Journal of Nursing Management, 2010, 18, 145–156

A literature review of conflict communication causes, costs,

benefits and interventions in nursing

ROSS BRINKERT PhD

Assistant Professor of Corporate Communication, Department of Corporate Communication, The Pennsylvania State
University, Abington, PA, USA

Correspondence B R I N K E R T R . (2010) Journal of Nursing Management 18, 145–156

Ross Brinkert A literature review of conflict communication causes, costs, benefits and
Department of Corporate interventions in nursing
Communication
The Pennsylvania State University Aim This paper reviews the literature on conflict communication in nursing in order
1600 Woodland Road to prioritize research, theory and interventions that will support nurse managers and
Abington staff nurses.
PA 19001 Background Conflict is pervasive in nursing and has many costs, including burnout,
USA higher absenteeism and higher turnover. Increased and more effective use of conflict
E-mail: rsb20@psu.edu management seems important in sustaining and developing the field.
The author has previously Methods The literature study focused on the intersection of nursing, communica-
received payment for conflict tion and conflict. The review primarily drew from the nursing and communication
interventions work. disciplines.
Results While much is known about the sources and costs of conflict in nursing,
more can be done to research the benefits of conflict and intervene effectively.
Conclusions Conflict is a routine feature of nursing. Nonetheless, sources can be
managed, costs decreased and benefits increased with indirect and direct interven-
tions.
Implications for nursing management Nurse managers can support themselves and
others in working through conflict by normalizing conflict, employing proven
proactive and reactive interventions and by helping to build integrated conflict
management systems.
Keywords: communication, conflict, intervention, manager, nurse

Accepted for publication: 12 October 2009

is a serious issue in the profession and one that is on the

Introduction
rise around the world (Farrell 1997, Hesketh et al.
Across occupations, 25% of respondents cited interper- 2003). The fact that new entrants to the field get mired in
sonal issues as the most challenging workplace stressors conflict (McKenna et al. 2003) is of particular concern
(Smith & Sulsky 1995) with negative social interactions given ongoing efforts to improve attraction and retention
with others accounting for 75% of the total work situ- figures. Unfortunately, nursing still has not broken from
ations respondents described as detrimental (Schwartz & the past in terms of Ôeating its youngÕ (Baltimore 2006).
Stone 1993). Within nursing, the ability to manage The management of conflict among nurses and among
conflict effectively has been recognized as an important nurses and others in the workplace are central issues to
skill (Hillhouse & Adler 1997). As Almost (2006) doc- the profession that need to be further addressed in terms
umented, persistent conflict among nursing co-workers of theory, research and practice.
DOI: 10.1111/j.1365-2834.2010.01061.x
ª 2010 The Author. Journal compilation ª 2010 Blackwell Publishing Ltd 145
R. Brinkert

