UMEA INTERNATIONAL SCHOOL OF PUBLIC
HEALTH
CONFLICT
MANAGEMENT
ORGANIZATIONS.
IN
HEALTH
CARE
A protocol for a study in Umoru Shehu ultramodern
hospital Maiduguri, Northeast Nigeria.
Oraegbu Anthony .C.
Master thesis in public Health, 2012
Supervisor: Yulia Blomstedt, PhD.
i
LIST OF ABBREVIATIONS
DCM
FGD
IRP
USUM
Dual Concern Model
Focus group discussions
Interest-Right-Power
Umoru Shehu Ultramodern hospital Maiduguri
ii
ACKNOWLEDGEMENT
I acknowledge with thanks all those who have in one way or the other contributed to or
supported this work especially:
My thesis supervisor Yulia Blomstedt for your invaluable expertise and for guiding me
through this work. Thanks so much.
To the entire members of staff of the department of Epidemiology and Public health for
your friendship, support and the knowledge imparted.
To Sabina Bergsten and Karin Johansson for your administrative and personal support.
Thanks a lot.
To my colleagues in the MPH pogramme and my friends for your company and the
moments we shared.
To the entire staff of Umoru Shehu Ultramodern hospital especially the medical director
Dr Ville Samuel and the chapter president of the Nigerian association of nurses and midwives Mr Barde Wazimtu Tampul for the information you provided.
To Dr Evans Osabuohien of the department of Economics and Development studies,
Covenant University, Ota, Nigeria; Dr Margaret Mahon of the Catholic University of
America and Dr Jean Burley Moore (USA) for your scholarly inputs.
To Annemarie Pettersson for your kindness.
To the entire members of my family for your love and support.
To my father Pa lawrence Oraegbu and my brothers Reginald Oraegbu, Ken Mekea and
Lawrence Oraegbu for your continued support.
Above all, to Almighty God for your grace to go through this programme.
iii
ABSTRACT
Conflict is an inevitable, widespread social phenomenon in both human and
organizational life especially as people socially interact with themselves. The root sources
of conflict are universal but the specific triggers are context dependent; and conflict is
good or bad depending on how it is handled. Umoru Shehu Ultramodern hospital had
experienced repeated conflict among its health workers which resulted in a temporary
withdrawal of services to the public with dire consequences.
This thesis aims to review literature to summarize and analyze existing knowledge about
the sources, management and effects of conflict in organizations in general and in health
care in particular and to design a protocol for a study aimed at exploring the sources and
management of conflict among health care workers in Umoru Shehu ultramodern
hospital Maiduguri (USUM), northeast Nigeria as well as develop recommendation for
improvement of strategy for conflict management in the hospital.
Hence, literature search at the university and medical libraries and computerized search
of databases such as Pubmed , Scorpus, CINAHL and so on, was conducted for relevant
scientific papers for review and to design the protocol. A general review of the literatures
revealed the different perspectives of researchers/authors regarding the different
attributes of conflict in organizations. Further, specific review of empirical studies of
conflict in health care organizations showed amongst others that there is limited
information on conflict in health care organizations in Nigeria; that there are limited
studies which utilized conflict framework; and that less attention is given to intergroup
conflict in health care.
A protocol suggests to use an exploratory qualitative design to collect data on the
informants’ lived experiences with intergroup conflict in line with the context of the
study setting (USUM). Focus group discussions will be used to capture informants’
subjective realities (knowledge, comments, emotions and so on) with conflict from
interviews with different groups of health workers. Data will be analyzed through content
analysis. This study is expected to provide new insights into conflict in the hospital, to
understand the whole picture (conflict process) and to contribute to developing an
effective tool to manage future conflict in the hospital. Ethical and methodological issues
are also discussed.
Key words: conflict, conflict management, health care organizations.
iv
CONTENT
Page
TITLE
i
ABBREVIATIONS
ii
ACKNOWLEDGEMENT
iii
ABSTRACT
iv
TABLES AND FIGURES
viii
INTRODUCTION
1
1.1 Nature of conflict
1
1.2 Definition of conflict
1
1.3 Conflict and organizations
1
1.4 Nigerian context
2
1.5 USUM context
3
1.6 Objectives of proposed study
3
1.7 Aim of thesis
4
2
METHODS
5
3
FINDINGS
7
3.1 Conflict in organizations
7
3.1.1 Definition of conflict in organization
7
3.1.2 Theories of conflict
9
3.1.2.1 Interdependence theory
9
3.1.2.2 Social identity theory
10
3.1.2.3 Socio-cognitive conflict theory
10
3.1.3 Types of conflict in organizations
11
3.1.4 Sources of conflict in organizations
13
3.1.5 Conflict dynamics (process)
17
3.1.6 Conflict consequences/outcomes
19
3.1.7 Cross-cultural variation in conflict sources and outcomes
20
3.2 Conflict management
22
3.2.1 Definition
22
3.2.2 Perspectives of conflict
23
3.2.2.1 The traditionalist perspective
23
3.2.2.2 The behaviouralist (human relations) perspective
24
3.2.2.3 The interactionist perspective
25
v
3.2.3 Theories of conflict management
3.2.3.1 Deutsch’s theory of cooperation and competition
26
3.2.3.2 The Dual Concern Model
26
3.2.2.3 The Interest-Rights-Power theory
27
3.2.3.4 Conflict Management Systems: Systems Approach
28
3.2.4 Managing conflict through resolution: Conflict management styles
30
3.2.4.1 Definition
30
3.2.4.2 Competition
31
3.2.4.3 Collaboration
32
3.2.4.4 Compromise
33
3.2.4.5 Accomodation
34
3.2.4.6 Avoidance
35
3.2.5 Managing conflict through stimulation
4
25
36
3..2.5.1 Restructure the organization
36
3.2.5.2 Introduce new individuals into the organization
36
3.2.5.3 Stimulate competition in the organization
36
3.2.5.4 Introduce programmed conflict
37
3.2.5.5 Use of communication
38
3.2.6 Cross-cultural variation in conflict management
38
3.2.7 Approaches to conflict management in health care organizations
39
3.3 Review of past empirical studies of conflict in health care organization
42
STUDY PROTOCOL
45
4.1 Objectives of the proposed study
45
4.2 Study setting
45
4.3 Justification and significance of the study
47
4.4 Theoretical frameworks
48
4.4.1 Moore’s ‘circle of conflict’ framework
49
4.4.2 Dual Concern Model
49
4.4.3 Integrated theoretical framework
49
4.5 Method of designing the study protocol
50
4.5.1 Study design
50
4.5.2 A pilot step
51
4.5.3 Main focus group discussions
51
4.5.3.1 Selection of participants
vi
51
4.5.3.2 Data collection
52
4.5.3.3 Data analysis
53
4.5.4 Additional focus group discussions
54
4.5.5 Developing recommendation for action
54
4.5.6 Establishment of trustworthiness
54
5 ETHICAL CONSIDERATIONS
57
6 DISCUSSION
58
6.1 Methodological considerations, rationale of the thesis and expected impact
58
6.2 Strengths and limitations of the thesis
58
6.3 Strengths and limitations of the study protocol
59
7 CONCLUSION
61
8 REFERENCES
62
9 APPENDICES
70
Appendix 1 Empirical studies of conflict in health care organizations
71
Appendix 2 An interview guide
81
vii
LIST OF FIGURES
Figure 1: Schemaic diagram of literature search
6
Figure 2: Levels of conflict in organizational behaviour
12
Figure 3: The conflict process
18
Figure 4: Two dimensional taxonomy of conflict handling styles (Dual concern model) 31
Figure 5: Map of Nigeria showing 36 states, federal capital territory and neighbouring
countries
46
Figure 6: Simplistic representation of an integrated theoretical framework of conflict in
health care organizations
49
viii
1. INTRODUCTION
1.1 Nature of conflict
Conflict is a social phenomenon which has been evident among humans since primordial
time (Keeley, 1996; Aminu, & Marfo, 2010). Conflict not only cuts across every sphere of
life – species, time, cultures and so on, its occurrence seems inevitable as people socially
interact with themselves (Benedict-Bunker, Rubin and associates, 1995; Morgan, 1997;
Spector, 2008; De Dreu & Gelfand, 2007).
Conflict generally is not a new concept. It is a term often mentioned in a wide range of
professional and academic disciplines to describe situations in which there is some kind
of disagreement between two related parties, be it individuals, groups or organizations. It
is a term which is often used interchangeably with words like “quarrel”, “controversy”,
“dispute”, “violence”, and so on (Almost, 2006).
1.2 Definition of conflict
The understanding and meaning of the term ’conflict’ are often based on the theoretical
perspectives of the various disciplines, usually reflecting its diverse forms and contexts
(Axt, Milososki, & Schwarz, 2006). Thus conflict has been defined differently in different
circumstances. Robbins (2005) defines conflict as a process that starts when one party
perceives that another party has or is about to negatively affect its concerns. Hellriegel,
Slocum and Woodman (1998) define conflict as a disposition to disagreement about
goals, thoughts or emotions within or between parties. Inherent in these definitions is
the perception of difference or disagreement by one or both parties as well as the
psychological and behavioural elements. This implies that conflict could be perceived
(subjective or objective) or felt, and either not expressed (latent) or expressed differently
(manifest) by the parties involved. Conflict therefore appears to be a multidimensional
concept.
1.3 Conflict and Organizations
Organizations constitute domains where the plurality of interests and aims creates an
environment for conflict to thrive. Virtually all organizations are constantly faced with
internal and external events causing change and conflict. And with the wide range of
changes in the world of work and organizations, the connection between collaborate
1
work and conflict has become stronger as these events of change permeate the fabrics of
organizational structures and functions. The strong interconnection between conflict,
work and organizations gives the perception that conflict cannot exist without people
being interdependent for their task achievements; therefore the belief that there is no
organization without conflict (Pffefer, 1997; De Dreu, 2008). Thus there is the likelihood
of emergence of conflict at all levels within and between organizations and their
constantly changing political, economic and social environment (De Dreu & Gelfand,
2007; Spector, 2008). This likelihood increases with increasing pressure to change
(Anderson, De Dreu & Nijstad, 2004; De Dreu, Van Dierendonck & De Best-Waldhober,
2002).
The diversity of change sometimes manifests itself as different forms and degrees of
conflict with some being more perceived (visible) than others (De Dreu & Gelfand,
2007). Since conflict is dynamic, occurring repeatedly over time throughout the
existence of organizations, its functions or consequences on both individuals, groups and
organizations are seen as both immediate and long-term (De Dreu, 2008), as well as
beneficial and detrimental (Jehn & Bendersky, 2003; De Dreu & Weingart, 2003; De
Dreu, 2006; Lovelace, Shapiro & Weingart, 2001; De Dreu & West, 2001; Simons &
Peterson, 2000; Anderson, De Dreu & Nijstad, 2004). These consequences of
organizational conflict reflect the extent of conflict perception and management
capability of individuals, groups and organizations (Aminu & Marfo, 2010). Health care
organizations are also vulnerable to conflict as they are faced with pressures from within
and outside while they strive to provide quality care to patients (Tyler-Evans & Evans,
2002). The nature of health care organizations with their multiple command and control
structure and functions makes the occurrence of conflict likely much so as they operate
within dynamic local contexts, further exposing them to external forces causing conflict
(Brief et al., 2005).
1.4 Nigerian context
The Nigerian health care sector, like any other sector in the country has witnessed spates
of industrial conflict both at local, state and national levels with various degrees of
impact on the population (Ojeme, 2012; Okafor, 2012; Obinna, 2011). Conflict has
become a common occurrence in the existence and operations of health care
organizations in the country, and Umoru Shehu ultra-modern hospital (USUM) is not
2
left out. These conflicts are often the resultant effects of failure to amicably resolve
perceived grievances/disagreement between the different stake-holders in the health
sector. The responses of employees to the dynamics of change in health care
organizations sometimes hinder or bring closer the occurrence of conflict (Osabuohien,
2010). Since the complex structure of health care organizations creates opportunity for
conflict to occur, the ability of management and employees to handle conflict is a sin qua
non for effective health care delivery.
1.5 Umoru Shehu Ultra modern hospital (USUM) context
Located in the sprawling suburb of Maiduguri, the capital city of Borno State in the
north-eastern part of Nigeria, Umoru Shehu Ultra-modern hospital (USUM), a stateowned 300 bed capacity tertiary health care organization was established in 2008 as a
referral centre to provide health care services to the people in the state and beyond. Its
establishment was considered an applause to the state health system which hitherto was
beleaguered with increasing unmet health needs of a fast growing population, more so as
the state health system also serves citizens of neighbouring countries. As expected of any
other tertiary health care organization of its kind, it is imperative that USUM lives up to
its set goals of providing quality health care that focuses on the need of patients.
To this effect, USUM became the habitat of people of diverse professional disciplines
brought together for a team work. In addition to providing equipment and facilities in
the hospital, the state government also established a high-powered task force comprising
seasoned health care professionals to complement the efforts of the hospital’s
management team in the bid to harness available human and material resources for the
smooth running of the hospital in order to realize set goals and objectives. Nevertheless,
since commencement of services the hospital has been plagued by repeated conflict
between the staff of the hospital and their managers, manifesting often as temporary
stoppage of health care services to the public. This brings about untold pain and
suffering to the public and generates insecurity among health care seekers. It also leaves
behind a rising death toll which could have been prevented if not for such strikes.
1.6 Objectives of proposed study
This proposed study therefore intends to identify the sources of conflict among health
care workers in Umoru Shehu ultra modern hospital. It will also look at the management
3
strategies employed by health care workers in situations of conflict and to develop
recommendations for improvement of strategy for conflict management in the hospital.
There is no gainsaying that the occurrence of conflict in such organization threatens
collaboration between the different stakeholders which is essential for continued and
effective service delivery. Since there is a myriad of factors that could lead to conflict in
such an organization, identifying their sources is key to developing effective conflict
management strategies (Havenga, 2005; Moore, 2003). Not only will this help restore
the much needed collaboration between stake holders for the smooth running of the
hospital, it will also forestall the destructive consequences of conflict both within the
hospital and beyond its boundaries.
1.7 Aim of Thesis
The aim of this thesis is twofold:
o
To review literature in order to summarize and analyze existing knowledge about
the sources, management and effects of conflict in organizations in general and in
healthcare in particular.
o
To design a study protocol that aims at exploring the sources and management of
conflict as well as developing recommendation for improved strategy to manage
future conflict in Umoru Shehu ultra modern hospital, Maiduguri, north-east
Nigeria.
4
2. METHODS
This section presents the approach used to collect relevant scientific papers in order to
achieve the aforementioned aim of the thesis, that is, to review literatures about conflict
in organizations especially health care organizations and to guide the design of the study
protocol.
Literature search focused on conflict as a major concept of interest and occuring within
the context of organizations in general and health care organizations in particular. The
literature sample was drawn from a range of disciplines that have studied conflict in
organizations like organizational psychology, social sciences, medicine, nursing, and
management science. The literature search was made at the university and medical
libraries for scientific journals, dissertations, and textbooks relevant to the issues. Books
like The Psychology of conflict and conflict management in organizations. C.K.W De
Dreu & M.J Gelfand; Handbook of negotiation and culture. M.J Gelfand & J.M Brett;
and other relevant books on conflict management in and beyond health care were used.
This was important in order to obtain scientific papers relevant to the concept of interest
and to guide the design of the study protocol.
