Running head: INTERVENTIONS

Therapeutic Nursing Interventions

Mary Ellen Cooper
Old Dominion University

INTERVENTIONS

Therapeutic Nursing Interventions

The University of Virginia Medical Center is a Magnet designated academic health
system associated with the University of Virginia. The hospital services Charlottesville, Virginia
and satellite locations in eight surrounding counties. Inpatient psychiatric care is provided by an
adult acute care unit with a 23 bed capacity. The clinical staff on the unit consists of two
attending physicians; first, second, and third year residents; registered nurses with varying
degrees of experience and education; and patient care assistants. Due to the ever-changing
residents, as well as a relatively recent high degree of staff turnover necessitating the hiring of
new employees to replace them, the psychiatric unit is one of constant flux. As per the facilitys
focus on diversity, numerous cultural backgrounds are represented on the unit. The current age
range of the nurses is from 23 to 74, and the gender ratio at this point is approximately 50/50.
This much change in the composition of the staff -- from a core group of primarily middle-aged
women to such a motley mix of ages, genders, and cultural backgrounds -- has created staff
conflicts that are negatively impacting patient care.
Clinical Problem Defined
The current practice within the environment in regards to resolving staff conflict before it
impacts patient care has proven to be inadequate. As it stands, too much work time and focus is
being devoted to individual staff members sitting in the managers office airing their grievances
regarding other personnel. The manager gives them tea and sympathy, so to speak, but as the
constant lament from staff goes, Nothing is ever done. The unit manager herself continually
laments the negativity and makes statements such as why cant everyone just get along.
This is obviously a very trying situation for her, and that trickles down to first staff and then

INTERVENTIONS

patients. The unit manager has many, more essential tasks to perform other than providing an ear
for disgruntled staff members. Given the current level of overt hostility apparent not only to
staff, but also to patients (as evidenced by patient satisfaction surveys and patient and family
accounts that cite overheard arguments between staff members), this issue needs immediate,
effective redress.
The following example will illustrate how staff conflict is a barrier to patient centered
care from the perspective of patient and family, told to me by the family member. One evening,
the family member approached a patient care technician (PCA) on the unit and asked if he and
his mother could visit in the comfort room in order to obtain some privacy. He was told he
would have to wait as the unit was very busy. The family member waited 20 minutes before
asking the same PCA if the staff now had time to let him and his mother into the comfort room.
Again, he was told to wait. On his third approach to the nursing station, he overheard the staff in
a heated argument, which included some very choice language, about the use of the comfort
room when the unit was busy. He heard the obviously frustrated PCA ask someone to make a
decision. When he was able to get the PCAs attention, he asked once more to be let into the
comfort room, explaining that his mother was upset and he felt she needed to speak to him alone.
This time he was told by the PCA, We are short staffed; I cant help you. The family member,
who I have a relationship with due to his mothers prior admissions, was upset enough by this
event to call me on the unit the following morning to relate this story. His mother complained to
the medical team that afternoon.
Current Practice, Formal Mechanisms

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The formal mechanisms set in place by the facility are found in Medical Center Human
Resources Policy, No. 701, Employee Standards of Performance and Conduct. The preface
states: To this end, all individuals working in the Medical Center shall treat others with respect,
courtesy, and dignity, and shall conduct themselves in a professional and cooperative manner
(University of Virginia Health System, 2015). Examples of serious misconduct include, but are
not limited to: mistreatment of a patient, visitor, or fellow employee; use of profanity or
offensive language in the workplace whether verbally, through gestures, or in writing. The
classification of the offense as either a performance deficiency or misconduct is at the sole
discretion of the unit manager. If the manager deems the offence to be misconduct, then
progressive counseling may be initiated - informal counseling, formal counseling, performance
warning, and/or suspension or termination (University of Virginia Health System, 2015).
According to Iacono (2000), in regards to progressive counseling, The managers role is not to
eliminate all conflict, but to minimize anger and inappropriate behavior, as well as suboptimal
care delivery related to unresolved conflict (p. 262). These formal mechanisms for managing
conflict need to be utilized for the sake of the overall health of the unit, which ultimately impacts
patient care.
Current Practice, Informal Mechanisms
The informal practices in place at this time include the individual parties going to the
manager initially to discuss a conflict with a fellow employee, but then using ad hominem
arguments to make their point. Another informal practice is for the employees in conflict to
threaten each other with HR. Employees spend inordinate amounts of time trying to recruit
others to their way of thinking about a fellow employees practices. Some employees will have

