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Transcript of Health care leadership and conflict handling
How to Develop Nursing Staff Relationship Conflict Resolving Methods
in Health Care
Facilitative way
Mika Koskinen
A dissertation submitted to the International Management Centres/Revans
University in part fulfilment of the requirements for the degree of Masters of
Business Administration
2010
3
TABLE OF CONTENTS
1. INTRODUCTION
1.1 General remarks 6
1.1.1 Organization 11
1.2 Aim 12
1.3 Goals 12
1.4 Challenges 13
1.5 Limitations 15
2. PLANNED METHODOLOGY
2.1 Way of working 17
2.1.1 Research Planning 18
2.1.2 Literature Review Planning 22
2.2 Organisation review 23
2.3 Management overview 25
3. LITERATURE REVIEW
3.1 Execution 26
3.2 Conflicts 26
3.3 What kind of methods are there to 30
resolve conflicts
3.3.1 Leadership as a method 33
3.3.2 Organizational change as a method 37
3.3.3 Summary of Literature Review 41
4. RESEARCH
4.1 Execution 48
4.2 Research Results 50
4.3 Research Summary 57
5. SUMMARY OF RESEARCH AND LITERATURE 63
REVIEW
6. GENERATION, EVALUATION AND SELECTION OF OPTIONS
6.1 Options 67
6.2 Choosing Options 69
7. ACTION PLAN 73
4
Appendix I Budget and Schedule for the Action Plan 76
Appendix II Ten Essential Processes of a Facilitative Leader 78
Appendix III The Group Effectiveness Model 79
Appendix IV Trust and Organizational Learning 80
Appendix V Rapport from Tykkyläinen 81
Appendix VI Interview Minutes 83
Appendix VII Cover Letter for the HUS Questionnaire 85
Appendix VIII HUS Questionnaire 86
Appendix IX Cover Letter for the HUS Questionnaire in Finnish 87
Appendix X HUS Questionnaire in Finnish 88
Appendix XI Questions and Answers of IY/MBA Questionnaire 89
Appendix XII HUS Questionnaire Answers 96
Appendix XIII HRM Strategy in HUS 100
Appendix XIV Labour Process Theory 102
Appendix XV Basic Mediation Styles 103
Appendix XVI Innovation Challenges 104
Appendix XVII Intractable Identity Conflict Resolution Model 105
Appendix XVIII Roles of a Player 106
Appendix XIX TEKES Wellness and Health 107
Appendix XX HUS in a Business Environment 108
Appendix XXI DUTCH Model 109
Appendix XXII Plan Against Harassment 111
Appendix XXIII Conflict Assessment 112
Appendix XXIV References 113
Appendix XXV Glossary 118
List of figures and tables
Figure 1. Leadership principles and structures 7
Figure 2. Major conflict categories 10
Figure 3. Knowledge and trust in an organization context 14
Figure 4. Patient care is both the target and value that runs throughout
health care organization although the ultimate decisions are made by clinicians 23
Figure 5. Hierarchy suggestion of the leaderships based on learning 33
Figure 6. Summary of factors in a conflict situation 62
Figure 7. A suggestion of minimizing conflicts 71
Table 1. Main sources 21
Table 2. Conflict Prevention by IY/MBA 51
Table 3.Conflict Solving by IY/MBA 52
Table 4. Answering frequencies of the questionnaires 53
Key Words
Health care, KIBS, conflict management, relationship conflict, strategy, diversity
5
1. Introduction
1.1 General remarks
Working environments have, along with the developments of societies of all
mankind, become an ever changing prototypes and playgrounds of
development.1,2,3
There is a tendency of blaming individuals for the errors we
all have made: a cultural blindness to systems and processes when undesirable
outcomes happen.4 Evolution however, hasn’t been able to adapt to that move
with equal speed and this causes disturbances in our minds and organizational
structures.2,5
Hospitals differ from other organizations as what comes to
conflicts and there are many publications to support that.6,7,8,9
I’ve worked with
health care directly and indirectly for over twenty years, out of which the last six
mainly in consulting. I’ve grown accustomed to the different aspects of the
branch while working in the Helsinki University Central Hospital twenty-three
years ago for two years and after that at the same premises, parallel to my main
job, during eleven years. Eighteen years ago I did my diploma on public health
care marketing and I’ve been working as a consultant and facilitator for five
years. For approx. a year ago, we started to plan for a research plan of which
this dissertation work is the first phase after the planning period.
I presume, out of my experience, that one of the “evolutionary” gaps lies in
between organizational structures and processes. Some evidence exists to spoke
for that.10
For ex. Collins D. describes, that changes happen all the time and
organizations must make structural changes for ex. in a form of Business
Process Reorganization (BPR). The organizations of our time are designed to
reflect the old paradigm of business practice, and to automate the processes
1 Lucey J. Management Services Vol. 52, no.4 (Winter 2008), p.11
2 Handy C. Leader to Leader, Vol. 2002, No. 24 (April 2002), p.29-33
3 Riely J et al. National Productivity Review Vol.18, No. 3 (Summer 1999), p.63-68
4 Smith L. Journal of Innovative Management Vol. 12, no.3(Spring 2007), p.44
5 Engdahl R. Organization Development Change Vol. 23, No. 2 (Summer 2005), p.50-61
6 Porter-O’Grady T. Health Care Manage Review, Vol. 29(4), 2004, p.278-283
7 Nelson W. et al. Journal of Health care Management, Vol. 53, January/February 2008, p.41-53
8 Slomka J. Hastings Center Report, March-April 2005, p.45-46
9 Dreachling J. et al. Health Care Executive Nov/Dec 2006, p.9
10 Busby S.J. International Journal of Production Reseach Vol.31, No. 9 (September 1993), p.2183
6
doesn’t help.11,12
A standpoint of function might be created, but the processes
don’t usually follow the same borders, rather live their own lives.
Processes and leadership doesn’t exclude, but complement each others. In order
to be able to create processes, one has to lead the building of them. The
building of leadership processes are to be taken care of by the peer reviews,
where peers are from different process levels including the management. Some
kind of leadership processes lead to developments, that carry further and some
only to a short living victory. The leaders affect their subordinates through
their own interactions and organization’s culture.13
Already in 1982 Arthur
Turner pronounced:”Prescriptive consulting is telling clients what to do,
facilitative consulting is helping them to do it for themselves. Clearly demand
for the latter is increasing” 14
.
Figure 1. Leadership principles and structures in organizations (non human=systems,norms)
was processes work without constant leadership (source: author)
11
Collins D. Strategic Change Vol. 11 (2002), p.81-93 12
Ringhouse B et al. Health Forum Journal (March/April 1999), p.33-37 13
Chen L. Journal of American Academy of Business, Cambridge, Sep2004, Vol. 5 Issue 1/2, p432
*where L=leadership models, M=management models and O=organization models 14
Turner A. Harvard Business Review Vol.60, no.5 (September –October 1982), p.120-129
Management
Leadership
Authority Position
Human
HRM HR Systems
Non-human/non
existant
Processes
7
Relationship conflicts in this dissertation are controversies in a scale from
differences to battles/riots in between nursing staff at Hospital District of
Helsinki and Uusimaa (HUS) and of different occupations. I use the term
conflict as Havansi, to be a controversy, that has a juridical element at least so
much, that is might “materialize” to overcome the in 2005 mediation law 3§
restricted mediation barrier – in other words to legalize. He describes three
main types of resolution: order from a third party authority,
recommendation/mediation result from a third party or resolution by the parties
themselves.15
Disputes are legalized conflicts and they may also have their
origin from one person, bad leadership or structures and/or processes. The third
party finds or moderates some of the following “resolution sources”: resolution
by law (text/interpretation), or when no law exist “according to the habits of the
land” or by “right and economical” (ex aequo et bono) or non-legalized other
methods than mentioned above.16
At this level of consciousness, we deal with
either unconscious individual driven conflicts or conflicts that have already
come up to the surface (later stage).
Facilitation in nutshell means ways to avoid unilateral control in
communications and management and a way to solve differences by
empowering and engaging people to take responsibilities for their own as well
as organizational actions and decisions. Leadership is an important – but not
sole factor – in generating or prohibiting and dealing with conflicts. Conflicts
should be everybody’s concern. Facilitative leadership makes this possible.
The structures – facilities and working environments – and decisions facilitation
are key ingredients of facilitative leadership. The opposite is evaluative
leadership, which gives credits and punishments and creates win-loose
situations.
Conflicts in an organization are found in humans and systems and they are
categorised into intra-individual, between individuals, processes and systems,
15
Havansi E. Conflict Management Vaihtoehtoista Riidanratkaisua vai Vaihtoehtoista Konfliktinratkaisua
(Alternative Dispute Resolution or Alternative Conflict Resolution) , edited by Lindfors H. Gummerus
Kirjapaino Oy,Saarijärvi 2005, p. 10 16
ibid. p.11
8
but also as hot (human) and cold (processes, systems) and according to the
circumstances for ex. health care conflict or inside/outside –conflicts or public-
private or formal-informal or rational-non-rational17
.
If the mechanism of conflicts is taken into account, one could divide the
conflicts into individual, organizational and inter-organizational. Researchers
argue that the commonest reaction of the organism to a conflict situation is to
look for a way out of the dilemma18
. This might thus turn out to build
innovative systems for dilemmas or then not, in which case the dilemma might
get worse.
The different leadership types look like having corresponding tooling factors in
mediation:
Transactional leader – cognitive mediation
Transformational leader – transformative mediation
Values-based leadership – could be almost any, but mostly humanistic, narrative
and transformative (this is however evaluative)
Charismatic leader (value based) – same as above, but in a preventive sense
Facilitative leadership – mediation should be at its best (non-evaluative)
(based on own observations and different mediation models, see Appendix
XV).
17
Kolb D. et al. Journal of Organizational Behavior, Vol. 13 (1992), p.320 (the three latter ones)
18
March J. et al. Organizations, Blackwell Publishers, second edition, 1993, p.132-133
9
Figure 2. Major conflict categories (source: author taken from different ones)
Everyone knows from our own working experience, that conflicts exist (also in
hospital working environment)19
. The personnel responsible (according to their
own due diligence of human resource) for the planning of disturbing behaviour
handling in HUS have said, that this has been a prolonged process that has been
going on forever20
. According to Deutsch, conflicts exist where ever
incompatible activities occur.21
The challenge is thus, to resolve these kinds of
behaviours that disturb the working environment.
Heuristics is an often used method for problem, and hence, conflict solving.
Most of the conflicts are resolved by references to regulations and/or by passive
waiting. Secondly, they are taken care of by the persons themselves and/or with
the help of a supervisor if a third party is consulted - sometimes (about in 5% of
the cases of third party consultancy)22
by the internal health care professionals
or ombudsman of working safety. A leader should be able to engage people
and to make them achieve goals together by the help of information and
19
for ex. Haraway D.et al. Hospital topics Vol. 83, No. 4 (Fall 2005), p. 16 20
Personal discussion with Cenita Blomqvist, 30.3.2009. 21
Deutsch M. The Resolution of Conflict Yale University Press, New Haven (1978) 22
Jameson J. Conflict Resolution Quarterly (2001), Vol. 19 no.2, p.177
Conflicts
Relational (hot)
Own
Others
Task (cold)
Systems
Process
10
experience (capacity and ability) transferred to a sustainable change of
behaviour in a complex world of organizations.
1.1.1 Organization
HUS takes care of the primary and special health care services of an area in
Uusimaa municipality (Helsinki, Espoo, Hyvinkää, Lohja, Länsi-Uusimaa,
Porvoo and Vantaa health care districts), which has about 1,7 million
inhabitants. They employ some 21 000 people in 20 hospitals. They have one
CEO and the management is taken care of a central administration, called Group
Administration and Administration of Supportive and Special Service Areas
and an Executive Board of 15 members23
.
There are two ongoing projects concerning also this dissertation of conflict
management, namely leadership reorganization and harassment management.
Working community mediation was done there by my colleague, the report of
which is in Appendix V. It was a case where three from the same clinic had
been bullied. They reached an agreement, but a lot of criticism was heard.
HUS would like to see new tools to handle conflicts. They have seen an
increasing amount of conflicts in their own working atmosphere survey and the
interviewed confirmed that observation. They said, that constant organization
changes (smaller than BPR) have been going on since 80’s and two years ago
was a new strategy for eight consecutive years started. No changes, that could
disturb the results are ongoing, according to them, although the leadership plan
is going on parallel to the survey.
Some nationwide projects for occupational health care are ongoing
simultaneously. There is a National Action Plan to Deduce Health Inequalities,
which has managing stress at work, induction and guidance to work as a
foundation tasks on its program. They have an equality program for the years
2008-2011 as well (MSAH 2008:21). The government has also started a
program for renewing the municipal and service structures (law 169/2007) and
gender and salary equality programs (law 609/1986; more in the pages of
23
http://www.hus.fi/default.asp?path=59,404,4024,5796, 27.3.2009
11
ministry of social affairs and health:
http://www.stm.fi/en/occupational_safety/wellbeing).
The continuous plans are also listed at the end of the MSAH 2006:8)24
.
According to the rapports and the HRM managers, these shouldn’t bias the
results of this dissertation work.
1.2 Aim
To find ways to minimize and handle conflict situations with non-juridical
methods. A whole organization can suffer, when system-, process-, between
personnel or individual conflicts arises and they cannot be totally avoided.
There are many reasons for these conflicts and, however, many other reasons for
a suffering organization. The causality would be nice to know, but since other
disturbing factors are always present, we have to be satisfied with the ones
revealed in the literature review and asymptotically come as close as possible.
1.3 Goals
The present way of working doesn’t help in minimizing the conflict situations.
The goal is to find a new way of working with conflicts, that doesn’t jeopardize
the present methods, but helps to turn around the increasing trend of conflict
cases.
24
http://www.stm.fi/c/document_library/get_file?folderId=28707&name=DLFE-3949.pdf, 15.5.2009
12
1.4 Challenges
The dissertation questions are:
What could be done to prevent conflicts to happen?
What could be done to conflicts?
How to manage the conflict solutions in organization?
With what methods are the conflicts solved?
Leadership is a must, especially with a group of people targeting to a goal. A
group of people brings another need into the picture, namely organizations and
thus hierarchy, which means that procedural and distributive justices have to be
agreed upon tasks leading to the targets and goals. “Managers appear to be a
major source of the behaviours that are presented as bulliers (Rayner 1997,
Einarsen 1996) which is not surprising as it is felt by many that bullying is
linked to power relationships (Adams 1992, Bassman 1992, Ashford 1994,
Crawford 1997)25
”. Conflicts don’t vanish, rather pop up, when managers try to
avoid them.26
Management teams need to discuss about how to manage `the
self´, conversations and relationships. These kind of teams can built cooling
systems at the individual, team and organizational levels over time. These
practices can be learned.27
It is not going to be easy to make a fully proven
(significant correlations between the parameters of causalities) case that some
type of leadership or organization structure works better than others on long
term and with certain type of situations and people. The understandings of
management development are diverse and the temptation is to follow this up
with a set of recommendations as to how these understandings might “inform
practice”. This is highly problematical. 28
There is for ex. no universally agreed
social network theory to begin with29
.
25
Cooper C. et al.(Edited) Well-Being in Organizations, John Wiley & Sons Ltd (2001), p. 71 26
Edmonson A. et al. Californian Management Review Vol. 41, No 1 (Fall 2006), p.7-8 27
ibid. p.25 28
Maby C. et al. Management and Leadership Development (2008) , Sage Publications, p.228 29
Kildurff M. et al. Social Networks and Organizations, Sage Publications Ltd (2003), p.64
13
If different stages of organization, leadership and management development
claim different approaches, the managers should be aspiring. Many methods in
place already (Appendixes 11-VI,XI-XVIII,XXI-XXIII), prevent or minimize
conflict situations. To get through the hierarchy in any big (bigger than SME)
organization, is challenging and they don’t have a good system in place to do
that in HUS. They don’t exactly know what is causing the problem and what to
do with it.30
The non-linearity of knowledge and trust, that you see in Figure 3
below, shows that it is a continuous process and depends on other things like
values as well.
Figure 3. Knowledge and trust in an organization context. Conflicts can happen anywhere
here. The direction of the arrow doesn’t have to be only clockwise. (source: author)
30
personal interview with Cenita Blomqvist, working safety manager, HUS 127.4.2009
Knowledge
Value
Revenue Relations
Understanding and trust
14
1.5. Limitations
Law is not the predominant mode of social control in organizations.31
This
dissertation includes only, what I call outside of court room conflict resolution
methods (see glossary) and in-house conflict handling. This doesn’t exclude any
kind of conflicts, although task conflicts are outside of the scope of this
dissertation by definition. Most often, they don’t exclude access to juridical
methods, if either part of the conflict or dispute wants to do so. The juridical
methods could be categorized into juridical and half-juridical (juridical methods
might also include alternative dispute resolution and half-juridical methods).
I restrict the interview work to HRM managers at HUS, where one
representative of nursing staff was from an acute clinic. For comparison
reasons, the literature review and research include other disciplines as well.
The focus being in the conflict handling, when conflicts already exist, restricts
areas like causes of them. Causes like change and leadership are also cures and
conflict handling occasions one can work with, which is why they are given
attention to. This limits the practical usability of this work as well as the
practical measures, which could be directed to a different handling of the
conflicts dependent on the different causes of them. We focus on the
relationship conflicts, whatever reasons, causes or sources they might have. This
is why I chose to limit the methods to non-juridical and facilitative.
31
Kolb D. et al. Journal of Organizational Behavior, Vol. 13 (1992), p.318
15
2. Planned methodology
2.1 Way of working
The whole HUS was chosen to represent the title subject, because of the
working and conflict handling experiences I had. They were so many in so
many different places, that an interview would have taken too long and to pick
up some representatives here and there would not be a representative sample of
the whole organization. Interviews are planned at the later stage, when we know
more about the survey. IY/MBA were chosen to represent a control group,
again, because I have had contact with them and hence the contacts made the job
easier. I could have interviewed them, but an interview by me, whom they
know, would not have been reliable and an interview by anybody wouldn’t give
us reliable results either, since the delicate matter is better to get unanimously.
A survey is more standardized than an interview, which makes it more suitable
for bigger samples. The two personal interviews were about experiences about
conflict management methods.