The purpose of this paper is to report on a conflict • What do we know about conflict in nursing?
literature review. While Almost (2006) concentrated on • What do we need to know about conflict in nursing?
conflict between nurses, this paper broadens the focus • What are the implications for nurse managers?
to include conflict between nurses and other health care
providers as well as conflict between nurses and patients
Literature review methodology
and/or patientsÕ families. Also, while it is important to
recognize conflictÕs sources and effects prior to explor- This review emphasized the nursing and communica-
ing conflict management (Almost 2006), this study tion literatures given the central importance of the
addresses these foundational matters but then empha- nursing literature to this area and the authorÕs home
sizes conflict management interventions. discipline of communication. Literature from social
and organizational psychology and inter-professional
practice perspectives remain to be thoroughly consid-
Defining conflict
ered. The terms communication, conflict and nurse
Conflict has been defined as Ôthe interaction of inter- were searched in the following databases: CINAHL,
dependent people who perceive incompatibility and the Communication Abstracts, Communication and Mass
possibility of interference from others as a result of this Media Complete, ERIC, Medline Pubmed (nursing
incompatibilityÕ (Folger et al. 2009 p. 4). Communica- journals only), Proquest ABI, Proquest Nursing and
tion is central to conflict in that communication often Allied Health Source, PsycINFO and Social Sciences
creates conflict, reflects conflict and is the way in which Citation Index. The inclusion criteria were as follows:
it is productively or destructively managed (Wilmot & English language, peer reviewed, journal papers from
Hocker 2007). Although conflict is frequently viewed as 1995 to 2008 and all three search terms (or, where
negative, conflict can have positive functions, including available, related terms) in the title and/or abstract.
surfacing important problems (e.g. getting individuals One hundred and ninety-four unique papers were
to address power and relationship issues underlying referenced in the databases when accounting for the
content concerns), clarifying individual and shared presence of some papers in more than one database.
goals and helping overcome resentments and come to One referenced paper was dropped because neither the
mutual understanding (Wilmot & Hocker 2007). abstract nor the paper could be located. Fifty-four
Although a mixed (positive and negative) view of con- papers were dropped because they clearly fell outside
flict has taken theoretical hold in recent decades, the fundamental parameters of the literature review.
researchers have continued to concentrate on the neg- For a paper to be considered it had to focus on nurses
ative (Almost 2006). as direct conflict participants and address a hospital
setting (or nurse education setting with a hospital
link). The 139 remaining papers were closely consid-
Key questions
ered. Given the specific purposes of this literature
Three basic questions guided this literature review: review and space limitations, 74 (those entries preceded

Papers CINAHL Comm Comm & ERIC Medline

referenced 75 Abstracts Mass Media 2 Pubmed
in Searched 2 Complete (nursing
Databases 3 only) 24

Proquest Proquest Psyc INFO Social 194 unique

ABI Nursing & 28 Science papers
22 Allied Health Citation referenced
Source 97 Index 28 in databases

Dropped Not located Irrelevant Less

papers 1 54 relevant
65 120 papers
dropped

Papers 74 74 papers
integrated integrated
from from
Databases databases

Additional 35 35 additional
papers papers
integrated integrated

Grand total
109 total
= papers
integrated

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 Education designed to build a learning culture

