Using reflection to resolve conflict

AORN Journal,  August, 2006  by Barbara A. Hocking

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Working in a negative environment often leaves perioperative nurses feeling helpless or "swamped." When a conflict occurs, a nurse has a choice of behaviors--he or she can react in a way that leads to a disadvantaged environment, which creates more conflict, or he or she can react in a way that leads to an advantaged environment, which creates harmony and growth.

Quality patient care is the result of the deliberate actions of a diverse team of interdependent caregivers. The Joint Commission on Accreditation of Healthcare Organizations has targeted a breakdown in communication between these caregivers as the principle root cause of sentinel events. (1) Kotter (2) offers the following insight.

   When a high degree of interdependence
   exists in the workplace, unilateral
   action is rarely possible. For all decisions
   of any significance, many people
   will be in a position to retard, block, or
   sabotage action because they have
   some power over the situation....

      When the many parties who are
   linked together interdependently are
   very diverse from one another, they
   will naturally have difficulty agreeing
   on what should be done, who should do
   it, and when.... The greater the diversity,
   and the greater the interdependence,
   the more differences of opinion
   there will be. (2(p18))

The crisis in health care quality is characterized by three detrimental outcomes:

* fragmentation,

* medical errors, and

* inefficiencies.

Each of these outcomes erodes the core of both the art and the science of nursing.

Fragmentation of patient care implies both disjointed communication and fractured care. It is the opposite of seamless care, which is characterized both by standardized processes and evidence-based practice with minimal variation in outcomes.

The incidence of medical errors is widespread. The statistics in the Institute of Medicine report To Err Is Human: Building a Safer Health System reveal that medical errors are the eighth leading cause of death among Americans. According to the report, error-caused deaths each year in hospitals alone (ie, 44,000 to 98,000) exceed those from motor vehicle accidents (ie, 43,458); breast cancer (ie, 42,297); or AIDS (ie, 16,516). (3)

Inefficiencies in the health care setting include rework, interruptions in patient care, misunderstandings, changes in patient care plans, and incomplete patient education. Fragmentation, medical errors, and inefficiencies are often the result of conflict.

CONFLICT

Conflict arises when a person exhibits a reactionary response and either attributes negative characteristics to his or her teammates, avoids problem-solving, withholds feedback, or attempts to control or force the behavior of another person when a problem occurs. The Institute of Medicine's report Crossing the Quality Chasm offers a pessimistic premise on this subject:

   The current system shows too little
   cooperation and teamwork. Clinicians
   and institutions should actively collaborate
   and communicate to ensure
   appropriate exchange of information
   and coordination of care. (4(p1))

As early as 1974, the National Joint Practice Commission recognized publicly that divisiveness and conflict has a high cost for the nursing and medical disciplines. It has an even higher cost for society, however, in that it brings about

* duplication of effort,

* unnecessary conflict,

* energy-depleting discord, and

* the potential for greater risks to patients. (5)

THE CULTURAL ENVIRONMENT

An advantaged cultural environment supports professional nurses working together to achieve optimal patient outcomes through open communication, trust, and accountability. In many health care environments, however, this culture has not been achieved. Instead, unresolved conflict creates an undercutting not only of individuals but also of the health care system as a whole, and it creates in members of the health care team the feeling of being overwhelmed or swamped (ie, the person becomes mired in the problem as though it were a swamp). The proliferation of this swamping phenomenon in the workplace creates a void in which trust and accountability are marginalized (ie, a disadvantaged cultural environment).

The American Heritage Dictionary of the English Language defines a swamp as "a situation or place fraught with difficulties and imponderables." (16) It also characterizes swamping as the act of "inundating, burdening, or overwhelming." (6) Horowitz (7) describes a phenomenon she calls swamping in constitutional, social, economic, and cultural parameters. Her governing belief is that from the moment of conception, a person's development is influenced by constitutional, social, economic, and cultural factors. This development is defined broadly to accommodate both the increase and decrease in ability and function. These four factors continue to affect development across the life span in linear (ie, reasonable) and nonlinear (ie, unreasonable or strained) relationships. They influence a person's experiences and provide a set of circumstances or context that may create poor advantage, normal advantage, or high advantage in the process of development or personal growth.