Introduction Conflict is no stranger to the health care environment The daily

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Introduction Conflict is no stranger to the health care environment. The daily stress of work and the complex interplay of personalities create a situation where conflict can flourish. Individuals and organizations face many pressures as the health care landscape changes. Staffing shortages, financial constraints, and volume demands are a few of situations of which organizations face. The dynamic and transformative nature of such an environment can create a milieu prime for conflict (Zhang, Andreychik, Sapp, and Arendt, 2014). As such, conflict can exist at many levels, from individual to organizational (Khan, Langove, Sha, and Javid, 2015). When individual conflict manifests in the healthcare environment, it may have ripple effects throughout an organization. Such disputes can affect many people on many different levels. Health care leaders must be prepared to accept and be ready to manage, situations that arise between managers and staff, as well as between staff members. The healthcare work environment is similar to many others. Pace (2018) as cited in Singleton, Toombs, Taneja, Larkin, and Pryor (2011, p. 149) noted that as many as 85% of employees stated that conflict in the workplace is something they faced on a regular basis, and many as 34% attributed these situations to personality differences with co-workers. These disputes do not go unnoticed. Patients in healthcare settings are quick to notice disagreements between nurses, physicians, and allied healthcare providers. Such situations negatively impact employee and patient satisfaction which are essential drivers of staff as well as patient retention. Conflict in healthcare organizations extends beyond staff and patients and can spread to outside vendors of various services upon which organizations depend. The symbiotic nature of these relationships can become complicated and potentially volatile. A case studyCONFLICT IN THE HEALTHCARE ENVIRONMENT 4will illustrate a real-life example of such a relationship. This paper will describe how the case study conflict relates to the four basic types of conflict, and the five levels of conflict as outlined in Borkowski (2016). The discussion will address five conflict-handling modes as examples of how the case situation could have been resolved and potentially avoided. Finally, insight will be offered as to how a hospital administrator can best mitigate such a conflict from occurring in the future. Case Study Penn Highlands Behavioral Health operates 44 inpatient psychiatric beds on its main campus. Once staffed by seven employed psychiatrists, there has been attrition over the past three years. The medical director of many years retired, one psychiatrist died, and two psychiatrists left the organization. Due to a nation-wide shortage of psychiatrists along with challenges recruiting to rural areas, Penn Highlands was forced to hire locum tenens psychiatrists to supplement staff and keep the inpatient units operational. Health care entities negotiate locum physician contracts with the company who supplies the physician. The agreement typically includes the physician’s hourly, overtime, and on-call rate, airfare, rental car, and hotel accommodations cost, all of which are billed, in this case, to Penn Highlands monthly. One such negotiation was subject to conflict. The locum company asked that Penn Highlands agree to assume the apartment lease obligation a locum physician had incurred from a previous assignment, as a condition of the physician accepting the proposed assignment with Penn Highlands. While discussion regarding the payment took place, no agreement regarding the lease payment was ever finalized. The service line director agreed to discuss the payment with senior management, but never revisited the discussion with the locum company. PennCONFLICT IN THE HEALTHCARE ENVIRONMENT 5Highlands and the locum company executed a contract, and the physician started work without a conclusion to the lease issue. After approximately two months Penn Highlands began receiving invoices for the lease payment from the physician’s prior assignment. Somewhere in the process, there was a major communication breakdown. The Service Line Director (SLD) and locum company representative (LCR) discussed the situation, each having diametrically opposing opinions as to whether an agreement regarding the lease payment was reached. Several telephone and email conversations ensued, each becoming increasingly direct. The SLD challenged the LCR to produce proof of an agreement regarding the lease payment, which the LCR could not do. As payment of the lease obligation was ultimately the responsibility of the locum physician, the LCR threatened that non-payment on the part of Penn Highlands would result in the locum physician would exercising the 30-day out clause in his contract. The SLD supported that suggestion and informed the LCR that going forward, Penn Highlands would not accept a replacement physician from their company, nor would accept any physicians from their company in the future. This situation escalated into a conflict for which there was no resolution in sight. Literature ReviewTypes of Conflict Kahn et al. (2015) suggest that conflict, by definition, occurs when at least two entities express opposing views, attitudes, or perceptions of an event. Each party is dependent on the other, and such conflict may be major or minor, overt or covert, and may occur between individuals, groups, organizations. As noted in Borkowski (2016), conflict can be characterized as goal, cognitive, affective, or procedural.CONFLICT IN THE HEALTHCARE ENVIRONMENT 6Goal