with a * in the references) were integrated. The 65 based on an inability to set boundaries, role conflict
papers that were judged less relevant were tangential involving competing responsibilities, problematic rela-
to the literature review in terms of content and/or tions with other employees, breakdown in community,
redundant in terms of other more notable papers in a perceived unfair treatment of workers, value conflicts
sub-area. An additional 35 papers (those entries pro- and self-conflicts.
ceeded with a + in the references) were incorporated Verbal abuse is communication that is perceived to be
based on mention as sources or previously known an attack that is harsh, condemnatory and either per-
relevance. sonal or private (Buback 2004). Among peers it is
known as horizontal violence and tends to occur in
private (Buback 2004). There is a high incidence of
Origins of conflict in nursing
horizontal violence or bullying in nursing (Farrell 2000,
Sources of conflict in nursing were previously catego- Taylor 2001). Although it is not uncommon for nurses
rized in terms of individual characteristics, interper- to get attacked by patients, nurses are most concerned
sonal factors and organizational factors (Almost 2006). about aggression from nursing colleagues (Farrell 1999,
Sources of conflict are categorized here according to Abu AlRub 2004). Valentine (1995) noted that striving
conflict predominantly described as developing (1) for the positive qualities of nurturing, caring and
within and among nurses; (2) among nurses and other kindness may create a bind for nurses making con-
health care professionals; and (3) among nurses, frontation unattractive. Yet, directly addressing
patients and patientsÕ families. While any typology of important issues is much more likely to be beneficial
discrete sources can be illuminating, sources relate to (Baltimore 2006).
one another in complex ways. For instance, a qualita- Conflict among different generations of nurses has
tive study of nurse anaesthetists and anaesthesiologists been well established (Swearingen & Liberman 2004,
working side by side demonstrated how dyadic actions Kupperschmidt 2006). The generational differences
can perpetuate, transcend or transform a larger group within nursing can cause conflict and be a challenge for
conflict and therefore function at micro and macro leaders in particular (Sherman 2006). There are four
levels (Jameson 2003). generations in the present-day workforce: WWII gen-
eration, baby boomers, generation X and millennials.
While no individual can be adequately understood
Conflict within and among nurses
solely in terms of his or her generation, patterns within
Conflict within and among nurses was described as role generational cohorts and differences across cohorts can
conflict, horizontal conflict and intergenerational con- sometimes be useful for understanding conflict among
flict. A major source of conflict in nursing is the basic people of different ages.
fact nurses have multiple professional roles. The patient
advocacy role of nurses has been shown to be inherently
Conflict among nurses and other health
challenging from a role conflict perspective (Martin
professionals
1998) and the basic nursing functions of caring and
controlling can come into tension (Hewison 1995). To Numerous articles reported conflict between nurses and
have multiple roles is to have conflicts develop regard- physicians and nurses and other health care profes-
ing ethical obligations to various parties (Laabs 2003). sionals. The source of many of these conflicts concern
A programme evaluation in the United Kingdom (UK) challenges in perspective-taking, including the challenge
found both nurses and nurse managers experienced role of integrating points of view. Vertical violence and
conflict (Cooper 2003). tensions relating to administration, finances and patient
Three additional sources of conflict largely concen- care were also notable. Nurse–physician conflict has
trating on nurses that have received considerable various sources, including different professional judg-
attention in recent years are burnout, horizontal conflict ments (Chase 1995), different goals or lack of goal
and intergenerational conflict. A study of intensive care clarity (Weinert et al. 2001), different experience levels
unit (ICU) nursing staff in France indicated that 33% (Nicolson et al. 2005) and tensions around status
had severe Burnout Syndrome (BOS) with conflict cited relations (Brand 2006). Two dominant themes in the
as one important BOS area (Poncet et al. 2007). Espe- literature concerning nurse–physician conflict commu-
land (2006) generated a list of causes of burnout. Some nication were conflict originating in the operating room
relating to conflict communication include lack of goal and decision-making regarding end-of-life care.
and expectation-related information, role overload Aggressive tactics directed from an actual or perceived

