CHANGE AND CONFLICT MANAGEMENT

Change and conflict are ever present in health care today, thanks to constantly evolving
technology, new regulations, changing public expectations, increasing environmental concerns, and
heavy demand on scarce resources. In turn, nurses must be knowledgeable about the change process
and understand that conflict can result when the process is ineffective. In the dynamic environment of
health care, change is inevitable and unpredictable, and it affects staff, patients, and the organization
overall. Historian and critical feminist Joan Wallach Scott states, “Those who expect moments of change
to be comfortable and free of conflict have not learned their history” (Quote Garden, 2016). Change in
the work environment can create uncertainty and elicit emotional responses from employees (Bowers,
2011).

Although change is a very common cause of conflict, wise nurse leaders and managers recognize that
conflict is always present in the workplace (Porter-O’Grady & Malloch, 2013). Further, conflict is
dynamic and does not disappear; rather, it can only be managed. Nurse leaders and managers have a
responsibility to acquire the knowledge, skills, and attitudes to manage and lead change, engage staff in
consensus building, and conflict management (ANA, 2016

CHANGE THEORIES

Change is a dynamic process that results in altering or making something different. Change can
be planned or unplanned. Planned change is purposeful, calculated, and collaborative, and it includes
the deliberate application of change theories (Mitchell, 2013; Roussel, 2013). Change that is purposeful
and planned is usually well received by staff. In contrast, unplanned change occurs when the need for
change is sudden and necessary to manage a crisis. Unplanned change can cause anxiety and stress
among staff members. Successful nurse leaders and managers manage unplanned change “through
effective communication, adaptability, coordination, and the ability to remain grounded” (Erickson,
2014, p. 125). Highly effective nurse leaders and managers develop high-functioning, empowered teams
whose members know what is expected, remain calm during crisis, and do what is right for the patients
(Erickson, 2014). Closely related to and frequently an integral part of change is innovation, the process
of creating something new after thoughtful analysis of a phenomenon or situation.

The most common change theories and models used fall into two categories: 1) traditional theories and
models and 2) emerging theories.

Traditional Change Theories and Models Traditional change theories and models are linear and suggest
that change occurs in a sequential manner. For the change to be successful, the organization or unit
must progress through each stage. These theories require ongoing work to ensure that goals are met
and change is sustained.
Lewin’s Force-Field Model (1951)

Lewin’s Force-Field theory is one of the most widely used theories.

Lewin believed that change results from two field or environmental forces: 1) driving forces (helping
forces) that attempt to facilitate the change and move it forward and 2) restraining forces (hindering
forces) that attempt to impede change and maintain the status

This three-step change model involves unfreezing the status quo, moving toward the new way, and
refreezing or stabilizing the change for sustainability (Lewin, 1951; Mensik, 2014; Shirey, 2013)

1. The unfreezing stage is the point at which it is determined that change is needed, and driving and
restraining forces are identified. During this stage, nurse leaders and managers can help prepare staff
members for the change by helping them recognize the need for change, building trust, and actively
engaging staff in the change process. Motivation to change occurs in this stage.

2. The moving stage begins the initiation of the desired change. During the moving stage, the new
innovation is examined, accepted, and tried. Nurse leaders and managers can facilitate movement by
coaching those affected by the change to overcome fears and engage them in problemsolving and
working toward the desired outcome

3. The refreezing stage involves stabilizing the change and achieving equilibrium. The innovation is
incorporated into the routine. Nurse leaders and managers should reinforce the change through formal
and informal processes including policies, procedures, standards of care, and other common tools used
throughout the organization.

Lippitt’s Phases of Change Model (1958)

Lippitt, Watson, and Wesley (1958) expanded Lewin’s original theory by identifying additional stages of
the change process. The Phases of Change Model uses language similar to the nursing process and
focuses more on the people involved in the change process than on the change process itself. This
model stresses the importance of communication and rapport with those involved in the process. The
model follows these seven steps (Lippitt, Watson, & Wesley, 1958; Mensik, 2014; Mitchell, 2013

1. Diagnosing the problem involves identifying the need for the change and recruiting others to assist
with data collection. Effective communication is critical in the first phase to avoid miscommunication
through the grapevine

2. Assessing the motivation and capacity for change is actually assessing the unit or organization for
readiness to change. Nurse leaders and managers must communicate with those affected by the change,
respond to concerns, provide rationale for the change, and identify possible resistance to the change.

