One reason that health care is in crisis is preventable workplace conflict. The avoidable costs* resulting from conflict between people who should . . . and could . . . work together cooperatively drive up the cost of care.
An example is the retention of good employees, particularly nurses and other direct patient-care providers. The national average of voluntary resignations that result substantially from unresolved conflict is 65% — a figure surely higher in health care. A study reported in the American Journal of Maternal/Child Nursing (March/April 2005) shows that the cost of replacing a specialty nurse is 156% of annual salary. So, the cost-benefit of retaining just one nurse by resolving a conflict is over 300 times the cost of attending an upcoming Certification Course.
The Joint Commission on Accreditation of Healthcare Organizations recognizes this important fact. JCAHO issued a Sentinel Event Alert on July 9, 2008 amending its Leadership Standards to include among other requirements/recommendations:
- Develop an organizational process for addressing intimidating and disruptive behaviors (LD.3.10 EP 5) that solicits and integrates substantial input from an inter-professional team including representation of medical and nursing staff, administrators and other employees.
- Provide skills-based training and coaching for all leaders and managers in relationship-building and collaborative practice, including skills for giving feedback on unprofessional behavior, and conflict resolution.
It also recommends that JCAHO-accredited organizations utilize the practice of mediation in their workplaces. Read the 2009 Joint Commission Standards for conflict resolution (on-page PDF), Standard LD.02.04.01.
Certification Course attendees will learn to apply the core competencies for resolving, managing, and preventing workplace conflict — before it escalates to a level that often leads to resignation, retaliation, litigation or other extreme action.
The Professionals (Track 3) option is recommended for health care providers, administrators, human resources staff, and other professionals who work in hospitals, long-term or independent living facilities, and other health care settings.
Managers (Track 2) and key Non-supervisory Personnel (Track 2a) may attend to gain the core competencies for managing workplace conflict.
Or, eliminate the need for travel and extended time away from work by training your personnel through computer-based learning or participating in an upcoming public audioseminar or by scheduling a private audioseminar at a time of your convenience. Review this menu of all service options.
* Click for complimentary access to the Dana Measure of Financial Cost of Organizational Conflict, an on-line calculator producing immediate results. Estimate your financial return on investment in conflict management training.
Can't attend? Or need to train many employees at low cost? Consider using web-based training. Or train your entire team in one hour in your conference room for one low fee by joining an upcoming webinar.
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Edited by Melissa Zarda. See other bibliographies.
Contributors: Sultan Ahamed, M.D., Rose Orsini, Barbara Thompson, Michele Barnas, Cavit Kahya, Scott Martin, Suresh Dhandapani, Kristin Corum, Ramiz Khoda, Amy Brunquell, Claudette Graham, Erika Pereira, Larisa Budnovitch
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Scroll down or click here to view bibliographic references from the National Library of Medicine.
- Almost, J. (2006). Conflict within nursing work environments. Journal of Advanced Nursing, Vol. 53 Issue 4, p444-453
This article discusses the conflict in nursing work environments and how it can lead to job dissatisfaction, absenteeism, and turnover. The article states that Conflict has both positive and negative effects. The article continues on to describe the main consequences of conflict. The main idea of the article is that a better understanding of the sources and outcomes of conflict within nursing work environments would enable the prevention of such conflicts.
- Andrew, L. B. (1999). Conflict management, prevention, and resolution in medical settings. Physician Executive, 25(4), 38-46.
The author provides effective conflict management skills to aid physicians and their coworkers on how to handle conflict situations effectively. The article presents keys on how to prevent conflict, become a better communicator, and how to manage personal anger. The author implies that by using his strategies, it will help enhance individual experience with conflict, especially physicians.
- Aschenbrener, C., Siders, C. (1999) Managing low-to-mid intensity conflict in the health care setting - Part 2: Conflict Management. Physician Executive Sept-Oct.
This article discusses the different types of conflict: something you want or want to avoid, have and want to keep, belief you hold or an action you want or do not want to take. The article disucsses the three types of conflict physicians most incur and and the strategies to manage them.
- Baerlocher, M. (2006) Happy Doctors? Balancing professional and personal commitments. CMAJ 174, 13.
This article discusses the conflict physicians have in balancing their professional and personal commitments. The conflicts arise from work hours, call schedules and time for personal commitments. Managing these main items that cause instability between professional and personal commitments can help doctors deplete the amount of conflict they incur.
- Baker, K. M. (1995). Improving Staff Nurse Conflict Resolution Skills. Nursing Economic, Vol. 13, p295-317.
This article describes which one of the five important types of conflict management approaches is used by nurses in hospital environments. Nurses tend to use the avoidance method, which is not the most effective method in the newly developing hospital management structure that encourages team work rather than a hierarchical decision making structure. Nurses need training to be more effective in this new environment, which requires the collaborative conflict management approach.
- Baltimore, J. J. (2006). Fact or fiction? Nursing Management, 37(5), 28-36.
This article focuses on how to prevent horizontal violence in the healthcare workplace. The author comments on the role that academia plays in increasing conflict among students and staff by valuing student suffering as a passageway into nursing. The author also explores conflict that exists among current older nurses and new nurses when cliques are established. The author offers advice on how to avoid and prevent conflict in the workplace.
- Bloche, M. (2005) Managing Conflict at the End of Life. Perspective, 352, 2371-2373.
This article discusses the conflict that arose between Terri Schiavo's health condition and the law. The conflict is a large debate because although Terri's life is over, this could happen again in the future. Family members, law makers and health care providers need to know how to manage this type of conflict in the future.
- Brandt, M., Holt, J., Sullivan, M. (Nov 2001) How To Make Conflict Work For You. Nursing Management
Fostering an environment of collaboration allows staff room to solve conflicts among themselves. When differences arise among individuals who know how to collaborate, conflict can prove constructive rather than destructive. Teamwork facilitates understanding and leads to a true appreciation of differences, creating a system that values shared decision making and communication.
- Briles, J. (2005). Zapping conflict builds better teams. Nursing 2005, 35(11), 32.
Conflict affects job retention, and enhancing teamwork helps to prevent conflict. The directors of a California hospital wanted to improve their nursing work environment and teamwork. They initiated an outreach program to make nurses feel more cared for and to provide them with valuable skills. For instance, the directors offered monthly workshops on conflict resolution.
- Burda, D. (2006). Double dipping, no ethics. Modern Healthcare, 36(6), 23.