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R. Brinkert

superior towards someone of lower rank, is known as the financial, clinical and other areas of the organiza-
vertical violence (Buback 2004). Vertical violence often tion may find themselves in value conflicts, especially
occurs in front of others, has been documented as when facing budget constraints (Nowicki & Summers
occurring in the operating room by surgeons towards 2002). Patient-related and monetary goals clashed in
nurses (Buback 2004) and has been labelled surgical perinatal (Simpson & Knox 1999) and end-of-life set-
personality (Girard 2008). Whether or not it can be tings (Sorensen & Ledema 2007).
related to vertical violence in the development of a
particular conflict, time has been shown to be a resource
Conflict among nurses, patients and patientsÕ
negotiated among health care professionals (Riley &
families
Manias 2006) and research in operating rooms has
demonstrated it is also a source of tension and conflict A discourse study of palliative care nurses found emo-
(Espin & Lingard 2001, Walker & Adam 2001, Lin- tion talk can construct patients as troubled (Li & Arber
gard et al. 2002). 2006). The lack of alignment between a patientÕs verbal
Conflict communication was a major theme for and non-verbal communication can challenge nursesÕ
physicians and nurses in end-of-life decision-making abilities to comprehend effectively (Iwamitsu et al.
(Oberle & Hughes 2001, Keung & Chair 2006) and 2001). Researchers have recognized the ever present
life-sustaining dialysis treatment (Silen et al. 2008). intergenerational dynamic of older patients receiving
Conflict patterns were documented among different health care from younger professionals, specifically the
professionals in intensive care units (Hawryluck et al. relationship between lifespan stage, conflict styles,
2002, Halcomb et al. 2004). Ethical uncertainty has depth of conflict and conflict satisfaction (Bergstrom &
been linked to professional status ambiguity (Frederich Nussbaum 1996).
et al. 2002) and different basic approaches were noted A review of literature revealed parental involvement
for nurses and physicians (Robinson et al. 2007). in pediatric care was poorly executed and conflict can
In general, the basic differences in role-related per- develop when parentsÕ actions do not meet nursesÕ
spectives between nurses and physicians and among expectations (Corlett & Twycross 2006). A year-long
nurses and other professional groups were shown to study of paediatric intensive care patients with pro-
impede conflict resolution, if not an additional source of longed stays showed conflicts were common and the
conflict. A review showed congruent expectations of the majority were team–family (n = 33, 60%) and intra-
clinical nurse specialistÕs (CNS) role by the CNS, man- team (n = 21, 38%), with breakdowns in communica-
agement, staff nurses and physicians is important in tion reported as the top factor (Studdert et al. 2003).
avoiding negative conflict and other undesirable out- A qualitative investigation of collaboration between
comes (McMyler & Miller 1997). A comparison of nurses and relatives of frail elderly patients in Danish
critical care physiciansÕ and nursesÕ attitudes revealed acute hospital wards showed that nurses explicitly value
discrepant views about the level of collaboration expe- collaboration and yet it does not regularly occur
rienced (Thomas et al. 2003). Role perception gaps (Lindhardt et al. 2008). Factors included organization
were also found within a spinal cord rehabilitation team and societal values as well as the organization of care
(Pellatt 2005). The introduction of new nursing roles, and nursesÕ communication skills.
that were previously medical roles, was linked to con- Different points of view about end-of-life care, par-
flict among professionals (Price & Williams 2003, ticularly decisions involving physicians, nurses, patients
Davies & Lynch 2007). Conflict between nurses and and family members about whether to withhold or
other non-physician health care professionals was doc- withdraw life-sustaining therapy, can lead to deterio-
umented in a study involving hospital-based midwives rating communication and the need for a conflict reso-
(Kennedy & Lyndon 2008). Racial diversity in health lution process involving one or more third parties (Luce
care teams can be a challenge for communication effe- & White 2007).
ctiveness (Dreachslin et al. 2000). Evidence suggested there is often poor communica-
Conflict involving nurses emanated from the mix of tion about end-of-life decisions and thus conflict occurs
administrative and financial perspectives present among among clinicians as well as among clinicians and family
the many categories of professionals working in health members (Boyle et al. 2005). A study exploring ÔgoodÕ
care. Different groups of health care professionals, and ÔbadÕ deaths in the UK found the management of
including nurses and nurse trainees, had different views death in hospitals is a major point of conflict for nurses
of what constituted effective hospital administration with nurses mainly focused on their own sense of con-
(Vlastarakos & Nikolopoulos 2008). Those working in trol (Costello 2006).

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 Education designed to build a learning culture

