Thursday June 30th 2016

The art of engagement

Nurses, ANA work to address conflict

Engage in conflict? Many nurses would rather head for the hills, or at least down the hall. But at Gundersen Lutheran Health System, nurses are being asked to face conflict  head on to create a better workplace and ensure safer patient care.

“In general, nurses would rather avoid conflict,” said Rebecca Inglis, MSN, RN, patient education clinical practice nurse at Gundersen, located in La Crosse, WI. “So we’ve become very adept at creating and doing work-arounds.”

Conflict can stem from a disagreement over a patient’s treatment plan, worker scheduling, or having differing values, for example.

According to Inglis and other nurses familiar with the phenomenon, poor communication is often at the heart of conflict. And that, Inglis said, “puts patients at risk, teamwork at risk, and joy at risk.”

And Mary Lu Gerke, PhD, RN, Gundersen Lutheran vice president for nursing and chief nursing officer, noted that, “The intensity and speed of our work has increased so much that staff can become frustrated, angry, or despondent when a conflict arises.”

Many staff don’t intuitively know how to address potential conflict. Instead they are afraid to call a physician about an order or ask another nurse for help, or they feel bogged down with processes that take away from direct patient care, according to Gerke.

“[At Gundersen], we wanted to get our arms around the non-tangibles so that staff could focus squarely on the patients. And we wanted to create a culture of caring and safety, not only for patients and families but also for employees,” said Gerke, who has worked with others in her facility over the past several years to make a culture of caring, safety, and healing a priority. “At the time we needed tools to help us, so everyone could communicate with each other in a calm, therapeutic manner.”

Gerke found that help through her state nurses association, the Wisconsin Nurses Association, and the Center for American Nurses, which was offering an educational program on conflict engagement. At that time, the Center was an affiliated organization of the American Nurses Association (ANA), but its programs and services have since been integrated into ANA’s initiatives.]  She specifically wanted a program that used nursing language and culture to drive home the importance of building a conflict-competent environment.

Not an isolated case

Many organizations have recognized that health care workplaces are challenging — with the potential for communication breakdowns, bad behavior, and conflict.

• In several of its reports, including the groundbreaking To Err is Human, published in 1999, the Institute of Medicine identified a need to improve communication and teamwork among health care professionals to prevent errors and protect patient safety.

• In 2008, the Joint Commission issued leadership standards calling for a stop to disruptive and inappropriate behaviors and a process to manage them.

• The ANA House of Delegates passed separate resolutions aimed at preventing workplace abuse and harassment, including a 2010 measure.

“When conflict flourishes, patient care suffers,” said Terri Gaffney, MPA, RN, senior director of New Product Development at ANA. “Conflict engagement, on the other hand, transforms health care and ensures patient safety. But addressing conflict takes skills and practice.”

Loressa Cole, MBA, BSN, RN, chief nursing officer, LewisGale Hospital-Montgomery in Blacksburg, VA, and a Virginia Nurses Association member, helped pilot the conflict engagement program primarily among charge nurses and nurse coordinators at her facility.

“We felt we had a pretty good culture, but we wanted nurses to be able to better deal with conflicts when they did occur,” Cole said. “And conflict is inevitable in every workplace. It can be physical or verbal, or as subtle as gossip or a co-worker being miffed at someone so he or she withholds information.

“All caregivers need to know that communication issues are patient safety issues that we should all be concerned about. After participating in the educational program, nurses did feel more comfortable communicating and addressing conflict.”

Being reflective, not reactive, is better

Gundersen initially surveyed its 1,200 nurses to get their take on potential areas of workplace conflict. The top two sources of conflict reported by them were nurse-to-nurse interactions and physician-to-nurse interactions, according to Ana Schaper, PhD, RN, a nurse scientist at Gundersen.

With that information in hand, Gundersen offered the conflict engagement program to just under 150 nurses in two groups. The first group began in March 2010 and involved nurse managers and informal leaders, such as nurse educators and quality assurance nurses. The second group, which started in November 2010, was composed of charge nurses and other bedside staff leaders.

Nurses in both groups completed the self-assessment, the online education module, and in-person sessions with conflict engagement expert Diane Scott, MSN, RN. Staff nurses in the second group also attended monthly learning circles, in which nurses worked in small groups to practice their skills using specific scenarios and to consult with their colleagues. (Gundersen slightly altered the schedules of the groups and some of the program, such as increasing the time for role-playing.)

“Going into the program, there was a real lack of awareness among nurses about constructive conflict engagement skills and strategies, and what strategies they actually used,” Schaper said. “So there were a lot of ‘a ha’ moments after both the self-assessments and the learning circles.”

Some nurses, for example, realized they used a lot of self-destructive strategies, including the need-to-win-at-all-costs approach when dealing with conflict — whether it was a disagreement over a treatment plan or a scheduling problem.