This article examines the conflicts of interest among healthcare executives. Executives are criticized for sitting on boards of hospitals which they also have interests with vendors. Thus, depriving the institution and the public system of fair access to possible lower cost services and options.
- Burk, R.J., & Greenglass, E.R. ( 2000). Juggling act: work concerns, family concerns. The Canadian Nurse, (Volume 96, Issue 9; pp 20).
A study was conducted on a random sample of 3,900 full-time & part-time-time hospital nurses in Ontario . The data was collected using a confidential mail-out questionnaire. Measures were distributed into three categories; personal demographics, work situation characteristics and work family concerns. The mean response of the full-time and part-time nursing staff was compared for all of the study variables. The results reflected fourteen full-time and part-time employees, which differed significantly on certain demographic and situational areas.
- Butler, K. A. (2004). Ethics paramount when patient lacks capacity. Nursing Management, Vol. 35 Issue 11, p18-52
This article discusses the issues in healthcare decision-making for patients who cannot decide for themselves. It explores the conflicts that arise from such a situation between family members and practitioners. This article also describes the ways to resolve conflicts between family members and healthcare professionals regarding healthcare decisions of the patient who cannot decide for him or herself.
- Chen MD, D., Miller PhD, G., Rosenenstein MD, D. (2003) Clinical Research and the Physician-Patient Relationship. Perspective 138, 669-672.
This article discusses the conflict between physicians and their patients when dealing with the teaching of clinical research. Some physicians do not feel the same about clinical practice as they do about clinical research. This causes a conflict when patients ask their physicians for advice about clinical research. Physicians can help their patients understand the conflict they have by describing clinical practice versus clinical research, misconceptions, teaching and advice.
- Chin, M., Lantos, J., Gorawara-Bhat, R., & Roach, C. (2005). Physician response to conflicts between faith and medicine. The University of Chicago Hospitals. www.uchospitals.edu
This article discusses how doctors interpret and respond to conflicts between their medical advice and a patient's religious concerns. The article also addresses the conflicts that arise from the patients religious concerns. The article describes a study that was conducted and describes the three categories that the conflicts fell into.
- Clarke, R. L. (2004). Creating community connections: Hospitals are losing the public relations battle in the conflict over the appropriateness of charging and billing the uninsured. Healthcare Financial Management, 58(10), 148.
This article focuses on the appropriateness of hospitals charging and billing the uninsured more money compared to individual coverage by government or employee sponsored insurance. The author suggests that community groups should review discount and collection policies before they are finalized in hospitals. Thus, hospital image would be improved and they can aid in securing additional funding for the uninsured.
- Collins, T. (2005). Conflicts pitting doctors vs. patients. University of Toronto Joint Center for Bioethics. www.eurekalert.org
This article discuses the conflict between health care providers, their patients and patients' families over treatment options. It explains that the disagreements range from withdrawing treatment from a terminally ill patient to a family physician refusing a patient's request for antibiotics for a viral infection. The article also addresses the top 10 Ethical Challenges in Health Care according to a Canadian study.
- Craig, Donna J. & Cook, John A. Healing Thyself: ADR in the Healthcare Industry
Retrieve from the website August 26, 2005. Www.michbar.org/journal/article.cfe
The American healthcare industry is one of the largest segments of our economy. It includes care rendered by physicians in hospitals, nursing homes, etc. Conflicts in healthcare often arises between the patient right to quality care and the cost of such care. Arbitration and mediation are two of the most common ADR process used in healthcare conflict. The Michigan and federal arbitration acts provides a court enforceable award after a hearing conducted by the arbitrator.
- Davies, J. M. (2005). Team communication in the operating room. Acta Anaesthesiologica Scandinavica, 49(7), 898-901.
The author emphasizes there are six components of effective team communication: situation awareness, problem identification, decision making, workload distribution, time management and conflict resolution. The OR environment is compared to the aviation sector which in the past had severe issues with communication. Since "crew resource management" was implemented in aviation, the author suggests the same concepts should be utilized in the OR setting.
- DelBel, J.C. (2003). Conflict management, special part 1: Deescalating workplace aggression. Nursing Management, 34(9), 31-34.
Workplace aggression is common in healthcare and involves nurses and patients, families, and coworkers. Seven verbal interventions are included in this article to assist with deescalating aggression along with steps to negotiate through conflict. Unresolved conflicts may escalate into crises. In addition managers can help prevent escalation by creating administrative policies and providing training sessions regarding conflict and conflict resolution.
- Desivilya, H.S. & Dana, Y. (2005). The role of emotions in conflict management: The case of work teams. Conflict Management, 16(1), 55-69.
This article describes a study that examined the relationship between perceptions of the type of conflict and resulting emotions on the conflict management methods used in the healthcare setting. Findings showed that integrating and compromising patterns of conflict management were associated with positive emotions. Dominating patterns were associated with positive and negative emotions, and avoidance with negative emotions.
- Evans, M. (2005). Oversight shortfall. Modern Healthcare, 35(51), 12.
This article examines the failed attempts of directors and trustees to audit conflict of interest cases in non-for-profit hospitals. Two thirds of hospitals lack policies that enforce violators. Due to public and regulatory scrutiny, their efforts have improved to reform their current practices.
- Fontaine, D. & Gerardi, D. (2005). Healthier hospitals? Nursing Management, 36(10), 34-44.
Organizational conflict can be caused by poor communication among healthcare providers. This article encourages providers to break the silence referring to the national study, Silence Kills. Defensive behaviors, team breakdowns, staff turnover, and inappropriate hierarchies were some topics of concern to prevent conflict. By implementing organizational standards and AACN standards, healthy work environments can be achieved.
- Frederich, M.E., Strong, R., & VonGunten, C.F. (2002). Physician-nurse conflict: Can nurses refuse to carry out doctor's orders? Journal of Palliative Medicine, 5(1), 155-158.
This article revolves around a case study involving a man diagnosed with malignant melanoma of his lower lip. The patient was admitted to a hospice unit to receive controlled sedation, but the nurse assigned to him would not perform the sedation nor did she inform the doctor of her unwillingness. Fundamentally, nurses may choose not to participate in a patient's care for any moral reason. Improved communication and nurse-physician relationships assist with conflict resolution.
- Fye, MD, W. (2003) The power of clinical trials and guidelines, and the challenge of conflicts of interest. JACC 41, 1237-1242.