Computerized search was also conducted using the PubMed, Medline, Scorpus, APA
psycNET, PsychINFO, CINAHL, Libris and Google scholars databases in order to
improve sampling adequacy. General search was made with key terms such as “conflict”,
“conflict management”, “organizations”. Then further search on the same issues (that is,
conflict and conflict management) specific to health care organizations was made using
terms such as “healthcare”, “hospitals”. The computerized search focused on scientific
papers written in English language, peer reviewed and published between 1995 and 2011.
This is to facilitate an understanding of the articles, and be informed about key topics on
conflict, areas of similarities and differences in researchers/authors perspectives,
changes in the concept over time, and evolving trend on issues of conflict.
Furthermore, a paper was considered for review when it broadly addressed conflict in
organizations including health care organizations, when its title and or abstract captures
some or all of the search terms and when it focused on issues relevant to the aim of the
thesis.
The concept of interest in this literature search, ‘conflict’ has been used interchangeably
with multiple terms like controversy, disagreement, dispute, and violence to mention a
5
few. Thus, articles with such substitute terms which met the aforementioned criteria
were also considered. Regarding health care organizations, an article was considered if it
addressed a hospital setting or any setting (example education) linked to a hospital and
in which the conflict participants are health care workers, care receivers (patients)
and/or their relatives. Any paper which did not address issues of conflict within the
specified context and which did not meet the aforementioned criteria was considered
‘irrelevant’ and dropped. Papers whose texts could not be accessed were also dropped.
To complement the selected papers, a snowball sample of literatures considered to be
relevant and resourceful was also drawn and integrated following a review of the
citations of the selected papers and some textbooks.
After deleting all duplicate citations, a total sample of 121 papers was drawn for review
(Fig.1). Data provided by these articles were organized and channeled towards achieving
the purpose of the thesis. They also guided the major themes and references.
Furthermore, 17 articles were selected from the total sample, reviewed and presented
separately in the results. These are articles which present empiriclal studies conducted in
hospitals or institutions linked to hospitals and which address concerns within the scope
of the thesis.
Total papers referenced from
searched databases and library
160
Papers dropped
39
Not
accessible
15
Papers selected for
review
121
Empirical studies
in hospitals or
hospital-linked
institutions
17
Irrelevant
24
Figure 1: Schematic diagram of literature search.
6
General review
104
3. FINDINGS
This section presents existing knowledge from literatures obtained for review about
conflict in organizations including health care organizations through the search method
described above.
3.1 Conflict in organizations
Conflict in the work environment has generated a lot of attention and has become an
important issue in organizations across the globe. Its inevitability in the workplace
anchors on the inherent differences in needs, roles and responsibilities, goals, desires,
ideas and values which characterize environments in which there is significant
interaction and interdependence. Growing concerns about the potential harmful effects
of unresolved or poorly managed conflict on individuals, groups and organizations in the
work environment spark renewed interest on the issue with a bid to develop more
effective approaches to deal with it.
3.1.1 Definition of conflict in organization
Conflict is a fact of both human and organizational life. Since organizations are habitats
for interaction between individuals and groups performing interdependent tasks, often
in resource-scarce situations, it appears commonplace that conflict would occur. Conflict
has become a major term in labour-management relations in all spheres of the work
environment. Organization is a social setting where individuals and groups interact to
perform organized tasks as a team in order to achieve the goals and objectives of that
setting.
The various approaches to organizational complexity widen the way conflict in
organization is understood and interpreted (Brief et al., 2005). In addition, the diversity
of the forms of conflict in the workplace makes it difficult to proffer a single
comprehensive definition of workplace conflict (De Dreu & Gelfand, 2007).
However, it is important to define conflict in order to have a clear meaning and
understanding of the concept, and to have a vivid account and salience of the issues in
conflict – the cause, the context, who is involved, why and how people act/react to
issue(s) at stake and the consequences of their actions.
According to Almost (2006) most definitions of conflict agree that it is a process
involving two or more people, where a person perceives the opposition of the other.
7
However, conflict is defined as a process which starts when a party (individual or group)
perceives differences and opposition between itself and another party (individual or
group) about interests and resources, beliefs, values or practices that matter to them (De
Dreu, Harinck, & Van Vianen, 1999; Van de Vliert, 1997; Wall & Callister, 1995). Dana
(2001) defines conflict in organization as a situation occurring between and among
workers performing interdependent tasks, who feel angry and perceives the other party
as being at fault and act in a manner that creates problem for the organization; while
Rahim (2002) defines conflict as an interactive process which manifests as
disagreement, incompatibility and discordance within or between individuals, groups
and organizations.
Evident in these definitions is the dynamic nature of conflict in the work environment,
the conflict antecedents, involvement of interdependent parties which are related by
task, the perception of seemingly irreconcilable positions, behavioural and affective
(emotional) involvement and conflict outcome(s). The requirement of perception implies
that conflict does not exist if not sensed by the parties involved. On the other hand,
conflict is said to exist once it is perceived by either or both parties whether or not the
perception is correct.
Health care organizations are adaptive systems with unique characteristics. These
systems are designed to provide diverse health services to a wide range of clients often in
emotion-laden conditions. The complexity of their structures and the high interactions
between their constituent parts allow conflict to be built into them. Thus conflict is a
regular occurrence in health care settings.
Although there is a considerable variation in the definition of conflict, there is a
unanimous view of conflict as a process. Defining conflict gives logical meaning to the
concept and allows managers to have a good account and understanding of the conflict
process and the salience of the issues involved – the context, cause, disputants and their
interaction pattern, and the potential consequences. This would enable managers to
make prompt decision about management strategy to adopt in order to contain or
minimize the harmful effects or harness beneficial effects to spur individual, group and
organizational creativity and performance.
8
3.1.2 Theories of conflict in organizations
For decades, scholars have beeen trying to understand why conflict emerges between
people as they relate with each other. Several theories have been put forward by scholars
from different professional disciplines to explain how conflict could emerge from human
interactions. Although, there is no single theory that captures the whole essence of the
myriad of factors responsible for the occurrence of this multi-dimensional, pervasive
phenomenon, it is however important to provide perspectives that explain the origin of
conflict between individuals, groups and organizations. In this regard, three leading
theoretical perspectives are highlighted to explain why and how issues which cut across
cultures and which are considered fundamental to human co-existence and interactions
could lead to conflict in a wide of range of contexts including the work environment.
These perspectives are presented below:
3.1.2.1 Interdependence theory:
Rusbult and Van Lange (2003) following an earlier work by Kelly and Thibaut, put
forward this theory to explain how resources can be the cause of conflict at the
individual, group or organizational level. It assumes that individuals depend on each
other to obtain beneficial or positive outcomes and avoid harmful or negative outcomes.
Therefore their choice of behaviours, the evolving interaction pattern, and the extent to
which they reach their goals are determined by how their interests are or are perceived to
be related. From the social dilemma and mixed-motives perspectives, an individual’s
outcome is maximized when he is uncooperative while collective outcomes are
maximized when both parties cooperate; but both parties are worse off when they do not
cooperate with each other (Weber, Kopelman & Messick, 2004).
Therefore, conflict can occur when individuals or groups become pro-self and
unavoidably hurt collective interests (including the interests of interdependent others)
since such behaviours are not likely to be accepted. Also, conflict could occur due to
incorrect interpretation of actions and intentions of others. In all, when interests are
incorrectly aligned, behavioural choices which benefits interests at one level may harm
interests at another level resulting in conflict, the likelihood of which increases from
individual to group and organizational levels as more actors are involved and interaction
pattern becomes more complex (De Dreu & Gelfand,2007).
9
3.1.2.2 Social identity theory
It explains the basis of group discrimination in value and relationship conflict. It gives
insight as to why individuals of a group favour their group and strive to develop and
maintain positive group identity in relation to another group.
The core assumption of this theory is that individuals not only define or think of
themselves on the basis of their unique personal characteristics (personal identity) but
also on the basis of their perceptions about the groups to which they belong (social
identity). Thus an individual may think, feel and act differently and therefore present
with multiple social identities depending on the social contexts. According to Hogg and
Vaughan (2007), social identity describes the conception an individual has about himself
or herself due to his or her perceived membership of social group(s). The theory asserts
that this sense of membership of a group makes an individual to not only differentiate
the in-group from the out-group but also seeks to positively distinct it from other
comparison groups. Thus the individual tend to favour the in-group over the out-group.
The extent of this in-group commitment or favouritism is driven by the perception of the
relevance of the comparison group relative to the in-group within the prevailing social
context ( social categorization), the extent to which social contexts provide the forum for
differentiating in-group from out-group (social comparison), and the extent to which an
individual imbibes group membership such that group characteristics form part of selfidentity, that is, the extent to which the individual sees himself or herself as a
representative of the group (social identity) and therefore strives to project a positive
image of the group in relation to other individuals or groups in the organization
(Ellermers, Spears & Doosje,2002).
3.1.2.3 Socio-cognitive conflict theory
It provides a basis for addressing the differences in understanding and interpretation of
reality, the conflict arising from such differences, how people deal with such conflict and
its implications for learning, accuracy of perception, and for predicting and influencing
behaviours. The theory lies in the assumptions that people have accurate intuitive
understanding about themselves, others, the surrounding world and the tasks facing
them; that people lack relevant information and capability to process information and
are also limited in their rationality thereby resulting in diverse opinions, understandings
and beliefs on same issue; that people seeks general congruity, acceptance and approval
10
of their insights, beliefs and understandings by others and that differences in others’
insights, understandings and perceptions could lead to conflict. Thus, cognitive conflict,
also referred to as information or task-related conflict could emerge in organizations
from beliefs, opinions and insights not shared by others ( De Dreu & Gelfand, 2007).
These theories provide the framework for understanding why and how issues which are
fundamental to human co-existence and interactions and which are prevalent in every
culture can lead to conflict. They explain that the action and or reaction of individuals
and groups to perceived differences and competing needs regarding resources, a desire
to project positive identity about oneself and related group, and the understanding and
interpretation of reality could result in resource conflict (conflict of interest), social
identity conflict (value and relationship conflict) and socio-cognitive (task-related or
information) conflict respectively.
3.1.3 Types of conflict in organizations
There are several categorizations of conflict in literatures of organizational conflict with
considerable overlap of concepts. Nevertheless categorizing conflict helps create an
awareness of its existence in organizations as well as gives insight into the source and
form of the conflict. This will enable managers keep track of the emerging conflict
pattern and provide prompt and effective resolution approach. These categorizations
however are based on the different perspectives of researchers/authors.
De Dreu and Gelfand (2007) categorize conflict based on the different levels of analysis
of an organization. They explain that organizations can be divided into different levels:
the individual level, the group level, the organizational level, and the local and national
culture embedding the organization. Furthermore at each level of analysis, there are
varying antecedents, triggering events, conflict processes and consequences of conflict
with cross-level influences. Thus, macro (higher) level factors and events can influence
the nature as well as facilitate or inhibit the degree to which conflict occurs at micro
(lower) levels and vice versa. For example, macro level factors and events like national
and organizational cultures, leadership change, restructuring, merger and acquisition,
and downsizing could lead to value and relationship conflict as well as facilitate
occurrence of conflict at micro levels. In the same vein, individual factors like certain
personalities (example, competitive personality) can result in work groups and
11
organizations which are prone to resource base conflict and which adopt competition as
conflict management approach.
However, Luthan (1998) categorizes conflict into intrapersonal, interpersonal,
intergroup and organizational conflict based on the behaviours of the different units
which constitute the organization (Fig.2). He further posits that conflict in organizations
could also take different forms such as hierarchical, functional, line staff, formal and
informal conflict. He explains that hierarchical conflict occurs between two parties at
different levels of the organization’s formal chain of command. Functional conflict is
often resource-based or due to communication breakdown or role and goal disparity
between two groups. Line-staff conflict often results from authority or power ambiguity
between the line and staff personnel, while formal and informal conflict occurs between
formal and informal organizations.
Macro
Organizational conflict
Intergroup conflict
Interpersonal conflcit
Intra-individual
conflict
CONFLICT
Micro
Figure 2: Levels of conflict in organizational behaviour
Source: Adapted from Luthan (1998)
12
Conflict in organizations has also been categorized in relation to the sources of the
conflict. Robins (2005) categorized conflict based on his understanding that identifying
conflict sources is a tool for effective conflict resolution. He thus groups conflict into (i)
task conflict, relating to the content and goals of the work to be done; (ii) relationship
conflict, regarding the relationship between individuals and groups; and (iii) process
conflict, relating to how work gets done. Also, De Dreu and Gelfand (2007) classify
conflict into resource conflict, value or relationship conflict and socio-cognitive conflict
based on the origin (source) of the conflict.
Further, Moore (2003) puts forward a ‘circle of conflict’ framework consisting of five
types of conflict in health care organizations based on their sources. This includes: (i)
data conflict relating to variations in information and data interpretation, (ii) interest
conflict referring to content or procedural issues, (iii) relationship conflict referring to
poor communication or misconceptions, (iv) value conflict relating to differences in goals
and evaluation criteria and (v) structural conflict involving unequal resource
distribution, authority or control, or harmful interaction pattern. Nevertheless, in health
care organizations with their complex structures and interdependent roles and
interactions with patients, conflict is invariably experienced in different forms both at
personal, group and organizational levels.
Hence, there is considerable conceptual overlap of the different categorizations of
conflict in organizations. These concepts often reflect the different aspects of an
organization based on the different perspectives of the authors. These perspectives
include: the behaviours of the different units in the organization, sources of the conflict,
division of organization into different levels and so on.
Furthermore, not only do these typologies give credence to the existence of conflict, they
also give insight into the forms in which conflict occur in organizations as well as help to
identify the sources. Although health care organizations invariably experience conflict at
different levels, most studies often focus on interpersonal level between health care
workers.
3.1.4 Sources of conflict in organizations
Organizations do not exist in isolation. They are open, functioning, often complex
systems that interact continuously with the environment in which they are embedded.
13
The complexity of organizational structure and functions and the dynamic interactions
with a rapidly changing environment create the likelihood for conflict to occur. This,
added to the globalization of economies and the large scale migration of work force
which affect both the composition and the way organizations conduct their activities
further increase this likelihood (De Dreu & Gelfand, 2007). Though much of research
into conflict in organizations focused on sources of conflict (Greenberg & Baron, 1997),
scholars have suggested a number of potential sources of conflict which are meaningful
and have a firm basis in reality. Some researchers however opine that these
nomenclatures are concepts rooted in theories with a rarity of thorough empirical studies
thus making scientific justification for these assertions a problem. (Van Tonder et al,
2008). Thus, virtually all the identified sources of conflict in organizations are regarded
as antecedents or prior conditions required for conflict to occur (Robbins et al, 2003:
Stroh, 2002).
According to Almost (2006) these conflict antecedents can be grouped into (i) individual
characteristics such as disparities in opinions, beliefs, values and attitudes, personality
differences, educational status and demographic disparities like age and gender; (ii)
interpersonal factors such as interactional pattern like ineffective communication,
threats, reciprocated trust or distrust, and personal dislikes; and (iii) organizational
factors such as organizational structure, task interdependence, relative power position.
These antecedents could initiate a circular conflict process in which their effects lead to
alteration of the existing antecedents or emergence of new ones if the conflict is not
effectively resolved (Wall and Callister, 1995). Nevertheless, it is agreed that identifying
the sources of conflict helps to reveal whether or not and in what form conflict exist in
organizations and acts as a veritable tool for effective conflict management (Moore,
2006; Havenga, 2005; Moore, 2003).