The interviews are done before the questionnaires, so as to able for adaptations
to the situations found in them. Only the group interview was recorded in
minutes. The others (Pehrman, Laitinen) were done through phone and
documented after they were finished. The IY/MBA questionnaire was
distributed through Survey Monkey® ASP-software over the Internet and the
HUS with Webropol® through their intranet. The questions were formulated so,
that it would reveal the methods by which the conflicts are solved now – not
what methods there might be for solving conflicts. By concentrating to those
methods that we know are working or not, is the point. On the other hand, I
didn’t want to rule new developments out totally, so there were open questions
one could use for that. Literature review might be able to shed some light in the
methods coming up in the future.
Literature review articles were first selected with the help of search words (see
2.1.2) and then according to the interesting subject, author or reference articles
and books on the areas that were interesting under those search terms found
16
from the primary selection. The methods are taken from the Saunders book
“Research Methods of Business Students”. From the previous experience I
knew about the Change Laboratory program in place of some Finnish Central
Hospitals and about SOPU (mediate by talking, sovittele puhumalla in finnish)
in use at Valio Oyj.
To be able to show the dependences and causalities with the literature research
and to do a research that could show the same in HUS and maybe something of
conflicts severity for the organization is planned in this work. To be able to do
these, claims a broad literature review and a selection of a sample, where people
have faced conflicts and want to do something to them.
2.1.1 Research Planning
An exploratory and partly explanatory survey was planned to nursing staff in
HUS and to a consultant company Itsenäiset Yrittäjät Oy (IY)/MBA students
from my own group. Both IY and MBA got a short presentation about the
conflict handling plan before the questionnaire. The presentation was about
conflict handling in general terms, not about health care. This way, I didn’t
have to explain the circumstances in the cover letter. The HUS form was
different, because of the continuance of that work, where as the others are
dropped off after this dissertation. There were some additional questions in the
HUS formula as well. Only HRM managers and CEO at HUS got a presentation
of the plan before the questionnaire and they were asked not to participate in it.
Approximately (not the same wording and choices) same questions were about:
how long a working career have you had
have you resolved a conflict yourself
how should the conflicts be solved (oneself/management/employees’
health care, working safety or a 3rd
party)
is there any good coming out of the conflicts
The questions were formulated together with a focus group of five of the same
administrative chiefs, with whom I did a descriptive interview about the present
situation (contextual data). The mixed method interview revealed straight away,
17
that there are conflicts in every group of workers and leaders and they have
already started planning for a new instruction booklet about bulling as well as a
plan to restructure the leadership. I could thus plan the questions to rely on that
fact.
HUS
The choice of unstructured, “disguise”, group interview was supported by the
short time left for the interview of HUS staff due to an in-house plan that
interrupted everything else at the administrative level of operations for two
months time. It was also supported by the size of the group and the aspects to
explore in conflict handling (being a broad view of their own work, conflict
frequencies and multiple types as well as the professionalism of the
participants). The way the interview was structured (non-interviewer dependent
and not informed to the participants) suits the facilitative way of working and
would hence open the access to sent the questionnaire more easily, than for the
interviewer to take the control. It also increases the reliability, when the
interviewer don’t steer it by asking linear questions. A method to come closer to
the workable certainty was used, which uses same kinds of questions than
mediation: circular and reflective. Due to the delay and already stated plans to
cope with it, the HUS HR group wanted to take part in every step of the way. It
is known, and studied in HUS, that hospital working environments in general
have a high conflict frequency so the literature research and the questionnaire
and interview is planned to take methods and new ways of handling conflicts
into consideration. Therefore most of the questions are of qualitative nature to
support the dissertation question of how to develop a method for conflict.
I needed additional background information (in addition to the Juha
Tykkyläinen’s report, Elke Suomi’s thesis, internet, media and my own
experiences from years ago and during the short planning period of the work
with Working Safety Fund and HUS), so an interview before designing the
questions for the questionnaire was scheduled. A group interview has the
advantage of recovering many points of view.32
The topic stays: conflicts and
32
Saunders M. et al. Reseach Methods for Business Students, Pearson Educated Ltd., Harlow (2007) fourth
edition, p. 339
18
their handling; no bias to take into consideration. I also interviewed the two
professionals who had experience on the Change Laboratory™ method HUS is
thinking of using.
The motivation for doing a qualitative research interview is threefold.
Firstly, there are many leaders, who seldom take the time to answer to a
large number of questions – in this case, those participating in the
interview, were even asked not to. Secondly, we need to do a lot of open
questions due to the explanatory approach. Thirdly, we would like to
know the causality and reasoning for their decisions.33
These antecedents
of a task, when given for ex. to a mediator, are clear in their simple
message, but leaves a lot outside of the scope: suitability to strategy and
vision, non-tangible and tangible resources recovery, cultural and other
challenges.
The questionnaire was planned so, that these research questions got answers as
well as the HUS plan a base for needs in conflict handling. The group
interviewees, the leading head doctor of HUS and communication director read
through it. It was sent via intranet to reach the whole personnel and the results
gathered the same way as for the IY/MBA group i.e. Sunday and the first three
working days of the week.
The preliminary, ”disguise” interview was meant to give a picture of the conflict
management in HUS and their thoughts of how to deal with it. While the
unstructured interview would reveal things about the situation without a goal
and minimized pressure, the structured would focus it more to the findings from
the unstructured. I used a mixed model of Interventive Questioning, an action
learning method a consulting company and a researcher had been using in the
Danish Lego. On the other hand, I was letting the participants steer the dialogue
as much as possible. Interventive Questioning uses four types of questions to
work through the problem and paradox to a workable certainty:
1) Linear questioning planned to reveal a more precise problem (didn’t use –
already a known situation of too high a conflict frequency)
33
ibid, p.310-328
19
2) Circular questioning to accentuate the intricacy of issues
3) Reflexive questioning to spur double-loop learning
4) Strategic questioning to get to the workable certainty
This was planned to help the hospital staff to go beyond their problems and
paradoxes. It became obvious from the first interview and the literature, that the
middle management was sensing anxiety and defensiveness, which is common
when implementing a change.34
The structure, actions and plans that HUS has, and is going to take, are taken
from the updated internet homepages35
, thesis work of Suomi E. and human
resource manager’s interviews. Here, the environment is built on the idea that
an argument of the characteristics of knowledge could predict the structure of an
organization36
. It is also stated, that organizational design would enhance
strategy.37
Thus, the organization structure is or should adapt to strategy and
knowledge characteristics. Both strategy and organization have been changed a
couple of years back.
IY/MBA
A questionnaire was prepared for these groups I’ve worked with. It was
sent to a consulting company Valmennustalo Itsensäylittäjät Oy
(Traineer’s House Self Overcomers Ltd, author’s translation) and MBA
students from my MBA course. By doing so, I might be able to get
manager’s and/or supervisor’s view with this questionnaire (this was not
separated from the HUS nursing staff – we only separate employees doing
patient work). The HUS staff will both openly comment on the foreman
position in conflicts and whether they have been using their help in
conflicts or managed them themselves.
34
Lüscher L. et al. Academy of Management Journal Vol. 51, No. 2 (2008), p.221-240 35
http://www.hus.fi and subsequent pages, 3.5.2009 36
Birkinshaw J. et al. Organization Science ; Vol. 13, No 3, May-June 2002, p. 274-289 37
Lowell B.et al. McKinsey Quarterly Issue 2 (2007)
Information
sources
What kind What
information
How gained Relevance
20
Table 1. Main sources of information
Tykkyläinen^= Member of the same workplace mediation group as I. Mediated with Zotow
in HUS conflict
HUS* = Same group as HUS “disguise” interview plus head doctor and communication
director
Pehrman**= Doctors thesis work, that I have taken part into. He works for Valio Oyj and has
developed SOPU (sopimalla ja puhumalla paras=best to agree and talk) method which is used
in Valio Oyj
HUS Qual./Quant. Conflict Survey Main research
source
IY/MBA Qual./Quant. Conflict Survey Management/control
Tykkyläinen^ Qual. Mediation Interview Optional method
HUS Qual. Planning Interview
meeting
Survey planning
HUS* Qual. Situational Interview over
phone
General information
and survey planning
Laitinen Qual. Situational Interview over
phone and
experience
Change
Laboratory™
Pehrman** Qual./Quant. Situational Interview and
experience
Mediation and
Change
Laboratory™
Suomi Qual./Quant. HRM Thesis work Main target
Vartia Qual./Quant. HUS/Conflict Literature Main research target
EBSCO Qual./Quant. Literature IP Main literature
source
Tenttu Qual./Quant. Literature IP, Books Whole dissert.
DOAJ Qual./Quant. Literature IP Non-mainstream
Research area
FinnWell Qual./Quant. Literature IP Health Care
TERTTU Qual./Quant. Literature IP Health Care
MSAH Qual./Quant. Literature IP Health Care
21
2.1.2 Literature Review Planning
Some 100 peer review papers were written about mediation (as title) before
1980 and approximately 1200 after that according to EBSCO and some 17 000
and 19 000 according to Google Scholar respectively (but not as title and peer
reviewed). I chose the year 1978 as the last to be taken with. Tenttu and DOAJ
databases and some referenced (here at least one time) books serve as a basis
points for this dissertation for peer reviewed, scientific journal articles with
conflict, relationship, facilitative leadership, health care and organization
structure as well as all of their combinations as search words. The internet
pages used are not peer reviewed to my knowledge. I’ve also had all of the
referenced books in my possession. I read the reports from The Research
Programme for Health Services Research (=Terveydenhuoltotutkimuksen
tutkimusohjelma, TERTTU)38
and FinnWell (two major ongoing plans - the
former the one the continuance of which this dissertation work hopes to be part
of through the Working Safety Fund). One of the five weaknesses according to
the MSAH rapport mentioned earlier, was the lack of good practices in
psychosocial issues.39
Search words in addition to the title words and the ones mentioned above are:
Other conflict expressions and connotations: Conflict free, Conflict less,
Bullying, Harassment, Dispute, Disagreement, Argument
Other leading connotations: Leadership
Other facilitative connotations: Evaluative
Other solving expressions: Resolution, Restoration, Conciliation, Prevention
The time period of 1978-2009 was also chosen based on literature coverage
(with a couple of exceptions for books). In 1978 Argyris et al. published their
book “Organizational Learning”, Burns his “Leadership” and at the same time
another to be published book started its voyage: in 1990 Senge P. published the
learning organization article (and the book “The Fifth Discipline”) and last but
38
http://www.uta.fi/laitokset/tsph/terttu/ohjelmamuistio/to_rahoitus.html (15.5.2009) 39
http://www.stm.fi/c/document_library/get_file?folderId=28707&name=DLFE-3949.pdf, (15.5.2009), p.75
22
not least Schwarz R. published the “Skilled Facilitator” in 199440
- the same
time 1994 Möller described the term employeeship the first time41
. The method
should be facilitative , so I searched through the EBSCO database for mediation.
All the more so, evaluative methods had been used at HUS and they wanted
something new.
I took only peer reviewed, scientific journal articles with, that had the search
terms as titles, abstract or subject terms to begin with and to get a picture of the
proceedings during the whole time period. I didn’t want to use non-peer-
reviewed articles, since peer reviewed add objectivity. I work and follow
(work, volunteer job and read) these branches also through other than peer
reviewed, scientific articles, however. The interviews with the HRM people
from HUS add to the sources and are also increasing the reliability and validity
in form of a bigger sample and concentrated experience on conflict
management. They, if someone, should be aware of the recent proceedings,
since it is their job and they are constantly (like at the present time) reviewing
their processes on conflict handling and leadership. Suomi’s thesis on HRM
shows this (see Appendix XIII). It is part of their strategy and a statement of
values that they take care of the working atmosphere.
2.2 Organizational Review
Health care has a special need for organizing itself efficiently – as it has both an
ambulatory and non-ambulatory work. Time limits the possibilities to lead and
manage these kinds of systems. They are often financed or at least partly
supported by government treasury. The customer’s value is often the most
valuable – life. Almost the whole staff is highly trained and educated and could
thus be described as an expert organization. HUS has a centralized background
and is trying to decentralize and to defractionize decision powers – special area
CEOs and HRM strategy being examples of that. The ultimate decisions lay in
the hands of the clinicians on patient’s treatments and the decisions on personnel
in the hands of department head nurses. The administrative leadership is run by
40
Senge P. Sloan Management Review Vol. 32, No. 1 (Fall 1990), p.7-23 41
Møller C. Empowermant in Organizations, Vol. 2 , No. 2 (1994),p.4-13
23
clinicians, but there is a tendency to replace at least some of them with
professional leaders.
Leadership powers, or should we say rights in this case, are thus diversified
Figure 4. Patient care is both the target and value that runs throughout the health
care organization although the ultimate decisions are made by clinicians (source:
author)
with the exception of the ultimate patient care that lies in the hands of treating
clinicians. This creates an overlap both in patient care and the staffing and
administration for the good of the patient care. The budget runs in 1.4 milliard
Euros and staff in 21 000. It consists of five district hospitals and one central
hospital within a serviced area of some two million inhabitants.
Patients Staff Adminstration
24
2.3 Management Overview
Management in HUS is divided like in a corporate to centralized administrative
processes and to special divisions of specialities for the rest. This has been
according to the media the biggest source of trouble. My own findings42
support
this: in 1991 management was not mentioned in media at all and by the 2008
the situation was changed to a constant debate.
The metrics used are based on economical measures. A working atmosphere
survey is taken almost annually (not always so) as well as some quality
measures. The performance of personnel is not measured directly. The
innovativeness, conflict handling, problem solving and social capabilities are not
monitored. Operative efficiency and development should be the key entities, but
they are only indirectly measured (capacity of treating patients and the length of
surgical queues). The automation and IT should at large be used for controlling,
cost calculations and streamlining the processes to help managing the
production and customer operations.43
I look at the leadership and management the same way as Roger Herman.
Leaders are those, who people want to follow and have as their leaders.
Facilitative leadership, according to him, is about assuring and
understanding of objectives, providing resources, coaching, teaching,
encouraging, measuring and giving objective feed-back. 44
Still, managerial skills are needed and they significantly influence the
performance of the firm45
.
42
Koskinen M. Diploma in marketing, Marketing Intitute (1991) 43
Lewis L. et al. Journal of Computer Information Systems (Summer 2004) p,16-26 44
Herman R. Employment Relations Today (Winter 2000), p. 73-82 45
Barth H Journal of Small Business Management; Vol. 41, No. 2 (2003). p. 141
25
3. Literature review
3.1 Execution
Literary review was done by the help of the advanced search possibilities
provided by the service providers, and after they were gathered to one file,
the search engines provided by the Windows® Office programs. The
abstracts, conclusions and discussions of each paper were read through at
least once to get an overview of the subject for the interviews,
questionnaires and literature review. A written rapport by Tykkyläinen
(Appendix V) about a mediation in HUS was included as well as thesis
about HRM in HUS (Appendix XIII) were used. As planned in
Organizational and Management Overview, leadership, which is missing
now, lead to the inclusion of them into the methods of conflict
management both in Literature Review and Research.
3.2 Conflicts
Why conflicts should be resolved
A lot of publications on the differences in conflict handling and methods in
health care and others have been published. 46,47,48,49
Simply put:”
Health care is a particularly humanistic environment, requiring higher levels of
relationship and functional interaction between and among the members of the
work community. The opportunity for conflict is accelerated by increased
intensity of interaction and human communication50
”. Conflicts are a source of
frictions in organizations.51
A study says that 30-42% of management times go
to conflict handling.52
Also salesmen take a hit of 1/6th
of their working time
going to conflict solving.53
Staff time loss of 20% has been reported in a health
46
Porter-O’Grady T. Health Care Manage Review, Vol. 29(4), 2004, p.278-283 47
Nelson W. et al. Journal of Health care Management, Vol. 53, January/February 2008, p.41-53 48
Slomka J. Hastings Center Report, March-April 2005, p.45-46 49
Dreachling J. et al. Health care Executive Nov/Dec 2006, p.9 50
Porter-O’Grady T. Health Care Manage Review, Vol. 29(4), 2004, p.283
52
Murtha B. Fairfield County Business Journal (2005), p.42 53
Bradford K. et al. Journal of Personal Selling & Sales Management Vol. XXIX, No. 1 (winter 2009), p.33
26
care publication.54
Also taken from health care, conflict produces organizational
stress and reduced well-being, helplessness and flight behavior.55
Not that I’m
concentrating on the drawbacks, rather exploring the predominant conflict issues
at large (more about it in for ex. Conflict Dialogue, Kellett P, 2006).
As for ex. Jameson states, mediation is not a broadly used conflict handling
method. According to him, the biggest hindrance is prejudice on its
functioning.56
. Another study mentions another likely explanation to be that
solving problems belongs to the role of the manager and they are not ready to
give up the responsibility to their subordinates57
. Mediation is also not generally
used to solve problems in Finland.58
It probably should, since Finland tops the
European Union countries of workplace bullying.59
According to a survey done
by The Finnish Forum for Mediation, Switzerland has used working community
mediation actively. They have some 30 private practitioners for that.60
The benefits of conflict handling for health care are well documented: better and
positive working environment that supports conflict discussions and reduces
stress61
, diminished, conflict related health problems62
, growing pre-social
behaviors63
as well as less occurrences of aggressive behaviors64
. The opposite
also applies generally to changes within relations in an organization (they are a
source of psychological morbidity, early retirement, increased job strain,
sickness absenteeism and injuries).65
The same has been shown about the
negative correlation of relationship conflicts on “employees’ attitudinal
54
Miller M. et al. The Physician Executive (July-August 1999), p.46 55
De Dreu et al European Journal of Work and Organizational Psychology Vol. 14, No.2 (2005), p113 56
Jameson J. Conflict Resolution Quarterly, Vol. 19, No.2, Winter 2001 57
Kolb D.M. et al. Negotiation Journal, Vol. 1, 1985, p. 379-388 58
Pehrman T. Valio Manager of development and training, preliminary results from his thesis work 59
Publication of the Ministry of Social Affairs and Health, Occupational Safety and Health Strategy, Follow-up
Report 1998-2007, Helsinki (2008), p. 19 60
Pehrman T. Valio Manager of development and training, preliminary results from his thesis work 61
Murphy L Trends in Organizational Behavior, Vol. Z,1995, p.1-14 and Haraway D. et al. Hospital Topics,
Vol. 83(4), Fall 2005, p. 11-17 62
Stokols D, Hostility, Coping and Health, Washington, DC:APA, 1992, p. 65-76 and McGabe D. Corporate
Nonunion Complaint Procedures and Systems, Praeger, New York,1988 and Shapiro D, Justice in the
Workplace, Hillsdale NJ, Erbaum, 1988, p.51-78 and Shapiro DL et al. Journal of Personality and Social
Psychology, Vol. 65, 1993, p.1167-77 63
Greenberg L. et al. Organizational Behavior, Wiley, New York, Vol. 3, 1996,p.49-64 ja Domenici K et al.