INTERVENTIONS

an argument with another staff member and then spend a large portion of their shift looking up
policies they think will support their view, then posting these policies all over the unit. As an
example of the time-wasting component of this problem, I personally witnessed a day shift
employee in conflict with a night shift employee spend nearly two hours of her shift writing a
multiple page letter to the manager about the incident. This sort of dysfunctional conflict is
negatively impacting the unit on multiple levels, including impacting employee job satisfaction,
employee wellbeing, and most importantly, the quality of patient care (Patton, 2014, p. 4).
Analysis of Discrepancies
The antecedent to the problem was the hiring of numerous new staff members, with no
thought as to how they might fit into the existing culture. In a matter of six months, the unit
hired several clinician 1s, six men, multiple nurses who had worked for the state psychiatric
hospital for years (who believed they knew how it should be done), and three immigrants to
this country. Following hiring, these new employees were not properly monitored during their
probationary period, and issues were never addressed. We had a large influx of new staff who
behaved in a quite competitive manner with each other, and this led to conflict amongst
themselves as well as with existing staff members who tried to promote the concept of
teamwork. By the time the manager was even aware of the problem, after being out on medical
leave for two months, the behaviors were firmly entrenched. The primary reason for the
discrepancies between the formal mechanisms and informal mechanisms regarding staff conflict
is this absence of the manager at a critical time for the unit.
Nursing Interventions

INTERVENTIONS

The first intervention that I would implement on my unit would be mandatory

interpersonal competence training. I would offer to partner with the Faculty and Employee
Assistance Program at the hospital, which there is a precedent for, to help create a customized inservice for our unit. Conflict is inevitable in any workplace; employees just need the skills to
deal with it in a constructive, rather than destructive manner. One method that could be taught is
how to discern if the nurse the participant is having an issue with is in an approachable frame of
mind. In a study conducted by Duddle & Boughton (2007), it was determined that nurses who
had skills in negotiating with each other tend to assess the potential for a successful interaction
before approaching another staff member (p. 33). One component of the competence training
should be an opportunity to reflect on personal motivators, as well as attitudes and beliefs that
affect collegial relationships. Another study, out of Canada, testing the applicability of Deutschs
theory of constructive conflict management, found nurses need to recognize the foundations of
their work contexts that are facilitative of effective conflict resolution and understand how their
personal dispositions affect the conflict management process (Siu, Laschinger, & Finegan,
2008, p. 252). Self-reflection is, of course, crucial for improvement and change.
The second intervention that I would apply is advocating for the implementation of a
mentor program. As a senior staff member, I could offer myself in this role. Both the mentors
and mentees could keep journals on agreed upon topics, one of them being conflict resolution,
and then compare notes. A study conducted by Latham, Ringl, & Hogan (2011) designed to
evaluate the effect of mentoring and shared governance on nurse perceptions of the supportive
culture of the workplace environment, professional skill development, decisional involvement,
and retention and vacancy rates found that, although it took three years, both mentors and

INTERVENTIONS

mentees reported improved team building and conflict resolution skills (p. 344). These are skills
that mentees can use for the remainder of their careers. The mentors could also serve as role
models for professional behavior and appropriate conflict resolution. Given that new employees
and students will learn from and model current staff whether this is a formalized arrangement or
not, it seems prudent to choose proven professionals for this role. The mentees would then have
the benefit of their role models experience in fitting into a new culture without undue conflict.
The mentor also benefits from being perceived as a role model in that, consistent with Albert
Banduras social learning theory, the mentor may be inspired to continue to model good practice
(Vinales, 2015, p. 533). Both parties in the mentor/mentee relationship stand to benefit
enormously from the relationship.
The third intervention I would employ is the use of employee appreciation cards to let a
nurse recognize another nurse (or doctor, PCA, et cetera) for what he/she values about their
practice. According to the Harvard Mental Health Letter (2008), appreciation is a core concern
when disagreements between staff members arise. We all can become defensive when we feel
misunderstood and under attack. Expressing appreciation in this context involves finding
merit in someone we are at odds with in a desire to prevent escalation and foster good relations
(p. 4). Everyone wants to feel appreciated in their work setting and this sense of whether or not
one has value to colleagues has a direct effect on an employees level of commitment. When an
employee lacks a feeling of commitment, performance declines, complaints about work,
colleagues, and management become more strident, and attendance issues may arise (White,
2012, p. 144). We would all have the ability to positively influence the behavior of our

