Dimensions of Critical Care Nursing

Dimensions of Critical Care Nursing

(C) 2006 Lippincott Williams & Wilkins, Inc.

Volume 25(1), January/February 2006, pp 22-28

An Overview of Conflict[Leadership DIMENSION]

Kelly, Jacinta RNJacinta Kelly, RN, is currently a nurse lecturer at the Department of Nursingand Midwifery, Brookfield Health Sciences Complex, University College Cork,Ireland.Address correspondence and reprint requests to: Jacinta Kelly, RN, NurseLecturer, Department of Nursing and Midwifery Brookfield Health SciencesComplex, University College Cork, Ireland (Amnesia104@hotmail.com).

Abstract

Conflict is found in all aspects of society and nursing is not immune. Conflictis also found in critical care units. However, conflict within the nursingprofession has traditionally generated negative feelings and many nurses useavoidance as a coping mechanism. This article will provide an overview ofconflict, conflict management, and conflict resolution.

----------------------------------------------

INTRODUCTION

Conflict is an integral part of the fabric of a postmodern society which islitigious, competitive, complex, and alienating.1 Subsequently, modern-dayintensive care environments are exposed to many of these conflicts which arecompounded by increased demands on an ever-limited staffing supply, a decreasein available resources, and a profound period of change. These complexities andtensions in modern intensive care settings will undoubtedly continue, and evenescalate, providing fertile ground for conflict among healthcare professionals.2

However, conflict within the nursing profession has traditionally generatednegative feeling. It has been seen as draining energy, reducing focus, andcausing discomfort and hostility.3 It is, therefore, not surprising thatintensive care nurses are more known for their use of avoidance, as opposed to amore open acknowledgment of the factors contributing to the issues causing theconflict.4

Valentine 5 argued, however, that the use of avoidance as a conflict managementstrategy produces unsuccessful results and that it only ensures that conflict ispostponed. This article will examine the subject of conflict in the contemporaryintensive care environment and the circumstances that predispose intensive carenurses to adopt avoidance as a management strategy when conflict arises.

DEFINING CONFLICT FOR NURSES

Although a generally accepted definition of conflict does not exist, Walton 6defined conflict as processes occurring within a group in any of several forms,such as hostility, decreased communications, distrust, sabotage, verbal abuse,and coercive tactics. However, this definition engenders a negative andinflammatory approach to conflict. Marquid and Huston 7 defined conflict lessmalignantly as the internal discord that results from differences in ideas,values, or feelings between 2 or more people. Although this definitionrecognizes the existence of interpersonal and interorganizational conflict, itdoes not acknowledge the conflict that can develop within a person or theintrapersonal conflict. The discipline of intensive care nursing needs toestablish a definition of conflict that is both positive and comprehensive sothat conflict in the critical care area can be better understood and moreconstructively approached within the workplace.

CONFLICT MANAGEMENT STRATEGIES

Conflict management can achieve successful conflict resolution and also removefrustration, which can lead to higher effectiveness, trust, and openness.8 Lewis9 identified various conflict resolution strategies such as compromising,competing, accommodating, avoiding, and collaborating. Goodman 10 maintainedthat, in general, avoidance behavior or suppression is the most common reactionto an emerging conflict. Cavanagh 4 and Valentine 11 maintained that nurses inthe intensive care setting commonly use avoidance as they feel they need toprevent open conflict, preserve relationships, and be exemplary role models forstudents. However, the causative factors, which contribute to the use ofavoidance as a conflict management strategy in the intensive care setting, aremore far reaching. Observably, stereotypical and gender behavioral expectations,issues of nurses' self-esteem together with management and leadership stylespredispose nurses in the intensive care environment to adopt avoidance as theprimary conflict management strategy.

Stereotypical Perspective

"Nice" Nurses Avoid Conflict:

Although caricatured images of the nurse as the starched to the core battleaxe,the control freak, the naughty nurse, or the doctor's handmaiden are evident,the overriding perception of the nurse in the public domain is one of ministeringangel who is gentle and caring.12 Subsequently, there is almost a stereotypicalexpectation that nurses should not engage in conflict as people prefer nurses tohave warm, kind, and sympathetic personalities.13 Indeed, intensive care nursesare considered by the public to be "nice" people and that "nice" people avoidconflict, accommodate other people above themselves, and adapt their behavior tomatch what they think people expect of them.14 However, Fisher et al 15maintained that in conflict management it is necessary to concentrate on theproblems and not on the personalities.