3. Assessing the change agent’s motivation and resources must be done for successful change to occur
This phase requires nurse leaders and managers to identify their role in the change process. They must
be realistic about the time commitment necessary and recruit assistance.

4. Selecting progressive change objectives involves clearly defining the change, establishing realistic
goals, and developing a plan for change. Nurse leaders and managers actively assess their team and
delegate appropriate responsibilities during this phase of the process.

5. Choosing an appropriate role for the change agent and implementing the plan for change comprise
one of the final steps. It is important that nurse leaders and managers remain flexible during this stage.

6. Maintaining the change after it has started and as it is being incorporated into the unit or organization
culture is critical. Communication and feedback are critical during this phase to avoid regressing to the
previous state.

7. Terminating the helping relationship once the process has stabilized occurs when the change agent
withdraws from the process and the change is evaluated. Nurse leaders and managers continue
monitoring and evaluating the change for sustainability.

Rogers’ Innovation-Decision Process (1995

Rogers (1995) broadened Lewin’s theory and developed a five-stage innovation decision process, which
consists of a series of actions and choices over time that an individual or decision-making unit must
follow:

1. Knowledge occurs when an individual or decision-making unit is exposed to an innovation and gains
understanding of how it functions

The perceived attributes of the innovation are key in this stage.

3. Decision occurs when an individual or decision-making unit engages in activities to adopt or reject the
innovation. To facilitate adoption, nurse leaders and managers may want to pilot the innovation on a
specific unit

4. Implementation occurs when an individual or decision-making unit begins using an innovation. Nurse
leaders and managers must ensure that adequate technical support and proper infrastructure are
available during implementation to avoid stalling the innovation

5. Confirmation occurs when an individual or decision-making unit seeks reinforcement of a decision

made or reverses a previous decision to adopt or reject innovation (Rogers, 1995, p. 162). Overall, staff
members desire to avoid conflict and work to keep the innovation going.
Kotter’s Eight-Stage Process of Creating Major Change (1996)

Kotter (1996) suggested that successful change involves a multistep process that overcomes all sources
of resistance and must be directed by high-quality leadership. He describes eight stages of the change
process that can help nurse leaders and managers manage change cognitively as well as emotionally
(Kotter, 1996):

1. Establishing a sense of urgency involves examining the competition or need for change to improve
quality and/or safety.

2. Creating the guiding coalition means putting together a group with the necessary power to lead the
change and getting everyone to work together.

3. Developing a vision and strategy means creating a vision to direct the change effort

4. Communicating the change vision to everyone involved in or affected by the change is important, as
is having the leader or manager model the behavior expected of employees.

5. Empowering broad-based action involves changing systems or structures that undermine the vision,
getting rid of obstacles, and encouraging risk taking and non-traditional ideas

6. Generating short-term wins consists of planning for and creating improvements in performance, or
“wins,” and visibly recognizing and rewarding those responsible for the “wins.”

7. Consolidating gains and producing more change include using increased credibility to change systems
and processes that do not fit the vision. This stage also involves hiring, promoting, and developing those
who can implement the vision, as well as reinvigorating the process with new projects and themes.

8. Anchoring new approaches in the culture is creating better performance through productivity
orientation and through better and more effective leadership and management.

Nurse leaders and managers are seen in Kotter’s model as important during the various phases of the
process because of their keen communication skills, ability to anchor the vision of the change, and skill
in persuading staff members to embrace the change (Salmela et al., 2013).

Emerging Change Theories

Emerging theories are cyclical rather than linear and require organizations to react with speed and
flexibility. Change and innovation from the perspective of complexity science are highly interrelated,
dynamic, and unpredictable (Porter-O’Grady & Malloch, 2013).
Two theories based on complexity science and systems theory, chaos theory and learning organization
theory (discussed in detail in Chapter 8), are actually used to understand organizational behavior. Chaos
theory and learning organizations theory are also used to understand change and innovation. Nurse
leaders and managers who understand these theories in relation to change and innovation can assist
staff through the change process successfully.

Chaos TheorY

Chaos theory is nonlinear and unpredictable, and it explains why a small change in one area can
have a large affect across an organization. This is also known as the “butterfly effect,” or the notion that
the flapping of a butterfly’s wings in one part of the world can have a major impact, such as a hurricane
or tsunami, on the other side of the world (Crowell, 2011; Mensik, 2014; Porter-O’Grady & Malloch,
2010). Nurse leaders and managers must be aware of the complexity of health care, the unit, and the
organization. Further, they must understand that, because of multiple factors, decisions made can result
in changes that were unintended.