This article discusses the clinical trials and practice guidelines that have changed. Through the changes there has been a development of financial conflicts between the academic portion of medicine and the industry. Future doctors and patients rely that enhancements in medicine be made in the future. Therefore, the conflicts of interest must be managed.
- Gattuso, S., & Bevan, C. (2000). Mother, daughter, patient, nurse: women's emotion work in aged care. Journal of Advanced Nursing, Vol. 31 Issue 4, p892-899, 8p.
This article examines the emotional work within the predominantly female environment of aged-care nursing. The article describes the high levels of stress experienced by staff, related to emotional labor and to the conflicts around the decreasing standards of care. The article continues on by describing a research study that was conducted and its findings.
- Gerardi D. Using mediation techniques to manage conflict and create healthy work environments. American Association of Critical Care Nurses Clinical Issues. 2004; 15:182-95.
Techniques developed by mediators for effectively solving conflicts in the complex critical care delivery systems are explored. Listening for understanding, reframing, elevating the definition of the problem to decrease the level of conflict and create healthy work environments is emphasized.
- Haraway, D. L., & Haraway III, W. M. (2005). Analysis of the effect of conflict-management and resolution training on employee stress at a healthcare organization. Hospital Topics, 83(4), 11-17.
The authors examine the impact of having 23 supervisors and managers participate in conflict management and resolution training. Each participant was required to attend two 3-hour sessions on how to learn practical conflict management strategies, and how to apply it to their work environment. The researchers focused on four areas of improvement, role overload, role boundaries, psychological strain and interpersonal strain. They compare participants pretest and post test, to evaluate the learning objectives.
- Harmer, B. M. (2006). Do not go gentle: Intractable value differences in hospice. Journal of Healthcare Management, 51(2), 86-93.
This study explored the causes and consequences of conflict in five New Zealand hospice facilities. Areas of conflict were identified by participants' narrative descriptions. The areas that were most common were participants avoiding conflict in fear of not being portrayed as "nice". The other area of conflict was the opposition of values among staff.
- Hendel, T., Fish, M., & Galon, V. (2005). Leadership style and choice of strategy in conflict management among Israeli nurse managers in general hospitals. Nursing Management, 13(2), 137-146.
The study discussed in this article examines the relationship between conflict management and leadership style. 60 head nurses of Israeli hospitals were given the Thomas-Kilmann Conflict Mode Instrument, the Multi-factor Leadership Questionnaire, and Form 5X-Short. Results showed that head nurses viewed themselves as transformational leaders as opposed to transactional leaders. In addition, compromise was the most commonly used conflict management strategy.
- Herzog AC. Conflict resolution in a nutshell: tips for everyday nursing. Spinal cord injury nursing. 2000; 17:162-6.
In this article five conflict behaviors namely avoidance, competition, accommodation, compromise and collaboration are discussed. They can be right or wrong in different circumstances. Planning resolutions and evaluating the results to complete the process is emphasized.
- Hyman, C.S. & Liebman, C.B. (2004). A mediation skills model to manage disclosure of errors and adverse events to patients. Health Affairs, the Policy Journal of the Health Sphere (Volume 23, pp 22-32).
This paper identifies a model that encourages health care providers an effective way to communicate to patients following an adverse event of medical error, thereby adverting serious conflicting situations. If the disclosure models are used correctly it can effectively create benefits to both patient safety and can minimize litigation risks.
- Jameson, J.K. (2004). Negotiating autonomy and connection through politeness: A dialectical approach to organizational conflict management. Western Journal of Communication, 68(3), 257-277.
The dialectical tension involving the need for autonomy with the need for connection contributes to interpersonal and organizational conflict. Politeness strategies allow for these concepts to be managed simultaneously. Specifically, politeness strategies include: emphasize respect, emphasize solidarity, provide explanation, show deference, and discuss in private after the fact. Within this study, providing explanations was the most effective method to reduce this dialectical tension between anesthesiologists and registered nurse anesthetists.
- Jameson, J.K. (2003). Transcending intractable conflict in health care: An exploratory study of communication and conflict management among anesthesia providers. Journal of Health Communication, 8(6), 563-581.
This article describes a research study that examined the conflict between anesthesia providers, specifically anesthesiologists and certified registered nurse anesthetists (CRNAs) via a qualitative methodology. Results suggested identity issues, distortions of perceptions, and rigidification as factors that influence conflict. In addition, communication behaviors between anesthesiologists and CRNAs may lead to either conflict escalation or conflict de-escalation.
- Jervis, L. L. (2002). Working in and around the 'chain of command': power relations among nursing staff in an urban nursing home. Nursing Inquiry, Vol. 9 Issue 1, p12-23, 12p
This article discusses the power relations among nursing staff in an urban nursing home. The article also explores the power relations among nursing assistants and nurses in an urban nursing home in the United States and the factors contributing to tensions among the nursing staff.
- Jividen, T. C. (2006). Practitioner application. Journal of Healthcare Management, 51(2), 93-95.
This article examines the debate between the interest of the welfare of hospice patients and the financial gain for hospice facilities. The author reports on Brian Harmer's research and cautions that when conflict arises in a facility, it must be addressed and not avoided. Avoidance in his example of a volunteer hospice center, created tensions between staff members, the hospital affiliation and the public.
- Jordan, P., Troth, A. (August 2002). Emotional intelligence and conflict resolution in nursing. Contemporary Nurse 13(1):94-100.
How nurses maintain relationships and resolve conflict in the workplace is considered an important skill in the nursing profession. This paper explores the utility of emotional intelligence in predicting an individual's preferred style of conflict resolution. Theorists such as Goleman (1998) have proposed a strong link between emotional intelligence and successful conflict resolution. A preliminary analysis of the empirical study indicates that individuals with high emotional intelligence prefer to seek collaborative solutions when confronted with conflict. Implications for the nursing profession are discussed.
- Jormsri P. Moral conflict and collaborative mode as moral conflict resolution in healthcare. Nursing Health Science. 2004; 6:217-21.
Duties and obligations of healthcare providers differ widely in delivering care. A collaborative mode for moral conflict resolution by applying the process of collaborative practice where all members respect each other's opinions, values and responsibilities in patient care is discussed.
- Kelly, A. E. (2005). Relationships in emergency care: Communication and impact. Topics in Emergency Medicine, 27(3), 192-197.