De Dreu and Gelfand (2007) make a distinction of three root causes of conflict found
across levels in organizations. These include: (a) scarce resources, (b) the quest to project
positive view of the self, and (c) the need to hold a socially approved and co-sensuous
view of the world. They explain how mixed-motive nature of social interdependence in
organizations forms the foundation for conflict to occur. Thus, task interdependence
could lead to resource conflict which is more likely to increase rapidly and become more
intricate from individual to organizational level. This view is supported by Spector and
14
Bruk-Lee, Pruitt, and Friedman et al. (2007) who explain that resources are the source of
stress and dissatisfaction among individuals, the cause of intense conflict and
competition among groups and the strong force behind labour-management relations.
Brief et al. (2005) also add that competing for resources at contextual (local or national)
level could negatively impact organizational attitudes.
Conflict embedded in threatened self identity or self view (value or relationship conflict)
though often occur at individual and group levels can also occur between organizations
especially at the interpersonal and intergroup levels between organizations that have
merged or in situations of acquisitions (Witt and Kerr, 2005).
Socio-cognitive (task-related, informational, or substantive) conflict is an awareness of
diverse opinions and view points and insights among individuals regarding a group task
(Jehn & Mannix, 2001).
Vecchio (2000) notes the role of communication in the evolution of conflict and posits
that sources of conflict in organizations can be in three categories: structure,
communication process and behaviours of individuals.
The nature of the complexity of health care organizations in terms of their highly diverse
multi-level health services provided to meet health needs of equally diverse groups of
people, the diverse and highly interdependent work force with varied professional
training, ethnic background, age, communication styles, different gender, personal,
political and religious values, the rigid hierarchical chain of command, the technical
rules, procedures and policies guiding activities, and the complex human interactions
make them highly prone to conflict (Marshall & Robson, 2005).
Conflict may exist within and between the different professional disciplines as well as
between entire staff and management in the hospital. The common causes of conflict in
hospitals include ambiguous responsibilities and job description, incompatible roles,
scarce resources, stress and poor communication (Danna & Griffin, 1999; Tenglilimoglu
& Kisa, 2005). Conflict may occur between health profesionals over resources and the
referral system, professional values, conduct, leadership struggle, salary differences, job
description and unionism; between hospital staff, patients and their relatives over the
quality of care, differences and expectations regarding interests, values and so on;
between staff and management or employer over resources like wages and salaries,
15
working conditions, unfulfilled promises, poor hospital management style, political and
socio-economic policies of government, unionism, lack of career advancement
opportunities, and so on (Osabuohien, 2010; Nayeri & Negarandeh, 2009; Moore &
Kordick, 2006;Marshall & Robson, 2005; Tenglilimoglu & Kisa, 2005; Jameson, 2003).
Aschenbrener and Siders (1999) however group common antecedents of conflict in
health care settings into three categories: (i) conflict with peers, resulting from patient
management approaches, work schedules, balancing different roles, budget management
for a unit or group, vying for laboratory and clinical space, failure to deal with peers’ low
performance, sharing the burden of patient care; (ii) conflict with subordinates
emanating from low performance among subordinates, reluctance in changing behavior
or practice, quality and volume of work, interpersonal relationship among subordinates,
interaction with superior, workloads and schedules; and (iii) conflict with authority
arising from broken promises, overall workload, salaries, ethical issues, disparity in
values between authority and employees, discrimination and inconsistent actions of
authority.
Also, Dove (1998) in his study of conflict at organizational level, notes that competing
needs for funds, information and role ambiguity are sources of conflict among many
departments in the hospital.
In spite of all these typologies, some scholars still opine that there is substantive lack of
empirical research to validate these acclaimed sources of conflict (Van Tonder et al,
2008).
Hence organizations are social units that continuously interact with its operating
environment often in resource scare situations. There is a myriad of factors that can lead
to conflict in organizations. The more complex an organization is in terms of its structure
and functions, the greater the likelihood of these factors resulting in conflict. This makes
health care organizations very susceptible to conflict. Nevertheless, conflict in
organizations could originate from more than one source; and therefore identifying the
sources is crucial and forms practical rationale for effective conflict management.
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3.1.5 Conflict dynamics (process)
The aforementioned definition of conflict as a process is supported by several literatures.
This definition suggests that conflict is not a static but rather a dynamic event. Scholars
assert that conflict is a part of the fabric of organizational life, embedded in the structure
of social relationships and given definitions and forms as parties involved take action
(Kolb, 2007). The myriad of the sources or antecedents of conflict including the
complexity of organizational structure and functions, the interactions among the various
organizational units and the organizations interaction with its changing environment
could trigger a chain of events resulting in various consequences. A theoretical
knowledge of this chain of events provides an understanding of the emerging conflict
pattern as disputants take action and thus equip managers with the basis for prompt
effective action to control the situation in order to prevent the harmful effects of conflict
to individuals, groups and organizations concerned. Different concepts of conflict
dynamics have been put forward but with obvious similarities between them. However,
some of the concepts are by and large, elaborations of the others with additional
nomenclatures.
Kreitner and Kinicki (1997) stated that conflict as a process can be explained in several
stages. These stages include: (i) the antecedent conditions, (ii) perceived conflict phase,
(iii) manifest behaviour, (iv) conflict resolution or suppression and (v) the resolution
aftermath (Fig.3). They explain that antecedent conditions are those in which there is
increased likelihood for conflict to occur. Conflict antecedents include role ambiguities,
organizational complexity, personality and value disparities and so on (Greenberg and
Baron, 1997). These conditions precede or cause conflict and their persistence could lead
to the perceived conflict phase. At this stage, parties perceive that their interests are
threatened resulting in frustration, emotional and mental strain for a period of time.
There is an atmosphere of mistrust and insecurity and pressure builds up within the
respective parties and the conflict remains latent.
Thereafter, disputants personalize conflict and start exerting behavioural responses
(manifest behaviour) to their perceptions. Thus, a previously latent conflict evolves into
manifest conflict. These responses could take any form including physical confrontation,
written or verbal attacks. With time, parties eventually realize the need for resolution of
the conflict. At this stage, they try to suppress or resolve the conflict. Resolution
17
aftermath describes the consequences of the approach employed to resolve the conflict
and how they affect both parties’ future interactions. These stages lend credence to the
time dimension of conflict since it reveals that conflict evolves over time. However there
is paucity of literature on this vital aspect of conflict which could be beneficial in
explaining when different conflict types can impact for later performance (Jehn &
Mannix, 2001)
Antecedent
conditions
Perceived
conflict
Felt
conflict
Manifest
behaviour
Conflict resolution or
suppression
Resolution aftermath
Figure 3: The conflict process
Source: Adapted from Milton (1981)
However, Dove’s (1998) concept of conflict process has seven stages which is an
elaboration of Kreitner and Kinicki’s model. He describes a felt conflict stage which
follows the perceived stage in which conflict is either personalized or depersonalized and
involves the expression of attitudes and feelings of threats and vulnerability and negative
judgements. This is followed by a stage of depersonalized conflict in which disputants are
less judgemnetal but their attitudes heat up the situation and create a problem. This
stage is followed by the manifest stage (manifest conflict) and so on.
Hence, conflict is a part of organizational life and is widely understood as a dynamic
event with emerging pattern and therefore can assume different levels and impacts on
individuals, groups and organizations over time.
The conflict process reveals the chain of events that occur from the antecedent which sets
the stage for conflict to the post-resolution aftermath which is largely a consequence of
the resolution approach to conflict. An understanding of this dynamic process, alongside
18
the underlying antecedent(s) poses great challenge but would also enable healthcare
managers and professionals make prompt and informed decision about when, and what
strategy to employ for effective management of the conflict.
3.1.6 Conflict consequences (outcomes)
There has been on-going debate on whether conflict in organizations is beneficial or
harmful regardless of the type. Some scholars argue that the effects of conflict are largely
negative, but others view conflict in positive light. While scholars try for decades to
explore these positive and negative functions of workplace conflict, much of this debate
revolves around the consequences task and relationship conflicts have on individuals,
groups and organizations (Guerra et al., 2005).
Managers need to be aware of the consequences of conflict because of their implications
to individual, group and organization’s well-being and performance. Also because these
consequences have the potential to trigger further conflict and therefore lead to a
spiraling of the conflict situation if not properly handled. Conflict functions or outcomes
are viewed as the values lost or gained by concerned parties alone or together (De Dreu &
Gelfand, 2007).
There is a growing literature showing that moderately intense conflict spur individual,
group and organizational performance and innovativeness than persistently harmonious
settings (Carnavale & Probst, 1998; Anderson et al., 2004).
Tjosvold (2007, 2008) argues that the course and consequences of conflict are
determined not by the type or source, but in the way it is managed adding that conflict,
especially task-related conflict if properly handled could improve individual and team
relationships and thus improve the effectiveness of organizational functions. On the
other hand, De Dreu (2008) notes that while the consequences of conflict in
organizations are largely negative, positive outcomes are located only in very few
situations, particularly in task-related conflicts of moderate intensity or in situations of
high intra-group trust and psychological safety. However, disputants may be involved in
a destructive or constructive debate/argument depending on how compatible or
incompatible they perceive their goals to be related.
Conflict is a driving force for change and vice versa, and therefore there is need for
organizations to adapt to this change for survival. Nevertheless, Almost (2006) in his
19
review notes that the consequences of conflict cut across all the levels of the organization
and can be grouped into three levels: (i) individual effects, (ii) interpersonal effects and
(iii) organizational effects.
The individual effects of conflict include stress, psychosomatic complaints, low selfesteem and self-efficacy, low levels of job satisfaction and commitment, increased
resignation, absenteeism, and a desire to quit the profession particularly among nurses
(Nayeri & Negarandeh, 2009; Lambert et al., 2004; McKenna et al., 2003; Cox, 2003;
Warner, 2001).
Interpersonal effects of conflict include aggression and escalation, increased turnover
and stress, group innovativeness, performance, commitment and satisfaction or the
contrary; while organizational effects may include improved or reduced effectivemess of
an organization (Spector & Jex, 1998).
Furthermore, conflict in health care organizations could lead to more dire situations
because of the peculiar nature of the services they render which directly affect human
conditions and in turn, the socio-economic development of any country. Thus, the effects
of conflict in hospitals are more often than not felt beyond their physical boundaries. For
example, conflict between union of staff and management especially those affecting the
core concerns of the staff like salaries and wages, working conditions and so on can lead
to temporary stoppage of services with resultant detrimental effects on population health
(Obinna, 2011) and thus retardation of the country’s economic growth in the long term.
It can also lead to the emigration of skilled health workers (Osabuohien, 2010).
Hence there is no doubt that unresolved conflict could have multiple consequences on
individuals, groups and organizations and beyond organizations’ boundaries affecting
whole population, and that the quality of agreement in conflict resolution greatly
influences future relations and performance. Therefore, managers need to be aware of
the destructive and beneficial consequences of conflict in order to effectively manage
conflict for organizational growth and development.
3.1.7 Cross-cultural variation in conflict sources and outcomes
Culture is a set of shared beliefs, values, behaviours and ideas that have been
internalized and form the norms of any society or environment. It is a factor that guides
the actions and reactions of people in any setting.
20
Organizations operate in different environments with their peculiar cultures which vary
across the globe. De Dreu and Gelfand (2007) point out that resources, the need to
project self or group identity, and views about the world are likely to be core needs found
across national cultures, and suggest that conflict arising from them, that is, conflict of
interest, value and ideological conflict, and socio-cognitive conflict are likely to be
universal with cross cultural differences in the precise triggers of these conflicts. This
view is supported by Shteynberg, Gelfand and Kim (2005) who argue that conflict
processes are set off in different cultures when the fundamental cultural issues are
treated with disrespect thus different events could trigger conflict across cultures.
The interplay between individual or group tendencies and the culture of the environment
in which organizations are located determine the type of conflict occurring in
organizations and the levels at which it occurs. Given that individuals in individualistic
cultures focus on self concept and that individuals in collectivistic cultures focus on
group values, research show that self processes like self-esteem and self enhancement
facilitate value conflict more in individualistic cultures than in collectivistic cultures
while the reverse is the case for group level values or constructs (Gelfand et al., 2002;
Chen & Li, 2005; Triandis et al., 2001). Thus there may be cultural variation of the
precise triggers of conflict in organizations though the broad categories of conflict in
organizations are likely to be universal.
Research reveals that national cultures moderate the impact of conflict in organizations.
Jehn and Bendersky (2003) explained that national cultures can reduce the undesirable
effects of conflict or suppress the positive effects of conflict in organizations. Generally,
individuals in collectivistic cultures are more likely to ascribe outcomes to situations
while individuals in individualistic cultures are likely to ascribe outcomes to dispositions
in a wide range of situations and especially in situations of conflict (Valenzuela,
Stivastava & Lee, 2005) implying that the undesirable effects of conflict on individual
health especially on members within groups is less pronounced in collectivistic than in
individualistic cultures. Research also shows that in collectivistic cultures, there is a
stronger desire to comply to pressures and an increased concern for peace for mutual
benefits. On the other hand, high levels of arguments benefited groups in individuslistic
culture like the United States (Adair, Okumura & Brett, 2001; Nibler & Harris, 2003).
21
Hence culture is a guiding factor of human actions and reactions in any setting and it
varies widely across the globe. Although there are cross-cultural variations in the precise
trigger of conflict which are often related to fundamental cultural issues, the root sources
of conflict are however universal. Also, conflict outcomes are influenced by local and
national cultures resulting from the way conflict is perceived and handled.
It is important to stress that although much of the study on outcomes of organizational
conflict were carried out in Western Europe and the United States, literatures on conflict
outcomes across cultures are still limited, more so in Africa and Asia.
3.2 Conflict management
3.2.1 Definition
Virtually all organizations regardless of their complexity or size are involved in one form
of conflict or another and thus have mechanisms built into the structures of the
organization to help manage conflict. However, the approaches adopted by organizations
to manage conflict vary widely as its sources and contexts. It is therefore important that
managers and employees are knowledgeable and competent to deal with conflict for
organizational benefit. According to Van Tonder et al (2008), the way individuals,
groups and organizations conceptualize conflict especially the events which lead to
conflict and the anticipated potential consequences largely affect the way conflict is
approached and managed. Thus, regardless of the origin of the conflict, management
approach to conflict is a potential moderator between the evolution of conflict and the
likely outcome (Tjosvold, 2008).
Van de Vliert (1997) defines conflict management as intended or actual actions of
individuals, groups or organizations involved in conflict. Hellriegel and Slocum (1996),
state that conflict management is a process that involves actions taken not only to
minimize conflict, but also to increase insufficient (functional) conflict. It involves the
planning and implementation of organizations procedures and policies for effective
conflict management.
De Dreu and Gelfand (2007) group the various conflict management strategies often
employed by organizations into a three-way system: (i) unilateral action, (ii) joint action,
and (iii) third-party decision making. They explain that unilateral action consists of
strategies which only one of the parties can implement without the opponent’s consent
or cooperation and these include dominating or forcing, withdrawal or inaction, and
22
yielding or giving in. On the other hand, joint action consists in employing tactics that
requires the agreement and cooperation of the opposing party and these include
negotiation, compromise and mediation. Third party decision making involves handing
over the control of decision to the discretion of another party different from the two
disputants and this includes arbitration, mediation and adjudication. Nonetheless, they
stress that these conflict management strategies can be used in combination.