Inglis added, “Avoidance was also a common strategy. For example, when a nurse encountered eye rolling from a colleague or had a peer refuse to help, it was easier for the nurse to say, ‘Oh, that is just how they are’ instead of addressing the behavior.

“After the program, participating nurses had a real desire to quit creating work-arounds to avoid conflict because they had stronger skills to comfortably and respectfully address it.”

Another constructive strategy that resonated with nurses was perspective-taking, in which participants were asked to not make quick assumptions about the person they may be in conflict with, Schaper said. Instead, they were encouraged to ask more questions of the person, clarify information, and if needed, step away from the person to think more about the situation.

“This gives them the opportunity to be reflective, not reactive,” she said.

Sharon Holland, BSN, RN, a nurse expert leader for home care and hospice at Gundersen, found the conflict engagement program extremely valuable. Holland graduated from nursing school when she was 36 years old — an age that, oddly enough, led to some conflict early on in her career.

“Because I was older, I found myself in situations where people thought I knew more than I did, had more experience than I did,” said Holland, who has been a nurse since 1992. Added to that, she said, “I felt I was trained to be an intelligent professional, and instead of being treated as a professional, I sometimes was chastised for speaking up for my patients or myself — by physicians and even some nurses. That was really shocking and dispiriting to me.”

Over time, Holland learned to “set her priorities” and handle conflict better. However, the recent conflict engagement program served to strengthen her skills.

“The speaker delivered the information in such a powerful way and, because she was a nurse, in a way that we could relate to,” Holland said

Holland said she also benefitted from the self-assessment tool.

“I was surprised by some of the results,” she said. “I thought I had a handle on how to react to conflict. It helped me recognize what some of my hot buttons are, and the learning circles with other nurses helped me master how to react better to conflict in different situations and internalize those skills.”

“Conflict can be scary, but if you engage in a way that is respectful and honorable, it can lead to stronger outcomes in the workplace — for patients and for ourselves.”

Since the program was offered, some nurses have set their own personal goal to become more adept at strategically working through issues. And, not surprisingly, the amount of conflict reported at Gundersen has gone up somewhat — because staff are no longer sweeping it under the rug.

“Nurses also are beginning to come to the table more with their concerns about systems issues and potential solutions,” Schaper said. “And that‘s when engaging in conflict can lead to innovation.”

Gundersen nurse leaders plan on continuing to build on these conflict engagement skills and their culture of caring.  They are creating a conflict engagement video using role-playing to educate more staff and multidisciplinary groups within the facility and beyond. They also will continue to present their experiences at professional meetings, such as the Improvement Science Summit in Texas and at an upcoming Sigma Theta Tau International Conference, as well as through publications.

“We want a caring, team approach to patient care and the interdisciplinary team to be led and facilitated by the nursing profession,” Gerke said. “Programs like this help us learn, and it’s doable for every organization. What is so evident to our patients, families, and visitors is that we elicit fear when we disrespect each other. A family member once described an event in which a physician was raising his voice to a nurse in a disrespectful manner. The family said, ‘We see this behavior and we wonder if we will be the next one disrespected, or if they even listen to each other about us.’”

Added Inglis, “Our first priority is to give good care to our patients, but we also need to value how we treat ourselves and each other.”

ANA helps nurses take on conflict

The ANA conflict engagement education portfolio is comprised of three parts. The first is an online education module, which allows participants to gain or increase their knowledge of conflict engagement and conflict resolution. It provides an overview of the issue, and includes case studies and reflective exercises that address various aspects, such as conflict styles, self-assessment, and healthy conflict strategies.

The second part of the program focuses on building competency skills around conflict engagement. This portion of the program is led by conflict experts, including Diane Scott, MSN, RN. It includes a pre-training assessment, teacher-led, skills-based training session, and a post-training assessment. Content covers topics, such as initiating difficult conversations and responding to strong emotions.

The third component centers on coaching, which allows participants to use their knowledge and practices their skills using certain real-practice scenarios and get feedback on approaches.

More information on these components and a free, self-assessment tool can be accessed at http://www.centerforamericannurses.org/displaycommon.cfm?an=1&subarticlenbr=235.

ANA also is expanding its resources on conflict engagement and related topics. For example, there currently are two new continuing education offerings available through ANA’s CE website at http://ananursece.healthstream.com. Click on conflict competence at the left.

“ANA sees conflict engagement as crucial to patient safety, and we want to help nurses and facilities create an optimal team environment,” said Terri Gaffney, MPA, RN, senior director of New Product Development at ANA.

To meet that goal, ANA is working to expand its conflict engagement program to include an inter-professional approach, Gaffney said. She noted that there are workforce training program grants available in states that may be used to fund the conflict engagement program.

For more information or to request the education program, send an e-mail to conflict@ana.org.

To access the Conflict Engagement Portfolio, go to http://tinyurl.com/3k7x3su.

— Susan Trossman is the senior reporter for The American Nurse.

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