Developing a model for conflict management in intensive care units: A grounded theory study

Abstract

BACKGROUND:

Conflict is a very common phenomenon in the intensive care unit (ICU). Nonetheless, the aim of conflict-related strategies is not to eliminate conflicts but to effectively manage them. The aim of this study was to develop a model for conflict management (CM) in the ICU.

MATERIALS AND METHODS:

This qualitative study was conducted in 2024 by using Corbin and Strauss’s grounded theory design. Data were collected via 32 semi-structured interviews with 18 ICU nurses, observational notes, field notes, and memo writing. Participants were purposefully selected from hospitals affiliated to Zanjan University of Medical Sciences, Zanjan, Iran. Corbin and Strauss’s method was used to analyze the data. Then, Walker and Avant’s method was used to develop a prescriptive CM model.

RESULTS:

Participants’ main concern was a vicious relational cycle, and their strategy for its management was striving to build CM-based relational bridges. The outcome of this strategy was doubtfulness over compromise or silence. The compromise-based relationship model for CM was developed with three main components, namely the management of the situation, awareness of CM strategies, and development of communication skills.

CONCLUSION:

The CM process depends on the sociocultural characteristics of nurses and healthcare organizations. The establishment of appropriate relationships is the key prerequisite to CM and depends on the development of nurses’ professional skills and strong organizational support. Therefore, health policymakers should consider developing communication and CM skills in nurses.

Introduction

Conflict is an inevitable component of human relationships and an indicator of healthy organizational performance.[1,2] It can occur at personal, interpersonal, and organizational levels.[3] Personal factors contributing to conflict include differences in personality, values, attitudes, information, abilities, skills, and experiences, while organizational factors contributing to conflict include resource limitations, role ambiguity, and differences in organizational goals, culture, and regulations.[4,5] Conflict in healthcare and nursing systems is a completely normal and inevitable phenomenon.[6]

Nurses, particularly those in the intensive care unit (ICU), face conflict during their daily practice. Conflicts in the ICU are mainly due to advanced ICU technologies, high occupational stress, ethical issues, patient death, staff shortage, progressive development of nursing knowledge and roles, unclear job specifications, and poor physician-nurse relationships.[7,8] The prevalence of conflict in the ICU has been reported to be more than 70%.[9,10]

High levels of conflict reduce care effectiveness and thereby reduce healthcare providers’ and clients’ satisfaction, decrease providers’ productivity, and increase absenteeism and turnover intention. Ineffective conflict management (CM) can also threaten organizational performance and survival.[11,12] The aim of CM is not to eliminate conflicts but rather to manage them effectively and restore balance. An effectively managed conflict is not only not harmful but can also lead to performance improvement.[7,12] The most important CM strategies include accommodation, compromise, avoidance, competition, and collaboration. Collaboration usually leads to the best outcomes. Successful collaboration in CM depends on the prioritization of problem-solving and organizational aims by all individuals involved in the conflict, instead of attempting to unilaterally win the situation.[11,13] A review study on 25 studies into CM identified accommodation as the most commonly used CM strategy, while avoidance and competition were the least commonly used ones.[12]

Most previous studies into CM addressed CM strategies, and to the best of our knowledge, there is no study that proposes a context-bound model of CM in the ICU. This study explores the management of conflict experienced by nurses in the ICU and provides strategies to improve the quality of care and the efficiency of the healthcare team. Thus, we conducted the present study to develop a model for CM in the ICU.

Materials and Methods

Study design and setting

This qualitative study was conducted using a grounded theory design in the educational hospitals of Zanjan University of Medical Sciences in 2024. Grounded theory is appropriate for exploring processes in their social contexts and analyzing and interpreting the factors and situations relevant to those processes. It deals with the identification, description, and explanation of interactive processes among individuals and groups in a social context.[14] The present study was conducted in two main phases, namely development of a descriptive theory and synthesis of a prescriptive model.

Study participants and sampling

Phase 1: Descriptive theory development

Eighteen ICU nurses were purposefully selected from hospitals affiliated to Zanjan University of Medical Sciences, Zanjan, Iran. Sampling criteria were an ICU work experience of at least one year and agreement to share CM-related experiences.

