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Conflict management in institutional nursing: Risk or opportunity?

Manuel Amezcua
Facultad de Ciencias de la Salud, Universidad de Granada, España

Index de Enfermería [Index Enferm] 2012; 21(1-2): 7-8

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    The Director of Nursing tried to communicate bad news. He tried to notify the surgical nurses of a series of extraordinary measures that came as a result of the application of a recently adopted decree of cuts by the public administration (salary reductions, increased working hours, suspension and readjustment of bonuses and incentives, etc). The unrest among the attendees grew, as he outlined, with the precision of a surgeon, the insidious measures that would have a decisive impact on the lives of each person. Faces of perplexity and indignation appeared as they realized that in the logic of the administration they were only numbers, easy to tally as a rudimentary balance between workers and hours, seeing if they could let go of any workers. Any attempt at reasoning was cut short with a single argument, monotonous and heavy as a stone, like the bunch of papers he brandished in an upheld fist in a mix of indignation and hidden delight: "I have not made this decree, what you have to say about the subject, you know who is responsible." The irrelevant argument about figures frustrated all attempts at dialogue (Julián Marías said the reason is always narrative).  It ended with an angry refusal to give further explanation. Among the nurses there were no reactions other than conversations during shift changes and refusal to cooperate with supervisors in some activities entailing wilfulness.
    This is the scene of a conflict between professionals and their command structure, so common in healthcare organizations that it is easily recognizable, no matter where it is carried out. The question is whether clinical nurses, on top of suffering though this, are aware of the origin of the problem and are capable of analyzing it and discerning a reasonable explanation. The answer is yes, although they rarely verbalize it in public forums. To my question, this is the response given by a clinical nurse: "In our healthcare system coexist two models of management, those that generate conflicts internally (with oneself) and externally (with other professionals) when understanding work, especially among nurses. This is probably due to that we play with the rules and requirements of one model and the convictions of the other, making it so that the quality of work is declining. Working for objectives, as proposed by the clinical management style, can be a source of patient safety, motivation for professionals and efficiency for the healthcare system but can also be a double edged sword when no one believes in the objectives, when people work for tax purposes and above all, when the objectives, instead of becoming a source of motivation, become a numbers game. To work for goals, people must believe in and trust them. And to believe in goals they need managers who know how to negotiate, explain and communicate them in a coherent way" (María Gálvez González, vía email 08/16/2012).
    In a time in which organizational engineering advocates new ways of managing people, in which each day the role of shared decision making acquires a greater importance, as well as the responsible participation of qualified professionals, how is it possible that nursing directives anchored in obsolete administrative models survive? How do they persist in places that are ready for a health alternation? How are nurses who serve as directors able to install management styles that represent opposing values? Is it consistent that those responsible, who were trained and selected based on organization models of the past, have passed through various reforms without adapting their management style? How have they marginalized highly qualified emerging professionals in the area of decision-making, professionals who have reached higher cycles of education, including specialized management programs and who would opt for a performance more fitting to the time we live in? Why do knowledge and culture have such bad press in some management styles?
    Although timidly, scientific literature is providing some clues to answer these and other questions. This issue of Index de Enfermeria includes two papers about conflict management in the context of institutional nursing.^1,2 This issue is not new to the journal, which in recent years has been promoting alternative views on nursing management, an area as innovative as it is necessary. I will try to systematize some of the latest published works with the aim to arouse interest in this line of suggestive research.
    It seems necessary to start by mentioning the economic crisis, which has mainly affected Western countries. Given the shocking figures engineering economics produces daily, some legitimate democratic governments are being impersonated by technocratic governments, sustained by the supposed capabilities of redemptive super-executives that accumulate unusual powers and a rare ability to control. These concessions to democracy would not be made without the belief that organizations are complex entities that are highly conditioned by the model of government they adopt. Mintzberg, who maintains a critical stance regarding the sustained formula of the "manager who can do everything," has identified five possibilities of administrative management (machine and performance monitoring, network administration, virtual administration and regulatory control), recognizing that none of these models is better than the other and that we currently operate with all of them.³ In fact, it is common in health organizations to juxtaposition theoretically antagonistic management models, which is often a source of conflict. The Spanish case may become emblematic: although the healthcare system opted more than a decade ago for a new participatory and decentralized management model, utilizing Clinical Management Units, that gives autonomy and responsibility to clinics,⁴ what still predominates in healthcare institutions is a compartmental and hierarchal style with vertical power structures and excessive dependence on the managers by members of the organization, managers who are almost always imposed by the organization itself.
    And in the case of the nurses? It has been noted that the healthcare system, its resources and their distribution, the nature of healthcare systems and the type of management of the organizations have a direct influence on the practice of nursing, which impacts the patient and the family as an object of care.⁵ In the analysis of Brazilian production, it was found that the hospital is the focus of studies related to conflict management by nurses, which allude to issues such as the institutional physical conditions, the organization of work, logistics, and the guidelines defining action.⁶ In their proposal of edifying use of conflict in the nursing profession, Machado et al. identify the sources of inequality that cause practitioners to express their differences; the presence of disparities in technical implementation, in position and social valuation, and in the autonomy of decisions.²
    In the first aspect, the technical application of care, the work of Betrán Salazar records the significance of the lack of nursing care to patients. He shows that the lack of nurses at the bedside of patients (i.e. neglect) and the lack of interaction in care leads to distrust and rejection.⁷
    Regarding the position of nurses in their organization and their social valuation, the Foucaultion perspective by Irigibel Uriz is enlightening. He reflects on the docility of nurses; its power to individuals and communities and the weight it holds in hegemonic healthcare systems. The discipline of nursing, which shows its usefulness as an instrument of government in the service of state ideology, focuses on the construction of heteronymous subjectivity in the health of people and communities, and distances the discipline of its fundamental ethical principles and its ideal goal.⁸
    Collaborating the communication mediums, Heierle Valero has observed that nurses are not identified in papers as individuals but instead are perceived as a group within the work team. The social collective image represented in the media that returns to each nurse does not help them to understand the abilities they possess or the work that they do.⁹ The discordance between identity and image, according to Calvo Calvo, is due in part to the fact that the nurses themselves have not worried enough, individually and collectively, to effectively communicate their true identity to society.¹⁰ Other authors attribute the lack of social recognition of nursing to the influence of gender in the nursing profession, being symbolically associated to feminine characteristics.¹¹
    The third issue that is a source of organizational conflict (autonomy of decisions) has produced articles, such as that of Yáñez Gallardo et al. about the emotional consequences of distrust in nursing leadership, identifying anger towards the perception of injustice as the primary emotion and the trigger situation of organizational silence while associating with non-participating management styles.¹ A silence that if at an individual level decreases self-esteem and provokes feelings of frustration or anger, at a group level can produce even greater cohesion to avoid discussion of any kind.¹²
    Finally, we also find proposals that seek to balance the nursing performance in the organization, such as one that advocates informational literacy (support of evidence based practices) by proven impact on the quality of care.¹³ Undoubtedly one of the most daring is one that proposes the nursing proffesion to live reflectively, by the domination of others as a risk and a challenge at the same time.¹⁴ The theory of practice of Bourdieu, Acebedo-Urdiales et al. defends the necessity to work beyond autonomous job descriptions and collaboration and to situate nursing practice in a culture of compromise with the ability to promote an environment with the capacity of offering knowledge and recognition of intentional care.¹⁴
    Thus, the nurses of that hospital's surgical unit should reflect on the symbolic capital that constitutes the accumulated experience in their field, that qualifies and gives them authority and that opens the possibility of cultivating co-responsibility with respect to their bosses, other professions and the people they serve. Their "trade" and practical wisdom allow them to follow the rules with authority and autonomy. But these rules must be tested with bravery and validation of consequences.