Several researchers however suggest that for effective management, the substantive and
affective dimensions of workplace conflict should be considered (Jehn, 1997;
Amason,1996). While the affective dimension entails issues that are caused by the
negative reactions of members of the organizations (for example personal attacks and
racial discordance), the substantive dimension entails issues relating to tasks,
organization’s policies and so on. However, some scholars believe that these two
dimensions are one entity which should not be considered separately (Rahim,2002).
Whatever the strategy employed, conflict management aims at containing or minimizing
the destructive effects of conflict as well as finding satisfactory and acceptable solution to
the conflict.
3.2.2 Perspectives of conflict
Conflict is a complex, regularly occurring and inevitable social phenomenon which
permeates the fabrics of human and organizational life. Its ubiquitous and widespread
nature has earned it different definitions and meanings. There are different perspectives
(views) about conflict regarding the approach managers should have towards handling
conflict in the workplace. These perspectives however reflect the different management
approaches to conflict as well give insight into how the evolving pattern of the perception
and conceptualization of conflict over time forms the basis for such management
approaches. These different perspectives include: the traditionalist perspective, the
behaviouralist (human relations) perspective and the interactionist perspective.
3.2.2.1 The traditionalist perspective
This was the earliest and prevalent view in the conflict management domain in the later
part of eighteenth century all through to the mid 1940s and its position was simple conflict is bad and should be eliminated or suppressed. It is not surprising that in
societies where people are taught the ideals of maintaining peace and cordial
23
relationship with others, individuals would grow up as managers who would see conflict
as a bad event which negatively affects organizational effectiveness. Supporters of this
view hold that conflict is harmful to organizations and should therefore be resolved
promptly by appropriate managerial action which often than not is by elimination. They
believe that conflict is a preventable phenomenon and that organizational structures can
be designed to prevent or completely eliminate conflict whenever it emerges. With this
view, managers are therefore faced with pressures to employ actions which prevent or
promptly eliminate conflict as well as create enabling environment for organizational
effectiveness. Therefore, managers try to look good before their evaluators by trying to
ensure a harmonious working environment thus making it difficult for them to depart
from this traditional view.
However, this view has faced much criticism from scholars with opposing views,
especially with the emergence of findings about the positive values of conflict and
concerns about the short and long term consequences of suppressing conflict in
organizations. Opponents argue that conflict is unavoidable and can impact positively
on organizations and that trying to eliminate or suppress it is not only unrealistic but
could have undesirable consequences in the short or long term (De Dreu, 2008;
Ivancevich & Matteson, 1996).
3.2.2.2 The behaviouralist (human relations) perspective
This view emerged in the late 1940s and prevailed through to the mid 1970s following
criticism and departure from the traditional thinking about conflict. The increasing
evidence of the inevitability of conflict and the functional effects conflict has on human
and organizational life further strengthen this position. Supporters of this view hold that
conflict is natural and built into organizational structure, thus it is unavoidable and
should be accepted. They opine that conflict is neither inherently bad nor good and could
result in negative or positive consequences depending on many factors (Ivancevich &
Matteson, 1996; Robbins & Coulter, 1998). The implications of this assertion is that
regardless of the organizational design or managerial approach, conflict would always
occur, that not all conflict is bad, and with the use of the appropriate managerial strategy
not necessarily elimination or suppression, conflict could benefit organizations.
24
3.2.2.3 The interactionist perspective
This is the current perspecive which holds that conflict is not just a functional force but
also a necessary catalyst to spur group and organizational development and
performance. It states that conflict stimulates change and no organization can survive if
it cannot adapt to change which is a must. It views conflict management as a process by
which conflict is not just resolved but also stimulated for the overall benefits of the
organization.
It therefore prescribes that managers should not only endeavour to resolve conflict but
also to stimulate or encourage constructive controversy or functional
oppositions
among groups for innovativeness and quality decision making needed for organizational
effectiveness and survival, adding that a persistently cooperative and harmonious
organization could become static and non-responsive to the changes occurring in its
environment and thus be prone to failure or extinction (Robbins & Coulter, 1998).
Although the interactionist view does not support the belief that all conflicts are
functional, some scholars however believe that there is a level that could be considered
optimal for every organization in order to achieve the positive benefits of conflict
(Ivancevich & Matteson, 1996).
3.2.3 Theories of conflict management
In the study of conflict, researchers have always been concerned about how parties
involved in conflict resolve their disputes and what effects are associated with conflict
resolution choices they adopt. The various definitions and meaning of conflict which aim
at understanding how parties manage their contentions lie on the premise that there are
differing preferences between both parties which prevent each of them from satisfying
their interests (Shapiro & Kulik, 2004). Thus, scholars have developed frameworks or
theories to capture how disputants in this situation act in order to meet their goals at
individual, group and organizational levels.
25
3.2.3.1 Deutsch’s Theory of cooperation and competition
This model reflects disputants tendencies towards beliefs on how their mixed motives or
goals are interdependent – the fact that most conflicts involve a mixture of competitive
and cooperative motives and that peoples’ perception of how their motives or goals are
related determines how they interact with other parties and the resulting effects. The
central element of this theory is the type of goal interdependence existing between the
disputants. The theory argues that disputants may perceive their goals as positively
related, negatively related, or not related (independent). The close relations of this
theory with the pro-self and pro-social concept (Beersma et al., 2007) implies that when
disputants perceive their goals as competitively interdependent or to a lesser extent
independent, they become pro-self. That is, they strive to maximize their own outcomes
regardless of, or sometimes with negative regards to the outcomes of the other party. The
relationship between disputants becomes competitive with a win-lose approach to
dispute management.
Thus there is a display of negative characteristics like suspicions, strained or lack of
communications, antagonistic attitudes, threats, deceptions, persuasive arguments,
commitments to position, and the desire to weaken the opponent’s power and to
dominate. On the other hand, when goals are cooperatively interdependent, disputants
become pro-social and tend to regard and maximize the outcomes of both themselves as
well as others. Therefore, it is likely that disputants would act positively towards each
other and engage in constructive controversy or mutual orientations such as trust,
constructive information exchange and coordination, honest and friendly attitudes and
willingness to support and strengthen the position of the other party (Tjosvold, 1998).
3.2.3.2 The Dual Concern Model (DCM)
This model explains the individual’s preference of conflict handling style and paves the
way for a shift of focus from generalized predispositions to strategic choice dictated by
the conflicting parties’ conceptualization of the events. It argues that the specific choices
that disputants make are a reflection of their concerns for the welfare of self and others.
It states that conflict management is a function that combines the level of assertiveness
with the level of cooperativeness, that is, a combination of the level of concern (high or
low) for “self” with the level of concern (high or low) for “other” respectively. The theory
which aims at predicting strategy use from a set of strategies, presumes that both
26
concerns are not in direct opposition and so styles can be combined in resolving conflict
(Shapiro & Kulick, 2004; Olekalns et al., 2007).
A consideration of these combinations of concerns results in a set of conflict handling
styles or behaviours that disputants may choose. These include: (a) domination (forcing,
competition or contending) in which there is high concern for self and low concern for
other. Disputants engage in a win-lose relationship including persistent and persuasive
arguments, verbal dominance, and positional commitment; (b) collaboration or
integration in which there is high concern for self and other. Disputants are therefore
likely to engage in constructive approach and willingness to resolve the conflict; (c)
compromise is preferred in situations where disputants have moderate concerns for self
and others and thus decide to split the difference or meet the parties’ interests half-way;
(d) avoidance or inaction is a preference chosen when disputants have low concern for
self and other and thus fail to confront the problem and may not communicate with
themselves or ignore their differences or simply withdraw from the scene; (e)
accommodation or smoothing is chosen when disputants have low concern for self and
high concern for other and as such are willing to yield or oblige in order to resolve the
conflict. Shapiro and Kulick (2004) however note that with the exception of avoidance,
all these set of behaviours or conflict handling styles require concession to be made by
one or both parties.
3.2.3.3 The Interest-Right-Power (IRP) Theory
This theory argues that interests, rights and power are not only the basic elements of a
dispute but are also the messages that disputants communicate to each other while
trying to resolve conflict. It explains that interest oriented communications are
integrative and less costly, and can bring about a sense of mutuality and a willingness to
share information, better working relationship, a satisfying resolution and less
recurrence of future conflict between disputants. This communication approach which
aims at reconciling interests could be achieved through joint actions or through a third
party, that is, through negotiation or mediation and facilitation.
Shapiro and Kulik (2004) explain that rights oriented communications focus on the use
of norms, existing rules or laws or any means of achieving fairness to resolve disputes,
for example, arbitration; while power based communications are dominating and
threatening in nature and has a win-lose orientation, for example, industrial strikes.
27
However, Buss (2009) notes that although less costly, interest- based approach may not
always be the best approach and that it is often resorted to after disputants must have
employed rights and power based approaches without success; adding that there are
situations that may require a more authoritative approach hence the use of the other two
approaches. He adds that the cost of resolving conflict, the quality of the resolution and
its immediate and long term consequences are some of the considerations that should
guide the choice of approach. However, as in the dual concern model, these three
approaches are not mutually exclusive and could be used in combinations. Whichever is
the choice made, Brett et al (1998) advice that disputants should avoid the use of rights
and power approaches at the early stages of conflict resolution as they are likely to make
the conflict situation more intense and thus more difficult to resolve.
Shapiro and Kulik (2004) posit that the dual concern and IRP models share some
common assumptions which include: (a) that disputants have varying levels of concerns
for a known “other”,(b) that disputants choose a dispute resolution strategy from a list of
options, (c) that disputants are opportuned to directly or privately communicate with the
opposing party and (d) that avoidance or withdrawal is a less preferred option to a direct
one-on-one tactic. They stress that these assumptions reflect communication as a central
issue in dispute resolution and perhaps the reason why these two models are persistently
used to reflect conflict processes. But there are concerns that these assumptions may not
capture the complexity of modern day conflict.
3.2.3.4 Conflict Management Systems: Systems Approach
An organization is a complex system that constantly interacts with equally complex
environment in which it operates. The complexity of an organization in terms of the
systemic interdependence, network connections and dynamic interactions of its
constituent parts coupled with the changes occurring within the organization result in
non-linear, emergent properties or behaviours which are more than the sum of the
properties of its constituents parts, that is, these emergent properties are not directly
linked to the individual constituent parts but reside only in the system as a unit or whole
(Hazy et al.,2007; Hughes,2004). Systems thinking tries to understand the “whole”
closely connected to the problem situation, the interactions across multiple levels over
28
time as well as the non-linear emergent behaviours resulting from these interactions
which have posed problems for managers in situations of conflict (Waldman, 2007).
Rahim (2002) points out that for any dispute management strategy to be effective, its
plan or design should meet certain criteria: (a) it should improve learning by allowing
members of the organization to challenge existing organizational frameworks – policies,
structure and goals, and not just use them to resolve conflict, (b) it should clearly identify
and include the right stakeholders for the resolution of disputes so as to facilitate
collective learning and organizational performance, (c) it should be ethical, that is, it
should lead to moral actions from all stakeholders for the benefit of everyone.
Several models of conflict management systems based on systems thinking framework
have been put forward to address multiple view points including interests, rights and
power relations in interventions, boundary considerations in terms of what issues should
be added or left out and who is involved or affected (stakeholders) by these issues, the
purpose or objectives of the system, the change process(es), outputs and feedbacks all in
the bid to produce an ethical framework (Constantiono & Merchant, 1996; Midgley,
2003; Achterkamp & Vos, 2007).
Although there are no clear definitions, Lipsky and Seeber (2006) defines conflict
management systems as a comprehensive set of policies designed to manage workplace
conflict. Bendersky (2003) opines that conflict management systems basically consists of
three categories of dispute management choices:(a) interest based processes such as
facilitation and mediation in which a third party has control over the resolution process
but not over the decision(outcome), (b) rights based processes such as arbitration in
which a third party allows disputants to have process control while it controls the final
decision or outcome through the use of contracts or law and so on and (c) negotiation, a
process in which disputing parties resolve their conflict by themselves without the
involvement of a third party. However, in an attempt to address observed pitfall(s) in the
conflict management system framework, a more comprehensive integrated conflict
management system was put forward to address the sources of conflict and to provide an
approach for enhancing competence in handling conflict across all levels of organizations
(Gosline et al.,2001).
29
3.2.4 Managing conflict through resolution: Conflict management
styles
Conflict is a natural, pervasive and unavoidable social process or phenomenon that is
built into the structure of the workplace. It is a complex process that cuts across the
multiple levels in the organization and can involve individuals, groups or the whole
organization at a time. Thus managers are often faced with the challenges of how to deal
with whatever differences exist between disputing parties and how to align those
differences to achieve an outcome that will benefit the organization. Therefore managing
conflict is one of the fundamental tasks of management in the organization and this is
important for interpersonal relations, group cohesiveness and effectiveness, strategic
decision making and the overall development and performance of the organization
(Eisenhardt, 1997; Amason, 1996). The level of conflict experienced in the organization
depends not only on personal dispositions, group norms or organizational culture but
also on the variations in the styles or approaches to handling conflict (Friedman et al.,
2000). Therefore, the way people respond to situations of conflict has been a key interest
of researchers for a long time. However, research is still on-going in trying to understand
this somewhat complex process by which people handle their differences as they
unavoidably relate with each other at every facet of human endeavours especially at the
workplace.
3.2.4.1 Definition
Friedman et al (2000) view a style as a response to a particular situation. While some
scholars view conflict management styles as individual characters or behaviours which
are stable across situations and over time, others view them not as stable inherent
qualities or traits but as strategic choices individuals make to deal with the conflict
situations they face. However, there is evidence to show that approaches people adopt to
handle conflict are a combination of both situational factors and dispositional
tendencies. For example, Graziano et al (1996) observes that the choice of conflict style is
influenced by who is involved, and by agreeableness which is a personal trait. Each of the
five conflict handling styles are associated with distinct set of behaviours and they
include: competition, collaboration, compromise, accommodation and avoidance (Fig.4).
30
.
Figure 4: Two dimensional taxonomy of conflict handling styles (Dual concern model).
Source: Adapted from Thomas and Kilman, 1974, p.11
2.3.4.2Competition
Also referred to as dominating or contending, it is a power oriented strategy in which the
disputant has high concern for self and low concern for others. Thus, the disputant
becomes very assertive and uncooperative, adopts a win-lose orientation and therefore
uses any form of power - coercive or position(authority) at his disposal to subjugate the
other party (Schermerhorn, 2000). Positional commitment, verbal dominance including
threats, use of force, holding back information that could give the other party a
competitive edge, exploitation of the other party’s weakness, persuasive or persistent
debate or argument for one’s needs and reiteration of goals are some of the behaviours
shown. Disputants who adopt this style may either have the power or authority, are
higher in the hierarchical chain or are connected to powerful groups sufficient to force
their opponents to accept their resolutions.
31
Conflict is often resolved through a unilateral action taken by the powerful party without
any consideration for the view of the other party. This style is desirable when quick
decisive actions that affect organizational performance is vital particularly when the
enforcer is right. For example, the decision to lay off an unproductive staff, cut budget,
and so on which may improve organizational effectiveness. It can also be used when
there is the need to stand for one’s rights. On the other hand, when over-used or when
the enforcer is wrong, this style has the disadvantage of straining relationships between
individuals and groups in the organization, creates retaliatory tendencies, resentment,
hostilities and sabotage, negatively affects health and well-being and leads to overall
poor performance (Lussier, 1997).Thus, what started as a win-lose approach might
result in a lose-lose outcome if not wisely handled.