Serve People Assertively:

Yoder-Wise 16 advised that when avoiding conflict, people neglect their ownneeds, goals, and concerns while trying to satisfy those of others and thisapproach has an element of being self-sacrificing and simply obeying orders orserving other people. Indeed, this stereotypical self-sacrificing behavior isstrongly supported by the altruistic philosophy of nursing. Although thisapproach may, on the surface, appear laudable, nurses as a result display a lackof assertive behavior in conflict management, preferring instead to take apassive role.17 However, assuming a passive role in the contemporary intensivecare setting is a recipe for low morale among intensive care nurses andultimately serves poorly the needs of critically ill patients.18 On the otherhand, assertiveness can be a means of expressing feelings honestly and directly,while still showing respect to the other person.19 Assertive behavior could,therefore, provide intensive care nurses with the potential to actively improvecommunication and achieve goals, which would ultimately serve the needs ofpatients in the intensive care unit more usefully.

My Way or the Highway!:

Although the underdevelopment of assertive behavior in critical care nursing maybe just dismissed as stereotypical behavior of the "nice" or "sympathetic"nurse, anecdotal evidence also suggests that unassertive behavior may welloriginate from the temporary nature of the nurses' employment in many acute caresettings in Ireland. Many nurses may be reticent to engage in conflict, such asopposing traditional and ritualized approaches to nursing care, as the"offending" practitioners may be viewed as agitators or conspirators and mayfear imposed relocation to other clinical areas. More permanent positions areoffered to staff nurses within the acute hospital setting. However, it could beargued that opportunities for permanent staff nurse posts specifically in theintensive care setting continue to be scarce and that this problem needs furtherattention if open and fruitful exchange of views are to take place without fearof recrimination.

Horizontal Violence:

Alternatively, McKenna et al 20 asserted that staff nurses, regardless of theiremployment position, should not be sanctioned for expressing an opinion.Although bullying is commonly acknowledged as the persistent, demeaning, anddowngrading of humans through vicious words or cruel acts that graduallyundermine confidence and self-esteem, Rayner 21 also cautioned that denial ofaccess to opportunity also constitutes horizontal violence or bullying. Thisform of interpersonal conflict can be deleterious in the intensive careenvironment as it is known to be a potential source of organizational problemssuch as absenteeism, mistakes, and poor quality assurance.4 Therefore, intensivecare nurses should advocate confronting conflict openly and respectfully, whichin turn would promote dignity and prevent violence in the workplace.

Think Conflict, Think Critically:

Cavanagh 4 believed that avoidance of conflict could be of benefit during timesof high stress, frequently encountered in the intensive care setting, wherebeing able to put to one side interpersonal difficulties becomes very important.By example, it may be expected that the stereotypically sympathetic and kindnurse ignore the temper tantrums of an intensivist stressed with the responsibilityof attending to acutely ill patients. "Nice" nurses should overlook or indulgeother healthcare providers' difference of opinion for the sake of peace andquiet in the unit. However, Lee 22 argued that conflict is a fact of life in anyinterpersonal relationship and that conflict only grows in intensity whenignored. When managed constructively through better communication, conflict canlead to stronger and more satisfying interactions. Furthermore, in progressiveintensive care facilities, the welfare of the critically ill patient is notinterpreted as the sole responsibility of the intensivist. Instead, the criticalthoughts and contribution of each member of the multidisciplinary team areacknowledged as a vital link in the chain of quality patient care.23 Therefore,nurses in the intensive care setting should embrace conflict as a medium forreconstituting the stereotypical attributes of the critical care nurse toinclude critical thinking and good communication.12

Gender Perspective

Sexism:

Women favor peaceful coexistence in the workplace and do not engage inconfrontational behavior as much as their male counterparts.11 As nursing todaystill figures predominantly as a female occupation, this undoubtedly contributesto the use of avoidance as the chief conflict management strategy in intensivecare nursing.24 Observably, nursing suffers from an inherent sexism, which keepsmen outside the profession. Indeed, the very name of nursing should be changedbecause descriptions of people looking after ill people have always been femaleoriented such as "nurse" or "sister."25 Possibly, then the recruitment of a morehealthier gender mix to intensive care nursing would promote more openconfrontation as opposed to avoidance of workplace issues, and indeed, improvestaff retention in the intensive care setting.26

Emotional Women:

Women are more reluctant than men to engage in conflict as they feel they may bedismissed as "emotional women."7 Oakley 27 maintained that women avoid conflictbecause if they complained about a situation or a system they would be liable tobe called ill, neurotic, menopausal, premenstrual, or in need of some curativerelationship with a man. Indeed, in traditional nurse training programs, nurseswere trained to conceal their emotions and to display more rational thought.28Undoubtedly, emotions of anger make conflict or rational problem solvingdifficult in the workplace.16 However, Fuimano 29 affirmed that emotions ofempathy and compassion should not be suppressed in nursing, otherwise intensivecare nursing care would be unmotivated, robotic, and detached. Instead ofavoiding conflict, nurses in the intensive care setting should therefore beprovided with emotional intelligence training so that rational thought(cognition) and emotional response (affect) could be used in harmony to dealwith conflict more openly and competently.30

Conflict is Caring:

Astoundingly, Lee 22 maintained that many women avoid conflict because they havebeen brought up to believe that they are not to be involved in conflicts,express negative communications, or to have an opinion regarding most matters.Farrell believed that if nurses' behavior does not comply with either motherearth (nurturing and caring), they are cast as "iron maiden-tough, dangerous,and unfeminine."31 Nurses are presumably therefore expected to preserve theirfeminine or "ladylike" image and submit to the other's perspective. Valentine 5suggested that intensive care nurses, consequently, avoid confronting crucialissues and solutions are frequently arrived at by default. However, it would beremiss of nursing professionals to rely on "default" to solve the complex issuesin the contemporary intensive care environment. Instead, the ability to confrontproblems positively and to offer an opinion should in fact be promoted as a verycaring and honorable trait in the intensive care nurse where intraprofessionaland interprofessional cross-pollination of views is essential for the commongood of the critically ill patient.

Girl Power:

Women are often considered to be a subordinate and powerless group withinsociety in general and the healthcare arena in particular.5 Farrell 32 perceivednursing as a discipline that is "oppressed" by men. Davidhizar and Cramer 33maintained that the health sector has a disportionately high number of men insenior nursing management positions in relation to their percentage of thenursing workforce. Most physicians, administrators, and nurse mangers are menwho use power or competing to resolve conflict, whereas nurses who are mainlywomen tend to be coerced into a compromise.34 However, competition andcompromise, like avoiding, are inadequate approaches to conflict resolution inthe intensive care setting because they are selfish and positional approaches,but also because they can generate ill will, a win-lose stance, and a commitmentto inaction within groups.7 Evidently, intensive care nurses avoid conflict asthey feel perhaps that a win-lose outcome is a foregone conclusion in such anoppressed discipline as nursing. Alternatively, there is a need for moreproportionate representation of women in executive positions in healthcare sothat intensive care nurses are imbued with a sense of empowerment to engage inmore productive conflict management strategies.

Independent Thought:

Intensive care nurses lack autonomy, accountability, and control over theirpractice, as medicine, which is predominantly male, is the dominant culture.Nurses in intensive care settings therefore rely heavily on hierarchical systemsand rule following.35 Within such professional practice confines, the nurse haslimited opportunity to develop independent thought, and engagement in conflictis difficult and possibly therefore avoided. Furthermore, it is more exertingand taxing for nurses to exercise independent thought and to articulatealternative and informed opinions. Autonomy brings with it enormous commitmentand initiatives, and aspiring to having control over one's practice as a nursein the intensive care environment demands substantial challenges, responsibilities,and increased accountability. Indeed, Kafka 36 observed that it is safer to bein chains than to be free.

