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CONFLICT IN HOSPITAL & ITS MANAGEMENT

1. Conflict can be defined as distress due to opposition to incompatible

wishes or desires. To the extent that group goals and individual goals are in
agreements, there develops a sense of group identity, loyalty and co-
operation. But when members of one group are confronted with the
individual or group not conforming to his group norms, a state of conflict
develops.

2. A certain amount of conflict is beneficial to organization because it

leads to tension which subsequently brings change and innovation. The
potential for conflict in hospital is readily apparent. It is doubtful that any
other organization has such a wide range of specialized personnel
gathered together in one work group. The administrator is continually
faced with eruptions of personal or departmental conflict. Periodically,
administrator-medical staff conflicts break into public view. Consumers of
hospital services level changes of inefficiency and in-attention to consumer
expectations and employees strikes receive wide publicity. In addition the
unexpected and emergency nature or many of the treatments provides
situations of stress that can lead to conflict. It, therefore, behaves the
administrator of a hospital, to be able to manage conflict, the
administrator must identify underlying factors.

THE NATURE OF CONFLICT

3. Conflict affects the quality of patient care adversely. There is higher
quality care in hospitals where physicians and Nurses had a greater under
standing of each other’s work, problems and needs. Studies of mental
hospital report that patients are affected adversely by staff conflict. While
conflict may faster institutional innovations and progress, the welfare of the
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individual patient is served more effectively by institutional stability and
harmony. Moreover system in which it occurs and lead to gross distortions
of reality. Conflict can be divided into
a. individual conflict
b. Interpersonal conflict
c. Group conflict
d. status factor
e. Client-hospital conflict.

INDIVIDUAL CONFLICT
4. Conflict can be interpersonal, that is, within the individual himself, we
sometimes bear of the employee whose standard of living exceeds the pay
he receives from his job. If there is no change in this situation, he soon
becomes in conflict with himself because his needs are not met. One
reaction is for him to strike out at supervisors and fellow employees as an
escape from his dilemma. We sometime note this type of reaction when
other needs such as security or self-esteem are not met. An individual
employee in a hospital may also find the work situation frustrating because
there are no promotional opportunities without more education. To
complicate the situation even more education is costly and means loss of
income while pursued. Personal attributes can also contribute to conflict.
Kahn’s studies relate personality. Variables to experiences of strain. He
found tension more pronounced of introverts, emotionally sensitive people
and individuals who were strongly achievement oriented. Personality
characteristics also affected the degree of individual conflict and tension.
Individuals who were relatively flexible and these who were achievement
oriented were more susceptible to conflict pressures.
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INTERPERSONAL CONFLICT

5. The second type of conflict relates to interpersonal factors. An

individual’s role in the hospital can have major effect on the conflict to which
he is subjected. His personal characteristics and past experiences will
determine how will he can cope with role conflict. Role theory, including role
conflict has received considerable study, although little in hospital setting,
Katz & Kanh define ROLE CONFLICT as “the simultaneous occurrence of
two or more role sending such that compliance with one would make more
difficult compliance with the others”
It is easy to imagine the role conflicts raced by physicians, nurses and
administrators, physicians, for example function as agents for the individual
patient, their own specialists, their profession, their staff, their institution
and their community as well as in the role of individual practitioners,. The
physician’s obligations to these individuals and group and their obligations
to themselves, are periodically in conflict (defined as inter-role conflict). The
nurse is frequently caught between multiple lines of authority (intersender
conflict). The administrator often functions in a boundary role, between
nurse and physicians, two physicians, patients and the employee and soon.
Role ambiguity is related to role conflict. It can be defined as uncertainty
about the way one’s work is evaluated by superiors, and about scope of
responsibility, opportunities for advancement, and expectations of other for
job performance, a verity of studies have demonstrated that there is
frequently a wide disparity between what a superior expects of a
subordinate and what the subordinate thinks is expected. In an industrial
setting Kahn found the individual consequences of role ambiguity generally
comparable to the individual effect of role conflict. These consequences
include
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a. Low job satisfaction