This article examines the challenges emergency room healthcare workers encounter with communication between patients and staff, relationships with other healthcare workers and conflicts that occur in the workplace. The author suggests that healthcare workers must create an inviting, safe, timely, and nonjudgmental environment setting for patients. They can improve communication with patients, staff, organization and community by becoming active listeners, validating understanding, and matching nonverbal and verbal messages. In addition, conflict can be addressed either in an assertive stance or with negotiation.
- Kelly, J. (2006). An overview of conflict. Dimensions of Critical Care Nursing, 25(1), 22-28.
Nurses typically use avoidance to deal with conflict in intensive care. Nurses typically avoid conflict due to nursing and gender stereotypes, self-esteem issues, and management and leadership styles. In order to provide quality patient care, conflict must be dealt with in an open manner. Transformational leadership facilitates conflict management by creating an environment that empowers nurses.
- Kharicha K, Illife, S, Levin E, Davey, B, Fleming C. Tearing down Berlin wall: Social workers' perspectives on joint working with general practitioners. Family Practice. 2005; 22:399-405.
Perceptions and conflicts between social workers and general practitioners in delivering care to the elderly in England and Wales is explored in this article. The two groups agree on working together but differ widely in perceptions and want the other group to change. Differences in power and hierarchical authority are evident. Conflict resolution strategies using case specific solutions and nurses as mediators are explored.
- Kirkwood, A. (2004). Akron nurses participate in pilot conflict resolution program. Ohio Nurses Review, 79(6), 12.
This article describes a trial of the Dynamic Adaptive Dispute System (DyADS) at Akron General Medical Center. DyADS provides a means for registered nurses to resolve conflict in the workplace setting and represents both union and nonunion employees. DyADS is expanding to include an Ombuds Office and aims to reduce the monetary and emotional costs of conflict in the hospital setting.
- Klunk, S.W. (1997). Conflict and the dynamic organization. Hospital Materiel Management Quarterly, (Volume 19, Issue 2; pp8).
Change is constantly evolving in today's workforce, which in turn creates many sources of conflict. This article will explore three areas of conflict that include; organizational conflict, organizational change, and internal conflict. It is important for an organization to understand the difference between functional and dysfunctional conflict. Dysfunctional conflict blocks change and the positive progression within an organization while functional conflict when used effectively will produce a healthy environment.
- Kofke, W. A., & Rie, A. M. (2003). Research ethics and law of healthcare system quality improvement. Critical Care Medicine, 31(3) Supplement: S143-S152 www.ccmjournal.com
This article addresses the conflict of cost containment and quality in healthcare. The article also discusses quality improvement and its importance in the safety and efficacy of patient care. The article also discusses the driving forces for improvement and maintenance of patient care quality vs. the societal mandate to control healthcare costs.
- Kressel, K. & Kennedy, C.A. (2002). Managing conflict in an urban health care setting: What do 'Experts' know? Journal of Health Care Law & Policy, (Volume 5). Retrieved from the Web August 25, 2005. www.law.umaryland.edu.
This article highlights interviews 17 health care providers, each to disclose a recent health care conflict of which they were involved in. Each respondent was asked for their views on major obstacles in conflict management in health care, their views on the importance of training in conflict management, and any aspect that may have influenced their approach to any conflicting situation.
- Kurtz, S., Stone, J. L. & Holbrook, T. (2002). Clinically Sensitive Peer-Assisted Mediation in Mental Health Settings. Health & Social Work, Vol. 27, p155.
In the article the author talks about the benefits of using mediation as a conflict management technique for conflicts between patient and staff, as well as patients' interpersonal conflicts. Mediation is thought to empower the mentally ill patients to be able to resolve their own conflicts and encourage effective communication pattern.
- Lachman VD. Breaking the quality barrier: critical thinking and conflict resolution. Nursing case manager. 199; 4:224-7.
The author discusses barriers to critical thinking and how to create a culture of openness and flexibility. Skills of assertiveness and negotiation and how to deal with defensiveness are explained.
- Lask B. Patient-clinician conflict: causes and compromises. Journal of cystic fibrosis. 2003; 2:42 -5.
Conflict between physicians and patients in chronically ill is explored in this article. Children and adolescents make up half of these patients and the conflict is intensified because of the involvement of the parents. Case reports are presented and basic principles of conflict resolution are outlined. Useful techniques are described.
- LeTourneau, B. (2004). Physicians and nurses: Friends or foes? Journal of Healthcare Management, 49(1), 12-15.
Nurses and physicians must work collaboratively to execute safe patient care. Since their roles have changed from the past, new strategies must be implemented to prevent conflict between the two professionals. This article offers suggestions on how to improve the nurse/physician relationship. The relationship will only improve if a hospital wide system change is implemented.
- Lieberman MA, Fisher L. The effects of family conflict resolution making on the provision of help for an elder with Alzheimer's disease. Gerontologist 1999; 39:159-66.
This study explored focused decision-making style and positive conflict resolution methods. 211 families with an elder with Alzheimer's disease were studied. Results explained the effects of the conflict resolution methods and how it helped to increase the amount and kind of help offered by the families.
- Lumsdon, K. (1995) Why executive teams fail and what to do. Hospital & Health Networks, (Volume 69, Issue 15; pp 24).
Creating an effective organization starts from the top down. This article focuses on the healthcare industry, where lower ranked individuals have been parlayed within the organization. Top management tends to look at the big picture, forgetting about the “touchy feely” team building approach. In the following paragraphs four tales are illustrated on classic team conflicts and resolution.
- Mantone, J. (2006). The cost of bad behavior in OR. Modern Healthcare, 36(28), 21.
This article examines the role of disruptive behavior and conflict in the OR that can contribute to adverse events. The responses of nurses, physicians and anesthesiologists concluded that disruptive behavior could be linked to 67% of adverse events, 58% of compromised patient safety and 28% to patient mortality.
- Marcus, L. J. (1999). Renegotiating health care: Resolving conflict to build collaboration. Hoboken, NJ: Jossey-Bass.
The author shows us that conflict may not be inescapable but can be used as a means for change. The author introduces us to the topic of conflict resolution, and how these conflicts can damage lives and company finances. The books offers sound methods by giving those in conflict the tools they need to put the conflict in perspective and "create workable solutions".
- Maurer, Keith. (2005).The Metropolitan Corporate Counsel. Dispute Resolution: A Vital Component for Improving American Healthcare.
The primary rationally underlying our legal system was to provide disputing parties with a just, speedy, and inexpensive system to resolve their disagreements. Unfortunately, the litigation system no longer can do what it once promised. The ripple effects of costly litigation are felt throughout the healthcare system. Premium and legal costs are passed on to consumers, furthering patient dissatisfaction with the healthcare systems. Healthcare providers and insurers are turning to alternative dispute resolution process.