Mediation, Waveland Press, 2001 64
Greenberg L., Justice in The Workplace, Justice in the Workplace, Hillsdale NJ, Erbaum, 1993, p.79-103 ja
Shapiro D. et al. The Legalistic Organization, Sage, Thousand Oaks CA, 1994, p. 303-06 65
Saksvik P. et al. Work & Stress Vol. 21, No. 3 (July-September 2007), p.244
27
responses, such as satisfaction and commitment, employees’ psychological well-
being and affective acceptance of group decisions and further more they
increase group members’ stress and anxiety and job tension”66
.
Task to relationship conflicts
The same paper (Gamero) states with a help of a meta-analysis, that this doesn’t
apply to task conflicts, which have been shown to have negative, no effect or
even to have some positive effects on job satisfaction with group’s decisions and
a desire to stay in the group. They conclude that relational conflicts have more
negative effect than task conflict on job satisfaction. Further, some evidence was
found, that the task to relationship conversion happens, when a biased
information processing or self-fulfilling prophecy triggers it. This is more
pronounced, when the issues are serious and there is a potential of great personal
gain or loss. So, the negative effect of task conflict might be due to a
hidden/unnoticed transformation to a relational conflict. This task conflict effect
has been shown in a clinical medical department of 182 members67
. Their own
analysis showed that this applies for a team as well: a relationship conflict
mediates the positive relationship between task conflict and team tension and
negative relationship on team enthusiasm. Social interaction was shown to
moderate this so, that when it is high, the relationship is weakened and when
low enhanced.68
Relationship conflicts are shown to mediate the effects of value
diversity, which decreases satisfaction, intent to remain and commitment to the
group.69
De Dreu found that when constructive conflict management and
integrative negotiation yielded high joint value in the short run - innovativeness
decreased in the long run.70
However, it is not easy to distinguish between task
and behavior (read relationship conflicts) conflicts. Task conflicts increase
performance and behavior conflicts, central to bullying, decrease it.71
This
might help to differentiate them.
66
Gamero N. et al. Journal of Occupational and Organizational Psychology Vol. 81(2008), p. 50 67
ibid. p.50-51 68
ibid. p. 53-64 69
Jehn K. et al. Administrative Science Quarterly Vol.44 (1999), p.741 70
De Dreu C. Journal of Organizational Behavior Vol. 29 (2008), p. 7 71
Cooper C. et al.(Edited) Well-Being in Organizations, John Wiley & Sons Ltd (2001), p. 71
28
Bullying
The strongest predictors of bullying were found to be role stressors, social
climate and leadership behavior72
. Another group studying managers in teams
found that:”substantial conflicts erupt in management teams, dysfunctional
group dynamics followed by frustration and flawed decisions may be the rule
rather than the exception. Clearly, realizing the promise of teamwork at the top
requires finding ways to help management teams deal constructively with tough
conflicts”73
. They didn’t find silencing to work, but found that relationship
conflict handling could be learned. They argued, that organizations with
relationship conflict perform weaker, that those without. It might also be that
this is due to co-occurrence of task and relationship conflicts.74
I found two studies about bullying among municipal workers in Finland.
The other states that: “Bullying differs from ordinary ‘conflict’ since there
is generally a victim-perpetrator configuration, such that the person on
the receiving end feels unable to defend him or herself successfully. It is an
accumulation of many ‘minor’ acts amounting to a pattern of systematic
maltreatment”75
. The other paper found, that 10,1% of the ones, that
answered to their questionnaire (n=949) suffered from bullying. Envy, a
weak superior, competition for tasks or advancement and competition for
the supervisor’s favor and approval, were the most common reasons. Also
features in the functioning of the work unit were listed: poor information
flow, an authoritative way of settling differences of opinion, lack of
mutual conversations about the task and goals of the work unit and
insufficient possibilities to influence matter concerning oneself.76
A meta-analyze came into a conclusion, that 13 different studies have
resulted in a moderate and positive correlation between conflicts at work
and psychosomatic complaints. They also found studies of work place
72
Hauge L. et al. Work &Stress Vol. 21, No. 3 (July-September 2007), p. 224 73
Edmonson A. et al. Californian Management Review Vol. 41, No 1 (Fall 2006), p.6 74
ibid. p. 29,citing Jehn and Amason in Journal of Applied Psychology 85/1 (February 2000) 75
Salin D. Scandinavian Journal of Management (2008) doi:10.1016/j.scaman 2008.04.004, 18.06.2008. 76
Vartia M. European Journal of Work and Organizational Psychology Vol. 5, No. 2 (1996), p. 203
29
conflicts to correlate with anxiety, frustration and burnout.77
There have
also been contradictory findings about bullying. Einarsen states, that
bullying cannot simply be explained in terms of the personality traits of
those involved or of the situation78
.
3.3 What kind of methods are there to resolve the conflicts
Most often, the methods of choice are passive, like waiting for the problem
to solve itself avoiding contacts or prioritizing something else. “Each
source of conflict suggests a different approach, which ranges from
avoidance strategies, such as solution, cover-up, resignation, and
withdrawal, to engagement through negotiation, arbitration, and
compromise. Whatever the character of the conflict, it usually has three
primary components: emotions, verbal content, and procedure.”79 Kolb is
suggesting almost similar methods: self-help (force, vengeance),
avoidance (withdrawing from the relationship), “lumping it” (tolerance the
situation without public comment), negotiation, and the involvement of
third parties as mediators, arbitrators, and/or adjudicators.80
In Knowledge Intensive Business Services (KIBS), like HUS, we learn
through knowledge assets that have a paradoxal aspect: they must be
codified if they are to become an asset but once this happens, they lose
value. A mainstream definition of knowledge is the capacity to act and of
organization, that they are taken to be learning, knowledge-generating
systems of individuals interacting with each other in group/social contexts.
Individuals and contexts are two distinct phenomenological levels
interacting with each to form the whole system. It is then taken for
granted, that these must be managed. In other words, one has to manage
the individuals, who possess the tacit knowledge.81
People need
knowledge to act and that could be provided by education, which have
77
De Dreu C. et al European Journal of Work and Organizational Psychology Vol. 14, No.2 (2005), p112
citing Spector and Jex (1998) meta-analysis 78
Cooper C. et al.(Edited) citing Einarsen in Well-Being in Organizations, John Wiley & Sons Ltd (2001), p. 70 79
Arwedson I et al. Work, Vol. 28 (2007), p. 3-11 80
Kolb D. et al. Journal of Organizational Behavior, Vol. 13 (1992), p. 316 citing Black, 1987, Nader&Todd,
1978) 81
Stacey R. Complex Responsive Processes in Organizations, Routledge, New York and London, 2001, p.17-39
30
been shown to work in conflict resolving. They can benefit (holding at
least during one year follow-up) from even a short conflict resolution
training program.82
This was also supported by a study among nurses in
the U.S.83
Canadians did a three factor conflict resolution trial including
mediation and negotiation training and found out that all three worked
well, but negotiation training (on the top of the rights-based) only, didn’t.84
“Mediation has been advocated as an effective and fair method for
resolving disputes. Studies of mediation in simulated organizational
contexts suggest that people find it fairer and more satisfactory than other,
more controlled forms of intervention (Karambayya and Brett, 1989;
Lewicki and Sheppard, 1985, Sheppard 1984). Despite these desirable
attributes, recent research suggests that managers are not natural
mediators (Kolb, 1989a; Sheppard, 1984).”85
Methods for structure and context
The differences in goals, perceptions and feel for joint decision making are
the key players in intergroup conflicts. There are less perceptual conflicts
in an organization when less external sources of information exist (like in
medical care) and this also impacts the extent of conflict as the source
might be a homogeneous outside group. If we have autonomous
departments rather than decentralized, there will be more perceptual
conflicts. For a prediction one needs an explicit specification not only of
cross relationships, but also of their functional form and the values of their
critical parameters. March et al. came into a conclusion, that in restricted
resources situations the relations between individuals become strictly
competitive and as resources are reduced further, intergroup conflict tends
to increase. 86
82
Zweibel E.et al. Conflict Resolution Quarterly Vol. 25, No.3 (Spring 2008), p.321-350 83
Haraway D. et al. Hospital topics Vol. 83, No. 4 (Fall 2005), p. 11 84
Bendersky C. Industrial and Labor Relations Review Vol. 60, No.2 (January 2007), p.221 85
Kolb D. et al. Journal of Organizational Behavior, Vol. 13 (1992), p. 316 86
March J. et al. Organizations, Blackwell Publishers, second edition, 1993, p.140-149
31
Also, the organizations react to conflicts in four major ways: solving
problems, persuasion, bargaining and “politics”. The disagreements over
goals are fixed in bargaining and less fixed in “politics”, but not in
persuasion or problem solving where there is reliance on information
gathering. On the top of that, persuasion uses testing of sub goals for
common goals and evoking relevant criteria. The use of politics within the
organization solves intergroup conflicts. The difference in the use of
solving conflicts is either on analytic processes in problem solving and
persuasion (individual rather than intergroup conflicts) or on the other
hand bargaining in bargaining and “politics”. One of the problems with
bargaining is acknowledgement and legitimating of heterogeneity of goals
and that it almost necessarily places strains on the status and power
systems in the organization. Therefore an organization will perceive all
conflict as individual rather than intergroup and hence, as problems in
analysis. They argue that neither psychological nor sociological research
has provided assumptions to generate solutions to two person and n-person
cooperative games.87
I also looked for evidence for a theory in social
network for this in other publications used in this dissertation and found
none.88
There is however an Intractable Identity Conflict Resolution
Model (Appendix XVII) that rely on the social and organizational identity
“theories”. A Midwestern hospital conflict with broad consequences was
an example in this study. Physicians couldn’t cope with administration –
characteristics, that could be from HUS as well. The Mode is a four
phases, sequential identity change method.89
Suggestions where to look
for conflict methods are many; like one example: take compromising angle
together with problem solving angle with in all conflict handling90
. These
kinds of methods multiply the amount of methods by using basic methods
and adding something to them.
87
ibid, p.150-151 88
for ex. Kildurff M. et al. Social Networks and Organizations, Sage Publications Ltd (2003), p.64 89
Fiol C. et al. Academy of Management Review Vol. 34, No. 1 (2009), p.32-55 90
De Dreu C. et al. Journal of Organizational Behavior Vol. 22 (2001), p. 665
32
3.3.1 Leadership as a method
There are many models for the leaders to follow. The most recent ones entering
this arena have been knowledge based (information management), values based
(part of which is facilitative), coaching and shared managing systems adapted to
many organization models. Knowledge elicitation is a process of assisting
others to generate their own knowledge. 91
By knowledge based leadership, one
does not, hence, refer to the old management style of managing by holding on to
pieces of information and let others pay for it. They all work together for a
better outcome than a single system - or would it be better to find own way
around. The form in this case could look like: L x M x O* = different
possibilities (result is more than the sum of parameters). When different
circumstances and ways to analyze these are taken into account, the job of
finding a right structure in every situation would be a challenge.
As management (for ex. by Kotter) is described to bring order, consistency and
quality, leadership is about preparing the enterprise for change and helping
employees cope as they struggle through it92
; I chose leadership to these
methods of conflict handling.
91
Dawson R. Developing Knowledge-Based Client Relationships, Butterworth-Heinemann, Boston (2002), p.17 92
Mabey C et al. Management and Leadership Development, Sage Publications Ltd (2008),p.29
33
Figure 5. Hierarchy suggestion of the leaderships based on learning
organization. (source: author) Visionary and spiritual leaderships might be
included in every one of them (with the exception of Laissez-faire).
Relatively little is found on the interactional effects on job stressors and
bullying. According to a publication from Norwegian researchers
(Einarsen et al.), who has published many papers on conflicts in working
conditions, they found only three - theirs and one from Vartia M. and
Vartia M. et al. They showed, that role conflicts, interpersonal conflicts
and tyrannical and laissez-faire leadership behaviour are strongly related to
bullying. “Support was found for an interactive relationship between
decision authority and role conflict at different levels of laissez-faire
leadership. Hence, bullying is likely to prevail in stressful working
environments characterized by high levels of interpersonal friction and
destructive leadership styles.” They found also, that supervisors role in
intervening and managing stressful situations is particularly prevalent.93
A
hierarchic system together with responsibility and eagerness to help others
creates a conflict prone combination, in which management have a
93
Hauge L. et al. Work &Stress Vol. 21, No. 3 (July-September 2007), p. 221
Shared
Facilititative
Coaching
Value-Based
Knowledge-Based, Process-Based
Consultative
Servant
Entrepeneur
Motivational
Self
Authentic
Laissez-faire
34
significant role.94,95
A lot of evidence speaks for active participation on the
job to be associated with better worker health.96
In the U.S. the Joint Commission of Accreditation of Hospitals has pre-
published standards that require health care organizations to have specific
process to address impaired physician behavior. The leaders
must proactively create high-performance work cultures that enable
talented professionals to realize their full potential, which is limited by
disruptive behavior. This policy is seen as one of the organization-wide
initiatives the administration has to take into account. They have found
that most bullies (72%) are bosses.97
The symptoms of bullying might not all be easy to notice: “verbal or
physical attacks, excluding or isolating from the peer group, taking away
responsibilities or devaluating one’s work and efforts, social isolation and
exclusion exposures to teasing, insulting remarks and ridicule98
”. The
same symptoms mentioned in the publications in the conflict chapter
(3.2.1.). They continue by stating that bullying is not an either-or
phenomenon, but a gradually involving process. The supervisors are
found to be the most frequent perpetrators of bullying, role and
interpersonal conflict and leadership behaviour are the strongest predictors
of bullying99
.
Role conflict is not only a challenge for leadership. When identities are
implicated in a conflict, the conflict tends to escalate, encompassing an
ever-widening number of issues. Parties then become trapped in an
ongoing conflict spiral from which they have difficulty extricating
themselves.100
Some nine parameters (attributed charisma, idealized
influence, inspiring motivation, intellectual stimulation, individualized
consideration, contingent reward, manage-by-exception passive, manage-
94
Nelson W. et al. Journal of Health care Management, Vol. 53, January/February 2008, p.41-53 95
Dreachling J. et al. Health care Executive Nov/Dec 2006, p.9 96
Deutsch S. Labour Studies Journal (Spring 1981), p. 128 97
Martin W. Hospital Topics Vol. 86, No. 3 (Summer 2008), p. 22,26 98
Zapf D. et al. European Journal of Work and Organizational Psychology Vol. 10, No. 4 (2001), p.370 99
Hauge L. et al. Work &Stress Vol. 21, No. 3 (July-September 2007), p. 224, 234 100
Fiol C. et al. Academy of Management Review Vol. 34, No. 1 (2009), p.32
35
by-exception active and the non-leadership dimension of Laissez-Faire)
were measured for subordinate resilience association. They found the
latter three not to correlate, rather the opposite, and inspiring motivation
not to have a positive effect. The participants were asked a question of
how they managed the situation. Those indicating help from their
managers had better resilience. 101
Facilitative leadership activates the participants to a joint leadership force.
Everyone leads something. One has to carry some strength and means of
intercourse in a facilitative working environment. One of the metaphors
that come into mind is power. “Power within dialogic is seen as relational
and rooted in discursive practices, thus not amendable to being ‘held’ as
possession by any particular individual or group. In contrast, both power
and knowledge within the critical perspective are indeed conceptualized as
possessions. These are possession that can be exploitative in the hands of
dominant but which also have the potential to be emancipatory in the
hands of the oppressed. “102
The relation of management and labour in processes has gained ground
since Braverman’s Labour and Monopoly Capital (1974). Kauppinen T.
has also published a book on a good employee and has thus contributed to
a Finnish view of management labour relations. Critical Disclosure points
out this dualism (for ex. individual/collectivism) and “embrace
‘reflexivity’ which extends the notion of critique to one’s own knowledge
and truth claims. This requires that all those involved in the development
of managers (including managers themselves) be constantly and critically
aware of their own presuppositions, values, motivations and social
positioning.”103
I presume that “all those involved” refer to operational
workforce as well and “social positioning” to all social hierarchies. The
Labour Process Theory (see Appendix XIV) assumes an inherent power
imbalance which creates the structural tendency for antagonism between
101
Harland L. et al. Journal of Leadership and Organizational Studies Vol. 11, No.2(2005), p.2 102
Mabey C. et al. Management and Leadership Development, Sage Publications Ltd (2008), p. 131 103
ibid. p.127-128
36
labour and capital. The broad areas of Critical Disclosure to management
development can be divided according to the following broad areas104
:
• Power, control, resistance and
• Ideology critique
o of specific or ‘micro’ development initiatives
o wider-scale discourses
• Critical management pedagogy
o emancipator action learning
o reflections on attempts to critically educate managers
De Dreu on the other hand has suggested that handling relationship
conflicts in teams are best done by avoidance rather than collaborating or
contending. 105
3.3.2 Organizational Change as a method
There is no one, all-encompassing, broadly accepted theory of
organizational change and there are no agreed guidelines for action by
change agents106,107
. Resistance is not necessarily a result of poorly
managed change implementation; it is merely an expected human
response. On the top of this, good health care organizations (at least in the
U.S.) are found particularly difficult to build108
. If this resistance is
brushed aside as being “irrational”, it can make bad matters worse. The
concept of resistance is by definition synonymous with conflict, and it
implies disagreement either about the change content, the change process,
or both. Through the use of constructive conflict, the employees will be
more adaptable and flexible as they feel more involved during the process.
