Strategies used by nurses for conflict mediation

e20190894 http://dx.doi.org/10.1590/0034-7167-2019-0894 7 of ABSTRACT Objective: to understand what are the strategies used by nurses to mediate conflicts. Method: a qualitative and descriptive study that used oral history, carried out in the organ transplant unit of a university hospital located in the city of São Paulo, SP, Brazil. The population consisted of seven nurses with one year or more of experience in the unit. Data collection took place with semi-structured interviews. The reports were transcribed, and their content was analyzed according to Minayo’s model. Results: three categories have emerged: Conflict-generating sources; Strategies for conflict mediation such as collaboration, dialogue, standardization, and expressive action by nurses to mediate conflicts; Consequences of conflicts. Conclusion: there is a need to invest in the training of nurses to mediate conflicts, and it is important to develop skills such as interpersonal relationships and communication for the success of their professional performance. Descriptors: Nursing; Negotiation; Professional Competence; Nursing Administration Research; Qualitative Research.


INTRODUCTION
Conflict is a situation inherent to any human being living in society, and can occur in any type of environment where the person is (1) . The definition of conflict can be divided into two distinct strands, that of being beneficial in some situations and that of bringing negative consequences. According to nursing literature, the benefits of a conflict may include better understanding of tasks, team improvement, and joint decision-making; meanwhile, negatively, there is the possibility of distractions and wasted resources and time to resolve them (2) .
Conflict can emerge from disruptive behavior, which is defined as any inappropriate attitude that generates confrontation. It can cover verbal abuse, physical and/or sexual harassment, bullying, horizontal violence and hostility. Studies reveal that these are already very present in hospital and care institutions as a whole (3) . Thus, the levels of stress and frustration on the part of those involved in some type of conflict become problems in their mental and physical health (3) .
It is observed that, at work, daily contact with people from different cultures, opinions and values can be a means of disagreement among professionals (1) . Conflict is inevitable in all social and organizational spheres, therefore, in the professional practice of nurses, it would be no different. In a hospital, divergences can occur between doctor-nurse, nurse-patient, nurse-nurse and nurse-other staff (4) . In this sense, nurses are responsible for mediating conflicts.
It is noteworthy that if conflicts are not resolved or mitigated, especially when it is a situation of difficult intermediation, they can interfere and generate poor quality in the provision of care to patients.
A study (5) describes that horizontal hostility (HH) and horizontal violence (HV) are closely related to conflict situations. HV episodes occur at least once a week for a period of at least six months; or, according to other authors, "at least twice a week", and they are defined as bullying (5) . Emotional abuse is particularly common in emergency departments (62.4%), with a lower rate in intensive care units (28.8%) (5) . These data are presented by an Italian survey; however, the literature suggests that HH and HV occur in nursing workplaces worldwide. This study showed that 79.1% of these nurses reported being a victim of HH, while in the United States, 65% of the 1,850 nurses interviewed, covering all nursing positions and in various clinical settings, reported being victims (5) .
In Brazil, no intervention studies have been found that present results on conflict management; however, there is a consensus that in addition to their essential care role, nurses are responsible for mediating conflicts between health team professionals (6) .

OBJECTIVE
To understand which strategies are used by nurses to mediate conflicts.

Ethical aspects
The study was carried out after approval of the research project by the Research Ethics Committee (REC) of Universidade Federal de São Paulo (UNIFESP) and after authorization from the person in charge of the Directorate of Nursing and the participants' consent, which was carried out after signing the Informed Consent Form (ICF).
The selected participants were contacted personally to present the research project and the ICF. At that moment, the theme of the study, its relevance, the objectives and the method of recording data (audio recording of testimonials) were explained. After acceptance, participants were contacted to schedule the interviews, according to availability and in places chosen by them. Before starting the interviews, they signed the ICF, which included the deposition of testimonies for teaching and research purposes, which dispenses with the elaboration and signature of the Copyright Transfer Agreement.

Type of study
This qualitative study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) and carried out through oral history. This method provides the narrator with devices for reconstructing the experiences acquired by the interviewees, promoting an approximation and bond with the employee (1) .