3.2.4.3Collaboration
This style is also referred to as integrating or problem solving in which case the disputant
has high concern for self and other. Though disputants show a high level of assertiveness
and cooperativeness, they seek to resolve their conflict by adopting a win-win
orientation. Hence there is a willingness to collaborate, a high sense of mutuality,
positional flexibility, a willingness to share information and engage in constructive
argument and work through their differences for the benefit of both parties (Ivancevich
& Matteson,1996; Olekalns et al.,2007). Lussier (1998) prescribes five steps for dispute
resolution through the use of collaborative style: (a) designing a (joint) plan to define the
problem and ensure ‘ownership’ of the process and decision, (b) presenting the plan and
working towards a solution often highlighting and emphasizing common grounds and
de-emphasizing their differences, (c) presenting possible resolution options which reflect
mutual trust and respect and concerns for both parties, (d) agreeing on a resolution, and
(e) an evaluation or follow-up to ensure compliance and maintenance of the resolution.
However, collaboration may also involve the use of a third party to mediate or facilitate
the resolution process while allowing the conflicting parties to exercise control over the
decision. The third party helps the conflicting parties to be responsive and engage in
constructive talks as well as create an environment where each party perceives and
appreciates the self-defeating actions of the other and a shift from their declared policies
or positions. This in turn gives impetus to the resolution process, heightens mutual trust
32
and respect and the willingness to find a common ground to amicably resolve the
conflict.
Collaboration is appropriate when maintaining relationship is important and there is
ample time, when there is strong positional commitment for which reaching a comprise
will prove costly, when dealing with issues that require optimal or quality decision
making, when people are more pro-social than pro-self, that is, when they place group
before self interests, and when dealing with complex issues (Kreitner & Kinicki, 1997;
Lussier, 1998). Thus. collaborative style fosters ownership of decision making and
improves quality of decision making. It enhances good working relationship and group
cohesiveness, builds mutual trust and respect and improves the overall performance of
the workplace. On the contrary, it is a time consuming strategy and may be inappropriate
when dealing with important issues which require quick decision making.
3.2.4.4Compromise
This is a style in which the disputant has moderate concern for self and other. That is,
disputants show moderate degree of assertiveness and cooperativeness during the
resolution process. Thus, they approach each other in a ‘win some-lose some’ manner
and a willingness to resolve the conflict by ‘reconciling or splitting the difference’.
Therefore, both parties engage in making some concessions of their interests, usually
those interests which are fundamental to the positions they adopted and thus settle for a
middle ground that partly satisfies their needs.
Reaching a compromise could be achieved through direct communication with the other
party (negotiation). It could also be achieved by involving a third party as a facilitator or
a mediator for example, high ranking personnel, or as an arbitrator especially when
negotiation fails and thus the need to seek the intervention of a neutral third party
(Ivancevich and Matteson, 1996). While arbitration entails the third party exercising
control over the final decision, mediation or facilitation entails that the third party fully
controls or shares the resolution process to get the disputants engaged in constructive
talks but does not exercise control over the final decision or outcome (Olekalns et al.,
2007).
The use of compromise to resolve disputes is appropriate in situations involving parties
with relatively equal status or authory who are equally committed to mutually exclusive
33
goals, when goals are moderately important to individual or team effectiveness and when
timely decision making is necessary in complex issues.
It has the advantage of resolving conflict relatively quickly and since disputants have
something of their original positions, some level of working relationship is maintained
(Lussier, 1998). On the contrary, compromise can lead to sub-optimal decision making
which could be low productivity. Because neither of the parties’ interests is fully satisfied,
working relations could be strained which in turn could lead to escalation of the conflict
and counter productivity. Also, if demands are too great and positional commitments so
strong as is usually obtain in value and relationship conflict, compromise would fail.
3.2.4.5Accommodation
It is a style in which a disputant has a low concern for self and a high concern for other.
Thus one party shows greater concern for the needs of the other than for his or her own
needs leading to a lose-win solution. Also referred to as smoothing or yielding, it is a
strategy in which the disputant is unassertive but highly cooperative with the other
disputant, playing down the conflict, overlooking their differences and obliging to the
other disputant for a peaceful resolution (Schermerhorn, 2000;Olekalns et al., 2007).
This style is desirable in situations where one realizes he or she is wrong and learns from
his or her mistakes, when one is willing to allow the other party (especially a
subordinate) to learn from his or her mistakes, to minimize loss when one perceives that
he or she cannot win, when both parties’ common interests are more important and
outweigh their differences, when the conflict is difficult to resolve especially ideological
and value conflict, when the issue at stake is of less importance to one party than to the
other, and when keeping peace is extremely important for individual and team
performance (Hellriegel & Slocum, 1996). Although it has the advantage of resolving
conflict within a short time, it does not address the root cause of the conflict, thus the
quality of agreement might be low and this could worsen future relations. Also, because
this style requires one of the parties for example the manager to be unassertive, his or
her ideas might not get attention and therefore his or her authority and credibility could
be undermined.
34
3.2.4.6Avoidance
This is a conflict handling style in which one party has a low concern for self and ‘other’,
that is, the party is unassertive about his or her interests and at the same time
uncooperative with the other party in reaching a resolution. This implies that the
concerned party does not have the will or desire to resolve the problem at first. Also
referred to as inaction or withdrawal, managers that employ this style postpone, fail to
confront, or simply ignore the problem and pretend they do not exist and therefore fail
to address the root cause(s) of the conflict (Olekalns et al.,2007). Because the root causes
are not addressed, the conflict remains unresolved and consequently impart negatively
on future relations and on organizational goals.
Therefore, this style is not effective in dealing with conflict and managers who employ
this strategy may not be well equipped to handle conflict that actually need their
audience. However, it has the advantage of creating opportunity for disputants to diffuse
tensions and to reflect on the conflict situations during which they can both decide to
start a new but constructive negotiation or decide to put an end to the dispute.
Nevertheless, avoidance style can be used to address trivial issues in the presence of
more pressing ones or where relationship is at stake, when conflict becomes too
emotionally laden and there is need to diffuse tension and allow people rediscover their
views, when it is more important to gather information for a new negotiation than
making immediate decision, when the potential consequence of the conflict is more
destructive than beneficial, or when one is dealing with a stronger party and perceives
no chance of getting his needs (Lussier,1997).
These five strategies have long been used in literature on conflict, and researchers
suggest that those strategies which involve concession by all the concerned parties, for
example, integration and compromise, are likely to lead to a mutually satisfying, longlasting resolution. But integration has been found in empirical studies and in theory to
be the most effective approach to resolving conflict since, in contrast to compromise, it
explores all possible options to fully or almost fully meet the needs of all the parties
involved in the conflict (Gross & Guerrero, 2000).
35
3.2.5 Managing conflict through stimulation
The concept of stimulating conflict is rooted in the interactionist view that conflict can be
beneficial (functional) to organization and should therefore be encouraged. Advocates of
this view argue that a persistently peaceful and highly cooperative workplace could
become unenthusiastic, static, and unresponsive to change necessary for survival of the
organization. Thus, this view rationalizes the existence of conflict and encourages
managers to accept and maintain an optimal level of conflict in order to foster creativity
and improve organizational performance (Verma, 1998).
Scholars have described the various techniques by which managers can stimulate conflict
in the workplace and these include: (a) restructuring the workplace, (b) introducing new
individuals into the workplace, (c) stimulating competition in the workplace, (d)
introducing programmed conflict, (e) use of communication, (f) changing workplace
culture.
3.2.5.1 Restructure the organization
Restructuring the workplace involves altering the structural variables in order to
interrupt the existing state of affairs and eventually increase the level of conflict in the
organization (Robbins & Coulter,1996). For example, managers may choose to increase
the size of a work group, realign work groups or increase interdependence between them
in order to stimulate creativity and innovativeness. Managers may also decide to
strengthen or increase the formal structure in the workplace for improved performance.
3.2.5.2 Introduce new individuals into the organization
Introducing new individuals into the organization could instil thoughtful and useful
ideas that could shift group or organizational focus to a different perspective. This has
the potential of increasing group learning and promoting group creativity and
innovativeness. For example, managers may introduce an expert or consultant into the
workplace to help improve group cohesiveness and effectiveness by introducing and
fostering group partnering and a win-win orientation (Verma,1998).
3.2.5.3 Stimulate competition in the organization
Ivancevich and Matteson (1996) opine that competition can be stimulated in the
workplace through various means. For example, a managers can stimulate competition
36
between work groups by introducing incentives like awards or bonuses for tasks
accomplished within a given time frame and available budget. This would eventually
impact positively on the overall performance of organizations if carefully implemented.
However, managers should be careful when using this technique and ensure that groups
adopt a win-win orientation in order to achieve set goals.
3.2.5.4 Introduce programmed conflict
Ivancevich and Matteson (1996) describe programmed conflict as a technique by which
conflict is intentionally and methodically designed into organizational process like
planning, decision making and so on, even when no real difference exists. It allows
individuals and groups to raise their ideas and opinions on issues regardless of the
positions of the manager. The manager can employ one of two approaches: (a) ‘devil’s
advocate’ approach which helps to arouse critical thinking among individuals and groups
by appointing someone with values or background (a neutral person) different from
those of the concerned parties to make a critique of the different viewpoints before a
decision is made; or (b) a dialectical approach in which individuals or groups after
deliberating on the course of action, come up with counterproposals based on different
assumptions. Then, advocates are asked to make a defense of their proposals to clarify
the different views before a decision is reached. Thus individuals and groups are
motivated to defend or criticize the different view points based on relevant facts and not
on interests.
Programme conflict not only helps to make far-reaching changes in power relations and
interaction pattern in the organization, but also creates a ‘sense of ownership through a
platform on which the different viewpoints of individuals and groups contribute to the
overall performance of the organization. Furthermore, it enhances creativity and quality
of decison making. However, it has the disadvantage of time wasting thus a delay in
making decision. In addition, because it demands the necessary skills to implement,
training personnel for such skills is capital intensive. Also, this approach could instigate
a win-lose orientation between concerned parties which could negatively affect working
relations and effectiveness (Kreitner & Kinicki, 1997).
37
3.2.5.5 Use of communication
Communication channels in the workplace can be manipulated by managers to stimulate
functional conflict. Thus, formal channels can be used to suppress information, transmit
excessive information, or transmit information that are unclear or threatening. For
example, a manager may choose to hold back vital information to stimulate conflict
between work groups. This could lead to reduction in apathy among work groups and
promote greater group thinking and creativity. However, when he observes that the
conflict is getting more intense creating hostility and becoming dysfunctional, he then
releases the information to the groups. Also, the release of vague information can
stimulate conflict among work groups but subsequent release of clear information help
reduce the conflict. Robbins (1997) posits that manipulating communication channels
make individuals and groups become aware of their differences in ideas or opinions and
thus have the drive to deal with them.
3.2.5.6 Change the cultureof the organization
Changing organizational culture entails that individuals and groups should be aware of
the legitimacy of conflict in the workplace, and therefore should be open to criticism and
challenges from others. Robbins and Coulter (1997) posit that this conflict culture should
be exemplified by managers adding that the culture of conflict would enhance the ease
with which managers use other conflict stimulating techniques in the organization.
3.2.6 Cross-cultural variation in conflict management
There is a large body of literature on culture and conflict management styles especially
studies on differences across cultures regarding the preferred handling styles. This
underscores the greater acceptance of conflict as a natural, inevitable phenomenon in the
workplace and thus a greater interest or concern on how to handle it. Also, the increasing
diversity of organization comprising people from different backgrounds including culture
and the conflict emanating from this diversity further strengthen this concern.
Generally studies reveal that individuals in individualistic cultures prefer dominating
styles and integrating interests when resolving conflicts while individuals in collectivistic
cultures have preference for power strategies or avoidance styles especially when
involved in conflict of high intensity or in conflict with members of the same group or
with superiors (Holt & Devore, 2005; Tinsley,2001;Freidman, Chi & Liu,2006; Oetzel
38
etal., 2001). However, not too many studies have assessed whether the assumptions
underlying existing theories like the IRP theory and the dual concern model can be
applied to other cultural settings. For example, contrary to the basic assumptions of the
dual concern model, the style of avoidance has been shown to be an expression of
concern for others rather than a lack of it; and that managers in collectivist culture like
Asia have high preference for avoidance style because of the relatively high value they
place on conformity and tradition while managers in individualistic cultures like the
United States prefer the dominating style because of the relatively high value they place
on self enhancement (Gabrielidis et al., 1997; Morris et al.,1998). While avoidance style
is perceived in bad light in the western cultures, the contrary is true in the eastern
cultures although both cultures agree that it is the least effective strategy for resolving
disputes (Brett & Gelfand, 2005; Morris et al., 1998; Cai & Fink, 2002).
Hence conflict management is a process involving the intended or actual actions of
individuals, groups or organizations aimed not only at minimizing or containing the
destructive effects of conflict but also stimulating insufficient functional conflict. There is
an evolving pattern of views regarding the perception and conceptualization of conflict
over time which form the basis for management approaches. The different approaches to
conflict management which these views present could pose a challenge to managers in
terms of choosing the appropriate and effective style in conflict situations. These
strategies vary across cultures.
Also, different management theories provide frameworks to explain how disputants act
and react in conflict situations in order to meet their goals.These theories reflect
communication as a central issue in conflict management.
3.2.7 Approaches to conflict management in health care organizations
Hospitals are health care organizations where people of diverse backgrounds and
inclinations converge to provide health care often in teams to people with diverse health
needs. As part of a larger health system, hospitals are saddled with the responsibility of
maintaining a healthy population through the provision of a wide range of quality
services in a responsive manner. In order to meet this goal, cautious planning and
resources are required, and a harmonious interaction with other components of the
health system is important. However, the range and quality of services provided are
influenced by political, socioeconomic, and cultural factors, and hospitals often operate
39
in environment of scarce resources and uncertainty thus paving the way for conflict to
occur.
Also the complex nature of hospitals namely their complex structures with rigid
hierarchical chain of command and communication, the complex workforce, the complex
nature of work in terms of the diverse health care services provided to meet equally
diverse health needs of people, the complex human interactions closely linked to rules,
policies and procedures, and the ethical codes guiding professional expectations make
hospitals easily prone to conflict. It is in this interlocking web of complexity that the
unique role of hospitals in restoring, maintaining and promoting health of the
population is vested. This is particularly challenging and demands enormous ethical and
moral responsibilities from health managers and professionals in ensuring a stable and
adaptive system. Research shows that ample time is spent daily by health professionals
and managers in resolving conflict in the workplace (Pavkalis et al., 2011}. A study
conducted by the America Management Association reveals that health managers spend
an average 20% of their time handling conflict in the workplace (McElhaney, 1996).
Therefore, acknowledging that conflict is inevitable and would naturally occur in such
settings is a crucial step in its management (Goodyear,2006).
Different approaches to conflict management in organizations have been identified in the
literature. These are mainly conflict management by resolution which includes
avoidance, accomodation, compromise, competition and collaboration, and conflict
management by stimulation techniques. It is however conveneient to explore how often
these approaches are employed, the factors which determine the approach of choice, and
the consequences of their use in health care organizations.
A study conducted by Pavlakis et al (2011) show that health care professionals use
avoidance and collaboration styles when dealing with conflict but that avoidance is
commoner with nurses. This corroborates the studies conducted by Cox (2003) and
Mahon (2011) who observe that nurses often use avoidance strategy in conflict situation
which is more often the case, particularly when in conflict with patients’ families (Sofield
and Salmond, 2003). Nevertheless, studies conducted by Hendel et al (2005, 2007),
Todorova and Mihaylova-Alakidi (2010) and Leever (2010) show that compromise,
accomodation, collaboration and avoidance are preferred styles by nurses and
40
physicians, noting that collaboration is commoner with nurses than with doctors and
that compromise could be achieved either by direct interaction between parties involved
or through a third party.