INTERVENTIONS

workmates with this method, instead of continuing the current practice of a steady stream of
employees going to the manager to demand she do something.
Analysis of Interventional Support
There is ample support from research and other literature for the contention that poorly
managed staff conflict negatively impacts the quality of patient care, as well as employee job
satisfaction and wellbeing. Evidence-based practice interventions proved somewhat more
difficult to find, however. It appears that there is a consensus on the negative effects of the
problem, but very little in the way of suggestions for what to do about it. There are numerous
articles (not cited here) that I found on general reading regarding the problem that provided some
suggested solutions, but they were not specific to nursing.
Identification of a Potential Research Study
I propose a research study with the hypothesis: Nursing satisfaction scores on nurse
surveys are higher on psychiatric units who add a conflict resolution group, led by nurses on a
rotating basis, to their milieu therapy offerings.
Summary
The relatively recent influx of new staff of varying ages, genders, and cultural
backgrounds on the psychiatric unit has created conflict that has now unfortunately manifested in
numerous maladaptive conflict coping strategies. These include gossiping, ad hominem attacks,
and threats to report someone to Human Resources for unprofessional behavior. This issue
was complicated by the fact that the manager was out on extended medical leave during the time
when issues first began to arise, leading to unhealthy behaviors becoming entrenched. I propose

INTERVENTIONS

three interventions to deal with the problem of unhealthy staff conflict: mandatory interpersonal
competence training, the implementation of a mentor program, and employee appreciation
cards.

References
Duddle, M., & Boughton, M. (2007). Intraprofessional relations in nursing. Journal of
Advanced Nursing, 59(1), 29-37. doi:10.1111/j.1365-2648.2007.04302.x
Harvard Mental Health Letter (2008). Dealing with the emotional aspect of conflict: Stimulating
positive emotions to resolve disputes and improve relationships. Harvard Mental Health
Letter, 25(5), 4-5. Retrieved from
http://eds.a.ebscohost.com.proxy.lib.odu.edu/ehost/pdfviewer/pdfviewer?sid=ab075dc448ed-451f-9ce6-d695c313ee48%40sessionmgr4002&vid=7&hid=4202
Iacona, M. (2000). Managing conflict/employee counseling. Journal of PeriAnesthesia
Nursing, 15 (4), 260-262. doi:10.1053/jpan.2000.9469
Latham, C., Ringl, K. & Hogan, M. (2011). Professionalization and retention outcomes of a
university-service mentoring program partnership. Journal of Professional Nursing,
27(6) 344-353. doi: 10.1016/j.profnurs.2011.04.015
Patton, C. M. (2014). Conflict in health care: A literature review. The Internet Journal of
Healthcare Administration, 9 (1), 1-11. Retrieved from
http://ispub.com/IJHCA/9/1/20081
Siu, H., Laschinger, H., & Finegan, J. (2008). Nursing professional practice environments:
Setting the stage for constructive conflict resolution and work effectiveness. The Journal
of Nursing Administration, 38(5), 250-257. doi: 10.1097/01.NNA.0000312772.04234.1f
University of Virginia Health System (2015). Standards for Professional Behavior. Retrieved
from http://www.healthsystem.virginia.edu/newdocs/manuals/policies/mc/A70A3BEF110A-2E68-144BF85F9D6993A3/Human%20Resources/standards-for-professionalbehavior
Vinales, J. J. (2015). The mentor as a role model and the importance of belongingness. British
Journal of Nursing, 24(10), 532-535. doi:10.12968/bjon.2015.24.10.532

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10

10

White, P. (2012). Unhappy? Low morale? Try the 5 languages of appreciation in the
workplace. Journal of Christian Nursing, 29 (3). doi: 10.1097/CNJ.0b013e318256c587

Therapeutic Nursing Intervention

Grading Rubric
Comments
Points

Content Area
Introduction
including clear discussion
of practice setting
nursing practice issue to
be discussed (15)
Clinical Problem clearly defined
why it is a problem in this
practice setting
why chosen for this
discussion
Specific examples used
(15)
Current Practice
Formal mechanisms
(present or absent)
Informal mechanisms
related to the problem
(present or absent)
Rationale for
discrepancies between
the formal and informal
method
Literature to support
formal and informal
mechanisms (15)

Nursing Interventions
3 Interventions identified
which are not currently in
practice
At least one intervention
is from a primary research

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11

11

article, or evidence based

practice literature
Consider an intervention
that reflects an
understanding of the
culture.
Interventions are based
on current literature and
could be incorporated into
your environment. This is
not just a review of
literature, it is to be
applied to your practice
setting. A specific strategy
to implement (15)

Use of literature support

Total 6 sources of
professional literature
At minimum 2 sources are
primary research, or
evidenced based practice
literature
Analysis of relationship
between clinical problem,
research support and
other literature (15)
Summary (5)
APA format (10)
Grammar/Syntax (10)
Grade

I pledge to support the Honor System of Old Dominion University. I will refrain from any form
of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a
member of the academic community it is my responsibility to turn in all suspected violations of
the Honor Code. I will report to a hearing if summoned.
Mary Ellen Cooper