Place of study
The study was carried out at the organ transplantation clinic of a university hospital in the city of São Paulo, SP, Brazil, in the morning, afternoon, and night shifts. As it is a unit with a great inclusion of undergraduate students, residents and professors, the environment becomes susceptible to stress and generation of conflicts among nursing members. Nurses are responsible for managing and organizing a heterogeneous team, in addition to providing quality care to patients. We chose this research field due to the need to understand the relationships between nursing professionals within the clinical unit.

Selection criteria
Nurses who had at least one year of experience in the unit were invited to participate in the research, since, during this period, the professional could have experienced some type of conflict. Resident nurses and those who were absent from work during the data collection period were excluded.

Population
Seven professionals participated in the research, four nurses and three nurses. Two of them worked in the morning shift, one in the afternoon and four in the two night shifts.

Data collection
Data collection was carried out through semi-structured interviews. We use the guiding question "What are the ways you use to mediate conflicts?". Furthermore, a script was built with questions to be added, according to the need for clarification and further study or in order to resume the focus of research. The interviews were conducted during the interviewees' shift hours, of Strategies used by nurses for conflict mediation Sbordoni E, Madaloni PN, Oliveira GS, Fogliano RRF, Neves VR, Balsanelli AP.
in a private room and in order to make the narrator feel free to testify, although there were some interruptions by the sector team related to continuity of assistance at that time.
The interviewees' testimonials were identified with a numerical sequence such as I-1 (Interviewee 1).

Analysis and treatment of data
For analysis, we conducted the following steps (7)

RESULTS
From data analysis, three categories emerged, which are presented below.

Conflict-generating sources
Non-adherence to an institutional standardization among the nursing staff of all shifts was identified as a potential cause of conflict by one of the interviewees: On the duty roster, patients are divided between assistants, and there is also a division of tasks. Who is going to replace material that is missing, who is going to organize the purge… when I entered here, there was no such division and I managed that only on our shift, at least, it was done this way. (I-1) The lack of understanding of the role of comprehensive nursing care was also mentioned by some of the interviewees: When a family member started to study nursing, I asked her "what do you intend to do next?", and she said "I want to be a nursing manager". I thought "how is she going to be a nursing manager without having graduated? It's not possible". Although I believe that this thinking is changing at graduation, there are still mistakes regarding the nurse's care function, such as believing that these professionals are limited to hygienic care. (I-4) Bath time is conflicting for nursing assistants, especially when the patient is overweight. In the perception of nurses, there is the ability to assess the degree of complexity of each patient. However, even so, employees show resistance, put obstacles stating that such a patient demands a lot of care time either for dressing or changing diapers. However, dressing, diapering and bathing are associated with the profession. But sometimes, employees do not want to provide that care, they want tranquility. (I-5) The nurses' perception regarding the interpersonal relationship between the nursing team and nursing students, as well as the relationship between the multidisciplinary team, appeared as one of the conflict-generating sources: Before, technicians criticized a lot and doubted the students' knowledge. Today, they do not criticize because they know that decisions made by students are based on theory. Sometimes the team questions the link between theory and practice. However, it is a teaching hospital, where the team, in addition to exercising other functions, must collaborate with the development of people (I-4).
Nursing deals with many people -patients, family members, nurses on other shifts, doctors, physiotherapists -who think differently and this results in conflict. (I-6) Gender relations in the workplace were also identified as causes of conflict: Dealing with the human being is complex, especially the female gender. In this profession, women are the majority and they always want to be right. (I-2)

Strategies for mediating conflcts
The opportunity was mentioned to individuals so that he, alone, could lead the conflict situation, developing their emotional intelligence: The opportunity must be given so that the other alone can resolve. However, if the situation gets out of control, the ideal is to call everyone for a conversation and try to mediate, leading and taking responsibility for that team. If there is a conflict with another duty, the nurse, out of respect for the other, does not speak directly to the technician, but seeks the responsible nurse and discusses the situation. (I-4) Once, when two employees got into conflict, I decided not to get involved, and I put the two of them to work together every day. They did it and managed to solve it, but this strategy doesn't always work. (I-4) According to interviewees, dialogue and empathic listening can also be beneficial: Dialogue is the best strategy. Sometimes, the person is stressed, you allow that moment of stress to pass and propose a conversation. (I-5) There is the situation where the assistant, after a conflict with another, does not accept help for patient care. This interferes with work, so you need to talk to resolve the situation. (I-1) of Strategies used by nurses for conflict mediation Sbordoni E, Madaloni PN, Oliveira GS, Fogliano RRF, Neves VR, Balsanelli AP.
Personal ethical conviction of justice was indicated by one of the deponents:

Above all, nurses must be fair, listen to what the other has to say and do the right thing, regardless of the relationship they have with the other person. I have always acted like this since I started working, and this has worked well until today. (I-1)
The use of institutional protocols, mentioned as a cause of conflict, was also presented as a solution: There are protocols in the unit that we need to follow. Faced with the refusal to use them, I try to show that it is correct and this brings credibility. (I-1) Unlike centralizing work, collaboration and union between the nursing team is a strategy used by nurses:

In my shift, there is collaboration between the team and this has worked. (I-1)
Readiness to resolve the conflict, preventing it from getting worse, was pointed out by one of the interviewees:

Consequences of conflicts
The negative consequences were expressed as a shaky interpersonal relationship and failure to manage length of service: The bad thing is that friendship and collegiality are shaken. Despite the attempt to show the situation, the person is not always satisfied. This creates a little conflict. (I-7) With the time that employees use to discuss whether that bath is from the morning, afternoon or night shift, they would have been able to shower. This delays the procedures and, at the end of the shift, employees need to run to handle everything. (I-5) Updating knowledge and the possibility for self-analysis and behavioral change of individuals are the positive consequences brought by the interviewees: I think it is positive when, confronting ideas, we reach consensus. Once, an employee did not agree with the medical prescription, and questioned me. I gathered the whole team, discussed the matter, clarified doubts and it was an opportunity for improvement. (I-1)