b. Low self confidence
c. A high sense of futility
d. A high score on the tension index
House and Rizzo, however, suggest on the basis of their research with
business executives that more emphasis should be place upon
eliminating role ambiguity as an intervening variable between
leadership behavior and organizational effectiveness. Thus
interpersonal conflict is defined broadly to include:-
a. Interpersonal disagreements over substantive issues such as
policies and practices.
b. Interpersonal antagonism that is, the more personal and

emotional differences that arise between independent human

beings.
Both forms are very common in the hospital setting although
interpersonal antagonism would seem to be more prevent because by
nature they deal with emotions. However, no studies were found
concerning the relative frequency, severity, or source of interpersonal
conflict in hospital. Surveys in industrial enterprises found that tension
and strain increased directly with occupation status. Individual in
professional and technical occupations experienced the most tension
followed by managerial, then clerical and sales. However, Kahn found
the medical administrator in the industrial plant who works under
conditions of high role conflict scored low on tension. In a case study
he found that administrator kept potential conflicts in a delicate
balance by retreating into their own section of expertise, that is
statistical and financial management. The obvious implication is that
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administrations can minimize conflict by restricting their role. While this
study has been carried out in non-hospital setting, one can logically
assume that there will be a positive relationship between the scope of
the administrator, role and efforts to effect changes and the ;degree of
administrative conflict, a coping mechanism that limits scope may aid
the equanimity of administrators but will not help fulfill their broader
obligations and responsibilities, considerable basic conflict in nursing
is evident from many studies. Most of these inquiries indicate that
nurses are satisfied with their vocation, but dissatisfied with specific
conditions of salary, working hours, etc. However, Argyris suggests
more basic problems such as frustration of the dominant
predispositions of nurses. He reports that nurses in the hospital be
studied were not able to fulfill effectively important dispositions, such
absent being self controlled, indispensable, compatible and expert,
status may be a source of conflict among nurses. In year pat, nursing
was one of the few careers Women could enter and attain some
degree of professional prestige. today, many more vocational
opportunities are opening to women as sex discrimination continues to
decline. Women can, or at least believe they can, gain greater
recognition in fields such as business, government, medicine and
teaching. Whereas in the past nurse were virtually the only
professionals in the hospital besides physicians, they are new
receiving increasing competition for status from a proliferation of allied
health professional, many of whom have higher standers of education,
pay and autonomy. Organizational forces present conflict for nurses.
Nurses career advancement has shifted from an individual to an
organizational context in which a nurse must move through the
bureaucratic hierarchy to gain recognition. In this hierarchy, however,
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rewards are not given for professional patient care, but rather for
administrative skills, the development of clinical nurse specialization is
a reaction to this “ person-role conflict”.
The nurse also has to contained with increasing numbers of
technicians such as the clinical pharmacist. All these changes call for
a new role and an examination of the professional position of the
nurse.
GROUP CONFLICT
6. Certain internal characteristics inherent in the hospital
organization faster conflict, for example, interdependence,
specialization and heterogeneity of personnel and levels of authority
all spear to be correlated positively with conflict. In fact few
organization require as many diverse skill as the hospital which has an
average of about three employees of each patient, and use a
heterogeneous health team influenced by over 300 different prefers
signal societies and association.
In industry, top executives usually enjoy both formal and informal
power and status, in the hospital organization however, power and
status do not appear to be centered in the same individuals. This
characteristics, probably unique to hospital organization in a basic
source of administration-medical staff conflict.
Power has been defined as the maximum ability of a person on group
to influence individuals or groups. Influence is understood as the
degree of change that may be effected in individuals or groups.
Authority has been defined as legitimate power. From their review of a
verity of authors filly and house have house have summarized the
basis of power derived.
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Forms:-
a. Legitimacy
b. Control of rewards and sanctions including moony
c. Expertise
d. Personal liking
e. Coercion
Observations fells us that the hospital administrator has :-
a. Legitimacy from delegated authority for hospital affairs from the
governing board.
b. Effective control of funds, beds and other resources.
c. Increasing expertise particularly as management information
system improve.
d. Personal liking
e. The ability to coerce through the demands of outside agencies
such as the joint commission on the Accreditation of hospitals.