A sense of active participation and the acceptance of expressing one’s
104
ibid, p.139 105
De Dreu C. et al. Journal of Organizational Behaviour Vol. 22 (2001), p. 309 106
Dunphy D. Human Relations Vol. 49 (1996), p.541 107
Saksvik P et al. Work & Stress Vol. 21, No. 3 (July-September 2007), p.244 108
Tucker A. et al. California Management Review, Vol. 45 (2), Winter 2005, p.55-71
37
views imply a feeling of control and influence, and lessen the chances of
feeling victimized and ignored during the change process.109
Stress (could be a cause of change) have also been shown to have a
negative effect on bullying. The researchers conclude by referencing
Leymann (1996) and Zapf &Einarsen (2003), that “if the management of
organizations avoids or neglects its inherent responsibility to adequately
address stressful work conditions, this may be a particularly high risk
situation in terms of the development of bullying at work110
”. Role conflict
and role ambiguity needs to be addressed as soon as possible, since it has
consequences for the change implementation per se, for the work group
and for the individuals.111
Jimmieson et al claim that, if the employees have control and a sense of
prediction and understanding about impending organizational change
implementation, they are more likely to appraise the situation.112
According to Morsing, organizational culture, that encourages constructive
conflicts ,will create an enhanced ability to change. 113
Saksvik concludes
that awareness of norms and diversity, early role clarification, manager
availability and the use of constructive conflicts to cope with change were
indentified in his study to minimize conflicts.114
The less conflicts there
are the more likely the partners are to have confidence for each other in
time.115
Wheatley is recommending free dispersal of knowledge, delegation of
authority, individual empowerment, network of relations and continuous
organic change of the organization.116
109
ibid, p.255 110
Hauge L. et al. Work &Stress Vol. 21, No. 3 (July-September 2007), p.237 111
Saksvik P et al. Work & Stress Vol. 21, No. 3 (July-September 2007), p.255 112
Jimmieson N. et al. Journal of Occupational Health Psychology Vol. 9 (2004), p.11-27 113
Saksvik P et al. Work & Stress Vol. 21, No. 3 (July-September 2007), p.255 citing Morsing 114
ibid., p.256 115
Bayer S. et al., System Dynamics Review Vol. 22, No. 3, (Fall 2006) 116
Czajkiewics Z. et al. Economics and Organization of Enterprise Vol. 2, No.2 (2008), p.9 citing Whealey
38
Visionary leadership is called for to motivate professionals in demanding
environments (what they call the edge of chaos=state where complexity
absorption and reduction take place) and overcome reluctance to share
knowledge. Dialogue, as a special form of relating, is to be used as a tool
to develop knowledge.117
Spiritual leadership goes beyond dialogue and
works with facilitating their feelings of completeness and joy working
together.118
These forms of management control are linked to calls for a
shift in organizational design from hierarchical structures to network
organizations consisting of webs of self-managing professionals with
shared interests and common values. These kinds of systems are based on
dual theory:
-Rationalist teleology, which basically holds that the cause of human
action is human motivation expressed in autonomously chosen goals and
means of achieving them, arrived at through rational reasoning expressing
ethical universals
-Formative teleology, which is a systemic theory of causality in which a
system unfolds patterns of behaviour that are already enfolded in its
structure in movement to a mature state that can be known in advance 119
Learning
Action is a choice made on the basis of knowledge and that knowledge is
evaluated in the light of the consequences of the decisions and actions it
leads to. This is a systemic, error-activated notion of learning. 120
Argyris
and Schön made notions of single and double loop learning, which means,
that Model I is a debating mode in which they seek to win and not to lose
and in which they withhold information and is a loop without a loop of
dialogue, which exist in Model II.121
Learning and knowledge creation
becomes shared routines that are stored in the form of culture, social
structure organizational procedures, traditions, habits and norms. This
higher level consists of sets of shared assumption, beliefs and behaviours
which are internalized by individuals as part of their individual mental
models. Stacey calls this mainstream theory of learning (that is a systems
117
Stacey R. Complex Responsive Processes in Organizations, Routledge, New York and London, 2001, p.25 118
Pawar B. Leadersip&Organization Development Journal Vol. 29, No.6 (2008), p.544 119
Stacey R. Complex Responsive Processes in Organizations, Routledge, New York and London, 2001 120
ibid. 121
Argyris C. Academy of Management Learning and Education Vol. 1, No. 2 (2002), p.206-218
39
theory). There has been shown, though, that knowledge is also created in
stories a community of practitioners tell each other122
. This has been used
for ex. in Anu Kajamaa’s dissertation in health care professionals at Oulu
University Hospital.
Hindrances for our learning tends to hold on to unilateral control,
maximize winning and minimize loss, suppress negative feelings as well
as trying to be as “rational as possible in a situation. 123
A cure for
unilateral control has been found in bilateral control: heedful interrelating
is a missing link between trust and performance124
.
Boisot things that people are information processors, who pay an
evolutionary price for complexity production, where complexity is an
increase in data.125
Stacey concludes:” that knowledge is the act of
conversing, and learning occurs when ways of talking and therefore
patterns of relationship, change. The knowledge assets of an organization,
then, lie in the pattern of relationships between its members and are
destroyed when those relational patterns are destroyed. This begins to
suggest very different ways of thinking about what it might mean to
‘manage’ knowledge in an organization.”
Olson et al. says, that “every strategy needs different combinations of
organization structures and strategic behaviours for success126
”. The
changes may come from internal- or external sources, but must be
compensated by simultaneous changes in organizational structure. But, as
P.Duncker said: “the core is innovativeness and marketing” and Vargo and
Lusch said:”skill and knowledge is all you need”.
122
Stacey about Lave, Wenger, 1991,Brown and Duguid, 1991, in Complex Responsive Processes in
Organizations, Routledge, New York and London, 2001, p.36. 123
Argyris C. Reflections Vol. 4, No. 2 (Winter 2002), p.8 124
Biljsma-Frankema K. et al. The Internal Journal of Human Resource Management Vol. 19 No. 1(January
2008), p. 19-20 125
Stacey R. about Boisot M. (1998)Knowledge Assets:Securing Competitive Advantage in the Knowledge
Economy, Oxford University Press, Oxford in Complex Responsive Processes in Organizations, Routledge, New
York and London, 2001, p.22. 126
Olson E. et al. Journal of Marketing; Vol. 69 (2005), p. 49
40
There are two ways of making up the knowledge management strategy,
namely codification and personalization. When codification is used,
technocratization is the only way to structure the organization.127
When
personalization is used, one can also use centralization, which means, that
decentralization needs decentralization of knowledge management. HUS
uses codification, but is not technocratizised (and cannot be, authors note).
One could add that this applies to mediation as well. The mediators use
this, when they steer the dialog into affective or fact based.
Of the organization studies the 7-S’ are applied here. When making the decision
to intervene in conflict resolving:
1. Strategy
2. Structure
3. Systems
4. Skills
5. Staff
6. Style
7. Super ordinate goals128
are to be taken care of, since task conflict can be used for the benefit of the
organization and some are better to discuss through some to neglect.
When the cultures collide, one should also compare some of these key
characteristics and avoid resistance and challenges in change management by
taking these into account proactively. If the cultural differences are big and
products are complex, one should have trust and flexibility as a goal and stay
away from process control, which is counterproductive.129
Right kind of
control, on the other hand, might be beneficial. Diversity in a sense of
demographical and cultural differences and powers to foster innovation and
problem solving, has been shown to benefit organizations130
, but to be one of the
greatest challenges as well131,132,133
. Jehn has recently revealed some of the
mysteries in conflicting results on diversity:” It is the diversity associated with
127
Liao Y-S. International Journal of Management Vol. 24, number 1 (March 2007), s.53-60 128
Pascale et al. McKinsey 1981 129
Solberg C. Journal of International Marketing Vol. 16, Number 3 (2008), s.57-83 130
Orlando R. et al. The International Journal of Human Resource Management; Vol. 17 (2006), p.2091-2109 131
Bryce D. Harvard Business Review (May 2007), 87-92 132
Pascale et al. McKinsey 1981 133
Fiol C. Academy of Management Review Vol. 221, no.4 (1996),p.1012-1021
41
values, and not social category that causes the biggest problems in and has the
greatest potential for enhancing both workgroup performance and morale134
“.
Conflicts tend to silence people and measurements have to be taken, if
innovation is needed. The cultural differences by nature take more resources
than homogeneous structures, but there is a lot to gain. It can very well be that
diversity is the only and the most important activity parameter on this century135
.
The same researchers that pointed out the problems that developments
bring into organizations came up to the conclusion, that we should “see
through the dominant Discourse/discourses to which we are exposed to
and might thus be able to reflexively form a personal and subjective
judgement as to where we stand on the issues this rises” 136
.
De Dreu and others have recently pointed out, that the positive effects of
conflicts that could take place in narrow circumstances in organization are
easily outperformed by the negative ones.137
They also found in a study of
27 partly-autonomous teams, that collaborating and cooperating works
with task conflicts whereas relationship conflicts are better to leave as they
are.
3.3.3 Summary of Literature Review
Relationship conflicts hurt commitment, satisfaction, psychological well-
being, acceptance of group decisions and are a source of stress, anxiety
and tension. The meditative effect might be moderate or high. It is
mediated through value differences among other things. Help from
leaders are needed to fix roles and leadership challenges to avoid value
diversities. Silencing conflicts didn’t work, although it is mentioned (for
ex. by Arwedson and De Dreu) as one of the conflict management
methods (among negotiation, arbitration and compromise – Kolb adds self
help and some other third parties). The origin might be also task conflicts
turning to relationship conflicts while left unattended. A Finnish study
134
Jehn K. et al. Administrative Science Quarterly Vol.44 (1999), p.758 135
Wheeler M. Harvard Business Review (March 2005) p.S1-S6 136
Maby C. et al. Management and Leadership Development (2008) , Sage Publications, p.228 137
De Dreu C. et al. Journal of Organizational Behavior Vol. 22 (2001), p. 309-328
42
revealed this to be a problem in HUS138
. They had weak superiors,
competition, poor information flow, authoritative way of working, lack of
communication on mutual visions and they could influence matters
concerning oneself. Psychosomatic complains are shown to correlate with
conflicts.
Heedful interrelating is proposed to be a missing link between trust and
performance139
. The demand of control is elementary to an organization
and among others Merton, Sleznick and Gouldner has made models of it.
Merton emphasizes rule as a response to the demand for control and
Selznick delegation of authority and Gouldner the use of general and
impersonal rules regulating work procedures in part of the response to the
demand for control from the top hierarchy.140
It has also been found that
control (felt by the study population) is a mediator of psychological
ownership to a job and an organization and there is a positive correlation
in between them. 141
Further, a narrow managerial span of control
(MSOC) positively correlates to gender diversity142
providing further
evidence of heed as a missing link between trust and performance.
Recently in German a research group claimed, that in leader-member –
relation, the member “needs” support to feel the well-being at job.143
A
sort of control was also used in a longitudinal study in a health care setting
of elderly care, were 188 workers answered a questionnaire on a
transformational leadership environment. A positive effect on their well-
being was found, when leadership had a feed-back loop to help the
employees to perceive their work in a transformative manner.144
138
Vartia M. European Journal of Work and Organizational Psychology Vol. 5, No. 2 (1996) 139
Biljsma-Frankema K. et al. The Internal Journal of Human Resource Management Vol. 19 No. 1(January
2008), p. 19-20 140
March J. et al. Organizations, Blackwell Publishers, second edition, 1993, p.55-63 141
Pierce J. et al. Journal of Social Psychology Vol.144, No. 5 (2004), p.507 142
Richard O. et al. International Journal of Human resource Management Vol. 17, No. 12 (December 2006),
p.2102 143
Schyns B. et al. Leadership & Organization Development Journal Vol. 29, No. 7 (2008),p.631-646 144
Nielsen K. et al. Work & Stress, Vol. 22, No. 1 (January-March 2008), p.28
43
Framework of facilitative leadership:145
Valuable information
Free and informed choice
Internal commitment
Compassion
This becomes reality:
Test assumptions and inferences
Share all relevant information
Use specific examples and agree what important words mean
Explain your reasoning and intent
Focus on interests not positions
Combine advocacy and inquiry
Jointly design steps and ways to test disagreements
Discuss undiscussable questions
Use decision making rules that generates the commitment needed146
The change and conflict (resistance) antecedents resemble each other,
which suggest that they are related. Change becomes easier when these
above mentioned facilitative methods are in use and roles defined in time.
Constructive conflicts might help in change and some leadership models
(for ex.visionary, facilitative, spiritual, self are participative) could
enhance it. The power of expert service-entrepreneurs is humanity147
. As
one group says this:”We cannot build a company that fits for the future
unless we built the company that fits for the human beings. Only human-
friendly organizations can win, develop and compete. Like Porter-
O´Grady said, the job of health care professionals is very human and he
suggested a conflict resolution program with mediation for the whole staff.
145
Schwarz R. The Skilled Facilitator: A comprehensive Resource for Consultants, facilitators, managers,
trainers and coaches, San Francisco (2002), Jossey-Bass 146
http://www.schwarzassociates.com/files/229.pdf, 12.4.2009 and Moore T. Library Trends Vol. 53,
No. 1(Summer 2004), p. 231
147 Pietiläinen T. et al. Tiedon kauppiaat (Knowledge Sellers), WSOY (2007 ) first edition, p. 258 translated
from Asiantuntijapalveluyrittäjyyden voimavara on inhimillisyys
44
A mediator should always be available.148
Consequently, trust is the
attention as trust is the core element of all human being relationships.” 149
Leaders have to manage the reciprocity and transitivity in social networks
and this cannot be a one man responsibility. Everyone has to be a leader
in its own rights. Knowledge and emotions are tied together through
believes or assumptions, they are the first indicators of change and
constitute thus a lot of useful knowledge to back-up business decisions150
.
Stacey handles knowledge as Sveiby – it has to be turned into action (see
Organizational Change).151
Mabey has pointed out the power and
knowledge dimension of them as possessions. There is need for organic
change since knowledge is created in stories community practitioners tell
each other and on the other hand we (according to Stacey and Boisot)
seem to be victims of an evolutionary process of information flow and pay
the price of complexity for that. Knowledge is a process and conflicts are
highly contextual, which many mediators pay attention to. 152
Conflicts
affect the emotional atmosphere and break cooperational working
relationships.153
People learn better through emotions154
, which could
mean that by facilitating knowledge and emotions and conflicts
performance should follow. Education at least for middle management in
a form of mediation and negotiation training is motivated.155
Mediation
has been shown to work, but managers might not be natural mediators and
need education.
148
Porter-O’Grady T. Health Care Manage Review, Vol. 29(4), 2004, p.281 149
Czajkiewics Z. et al. Economics and Organization of Enterprise Vol. 2, No.2 (2008), p.9 150
Pietiläinen T. et al. Tiedon kauppiaat (Knowledge Sellers), WSOY (2007 ) first edition, p. pages 216,217 and
221 that refer to Martha Nussbaum Upheavals of Thoughts, Cambridge University Press (2001).Freely
translated from Nussbaum: translated from Asiantuntijapalveluyrittäjyyden voimavara on inhimillisyys
,rakentaa tunteiden ja tietämisen yhteyttä uskomusten kautta. Tunteminen on tietoista ajattelua nopeampi keino
tunnistaa ymäristön muutokset.Tunteet sisältävät paljon käyttökelpoista tietoa liiketoiminnan
päätöksentekotilanteissa. 151
Stacey R. Complex Responsive Processes in Organizations, Routledge, New York and London, 2001
p.223 152
for ex. Isaacs H. The CPA Journal (September 1999), p. 52 153
Pietiläinen T. et al. Tiedon kauppiaat (Knowledge Sellers), WSOY (2007 ) first edition, p. 232. Freely
translated from Ristiriitatilanteet vaikuttavat tunneilmpiiriin ja rikkovat yhteistyösuhteita. 154
Hart J. Modern Eclectic Therapy (1983), Plenium Press, New York 155
for ex. Bendersky C. Industrial and Labor Relations Review, Vol 60, No.2 (January 20027), p.221, Zweibel
E. et al. Conflict Resolution Quarterly Vol. 25, No.3 (Spring 2008), p.321-350
and Haraway D. et al. Hospital topics Vol. 83, No. 4 (Fall 2005), p. 11
45
Of relevance to HUS is the notion, that autonomic departments mean more
perceptual conflicts where as lack of resources, intergroup conflicts.
Politics help for the latter, but organizations have a tendency to perceive
conflicts as individual and use analytic methods (more suitable for private
conflicts) to solve them. Bargaining used for intergroup conflict
management can cause legitimating of goals heterogeneity and thus strains
in power systems (read problems of leadership). This is shown with
tyrannical and Laissez-faire leaderships and interpolated into “milder”
forms. Health care is prone to conflicts due to a combination of
interactive systems and responsibilities and eagerness to help among staff.
Supervisor role is prevalent. They should show attributed charisma,
idealized influence, intellectual stimulation, individualized consideration
and contingent reward. Active participation is a remedy for better worker
health.
Reliability
In many cases the findings were done by at least two independent
researchers or groups. Some lack of hospital nursing staff data was
apparent, but I found the major ones and the plans of TERTTU and
TEKES had similar findings, although the TEKES FinnWell is working at
the high political level and is not finished yet. The publications were peer
reviewed academic journals and the books from well known sources and
cited at least ones in the papers. Five different sources were used for
literary review to add to the reliability. I tried to use meta-analysis and
different sources from different cultures when possible. Also the number
of citations was a criterion to choose – the more the better and more likely
to be used in this dissertation. However, conflict resolving, being a new,
cross-scientific and innovative branch of research, needs more since
innovative ideas might come firstly from unknown sources. I took a wide
look at the papers and read the abstracts, conclusions and/or discussions in
over thousand of cited and not cited papers. The DOAJ is a source of such
publications.
46
Validity
The nature of human actions in such a complex context as conflict
situations hospitals is almost impossible to comprehend. I looked for
theories, which are usually better formulated and wider than hypothesis of
a couple of parameters of situations. When I found an observation in a
paper I also searched for its counterpart (like conflict – conflict free) to get
hold of the causalities. The papers and books were all from the recent time
period after the major findings in organizational learning. The conflict
resolution programs are relatively new to the health care system.156
I also
found a couple from Finnish hospitals and from HUS, which comes
culturally closer to the interviewed material. The works of Yrjö Engstöm,
Juhani Aer are not ready, but Elke Suomi’s has already been published.
Both a personal interview with a pioneering hospital director Dr. Päivi
Laitinen157
and with Timo Pehrman158
convinced, that the Change
Laboratory doesn’t have a significant effect on conflicts at least not in a
couple of years perspective. Juhani Aer is not ready with his work with
the clinic of psychology and that could be used in this dissertation work
either. I could have improved the validity by concentrating on the hospital
context only, but then the reliability in such a small material would have
been jeopardized. I have my experience to thank, that I could choose the
right papers in the second view (after the initial filtering with the databases
with their search engines).
156
Porter-O’Grady T. Health Care Manage Review, Vol. 29(4), 2004, p.283 157
Telephone interview with Dr. Laitinen on the 7.11.2008 (they have used Change Laboratory since 2004) 158
Interview with MBA Timo Pehrman on the 19.5.2009 (have familiarized himself with Change Laboratory
through literature and interviewed HUS personnel)
47
4. Research
4.1 Execution of Research
The interviews had two most important questions embedded into five to
secure, at least partially, the repeatability of them. It is unlikely that an
interview, not revealed to be an interview and questions that doesn’t just
include those answers are critical for the work, would steer the answers.