Data collection

Data were collected using semi-structured interviews, observational notes, field notes, and memo writing. Observational notes were written during formal observations, field notes were written during interviews, and memos were written during data analysis. Some participants were interviewed twice for further clarification of their first interviews. Therefore, 32 interviews were held with 18 participants. Interviews were started by asking participants to explain their conflict-related experiences in the workplace. Further interview questions were determined and used based on participants’ responses. The duration of the interviews was 30–45 minutes. The most important criteria to determine the number of participants and interviews were the use of key informants, data quality, emerging categories and theory, and theoretical data saturation.[15]

Data analysis

After holding each interview, it was transcribed word by word, and the transcript was analyzed using Corbin and Strauss’s (2015) approach. In the open coding step, the data were analyzed to develop the concepts, determine the context, bring the process into analysis, and integrate the categories. Accordingly, each interview transcript was perused, and its CM-related words, expressions, and paragraphs were coded. Constant comparative analysis was performed using techniques such as questioning, word analysis, flip-flop, and waving the red flag.[16] Data management was handled using the MAXQDA (v. 2018) software.

Phase 2: Descriptive model synthesis

In this phase, Walker and Avant’s three-step method was used to develop a prescriptive CM model. Prescriptive models can experimentally be critiqued, and their level of abstraction is less than descriptive theories. They can be tested in different clinical, educational, and research settings.[17] In the first step, we determined the necessary key concepts of the model. The core category developed in the first phase and the four metaparadigm concepts of nursing, i.e., person, nursing, environment, and health, were considered as the conceptual framework of the model. In the second step, a literature review was performed to determine relevant factors to the main and metaparadigm concepts. The aim of the literature review in this step was to obtain data for the development of the model and its components. Accordingly, all accessible documents on CM models published in Persian and English between 1990 and 2023 were reviewed to determine the relationship among the concepts and their influential factors. The results of our grounded theory were also considered. In the third step, concepts and statements were organized and presented in an integrated model.

Trustworthiness

Guba and Lincoln’s criteria were used to guarantee trustworthiness. These criteria are credibility, dependability, confirmability, transferability, and stability.[18] To increase the credibility of qualitative results, investigator triangulation (analysis of qualitative data by multiple researchers) and method triangulation (data collection using interviews, observational notes, field notes, and memo writing) were used.

Ethical consideration

This study was conducted with the ethical approval of the Ethics Committee of Zanjan University of Medical Sciences, Zanjan, Iran (code: IR.ZUMS.REC.1402.186). All participants received information about the study aim and signed the informed consent form of the study. Data confidentiality and the right to voluntarily withdraw from the study were among the ethical considerations of this study.

Results

Eleven female and seven male ICU nurses from all work shifts participated in this study. On average, participants’ age and work experience were 39.38 ± 3.1 years and 14.66 ± 3.8 years, respectively. Data analysis resulted in the development of nine subcategories and three main categories, namely vicious relational cycle, striving to build CM-based relational bridges, and doubtfulness over compromise or silence [Table 1].

Table 1.

Categories and subcategories of the study

Categories		Subcategories
Vicious relational cycle		Cure-oriented care context
		Extensiveness of relationships in the healthcare team
		Lack of relationship management skills
Striving to build CM-based relational bridges		Managing the situation
		Improving professional socialization
		Striving to attract organizational support
Doubtfulness over compromise or silence		Striving for continuous cognitive development for CM
		Ambivalence in CM
		Regression in CM

Category 1: Vicious relational cycle

The main concern of participants was a vicious relational cycle. Participants highlighted the inability to establish appropriate relationships as the most important contributing factor to conflict. The subcategories of this category are cure-oriented care context, extensiveness of relationships in the healthcare team, and lack of relationship management skills.

Subcategory 1.1: Cure-oriented care context

Although hospitals, as healthcare organizations, attempt to provide quality care services, they mostly focus on medical service provision and may pay insufficient attention to the other aspects of the organization, such as nurses’ interactions and organizational conflicts. Consistent organizational principles, valuing all aspects of healthcare services, and development of clear and comprehensive guidelines can facilitate CM. Participants highlighted that the characteristics of the cure-oriented care context, such as difficult work conditions, inefficient care planning and supervision, silence-based organizational culture, role multiplicity, and role conflict, affect CM in the ICU.

• Sometimes, we know that there are some problems or some nurses have conflicts with each other. Nonetheless, we insist on ignoring problems or avoid talking about them in order not to aggravate them. Sometimes, some of us support one side of the conflict and others support the other side and thereby, form two opposing teams. Well, if we talk about problems from the very beginning of their emergence, they will not worsen in a snowball manner and will have fewer negative consequences (P. 13).