THE STATUS FACTOR

7. Georgopoulas and Mann after describing the
administrators as the most influential persons attribute their sources of
influence to delegated authority from trusses, the source of physicians,
influence are said to include their expertise prestige, status and power
in relation to both patients and the community. On the other hand, a
1968 survey reported that “Trustees and medical staff do not view the
administrator as a leader, but as a generally passive influence cought
between the board and doctors. Gopss suggests that physicians tend
to view administration as less prestigious kink of work and Bellin
describes the administrator’s need for status. Moreover, a University
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of Chicago survey of patients and physicians in three Chicago hospital
found hospital administrators prestige ranked behind the various
physician specialists and behind the director of Nursing service and
the pharmacy profession.
Hospital administrators drive for professionalism and their desire for
more prestigious titles such as president or executive vice- president
suggest that they too feel a need to improve their status. Since
physicians attempt to maintain or increase their power and the
administrators to improve their status, both presumably feel
threatened. Under such circumstances conflict increase physician and
nurses, like professional in other fields, give their first allegiance to
professional rather than organizational status. Hence, the potential for
profess sional institutional goal conflict is present. the hospital
origination is sometimes referred to a duopoly with essentially
autonomous and medical staff origination. Group suggests that
each system is oriented to a different set of values, one
emphasizing provision of service, the other maintenance of
operation of organizations. The bar report relate hospital
inefficiencies to this dual management authority. Germane to our
discussion of group conflict is the concept of territory. Ardery
point out that “TERRITORY” has physical and psychological
identification. When a territory has been staked out in terms of
professional contact, education on work interests, it will be
defended. The higher the degree of commitment, the grater will
bee the defence against intrusion or change by an “Outside”. In
addition if the “intruder” is considered to be a “threat” to the group
territory, the defense will be greater. According to the group such
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was administrative personnel, medical staff or newly crated

technical assistants begin to encroach what was once the
exclusive of the specialists, conflict can be expected.
An interesting offset the idea of territory is Barnard “Zone of
indifference”. Barnard believes that, within limits, people are
indifferent to change or encroachment. This suggests that one
way to reduce group conflict where territorial concepts are
increase the zone of indifferent to change or encroachment. This
suggests that one way to reduce inter group conflict where
territorial concepts are involved is to increase the zone of
indifference. This may be achieved through participations in
decision making, improved communication of change in status, to
name only a few possibilities.