Other research demonstrated that communication ten-

Costs of unmanaged conflict in nursing
sions and conflict talk are a normal part of coopera-
The review of the literature showed that unmanaged tively performing health care work. The needs for
conflict was costly not only in a monetary sense and not autonomy and connection are necessary for health care
only for nurses. Arford (2005) summarized the steep professionals and can themselves cause conflict (Jame-
costs of nurse–physician conflict by pointing out the son 2003, 2004). It is helpful that they can often be
links to medication errors (Kohn et al. 2000), patient reconciled with the use of politeness, thereby meeting
injuries (Page 2004) and patient deaths (Tammelleo the organizationÕs needs for collaboration (Jameson
2001, 2002). Earlier Gerardi (2004) provided extensive 2003, 2004).
listings of direct and indirect costs of conflict. Direct
costs of conflict included litigation costs, lost manage-
Conflict communication interventions
ment productivity, employee turnover costs, disability
and worker compensation claims, regulatory fines or The literature indicated good communication and con-
loss of contracts or provider status, increased care flict management were important in nursing. A Euro-
expenditures to handle adverse patient outcomes and pean study found communication quality was
intentional damage to property. Indirect costs of con- significantly better in hospitals with good attraction and
flict included damaged team morale, lost opportunities retention rates for nurses (Stordeur et al. 2006). A
to manage future-oriented projects, costs to patients, survey of nurse experiences in Lithuania found, in part,
cost to reputation loss of market position, increased that nurse motivation increased when they were able to
incidence of disruptive behaviour by organizational collaborate with physicians, when they were recognized
insiders and emotional costs. as autonomous and when there was effective interper-
The negative effects of persistent conflict are a major sonal communication and conflicts were solved con-
concern (Almost 2006). For example, workplace con- structively (Zydziunaite & Katiliute 2007). A study of
flict has been linked to decreased work satisfaction and six ICUs in a Belgian hospital found nursing leadership
team performance in nursing (Cox 2003). It damages and authority, communication and conflict manage-
the work climate as well as the individual, both physi- ment most influenced perceived unit effectiveness and
cally and psychologically (Danna & Griffin 1999). job satisfaction (Vandenberghe & DÕhoore 1999). In the
Nurses in conflict with other nurses in Japan reported a United States, enhanced communication mechanisms
higher likelihood of leaving their current job (Lambert comprise one of the strategies for more effectively
et al. 2004). Persistent conflict resulted in higher turn- dealing with a managed care environment (Buiser
over and absenteeism, lower coordination and collab- 2000). A number of interventions were implemented
oration and lower efficiency (Spector & Jex 1998, De that have improved conflict communication involving
Dreu et al. 1999). Finally, given the increased attention nurses. Some of these interventions advanced conflict
verbal abuse has received in recent years, it is worth communication as a primary goal, others as a secondary
noting that it specifically was shown to negatively im- goal, and some impacted it indirectly (i.e. were not
pact patient care, work satisfaction and turnover rates seeking to impact it and yet recorded an impact).
(Manderino & Berkey 1997) as well as morale, pro- Conflict communication gains were documented for a
ductivity and error rates (Watson & Steiert 2002). number of nursing education and mentorship pro-
grammes (Langan 2003, Murphy & OÕConnor 2007,
Latham et al. 2008, Seren & Ustun 2008). A compari-
Beneficial and normal conflict communication
son study of nursing students in Turkey using a prob-
While conflict was often referred to negatively and lem-based learning (PBL) curriculum showed conflict
aberrantly within the arena of nursing communication, resolution skills and related skills for the PBL group
its positive and normal functions were highlighted at were significantly higher than those using a conven-
times. For example, a professional team may combine tional curriculum (Seren & Ustun 2008). A study of
perspectives ensuring that various important interests staff nursesÕ role experiences within a practicing and
are represented (Palmeri 2004). Studies of gossip non-practicing nursing faculty demonstrated that staff
(Waddington & Fletcher 2005) and emotion talk (Li & nurses working within a practicing nurse faculty expe-
Arber 2006) demonstrated conflictÕs sometimes positive rienced lower levels of role overload, conflict and
(e.g. building relationships and managing emotions) ambiguity (Langan 2003). A preceptorship programme
and sometimes negative nature (e.g. damaging rela- intended to better transition new nurse graduates into
tionships and causing emotional upset for others). the clinical environment was successful in preventing