However, Bwowe (2002) shows that health care managers make use of collaboration
and compromise more often while avoidance and accommodation are less often used to
resolve conflict in the hospitals. He notes that the choice of conflict management
approach is influenced by their perceptions about the nature and intensity of the conflict,
and the significance and urgency of the problems. However, stimulating techniques are
not in any way used as managers do not believe in intentionally introducing conflict into
the organizations simply for the purpose of reaping its benefits. Also, because they
believe it is unethical to do so.
Skjorshammer (2001) notes that avoidance followed by dominating and negotiating
(compromise) are the preferred strategies among health professionals, and that the
choice of style is determined by two main contextual factors: perception of
interdependence between the parties involved and perception of urgency of the situation.
Furthermore, Leever (2010) in his study posits that the choice of conflict handling style
used by health professionals is determined by five factors: personal motives of parties,
the influence of oneself, the influence of the other party, the nature of the conflict and
the circumstance surrounding the conflict (conflict context).
There are few studies in the reviewed literature that relate the consequences of conflict to
the choice of management style. Friedman et al (2000) show that the level of conflict,
and stress in the work environment are decreased by integrating and obliging styles and
increased by avoiding and dominating styles. Nevertheless, obliging could increase stress
in intense conflict when parties involved are not able to assert their interests. This
observation is partially contrary to a later study by Tabak and Koprak (2007) wh0 reveal
that integrating and dominating styles are associated with low work stress while avoiding
and obliging are associated with higher stress. This could be due to a number of factors
including the context in which the conflict occcur. Unfortunately however, a dismal high
proportion of health care managers and professionals lack the competence to manage
conflict. A large proportion of them do not have knowledge of the strategies necessary to
manage conflict let alone acquiring the needed skills (Pavlakis et al., 2011, Sofield &
41
Salmond, 2003).This portends a dangerous trend considering the unique nature of work
health care organizations perform.
Hence,the five conflict handling styles used in other organizations, that is, competition,
collaboration, compromise, avoidance and accomodation are also used in health care
settings. For example, avoidance, compromise and to a lesser extent collaboration are
the most appreciated conflicting handling styles among health care professionals while
competition and accomodation are seldom used.Techniques to stimulate conflict in
health care settings are never used for ethical reasons. The preferred choice of style is
determined by a number of factors including the perception of disputants regarding the
nature and intensity of the conflict, the urgency of the problems and context in which the
conflict occur. Furthermore, the choice of handling style influences the level and
consequences of conflict in the organization.
Unfortunately, many health care managers and health professionals lack the knowledge
and skills needed to manage conflict.However, the unique nature of work that hospitals
perform and its implications on population health and socio-economic life requires that
conflict in health care be accepted, discussed and managed in ways that foster human
interactions, organizational development and performance,and consequently improve
the overall health of the population. To achieve this therefore, health care managers and
other health professionals need to possess the necessary competence to manage conflict
bearing in mind that not only could poor handling of conflict impart negatively on
effective functioning of the hospital but could also lead to grave consequences on human
populations. Research on sources of conflict and conflict management approaches in
hospitals in less developed countries is scarce, requiring more studies.
3.3 Review of past empirical studies of conflict in health care
organizations
There is a large body of literature on conflict in health care organizations. However, in
view of the scope of the thesis, a number of articles that present empirical studies are
selected from the overall sample for review in this section. These selected articles
contribute to the body of the lierature review and have been cited accordingly.
Nevertheless, these are presented in tabular form (Appendix 1) with focus on the author,
title and year of publication, the aim of the study, method and setting used and the
results of the study. This is to present a snapshot view and facilitate easy reading and
42
understanding of the articles by the reader. It helps to provide insight into the scientific
approaches employed to reach their respective conclusions. It will also serve to guide
approach into the design of the study protocol and to identify knowledge gaps that could
be explored in future studies .
The empirical studies reviewed in this section were published between year 2001 and
2011. Although the aims of each study are presented as stated in the respective articles,
particular attention was given to aims which addressed some concerns within the scope
of the thesis and which dictated the results presented in this review. These are aims
which addressed sources of conflict and the conflict management styles used in health
carein line with some of the objectives of the proposed study suggested by the study
protocol.
More than 50% of the studies were cross-sectional study using quantitative method
alone, while about 25% made use of only qualitative methods, and a small percentage
(approximately 11%) made use of combine qualitative and quantitative methods. In most
of the studies, sample of participants was obtained through non-randomize sampling
method, more often by convenience sampling and purposive sampling while only a few
studies made use of randomized samples. Most of the samples comprise a mix of the
different health care professionals while some are homogenous sample of nurses.
However,only one study has sample that comprise patients and family members.
Different instruments were used to collect quantitative data based on the researchers’
perspectives of the apprpriateness, validity and reliability of the instruments. However,
qualitative data was obtained mainly through in-depth interview.
Studies were conducted using participants either from hospitals as was often the case, or
in institutions linked to hospitals. Majority of the studies were conducted in developed
countries particularly in Europe and United States of America, with few studies in Africa
and Asia. This sample is a fair representation of existing published studies on the subject
in the different continents. Furthermore, with regards to Africa, all of the three selected
studies were conducted in Sub-saharan Africa with two from the southern part of
Nigeria.
43
Results reveal that there is a variation in the sources of conflict across settings with
some similarities, which could be contextual; and that studies which utilized conflict
framework to determine sources of conflict in health care organizations are scanty.
Also, the different conflict handling styles used in other organizations are found to be
used in health care settings.
Furthermore, the following observations were made from the literature:
(i) There is paucity of literature on conflict in health care organizations in Africa
including Nigeria, neccesitating more research on the subject in this part of the globe.
This might help increase awareness of the phenonmenon as well as give insights into the
contextual factors that facilitate emergence of conflict in health care in this part of the
world.
(ii) Literature of conflict in health care from the perspectives of the patients and their
families is rare, requiring more research which include these groups of people. This is
because not only are patients important stakeholders in health care (since hospitals are
built for them) but are often indirect victims of consequences of conflict in health care
organizations.
(iii) Majority of studies of conflict in health care organizations is on interpersonal
conflict between health care professionals. Thus, reseach is needed to examine conflict at
intergroup level (example, between different departments, workers unions) in the health
care system. This is because some major decisions taken by disputants which could
adversely affect the overall organizationcal performance and consequently population
health are taken at group level. For example, decision to temporarily stop the provision
of health care services to the public by some or all the staff is often taken by professional
groups.
(iv) Gender issues on conflict in health care organizations especially relating to conflict
management styles among female health care professionals need to be researched into
in order to understand the role of gender in the conflict process.
These are areas that could be explored in future studies.
44
4.STUDY PROTOCOL
This section seeks to provide scientific approach into determining the objectives of the
proposed empirical study by exploring opportunities described in the existing literature.
Considering the situational context in Umoru Shehu ultramodern hospital (USUM) and
the rarity of empirical studies on intergroup conflict in health care organizations, this
protocol therefore suggests a study which seeks to assess the sources and management of
conflict between the various workers’ groups/unions including the management in
USUM. The study will explore conflict which led to the temporary stoppage of services by
health care workers since inception of the hospital because it affects patients the most.
Hereafter, the term “conflict” refer to this context.
4.1 Objectives of the proposed study

Broad objective:
-
To assess the sources and management of conflict among health care
workers in Umoru Shehu ultra-modern hospital.

Specific objectives:
-
To identify the sources of conflict among health care workers in Umoru
Shehu ultra modern hospital.
-
To identify conflict management strategies among health care workers in
Umoru Shehu ultra modern hospital.
-
To develop recommendation for improvement of strategy for conflict
management in the hospital.
4.2 Study setting
The study setting is Umoru Shehu ultra modern hospital (USUM), a 300 bed public
tertiary health care organization located in the sprawling suburb of the capital city of
Maiduguri, Borno state in northeast Nigeria. Borno state is situated in a semi-arid
region of the country and shares boundaries with three countries – Niger republic in the
north, Chad republic in the northeast and Republic of Cameroon in the east (Figure 5).
In 2008, USUM commenced delivery of health care services to the public as a referral
centre to hospitals within the state and beyond including citizens of the aforementioned
neighbouring countries some of who also seek health care in the state. On inception, the
hospital was directly supervised by the state ministry of health which was quite unusual.
45
However, in late 2010 this function was transferred to the state’s hospitals management
board which is responsible for the supervision of all state owned hospitals.
USUM constitutes a domain for interaction between different health workers namely,
physicians, pharmacists, nurses, mid-wives,physiotherapists, laboratory scientists,
ancillary staff and so on. There are three different workers’ (labour) unions which
represent the interests of the health workersin the hospital namely, the association of
resident doctors (for physicians), the national association of nurses and mid-wives of
Nigeria (for nurses and mid-wives) and the medical and health workers union (for
scientists, administrative staff, maintenance staff, enigineers and other staff). Each
union has its elected representatives. Members of the medical and health workers union
and the association of nurses and mid-wives constitute over eighty percent of the
hospital’s workforce. However, typical of any health care organizations of such
magnitude, group (team) work, task interdependence and a complex human interaction
are inherent features crucial for the achievement of organizational goals.
Figure 5: Map of Nigeria showing the 36 states, federal capital territory and neighbouring countries.
Source:www.geographic.org/maps/nigeria_maps.html
46
4.3 Justification and significance of the proposed study
Although the Nigerian health care system is a public-private mix, the nation’s
constitution puts the responsibility of health care provision in the hands of the federal,
state and local governments. These three tiers of government through the collaboration
of their various arms (ministries, parastatals and departments) coordinate and execute
these services. These services are provided to the public by several health
institutions/facilities located throughout the country. However, the Nigerian health care
system is not without its problems prominent among which is conflict between the
different stakeholders. The conflict is often confined to the concerned health institutions
but sometimes escalate affecting health system activities at local, state or national level
with dire implications on human health (Ojeme, 2012; Okafor, 2012; Obinna, 2011).
USUM is not left out in this regard. Since commencement of services in 2008, the
hospital had at different times witnessed repeated conflict involving different cadres of
health workers due to disagreement over issues of concern to the different stakeholders
in the hospital (for examle, difference in salaries among health workers). In four years of
its existence the hospital had experienced about five conflicts that led to a temporary
withdrawal of services by its staff. Some examples of such conflict are stated in the text
box below. The partial or complete withdrawal of services by one or all the disputing
workers’ groups brought untold pain and suffering and avoidable deaths to the general
public, as well as generated fear and insecurity among health care seekers. Because
unresolved conflict in USUM has the potential to disrupt provision of health care services
to patients with enormous implications within and beyond its boundaries, the need to
understand the sources and management approach towards conflict through research
becomes imperative.
The proposed study therefore seeks to assess the sources and management of conflict
between the different groups of health workers in the hospital, particularly, conflict that
led to a temporary withdrawal of services by its staff since decisions to withdraw services
are often taken by workers’ groups (workers’ unions) rather than by individual health
worker and considering their impacts on the populace. The purpose is to better
understand the sources and management of conflict in the hospital by obtaining data
which can act as baseline information for the hospital. Also, because identifying the
sources of conflict is essential for effective conflict management in such an organization,
47
information obtained from the study could be used to develop recommendation which
might be useful to stakeholders in USUM to design effective strategy to manage future
conflict between different health workers in the hospital. Information obtained might
also be of interest to similar health care organizations, health professionals and
researchers, as well as contribute to the body of knowledge on the subject.
Text box 1. Examples of conflicts at USUM that led to a temporary withdrawal of
services by its staff

In 2008, there were two separate conflicts between all the health workers of
the hospital and their managers about low salaries, shortage of personnel
and failure to provide uniforms (hospital wears) for staff. Each of these
conflicts resulted in temporary withdrawal of services by all the health
workers (except top management) for two weeks. The conflict was resolved
though some of the health workers demands were not satisfied, thus the
likelihood of occurrence of conflict and industrial strike in the future.

In 2010, there was a protracted conflict between all the health workers and
their managers about low salaries (owing to failure of the state government
to implement the national salary structure for workers in tertiary health
institutions). This led to the withdrawal of services by all the health workers
(except top management) for six months.The demands of the doctors were
fully satisfied while the demands of the other health workers were only
partially satisfied. Because of the way the conflict was resolved, there is a
risk of further conflict and industrial strike in the future.
4.4 Theoretical frameworks
The propoesd study will utilize two theoretical frameworks to develop and improve the
initial interview guide for the group discussions as well as guide data analysis in order to
achieve the objectives of the proposed study. These are: (i) Moore’s ‘circle of conflict’
framework for determining the sources of conflict and (ii) Dual concern model for
determining the management styles of disputants in conflict situations.The definitions of
the concepts in both frameworks will be operationalize in order to make the sources of
conflict and the handling styles distinctive and easy to analyze.
48
4.4.1 Moore’s ‘circle of conflict’ framework
This framework categorizes conflict into five types on the basis of their sources. These
are data conflict, interest conflict, value conflict, relationship conflict, and structural
conflict. The purpose is to facilitate identification of the sources of a conflct. It will
therefore be used to inform the interview guide and data analysis in order to assess the
sources of conflict between health workers’ groups in the hospital. New information from
informants’ responses to questions to identify the sources of conflict in onefocus group
discussion (FGD)would guide the questions for the next FGD and so on. The theory
would also guide preliminary analysis of the data as a starting point while keeping an
open mind to other theoretical frameworks as the pattern of data is allowed to emerge in
an inductive manner.
4.4.2 Dual concern model
This model classifies conflict handling modes into five namely contending, collaborating,
compromising, avoiding and accomodating based on attempts to satisfy one’s own or
others’ concerns. It will be used to inform the interview guide and analysis of data from
focus group discussions in order to determine the conflict management strategies of the
different groups of health workers in the hospital. As the pattern of data emerges, the
different handling modes will be identified in the informants’ responses. Further, these
frameworks are combined and represented in a simple manner in figure 6.
4.4.3 Integrated theoretical framework
A health care organization is part of a larger health system both influcenced by prevailing
political, economic , structural and cultural factors.The integrated framework (Fig.6)
describes conflict in organization as a cycle of events that occur from the source or
antecedent which sets the stage for conflict to the conflict outcome which is largely a
consequence of the conflict handling modes of the disputants (Moore, 2003; Havenga,
2005; Moore, 2006; Tjosvold, 2007, 2008). It provides a basis for understanding
conflict in organization by examining the contexts, the interactions or interrelatedness of
the different social elements/levels (individuals, groups, organization, health system)
and the effects of these interactions on the emergence of conflict. However, because of
the interrelatedness of the different social elements/levels, personal contexts could be
brought into focus when exploring people’s experiences with conflict between different
groups.
49
Cultural
z
S
t
r
u
c
t
u
r
a
l
Sources of
conflict
Conflict
Organization:
Conflict
outcomes
-context
Organization
-culture
-structure
-culture
E
c
o
n
o
m
i
c
Conflict
handling
modes
Political
Figure 6: Simplistic representation of an integrated theoretical framework of conflict in health
care organization.
4.5 Method of designing the study protocol
4.5.1 Study design
An exploratory qualitative design to examine the experiences of informants with conflict
between health careworkers which led to the temporary withdrawal of services in the
hospital.
