management is left unattended, it
can tear a team apart and waste human potential. Therefore, the ability to
creatively manage internal conflict in the organization is becoming a standard
requirement.17 Ideally, the goal in conflict management is that healthcare
providers are encouraged to collaborate creatively and flexibly to achieve a
win-win solution for all involved.7 Transformational management or leadership is
a style, which is ideally suited to the present climate of change in healthcare
because it actively embraces and encourages innovation and change.37 However, in
many modern healthcare organizations, this could be an arduous task, as
hierarchical and bureaucratic organizational cultures do not promote freedom of
planning or professional latitude.48,49 Undoubtedly, this rigid form of
management encourages nurses in intensive care to opt for avoidance as a
conflict management strategy as a win-lose outcome in favor of management is
presumed. However, succumbing to avoidance strategies as a conflict management
only reinforces the intensive care setting's authoritative and autocratic
structure and renders any hopes of collaboration impossible.
"Our Antagonist is our Helper":
Dealing successfully with conflict requires the manager to have a basic
understanding of what is causing the conflict.50 Understanding the sources of
conflict can be realized when managers engage in careful listening.22 However,
if nurses in the intensive care setting labor under a mandating management
structure, which does not listen to its employees, then this may have an
alienating effect on staff and it may prove difficult for management to
ascertain what is actually causing conflict. Alternatively, managers should view
nurses more as invaluable resources for collective problem solving in the
clinical intensive care setting. Burke agreed that "he that wrestles with us
strengthens our nerves and sharpens our skill. Our antagonist is our helper."51
Indeed, in today's postmodern society, everyone wants to participate in making
decisions that affect them; fewer and fewer people will accept decisions
dictated by someone else.15 Accordingly, collaborating is the most desirable
approach as it is the creative stance, it is both assertive and cooperative
because people work creatively and openly to find the solution that most fully
satisfies all important concerns and goals to be achieved.16
Task Masters:
Transactional managers have been described as those people in organizations who
honor stability and control; they tend to promote task-oriented nursing care and
are comfortable with that which is rational, quantitative, and logical.52

Although this transactional approach to leadership in the intensive care can

offer prompt solutions for immediate staff needs, particularly under stressful
conditions, it is nonetheless, lacking in vision for the future and endorses
only policy or procedures rather than organizational or cultural change.53
Therefore, transactional management encourages nurses in intensive care
environments to concentrate on the completion of tasks and, subsequently, nurses
have little energy or time to engage in conflict or negotiation.
However, nursing care in the intensive care unit should not be reduced to a sum
of tasks or a laboratory-like atmosphere where only measurements and controls
represent "caring" or where concern for the people they manage becomes
subordinated to organizational goals.37 Instead, the emerging paradigms in
healthcare require managers who are able to be strategic in their thinking and
facilitative in their style so that nurses in the intensive care setting can
collaborate with others to tailor their care creatively to the individual needs
of the patient.
Transformational leadership would be the ideal form of leadership to facilitate
nurses in the intensive care setting because it is caring and highly ethical.54
Transformational leadership utilizes components such as charisma, idealized
influence, inspirational motivation, intellectual stimulation, and individual
consideration.17 However, anecdotal evidence suggests that there are very few
people in nursing with these characteristics, especially charisma, and that the
subsequent absence of innovative and empowering leadership leads to avoidance of
conflict by nurses in the intensive care setting.
IMPLICATIONS FOR PRACTICE
The following are implications for nursing practice:
* Nursing requires a guiding definition of conflict that is positive and
comprehensive so that conflict is embraced constructively in the intensive care
setting.
* Similar to any other profession, nurses are permitted to engage in conflict
assertively, yet respectfully, as a medium for growth and innovation in
practice.
* Practitioners in the intensive care setting must appreciate the fine line
between assertive behavior and horizontal violence or bullying in the workplace.
* Conflict can be resolved through careful listening and good communication.
* In conflict management, it is wise to concentrate on the problems and not on
the personalities.

* Emotional intelligence training should be provided in nurse education to allow

nurses to deal with conflict more effectively.
* Nurses in intensive care need to embrace autonomy and increased accountability
in their practice so that independent thought can be developed and their
engagement in conflict is more effective.
* Educational opportunities should be provided equally to all intensive care
practitioners to ensure that they are educationally equipped to deal with
conflict situations.
* Transformative management and leadership styles are key to facilitating
empowered participation in conflict.
CONCLUSION
Although conflict is regarded as a natural phenomenon in every human relationship,
nurses in intensive care have traditionally used avoidance as a conflict
management strategy because of stereotypical and gender behavioral expectations,
self-esteem issues, and management and leadership styles. Analysis of the issues
indicated that nurses avoided conflict in the intensive care setting because
they felt the public's stereotypical image of them demanded that they be "nice,"
self-sacrificing, and submissive nurses and that if they engaged in conflict
they would be branded emotional or unfeminine women. However, it is believed
that in conflict management, it is necessary to concentrate on the problems and
not on the personalities and that patients' needs are better met when practitioners
confront conflict openly and assertively.15
As a largely female-dominated occupation, nurses in intensive care settings
avoided conflict because of the disproportionate amount of men in administrative
and managerial positions and because of the dominance of medicine in the
healthcare arena. It was argued that historically low levels of self-esteem in
nurses and the existence of autocratic and transactional managerial structures
have encouraged nurses to avoid conflict. Arguably, these problems are best
remedied by nurses seeking autonomy and control over their own practice and
mobilizing independent thought to confront conflict confidently instead of
relying on rule following and hierarchical structures.35 Transformational
leadership was thought to be key in leading nurses to empowering and innovative
working conditions and providing the courage to engage in constructive conflict
management.
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Keywords: Conflict; Conflict management; Conflict resolution; LeadershipAccession
Number: 00003465-200601000-00007