The questioning was carried out at the same timeframe and by the same
interviewer. The semi-structured (with a theme), group interview is rich
of facts, perceptions, feelings and opinions159
, which would be of help in
this work with conflicts. The group interview is better than separate ones
since the theme doesn’t hold from one situation to another and could
disturb the results. Also an action resource spiral of the kind Saunders
show in his method book is possible throughout the interview.160
The
group helped to formulate the questions for the questionnaire buy
circulating the proposals through the different leaders and managers –
some of them a couple of times. I worked with the interview the Working
Through the Paradox method in mind to make it clear that we have gone
beyond the problem and have something comprehendible in my hands.161
A “disguise” interview was done with a group of HRM managers. It was
agreed that I’d prepare the minutes. Everyone invited could attend. I had
chosen a manager from every HRM area. The atmosphere was open (also
because it went under the “disguise” name of informal coffee break
meeting for looking at different options to work out the plan for the bigger
plan of Working Safety Fund/HUS research) and relaxed. It went well
and discovered that there were an increasing amount of conflicts. I did
have to interrupt the proceeding discussion once, when one of them hadn’t
said anything yet.
The HUS questionnaire was sent to all in direct patient care working nursing
staff, but the self-selected random samples was prematurely agreed to represent
those answering within the first four days (from Sunday on) of total nursing staff
159
Greiner L. et al. Consulting to Management (1983) Prentice_Hall Inc., Englewood Cliffs, p. 220 160
Saunders M. et al. Research Methods for Business Students, Prentice Hall, Essex (2007 ) fourth edition, p.141 161
Lüscher L. et al. Academy of Management Journal Vol. 51, No. 2 (2008), p. 228
48
of some 14 000 to correlate with the IY/MBA answering time. The whole
project is of action research character, but this dissertation is only about the first
phase of it, which is why the answering time exceeds that of this work.
The questionnaire is circulated through a pilot audience of one clinic before
sending to the sample population. No other premature methods were used (like
pre-survey contact letter), since the organization has an informed plan on
organization leadership and conflict handling already in place.
The other survey was sent to 29 persons representing leaders (age 32-64) from
different backgrounds and jobs. This was done to add to the reliability of this
qualitative work.
The HUS questionnaire was sent to the whole staff and nursing staff (those
working with patients) was diluted from it by the help of one question.
Both surveys were circulated and recovered under a short period of time.
Meaning was to get the first response, which should mirror those
interested in conflict handling (either positively or negatively) and filter
out those, that didn’t see the need to respond. This was done to maximize
the recovery. In the case of IY/MBA survey I made one mailing to notice
about answering due to the limited number of participants. In the case of
HUS, none was sent due to the large number of participants.
The questions were designed to reveal the validity and extend of conflict
experience among the participants. This is why the years of over all
working experience and working experience at the same employer were
asked as well as how often they had faced conflicts. The method question
was the most essential one and taken from the prior literature review
fractioned to sub-questions of task/relationship conflicts as well as own
and supervisor/managerial involvement, ways the conflicts are resolved or
disappeared or prevented. Reason question was there for the importance
of resolving the conflicts and thus a sort of validity question.
49
4.2 Research Results
IY/MBA
The IY/MBA –survey was answered by 15 of 29 persons (52%) with a help of
one E-Mail reminder three days after the first one. Over half of the participants
had been working for at least 20 years and none less than 10. 11 of the 14 that
answered had over 8 years of working experience as a supervisor or a foreman
(only three of the 14 had less than five years of experience). Mode is 15 years of
experience. There was thus enough working experience of both
as a member and as a supervisor/foreman in this group to make the answers
relevant.
They had experienced a conflict situations in a working community from very
seldom to often (mode: not often/not seldom by 6 of them) and likewise been
involved in them themselves (although the mode shifted to very seldom, by 8 of
them). They had contributed or self solved conflicts from very seldom to very
often (mode: often by 5 of them). They had been involved in solving the
conflicts at least as frequently as they had experienced them. There is, namely, a
possibility here to change the attitude from the amount of conflicts they had
experienced to how many times they felt they should have been active in
resolving them. The result was almost the same, when the same question about
their involvement was asked in their supervisor/foreman post or someone else as
a supervisor/foreman. There was no significant difference on their own
involvement and resolved frequency by the parties themselves although they
hadn’t been involved in the conflict themselves at the same frequency (rather the
opposite).
In less than half of the cases were the conflicts solved passively (passive
forgotten/waiting). The previous results correlate well with the third party
involvement: from not even once to not often/not seldom (mode: not even once).
The conflict frequencies and solutions are thus valid results. I checked the
individual answers for controversy and found none. The two who replied not
50
often/not seldom had both long working experience, but there were more (5) in
the not even once category, who also had a long working experience.
Conflict prevention measures were answered by eight (53%), but there were no
comments about them either, which could give us reasons not to (like for ex.
question not understandable etc.) rely on them. This was probably due to an
open question format. However, open or clear communication or discussion was
mentioned in each of them. Norms in a form of agreements, citizenship skills or
policies or procedures were mentioned in all but two. Respect was mentioned in
three answers and education and/or learning in two. According to two,
separation was a good preventive method. Likewise two took managers into the
conflict solving procedure and one talked like he/she was a manager.
Conflict prevention (n=8)
Talk/Speak etc. Norms Respect Manager or Education Separation
Policies etc. Manager with
8 6 3 3 2 2
Table 2. Conflict Prevention
Conflict resolving question was answered by 10 (75%). Nine spoke about
discussion or conversation or talk and one didn’t directly mention them,
although a procedure mentioned could be interpreted as one. One mentioned
that knowing each other helps. A third party and/or management involvement
was considered to be a good procedure by seven of them. One didn’t want to
have any outside help due to bad experience and two suggested having help from
an outsider (the other talked only about relationship conflicts). Outside help
with a combination of something else was mentioned by five. Seven mentioned
that the parties themselves were the best to solve the problem. A combination of
parties’ involvement and management and/or a third party involvement if the
parties cannot do it, is the answer to conflict solving activities. There was one,
though, who suggested, that management rules could take care of the small
conflicts, but others should be resolved by the parties.
51
Conflict resolving (n=10)
Talk/Speak etc. Talk/speak 3rd party 3rd party Parties
and supervisor and something else themselves
9 7 7 5 7
Table 3. Conflict resolving
Majority of respondents 12 out of 15 (80%) answered to the questions about
conflicts role in working communities. Majority thought them to do also good,
to disturb working environment, to cause health problems, asocial behaviours
and absenteeism. Only some voted for conflicts as a cause of injuries and result
decline. Revealing faults, creating innovations and problem solving, progress as
well as developing working actions and task was seen as the good sides of
conflicts. A good working atmosphere after a conflict was also mentioned.
The HUS survey accommodated the results of the same questions asked from
both audiences, namely, long working careers, participation in conflict solving
and how the conflicts should be solved and lastly, whether there is something
good about conflicts as well. Less nursing staff workers voted for management
or 3rd
party involvement in conflict solving activities and approx. the same
amount have resolved the conflicts by themselves compared to IY/MBA (64% to
70% respectively).
HUS
Over 200 answered, and 72 were filtered to represent nursing staff who have
worked over two years without changing jobs during that time. This is well
above the usually used n=30/category)162
and leaves room for a possible low
response percent due to time limit. The rest is to increase the reliability
(marginal of error) and viability in numbers, if a bigger sample size would be of
use.
162
Saunders M. et al. Research Methods for Business Students, Prentice Hall, Essex (2007 ) fourth edition, p.
210-213
52
Table 4. Answering frequencies of the questionnaires (x-axis are days)
HUS nursing staff was also asked about the use of employees’ health care and/or
working safety personnel in conflict resolution and if, to all conflicts or only to
the ones they have participated in themselves. By subtracting the all from those
of their own we get the recommendation of their use to others, which was high
compared to own use. The majority hadn’t used either one, which positively
correlates to literature findings. They have been solving relational conflicts
more than task (which according to literature review means they have not
resolved their task conflicts in time). Disagreements, disputes or conflicts were
seen to be the biggest cause of working atmosphere (74%) and lack of time or
resources to cause them. There were needs of foreman (23%) and cooperational
(23%) consultancy (concern the other departments directly, like closing them)
that goes over one’s own department on decision making. However this was
only an expression of need. Majority answered, that conflict handling didn’t
show in leadership or activity plans, which suggests, that more should be done.
This was a dual question as I wanted to have them combined in their thinking,
but this doesn’t mean they answered like that- it can be either or both, which is
fine since the correction is made on both anyhow.
The position of a foreman in a conflict came out as a bit of a controversy. 24%
wanted to have a foreman that would mediate or resolve the conflict and 21%
didn’t want him to have any role. However, 17% wanted him to take up and
interrupt the conflict. Almost half (32%) of the conflict that the respondent
0
20
40
60
80
100
120
1 2 3 4 5
Am
ou
nt
Answering frequency
IY/MBA
HUS
53
hadn’t resolved themselves were handled by their supervisors or foreman. This
is approx. half of what the IY/MBA mentioned.
The medium amount of conflicts resolved by the participants themselves was
over 4 (50% answered) and six answered many (not counted in this statistics of a
medium >4). Less than 39% minority hadn’t solved conflicts by themselves.
The most used method of conflict resolving was discussion (61% by the parties
or with the help of a supervisor) holding its position (together with negligence)
also, if the conflict wasn’t resolved by the first attempt. Whether it is a good
method or not depend on what the target is. There were a number of persistent
cases that either weren’t solved at all (11%), were neglected or forgotten (4%) or
solved by separation (3%) or solved naturally (1%). Together this is 19% which
correlated well with the 13% (51 out of 401 all, unfiltered answers gathered in
six days) of a bigger sample (2% of the whole personnel of HUS instead of the
0,3% filtered answers used in this study). Taken, that somewhere around 20%
of working time goes to solving conflicts and about 80% of them are resolved is
not so bad relation since 46% saw a positive effect on conflicts as well. These
are bigger numbers, when translated into financials.
Out of the 36 that answered, that they had resolved relationship conflicts, 36%
answered not seeing any positive effects of these conflicts. 42% of those who
had resolved task conflicts answered “no”. Out of the ones that had solved only
relationship or task conflicts (subtracting the combinations) the relationship
conflict resolvers answered according to the literature review (majority “no”),
but not the task resolvers (majority answered “no”). Since the sample size is
only 6 and 8 respectively for the latter ones (single resolvers), this cannot be
taken as a proof against the literature review.
Here are some examples of the HUS survey answers:
“The respect of workers increases and reminds the foremen that humanly
treatment isn’t authoritarian or indiscriminate”
They clean also”the air” all right and belong to life. The dealing with them just
halts...”
54
”When some conflict is brought up – it goes either to a favorable direction or
not. At one case in my working department, everyone started to think about
their own behavior and tolerance”
Validity
The leadership and bullying restructuring at HUS could render the survey to be
biased to be too positive on management usage in conflicts. This is why I used
the IY/MBA survey to be able to compare the results. However, the results in
HUS are diluted, because managers and members were not separated and in
IY/MBA all were managers, which wouldn’t give a valid result. Therefore I put
a notion to the questionnaire for everyone to answer as they would be a manager
supporting it by the fact that they are (at least their own). This is not going to
take away the possible positive bias against using managers. It depends on the
relation between member-manager participation, which is also overestimated
since the members don’t have as easy access to the questionnaire as the
managers have. The diminishing factor is the amount of managers to leaders
overall (the ratio been somewhere in 1/10, which came through at the interview
with managers). Furthermore, the managers might on the other hand feel that
the conflicts are their responsibility and on the other hand, they might want to
show, that there are many conflicts with the present leader. No one interviewed
had the answer to that. The managers are not natural born mediators. Their
conflict management has at least looked like (in the80’s) an exercise of authority
than third party facilitation.163
The results validity is jeopardized by these facts as
what comes to the use of management and somewhat 3rd
party use as well. This
is why we used the first answers that are more likely to come from the managers
(previous experience, since the managers have more responsibility, they a
courage to use PC’s and better access to the intranet) and we could compare
these to the IY/MBA manager’s answers. Since there was no significant
difference between those, I conclude that the two forces balanced each other or
the forces were too small to show up. The question of how to resolve conflicts
was the topic and answers to that question require experience. Therefore the
filtering was used to get the first results in (those interested in the subject) from
people that have worked over 2 years in the same community. No reward other
163
Kolb D. et al. Journal of Organizational Behavior, Vol. 13 (1992), p. 316
55
than a mention about the incentive effect of participating to one’s own working
community.
I used both closed and open questions (despite lowering effect on the number of
answers) and comment lines to add to the validity of dissertation. There were no
comments about interpretation of the questions or difficulties to answer, but one
supportive to the findings. I also cross-checked individual answers for
conflicting answers – there were none.
The nature (see Picture 6.) of conflict in a social context makes it difficult to
justify when trying to find the cause and the cure. There is an ambiguity about
the causal direction. For ex. many papers and some of the answers talked about
a good leadership being able to minimize conflicts were as bad leadership does
the opposite. Same with discussions: dialogue was seen as a good thing and
wrongly timed or managed (mood and choice of words) conversation was bad.
The questions and interview summaries could be made directly (without
using any interpretative methods) from the documents, which helps to
decrease the errors, but there is a possibility that categorization might have
increased them. This is why I went through them three times.
The results of the questionnaires cannot be generalized, since the there is only a
separation between nursing staff and others between HUS and IY/MBA and
inside HUS (separating question in the questionnaire). The amount is too small
in IY/MBA and the non-nursing staff of HUS work at the same facilities and
thus with almost the same (with the exception of patient contact effect)
challenges of conflicts. The timing and chosen (patient care, nursing staff) adds
to the validity. Like Porter-O´Grady says, 90% of conflicts will emerge at the
point of service164
. The literature findings were however similar (congruent) in
conflict existence, their bad influence, managerial responsibility and negotiation
(or other talkative) ways to prevent and resolve conflicts as well as use of
mediation, but differences in between health care organizations themselves have
been found165,166
, which doesn’t speak for generalization either.
164
Porter-O’Grady T. Health Care Manage Review, Vol. 29(4), 2004, p.281 165
Sportsman S. Nursing Management, April 2005, p.32-40
56
Reliability
The time of both questionnaires we also picked up so, that the answers were
collected on Wednesday when the questions were sent the weekend before.
People feel usually more stressed on Mondays. This doesn’t display the actual
conflict occurrence and handling frequencies and opinions, rather a positive bias
could be found. This was, like mentioned, done to get into the most
stressed moments. The leisure period bias was overcome by sending the
questions out in between winter and summer holidays.
Like Elke Suomi in her masters work refers to Hirsimäki&Hurme:” to ensure the
reliability of a qualitative research the research data should be of high quality
and the interview outline well prepared, additional questions should be
considered in advance, interviews should be analyzed carefully, and
interviewees should be given a chance to comment on the researcher’s
interpretations.”167
4.3 Research Summary
The HUS and IY/MBA interviews showed that communication and norms were
by far the most used methods for conflict handling in both prevention and
resolving them. A bit of variations was seen in the semantic level. Instead of
communication, many other information exchange connotations were used
(conversation, discussion, talk etc.) and they were categorized to the same
category. Other than that, there was a mention of norms in forms of rules,
contracts, agreements and polices. Separation had also been used to solve the
conflict. A couple of answers went into details resembling mediation like
methods when describing the conflict handling procedure.
Talking in its various forms is hence already in use at HUS. They have also
started to work for a leadership development. These were found to be good
praxis to decrease the frequencies of conflicts taken they work with them
correctly. They are both ambiguity – when done right, there results are good and
vice versa. The dissertation points out some by HUS unused methods, which
166
Garman A. et al. Journal of Organizational Behavior, Vol.27, 2006, p.829-849 167
Suomi E. Master’s Thesis, Helsinki School of Economics (Fall 2008), No. 77679, p.38
57
would help them to minimize nursing staff conflicts, namely facilitative
leadership, heedful interrelating and mediation. These work as preventive
actions and present conflict resolving. Present relational conflicts are shown to
turn back to task conflicts by the help of shared goals and others interest. To
prevent task conflict to turn into relationship conflicts trust should be there.
Facilitative leadership, heedful interrelating and mediation are all good for
building trust on employees and supervisors (although heedful interrelating
didn’t have a significant correlation). Good results on working community
mediation have been gained with SOPU method in Valio168
. Also the peer
mediation at schools and victim offender mediation at the municipalities’ pupils
work well and the promises they make about their disputes hold approx. 95%:ly
during a follow-up period (usually two weeks). The victim offender mediation
doesn’t yet have (but is soon going to have) statistics on how mediation works
with adults.
Participation becomes apparent in organizational changes which are the
showrooms for leadership. Care should be taken when planning or confronting
changes, since they are prone to conflicts. A discrepancy seems to lie in the kind
of conflicts. If leadership is using constructive conflicts right and making
organic changes – the results will be better than facing outside pressure for
changes - and having to use norms, diversity and role clarification will enhance
this further.
Education was possible according to both literature review and research. The
plan, of which this dissertation is a part of, is going to address this with
leadership education.
Some decrease in conflict frequencies should be found outside of the major
suggestions of facilitative leadership, heedful interrelating and mediation. Taken
from the research and literature review complex systems (incompatible activities
– attention to them) and norms (although many times done and controlled by
management) are suggested and found to work. The study pointed out, that
168
Pehrman T. Business Development and Training Director at Valio Oyj, interview and personal
correspondence and education with the pioneering group of working community mediation I belong to
58
employees’ health care and working safety are not commonly used – so these
could be better utilized and they could also work with mediation (this is the plan
already) and facilitative leadership. They also have some power over control
that could be used in heedful interrelating ways. Participation could also take a
form of between departments networking, which was a need expressed at the
research answers. This is not done at the present time other than in exceptional
cases, which renders the departments autonomic and team like working places
where according to literature, great cause have to be taken when leading and
managing it.
Conflict has been (by Saksvik P. et al.) compared to organizational
changes in relations. What applies to relationship conflicts as a mediator
of task conflicts and team’s affective climate is also true for individual
conflicts. Hence, I took a closer look at relationship conflicts. I found
similarities among many researchers as what comes to the roles of
leadership, conflict management and occupational well-being.