Learning Organization TheorY

Senge (1990) defined a learning organization as an “organization where people continually

expand their capacity to create the results they truly desire, where new and expansive patterns of
thinking are nurtured, where collective aspiration is set free, and where people are continually learning
how to learn together” (p. 3). Senge identified systems thinking, personal mastery, mental models,
building shared vision and team learning as five disciplines that organizations need to adopt and practice
to become learning organizations.

Members of a learning organization are continually practicing the five disciplines and are
continually learning. The more learning that occurs, the more aware the members become of what they
can still learn.

MANAGING CHANGE AND INNOVATION

Managing change and innovation requires nurse leaders and managers to know the who, why,
what, when, and how of change (Porter-O’Grady & Malloch, 2013):

Who: The who of change are the key stakeholders (e.g., patients and families, employees, communities)
related to the work to be changed.

Nurse leaders and managers must be self-aware regarding their knowledge or lack of knowledge of the
change process, personal comfort with change and risk taking, relationships, conflict, and negotiation
skills.
 Why: The why of change is a reasonable rationale for the change. A lack of understanding for the
reason for change can result in resistance and unsuccessful implementation of the change and
innovation.

What: The what of change is the actual change or innovation being implemented. Identifying what to
change is determined after the rationale for the change is clear

Keep in mind that implementing the specific change may require additional resources and technology as
well as education and competency development for staff

When: The when of change is determining at what point to start the change process and how long it
will take to achieve the change.

How: The how of change involves the techniques or processes needed for successful and sustainable
change.

Facilitating change and innovation is more than establishing and implementing a plan

It requires four specific competencies (Porter-O’Grady & Malloch, 2013, p. 51):

1. Personal knowledge of and accountability for one’s own strengths and limitations specific to change
and innovation, including technical capability and computer literacy

2. Understanding the essence of change and innovation concepts as well as the tools of innovation

3. The ability to collaborate and fully engage team members

4. Competence in embracing vulnerability and risk taking

Becoming a Change Agent

A change agent is one who leads and manages the change process, including management of group
dynamics, resistance to change, continuous communication, and the momentum toward the desired
outcome. The responsibilities of a change agent can include the following:

Change agents must be effective communicators and must excel at interpersonal skills. Change agents
need to develop the knowledge, skills, and attitudes to align people, processes, and purposes to achieve
the change and innovation. Nurse leaders and managers often find themselves functioning as change
agents. As change agents, nurse leaders and managers are responsible to manage change and assist staff
in the change process. When nurse leaders and managers model a positive and enthusiastic approach to
change and innovation, they can inspire staff
Responding to Change

Nurse leaders and managers can help staff cope with change by making sure the rationale for the
change is clear and allowing staff members to verbalize concerns and express their emotions. During the
change process, nurse leaders and managers can also help staff members cope by ensuring open
communication, providing feedback on a regular basis, and empowering them throughout the change
process.

Chinn and Benne (1969) described three common change strategies that can be useful for nurse leaders
and managers during the change process

Normative-re educative strategy focuses on the relationship needs of staff members, uses peer
pressure, and relies on staff members’ desires to have satisfactory work relationships (Chinn & Benne,
1969). The normative-reductive strategy is used when some resistance is expected but nurse leaders
and managers believe that staff will succumb to peer pressure rather than resist the change.

Empirical- rational strategy assumes that staff members are essentially self-interested and providing
information and education will assist staff in changing behavior and adopting the change or innovation
(Chinn & Benne, 1969).