- Miller M, Wax D. Instilling a mediation-based conflict resolution culture. Physician executive. 1999; 25:45-51.
The hard costs and soft costs that arise from conflicts erode the bottom line. The authors offer a strategy to resolve conflict in its early stages that involve three areas- (1) patient grievances and health plan disputes, (2) internal employee and management disputes and (3) payer, provider and vendor disputes.
- Moore, J (2006). Sources of Conflict Between Families and Health Care Professionals. The American journal of managed care.
It is essential to examine conflict between patients and health care professionals from the patient's perspective. This phenomenological study focused on children with cancer and their parents' perceptions of conflicts with health care professionals as well as what they thought helped with such conflicts. Nursing interventions reported by children and parents to be helpful in preventing or alleviating conflict were identified.
- Morten, S. (2001). Conflict management in a hospital - Designing processing structures and intervention methods. Journal of Management in Medicine, Vol. 15, p156(11)
In this article, the author used an applied case of dispute resolution system developed in a hospital. He explains how they've developed conflict resolution mechanisms, defined managerial requirements and realized the benefits of this system. The process of development and involvement of local expertise has taken an important role in this conflict management system design project.
- Nelson, W.A. (2005). An organizational ethics decision-making process. Healthcare Executive, (Volume 20, Issue 4; pp 8).
In the health care profession, decisions are made and actions need to be taken in response to ethical questions, because they have a direct impact on quality of care. A systematic decision making process is outlined to help promote ethical standards of practice. The following systematic process is as follows; to clarify ethical conflict, identify all stake holders and their values, understand the circumstance of ethical conflict, identify ethical perspective, identify options of action, select an option, implement decision and review decision.
- Nerenberg, L. (2002). Abuse in Nursing Homes. National Center on Elder Abuse.
This article discusses the conflicts that happening in nursing homes across the country. The article discusses the different types of research that has been done on nursing home abuse and the obstacles it has faced. The article also addresses the variety of options that have been proposed to reduce nursing home abuse.
- O'Mara K. Communication and conflict resolution in emergency medicine. Emergency medical clinics of North America . 1999; 17:451-9.
Relationships between the emergency physicians and patients, nurses and physician colleagues are explained in this article. It outlines the fundamental processes involved to avoid miscommunication between these groups.
- Orr, R.D. (2001). Methods of conflict resolution at the bedside. American Journal of Bioethics, 1(4), 45-46.
This article examines the possible conflict management strategies used by healthcare ethics committees. There are three different types of alternative dispute resolution: negotiation, mediation, and arbitration. These three methods differ based on partiality versus impartiality and the extent to which they believe in and adhere to standards. The examples of alternative dispute resolution provide a framework for ethics committees but may not accurately describe the role of an ethical consultant at the bedside.
- Papa T. A systems approach to resolving OR conflict. AORN journal. 1999; 69:551-3.
Conflict situations between two hospital departments and the operating room are presented. Conflict resolution methods using a systems approach are explained with the resultant over all improvement of the OR environment.
- Payne, G.T., Shook, C.L., & Voges, K.E. (2005). The “what” in top management group conflict: The effects of organizational issue interpretation on conflict among hospital decision makers. Journal of Managerial Issues, (Volume 17, Issue 2; pp 162).
The article presented a study on fifty-two hospital top management groups in three southwestern states. The study starts with the organizational issue and examines the relationship between the interpretation of the issue and the type of conflict experience during resolution of the issue. Organizational issues are particularly important in the top management group decision-making process. The results demonstrated the importance of organizational issue interpretation on conflict experienced during the resolution of the issue.
- Pettrey, L. (2003). Who let the dogs out? Managing conflict with courage and skill. Critical Care Nurse, 23(1), 21-24.
Effective communication enables nurses to influence their work environment and to resolve conflicts. This communication supports controlling emotional responses, seeking understanding, identifying common needs and interests, and seeking mutual benefits, which are all strategies and components of conflict resolution. Proper conflict management promotes retention, work satisfaction, and quality patient care.
- Porter, S.E. (2005). Apologizing: Trying to get it right. Journal of Psychosocial Nursing & Mental Health Services, (Volume 43, Issue 5; pp 8).
This article highlights the steps in which you can utilize and deliver a sincere apology. Many times people struggle with the idea of apologizing because it makes them appear vulnerable. However, research indicates that apologies are considered to be a sign of strength. By practicing these steps, engaging in the apology process will become less painful.
- Porter-O'Grady, T. (2004). Embracing conflict: Building a healthy community. Healthcare Management Review, 29(3), 181-7.
This article examines some reasons why conflict exists in healthcare organizations. Ambiguity, role conflict, the leader's affinity for conflict and identity conflict are reviewed and analyzed. The best approach to prevent conflict, is for leaders of the organization to invest in staff development to improve, conflict resolution management skills, application and evaluation.
- Raytheon, Rawls (1998). The hurt that never heals: Conflict management in health care. Georgia Nursing, from
An instructor who taught conflict management to a group of nurses refers to an article which details a lawsuit filed in federal court by a surgeon against the hospital where he worked. The basis of the lawsuit was a charge of discrimination. The final outcome did not lead to resolution but to further conflict that effected not just the parties involved but the hospital and their families as a whole.
- Redwood, H. (1998). Pharmaceutical Cost Containment and Quality Care: Conflict or Compromise? PharmacoEconomics, Supplement 1, Vol. 14, p9-13.
This article addresses the conflict between cost containment and quality in the pharmaceutical industry. The article also describes other healthcare conflict due to the unaffordable drugs. The article states that a compromise between pharmaceutical cost containment and quality is realistic by reevaluating drug pricing, and re-engineering decision-making.
- Reece, R.L. July- August (1999). Renegotiating Health Care: an Interview With Leonard Marcus, PhD- Conflict Management-Interview.
The article starts out by briefly giving an overview of Leonard Marcus's work history and how he became involved with conflict management. The author interviews Leonard Marcus about different sections in the book and Leonard gives insight into the process of writing the book and why he structured it the way he did. They briefly go into detail about various chapters in the book and the interviewer inquires to the background of some of the other authors of the book.
- Riesch SK , Jackson NM, Chanchong W. Communication approaches to parent-child conflict: young adolescence to young adult. Journal of pediatric nursing. 2003; 18:244-56.