Knowledge and staff are the main constituents of an organization. They
make the organization work. This is postulated by Stacey: Knowledge
must be codified to become an asset but once this happens, they lose
value.169
A mainstream definition of knowledge is the capacity to act and
of organization that they are taken to be learning, knowledge-generating
systems of individuals interacting with each other in group/social contexts.
Individuals and contexts are two distinct phenomenological levels
interacting with each to form the whole system. It is then taken for
granted, that these must be managed. In other words, one has to manage
the individuals, who possess the tacit knowledge. This goes well along the
lines of Nonaka &Takeuchi.
169
Complex Responsive Processes in Organizations, Routledge, New York and London, 2001, p.23.
59
The answers to the research questions of:
What could be done to manage conflict resolving in organizations?
By pursuing to take care of a situation of change by paying attention and making
them to take part of the different options and choices. Prevention by education
has also worked. When task conflicts arise, they should be taken care of, since
there is a risk, that they convert to relationship conflicts, which are not so easy
to handle and have also a negative effect on the team and relations.
It is stated in HUS bullying handling instructions and came through in the
interviews and literature search that it is everyone’s responsibility to intervene
or to do something.
What could be done to prevent conflicts to happen?
Since the process from a small disagreement to bullying is gradual and the
symptoms hard to notice (like mentioned in the leadership chapter 3.2.2), the
preventive and educational measures become handy. Preventive measurements
are a lot in the hands of the leadership, team mood and structures (norms).
Supervisors and leaders should apply a heedful interrelation/control on the staff
responsible of operations and processes. Control here doesn’t mean en external
one that harms the relationships and systems as a power of someone over
another. What makes such control harmful is that not only does our belief in it
create the problems we are trying to solve, but it is also used to deal with the
problems170
. Communication (also dialog) and free choice based on free
information flow are important organizational entities. Stress was one of the
factors contributing to bullying and the responsibility of management to see, that
it doesn’t effect a satisfactory working environment171
170
Smith L. Journal of Innovative Management (summer 2007), p. 48 171
Hauge L. et al. Work &Stress Vol. 21, No. 3 (July-September 2007), p.237
60
What could be done to conflicts
Most of the conflicts are resolved by references to regulations and /or
passively letting them be
They are taken care of by the persons themselves
Time takes care of some of them
Education helps
Some should be dealt by supervisors. The leaders should have emotional
management skills, time and a procedure to handle the conflicts. No
every leader has that.
A third party has three basic choices to intervene: order from authority,
by law - or if no law exist/apply – by according to the habits of the land
or by non-legalized other methods.
Mediation and facilitative leadership (including control) is the authors
choice after this dissertation job and by experience with health care
professionals
With what methods are the conflicts solved?
This would mean that task conflicts are taken care of in the early stages, before
becoming relational. Orienteering to new entrants take care of the cultural,
conflict prohibiting procedures in the occupational surroundings of everyone
and other education is also provided along the way, since changes are precursors
to conflicts.
Such a structure/atmosphere/culture of only progressive conflicts could be a
result of a combination of structure (information and communication flow,
dialog, low hierarchy in a kind of matrix/project type of organization ,
centralization/decentralization, networking and partnering), leadership (control,
facilitation), roles, team and individual learning and steering (self-steering
responsibility of others well-being and working processes). There is for ex. a
model called adaptive self-regulation that decreases the amount of laissez-faire
61
and passive management by exception and increases transformational
leadership.172
De Dreu spoke against participation in relationship conflicts as she saw
avoidance being better than contending and collaboration. Pietiläinen et al.
propose that the conflicts are turned into a positive collision. To do this, one
needs emotional management skills, enough time and the procedure to solve it.
Other suggested shared goals and others interest (taking them into account).
They also refer to The ministry of Social- and health care publication from
2002: Working society conflict ruling – violence or creativity
(Työyhteisökonfliktien hallinta- väkivaltaa vai luovuutta , Sosiaali- ja
terveysministeriö). This is a method, were a foreman instead of a mediator work
in a similar manner, than in SOPU-mediation.
172
Sosik J. et al. The Journal of Social Psychology Vol. 142, No. 2 (2002), p.211
62
5. Summary of Research and Literature Review
Figure 6. Summary of factors in a conflict situation (those in blue may work for and
against)
We ought to take care of the intern processes, since these are not likely to
match nor are they going to be unaffected by these changes. Managing and
leading differences doesn’t come automatically in our culture173,174
. The
moderators of the diversity-performance relationship, managerial span of
control and organizational lifecycle are related.
The above (see 2.1) mentioned McKinsey 7-S’s, are guidelines for
marketing. Strategy (for ex. generic innovation), structure (for ex.
centralized, decentralised), systems (for ex. operative), skills (for ex.
173
Hoofstede G. Culture’s consequences,Surge 2003 (100 000 IBM workers) 174
Javidan et al. Cultural Acumen for the Global Manager: Lessons from Project GLOBE, Organisational
Dynamics Vol. 29,No. 4 289-305,2001
Trust and commitment Knowledge-Dialogue Delegation of authority Network of relations Empowerment Shared goals and interest Leadership Participation
Stress and frustration Absenteeism and flight behavior Reduced well-being (renewal, innovation, chance, good working atmosphere)
Organization Leadership and mediation and talk Change and constructive conflicts Control/heedful interrelating Norms and policy
People Time 3rd party Supervisor Education Separation Talk
Conflict
63
marketing), staff (for ex. education), style (for ex. design) and super
ordinate goals (for ex. growth) and the mix of these are part of the
organization and thus conflict management. In other words, we have here
7x7 different combinations of major functions, that all account for many
subcategories, which renders the options and opportunities uncountable.
One cannot follow every path all the way through, but have to prioritize.
There was some diversity about the importance of the factors or mediators
of conflict. The “serious” ones are questioning the whole idea of conflict
reduction. “Conflict is a fuel that drives system growth and enables
learning and adaptive behaviours, making innovation possible.” 175
These
researchers think that managers should focus on encouraging mindfulness,
improvisation and reconfiguration as responses to conflict that enable
learning and effective adaptation. The diversity deals mostly about some
(like Laymann 1992) stating, that working environment is a sole cause of
bullying or (like Brodsky in 1976), that leadership is inevitably the major
player. Also about whether it has more negative or positive effects
(Hansen et al. 2006, Baumeister et al. 2001, Laymann 1996) . Also gender
has got votes from Eriksen et al. in 2004 among assistant nurses making a
difference of been bullied and Vartia among municipal workers that there
was no effect.
There have been two different perspectives to conflict and bullying,
aggression-frustration and social-interactions. Both are still been worked
at. The working place conflicts are a pretty new object to studying. It
started in late 80’s in Nordic countries176
. It is in other words early days –
we are not long from heuristics and the different measuring methods since
Einarsen’s (1994) 177
days are not yet sophisticated enough to measure
cause and effect dependences. De Dreu uses the word in its infancy, when
he talks about interrelations between conflicts and other variables than
175
Andrade L et al. Emergence:Complexity and Organization Vol 10, No. 1 (2008), p.23
176
Zapf D. et al. European Journal of Work and Organizational Psychology Vol. 10, No. 4 (2001), p.370 177
Einarsen et al. European Work and Organizational Psychologist Vol. 4, No. 4 (1994), p.381-401
64
individual and work team effectiveness.178
I started with well-being and
the effects of conflicts to it. On the side of social theories also
psychological theories and management and organizational theories are
adopted in this field.179
A new psychometric test has been tested for
conflict management at work. The researchers suggest, that five factor
taxonomy should be used in conflict management instead of the usually
seen compete-cooperate. These five factors are: avoiding, compromising,
problem solving, forcing and yielding (Appendix XVII). 180
Newest
method might be the intractable conflict handling method which stem
partly from social identity theory, where both in-group distinctiveness and
intergroup differentiation are promoted in a sequential manner or a
computer aided dispute resolution model (if developed further from formal
ADR).181,182
The collaborative process of working through paradox183
could help and
gain ground, since it suits the format of heedful interrelating. In a study
of nurses in a U.S. Hospitals the problem solving was mostly done (in
93% of the cases) by correcting just the present situation without
communicating it to supervisors or to the ones that would have had the
best knowledge. While picking up – if doing that at all – the socially
closest individual, they didn’t lose their credibility and trust. But this is
not a ground for organizational learning in many organizations184
. A study
done with students working in many different occupations highlight the
importance of high-quality relationships of cultivating and developing
perceptions of psychological safety and ultimate learning behaviours in
organizations.185
We have not climbed the whole way up the ladder of
communication and information while most of the problem solving stays
178
De Dreu et al European Journal of Work and Organizational Psychology Vol. 14, No.2 (2005), p113 179
Stacey R. Complex Responsive Processes in Organizations, Routledge, New York and London, 2001
p.39 180
De Dreu C. at al. Journal of Organizational Behavior Vol. 22 (2001), p. 645-668 181
Fiol C. et al. Academy of Management Review Vol. 34, No. 1 (2009), p.32-55 182
Zondag B. et al. International Review of Law Computers & Technology Vol. 21,No. 2 (July 2008), p.191-205 183
Lüscher L. et al. Academy of Management Journal Vol. 51, No. 2 (2008), p. 221-240 184
Tucker a. et al. Californian Management review Vol. 75, No.2 (Winter 2003), p.55-72 185
Carmeli A. et al. systems Research and Behavioral Science, Vol. 26 (2009), p. 81
65
at the problem level and doesn’t continue with circular, reflexive and
strategic questioning into a workable certainty.
In mediation, these steps can most often be shortened since one works for
a sole conflict in one’s hands. Having said that, many people (like Vartia
have shown to apply to observers of bullying) and many parameters are
involved and a broader view could be of use. At least, a follow-up period
should be agreed upon and if many symptoms come alive in this kind of
longitudinal search, deeper involvements are in place.
Looking at the data it became obvious, that discussion is the method of
choice but some new remedy surfaced. It doesn’t matter in what extent in
a qualitative study. Mediation is something I’ve seen to work with pupils
and violent offender mediations. Although it hasn’t been extensively
tested with working communities (except in Scotland), it doesn’t mean,
that it couldn’t become a major player. It is a question of timing and
probabilities.
66
6. Generation, evaluation and selection of options
6.1. Options
The requirements for a chosen method: 1)it should minimize (at least
lower as there isn’t any literature nor this research which was qualitative
to measure what could the difference in minimizing and decreasing be)
the relationship conflict frequency and 2) be a new method, which they
haven’t used yet 3) it should be facilitative.
These are the options driven from the literature review and/or research that
HUS could consider:
A) One possibility should always be to continue or to make a break and
discuss every other option including the present situation – busier than that
one should be. Like stated, the organism tend first to find a way out of the
dilemma,186
so it might be, that other solutions could be better. Conflicts
might vanish, when time goes by. It has already been tested here, without
any significant results on the conflicts that come to the attention of the
supervisors and leaders.
B) A second possibility is to continue neglecting and “forgetting” the
conflicts, but contrary to option A other parameters might be changed
C) A third option is to take a third party in the picture (be it an outsider or
not) and let them take control or have them as a mentor.
D) A fourth possibility is to influence the source with education and
facilitative leadership making local and present circumstances more
repellent to relationship conflicts while allowing constructive conflicts to
erode
E) A fifth option is to start mediation for conflict management.
F) A sixth option of making the whole organisation repellent to conflicts
by making the structure, processes, norms and culture to leave no room for
conflicts (especially role clarifications in mind)
186
March J. et al. Organizations, Blackwell Publishers, second edition, 1993, p.132-133
67
G) The seventh option is influencing the mediator role the conflicts have
on cause and consequences (like using task conflicts in enhancing
innovativeness and performance which in turn, indirectly could lower
relationship conflicts, using heedful interrelating, shared goals and/or
others interest)
H) There was lack of time and resources known (literature review) to
cause conflicts at HUS, so the eight option is to find resources Also
urgent jobs we according to the research shown to cause conflicts which
could be another option or counted in depending on the target of the new
resources. This differs from option A in that it would be an active search
of new resources
I) A hierarchic system with the combination of eagerness of its staff to
help increases conflicts, so the ninth method could be to change the
hierarchy so that the conflicts become more perceptual and easier to
minimize
J) Working atmosphere correlated, according to the literature review and
research, to conflict frequencies. To influence working atmosphere
positively would thus lower the conflict frequencies (alas with the cost of
innovativeness) is the tenth option. These are many and some of them
ought to be new.
K) The eleventh possibility could be any, other, to HUS new method we
could develop to work better and to be facilitative and lower the
relationship conflicts
L) The relationship conflicts could be turned into something else with the
help of shared goals and others interest. This differs from G-option as the
influence is directed only to the relationship conflicts
M) Any combination of the above that would further decrease the
relationship conflicts. These methods can all be combined, since they
don’t disturb each other.
N) Leadership; as according to the interviewed group there hasn’t been
any.
68
6.2 Choosing the option
The firstly mentioned possibility to stay put and discuss whether other
options are better. If found not to and the decision is to stay put and do
nothing would mean, that the outside, independent conditions would
change to favour relationship conflict decrease at HUS. In a form of
resources, I could think it could work, but this is for the first too unlikely
and for the second not a new approach or system and not a permanent
facilitative way, which was a request from our research interview and the
choice.
The secondly mentioned B-option hasn’t been according to the two
research groups yet scientifically shown to work in general. Nor does our
research support it. Having been already in use, it wouldn’t be a new idea.
The third C-option of a third party is not new, but shown to work also in
hospital surrounding including HUS in this research. These third parties
have been high management (managers are no better off, than anybody
else in this sense, rather worse.187
) employees’ health care/working safety,
but not consultancy/outsourcing. This is a candidate if a new party with
facilitative capabilities is chosen that would make it a new method.
The D-option fills every requirement and is thus a candidate.
E-option of mediation is a candidate while it also fills every requirement.
The sixth F-option is not new and not facilitative in a long run so it
doesn’t count.
G-option is new as far as I know and it has been shown to lower
relationship conflicts. It is also a bit facilitative in a sense it activates
people to find the ways to do it but leaves a question mark on how much it
187
Nugent P. et al. Academy of Management Executive, Feb2002, Vol. 16 Issue 1, p139-154
69
will affect the relationship conflicts (will it be measurable) since it will
increase the task conflicts levelling the consequences if the knowhow is
not found. The literature review revealed it to be circumstantial and thus
sensitive. It is a candidate with fewer guarantees than C,D and E.
Option H is not new (they are constantly trying to find organic and outside
resources and also found some, like nurses from Philippines). It has an
impact on decreasing the relationship conflicts according to our literature
review, but it is only half facilitative since it only facilitates the structures
not empowering and facilitating learning and decision making. This
doesn’t rank high – not an option.
Option I is not new, but facilitative if the hierarchy was working against
the performance and it would most probably decrease the relationship
conflicts. It is a candidate if HUS themselves would succeed in lowering
the hierarchy and would thus back away from the requirement of a new
method.
There is a possibility to find new methods to work for a better working
atmosphere that could simultaneously be facilitative and has been shown
in this dissertation paper to lower relationship conflicts. Problem now is,
that we know that plenty has been tested and not documented. It would be
almost impossible to find one. J-option is not a candidate.
K-option was searched once again through the documentations and
interviews made. Nothing was found – not an option.
Option L is the 12th
candidate could fill all the requirements, but as with
K, I couldn’t find others interests (if not our plan is taken into account or
the nationwide plans would have an impact) nor new shared goals, which
renders L not an option outside of our own plan since the nationwide
programs are indirect (relationship conflicts are not directly their target)
factor with limited guarantees of working. Some nationwide plans
haven’t decreased the well-being at work at all, sometimes on the
70
contrary188
, it remains to be seen how big an effect this will have on
nursing staff conflicts. Not a viable option at least for now and what we
know.
M-option works if there are two or more options that fill the requirements
and support for the combination found in the literature (or no opposite
impacts).
N-option is found to have even a strong impact and a facilitative
leadership type, which is new to HUS can be found. To predict, that
facilitative leadership would have a huge minimizing effects on conflict
occurrence and negative effects of work, is not confirmed by this single
dissertation. What speaks for it, is the fact that the earlier one
acknowledges and acts on a conflict, the smaller the impact. Facilitative
leadership gives power to everyone to act upon finding conflicts and make
suggestions to minimize them and their effect. A candidate.
Conclusion
The options are thus C,D,E,M and N with conditional G and I. This
translates into a third party involvement with mediation and education
programs and facilitative leadership type as well as with the possibility to
influence the mediator role of conflicts and hierarchy in HUS. These are
not shown to collide and could be mixed together. With any of these the
goal is met, but the work continues to find out about more and to narrow
down the selction.
Using other methods for conflict handling than mediation has been based
on negotiations between supervisors and parties or between working
safety and/or employees’ health care. It has also been steered from values
and norms. This is why the negotiating parties liked to see other tools to
be used as well.
Some (24%) mentioned mediation or mediation-like resolving methods
having helped them or wanted their supervisors or foreman using them.
188
http://www.uta.fi/laitokset/tsph/terttu/ohjelmamuistio/to_rahoitus.html (15.5.2009)
71
Figure 7. A suggestion for minimizing conflicts. Conflicts II and III might
stay the same way as the original or evolve to something different
By facilitating and mediating one tries to solve the same conflict as the
antecedents are better known and the conflicts earlier noticed.
Conflict
precursors
Norms
Conflict
Discussion
Conflict II
Discussion II
Conflict
precursions
Facilitative
way, education
Conflict
Mediation
Conflict
Discussion
Conflict III
3 rd party
72
7. Action plan
The plan was made together with the personnel of HUS and the financing
institution (The Working safety trust) at the beginning of this year (see
Appendix I for schedule and resources). It comprises of a series of
interviews, meetings and check-up points. The interviews are carried with
10 different entities and the meetings with their and the personnel leaders.
This is to ensure, that we are in a right path and that we run in parallel
with the leadership and bullying plans of HUS.
The comparison with MBA students and a consultant company doesn’t
continue since it was just to compare the conflict situations at one point.
However, there is a similar work ongoing at the Kuusamo Community,
which includes health care and this is used for benchmarking.
Since we can anticipate at the light of this dissertation work, that there
aren’t any preventive methods to stop the conflict situations to rise at time
to time, we are implementing a series of educational sessions and a
training course with the HUS staff. The plan is that this is done by the end
of this year so that we are able to observe the results. I take the
responsibility of planning these 3 x 3 hour sessions together with the HRM
team. I take a partner from the mediation group of the trained Pehrman
group and work through the 10 cases. By the end of those, there will be a
big seminar held to the management by the end of 2010 to go through the
results and make a decision on the method and timetable for the conflict
management. There will be an outside mediator in place for their disposal
during the time of the plan.