However, the development and growth of the discipline of intensive care nursingwould resultantly stagnate and the discipline of intensive care nursing wouldnot be allowed to advance to meet the contemporary needs of the critically illpatient. Alternatively, autonomy and accountability need to be promoted inintensive care nursing so that nurses can mobilize their faculty for independentthought and be equipped with the means to engage competently in conflictmanagement. Subsequently, the ability to find innovative solutions, to extendbeyond their boundaries of comfort, and to test new ways of doing things, willmove nursing further into the center of the arena of the new healthcareservices.37

Self-Esteem

Nightingale's Legacy:

Florence Nightingale in 1881 remarked that nursing was done by those who weretoo old, weak, drunken, or stolid or could not do anything else.38 It istherefore not surprising that nursing has historically been viewed as alow-status and inferior profession within the healthcare system and that it hastraditionally wrestled with low levels of professional esteem and low self-image.39Evidence suggests that nurses in intensive care settings continue to be held inlow esteem.40 Doctors continue to make intensive care nurses feel that theircontribution is not valued by not waiting for nurses to join decision-making ordiscussions on unit rounds. Self-esteem is generally considered to be a majorpredictor of behavior.41 Hall 42 maintained that this lack of professionalesteem creates a submissive culture in critical care environments. Subsequently,nurses lack confidence and self-assuredness when challenging authority figuresor confronting conflict in the intensive care setting.

Educated Conflict:

Mannahan 43 maintained that professional development is viewed as key forintensive care nurses to increase their self-esteem. Admittedly, attempts havebeen made to effect parity of esteem with other members of the multidisciplinaryteam through undergraduate degree programs and postgraduate critical carecourses. However, McCarthy 44 believed that many nurses who wish to be treatedas esteemed professionals are still educationally unprepared. Although, An BordAltranais 45 specified that nurses must maintain and develop competenciesthrough continuous education and professional development, the nursingprofession in Ireland continues to labor under deficiencies in continuingeducational programs with regard to conflict management. Although assertivenessand conflict management educational sessions may be offered in major cities,provincial hospitals are observably, poorly served. Perhaps, nurse managers feelthreatened by the prospect of providing a subordinate with assertiveness andconflict management skills and may accordingly be disinclined to authorizefinancial support and study leave. However, gaps in professional developmentneed to be addressed to elevate the esteem of intensive care nurses and to imbuenurses with the confidence and knowledge to engage competently and actively inconflict management strategies when conflict arises.

Career or Conflict:

Farrell 31 maintained that because nursing is a low-status profession within thehealthcare system, nurses wish to align themselves with groups that areperceived to be of high status, such as doctors, nurse managers, and administrators.Kelly 46 concurred that nurses in contemporary intensive care settings view theexperience and education of critical care nursing as a springboard to perceivedhigher positions such as clinical nurse specialist, advanced nurse practitioner,or nursing manager. However, it could be argued that this predisposes intensivecare nurses to avoid conflict with doctors or managers as they may feel thatengaging in conflict may jeopardize their career advancement. Consequently,intensive care nurses continue to reproduce a system that values medical/interventionistcare and managerial positions at the expense of marginalizing "basic" nursing-aprejudice that will unintentionally ensure nurses remain assistants andsubservient to the biomedical model.47 However, instead of poaching the esteemof medicine, intensive care nurses should defend the worthiness and privilege oftheir own profession and, if necessary, engage in respectful conflict to developand illustrate their professional and holistic identity and expertise.

Management and Leadership

Collaboration Impossible:

Smith-Trudeau 26 maintained that if conflict management is left unattended, itcan tear a team apart and waste human potential. Therefore, the ability tocreatively manage internal conflict in the organization is becoming a standardrequirement.17 Ideally, the goal in conflict management is that healthcareproviders are encouraged to collaborate creatively and flexibly to achieve awin-win solution for all involved.7 Transformational management or leadership isa style, which is ideally suited to the present climate of change in healthcarebecause it actively embraces and encourages innovation and change.37 However, inmany modern healthcare organizations, this could be an arduous task, ashierarchical and bureaucratic organizational cultures do not promote freedom ofplanning or professional latitude.48,49 Undoubtedly, this rigid form ofmanagement encourages nurses in intensive care to opt for avoidance as aconflict management strategy as a win-lose outcome in favor of management ispresumed. However, succumbing to avoidance strategies as a conflict managementonly reinforces the intensive care setting's authoritative and autocraticstructure and renders any hopes of collaboration impossible.

