NUR5103 Module 5 conflict analysis and negotiated resolution example

Who Wakes the Patient at 0430: A Conflict Between Night Nurses and Respiratory Therapists, Analyzed With Thomas-Kilmann and Settled by Principled Negotiation

Student Name

American College of Education

NUR5103: Leadership and Management Theory in Nursing

Module 5 Assignment

Instructor Name

March 30, 2027

The Conflict

At the long-term acute care hospital followed in this course, the weaning protocol now pairs a daily sedation hold, in which sedative infusions are stopped to see whether the patient can wake, with a spontaneous breathing trial run by a respiratory therapist. The respiratory therapy lead set the sedation hold for 0430 so that therapists could complete breathing trials on all eligible patients before the 0700 shift change. Night nurses were told to stop the sedatives at that time.

On a Thursday at 0445, a 68-year-old composite patient became agitated during the sedation hold and pulled out his breathing tube before a therapist arrived. He was reintubated without lasting harm. At the next morning's huddle the night charge nurse said the therapists had set a time that suited their workload and left nurses alone with agitated patients. The respiratory therapy lead replied that nurses had been told to call for help and that the night staff were looking for a reason to avoid the protocol. Two nurses stopped doing sedation holds altogether the following night, and breathing trial completion on that floor fell from 68% to 45% in a week.

Sources of the Conflict

Almost et al. (2016), in an integrative review of 44 papers on conflict in health care teams, found that frequently identified sources included poor work environments, role ambiguity, lack of support and poor communication, along with individual factors such as emotional intelligence. Three of those sources are present here. The roles were ambiguous: the protocol said the nurse stops sedation and the therapist runs the trial, but it did not say who stays with the patient between those steps. Support was thin: at 0430 one therapist covers 20 patients, and the night nurses on the new team model each have five. Communication was poor: the 0430 time was set by the therapy department and announced by email, and no night nurse was asked.

The conflict looked personal at the huddle, but its structure was written into the protocol the day nobody decided who stands at the bedside while the patient wakes.

How Each Side Handled It

Thomas (1992) describes conflict-handling behavior along two dimensions, assertiveness, or how hard a party pushes for its own concerns, and cooperativeness, or how far it tries to meet the concerns of the other side. Combining the two yields five modes: avoiding and competing, accommodating and collaborating, with compromising in the middle. Thomas treats every mode as useful somewhere; the skill lies in matching the mode to the situation.

The respiratory therapy lead used competing: the timing was set to meet the therapists' concern about finishing trials, with little attention to the nurses' concern about safety, and the response at the huddle defended the decision rather than exploring the problem. The night charge nurse also competed at the huddle, but the two nurses who then stopped doing sedation holds were avoiding, withdrawing from the protocol without saying so. Their avoidance was the more damaging, because it moved the conflict out of view while patients bore its cost. The director of nursing had so far used a form of avoiding as well, by letting the protocol's gaps stand after the first audit. The situation called for collaborating, since both concerns were legitimate and the relationship between the two groups had to last.

Negotiating the Resolution

The director brought the respiratory therapy lead, the night charge nurse, a night staff nurse and a therapist together for an hour, using the four principles of principled negotiation described by Fisher et al. (2011). First, the people were separated from the problem: the meeting opened with the director stating that nobody had been careless, that the protocol had a gap, and that the patient's self-extubation was the protocol's failure to answer a question.

Second, the discussion moved from positions to interests. The therapists' position was 0430; their interest was completing trials on every eligible patient with one therapist on duty. The nurses' position was that sedation holds should stop at night; their interest was never being alone with an agitated patient whose airway was at risk. Third, the group generated options before choosing: moving the hold to 0600 when a second therapist arrives; staggering holds so that the therapist is present for each one; keeping 0430 but adding a nursing assistant at the bedside; and running trials on the day shift instead.

Fourth, the group judged the options against an objective standard rather than against each other's preferences. The standard was the randomized Awakening and Breathing Controlled trial, in which pairing sedation holds with breathing trials increased days free of the ventilator and reduced one-year mortality, while more patients in the paired group pulled out their own tubes, although the number needing reintubation after doing so was similar (Girard et al., 2008). The evidence showed that the pairing was worth keeping, that self-extubation was a known risk and that the answer was supervision, not abandonment.

Why Not Simply Decide

The director could have settled the dispute in five minutes by setting a new time and issuing it as policy. That would have been faster, and the outcome might even have been similar. It would also have repeated the original mistake, in which one group set a time that affected another group's patients without asking them, and it would have left the two nurses who stopped doing sedation holds with no reason to start again. A conflict about who holds responsibility at the bedside cannot be resolved by a third party taking responsibility away from both sides. The negotiation took an hour of five people's time; the week of avoided sedation holds before it cost patients on one floor roughly a quarter of their breathing trials. Measured that way, collaboration was the cheaper choice.

The Agreement and Its Follow-Up

The group agreed on a staggered schedule. Sedation holds begin at 0545, after the second therapist arrives at 0530, and are started in pairs, with the therapist at the bedside before the nurse stops the infusion. Any patient with a history of agitation during a hold will have it on the day shift instead. The protocol now names who stays with the patient from the moment sedation stops until the trial begins or the sedation resumes. The respiratory therapy lead and the night charge nurse presented the change together at both huddles. The director will review breathing trial completion and any self-extubation each week for a month and will meet the same group again in 30 days to ask whether the agreement is holding.

What the Conflict Taught the Director

Three lessons carry beyond this dispute. First, every protocol that passes a task from one discipline to another creates a moment between the two tasks, and that moment needs an owner in writing before the protocol starts, not after an event. Second, silence after a heated huddle is not agreement. The drop in breathing trials was the first sign that the nurses had moved from competing to avoiding, and the director will now review protocol completion rates weekly by shift during any practice change so that avoidance shows up as data. Third, the director's own avoidance mattered: the gap in the protocol was visible in the first audit, and the conflict would likely have been smaller had it been addressed then. The next module draws these lessons into a personal philosophy of nursing administration.

References

Almost, J., Wolff, A. C., Stewart-Pyne, A., McCormick, L. G., Strachan, D., & D'Souza, C. (2016). Managing and mitigating conflict in healthcare teams: An integrative review. Journal of Advanced Nursing, 72(7), 1490-1505. https://doi.org/10.1111/jan.12903

Fisher, R., Ury, W., & Patton, B. (2011). Getting to yes: Negotiating agreement without giving in (3rd ed.). Penguin Books.

Girard, T. D., Kress, J. P., Fuchs, B. D., Thomason, J. W. W., Schweickert, W. D., Pun, B. T., Taichman, D. B., Dunn, J. G., Pohlman, A. S., Kinniry, P. A., Jackson, J. C., Canonico, A. E., Light, R. W., Shintani, A. K., Thompson, J. L., Gordon, S. M., Hall, J. B., Dittus, R. S., Bernard, G. R., & Ely, E. W. (2008). Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): A randomised controlled trial. The Lancet, 371(9607), 126-134. https://doi.org/10.1016/S0140-6736(08)60105-1

Thomas, K. W. (1992). Conflict and conflict management: Reflections and update. Journal of Organizational Behavior, 13(3), 265-274. https://doi.org/10.1002/job.4030130307