Client Hospital Conflict

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Hospitals have not been immune from conflict with consumers, however,
few empirical studies have examined the problems. Patients have very little
view in hospital matters nor, until quite recently, have they seemed to desire
one. We suspect that is largely due to their faith in the professional’s ability
in decided what is best for them. Consumers activities apparently do not see
current constituencies or activities of hospital governing boards as an
effective voice for the client. The AHA patient’s bill rights is an example of
attempts to reduce conflicts and be more responsive to consumer
exportations.
A lack of clearly defined community service goals be an underlying factor in
client-hospital conflict. Etzioni suggests that sometimes an organization goal
become the servant of the organization rather than its master-goals can be
distorted by frequent measuring of organizational efforts because as a rule,
some aspects of its output are more measurable than other” Currently
hospital are susceptible to this inversion of ends and means as suggested
previously. The hospital financial statement, for example, is one of the few
easily understood measurement available to trustees and administrators
and it usually stresses institutional as opposed to patient goals.
Conflict or competition between hospitals is evident from the major
problems, such as comprehensive health planning, designed to reduce it.
However, three appears to be little comprisal research into the seriousness,
underlying sources, or measurable effects of such conflict. It can be
assumed that the displacement of community service goads by institutional
goals would have important
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consequences, since what is best for a particular hospital is not always best
for the community it serves.
MITIGATION OF CONFLICT
9. We have discussed many policies, practices and procedures in
hospital that tend to reinforce conflict. In part this is a perceptual problem,
however in hospitals as in other organizations there are certain traditional
loyalties and conflict may arise if these are challenged.
If, for example a situation is pushed to the point where employees must
take a pre-patient position this may resulting person-role conflict. Such
situation and the work flow patterns and pressures that result from
emergency events cannot be completely eliminated. However the wise
administrator will try to eliminate situation that end to reinforce conflict
behavior and resulting lack of effectiveness. Before presenting a decision
model that is useful in diagnosing and militating conflict, some general
managerial approaches to the problems can be reviewed.
Historically, one of the earliest approaches was to eliminate the
apposition. In the animal world we see many examples of the stronger
eliminating the weaker in the battle. The weaker member is not necessarily
killed, but he is certainly excluded from the battlefield.
10. The history of warfare certainly give us sufficient example of man’s
use of this approach. Certainly we do not see warfare situation in health
service organizations. However, the tactic of dominating or eliminating the
opposition is is certainly used. Opposing people are transferred or fired,
departments are re-organized or eliminated, salary increases are with held
or boycotts conducted. Finally, we are all familiar with the “put down
participated by many individual. In
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general, however, although the domineering approach may force
“underground” it is hardly a viable approach in this day and age.

11. A second general approach is the development of bureaucratic

rationality will its resulting policies, rules and procedures. In this situation the
concept of authority is contained either in document or in informal
procedures. Deviations are examined in the light of policy and basis for
eliminating the conflict inducing practice is provided. This type of approach
seem very efficient but is probably not effective, especially as for as
employees or patients are concerned. We have all been refused requests
for an explanation with the comment: II IS POLICY. Again conflict is not
mitigated.

12. The third general approach involves bargaining. Bargaining often

results in a win-loss situation “ I gain what you give up”. Probably if
bargaining were though of as a problem solving process rather than in term
of balance of power, it would be more useful in setting conflict. In fact it can
be argued that bargaining cannot exist unless there is conflict.

ACTION PROGRAMME FOR MITIGATION OF CONFLICT

COMPREHENSIVE INSTITIUTIONAL GOAL SETTING

13. Comprehensive goad setting is formalized programme to define goals

and objectives expiry. Too often goals are defined implicitly e.g
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“high quality care at low cost”. Explicit goals list measures that will affect
quality and cost. Often goals can be stated in terms of specially attainable
objective. Goal definition should begin with a study of the needs of the
society the institution intends to serve in order to obviate displacement of
goals. Medical staff members and employees, in addition to administrators
and trustees should participate. Sociologists, political scientists, and
economists as well as planner and citizens of the publics served, could
provide appropriate resource personnel. Explicit institutional goals aid
community understanding, assist internal and external evaluation of outputs
by reducing overemphasis on inputs such as coats and facilities, help
sublimate personal differences by focusing efforts on and results, and help
to marshal required resources for attaining goals.

ORGANIZATION CHANGES, PUBLIC RELATIONS ROGRAMMES

14. Communication can be improved by broadening the official lines of

communication with the citizens served by the institution. Policies for the
governing board membership might be revised to represent more
appropriately the constituencies served, or an advisory board might be
established to review expressed needs of the constituencies and hospital
programs to meet needs. A public relations programme based ion
appropriate client attitude surveys might be beneficial.
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COMMUNITY GOAL SETTING

15. While many communities are beginning to prepare plans for
community health services, some have not effectively articulated the explicit
goals and objectives that the plans are meant to serve. Appropriate
comprehensive health planning by the community should stimulate
institutions to focus on community needs and objectives rather than just on
institutional needs and objectives.