The personnel leaders and me sit in the steering group and lead the plan
the whole way through. Working safety trust is the project owner. The
plan suits their general plans of improving the HRM and leadership while
increasing innovativeness and cooperation. Consultancy is going to
73
increase.189
As this is also in the strategy of HUS and HRM, the option of
outsourcing should be discussed and we made some criteria for decision
making before we do the deal:
The outsourcing criteria (when thinking of process or part of a process
outsourcing) according to Insigne et al190
are:
alignment or outsourcing with the business strategy of the
enterprise
clarification of core capabilities and competencies
identification of strategic gaps and specific strategies for cost
saving and asset shedding
recognition of the enterprise’s significant dependencies and
vulnerabilities
They have constructed a grid of potential for an activity to yield
competitive advantage which is spotted against internal capability of the
enterprise to perform an activity in comparison with competitors.
Their key activities are:
Get capability
Built strength
Do in-house
Their Emerging activities are.
Partner
Collaborate
Share risk
Their basic activities are.
Buy develop second source
Make it a profit centre consider selling/buying
189
Suomi E. Master’s Thesis, Helsinki School of Economics (Fall 2008), No. 77679 190
Insinga R. Et al Academy of Management Executive; Vol. 1, No. 4 (2000), p. 58-70
74
Their commodity activities are:
Buy
Exit/buy
If the mediation education and conflict management minimizes the
amount of conflicts and improves at least some of the negative effects of
them, the plan has a chance to continue with mediation and facilitative
leadership coaching in 2011 and on. The measures are made from this
survey data to the next one by the end of 2010 and the interview results.
The measures are relationship conflict relation to overall conflict amounts
as well as a decrease in conflicts being the biggest, sole reason for a bad
working atmosphere question.
The interview with the managers and the mediations done in the clinics
should provide us with a better picture on leadership and we could start
planning for the facilitative leadership training and tutoring before the end
of 2010.
The second phase of this plan is to have some more people trained to work
place mediation who could then take the continuance of the mediation
processes under their custody. This takes place during 2012. The
selection of the mediators are done in cooperation with me and my partner
and department heads of these different clinic departments.
75
APPENDIX I 1(2)
BUDGET AND TIME TABLE FOR THE ACTION PLAN
Budget for the plan of Working safety in Health care 1.3.2009-28.2.2011 [a] [2a] [a] 2[a]
Compensations 61722 123444
123444 Sub-costs 1710 40824 17010 40824 Rents 2160 4320 2160 4320 ( 1/2 of a rent in a Office Hotel)
ICT 2650 5300 2650 5300 Travel (see below) 750 1499 750 1499 Bookkeeping 1100 2200 1100 2200 Material 100 200 100 200 Sub Total 68482 136964 68482 136964 Other* 930 1860 930 1860 Total 69412 138824 69412 138824 * universal price increase (1,4%), media of Nordea’s prognosis (20.1.2009)
á{€]/route or km Sum [a] Total 2 [a]
á{€]/matka tai km
Yhteensä [a] Yhteensä 2 [a]
Matkat (2 henkilöä) 1/a Helsinki-Kontiomäki-Helsinki 137,6 137,6 275,2
3/a Helsinki-Turku-Helsinki 0,45 405 810 HUS:iin ja klinikoiden väliset 0,45 207,4 414,8 Yhtensä
750 1500
137,6 137,6 275,2
0,45 405 810
0,45 207,4 414,8
750 1500
Financing plan
79% comes from Working safety funds and 21% from HUS (out of which some can be financed by a third party)
HUS don’t do any compensational work; work goes to the employer; alternatively and/or partly voluntary. Possible conferences and tradeshows abroad are financed by the parties themselves.
76
APPENDIX I 2(2)
Schedule (Operative activities) 7.1.2009-1.3.2009 Planning 1.3.2009-31.5.2009 Survey and the first interviews(admin., leaders, eye)
3.8.2009-15.9.2009 Interviews (endo., chir., allergy)
16.9.2009-19.9.2009 Reporting and meeting with Kuusamo reseachers and checkpoint of the plan
21.9.2009-23.12.2009 Reporting and follow up meetings with the interviewed 28.12.2009-27.2.2010 Interviews (otolar.- and lab., image.) 1.3.2010-31.3.2010 Reporting and interviews with the checkpoint leaders
1.4.2010-16.4.2010 Follow up with the interviewed 19.4.2010-31.5.2010 Interview(obd.&gyn. pedi. and the rest)
2.8.2010-3.9.2010 Reporting and follow up with the interviewed 6.9.2010-23.12.2010 Analysis and reporting
3.1.2011-28.2.2011 New survey and analysis
Reporting includes also literature review ICT and marketing plus marketing budgets separately
77
APPENDIX II
Ten essential processes of a facilitative leader (according to Ingrid Bens)
A New Leader Integration
Visioning
Team Launch
Operational Review
Survey Feed-back
After Action Debriefing
Need and Offers Negotiation
Peer Feed-back
Mediating Interpersonal Conflict
Coaching
Facilitative Leader Characteristics:
Ingrid Bens Global Business and Organizational Excellence (July/August 2007), p.43-55
(Reprinted from her book “Facilitating to Lead”: Leadership Strategies for a Networked
World, Jossey-Bass (2006))
78
APPENDIX III
The Group effectiveness model (by Schwarz R.)
A clearly defined facilitator role useful in a wide range of roles
Explicit core values
Ground rules for effective groups (see below)
The diagnosis-intervention cycle
Low-level inferences
Exploring and changing how we think
A process on agreeing how to work together
A systems approach
Grounded Rules for Effective Groups (by Schwarz R.)
Test assumptions and inferences
Share all relevant information
Use specific examples and agree what important words mean
Explain your reasoning and intent
Focus on interests not positions
Combine advocacy and inquiry
Jointly design steps and ways to test disagreements
Discuss undiscussable questions
Use decision making rules that generates the commitment needed
http://www.schwarzassociates.com/files/229.pdf, 12.4.2009
79
APPENDIX IV
TRUST AND ORGANIZATIONAL LEARNING
How the buyer gains trust on seller (Wood J. et al., 2008)
How to facilitate the organizational learning.
Copied from Carmeli A. et al. systems Reseach and Behavioral Science, Vol. 26 (2009), p.
91
80
APPENDIX V 1(2)
Rapport from the first mediation at HUS (by Juha Tykkyläinen)
Translation from the original Finnish description:
Working community mediation that was carried out in HUS Chirurgical
Hospital. It was a large mediation case in a sense that over 30 people
participated. Mediators were Juha Tykkyläinen and Marja-Leena Zotow. In the
core of the conflict was a bullying experienced conflict behavior of three
persons, but it turned out to handle multiple entities, that friction the working
atmosphere later on.
Mediation was carried out so that there were separate meetings open to everyone
to attend. About 18 people joined them. The purpose of the meetings was to
inform the participants about mediation process and principles that steer them.
Those, not participating in the separate meetings gained information through a
process description before the joined meeting. On the other hand, the
participants were asked about their visions about the conflict, the emotions it had
arisen and possible wishes on the resolution. There was also a strive at the
separate meetings to encourage participants to an open reciprocal
communication at the joint meeting.
The joined meeting started with “narrative rounds”, where everyone explained
their view of the conflict, its reasons and consequences as well as what kind of
resolution could be the best one. Because there were 30 people participating it is
clear, that the meeting carried on and on. A discussion was carried out after the
narrative round, which was lead by the mediators when needed. Much steering
wasn’t necessary because the participants were active and the discussion went on
in a constructive manner. At the end of the discussion a contract, where
corrective actions were collected, building took place.
At the end of a long discussion the participants began to feel tired and frustrated
and seemed to be waiting, that the mediators would have taken a more active in
writing the “conditions” of the contract. They were able to agree upon the
substance that seemed to suit everyone, however.
After a couple of month of the joined meeting, a feed-back –meeting took place
that was joined by ten participants or foreman. Critique was delivered above all
about bad information about the process flow although at the separate meetings
one tried especially to wipe off the uncertainty about the process flow. A part of
the participants felt also that the mediators remained too passive and didn’t bring
out their own thoughts about the conflict and its resolution enough. Third
issues that rouse critique was the experienced anxiety of the process and a
surprising difficulty for the attendants.
81
APPENDIX V 2(2)
In original Finnish:
Työyhteisösovittelu, joka toteutettiin HUS:n kirurgisessa sairaalassa. Kyseessä
oli suurehko sovittelujuttu siinä mielessä, että osallistujia oli n. 30 henkilöä.
Sovittelijoina toimivat Juha Tykkyläinen ja Marja-Leena Zotow. Konfliktin
ytimessä oli kolmen työntekijän välinen kiusaamiseksi koettu käyttäytyminen,
mutta prosessin edetessä paljastui monipuolisesti erilaisia työyhteisön ilmapiiriä
hiertäneitä seikkoja.
Sovittelu toteutettiin siten, että ensin järjestettiin erillistapaamisia, joihin saivat
osallistua kaikki halukkaat. Erillistapaamisissa kävi n. 18 henkilöä. Tapaamisen
tarkoituksena oli ensinnäkin informoida osanottajia sovitteluprosessin kulusta ja
sitä ohjaavista periaatteista. Ne, jotka eivät erillistapaamisiin osallistuneet, saivat
informaation yhteistapaamisen aluksi kerrottuna prosessikuvauksena. Toisaalta
osanottajilta kyseltiin heidän näkemyksiään kyseisestä konfliktista, sen
herättämistä tuntemuksista ja mahdollisista toiveista ratkaisun suhteen.
Erillistapaamisissa pyrittiin myös rohkaisemaan osanottajia avoimeen
vuorovaikutukseen sovittelun yhteistapaamisessa.
Yhteistapaaminen aloitettiin ”tarinakierroksella”, jossa jokainen osanottaja
vuoronperään esitti näkemyksensä konfliktista, sen syistä ja seurauksista sekä
siitä, minkälainen ratkaisu tapauksessa olisi paras. Koska tapaamiseen osallistui
kolmisenkymmentä henkilöä, on selvää että tapaaminen venyi mittavaksi.
Tarinakierroksen jälkeen käytiin asioista keskustelua, jonka kulkua sovittelijat
tarvittaessa ohjasivat. Ohjausta ei kuitenkaan tarvittu paljon, sillä keskustelijat
olivat aktiivisia ja keskustelu käytiin pääasiallisesti hyvässä hengessä.
Keskustelun päätteeksi ryhdyttiin laatimaan sopimusta, johon koottaisiin
tarvittavat toimenpiteet tilanteen korjaamiseksi. Pitkän istunnon päätteeksi
osanottajat alkoivat hieman väsyä ja turhautua, ja tuntuivat odottavan, että
sovittelijat olisivat aktiivisempia sopimukseen otettavien ”ehtojen” laatimisessa.
Osallistujat pystyivät kuitenkin löytämään itse sopimuksen sisällön, joka tuntui
tyydyttävän kaikkia keskustelijoita.
Muutaman kuukauden kuluttua yhteistapaamisesta järjestettiin palautetilaisuus,
johon osallistui kymmenen yhteistapaamiseen osallistunut työntekijää tai
esimiestä. Kritiikkiä saatiin erityisesti siitä, että osanottajat eivät kokeneet
tulleensa riittävästi informoiduiksi prosessin kulusta, vaikka erityistapaamisissa
pyrittiin erityisesti poistamaan epätietoisuutta siitä, miten prosessi tulee
etenemään. Jotkut osallistujista kokivat myös, että sovittelijat olivat turhan
passiivisia, eivätkä riittävästi tuoneet esille omaa näkemystään konfliktista ja
sen ratkaisusta. Kolmantena kritiikkiä herättäneenä seikkana koettiin prosessi
ahdistavuus ja yllättävä vaikeus osanottajille.
82
APPENDIX VI 1(2)
Interview meeting with the HRM staff in HUS, Meilahti Hospital on the 22.4.2009
Present:
Cenita Blomqvist, Working Safety Manager
Anne-Maria Mäkinen, Chief, Working Relationships
Päivi Vaheri, Human Resource Manager, belongs to the executive board and group administration
Iina Mikkola, Manager, Collective Negotiations
Anu Meriö, Department Head, Intensive Care
Mika Koskinen, undersigned and dissertation author
What kind of conflicts have you experienced here in HUS?
CB: I’d say all kinds and with increasing phase, although we have not a long history of surveying, rather
cuts feeling of what we’ve seen. Does everyone agree? (They did). They vary a lot in character, but
I’d say most of them are relational (at least what we have seen and know about) although they might
have been task conflicts at the beginning. Some of them have a very strong personal “pondus”.
So what have you done about that?
CB: We have conducted a TOP-survey under some six or seven years, but the questions have varied so it
cannot directly be used for this study. We have a version one bullying rule/guide published and the second
version is under way (see Appendix XXVI for the older version, authors notice). We have been
working with that during the six or seven years, but we haven't seen a decrease in the conflict cases.
PV: I’m quite new at this position, but I’ll agree with CB – new ideas are welcome, because I have
a handful of bullying cases right now. We have worked according to the instructions and had a lot
of talks here and they most often turn to us only after they have talked with their supervisors and/or groups.
Unfortunately, many have to be replaced or they leave, which is a huge loss in human and economical
resources.
A-MM:Also the unions are “in the picture” in almost every case, which depolarizes the situation –
it is not neutral.
AM: We were taking part at the first mediation meeting and I understand now, when you described the
situation, what went wrong. I’m in strong favour of mediation. The personal talks with the parties
don’t always help.
MK:In how many cases have you succeeded within your group.
AM: I don’t know exactly, but I’d presume that it is however in majority of cases.
MK: Iina, do you agree in what have been said?
IM: Yes, just that we have received phone calls and people here without them showing up in paperwork.
Plenty have gained “treatment”. It is just not enough, we need to think and do more somehow.
AM: Maybe people just wanted to sort thing out faster than they actually could.
MK: What could you do, if resources and knowhow wouldn’t be a limiting factor?
CB: this mediation program is of great interest. It is a new deal. We have thought about an
educational project on issue of ”how to start talking about untellable things” also. We have agreed,
that we have to have something new that we haven’t tried on yet. Situation is getting worse.
Of course the government and municipals could do a lot in terms of wellness policy and helping us
with planning and resourcing.
PV: I admit, that I don’t know everything about mediation or even, what I probably should know,
83
APPENDIX VI 2(2)
but I agree.
It sounds like a good idea. Of course there is a lot to do in prevention as well, but this might already change
the culture in here.
CB: We have already in 2006 tried to launch a talking culture and that could be of interest. What would
you suggest?
MK: For me, there are right now three options: try to work with the talking culture further, take part of this
mediation plan or to educate the personnel to conflict handling or a mixture and/or a combination of these.
You have a paradox in limited resources and a working atmosphere that is getting worse. What is there
for you?
A-MM: We are not ready to pick up either of them like straight, now.
AM: We have got the education of a mediator so could we use you and someone of us to mediate at least to
begin with. Education sounds probably less expensive, but it eats the working hours of the staff.
Mediation could gradually
turn the situation over and build a culture of caring people.
CB: This might be an idea. We are working already with a new leadership and organization. I feel
we ought to do something for prevention and eventually mediation could do the trick, I don’t know.
PV: I’m relatively new, coming from private side. This mediation is new, how long has it been in use.
MK: Six years in Finland and only in Valio, but in Scotland it is used quite wildly.
PV. Do we have other options? I’d like to discuss this more, but maybe not now.
CB: What should we do? Could we start by sending out the inquirely and plan for the next steps after that?
Is the plan in schedule?
MK: Yes, we are in time.
CB: Could A-MM take the responsibility of a coordinator here. MK send the proposal to her and
she will pass it through.
A-MM: Fine for me.
84
APPENDIX VII
The cover letter for the HUS questionnaire (translation from the Finnish cover letter)
DISPUTE OR CONFLICT SITUATION
As a part of my MBA dissertation I’m conducting a questionnaire on “Employees’ health care
and working safety usage”. My work is about conflict handling, i.e. how could one minimize
and handle them so, that they don’t disturb working atmosphere or cause disputes among employees.
I’m cooperating with HUS Human Resource Management and the answers are a part of a ground
work on a possible development plan of mediation implementation.
Would you like to answer right away, incognito. You cannot be identified from the information
you provide if you don’t write your name on it. All information will be treated in the strictest confidence.
There are 12 questions to answer.
We are waiting for your reply at the very latest on the 19th
of June 2009 – so answer directly, please.
The sooner you answer, the sooner we can start working!
A big praise for your help – you came to help yourself and your working community at the same time!
Mika Koskinen
Working Community Mediator, Aava Development Ltd
Tel. 050-4068128 or E-Mail [email protected]
85
APPENDIX VIII
The HUS questionnaire (translation from the Finnish questionnaire)
The use of working safety and employees’ health care services
HUS-health care services (the questions are about leadership, which concerns everybody – you are however at least the leader of yourself –
not about whether you are in a leading position, so please answer to all questions)
1. How long have you worked with the present job/vacancy in HUS?
2. Have you been changing jobs lately?
- if you answered yes, tell us how often
3. Are you working with patients?
4. What is the role of your supervisor in conflicts?
5. Have you been using our own working safety/employees’ health care in either of or in both of the following cases?
a) dispute, disagreement or conflict?
b) only for your own purposes (related to a dispute, disagreement or conflict) without taking other parties with?
6. Have you been using any other, than working safety/employees’ health care to resolve a disagreement, dispute or conflict?
7. Have you yourself settled a disagreement, dispute and/or conflict?
-if you answered YES, how many times
- which kind of disagreements, disputes or conflicts have you resolved?
a) between persons
b) about things
c) other
- how did you resolve them?
-if you answered NO – how did the disagreements/conflicts worked out?
8. According to your own judgment, are disagreements, disputes or conflicts the biggest factor of its own rights,
that has an effect on the deterioration of working environment?
9. Have you noticed that disagreements, disputes or conflicts could be beneficial?
-if you answered YES, how:
10. Are urgent situations at work a source of disagreements, disputes of conflicts and how does this become apparent?
11. Which kind of tasks cause over the department going decision-making processes, meaning, that they cannot be resolved within the department?
12. Does the nurturing of disagreements, disputes and conflicts show up in the plans and leadership?
86
APPENDIX IX
The cover letter for the HUS questionnaire in Finnish
RISTIRIITA/KONFLIKTITILANNE
Hyvä vastaaja,
Osana MBA-lopputyötäni toteutan ”Terveydenhuollon työterveyshuollon ja
työsuojelun käyttö ristiriita/konfliktilanteissa” koskevan kyselyn. Työni koskee
konfliktien hallintaa eli sitä, miten niitä voisi minimoida ja käsitellä niin, että ne eivät
pääsisi häiritsemään työilmapiiriä ja riitaannuttaa henkilökuntaa.
