ICU Volume 5 - Issue 3 - Autumn 2005 - Management

The Essentials of Conflict Management

Skill in conflict resolution and management is an important tool for those involved in any aspect of critical care medicine, but especially for those in leadership positions. Failure to accurately assess and manage conflict can result in a number of deleterious effects with important implications for patient care.


Conflict is an inevitable event for those caring for critically ill patients. Conflict may occur throughout all levels of healthcare organizations and clearly affects providers, staff, patients and their families. Conflict occurs within and between these entities and is the natural result of a variety of factors. It is important to remember that conflict is not necessarily bad. Indeed, if properly managed conflict results in mutually beneficial change. However, if mismanaged, conflict can cause lost productivity, erosion of trust, and lead to additional conflict with clearly negative implications for patient safety and care (Siders and Aschenbrener 1999). We will briefly review sources of conflict in the ICU, provide several examples and discuss methods of conflict resolution and management. The subsequent manuscript will describe some specific strategies utilized for patient-centred conflicts.

Factors Creating Conflict in the ICU

A myriad of factors in the ICU represent sources of or contributors to potential conflict. Individual needs, preferences and values may be in opposition to those of the organization. The dynamic nature of healthcare delivery may create conflict for providers. Examples include the implementation of best practices, process improvement, changing requirements and expectations of regulatory agencies and insurers, as well as pay for performance criteria all occurring in an environment of dwindling resources. Shortages of critical care providers and nurses are well documented and clearly contribute to conflict (Kelley et al. 2004). Culture, gender, individual beliefs and professional roles are diverse. The ICU is unquestionably complex with aspects that may be vague or uncertain and many physicians are averse to conflict (Andrew 1999.) Human factors such as fatigue, sleep deprivation and stress result from the 24 hour operations implicit in ICU care (Marco and Smith 2002). Frustration with systems problems may be directed at individuals (Marco and Smith 2002). The nature of ICU care involves teams that are constantly rotating and changing with disruptions in important relationships between team members, patients and families and team cohesiveness can vary widely (Hawryluck et al. 2002). Additionally, technology may influence conflict in unintended ways by creating difficulty interpreting emotional aspects of communication in email, because important verbal or body language cues are absent (Zweibel and Goldstein 2001). Finally, medical professionals often lack formal training in conflict resolution (Hawryluck et al. 2002; Marco and Smith 2002)

Aspects of Conflict

There are recurrent themes that are common to most definitions of conflict. These include perceived incompatibility of interests and a degree of interdependence of involved parties (Aschenbrener and Siders 1999). Low to mid-intensity conflict includes behaviours often observed in the ICU including clash of personalities, differences of style, disagreement and overt hostility. In addition to intensity, conflict may be categorized based on duration ranging from acute to chronic (Aschenbrener and Siders 1999).

Costs of Conflict

The costs of failure to manage conflict appropriately are extensive. Diversion of administrative resources to deal with problems can result in lack of attention to other pressing matters. Loss of time of involved parties and other stakeholders can undermine productivity. In extreme cases cost of litigation and lost labour are substantial. Additional liability exposure may result in cases involving labour, compliance, or harassment (Andrew 1999). Deterioration of the work environment, erosion of morale and decreased employee satisfaction can impair quality of work and produce staffing problems. These issues lead to decreased quality of patient care with increased risk of medical error.

Examples of Conflict in the ICU

Examples of conflict in the ICU include a vast array of issues. Conflict may arise over staffing patterns, personnel shortages and administrative procedures. Interpersonal conflict between physicians may lead to failure to obtain an appropriate consultation due to past conflict with the consulting physician (Andrew 1999). Differing views of how professionals interact as part of the ICU team are well documented and are an area of potential conflict (Thomas etal. 2003). Counterproductive staff communication patterns may be adopted by house staff leading to increased potential for interpersonal conflict (Lingard et al. 2002). The care team, patient and family values may conflict in end of life care decisions (Fetters et al. 2001).

Techniques to Manage Conflict

Conflict management implies the use of various strategies to produce resolution of the dispute while avoiding of the conflict and preserving a quality relationship between parties (Aschenbrener and Siders 1999). In the best-case scenario, effective management of conflict taps the creativity and problem-solving skills of involved parties, while providing solutions with input from diverse groups. A number of techniques may aid in conflict management. Assessment of the conflict should include a systematic approach that identifies critical information central to defining the conflict situation including pertinent issues, historical perspective, key players and other stakeholders. Organizational factors such as policy and environment should be considered. Personal issues should be explored and attention given to anger management.

The nature of the problem and influence of individual behaviour on the conflict should be elucidated along with a realistic examination of what is at stake and what can be changed. It is important to focus on those issues relevant to the situation and avoid diversion to peripheral matters, while focusing on the problem and refraining from directing blame or hostility at individuals (Siders and Aschenbrener 1999).

After defining the nature of the conflict, a number of strategies are available. Understanding the position of all involved players and clearly determining the stakes will aid in choosing an appropriate strategy. Strategies include competition, avoidance, compromise, accommodation, and collaboration (Aschenbrener and Siders 1999). Each approach has advantages and disadvantages and no single strategy will be best in all situations.

Competition will produce winners and losers. This approach may be considered in situations where the resources in question cannot be divided, time constraints limit the negotiation, or the parties in question refuse to take another approach. The loser may never fully engage team concepts again. Avoidance can lead to prolonging or intensifying the conflict and an impression of weakness. Avoidance is used when the nature of the conflict is extremely minor or when used strategically to allow a “cooling off” period before returning to manage the conflict in a more productive manner. Compromise, although commonly sought, also produces winners and losers. Compromise may be useful for a temporary settlement in a shorter period of time than is necessary for a collaborative agreement. Additionally, it may function as a back-up strategy when collaboration fails. Accommodation involves one side giving up their personal interests in order to preserve the relationship with the other party. This may be beneficial when the assessment of the conflict indicates that the issue is of much greater importance to the other party. Collaboration, or win-win, has the advantage of allowing the parties to understand the nature of complex issues and interdependent systems. Since resolution is achieved via building consensus for implementation, it increases the likelihood of sustainable change. The major drawback to this approach is that it is time consuming. 

Sometimes third parties are used for conflict management. These alternative dispute resolution methods vary in the role of the third party, the control that the parties in dispute maintain in the process, and in the partiality of the third party. Negotiation involves the entrance of a third party at the invitation of one of the parties in conflict. By definition the negotiator is partisan and seeks a resolution that is favourable to their side. In negotiation the parties in conflict maintain complete control. In mediation, a neutral third party is employed to aid the parties in dispute and the parties continue to have an intermediate level of control of the process as the decision of the mediator is a recommendation for resolution. Arbitration involves the use of an arbiter at the request of both parties to act as judge. The parties sacrifice significant control of the process to the arbiter. (Gerardi 2004; Orr 2001). The unbiased arbiter reaches a decision based on the merits of the case and their decision is usually final. 

While it is impossible to prevent all episodes of conflict, many issues can be prevented or have guidelines for resolution defined by contracts (Andrew 1999). Principles of practice documents generated by collaborative agreement of professional groups have been recommended to provide such guidance (Andrew 1999). When conflict does occur, control of anger can be useful in preventing escalation of a conflict, preserving the quality of relationship between the parties, and achieving a higher rate of settlement (Friedman et al. 2004).

Closing Thoughts


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