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R. Brinkert

conflict between new and more experienced nurses cially regarding conflict resolution (Hughes & Kring
(Murphy & OÕConnor 2007). It was also found that a 2005). The introduction of systematic conflict resolu-
coordinated team approach supported the preceptees, tion methods, including the use of techniques and pro-
decreased the stress and workloads of preceptors and tocols, in a peri-operative setting resulted in a reduction
fostered confidence in the new nurses. The 3-year study of surgical procedure delays, efficient ordering of sup-
of an academic hospital-registered nurse mentor and plies and enhanced interpersonal relations (Pape 1999).
advocacy programme found the use of comprehensive A study of the impact of a new organ donation protocol
mentor–mentee teams improved nurse–nurse percep- demonstrated that all measures of role stress, particu-
tions and the perception of nurses by others, reinforced larly role ambiguity and role conflict, were significantly
support by managers and colleagues and improved improved (Dodd-McCue et al. 2004, 2005).
patient care outcomes (Latham et al. 2008). These Breakthroughs in the area of verbal abuse have also
study outcomes were expected to support better nurse accumulated. Buback (2004) compiled a diverse list of
retention as well as patient safety. The overall pro- interventions in order to avoid and better respond to
gramme was carried out in partial acknowledgement of instances of verbal abuse. Noting early indicators of
the need to improve conflict resolution and succeeded in verbal abuse and documenting and reporting incidents
developing a culture of support. are important (Jacobs 2000). Institutions should have
Evidence has accumulated regarding conflict com- policies and procedures in place and respond to inci-
munication, supervisory support and development dents of verbal abuse with training and tracking
opportunities for frontline nurses. Within the supervi- (Cameron 1998). Assertiveness training and communi-
sor–employee relationship, open communication was cation training were found to be effective in coping with
important for the employee to negotiate his or her role verbal abuse (Cook et al. 2001). Other interventions
and this perceived role negotiation ability was linked to include counselling and education programmes
the experience of reduced role conflict and increased job (Anderson & Stamper 2001), with education and col-
satisfaction (Miller et al. 1999). Apker (2001) devel- laboration seeming especially important (Watson &
oped this line of work by demonstrating that supportive Steiert 2002).
and collaborative communication, especially with
managers, was very important for nurses coping with
Additional conflict communication strategies
ambiguities in a managed care environment. Apker
(2001) also found that nurses who had the opportunity Research detailing the gaps between the anticipated and
to develop their professional roles beyond their tightly actual work of nurses recommended more emphasis on
worded responsibilities acquired new skills, gained conflict competence in nurse education (Cheek & Jones
confidence and appeared to have increased job satis- 2003) and putting other strategies in place that reduce
faction and morale. An analysis of a small programme occupational stress, role conflict and role ambiguity, as
designed to teach practical conflict management strat- well as increase job satisfaction (Lu et al. 2008).
egies to supervisors and managers in a health care Heightened emphasis on communication and negotia-
organization resulted in significant differences regarding tion skills in nurse education was encouraged to
the handling of stress (Haraway & Haraway 2005). A improve paediatric care (Corlett & Twycross 2006).
charge nurse-development workshop that included Negotiation and conflict resolution skills were noted as
conflict management skills was judged to have a sig- important for nurses given health care reform, changing
nificant return on investment (Sherman 2005). A study roles, unclear lines of responsibility and other factors
of a leadership development programme for front-line (Hrinkanic 1998). The ability to manage conflict
nurses seeking, in part, to develop conflict and com- effectively was identified as important for nurses in
munication skills found that participants self-reported direct care roles (Rodney et al. 2006) and supervisory
understanding and ability gains both immediately and roles (Pillemer & Johnson 1998). Also, conflict pre-
3 months after training (Krejci & Malin 1997). vention was identified as one area for BOS improve-
The introduction of brand new roles and protocols ment (Poncet et al. 2007).
positively affected conflict communication. Training for Developing more effective conflict communication
the specialized new role of a paediatric nurse practi- was widely recognized as important in the professional
tioner enhanced conflict management abilities (Davies partnerships and teams in which nurses are involved.
& Lynch 2007). Implementation of dedicated charge Collaboration between physicians and nurses has
nurses in a busy medical–surgical nursing department become more sophisticated as nursing roles have
significantly increased perception of teamwork, espe- changed and, accordingly, collaboration continues to