"Our Antagonist is our Helper":

Dealing successfully with conflict requires the manager to have a basicunderstanding of what is causing the conflict.50 Understanding the sources ofconflict can be realized when managers engage in careful listening.22 However,if nurses in the intensive care setting labor under a mandating managementstructure, which does not listen to its employees, then this may have analienating effect on staff and it may prove difficult for management toascertain what is actually causing conflict. Alternatively, managers should viewnurses more as invaluable resources for collective problem solving in theclinical intensive care setting. Burke agreed that "he that wrestles with usstrengthens our nerves and sharpens our skill. Our antagonist is our helper."51Indeed, in today's postmodern society, everyone wants to participate in makingdecisions that affect them; fewer and fewer people will accept decisionsdictated by someone else.15 Accordingly, collaborating is the most desirableapproach as it is the creative stance, it is both assertive and cooperativebecause people work creatively and openly to find the solution that most fullysatisfies all important concerns and goals to be achieved.16

Task Masters:

Transactional managers have been described as those people in organizations whohonor stability and control; they tend to promote task-oriented nursing care andare comfortable with that which is rational, quantitative, and logical.52Although this transactional approach to leadership in the intensive care canoffer prompt solutions for immediate staff needs, particularly under stressfulconditions, it is nonetheless, lacking in vision for the future and endorsesonly policy or procedures rather than organizational or cultural change.53Therefore, transactional management encourages nurses in intensive careenvironments to concentrate on the completion of tasks and, subsequently, nurseshave little energy or time to engage in conflict or negotiation.

However, nursing care in the intensive care unit should not be reduced to a sumof tasks or a laboratory-like atmosphere where only measurements and controlsrepresent "caring" or where concern for the people they manage becomessubordinated to organizational goals.37 Instead, the emerging paradigms inhealthcare require managers who are able to be strategic in their thinking andfacilitative in their style so that nurses in the intensive care setting cancollaborate with others to tailor their care creatively to the individual needsof the patient.

Transformational leadership would be the ideal form of leadership to facilitatenurses in the intensive care setting because it is caring and highly ethical.54Transformational leadership utilizes components such as charisma, idealizedinfluence, inspirational motivation, intellectual stimulation, and individualconsideration.17 However, anecdotal evidence suggests that there are very fewpeople in nursing with these characteristics, especially charisma, and that thesubsequent absence of innovative and empowering leadership leads to avoidance ofconflict by nurses in the intensive care setting.

IMPLICATIONS FOR PRACTICE

The following are implications for nursing practice:

* Nursing requires a guiding definition of conflict that is positive andcomprehensive so that conflict is embraced constructively in the intensive caresetting.

* Similar to any other profession, nurses are permitted to engage in conflictassertively, yet respectfully, as a medium for growth and innovation inpractice.

* Practitioners in the intensive care setting must appreciate the fine linebetween assertive behavior and horizontal violence or bullying in the workplace.

* Conflict can be resolved through careful listening and good communication.

* In conflict management, it is wise to concentrate on the problems and not onthe personalities.

* Emotional intelligence training should be provided in nurse education to allownurses to deal with conflict more effectively.

* Nurses in intensive care need to embrace autonomy and increased accountabilityin their practice so that independent thought can be developed and theirengagement in conflict is more effective.

* Educational opportunities should be provided equally to all intensive carepractitioners to ensure that they are educationally equipped to deal withconflict situations.

* Transformative management and leadership styles are key to facilitatingempowered participation in conflict.

CONCLUSION

Although conflict is regarded as a natural phenomenon in every human relationship,nurses in intensive care have traditionally used avoidance as a conflictmanagement strategy because of stereotypical and gender behavioral expectations,self-esteem issues, and management and leadership styles. Analysis of the issuesindicated that nurses avoided conflict in the intensive care setting becausethey felt the public's stereotypical image of them demanded that they be "nice,"self-sacrificing, and submissive nurses and that if they engaged in conflictthey would be branded emotional or unfeminine women. However, it is believedthat in conflict management, it is necessary to concentrate on the problems andnot on the personalities and that patients' needs are better met when practitionersconfront conflict openly and assertively.15

As a largely female-dominated occupation, nurses in intensive care settingsavoided conflict because of the disproportionate amount of men in administrativeand managerial positions and because of the dominance of medicine in thehealthcare arena. It was argued that historically low levels of self-esteem innurses and the existence of autocratic and transactional managerial structureshave encouraged nurses to avoid conflict. Arguably, these problems are bestremedied by nurses seeking autonomy and control over their own practice andmobilizing independent thought to confront conflict confidently instead ofrelying on rule following and hierarchical structures.35 Transformationalleadership was thought to be key in leading nurses to empowering and innovativeworking conditions and providing the courage to engage in constructive conflictmanagement.