Subcategory 1.2: Extensiveness of relationships in the healthcare team

There are extensive intrapersonal, interpersonal, and organizational relationships in the healthcare team. Moreover, good interactions and great professional knowledge are among the key prerequisites to nursing care. Relationship is the base of the nursing profession and includes nurses’ relationships with patients, patients’ family members, nursing colleagues, and non-nursing colleagues. These individuals have different beliefs and sociocultural characteristics, and hence, relationships among them may lead to relational conflicts.

• All our activities in the hospital, from the moment we enter the ward to the time of our exit from the ward, are based on relationship—with patients, colleagues, and patients’ companions. Relationship is the core of nursing. We can have a good work shift with a good relationship and vice versa (P. 11).

Subcategory 1.3: Lack of relationship management skills

Professional nurses need not only great professional knowledge and clinical experience but also the ability to apply their knowledge and skills to establish appropriate relationships. Nurses who improve their relationship management skills experience fewer problems in CM. Nurses can improve their relationship management knowledge and skills through studying and exercising. On the contrary, their lack of relationship management knowledge and skills and their unfamiliarity with professional values may reduce their ability to manage conflicts.

• We need to accept personal differences. Some individuals are extrovert and some are introvert. Some like talking about problems and some don’t like. Some easily get angry and may cause several conflicts in a work shift. I think we need to accept these differences. We can’t change others. Rather, we need to learn how to establish appropriate relationships with different individuals (P. 12).

Category 2: Striving to build CM-based relational bridges

The main strategy of ICU nurses to manage their main concern of the vicious relational cycle is to strive to build CM-based relational bridges. They strive to have relationships with minimum possible conflicts despite their difficult work conditions, problematic organizational structure and culture, and their awareness of personal differences. The subcategories of this category are managing the situation, improving professional socialization, and striving to attract organizational support.

Subcategory 2.1: Managing the situation

Nurses may experience situations that cause them conflicts, and hence, they may attempt to manage such situations through maintaining multilateral relationships, improving their relationship management abilities, and avoiding the effects of the prevailing climate. They need to understand the conditions of others, accept them as humans, attract their trust and collaboration, establish relationships with them, and support them or keep their distance from them. The experience of working in the ICU teaches them that they need to have greater control over their emotions, and this helps them better cope with others’ misbehaviors and occupational problems.

• Some patients may receive cardiopulmonary resuscitation and experience death. Cardiopulmonary resuscitation tires us, and patient death causes a negative climate in the unit. Patients’ families may also experience distress after knowing about their patients’ conditions. Our inability to effectively manage both our colleagues and information delivery to families certainly faces us with conflict (P. 12).

Subcategory 2.2: Improving professional socialization

Participants’ experiences showed improving professional socialization as one of the effective strategies for CM. In the process of professional socialization, nurses internalize professional norms and values, develop their professional skills and identity, and get ready for professional role performance, which in turn improves their CM abilities and enables them to protect the professional status of nursing.

• It’s been twenty years since I became a nurse. I like nursing despite its hardships and bitterness. I have realized in these twenty years that I should recognize my status with my nursing clothes and nursing title. Any misbehavior on my part will damage the title and the status of nursing (P. 8).

Subcategory 2.3: Striving to attract organizational support

When nurses perceive that their organization is concerned with their welfare and supports its staff, they consider themselves a part of their organization, stay loyal to it, and show greater organizational commitment. Organizational support is a key component of CM. Planning for adherence to professional standards and striving to accurately perform professional responsibilities help nurses attract organizational support.

• Physicians, nurses, nurse aides, nursing managers, hospital managers, and the hospital dean constitute a team and all have the same goal. It is important that all team members are in their appropriate place, know their responsibilities, and perform them. For example, physicians provide patients and their family members with the primary information and nurses provide them with the complementary information. Everybody should know their position to prevent future legal problems and avoid putting pressure on each other (P. 3).

Category 3: Doubtfulness over compromise or silence

Participants’ striving to build CM-based relational bridges was associated with their doubtfulness over compromise or silence. The subcategories of this category were striving for continuous cognitive development for CM, ambivalence in CM, and regression in CM.