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 Education designed to build a learning culture

need to be supported in research and practice (Taylor- throughout the organization with the flow of conflict
Seehafer 1998). Given the known costs of dysfunction, resolution processes and activities clearly delineated.
health care organizations have the responsibility to
provide an environment for effective nurse–physician
Discussion
communication (Arford 2005). More effective conflict
communication has been called for between nurses and A consideration of the literature on conflict communi-
other professionals in specific areas, including childcare cation in nursing sheds light on a number of knowledge
health (Crowley & Sabatelli 2008), critical care (Corley gaps. While conflict cannot be entirely eliminated from
1998), end-of-life (Frederich et al. 2002, Keung & nursing, particular sources of destructive conflict may
Chair 2006), palliative care (Weissman 2003), perinatal be decreased or eliminated. For instance, teaching
care (Simpson & Knox 1999, Gilliland 2002) and conflict management to supervisors and managers
resuscitation (Robinson et al. 2007). significantly decreased stress (Haraway & Haraway
There have been calls for the design of health care 2005). More can be done to document existing
workplace conflict communication programmes to instances of controlling conflict sources, evaluate the
include mediation-related and emotional intelligence- effectiveness of these practices and design and evaluate
related content and skills. Gerardi (2004) proposed that additional such practices.
mediation skills and techniques could be used to Even when wholly or largely negative conflict is
improve health care work relationships and larger health unavoidable, it may still be possible to minimize the
care and health system goals. The finding that high emo- associated costs. For example, conflict between nursing
tional intelligence was associated with the desirable colleagues may get entrenched and jeopardize nursing
nursing conflict style of collaboration suggests emo- effectiveness and patient safety; however, the availability
tional management and conflict resolution components and use of mediation may help decrease the duration and
in training programmes for nurses and the other pro- costs of this conflict. The range of alternative dispute
viders with whom they interact (Jordan & Troth 2002). resolution practices, including arbitration, mediation
Resolving communication conflicts is important for and conflict coaching (Brinkert 2006, Jones & Brinkert
improving access to health care for multicultural and 2008), were designed in part to decrease the costs of
multilingual patient populations (Brice 2000). Collab- conflict. Their application and the study of their effec-
oration has been encouraged among health care pro- tiveness in nursing deserve more consideration.
fessionals, patients and families (Encinares & Pullan The benefits of conflict in nursing have only been
2003) and among all health care community members considered lightly. There are times when conflict may be
(Deutschman 2001). Better nurse conflict communica- desirable. For example, conflict on an interdisciplinary
tion skills are valued for nurses working with patients, team can mean the patient benefits from treatment
families and other professionals in various areas, decisions based on carefully considered and combined
including end of life (Halcomb et al. 2004, Costello expertise. More can be done to identify these kinds of
2006, Pierce 2006, Sorensen & Ledema 2007, Searle & instances and document how to make the most of these
McInerney 2008) and forensic care (Encinares & Pullan opportunities. Effective conflict management in nursing
2003). may at times involve strategically introducing conflict
While calls for intervention have mainly focused on where there was none in the past, such as when nurses
the interpersonal level, some have called for a combi- commonly and immediately confront each other about
nation of efforts. For example, in order to avoid con- patient care concerns thereby decreasing the potential
flicts regarding end-of-life treatments, Pierce (2006) for patient harm and more serious inter-professional
recommended the patient–provider partnership be rec- conflict in the future.
ognized, a communication mechanism needs to be in Although research has established the efficacy of
place for clarifying patient preferences and the effective some direct and indirect interventions, initial findings
integration of hospital office-level options (such as the could be verified and other interventions could be tested
ethics committee and legal department) needs to occur. for the first time. Care should be taken to both learn
Nurse–physician collaboration strategies are recom- from intervention research outside of the nursing arena
mended at the organization and policy levels (Corley and remain open to the potentially unique nature of this
1998). Porter-OÕGrady (2004) proposed that health setting.
care organizations develop a programmatic infrastruc- The many sources and steep costs of unmanaged or
ture and committed leadership team in order to effec- poorly managed conflict and the limited use of benefi-
tively manage conflict. The programme should apply cial conflict suggest additional interventions may well