This design will involve a number of stages. First, to conduct a pilot study; second, to
conduct the main focus group discussions using emergent design; third, to carry out
additional interviews and fourth, to develop recommendations.
50
4.5.2 A pilot study
After getting approval to conduct the study, two pilot focus group interviews will be
conducted in the hospital (USUM) with participants from two different groups of health
care workers. The participants would be individuals who meet the selection criteria for
participants mentioned below but who would not take part in the second stage of the
research design. Interview will be held at an agreed time and venue and the focus group
will consist of 5-7 participants to enable the researcher steer the group and allow
participants to freely discuss sensitive issues in order to obtain useful information.
Interviews will be administered and data collected the same way as for the main study,
and the time required for the interview recorded. Feedback will be obtained from
participants in order to identify unclear or difficult questions for review or removal.
The pilot step will enable the researcher to collect preliminary data for analysis in order
to test and improve the interview guide (what initial questions to pose, how to pose the
questions and probe questions) for the second stage of the study (Kvale, 1996). It will
enable the researcher and his assistants to be trained on many aspects of the research
process, assess the workability of the research protocol to allow for improvement or
redesigning prior to the main study (second stage) as well as evaluate the time required
for each FGD.
4.5.3. Main focus group discussions
4.5.3.1 Selection of informants
First, the head of the hospital and heads of the unions will be approached to discuss the
FGD since all workers are members of some unions, for example the association of
resident doctors (for physicians), the national association of nurses and mid-wives of
Nigeria (for nurses and mid-wives) and the medical and health workers union (for
scientists, administrative staff, maintenance staff, engineers and other staff). All heads
will be asked to provide a list of workers in their group from which the researcher will
purposefully select participants to reflect hierarchy, departments and gender. This would
ensure a full coverage/representation of the hospital workers since workers are obliged
to their various unions. Selected participants will then be approached for the interviews
explaining the purpose of the study and requesting consent to participate. Those who are
reachable and knowledgeable on the topic and who can openly share their views about
51
the topic would be invited for the focus group interviews. After guaranteeing anonymity
and confidentiality and obtaining their consent to participate, an initial purposive
sample of twenty eight (28) informants from different deparments, hierarchy and
affiliations to workers’ (labour) union in the hospital will participate in the study to
ensure variability in the sample and in the perspectives of the informants. The sample
will also reflect gender distribution of workers in the hospital.
The informants will be categorized into four focus groups based on their affiliations with
the aforementioned health workers (labour) unions in the hospital and the top
management. Each union will form a focus group while the top management will
constitute one focus group in order to easily steer the group and to facilitate discussion
among informants. Furthermore, each group will compose of seven (7) informants
(including some of elected union representatives). However, the eligibility criteria will
include the following: (a) that the informant has been a staff of the hospital, hospital
management board or member of the task force committee, and (b) that the informant
has been continually active in service in the last 3½ years in order to have access to
people who can provide useful information that could enable the researcher achieve the
objectives of the proposed study.
4.5.3.2 Data collection
Data will be collected using a semi-structured interview guide (Appendix 2) which will be
further informed by the interviews (emergent design). Focus group interviews will be
conducted mainly at the offices or at any other place of the informant’s choosing and
convenience in the hospital, with a seating arrrangement and composition that
encourage discussion. Thus, each group of informants wiil be affiliated by workers union
and be seated (with the researchers) in a circular arrangement in order to ensure eye
contact and to facilitate an all-inclusive discussion. Data will be collected by the
researcher and two trained assistants.
The researcher’s role will be to stimulate and support
group discussions using a
sequence of questions from the interview guide relating to the informants experience of
conflict with other workers’ groups. He would assume a neutral position and not be
judgemental to responses, ensure free flow of discussion by introducing the session,
establishing rapport and encouraging every informant to participate. He would
52
coordinate and steer the group so that it stays on track with the aims of the discussion
and thus ensure a progressive discussion. Also, at the end of each interview session he
would summarize the major issues discussed, verify whether all informants agree to the
summary and ask them for additional comments. The trained assistants will assist in
obtaining informants demographics, tape-recording, note taking of the discussion
including emotional aspects of informants and relevant comments during off-sessions
(in case the tape recorder malfunctions), timekeeping, and reminding the researcher of
missed questions or comments.
Follow-up/probe questions fo rclarification and to further explore the sources of
conflictand conflict handling styles will be based on informants’ responses to the initial
enquiries.
Each interview would last about 1 -11/2 hourand will be audio-taped with the informant’s
consent, otherwise interview data will be hand-written. Notes will also be taken of
important words and phrases of the informants and the interviews will be transcribed
verbatim shortly afterwards on the same day. Memos and log will be kept to enhance
trustworthiness.
4.5.3.3 Data analysis
Analysis will be done shortly after each interview to inform the interview guide for the
next FGD. Tape recordings of all focus group discussions will be transcribed verbatim.
Transcript will be entered into a matrix sheet for each group of informants inserting
citations where appropriate. Data will then be analyzed by content analysis using
Graneheim and Lundman approach.
After selecting a unit of analysis, in this case the focus group interviews, the first step is
forming meaning units from comments for each question. Meaning units are “groups of
words, sentences or paragraphs containing aspects related to each other by their content
and context” (Graneheim &Lundman, 2004). These are words or statements that are
connected to the same central meaning. Second step is condensing the text – shortening
the text while preserving the core meaning. Third step is abstracting the condensed text
through coding - describing and interpreting the text on a higher level of reasoning
(Graneheim & Lundman, 2004). Fourth step is creating categories by grouping the
codes. The fifth step is developing a theme from the categories.
53
Through this inductive approach, it is believed that the data will allow the researcher to
identify the root cause(s) of conflict among groups of workers and how they were
managed, to examine and draw a conclusion on whether or not the management styles
adequately addressed the root causes and design a set of recommendation for an
improved strategy to effectively manage future conflict.
4.5.4 Addtional focus group discussions
Additional focus group sessions will be conducted if data from earlier interviews did not
reach a point of saturation, that is when new relevant data are stiil emerging from the
interviews. Therefore one additional focus group of same size will be drawn from each
workers’ union using the same selection criteria, data collection and analysis techniques
as for the previous interviews. Topics not discussed in earlier interviews will be
emphasized and discussed. Interviews will however be discontinued when saturation is
reached.
4.5.5 Developing recommendation for action
This aims at suggesting a course of action which stakeholders can build on in designing
strategy for effective conflict management in the hospital.This stage would require the
combine efforts of the research team and some stakeholders (especially those involved in
the focus group interviews) in order to promote ownership of the recommendations by
stakeholders as well as increase their relevance. The recommendation process will take
into account the scope of the study and prioritization of the expected impacts.A brief
statement of the scope of the study, research findings and expected impacts will be
highlighted and presented to key stakeholders – heads of the hospital, hospital board snd
unions. A list of recommedations will then be developed, supported by evidence from the
research.
The recommendations will be concise, specific and achievable suggesting procedures for
implementing them. It will also be clear on who is in the best position to implement the
recommendations.
4.5.6 Establishment of trustworthiness
Establishing trustworthiness should be considered early when designing a qualitative
study and throughout the research process in order for the study to yield useful findings
which the readers consider worth believing judging by widely accepted criteria for
54
assessing trustworthiness. Though researchers use different terms for these criteria, they
however capture similar issues in trustworthiness. These common criteria for assessing
trustworthiness are truth value, applicability, consistency and neutrality which in
qualitative research are refered to as credibility, tranferability, dependability and
confirmability respectively (Dahlgren et al, 2007).
Credibility refers to the ability of the researcher to accurately record or express the
multiple realities of the informants under study (Dahlgren et al, 2007). Thus, not only
should informants be able to recognize their own reality in the researcher’s description of
the phenomenon, readers of the study findings should also be able to recognize this
reality if they find themselves in the same natural setting of the study informants. To
achieve this therefore the reseacher will ensure the selection of appropriate informants
for the study. Data will be collected from informants of different health professions so as
to ensure triangulation of data sources. Researcher will also ensure prolonged
engagement which allows him to get acquainted with the informants and their culture
and create opportunity for building mutual trust and respect important for informants
to open up during interviews. For this reason, the researcher will endeavour to visit the
informants at the study setting at least once before data collection would commence.
Transferability refers to the extent to which qualitative research findngs are applicable
to other contexts (refered to as external validity in quantitative research). Qualitative
researchers do not seek to make generalization of their research findings but instead
allow readers who are familiar with the new context to make decision about
transferability to other contexts (Dahlgren et al., 2007).
To meet this criterion, the researcher will ensure the selection of appropriate sample and
that the informant’s experience of conflict is vividly described. The researcher will also
ensure a detailed description (thick description) of the research context in terms of the
characteristics of informants, local and organizational culture, as well as the data
collection and analysis process of the proposed study.
Dependability refers to the ability of the researcher to account for the entire research
process, and the continuously changing conditions of the phenomenon studied as the
researcher interacts with the study informants (Dahlgren et al., 2007). It is related to
consistency of qualitative researh findings. It is the stability of data over time which
55
implies that research findings should be consistent if the study is carried out in a similar
context with the same psrticipants (Speziale & Carpenter, 2003). This requires that
external checks be carried out on the instruments for assessing consistency in qualitative
research which are the researcher and participants through an inquiry audit process.
This entails that another researcher (an auditor) be able to follow through the research
process and evaluate how sound and acceptable the data collection process, findings and
interpretations of the reseacher were. To meet this criterion, the researcher’s supervisor
will audit the research process and this will be facilitated by keeping notes, memos, log
and transcripts throughout the research process.
Confirmability is a criterion for assessing the quality of the data and refers to the
neutrality or objectivity of the data in which the researcher (takes a neural position and)
is able to correctly represent the realities of the studied participants. It is a strategy to
ensure that the research findings are explictly grounded in the data and therefore free of
bias. Confirmability is also evaluated using an audit trail in which another researcher
(inquiry auditor) systematically collects and examines materials and documents (raw
data, field notes, memos, log, transcripts and so on) which can enable him come to
comparable conclusions about the data. It permits a rigorous audit at the end of the
research and aims to elucidate that the evidence and thought processes along the
research path and within the research context allow another researcher the same
conclusions (Dahlgren et al., 2007; Speziale & Carpenter, 2003). To meet this criterion
therefore, the researcher will keep raw data, tape recordings, field notes, memos,
transcripts and all methodological decisions made throughout the research process.
56
5. ETHICAL CONSIDERATIONS
Ethical approval for the study will be obtained from the ethics committee in Borno state
ministry of health and top management of USUM for permission to conduct the study.
Participants will also be required to give informed consent for the study. The researcher
recognizes that he has a moral obligation to protect the rights of the hospital and in
particular of the paricipants who will provide the information needed for the study.
Therefore, the purpose and potential benefits of the study will be explained to the top
management staff, heads of departments of the hospital as well as would-be participants
in order to build trust and facilitate decision about conducting and participating in the
study. The researcher will inform and assure the staff of anonmity, the time required for
the study, voluntary nature of participating and freedom to withdraw from the study at
will without any consequence. Time and place of the interview will be mutually agreed
upon by both the informants and the researcher. Informants will also be informed and
assured of confidentiality of data collected. Therefore all notes, logs, interview tapes,
transcripts and other data will be kept safe and only within the reach of the researchers.
57
6. DISCUSSION
6.1 Methodological considerations, rationale of the thesis and
expected impact
To achieve the aim of the thesis, relevant scientific papers which met specific criteria
were collected from textbooks and databases. The literature review provided insights into
salient topics on conflict – conflict sources, consequences, management approaches and
theories. It also highlighted the conceptual changes and evolving trend on issues of
conflict and helped identify knowledge gaps that could be explored in future studies.
The study protocol proposed a study which aims at identifying the sources of conflict in
USUM, how they are handled and how they should be handled to avoid bad
consequences both within and beyond the hospital in the future. The thesis was inspired
by the recurence conflict which led to the partial or complete withdrawal of services by
one or all disputing group of health workers in the hospital since lives are risk of being
lost.
Further, in line with the context in USUM the study protocol suggested an exploratory
qualitative design to gather data about the informants’ experiences with conflict at
intergroup level by using FGD to capture informants’ subjective realities (knowledge,
comments, emotions and so on) with conflict from interviews with different groups of
health workers while assuring anonymity of informants and confidentiality of
information provided. Considering the rarity (limited information) of empircal studies
on conflict sources and management in health care organizations in Nigeria, particularly
in the northern region of the country, this study will help increase awareness and gain
new insights into conflict sources and conflict management in the hospital. It would also
help to explore and understand the conflict process as well as contribute to developing an
effective tool to manage future conflict in the hospital.
6.2 Strengths and limitations of the thesis
Strengths
1. The use of many data bases and textbooks for the literature review allowed for
assessment of the multiple perspectives of various disciplines about conflict.
2. The literature review revealed some knowledge gaps in the existing literature
including the rarity of data on intergroup conflict in health care organizations.
58
3. Hence the thesis designed a protocol which proposes a qualitative study to
explore sources and management of intergroup conflict between different groups
of health workers within the context in USUM.
4. The study protocol suggests focus group discussion which was rarely used in the
reviewed empirical studies of conflict in health care organizations as a technique
for collecting data. This technique is relatively less time consuming and data is
quicker to analyze than for in-depth interviews which was mainly used.
Limitations
1. Difficulties with accessing full texts of some relevant scientific papers for
literature review.
2. Some databases which could also generate relevant scientific papers might have
been missed out for the literature search.
3. The qualitative method suggested for the proposed study if used alone could raise
issue about the transferability of findings since it is context bound. Therefore,
combining this method with a quantitative method could enhance validity of the
study since more participants would be involved and thus a better picture of the
phenomenon would be obtained.
6.3 Strengths and limitations of the study protocol
Strengths
1. The protocol design is flexible and allows for improvement or redesigning.
2. The exploratory design enables new insights into the phenomenon within the
context.
3. The pilot step allows for an assessment of the workability of the protocol and an
acquaintance with many aspects of the research process.
4. The use of a purposive sample would enable in-depth information be obtained
from informants for optimal insight into the topic.
5. The semi-structued focus group interview is emergent and allows new questions
to be included based on the informant’s responses.
6. Face-to-face contact with the moderator encourages participants engagement,
captures non-verbal behaviours (expressions, attitudes),allows discussion to be
steered and questions to be clarified.
Limitations
1. It requires training and expertise of the research team.
59
2. The responses of informants could be influenced/biased because of group
environment.
3. It can be time consuming and costly.
4. The risk of non-participation in the study by the leadership/managers of the
hospital if they are not interested nor motivated to find lasting solution to the
repeated conflict in the hospital.
60
7. CONCLUSION
The thesis reviewed existing literature on conflict in organizations especially health care
organizations as well as design a study protocol to explore the sources and management
of conflict in USUM, Maiduguri, north-east Nigeria. The methods adopted to achieve this
aim have been described.
Existing literature revealed salient topics on conflict in organizations including the
sources , consequences, handling modes, related theories, similarities and differences in
the perspectives of researchers,changes in the concept over time and evolving trend on
issues of conflict. The literature also presented knowledge gaps for possible future
studies.
Conflict is pervasive and inevitable, and its effects in health care organizations including
USUM have been highlighted.
The sources of conflict, the way conflict is handled and the resultant effects are
interrelated. Thus conflict can be good or bad depending on the way it is handled.
Since conflict can be effectively managed if its source is known, the protocol described a
proposed study to identify the sources of conflict and the management strategies used by
health care workers in USUM through a qualitative approach.