Subcategory 3.1: Striving for continuous cognitive development for CM

Striving to build CM-based relational bridges requires nurses to continuously engage in establishing different relationships (with nursing and non-nursing colleagues, patients, and patients’ family members) and manage different relational problems. Therefore, it develops their communication skills and cognitive abilities.

• The more we attempt, the more we develop. This may primarily seem like a favor to the organization; but, it is in fact a favor to us. We learn how to behave both professionally and ethically in complicated conditions. The more time we spend and the more we attempt, the more experienced we will be and the more precisely we can manage conditions (P. 18).

Subcategory 3.2: Ambivalence in CM

Ambivalence in CM refers to nurses’ contradictory reactions, beliefs, or emotions toward CM-induced behaviors and their simultaneously positive and negative attitudes toward conflict. It refers to the situations where nurses experience contradictory motivations, goals, behaviors, or impulses, and is mostly due to their inability to make sound decisions. Their ambivalence is manifested by their attempts, doubtfulness, and passiveness.

• When a problem occurs, I really don’t know whether to attempt to manage the conflict or take no action. It is very difficult to decide upon whether to get involved or not (P. 9).

Subcategory 3.3: Regression in CM

Although nurses may make great attempts to manage conflicts, their attempts may be futile and the organization may experience regression in CM. Consequently, they may give up further attempts for CM and opt to stay silent about the conflicts. According to the participants, challenging and conflicting situations are inevitable and can be addressed through traditional strategies such as silence.

• On the one hand, I know that there is a problem and I should manage it. But on the other hand, I think about my previous attempts which were fruitless. This results in regret. I have attempted many times to prepare an atmosphere to talk about problems and manage them, but the result was problem aggravation. This has made me indifferent to some problems and stay silent about them (P. 17).

The descriptive theory of the study

Findings show that nurses attempt to manage their relationships with the fewest possible conflicts and cope with their conflicts through managing the situation, developing their professional abilities, and attracting organizational support. They can cope with their conditions by establishing healthy relationships with their social environment and fulfilling their aspirations. Therefore, their CM is the process of a “compromise-based relationship.” Although this theory is useful to understand the actions and interactions in the process of nurses’ CM in the ICU, it does not provide practical instructions to nurses about improving their professional relationships and CM abilities. The development of a prescriptive model is essential to provide such instructions.[19]

Synthesis of the prescriptive model of the study

In the literature review step, 2313 articles were found, and 34 of them were determined to be appropriate for the study. Quality appraisal was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The 34 articles were reviewed, and the results were combined with the concepts developed in the first phase to synthesize the prescriptive model for CM.

In the CM model, person is a bio-psycho-socio-spiritual being with different physical and mental needs who exhibits different behaviors to fulfill these needs in different conditions. Person is an individual who is involved in some conflicts in the environment. Nurse in this model is a trained and responsible individual with adequate professional knowledge and power who uses their knowledge and professional skills and adheres to professional regulations and standards. Environment is a set of elements and factors that surround the person and should sufficiently be healthy and motivating enough to help nurses perform their responsibilities. Health is the result of nurses’ appropriate and effective relationships in challenging situations and at appropriate time and place. Moreover, a compromise-based relationship is one based on the management of the situation, awareness of CM strategies, and development of communication skills [Figure 1].

Figure 1.

The compromise-based relationship model for conflict management

Respecting the management of the situation, attention to nurses’ CM-related attitudes and skills is important. Factors such as experience, education, self-management, organizational support, intraprofessional and interprofessional collaboration, and interpersonal interactions can improve nurses’ ability to manage the situation.

Respecting the awareness of CM strategies, careful attention to healthcare providers’ CM skills and coping styles in different situations is necessary. Healthcare providers need to pay attention to the principles of CM and the characteristics of the individuals involved in the conflict, including their age, gender, financial status, ethnicity, and culture.

Respecting communication skill development, nurses need to identify their own values and simultaneously identify and respect the personal values and culture of the individuals involved in the conflict. In fact, nurses’ professional practice and professional relationships should be based on respect for others’ values and beliefs.