Case studies of thirty-three families are presented. The conflicts from past when the individuals were between 11 and 14 years of age and recent conflicts between ages of 22 and 26 are explored. The approaches during teen age years between parents and children were negative, confrontational and avoidant. Recent experiences involved more direct and healthy communications.
- Robeznieks, A. (2006). A question of integrity. Modern Healthcare, 36(5), 10.
This article argues that healthcare executives such as Michael Davis, owner of HIMSS analytics which collects and analysis healthcare data for organizations, will not cause a conflict of interest in his new appointment as a board member for RMD networks. Davis states that although he will be receiving stock options he will not receive a salary and hopes to prevent situations which conflict of interest may occur.
- Rotarius T, Liberman A. Healthcare alliances and alternative dispute resolution: managing trust and conflict. Health care manager. 2000; 18:25 -31.
Collaboration between various entities involving medical groups, hospitals and others has resulted in an increase in organizational conflict. This article explains about the use of alternative dispute resolution to mitigate the conflict and refocus the attention away from an adversarial position to a complimentary existence.
- Rycroft, M. (1998). Equity and rationing in the NHS: past to present. Journal of Nursing Management, Vol. 6 Issue 6, p325-332
The article discusses the healthcare changes and the imbalance of healthcare provision in the UK. The article also explains that a conflict is rising due to the fact that the most helpless groups in society are being denied access to healthcare. Another conflict that the article discusses is the decisions regarding rationing are currently being made at a local rather than a national level.
- Saulo, M. & Wagner, R. J. (2000). Mediation training enhances conflict management by healthcare personnel. American Journal of Managed Care, 6(4), 473-83.
The objectives of this study was to measure the comfort levels of employees before and after they received training in mediation and how it affected their experiences in the work place and out of the work place. The research study involved 173 participants over a 3-year period. The overall conclusion was that skill training improved the comfort levels of the participants. The three main skills that were most often used by the participants were active listening, summarizing and reframing.
- Sciarillo W, Borenstein PE. Baltimore 's consumer ombudsman and assistance program: an emerging public health service in Medicaid Managed Care. Maternal and child health journal. 2000; 4:261-9.
This is a fascinating article in which the authors discuss the outcome of 1300 cases referred to the Consumer Ombudsman and Assistance Program . Ombudsman interventions resulted in conflict resolution for Medicaid enrollees using a continuum of education, mediation and advocacy.
- Sculpher, M. J., & Watt, I. (1999). Shared decision making in a publicly funded health care system. British Medical Journal, 319(7212): 725-726. www.bmj.com
This article discusses the interpersonal conflict between a general practitioner and how he or she decides to view a patient. The general practitioner could view his or herself as the agent for the patient, focusing on the effectiveness of treatment, or of the healthcare system and the population is serves, focusing on affordability.
- Skjorshammer, M. (2001). Conflict management in hospital designing processing structures and intervention methods. Journal of Management in Medicine, (Volume 15, Issue 15; pp 156).
This article examines a case on a hospital in a middle-size city in Norway . A tool was developed to improve the dispute mechanisms made available in the hospital to strengthen management skills of clinical leaders. The new system includes new procedures for managers to process disputes in the hopes to reduce the cost.
- Smith, A. & Nelson, G. (2005). Excise the dysfunction from your executive team. Nursing Management, 36(5), 18.
All dysfunctional executive teams in the healthcare setting, must have awareness of their own poor performance. Leaders must perform a self-assessment and review feedback from staff. There are four potential impediments that can contribute: trust, conflict, accountability, and focus. The importance of establishing trust, avoiding and recognizing conflict, acquiring accountability and focus, would help restore performance.
- Smith SB, Tutor RS, Phillips ML. Resolving conflict realistically in today's health care environment. Journal of psychosocial nursing in mental health service. 2001; 39:36-45.
“When used in a constructive manner, conflict resolution can help all parties involved see the whole picture. Conflict resolution is accomplished best when emotions are controlled before entering in to negotiations.”
- Sportsman, S. (2005). Build a framework for conflict assessment. Nursing Management, 36(4), 32-40.
Healthcare conflict can occur when different views from hospital departments and administration clash. By utilizing the framework for conflict assessment adapted from Weber's Conflict Map and the Wilmot-Hocker Conflict Assessment Guide, sources of the conflict, behaviors and perceptions can be determined. The framework assesses the person, event, power, regulation and style of conflict.
- Tengilimoglu, D. & Kisa, A. (2005). Conflict management in public university hospitals in Turkey: A pilot study. (Survey of Gazi University Hospital). The Health Care Manager, Vol. 24, p55(6)
In this article, hospital was surveyed about the most common causes of conflict to determine underlying reasons. The study revealed that personal education level, departmental access to financial resources and employees having multiple managers were the most common causes of conflict. To solve some of these problems the author recommended team work and collaboration among staff members as a conflict management.
- Wayne, N. H. (2000). Injustice and Conflict in Nursing Homes. Journal of Aging Studies, Vol. 14 Issue 1, p39, 23p.
This article describes the conflict exhibited in the two parties in America's nursing homes. The article explains that the possibility o f fair bargaining between staff and patients has been eliminated. He explains that a partisan, patient-directed ally could rebalance power and eliminate inequities in the nursing home environment. www.web18.epnet.com
- Weitzman PF, Weitzman EA. Promoting communication with older adults: protocols for resolving interpersonal conflicts and for enhancing interactions with doctors. Clinical psychology review. 2003; 23:523-35.
The authors explore ideas for promoting ideas for effective communication in older adulthood. They present training protocols for constructive conflict resolution for older adults and on enhancing doctor-patient communication.
- Wieck, K.L. (2006). Nursing that works: A publication for the Center for American Nurses. Wyoming Nurse, 19(2), 12-15.
Today's nursing workforce is shaped by two distinct generations, the Baby Boomers and the Twentysomethings. The respective generations tend to deal differently with conflict in the workplace. During the 1950s and 1960s, Baby Boomers practiced in an environment that typically condoned physician verbal, emotional, and physical abuse of nurses. Today's Twentysomethings were raised during an era of women's rights and do not tolerate abuse.
- Woolf, S., Chan, E., Harris, R., & Sheridan, S. (2005). Promoting informed choice: Transforming health care to dispense knowledge for decision making. Annals of Internal Medicine, 143(4), 293-299
This article reviews the development of the ideal design of decision making in healthcare choices. The author reviews the design of the system, which includes access to information and a trained third party to facilitate informed decisions, as well as, the barriers that healthcare organizations will face when implementing such a program. The article discusses various system designs, reviewing their advantages and disadvantages, while, noting at the very least, changes must be made to the outdated service model that currently exists.