MANAGEMENT BY OBJECTIVES AND ROLE DEFINITION

16. Management by objectives (MBO) is the participation between the
subordinate and his superior in setting, the subordinate’s goals. Through
interaction and discussion, a subordinate can determine precisely what is
expected of him, thus reducing the anxiety that results from ambiguity MBO
is designed to improve independence in task performance while at the same
time increasing accountability. Role definition through job descriptions and
administrative manuals can help reduce role conflicts and ambiguity.

CREATIVE PROBLEM SOLVING

17. Creative problem solving utilizes techniques that sublimate
antagonistic conflict and faster creativity. Maier notes the distinction
between “choice behavior” which is an examination and a selection from the
alternatives and problem solving “which is a searching or idea getting
process. When choice situation are turned into problems solving situations,
participants are apt to focus on end results rather than on who is presenting
on standing for what. This approach
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minimizes creativity and sublimates hospitality self pity and rigidity. Creative
problem solving promotes and results in which everyone wins rather than
choice situations in which there is winner and a loser or compromises in
which everyone loses. Transactional Analysis, the “ I am OK, you are OK”
adult to adult communications is another approach based on the philosophy
of trying to avoid interpersonal conflict.

CONSTRUCTIVE CONFRONTATION
18. Issues of conflict tend to proliferate when there are interpersonal
antagonism between individuals. A manager can take certain steps to avoid
issues may result in open interpersonal conflict. However, the indirect
effects of interpersonal antagonism will frequently persist and in the log run
may be more damaging than open confrontation. Walton suggests using
constrictive confrontation with third party intervention, particularly by
consultants from outside the institution. The components of the
confrontation include:-

a. Classifying the issues with parties.

b. Expressing feeling descriptively
c. Expressing facts and fantasies
d. Resolution and agreement

It would appear, however, that third party intervention should be

utilized sparingly.
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PARTICIPATIVE MANAGEMENT

19. Participative management is a philosophy of management in which

hospital employees and physicians participate in a meaningful way in the
administration of the hospital. It is a philosophy espoused by type D
administration role, by Rensis Likert and by late Douglas Mcgergors who
wrote of therapy X *& therapy Y. Studies by Coleman, crowin and other
support the view that board participation in authority system minimizes
major incidents of conflict, although minor incident may be more frequent.
Managements by objectives and comprehensive institutional goal setting are
examples of participative management. In this administrators do not
abdicate their responsibility, they share it by sharing planning, co-
coordination, control and management information, can actually gain more
control ever their responsibilities.

SENSITIVITY TRAINING

20. Sensitively training with emphasis on institutional social system

development, can help to overcome “HANG UP” related to concern over
status. Laboratory training is suggested in preference to the individual self-
awareness training that at tines borders on therapy.
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TRAINING IN A TEAM

21. Health workers are expected to work as a team yet they are seldom
trained to do so. Since hospital administrator spend more time with
physicians and nurse that any other group, it would be beneficial if they had
meaningful dialogs in the formal educational periods. This could be
arranged through seminars or research on subjects such as other legal
problems, group dynamics or contemporary problems in health.
Opportunities could be presented for informal as well as formal associations.
Interdisciplinary study could also be arranged through the work
environment. Combined degree programs between medicine and hospital
administration and or nursing and hospital administration should be
considered seriously. In addition to improving team association at the
educational level, such programs will help to improve the administrative
skills of those who in fact administer a large part of health services.

CONCLUSION

22. Conflict in hospital is a complex issue. While it deserves considerably

more research, much can be done to apply available knowledge of its
sources and mitigating activities. In general, increased demands for service
and attempts to diagnose and lesion conflicts will result in new policies and
procedures. Among these will be research studies to identify the impact of
various conflict situations. In addition we can expect to see changes in goal
setting, planning, organizational relationship and training programmes.