References

1. Yáñez Gallardo, Rodrigo; Valenzuela Suazo, Sandra; Dagnino Rivera, Paulina; Cuadra Olmos, Rossana. Las consecuencias emocionales de desconfiar en las jefaturas de enfermería. Index de Enfermería 2012; 21(1-2):28-32.
2. Machado, Bruna Parnov; Paes, Lucilene Gama: Diaz, Paola da Silva; Santos, Tanise Martins dos; Lima, Suzinara Beatriz Soares de; Prochnow, Adelina Giacomelli. Conflictos en las instituciones de salud: desafío necesario al trabajo del enfermero. Index de Enfermería 2012; 21(1-2):58-61.
3. Mintzberg, Henry. Gestionar el gobierno, gobernar la gestión. En Losada i Madorrán, Carlos (ed.). ¿De burócratas a gerentes? Las ciencias de gestión aplicadas a la administración del Estado. Banco Interamericano de Desarrollo. Washington, DC: 1999. Cap. VII: 197-211.
4. Matesanz, Rafael. Gestión clínica: ¿por qué y para qué? Med Clin (Barc) 2001; 117: 222-226.
5. Molina Mula, Jesús. El sistema sanitario: efecto sobre la práctica clínica de las enfermeras. Index de Enfermería 2011; 20(4): 238-242.
6. Guerra, Soeli Teresinha; Prochnow, Adelina Giacomelli; Cartana, Maria do Horto Fontoura; Santos, José Luís Guedes dos. El conflicto en la gerencia de enfermería: un análisis de la producción científica brasileña. Index de Enfermería 2010; 19(2-3): 147-151.
7. Beltrán Salazar, Óscar. Cuando las enfermeras están ausentes. Index de Enfermería 2010; 19(4):240-244.
8. Irigibel Uriz, Xabier. Enfermería disciplinada, poder pastoral y racionalidad medicalizadora. Index de Enfermería 2008; 17(4): 276-279.
9. Heierle Valero, Cristina. La imagen de la enfermera a través de los medios de comunicación de masas: La prensa escrita. Index de Enfermería 2009; 18(2):95-98.
10. Calvo Calvo, Manuel Ángel. Imagen social de las enfermeras y estrategias de comunicación pública para conseguir una imagen positiva. Index de Enfermería 2011; 20(3):184-88.
11. Arroyo Rodríguez, Almudena; Lancharro Tavero, Inmaculada; Romero Serrano, Rocío; Morillo Martín, Mª Socorro. La Enfermería como rol de género. Index de Enfermería 2011; 20(4): 248-251.
12. Leyva-Moral, Juan M. El silencio entre los profesionales de la salud, un arma de doble filo. Index de Enfermería 2008; 17(1): 34-8.
13. García-Martínez, Montserrat; Lleixà-Fortuño, María del Mar; Nieto-de la Fuente, Carmen; Albacar-Ribóo, Nùria. Competencia informacional en enfermería y otros profesionales de la salud. Index de Enfermería 2011; 20(4):257-261.
14. Acebedo Urdiales, Sagrario; Jiménez Herrera, María Fca.; Rodero Sánchez, Virtudes; Vives Relats, Carme. Re-Pensando las complejidades del rol profesional desde la teoría de Bourdieu. Index de Enfermería 2011; 20(1-2):86-90.