Discussion

This study aimed to develop a model for CM in the ICU. The vicious relational cycle was the underlying contextual factor of conflicts, which consisted of healthcare providers’ ineffective relationships with each other, patients, and patients’ family members. Relational cycle is a dynamic cycle in the healthcare system. Relationship is a dynamic process among human beings, through which they communicate their thoughts, emotions, and beliefs. An effective and quality relationship plays a pivotal role in nurses’ interpersonal interactions and depends on the accurate understanding of human behavior and quality education about conversation and listening skills. Establishing effective relationships is currently considered an art.[20] The continuation of the vicious cycle of interaction and inappropriate professional relationships in ICUs leads to the exacerbation of conflict. This issue can lead to job burnout, job dissatisfaction, and a decrease in patient safety and quality of care.[21] It seems that communication skills training can play a role in reducing interprofessional and intraprofessional conflicts and creating a healthy work environment.

In response to a conflict, study participants attempted to correct the vicious relational cycle by building CM-based relational bridges using three main strategies, namely managing the situation, improving professional socialization, and striving to attract organizational support. Appropriate professional socialization helps nurses develop their professional identity, cope with their professional roles, and improve their professional and organizational commitment. Thus, it improves care quality. On the contrary, inappropriate professional socialization may lead to negative consequences such as job burnout, decreased job motivation and satisfaction, poor professional performance, role ambiguity, and interpersonal conflicts.[22,23,24] CM skills should be included in the professional socialization process of nurses.[25]

We also found doubtfulness over compromise or silence as the outcome of striving to build CM-based relational bridges. In the study by White et al.[26] entitled “Conflict Management Education in the Intensive Care Unit,” the majority of participants also used avoidant and compromising CM styles. Different factors can influence the selection of either compromise or silence, which include professional attitudes and ideals, ethical values, education, congruence between theoretical and practical education, interactions, interdisciplinary collaboration, autonomy, and professional policymaking.[26,27] Ineffective CM may eventually lead to regression in CM, where healthcare providers follow ineffective traditional strategies for CM.[28]

The prescriptive CM model developed in this study was the compromise-based relationship model. In this model, compromise is the core category. In the Thomas-Kilmann CM model, compromise means that there are some levels of assertiveness and collaboration in CM. The statement “A good compromise does not satisfy anybody” characterizes the concept of compromise in the Thomas-Kilmann CM model. Compromise in this model may lead to further conflicts over time, while it provides a bypass to survive the current conflict.[29]

The CM model developed in this study highlights the importance of awareness of CM strategies. This is in agreement with the SALAM CM model, which highlights that unawareness of CM methods, isolation, or disinterest in CM among individuals involved in a conflict may alter effective long-term CM and require them to resort to short-term strategies.[30]

The compromise-based relationship model highlights the importance of developing communication skills. Most nursing theories recognize the importance of relationship in nursing, though none of them address all its characteristics and prerequisites.[31] Famous nursing theorists (e.g., Rogers, Watson, and Newman) consider relationship a main component of nursing and highlight that its consequences are well-being and protection of human dignity. Nursing is a profession in which role performance occurs through nurse-client relationships and interactions.[32] Roach believes that all steps of the nursing process require good communication skills.[33]

Limitations and recommendations

One of the limitations of most CM models, including our compromise-based relationship model, is that they are culture-dependent and not all inclusive.

According to the findings of the study, the following suggestions are made for future studies:

• Identifying and examining the factors affecting CM in future research will provide a clear perspective on improving this skill.

• Considering the importance of communication and the factors affecting it, conducting a study using the action research method with the aim of providing solutions to solve existing problems in the field of CM seems necessary.

Conclusion

This study shows that CM depends on the sociocultural characteristics of nurses and healthcare organizations as well as appropriate interpersonal relationships. In health policymaking, attention to the development of communication and professional skills among ICU nurses, alongside adequate organizational support, can reduce conflicts, improving the quality of care, and increasing nurses’ job satisfaction. The core of the compromise-based relationship model for CM is the creation of an appropriate context for relationship establishment in healthcare and community settings. Integration of CM courses into the nursing curriculum and in-service educational programs for nurses is recommended.

Artificial intelligence utilization for article writing

The authors declare that they did not use generative Artificial Intelligence (AI) and AI-assisted technologies in the writing process of this paper.

Author’s contributions

MR and SRS contributed to the study concept and design. MR, SRS and FGH collected the data, and analyzed and interpreted the data first. All authors were involved in the final interpretation of the data. FGH prepared the manuscript and, MR and SRS critically reviewed it. All authors approved the final version for publication.

Abbreviations

ICU: Intensive Care Unit; CM: Conflict Management.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This study was supported by the Vice Chancellor for Research and Technology of Zanjan University of Medical Sciences [ID research: 5547].