National Library of Medicine
Summary reviews are as they appear at NLM (The Medline and other sources).
- Baker KM. Improving staff nurse conflict resolution skills. Nurs Econ. 1995 Sep-Oct;13(5):295-8, 317.
As health care organizations restructure their organizations based on a team-managed philosophy, staff nurses will need new skills to function successfully in this type of environment. Specifically, staff nurses will need improved conflict resolution skills. Training and nurse managers' modeling of effective resolution techniques are key elements in developing improved conflict resolution skills among staff nurses.
- Curtis KA. Attributional analysis of interprofessional role conflict. Soc Sci Med. 1994 Jul;39(2):255-63.
Interprofessional role conflict is often a source of job dissatisfaction for health professionals. Attributional analysis provides a methodology to better understand the health care provider's perceptions of the causes of interprofessional conflict and the influence of these causal perceptions on future behavior. This paper reports a study in which 86 physical therapists reported the attributions (perceived causes) they held for situations in which they had compromised (failure) and other instances in which they had supported (success) their best professional judgment following incidents of interprofessional conflict with physicians. Comparison of reported incidents showed that there were significant differences in subject perceptions of the nature of the causes and their future expectations following success and following failure. Therapists tended to ascribe their successes to internal, stable and controllable causes, such as their personality, effort, assertiveness or the strategies they used and held high expectations for future success. Following failure, therapists ascribed the causes of their failures to more external and uncontrollable causes such as influence of the supervisor or the receptivity of the physician. Therapist causal ascriptions for failure to external and uncontrollable sources strongly correlated with high future expectations of failure. Patterns of causal thinking following incidents of interprofessional conflict clearly influence one's future expectations to avoid, withdraw or to seek a productive resolution to role conflict.
- Davidhizar RE. Accepting criticism. A positive process. AORN J. 1989 Sep;50(3):609-12.
Criticism often has negative connotations, even when it is a planned supervisory technique and is part of a comprehensive approach aimed at improving employee behavior without damaging employee morale. The nurse may be the target of criticism from a variety of other people that he or she encounters in the health care setting. The nurse's response to criticism is important to optimal conflict resolution and to maintaining relationships with integrity. The nurse's actions and attitudes in response to criticism should be planned deliberately and directed at resolving the conflict.
- Dubler NN. Mediation and managed care. J Am Geriatr Soc. 1998 Mar;46(3):359-64.
Managed care has not only intensified existing conflicts between patient and provider, it has, by its very nature, changed the shape and scope of the healthcare enterprise and introduced an entirely new set of disputes. The decision-making dynamics have been altered, and the cast of players has expanded. Traditionally, the therapeutic interaction took place between the physician and the patient although it occasionally included the patient's family. Whatever obligations existed, such as fidelity, confidentiality, and standard of care, they bound only those parties. Now, as the managed care organization has interposed itself between the patient and the physician, the dyad has become a triad. The power balance has shifted, and a new set of rights and responsibilities now flows between and among the players, each of whom has interests that may or may not coincide. This article argues that, because of its cost containment origins and orientation, managed care increases the likelihood that misunderstandings, disagreements and disputes will develop into full-blown conflicts. If managed care is to succeed financially and operate with integrity, it must develop techniques for managing the increasing conflicts that arise inevitably between and among the organizations, physicians, and patients. It is clear that the voice of the patient needs to be strengthened within the new complex decision-making, review, and appeal procedures. Mediation is the most appropriate method of dispute resolution for the managed care setting because it balances the disparities in power endemic to the bureaucratization of medicine and refocuses the interests of the various parties. Using bioethics consultation as a model for dispute mediation provides a set of principles and guideline tasks that can be applied effectively to managed care.
- Evans SA. Conflict resolution: a strategy for growth. Heart Lung. 1991 Mar;20(2):20A, 22A, 24A.
We have ample opportunities to practice negotiation skills every day. Our goal is to create an environment in critical care where confrontation regarding patient care issues, collaborative practice, shared governance, and standards of professional practice is the norm. Winning and losing are not the important factors. We should instead strive for establishing mutual interests, shared values, and a framework for decision making. Mutual gain is the goal of confrontation and conflict resolution. We must develop our skills to address conflicting interests at the bedside. It is essential that we have a better process to accept our difference and foster our mutual and shared interest, caring for the critically ill patient.
- Jezewski MA. Evolution of a grounded theory: conflict resolution through culture brokering. ANS Adv Nurs Sci. 1995 Mar;17(3):14-30.
This article describes the evolution of the middle-range substantive theory of culture brokering. The theory was generated by first conducting a concept analysis that yielded 12 attributes of the concept of culture brokering. The concept analysis was accomplished using the anthropology, health-related, and business literature. In addition, data from an interpretive ethnographic study were used to further develop the concept of culture brokering. The theory was then generated from four grounded theory studies. Each study was used to frame the grounded theory model and to strengthen and refine the categories and links between categories within the basic social process of culture brokering. The culture brokering theory can guide the practice of nurses in situations where conflict is present in the health care interaction. The theory is grounded in the experiences of nurses attempting conflict resolution in the context of health care interactions.
- Kennedy MM. A crash course in conflict resolution. Physician Exec. 1998 Jul-Aug; 24(4):60-1
Knowing how to resolve conflict with finality establishes positive changes in coworker relations, prevents drops in productivity, and frees a manager's time for more important issues. Conflict arises from four sources: (1) Real or imagined differences in values, (2) dissimilar goals, (3) poor communication, and (4) personalizing generic or organizational issues. Right now health care is full of the latter. It's possible--and useful--to make conflict productive rather than disruptive. The secret is using a process that produces a solution acceptable to everyone. This requires three steps: (1) Value differences must be addressed, (2) communication styles must be established, and (3) everyone must commit to mutually satisfactory resolution of the issues.
- Liberman A, Rotarius TM, Kendall L. Alternative dispute resolution: a conflict management tool in health care. Health Care Superv. 1997 Dec;16(2):9-20.