References

1. Bryant J. The Six Dilemmas of Collaboration. Chicester: John Wiley and Sons;2003.

2. Saulo M, Wegener RJ. Mediation training enhances conflict management byhealthcare personnel. Am J Manag Care. 2000;6(4):473-483. Bibliographic Links

3. Wilson JL. Conflict management does not have to create conflict. AccountToday. 2004;9(20):1-3.

4. Cavanagh SJ. The conflict management style of intensive care nurses.Intensive Care Nurs. 1988;4:118-123. Bibliographic Links

5. Valentine P. A gender perspective on conflict management strategies ofnurses. J Nurs Scholarsh. 2001;33(1):69-74.

6. Walton RE. Theory of conflict in lateral organisational relationships. In:Lawrence JR, ed. Operational Research and the Social Sciences. London, England:Tavistock Publications; 1966:1-276.

7. Marquid B, Huston C. Leadership Roles and Management Functions in Nursing.3rd ed. Philadelphia, Pa: Lippincott, Williams and Wilkins; 2000.

8. Van de Vliert E. Conflict and conflict management. In: Drenth JH, Thiery H,DeWolff CJ, eds. Handbook of Work and Organizational Psychology. 2nd ed. London,England: Psychology Press; 1998:1-310.

9. Lewis J. Conflict management. J Nurs Adm. 1976;6(10): 18-22. BibliographicLinks

10. Goodman B. Ms B and legal competence: interprofessional collaboration andnurse autonomy. Nurs Crit Care. 2004;9(6):271-280. Bibliographic Links

11. Valentine P. Management of conflict: do nurses/women handle it differently?J Adv Nurs. 1995;22:142-149. Bibliographic Links

12. Beauregard M, Deck D, Couglin K, et al. Improving out image a nurse at atime. J Nurs Adm. 2003;33(10):510-511. Ovid Full Text Bibliographic Links

13. MacGuire JM. From Student of Nurse. Oxford, England: Area TrainingCommittee; 1966.

14. Percival J. Don't be too nice. Nurs Stand. 2001;15(19):22. BibliographicLinks

15. Fisher R, Ury W, Patton B. Getting to Yes: Negotiating an Agreement WithoutGiving In. London, England: Arrow Books; 1997.

16. Yoder-Wise PS. Leading and Managing in Nursing. 3rd ed. Texas: Mosby; 2003.

17. Hendel T, Fish M, Galvon V. Leadership and choice of strategy in conflictmanagement among Israeli nurse managers in general hospitals. J Nurs Adm.2005;13(2):137-149.

18. Cox KB. The effects of unit morale and interpersonal relations on conflictin the nursing unit. J Adv Nurs. 2001;35(1):17-27. Bibliographic Links

19. Timmons F, McCabe C. How assertive are nurses in the workplace? A preliminarypilot study. J Nurs Manag. 2005;13(1):61-68. Bibliographic Links

20. McKenna B, Smith N, Poole S, Coverdale J. Horizontal violence: experiencesof registered nurses in their first year of practice. J Adv Nurs. 2003;42(1):90-96.Bibliographic Links

21. Rayner CH. Worplace Bullying. London, England: Taylor and Francis; 2002.

22. Lee D. Confrontation equals conflict management. Tennessee Nurse. 1999;62(2):21-25.Bibliographic Links

23. Adams S. Plugging the gap-critical care skills are the current universalcommodity. Nurs Crit Care. 2004;9(5):195-199. Bibliographic Links