The power-coercive strategy is based on power and authority and assumes that staff will respond to
authority and threats of job loss (Chinn & Benne, 1969) This strategy is used when resistance is expected
but nurse leaders and managers plan to implement the change regardless of how the majority feels. The
power-coercive strategy results in rapid change and is often perceived by staff members as they must
accept the change or find a new place to work

Dealing With Barriers to Change

Emphasizing relationships among staff members

● Building mutual trust and confidence

● Emphasizing interdependence and shared responsibility

● Ensuring that responsibilities are shared equitably among all groups

● Managing conflict effectively

● Supporting careers by permitting job movement

● Anticipating and rewarding change

● Modifying the nursing organizational structure to accommodate changes that

provide staff growth and development

● Promoting a “can-do” attitude

● Providing predictability and stability

● Sharing bad news early, when necessary

● Fostering a shift toward teamwork and process improvement

MANAGING CONFLICT

Conflict is a state of disharmony among people and occurs when people have differing views Nurse
leaders and managers must strive to promote “ongoing evaluation and continuous improvement of
conflict resolution skills” (ANA, 2016, p. 49). Nurse leaders and managers spend close to one-fourth of
their time in conflict management activities (Padrutt, 2010; Rundio & Wilson, 2013; Valentine, 2001). It
is imperative for nurse leaders and managers to learn how to deal with conflict and role model effective
conflict management for staff.

Types of Conflict

Intrapersonal Conflict

Intrapersonal conflict is an internal conflict, or a conflict coming from within a person. An

individual may be confronted with an issue or situation that creates a sense of discomfort within.

An example of intrapersonal conflict is a nurse trying to make a decision to go back to school for an
advanced degree who may experience conflict between personal and professional goals (e.g., balancing
family life and pursuing professional advancement).

Interpersonal Conflict

Interpersonal conflict occurs when there is a disagreement between or among two or more
people. example of interpersonal conflict is a difference of opinion between a nurse and a family
member regarding a patient’s living will

Intergroup Conflict

Also common in the workplace is conflict that occurs between groups of people, also called
intergroup conflict.

For example, the emergency department staff may complain that patients are not moved to
the intensive care unit in a timely manner, and in turn, staff members in the intensive care unit complain
that the emergency department staff is always demanding to transport patients before patients are
discharged, thereby making beds available.

Organizational Conflict
 Organizational conflict can result when there is disagreement between staff and
organizational policies and procedures, standards, or changes being made.

For example, administration implements a new procedure for nurses to use when
documenting nursing care without input from the nurses. This can cause organizational conflict because
administration implements a change without consulting those it impacts most, nurses at the bedside.

Conflict Management Strategies

Five common strategies for conflict management

1. The avoiding strategy involves withdrawing or hiding from the conflict. The strategy is not always
effective in resolving conflict and just postpones the conflict.

Because the conflict is not resolved, it may reappear again later.

2. Accommodating involves sacrificing one’s own needs or goals and trying to satisfy

Another’s desires, needs, or goals. This strategy does not resolve conflict and

May result in future conflict.

3. Individuals who use the competing strategy pursue their own needs, desires, or

goals at the expense of others. The competitor wants to win and is not cooperative. This strategy is
power driven and can result in aggression.

4. Compromising is an effective conflict management strategy. When compromising,

everyone gives something up, and everyone gets something they want in return.

However, to be effective, those involved must be on an even playing field.

5. Collaborating is the best strategy to use in conflict management because it involves

a shared approach to resolving conflict. Shared goals are identified, and a commitment to working
together is implemented by those involved. Collaborating

is time consuming, but it results in the best chance of a resolution (Padrutt, 2010).
Role of Nurse Leaders and Managers in Addressing Conflict

Nurse leaders and managers need to mediate when interpersonal or intergroup conflict occurs to avoid
negative effects on nursing care and patient outcomes. Elements that should be explored include the
following (Porter-O’Grady & Malloch, 2013):

● Mutual respect: Those involved in the conflict may need a reminder to be respectful and focus on the
issue and not the other person

● Needs versus wants: The nurse leader and manager must help those involved differentiate between
what they need and what they want.

● Compassion and empathy: Those involved in the conflict may need assistance understanding each
other and hearing the other person’s position.

● Staying in the “I”: The nurse leader and manager reminds those involved to focus on “I” statements
and avoid using “you” statements and avoid blaming.

The rapidly changing health-care environment today requires nurse leaders and managers to
develop knowledge and skills in leading and managing change and innovation. Nurse leaders and
managers must be skilled in understanding change theory, serving as change agents, and supporting
staff during the change process. Regardless of how important a change or innovation is, nurse leaders
and managers must consider human response and include strategies to help staff members cope with
change in the overall plan. Further, nurse leaders and managers must understand that conflict can result
from change and be willing to apply strategies to manage change as needed. Nurses at all levels must
also understand that conflict is part of change, it can be healthy, and it allows for new ideas to emerge

By: Ramona C. Dayrit