Information provided by the proposed studycouldequip the management and staff of the
hospital to effectively manage future conflict.
61
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Appendix 1: Empirical studies of conflict in health care organizations.
No
Author/Year/Title
1
Skjørshammer,
Aim
Method
Setting
M. To find out how hospital Qualitative study. using in-depth A
(2001). Co-operation and professionals
Result
middle-sized Avoidance,
forcing
and
are
the
manage interview on a theoretical sample of (225 beds) urban negotiation
conflict in a hospital: conflict related to work 29 staff representing the various hospital in Norway. preferred strategies, usually
Interprofessional
co-operation
professions and their unions, and Interview
differences in perception
and
management
hierarchy. Data analysis was by conducted at their
of
Grounded theory.
.
offices or at work
conflicts.
2
stations.
Bwowe, P.W. (2002). An To identify the conflict Quantitative
investigation
into
the management
conflict
management currently
styles
used
organizations
specific
some
and
used
by in-depth interview on a convenience the North region of frequently used strategies
in sample of 24 participants - 4 middle Eastern
with organizations
and to managers from four departments in South Africa.
Conflict stimulation was not
whether each hospital: doctors, nursing,
supported partly for ethical
to determine
organizations
province.
qualitative Six public district Collaboration
in managers
reference
eastern
and
styles methods using questionnaire and hospitals located in compromise are the most
in there are other conflict
support services, and the general
the northern region of management styles used administration.
the
was in that order.
20
questionaires
Cape by managers but not completed and returned, and 18
found
in
most participants interviewed.
literatures.
71
Cape, for
resolving
reasons.
conflict.
3
Jameson,
J.K.
(2003) To
identify An exploratory qualitative study. Two
Transcending intractable communication
community Intractable conflict at the
Data was obtained using in-depth hospitals
and
conflict in health care: practices that transcend interviews with Certified registered academic
an national
and conflict
between anesthesiologists.
conflict
management certified
among
anesthesia nursing
providers.
Data
could
serve
to
was U.S.A. Employment exacerbate or ameliorate the
registered analyzed by thematic analysis.
methods
Anesthetists
(CRNAs)
influences
hospital individual level interaction
An exploratory study of or enact the intractable nursing Anesthetists (CRNAs) and in North Carolina, which
communication
level
for conflict.
CRNAs
and
and
anesthesiologists
anesthesiologists.
differ between the
community
hospitals
and
academic hospital.
4
Sofield,
L.,
Salmond, (i)To describe registered A desriptive correlational design A
three
S.W. (2003). Workplace nurses’ experiences of using questionaires on a random hea;th
violence.
A
focus
on verbal abuse in a large sample
verbal abuse and intent multihospital
to leave the organization.
(ii)
to
variations
abuse
hospitals
of
1000
nurses,
461 the
hospital Causes of verbal buse are
system in high
in
verbal was used to measure verbal abuse
according
and
to and intent to leave the organization.
the
interpersonal
Physicians
reationship.
are
major
perpetrators of verbal abuse
followwed
patients’
72
stress,
Northeast power differentials, unequal
system, questionaipes were completed and region of U.S.A.
determine aanyzed. Cox verbal abuse survey
workplace
by
patients,
families,
peers,
relationship of verbal
supervisors
and
abuse with intent to
subordinates.
leave the organization.
was the preferred handling
Avoidance
style particularly when it
involves patients’ families.
5
McKenna B.G., Smith, (i)To determine the
A cross-sectional descriptive study. Registered
N.A.,
A convenience sample of 1169 in their first year of and relationship as well as
Poole,
S.J.
& prevalence of various
Coverdale, J.H. (2003). types of interpersonal
registered nurses in their first year practice
Horizontal
of
violence: conflict experienced by
Experiences
Registered
their
first
practice.
Nurses
year
practice
identified
with
the hospitals
nurses Conflict of interest, value
in task-related
conflicts
are
across prevalent mostly emanating
of nurses nationally in
register .of the nursing council of New Zealand
for
in their first year of
New Zealand. Data was obtained
being neglected, increased
of practice; (ii) describe
using
workload
.questionaire to explore
being
undervalued,
without
the characteristics of
interpersonal conflict, and impact of
appropriate support, lack of
the most distressing
event
measure
opportunities for learning,
incidents nurses
psychological distress, 551 (47%)
being distressed by conflicts
experience; (iii)
questionnaires was completed and
between other colleagues.
measure the
returned by mail. SPSS was used for
psychological impact of
analysis of data.
scale
these events; (iv)
determine the
consequences of
73
to
experiencing such
events; and (v)
determine the adequacy
of training received to
manage horizontal
violence.
6
Hendel, T., Fish, M., & To
Galon, V. (2005).
Leadership
choice
of
conflict
among
managers
hospitals.
identify
conflict A
and nurses
strategy
in
A Five
general nurses from the medical/surgical Israel
in hospitals and examine
and two intensive care units of each three
management the relationship between of
in
study.
general Compromise
and
mode choices of head convenience sample of 60 head hospitals in central accommodation
style
Israeli
cross-sectional
five
general
hospitals
owned
general of strategy in handling 3-part questionnaire: The Thomas-
different least
frequently
strategy
demographic
the
situations.
characteristics.
Questionnaire
MLQ
demographic data.
74
5X,
and
style
the nurses used only one
Kilmann Conflict Mode Instrument,
Leadership
used
respectively. About half of
conflicts and
Multi-factor
the
by most frequently and the
was organizations were management
nurse leadership style, choice selected and data obtained using a used.
are
in
conflict
7
Tenglilimoglu, D. & Kisa, To
A.
(2005)
outline
the
key A
cross-sectional
Conflict features of conflict in a Quantitative
study. Gazi
method
University Sources of conflict include
using hospital,
a
large poor communication and
management in public large modem hospital questionnaires to obtained data modem 587 beds information flow due to
university
hospitals
Turkey: A pilot study.
in that can be targets for from a ample of 304 different university hospital differential
hospital staff
with in Ankara, Turkey
among
education
successful
categories of
hospital
staff,
management.
varying periods of work experience.
resource allocation, lack of
94 Physicians, 91 nurses and 119
opportunity
other professionals.
advancement,
for
career
and
bureaucracy.
8
Moore,
J.B.,
Kordick, To identify sources of A
phenomenological
design.
A Oncology unit of Conflict
sources
between
M.F. (2006). Sources of conflict, to determine purposive sample of 27 informants ( Children’s National health care professionals,
Conflict
Between nursing
interventions 9 children with cancer, 14 mothers Medical Center and patients and their families
Families and Health Care that alleviate conflict, and 4 fathers) from various group Georgetown
Professionals.
and to test a conceptual meetings for parents and children. Medical
framework of sources of Data was obtained using in-depth both
conflict.
are:
Center expectations
located
interviews and data analysis was by Washinton
deductive and inductive approaches United
for sources of conflict and effective America.
nursing intervention.
75
differences
States
and
in
desires
in regarding data, interests,
DC structure, relationships, and
of values.
9
Hendel, T., Fish, M., & To identify and compare A cross-sectional correlational study Five
Berger,
O.
(2007). conflict mode choices of A
Nurse/Physician conflict physicians
management
and
convenience
125 hospitals
care Compromise was the most
at
of
collaborative the
relationship
questionnaire,
with their background obtained
characteristics.
was selected but 75 completed
of physicians and 54 nurses completed convenience.
conflict mode choices the
using
Data
the
the frequently used style by
Israel. both nurses and physicians.
mode nurses in acute care medical and surgical wards of 5 Questionaire
practice.
10
of
head physicians and 60 head nurses from centre
choices. Implications for hospitals and examine hospitals
improved
sample
acute
was
was Problem solving was more
at frequently used by nurses
and
least
frequently
by
physicians.
Thomas-
Kilmann conflict instrument mode.
Tabak, N. & Koprak, O. To examine what tactics A cross-sectional study using a Tel-Aviv university Integrating and dominating
(2007)
between
resolve
Relationship nurses adopt to resolve convenience sample of 200 nurses hospital located in are the most used strategies,
how
their
nurses conflicts with doctors from different departments. Data Tel-Aviv, Israel.
conflicts and how the different was obtained by questionnaires
with doctors, their stress tactics affect their level designed for conflict sources, the
and job satisfaction.
of
stress
satisfaction.
and
job Health Professions Stress Inventory
(HPSI) for workplace stress for
medical
personnel
and
a
questionnaire on job satisfaction
based on Hackman and Oldman’s
Job
Diagnostic.
117
completed
questionaires were analyzed.
76
while
obliging
and
avoidance are the least used
strategies.
11
Ogbonnaya,
L.U., To assess the health A cross-sectional descriptive survey Ebonyi
state Perceived sources of conflict
Ogbonnaya,
C.E., professions' perception among six health professions using university teaching include differential salary
Adeoye-Sunday,
I.M. of factors responsible questionnaire.
hospital Abakaliki, between doctors and others,
(2007). The perception for conflict.
Ebonyi
of health professions on
southeast Nigeria.
causes
state, physician intimidation and
of
discrimination
professions,
interprofessional conflict
ambition”
in
professions
a
tertiary
of
health
other
“inordinate
of
to
other
lead
the
institution in Abakaliki,
health care team, and envy
southeast Nigeria.
of the doctor by the other
professions.
Nayeri,
12
N.
&
Negarandeh, R. (2009).
Conflict among Iranian
hospital
nurses:
qualitative study.
A
the An exploratory qualitative research Tehran university Sources of conflict are
experience of conflict as method. A purposive sample of 30 teaching hospital, organizational
structure,
To
explore
perceived
by
hospital
nurses
Tehran,
Republic of Iran.
Iranian hospital nurses and nurse
Tehran,
in managers was selected to obtain culturally
Islamic data by using semi-structured in- society.
Iran.
A hospital management style,
Islamic nature and condition of job
assignment, and individual
depth interview. Data analysis was
characteristics.
by content analysis.
Mutual understanding and
interaction are the main
strategies for the prevention
and control of conflict.
77
13
Leever, A., Huls, M.,
To investigate the way A qualitative method. A purposive A 32 beds surgical Avoidance and compromise
Berendsen, A.,
nurses and physicians sample
Boendemaker, P.,
cope with conflict and physicians
Roodenburg, J., & Pols,
clarify the determinants selected
J. (2010).
of conflict management spectrum of gender, age, function The ward has 21
Conflicts and
conflict management in
styles.
of
12
and
to
participants
6
obtain
nurses)
an
(6 ward of a Dutch through direct or indirect (
was university medical third party) discussion are
optimal center (1339 beds). the preferred strategies.
and experience. Data was obtained physicians and 30
the collaboration
using
semi-structured
in-depth nurses. Groningen,
between nurses and
interview.Analysis was by Grounded Netherlands.
physicians – A
theory approach.
qualitative study.
14
Todorova, M; MihaylovaAlakidi, V. (2010)
Aspects of behaviour of
healthcare specialists in
conflict situations.
To define and analyze A cross sectional study. Quantitative Faculty of Public Compromise, followed by
Medical
behavioral
strategies, method using the Thomas-Kilman Health,
avoidance and collaboration
conflict
instrument
mode
on
40
University,
Plovdiv,
which
healthcare
are preferred strategies.
management specialists healthcare specialists to describe Bulgaria.
solving the types of behaviour in conflict
conflicts at work place situations, and the Questionnaire of
and
their
self D. Crown and D. Marlow for selfassessment for approval assessment of approval motivation.
use
when
motivation in the team.
78
15
Osabuohien, E.S. (2010). To assess the causes of A cross sectional study. Quantitative Lagos
“Industrial Conflicts and industrial conflict and and
Health Care Provision in the
Nigeria”
in
consequences
qualitative
methods
state Non-fulfillment of promise
using university teaching by
management
on structured questionnaire on 100 hospital in Lagos , /government,
Ninalowo health care provision.
health
professionals
delay
(doctors, Southwest Nigeria. payment
of
A.M.A., Badru, F.A. &
nurses, technologists and so on) and It has a history of salaries/allowances,
Akinyemi,
in-depth
R.(eds.)
An
interview
of industrial conflict.
interdisciplinary
representatives of labour union and
Discourse on the Human
management. SPSS and ANOVA
Condition.
were used for analysis of data of 72
in
and
poor working conditions are
the major causes of conflict.
conpleted questionnaires.
Pavlakis, A., Kaitelidou,
16
D., Theodorou, M., et al.
(2011).
Conflict
management in public
hospitals:
case.
the
Cyprus
To
assess the factors
leading
to
conflict
among staff members;
to
evaluate
the
consequences of conflict
arising; and to consider
the
strategies.
management
A
cross-sectional
study.
Quantitative method using selfadministered questionnaire on a
random sample of 1037 health-care
professionals in all (seven) state-run
hospitals in Cyprus. 821 nurses, 125
physicians, 23 psychologists, 49
physiotherapists
occupational
participated. Data
with SPSS.
and
19
therapists
was analyzed
All (seven) state- Main causes of conflict are
run
hospitals
Cyprus.
Questionaire
completed
in organizational
and communication gaps.
was Avoidance
and
by collaboration
are
participants at their preferred
places
convenience.
of .Avoidance
with
79
the
strategies
is
commoner
nurses
while
collaboration is commoner
with
psychologists
physiotherapists.
.
problems
and
17
Mahon, M.M., Nicotera, To
identify
A.M. (2011). Nursing and nurses
are
whether An exploratory study on a sample of Participants
likely
to 57 nurses of different specialties from
different strategy.
conflict communication: employ certain types of recruited by snowball sampling of setings
Avoidance as a preferred communicative
strategy.
nursing graduates. Wiseman and
strategies in confronting Schenck-Hamlin’s
interpersonal conflict.
were Avoidance is a preferred
(hospitals,
education, clinics)
compliance in
the
gaining strategies and Infante and states
eastern
of
verbal aggressiveness scales were Questionaire
U.S.A.
was
used to determine communication completed at their
strategies and inclinations to hostile convenience.
communication respectively.
80
Appendix 2: An interview guide
We thank you for availing yourselves and we are grateful for your willingness to participate in this focus group discussion.
Introduction of moderator and assistants: Background, roles in the focus group discussion.
Purpose of the focus group discussion
This focus group interview seeks to obtain information regarding repeated conflicts between the various groups of health workers
including management which led to either partial or complete withdrawal of services in the hospital since its inception. I am
particularly interested in understanding the cause(s) of these conflicts and how they were managed. I therefore solicit your honest
and open views on these issues. Having met the selection criteria, you have been invited to participate in this group interview
because you could provide useful information that would enable the researcher achieve the purpose of this discussion.
I hope that your responses to my questions would contribute to developing a recommendation in order to improve strategy for
conflict management in the hospital.
Ground rules:
1. Participants will do the talking: We want everyone to participate in the discussion. You may be asked to voice your views on
the issue being discussed. One person should talk at a time.
2. No response is right or wrong: We welcome different views. Everyone’s views are important. Voice out your views whether or
not you agree with others.
3. What is said here should be kept private: Participants should feel free to voice their views. No participant’s views should be
discussed with anyone who is not part of this group.
4. The discussion will be tape recorded: We want to record accurately what you say. Every participant will be anonymous and no
real names will be mentioned in the report.
81
No
Questions
1.
Are there conflicts between groups of health workers in the hospital?
2.
Which groups are involved?
3.
Conflicts about what?
4.
Why do these conflicts occur?
5.
How are they managed?
6.
Why are they managed/not managed in this way?
7.
Are there other ways to better manage these conflicts?
82
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