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R. Brinkert

be helpful. Conflict communication remains an under- tively handling sources, costs and benefits. Recogni-
developed area of nursing. Even where conflict inter- tion of conflict as normal makes it acceptable,
ventions have been shown to work (e.g. with nurse arguably even obligatory, to directly address conflict
mentorship programmes), other interventions may turn and treat it as a significant matter.
out to be equally valuable. Further, a redundancy of • The existing literature provides solutions that can be
interventions may be beneficial. Conflict interventions implemented to improve conflict processes and out-
are needed at all nursing levels and at all relational comes. Despite concern with the interpersonal and
interfaces. evidence of its effectiveness, Vivar (2006) noted there
There is a need to carefully evaluate the validity of are few conflict communication courses available for
findings in various nursing conflict communication sub- nurses and further conflict-related nursing education
areas, especially given the use of mixed methodologies is greatly needed for both staff nurses and nurse
across studies. These analyses could lead to a larger yet managers. Efforts towards enhanced communication
detailed mapping of the conflict communication litera- can be relatively easy and inexpensive for nursing
ture in nursing. Although the integration of work from leaders and other administrators to address (Buiser
different perspectives can be challenging, pragmatism in 2000).
the nursing arena and the complexity of conflict seem • Interventions are needed within and across nursing
well served by mix methods. areas and should extend beyond nursing roles. The
Given the reach of conflict in nursing, its documented overall depth and breadth of the programme means
origins and costs, its possible benefits and the fact that multiple stakeholders need to be engaged and conflict
the vast majority of interventions to date have been management resources need to be shared. Nurse
discrete, there seems to be a need to manage the overall managers almost certainly require support to carry-
endeavour. This may help ensure programme compre- out these activities. Local actions should be sensitive
hensiveness, consistency and continuity. to system guidelines. Likewise, the system should
It is notable that Porter-OÕGradyÕs (2004) focus on a adapt in the face of local successes as well as successes
systematic approach to conflict communication within beyond the organization.
health care is supported by more general efforts to • Conflict communication in nursing continues to un-
design organizational dispute systems (Lipsky et al. fold. Nurse managers can play an important role by
2003). These authors call for structuring conflict man- partnering with researchers when applying new and
agement in terms of specific principles: existing interventions.
• scope (include all internal organizational members);
• culture (welcome different perspectives and encour- Conclusion
age conflict engagement and resolution at the lowest
Conflict communication plays a central role in nursing.
levels possible);
The sources and costs of conflict have been well estab-
• multiple access points (ensure easy access to knowl-
lished. The benefits of conflict are apparent and need to
edge about the system and those capable of address-
be further established. The overall impact of conflict
ing the conflict in question);
communication in nursing suggests additional inter-
• multiple options (offer interest-based and rights-
ventions are necessary for all types and stages of nurs-
based options for resolution);
ing. Nurse managers may positively address conflict
• support structures (coordinate the conflict manage-
communication in nursing by normalizing conflict, uti-
ment system so it remains accessible and integrated
lizing proven proactive and reactive interventions and
with daily operations).
helping to build integrated conflict management sys-
These efforts support more empowered individual tems. Nurse managers can also advance this area by
employees, a more collaborative climate and can greatly collaborating with researchers to study existing and
lower the time and costs associated with managing emerging conflict communication efforts. Conflict
conflict. communication has been tied to major contemporary
issues in nursing including horizontal and vertical vio-
lence, the intergenerational workplace, burnout, turn-
Main implications for nurse managers over, better patient outcomes and financial success.
Based on these connections, it should be of intensified
• Openly acknowledging the central role of conflict in concern to all those involved with the advancement of
the work of nurses sets a foundation for construc- nursing.

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 Education designed to build a learning culture

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