DISCUSSION
Based on the three categories that emerged from the results, data from this study are discussed. Failure to adhere to institutional standardization has been shown to potentially generate conflicts. Nursing literature shows that standardization allows an organization of processes; and, with that, it is possible to reduce the variation of related clinical and administrative practices (8) and minimize conflicts (9) .
Misunderstanding of the role of comprehensive nursing care also resulted in conflicts, as professionals limit themselves to performing certain tasks and refuse to perform basic functions such as hygiene care. Corroborating this finding, there were also differences in perception between management and care workers. While the main concern of management is the ability of its action to impact the quality and resolution of care, nurses and technicians are concerned with physical and emotional overload due to difficulties in staff sizing (10) .
Bathing, identified as a source of conflict, is a complex process that requires several precautions before, during and at the end of this procedure. It ends up being neglected by the team at various times, causing poor quality of care provided. The Brazilian study Banho no Leito: Cuidados Omitidos pela Equipe de Enfermagem showed that inconsistencies can occur when reporting failures in bath communication to patients and complications during the procedure (11) . However, it is known that to develop and improve the nursing practice, it is necessary for nurses to understand that caring and managing constitute management of comprehensive nursing care and must be thought and developed in all dimensions of care. (12) . Nurses have a fundamental role in conducting this procedure. They need to be involved and demonstrate their availability in face of this care and not just value the performance of the technique.
There were moments of tension regarding the interpersonal relationship between the team and the nursing students who were interning at the unit. Negative criticism and intolerance on the part of the team were mentioned in relation to the students' performance. Welcoming students is essential for adapting to the internship sector. Nurses play a fundamental role, as they are an important reference for the student, acting as facilitators and integrators of students at the service, together with the health team (13) . In addition, it is in the internship with indirect supervision that students learn and apply the skills of leadership, decisionmaking, communication and administration and management of health services (14) . It is highlighted in nursing literature that integration and collaboration with the health team in providing care are promoters of the feeling of usefulness and, consequently, of confidence, self-esteem, and motivation to act according to what is expected as future professionals (15) .
Incorporating periodic team meetings, getting to know and valuing the role of each of its members is an encouragement to strengthen the bond between professionals beyond the workplace (16) . In this sense, the teams that manage to bring these aspects together are certainly able to strengthen the bonds between their members and, therefore, establish healthier interpersonal relationships in the workplace (17) . It is noteworthy that, from the moment that each one becomes aware of the other's work, roles and functions become clearer for all professionals and the work process flows better (18) .
A sexist issue of the female gender was raised as a potential source of conflict. This issue remains important, mainly because the persistence of gender discrimination contradicts the antidiscrimination rules promoted in modern societies (19) .
One of the strategies found was the development of emotional intelligence in the work team. It has been linked to well-being, reduced work stress, lower levels of tiredness and effective leadership (20) . Organizations must direct their goals and the work of their professionals, in addition to using all the tools and skills that this generation offers to develop the best work possible (21) .
Dialogue and empathetic listening emerged as communication strategies in work team mediation. As for decision-making in the face of ethical conflicts, it appears that nurses make decisions using dialogue. Concern with legislation and the principle of beneficence can be identified when referring to the action for the benefit of another person (22) .
When establishing a dialogical and collaborative leadership, nurses seemed to have adopted participatory leadership. They sought to establish a good interpersonal relationship with their team members. Also, they believed that leadership based on trust and mutual dialogue is fundamental to the quality of care provided to their patients (23) .
Personal ethical conviction of justice was also said to be a strategy. The nurses' concept of ethics and bioethics denotes the need for reflection on individual and collective actions and behaviors to improve professional ethical conduct (24) .
Using protocols proved to be a favorable strategy for conflict management. Assistance protocols are fundamental tools to guarantee the quality of care provided; they aim to promote a safer and more effective care practice, since they are prepared based on the best scientific evidence and supported by the standards of organs related to safe patient care. Nurses are responsible for guiding and ensuring that the protocols are followed by the team with excellence and rigor (25) .
Unlike centralizing work, collaboration and unity among the nursing team was a strategy chosen based on the organization, planning and relay of employees between beds and other activities, favoring greater work together. Co-responsibility for health care requires a supervisory process anchored in participatory management that promotes integrated planning of actions and the construction of continuing health education through problematizing everyday practices (26) .
Consequently, the conflicts had negative and positive points. The shaky interpersonal relationship was a negative point, which seems to be inevitable, since it depends on the understanding of each individual. Nursing literature establishes that good inter-professional relationship and horizontal communication promote articulated care, strengthening integrated actions and minimizing fragmentation of care (26) .
Moreover, conflicts can result in positive aspects, such as updating knowledge. The possibility to gather the team and discuss a certain procedure or medication allows professionals to remember and clear up their doubts. Nurses are important in this regard and often have an attitude to promote these educational moments.
To understand the difficulties of professionals related to training, it is suggested as a strategy that institutions promote changes in activities so that these moments of education can be reinvented according to the reality of the hospital. If institutions provide more freedom for nursing professionals, a change in this scenario of difficulties may occur, providing more opportunities for the team and promoting safe assistance with updated professionals (27) .
Furthermore, a conflictual situation can be an excellent opportunity for self-analysis and behavioral change. Emotional intelligence makes professionals able to control their own emotions, in addition to detecting, interpreting and dealing with them correctly (28) . These findings suggest a completely new approach for nursing managers to promote improvements in environments, with a view to patient care safety and quality (29) .

Study limitations
The impossibility of accessing the articles corresponding to the themes "readiness to resolve conflicts" and "failure to manage length of service" limited the deepening of these issues in the discussion.

Contributions to nursing
This study advances by verifying the main causes of conflicts as well as strategies for coping with them and their consequences among the nursing staff of a clinical organ transplant unit attended by various actors, where nurses are faced with the daily challenge of mediation. Furthermore, the results can generate important reflections and conduct new research that broadens the knowledge on this theme.

FINAL CONSIDERATIONS
The findings point to the need to invest in the training of nurses to mediate conflicts. Development of skills, such as interpersonal relationships and communication, is essential for the success of professional performance. Therefore, it is necessary to invest in continuing education actions that include the development of such skills. Moreover, to broaden the discussions on this theme in undergraduate nursing courses, especially during the practical activities developed by students throughout their training and preparing professors to identify and provide learning opportunities in which students can act as conflict mediators, are effective ways to enhance nurse performance in practice settings.