24. Department of Health. Commission on Nursing-Blueprint for the Future.Dublin, Ireland: Department of Health; 1998.

25. Suominen T, Kovasin M, Ketola O. Nursing culture-some viewpoints. J AdvNurs. 1997;25:186-190. Bibliographic Links

26. Smith-Trudeau P. Diversity consciousness: from conflict to collaboration.Vermont Nurse Connection. 2002;5(1):11. Bibliographic Links

27. Oakley A. The importance of being a nurse. Nurs Times. 1984;12(12):24-27.

28. McQueen A. Emotional intelligence in nursing work. J Adv Nurs. 2004;47(1):101-113.Bibliographic Links

29. Fuimano J. Raise your emotional intelligence. Nurs Manag. 2004;35(7):10-12.Ovid Full Text Bibliographic Links

30. Evans D, Allen H. Emotional intelligence: its role in training. Nurs Times.2002;98(27):41-42. Bibliographic Links

31. Farrell GA. From tall poppies to squashed weeds: why don't nurses pulltogether more? J Adv Nurs. 2001;35(1):27. Bibliographic Links

32. Farrell GA. Aggression in clinical settings: nurses' views-a followup study.J Adv Nurs. 1999;29(3):532-541. Bibliographic Links

33. Davidhizar R, Cramer C. Gender differences in leadership in the healthprofessions. Health Care Manag. 2000;18(3):18-24. Bibliographic Links

34. Tingle C. Conflict management. Pelican News. 1998;54(3):17. BibliographicLinks

35. Dunn H. Horizontal violence among nurses in the operating room. AdvancedOperating Room Nurse. 2003;78(6):977-980.

36. Kafka F. Metamorphosis. London, England: Penguin; 1916.

37. Sofarelli M, Brown M. The need for nursing leadership in uncertain times. JNurs Manag. 1998;6(4):201-211. Bibliographic Links

38. Davies C. Rewriting Nursing History. London, England: Croom Helm; 1980.

39. Von Dietze E, Orb A. Compassionate care: a moral dimension of nursing. NursInq. 2000;7(3):166-177. Bibliographic Links

40. Manias E, Street A. Nurse-doctor interactions during critical care wardrounds. J Clin Nurs. 2001;10:442-450.

41. Randle J. Experience before and throughout the nursing career. Bullying inthe nursing profession. J Adv Nurs. 2003;43(4):395-406.

42. Hall B. Fight your corner. Nurs Stand. 2004;18:18-19. Bibliographic Links

43. Mannahan CA. Professional maturity. The stages of developing self-esteem.Advanced Operating Room Nurse. 1989;49:593-596.

44. McCarthy G. Nursing in a changing world. In: Robins J, ed. Nursing andMidwifery in Ireland in the Twentieth Century. Dublin, Ireland: An BordAltranais; 2000.

45. An Bord Altranais. Guidance to Nurses and Midwives on the Development ofPolicies, Guidelines, and Protocols. Dublin, Ireland: An Bord Altranais; 2000b.

46. Kelly J. Accountability and recent development in nursing. Dimens Crit CareNurs. 2004;23(1):31-37. Ovid Full Text Bibliographic Links

47. Stevens J, Crouch M. Frankenstein's nurse! What are the schools of nursingcreating? Collegian. 1998;5:110-115.

48. Clegg A. Occupational stress in nursing: a review of the literature. J NursManag. 2001;9:101-106. Bibliographic Links

49. Kuokkanen L, Leino-Kilpi H. Power and empowerment in nursing: threetheoretical approaches. J Adv Nurs. 2000;31(1):235-251. Bibliographic Links

50. Mackenzie J. Ward Management in Practice. Edinburgh: Churchill Livingstone;1998.

51. Burke J. The Conflicting Minds. London, England: Penguin Classics; 1790.

52. Rodriguez I. Selecting, developing, empowering, and coaching staff. In: WiseY, ed. Leading and Managing in Nursing. St. Louis, Mo: Mosby Year Books;1995:2-20.

53. Murphy L. Transformational leadership: a cascading chain reaction. J NursManag. 2005;13(2):128-140. Bibliographic Links

54. Biordi DL. Ethical leadership. In: Marriner-Tomey A, ed. TransformationalLeadership in Nursing. St. Louis, Mo: Mosby; 1993:1-197.

Keywords: Conflict; Conflict management; Conflict resolution; LeadershipAccessionNumber: 00003465-200601000-00007