Conflict. Kleiman and Hassin (2013) note that goal conflict exists when preferredoutcomes are incompatible or conflicting. Goal conflicts manifest when two parties face situations where goals have competing behavioral and emotional implications. Berrios, Totterdell, and Lellett (2015) studied the effect of goal conflict and mixed emotion. They found that that goal conflict led to increased feelings of mixed emotion in conflict situations. Shaw, Friedman, and Kriglanski (2002) note that once a commitment is made to pursue a certain goal, cognitive inhibition prevents the pursuit of alternate courses of action. Cognitive Conflict. Badke-Schaub, Goldschmidt, and Meijer (2010) suggest that cognitive conflict occurs when ideas or thoughts are inconsistent. In the best-case scenario, such conflicts can have a positive effect on an individual and team performance (Amason, 1996). Carnevale & Probst (1998) note that if appropriately framed, these conflicts promote increased expression of ideas and creative thinking. Affective Conflict. Incompatible personality styles coupled with increased negative emotionality and disagreement promote the onset of affective conflict (Papenhausen & Parayitam, 2015). These conflicts are people-centered and can escalate to produce such feelings as irritability, suspiciousness, animosity, and extreme tension (Parayitam & Dooley, 2007). In the extreme, these emotional confrontations divert energy from tasks or issues at hand, and toward dealing with the negative emotionality between individuals. Procedural Conflict. Burnett (1993) explained that this type of conflict could center around specific disagreements related to procedural approaches such as planning and organizing, scheduling, staff alignment, work assignments, policy and procedure, and ironically the specific tasks required to resolve conflict.CONFLICT IN THE HEALTHCARE ENVIRONMENT 7Levels of Conflict Intrapersonal. Simply stated, this is a conflict which exists within an individual. O’Connor, DeDreu, Schroth, Barry, Lituchy, and Bazerman (2002) describe intrapersonal conflict as the internal struggle between what an individual wants to do, and what they know they must do. Lewin (1935, 1951) as cited in O’Connor, et al. (2002, p. 404) described three aspects of intrapersonal conflict. Approach/approach refers to pursuing two different goals each with a positive outcome. Avoidance/avoidance occurs when two different goals each have a negative outcome. Approach/avoidance occurs when an individual pursues one goal and avoids another at the same time. Interpersonal. These conflicts occur between individuals and usually, but not always, result in negative emotion due to differing views on the resolution of the conflict, goals, and points of view (Lawless and Trif, 2016). Interpersonal conflict is prevalent in the healthcare environment and is often contributory to the onset of mood-related disorders and extreme stress reactions (Rahim, (2002). The nature of these conflicts is insidious and not only affects employee well-being but the team environment in the workplace. Intragroup. In the workplace, intragroup conflicts occur between members of a workgroup or team (Borkowsi, 2016). These conflicts break down into three types. Relationship conflicts involve increased negative emotionality between individual group members. Task conflict relates to differing ideas on the specific tasks with which the group is charged Process conflict pertains to contention specific to who and how the details of the task performed (Jehn and Mannix, 2001).Intergroup. Intergroup conflict occurs when there disputes between distinct groups. CONFLICT IN THE HEALTHCARE ENVIRONMENT 8Characteristics of these conflicts include poor communication, mistrust, and self-centeredness of the groups (Borkowski, 2016). Nulty (1993) suggests four levels of intergroup conflict. First, vertical conflict takes place between employees at different levels within a company hierarchy. Second, horizontal conflict takes place between employees at the same level in the hierarchy. Third, line-staff authority relates to conflicts between different levels of management within an organization. Fourthly, diversity-based conflict relates to issues concerning race, religion, sex, national origin. Interorganizational. These are conflicts between interdependent organizations (Longest and Brooks, 1998). Mo, Booth, and Wang (2012) propose that these conflicts occur when one party believes the other party is operating in a fashion that impedes the interdependent relationship between the parties.Conflict Handling Modes. Thomas (1976) and Rahim (1983) put forth the most commonly conceptualized view of conflict handing modes. They propose five distinct methods that occur as strategies for managing conflict. Collaborating Mode. This mode requires mutual cooperation in order to reach a win-win as a conclusion to the conflict (Rahim, 2002). Accommodation. This mode requires that one party put aside their agenda, minimize differences and focus on the mutual interests of both parties (Rahim, 2002). Competing Mode. This mode is associated with a win-lose scenario. One party exerts its power or authority over the other party as a means of resolving the conflict (Rahim, 2002) Avoiding Mode. Avoiding is a means to deflect and minimize the impact of conflict. In an avoidance scenario, neither parties’ concerns are addressed. Confrontation is thereby CONFLICT IN THE HEALTHCARE ENVIRONMENT 9avoided at the expense of resolution (Rahim, Magner and Shapiro, 2000). Compromising Mode. Compromising occurs when each party agrees to “meet in the middle”” to reach a mutually satisfying conclusion. This is generally thought to be the most effective conflict resolution mode (Rahim