This article focuses on methods of resolving conflict either within or between health care organizations using an alternative dispute resolution (ADR) strategy. After identifying the principal sources of contemporary disagreements within health services settings, the authors describe the basis of ADR. This is followed by a discussion of some common obstacles to settling a dispute. The principal communication guidelines and stages of a mediation session are presented. An alternative dispute resolution framework is proposed that includes an Office of Dispute Resolution (ODR). Also provided is a series of attributes that together comprise the core of mediation as a discipline.
- Littlefield VM. Conflict resolution: critical to productive schools of nursing. J Prof Nurs. 1995 Jan-Feb;11(1):7-15.
Conflict, a normal component of university life, is enhanced in today's schools of nursing because of declining resources and increased expectations of faculty. Management of conflict for positive change and increased productivity is essential for academic leaders. A variety of strategies to diagnose, confront, and resolve conflict are important resources to facilitate change and allow faculty and administrators to respond to new opportunities and challenges. Collaboration and win/win strategies are ideal, but not always possible. Alternative approaches to confront destructive conflict, yet present options that benefit individuals as well as schools are also essential.
- Maher CA. A systems approach to managing conflict in orthopaedic nursing. Orthop Nurs. 1991 May-Jun;10(3):35-6, 38-44.
Conflict management is considered from a psychologic perspective. Therein, a systems approach to managing conflict is described with particular reference to orthopaedic nursing practice. Within that context, conflict management is portrayed as a process that is applied by orthopaedic nurses to particular conflict situations by means of separate, yet interrelated phases: clarification of the conflict situation; design of a conflict resolution plan; implementation of the plan; and evaluation of the extent to which conflict has been resolved. Application of this systems approach by orthopaedic nursing managers or by staff nurses may be valuable in focusing their attention and that of other health care providers on important behaviors, tasks, and accomplishments rather than on personality constructs and other noncontrollable correlates of managing conflict effectively. Directions for empirical inquiry relating to conflict management in orthopaedic nursing are briefly considered.
- Murphy C, Sweeney MA. Conflict resolution with end of life decisions in critical care settings. Medinfo. 1995;8 Pt 2:1696.
This demonstration will present the key modules from an innovative videodisc-based program that was designed as an educational tool for health care professionals. It provides a resource for learning to deal with patients and families regarding the increasing problematic area of end-of-life-decisions. Tough Choices: Ethics, the Elderly, and Life-Sustaining Technologies is an interactive program that combines abstract ethical approaches with the realistic drama of a critical care setting. The format integrates scientific facts about the patient with value questions regarding the utilization of life-sustaining technologies. The unique program provides health care personnel with strategies on how to guide family decision-making as well as examples of the various interventions. This interactive multimedia program opens up an opportunity for health care providers to participate in a clinical case in which life and death decisions are made. Learners can explore various perspectives and treatment options within the framework of the dramatic case presentation without the usual time constraints or worries about causing harm to patients. The program involves learners in a variety of ethical and legal dilemmas that centers around a patient, her family, and a variety of health care professionals. Dramatic advances in the development of life-sustaining medical technologies have given hope to many people whose conditions would have meant certain death only a few years ago. As access to the technologies has expanded, concern for their appropriate utilization has become an issue worthy of increasing attention. Questions about the benefits of life-sustaining treatments are being raised in many quarters, particularly when the technology is viewed as a modern means of postponing death and prolonging suffering. Tough Choices brings to life the story of Irene Sullivan, an elderly widow who has an unexpected heart attack. Suddenly, her very existence depends on the life-support provided by mechanical ventilation and cardiopulmonary resuscitation (CPR). This is a growing area of concern since more than half of the patients who receive CPR and tube feedings and one third of the people receiving mechanical ventilation are 65 or over. Mrs. Sullivan's health care team is forced to deal with the opposing viewpoints of several close family members regarding the utilization of advanced medical technology. The interactive program invites viewers to explore the complex ethical and legal dilemmas involved in making life-and-death decisions about her care. It also permits immediate access to supportive resources in three areas: the clinical chart, abstracts of relevant research studies on life-sustaining technologies, and information from the professional literature on advance directives. The program incorporates practical steps involved in implementing the Patient Self-Determination Act as it follows the patient from the time of hospitalization through a series of life-threatening crises. Two very different aspects of the role of the health care professionals were explored: a crisis mode which covers the steps in managing a full-blown crisis situation, and a prevention mode which analyzes steps that could have been followed to keep an ethical crisis from occurring. The strong role models for practice display many of the characteristics that the helping professions need to foster in an atmosphere of healthcare reform.
- Porter-O'Grady T. Constructing a conflict resolution program for health care. Health Care Manage Rev. 2004 Oct-Dec;29(4):278-83.
Resolving conflict throughout organizations requires a programmatic infrastructure and a committed management team. Leaders must recognize the need to approach conflict by building a format for learning, creating and managing an effective conflict management program. Careful attention to the elements of design and the stages of development can make all the difference in building a sustainable and useful conflict management approach.
- Safran JD, Muran JC. Resolving therapeutic alliance ruptures: diversity and integration. J Clin Psychol. 2000 Feb;56(2):233-43.
This article reviews and synthesizes the diverse contributions of the authors in this issue of In Session: Psychotherapy in Practice. It presents a schematization of direct and indirect interventions that therapists typically implement to address problems related to the tasks and goals of treatment, or the affective bond between therapist and client. We then present an additional perspective on the resolution of therapeutic alliance ruptures, emerging out of our own research program.
- Saravia A. Overview of alternative dispute resolution in healthcare disputes. J Health Law. 1999 Winter;32(1):139-53.
Various methods of alternative dispute resolution have gained wide acceptance in general commercial disputes. With the ever-increasing commercialization of the healthcare industry, many participants are examining ADR as a means of resolving disputes in this area as well. This Commentary provides an overview of the two most prevalent forms of ADR (arbitration and mediation), and discusses ongoing legislative, judicial, and industry activities that will guide the application of ADR in the healthcare arena.
- Volden CM, Monnig R. Collaborative problem solving with a total quality model. Am J Med Qual. 1993 Winter;8(4):181-6.
A collaborative problem-solving system committed to the interests of those involved complies with the teachings of the total quality management movement in health care. Deming espoused that any quality system must become an integral part of routine activities. A process that is used consistently in dealing with problems, issues, or conflicts provides a mechanism for accomplishing total quality improvement. The collaborative problem-solving process described here results in quality decision-making. This model incorporates Ishikawa's cause-and-effect (fishbone) diagram, Moore 's key causes of conflict, and the steps of the University of North Dakota Conflict Resolution Center's collaborative problem solving model.