Teen yhteistyötä HUS:n henkilöstöjohdon kanssa ja kyselyn tulokset ovat osa
taustatyötä siihen käynnistetäänkö HUS:ssa kehittämishanke mahdollisen
sovittelumenettelyn käyttöönotosta.
Vastaatko heti nimettömänä tähän sähköpostikyselyyn. Sinua ei voida tunnistaa
vastauksista jos et kirjoita siihen nimeäsi. Kaikki vastaukset käsitellään
luottamuksellisesti.
Kysymyksiä on 12.
Odotan vastaustasi viimeistään 19.6.2009 mennessä – joten vastaa heti.
Mitä nopeammin vastaat, sitä nopeammin pääsemme toimiin!
Suurkiitos avustasi – olet samalla tullut auttaneeksi itseäsi ja työyhteisöäsi!
Mikäli sinulle on aiheesta kysyttävää, ota yhteys:
Mika Koskinen
Työyhteisösovittelija, Aava Development Oy
Puh. 050-4068128 tai s-posti: [email protected]
87
APPENDIX X
The HUS questionnaire in Finnish
Terveydenhuollon ja työsuojelun käyttö terveydenhuollossa
HUS-terveyspalvelut
(kysymykset koskevat johtajuutta, joka siis koskee kaikkia- olethan ainakin itsesi johtaja – ei sitä oletko johtavassa
asemassa, joten vastaa kaikkiin kysymyksiin)
1.Kuinka kauan olet ollut nykyisessä ammatissasi/vakanssissa HUS:ssa?
2.Oletko välillä vaihtanut työpaikkaa ?
-mikäli vastaat KYLLÄ, kerro kuinka usein
3. Hoidatko potilaita?
4. Mikä on lähiesimiehen rooli konfliktinhallinnassa?
5. Oletko käyttänyt työterveyshuoltoa/työsuojelua molemmissa tai jommassa kummassa seuraavista?
c) riidan tai erimielisyyksien tai konfliktin vuoksi?
d) vain oman riidan tai erimielisyyksien tai konfliktin vuoksi ottamatta muita osapuolia mukaan?
6. Oletko tehnyt yhteistyötä jonkun muun tahon, kuin työterveyshuollon/työsuojelun kanssa riidan, erimielisyyden
tai konfliktin selvittämiseksi?
7. Oletko itse selvittänyt riidan, erimielisyyden ja/tai konfliktin?
-mikäli vastasit KYLLÄ, kuinka monta kertaa?
Millaisia riitoja, erimielisyyksiä ja/tai konflikteja olet ratkaissut?
a) henkilösuhteiden
b) asioiden
c) muiden
Miten ratkaisit ne?
-mikäli vastasit EI – miten riidat/konfliktit selvisivät?
8. Ovatko arviosi mukaan riidat, erimielisyydet tai konfliktit suurin yksittäinen tekijä, joka vaikuttaa työilmapiirin
heikkenemiseen?
9. Oletko havainnut, että riidoista, erimielisyyksistä tai konflikteista olisi hyötyä?
-mikäli vastasit KYLLÄ, mitä:
10. Aiheuttavatko kiireiset työtilanteet ristiriitoja, erimielisyyksiä tai konflikteja ja miten tämä ilmenee?
11. Millainen tehtävä aiheuttaa yli osaston meneviä päätöksentekoprosesseja eli asiaa ei voi ratkaista osaston
sisäisesti?
12. Näkyykö ristiriitojen, erimielisyyksien ja konfliktien hoito toimintasuunnitemissa tai johtamisessa?
88
APPENDIX XI 1(7)
IY/MBA (CONSULTING COMPANY AND MBA CANDIDATE) SURVEY QUESTIONS AND ANSWERS
Question No. 1
95
APPENDIX XII 1(4)
The Graphical Representation of the HUS questionnaire answers (in percentages)
Categorized answers (discussion group includes all connotations
and department nurse similarly)
0
20
40
60
80
EHC/WS Self Others
Who resolves the problems (n=72)
No
Yes
Own conflicts
0
20
40
60
Relational Task All
Which kind of problems (n=72)
0
10
20
30
40
50
60
Discussion Discussion and Department nurse
EHC/WS
How did you resolve them (n=44)
96
APPENDIX XII 2(4)
Categorized answers
0 5
10 15 20 25 30 35
Persistant Discussion Forgetting Discussion with Department
nurse
How did the conflicts resolve if you didn't solve them (n=28)
0
20
40
60
80
Yes No
Are conflicts the biggest, sole factor of making the working
atmoshpere worse (n=72)
97
APPENDIX XII 3(4)
Categorized answers (the first four of them according to percentage)
40
45
50
55
Yes No
Have you noticed that conflicts could have a positive effect
(n=72)
0 10 20 30 40 50
If you answered yes, tell us why (n=33)
0
10
20
30
40
50
60
70
80
Yes No
Are urgent situations a source of conflicts
98
APPENDIX XII 4(4)
Categorized answers (the first four of them according to percentage)
Categorized answers (the first three of them according to percentage)
0
10
20
30
40
Resources Saying Tension Planning
If you answered yes, how does it show (n=52)
0
10
20
30
Foreman Cooperations Complains
What kind of conflicts should be taken outside of department
(n=56)
0
20
40
60
Yes No
Does conflict handling show in activity plans or leadership
(n=72)
99
APPENDIX XIII 1(2)
Suomi E. Master’s Thesis, Helsinki School of Economics (Fall 2008), No. 77679, p.44
100
APPENDIX XIII 2(2)
Suomi E. Master’s Thesis, Helsinki School of Economics (Fall 2008), No. 77679, p.41
101
APPENDIX XIV
Labour Process Theory
1. The consideration of labour as an important source of surplus value within capitalism. 2. The necessity for constant evolution of the forces of production, including those related to labour
skills, all due to the profit imperative inherent within capitalism. 3. A related control imperative over the labour process in order for capital to be competitively successful
in extracting surplus value from the production process. 4. An assumption in inherent power imbalances which create the structural tendency for antagonism
between labour and capital. Responses of labour can include resistance but also accommodation, compliance, consent or even active cooperation.
5. Research that involves acting politically to ultimately eliminate such imbalances or, in the short run to at least ameliorate their effects. This includes critical reflection on the one’s own ethical stance towards the subject of one’s research to avoid reproducing the kind of domination the research is aimed at undermining.
6. An open –minded approach to methodology to include both quantitative and qualitative methods and both dialectical and non-dialectical reasoning.
7. Recognition that other forms of domination (i.e. transcending those of class, and extending to issues such as race and gender) are also manifest in the workplace.
Jaros S.J Marxian critiques of
Thompson’s (1990) ‘core’ labour
process theory: an evaluation and
extension. Ephemera, Vol. 5, Nro 1
(2005), p. 5-25
102
APPENDIX XV Six Basic Mediation Styles:
1. Generic style (1970) 2. Settlement driven style (1980) 3. Cognitive, systemic style (1980)[2] 4. Transformative style (1990)[3] 5. Humanistic style (1990)[4] 6. Narrative[5] (1990) style may be a new bud on the tree of the mediation development[6]. 7. Different styles of communication in mediation often depend on the mediation style adopted. Some methods of communication are
inconsistent with some forms of mediation. 8. 9. In generic and settlement-driven mediation the communication – at least in the beginning – goes through the mediator. Language is a
problem solving language. 10. 11. In the cognitive mediation questions are meant to initiate a thinking process rather than a feeling process. The question: “What do you
feel?” leads to a completely different process and answer compared to the question: “What do you think?” 12. 13. In the systemic mediation questions are meant to disturb the system in order to initiate reflections. Focus is not on the individual rather
than the relation between the participants constituting the system. 14. 15. In the transformative mediation questions are meant to clarify process issues and to encourage decision-making. Questions are never
meant to provide information. Statements are replaced with conversations on how to process. 16. 17. In the humanistic mediation questions in preparatory meeting are meant to clarify, to encourage, to empower and to encourage to
empathy and recognition. In joint sessions questions are meant to clarify process issues and to encourage decision-making. 18. 19. In the narrative mediation questions are meant to challenge the ownership to the conflict story, to de-construct entitlements to the
context and the labelling of describing terminology, to deconstruct the conflict-saturated story, to engage the party into the externalizing conversation freeing the party to act and shape his own life in relation to others and to construct the alternative story
http://uk.mediator.dk/46-advanced%20techniques.htm, (15.5.2009) A not peer reviewed
article, but some sources are referred to: [1] A further elaboration of chapter 8 in “Mediations processen”, Boserup and Humle, Nyt Juridisk Forlag, 2001. First presented at the VOMA conference in Portland, OR 2001. Later presented on international conferences in Ellsinore, Denmark, Fort Lauderdale, FL, Oostende, Belgium, Heidelberg, Germany. [2] Prominent representatives of this style are the late John Haynes www.mediation-matters.com/res-haynes.htm(first president of AFM) and his successor in AFM Larry Fong, Calgary, Alberta, Canada (http://www.fongmediate.com/). John Haynes: The Fundamentals of Family Mediation, Old
Bailey Press, 1993. [3] This style was refined and defined by Bush and Folger (Bush, Robert and Folger, Joseph: The Promise of Mediation, Jossey-Bass, SF, 1994). In 2001 clarified in: Designing Mediation – Approaches to Training and Practice within a Transformative Framework, 2001, The Institute for the Study of Conflict Transformation, NY. http://www.transformativemediation.org/
[4] Mark Umbreit: Interpersonal Conflicts and Victim meet offender. http://ssw.che.umn.edu/rjp
[5] John Winslade and Gerald Monk: Narrative Mediation, A New Approach to Conflict Resolution, Jossey-Bass, 2000.
103
APPENDIX XVI
Innovation challenges and leadership imperatives
according to reference No. 2 (p.270) (one of the many examples in this book)
Innovation challenge: how do I give innovation the best possible change to succeed?
◘ Identify the most fundamental factors in your organization that are getting in the
way of innovation – and remove them
◘ Try not to let external forces such as market downturns or rising cost get in the way
of your innovation progress. Find ways to address the burning issue without losing
focus on growth goals.
◘ Don’t expect to become an innovation champion by just reading this book. Put your
reading into practice and start “hitting some shots”, learning and progressing as you
go, and then learning and progressing some more.
Innovation challenge: How do I deal with the tension between innovation and efficiency?
◙ Make innovation a “full citizen” – with the same rights, visibility, and impetus
behind it as operational excellence.
◙ Design your organization to keep innovation and efficiency in tension – so that the
interests of each side can always be heard, and so that neither side ever scores a
permanent victory over the other.
◙ Don’t ignore the warning signs that indicate when the healthy tension between
innovation and day-to-day execution is getting out of kilter.
◙ Recognize and master all of the subtle paradoxes that exist within innovation, such
as being unbounded and focused, or creative and systematic, or impatient and
persistent -. By continuously “tuning” your innovation system to keep these tensions
in balance.
Own Comments:
Value creation (a part of which is innovation) can be organized through transactions
and the use of resources, within the product (experience, symbolic) or price/cost.
Innovativeness as well as QA goes right through all of them creates a framework of
relationship marketing. Since there is not much of a symbolic value (which doesn’t
mean that there isn’t any or that we could put it in) and since the prices follow the total
production volume*, we should put a lot of efforts (especially management) to
transactions and resources to be able to innovate more.
*Brown A. et al. Journal of Medical Marketing; Vol. 7, No. 3 (2007), p. 203
106
APPENDIX XIX
TEKES WELLNESS AND HEALTH
WHY?
Ageing and changes at the population structure
- Impact on service relations and health
- Developing the Finnish welfare society
- Individual and human point of view
- availability of the services, treatments and care point of view
- service system functioning, power and effectiveness
Knowledge, skill and technological usability potentials for individual and comprehensive
quality of life, health improvement as well as care and treatment enhancement
Kyselyn tulosten mukaan lähivuosien ja –vuosikymmenien merkittävimpien globaalien
innovaatioalueiden arvioidaan löytyvän energia-alalta (mm. hiilidioksidin hallinta), logistiikasta,
luontoon ja luonnonvaroihin liittyvistä asioista (mm. vesi, maatalous, biopolttoaineet), viestinnästä
sekä ihmisen terveyteen ja turvallisuuteen liittyvistä aloista.
Same in English:
According to the survey results, the global innovation areas during the nearest years and decades are
predicted to be found in energy (for ex.carbondioxide control), logistics, nature and its resources
related entities (for ex. water, agriculture, bioenergy), communication as well as human health and
safety related issues.
From the half year rapport (TEKES, Technology program rapports 8/2007, s.28)
Toimepidesuositus:
1. Prosessien ja rakenteiden uudistamista tukevien hankkeiden colyymin kasvattaminen
2. Yksityisen, julisen ja komannen sektorin valisten kumppanuushankkeiden osuuden merkittävä
lisääminen. Verkostomaisuuden ottamienn myös hankkeiden valintakriteeriksi
3. Monitieteisyyden distäminen aj tukemien hankevalinnassa ja –toteuksessa. Tulevaisuudessa
terveyden edistämisen kehittämiseen tarvitaan yhä monitieteisempää lähestymistapaa mukaan
lukien tekniset tieteet, lääke-, terveys-, yhteikunta-,käyttäytymis-,liikunta-, ja taloustieteet
sekä viestintä
The recommendations for action:
1. Plans to increase the volumes of processes and structures
2. Increasing relevantly the partnering of private, public and 3rd
sector operations.
Networking also as a criteria for choosing
3. Cross-sientific enhancing and supporting in choosing plans and executing them. In
the future we need more cross-scientifically approach including technical science,
medicine, health, community, behaviour, motional and economical sciences and
communication in promoting health enhancement development
107
APPENDIX XX
The comparisons according to the latest drives and theories (see 3.2 Literature review)
The latest tensions are between transaction vs. relationship marketing (Vargo S. et al.
and Palmatier R et al.), contingency or discontinuity (congruent) vs. disruptive markets
(Drazin R et al.,Vargo S. et al. and Christensen C.), Kaizen vs. innovative development
(Hamel et al.), brick by brick vs. leap of faith building as well as affective or cognitive
organization (Homburg e al.) or decentralized or centralized management (Simon H.).
Olson et al. says, that “every strategy needs different combinations of organization
structures and strategic behaviours for success*” But as P.Duncker said, the core is
innovativeness and marketing and Vargo and Lusch said, that skill and knowledge is all
you need, the targets should be customer’s (in a very broad, society wide meaning as
well) benefits and job opportunities coupled to one’s own benefits and cultural
developments of convergence, divergence or crossvergence (RalstonD. and Hofstede G.
and Beals R.).
Innovative development exists, but not in a disruptive way, rather like it always has. HUS is
therefore closer to Kaizen kind of gradual improvements. Same goes for the risk taking and
growth - gradually with almost zero risk.
Affective organization culture and responsiveness are far from our thinking. Cognitive turns
are typical and suits competition better than customers (Homburg et al.)
* Olson et al. Journal of Marketing; Vol. 69 (2005), p. 49
109
APPENDIX XXI 2(2)
A five factor taxonomy model by De Dreu C. at al. Journal of Organizational Behavior Vol.
22 (2001), p. 645-668
Yielding Problem
solving
O
T
H
E
R
S Compromising
Avoidance Forcing
OWN
This is taken from the Action Manual in
case of working community harassment,
HUS Corporate Board of Directors (2005),
p.4 (translated by the author)
APPENDIX XXII
Activity Plan in case or working
community harassment
Stage 1 Employee’s notice to the harassing
parties
Harassment continues
Stage 2 New notice to the harassing parties
Harassment continues
Stage 3 Talkative discussions between the
parties
Harassment continues/needs broader
clarification
Stage 4 Resolving, action and follow-up
with the help of a professional
Harassment continues
Stage 5 Start of continuing action Written Notice by the foreman, task organization,
staff transference
Actions carry a result or Harassment
continues
Peace reached or a second written Notice
and discontinuance of the post or job
Working Safety
Employees’
health care
Ombudsman
112
APPENDIX XXIV 1(6)
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80 ibid.
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83 ibid. p.11
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114
85 ibid. p.127-128
86 ibid. p.25
87 ibid. p.50-51
88 ibid., p.256
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115
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148 Porter-O'Grady T. Health Care Manage Review, Vol. 29(4), 2004, p.283
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151 Richard O. et al. International Journal of Human resource Management Vol. 17, No. 12 (December 2006), p.2102
152 Riely J et al. National Productivity Review Vol.18, No. 3 (Summer 1999), p.63-68
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154 Ringhouse B et al. Health Forum Journal (March/April 1999), p.33-37
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156 Saksvik P et al. Work & Stress Vol. 21, No. 3 (July-September 2007), p.244
157 Saksvik P et al. Work & Stress Vol. 21, No. 3 (July-September 2007), p.255
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Glossary APPENDIX XXV
ADR Alternative Dispute Resolution
ASP Alternative Service Provider
BPR Business Process Reorganization
Bullying Small accumulative acts, that have caused a situation amounting to a pattern of systematic
maltreatment (Salin D.)
CEO Chief executive officer
Conflict See explanation in Introduction. Term used here in a broad meaning (anything from
a small misunderstanding to long disputes and bullying)
Constructive conflict Conflicts that have a positive effect
CRM Customer resource management
Dispute (legalized conflict)
DOAJ Directory of open access journals: http://www.doaj.org/doaj?func=subject&cpid=18
EBSCO Public Library Database of EBSCO Publishing
Epistemology Theory of knowledge
Facilitative leader A facilitative leader doesn’t do for others, what the others can do for themselves (Rees)
Half juridical The decisions are not directly enforceable (by law enforcement)
Heuristics Problem solving with trial and error and experimenting
Hermeneutics Interpretation processes
HRM Human Resource Management
HUS Helsinki and Uusimaa healtcare district (Helsingin ja Uudenmaan sairaanhoitopiiri)
i.e. In this case
Identity conflict a bit like role conflict, since it has to do with social and organizational identity, but
more as a group thing (Northrup)
Intangible assets Like trademarks, logos, copyrights (see for ex. Weston Anson, Consor Intellectual
Asset Management)
Intellectual property Like contracts, drawings, designs, royalties (see for ex. Michael Mard et al.
Consulting Services Practice Aid 99-2: Valueing Intellectual Property and
Calculating Infringement Damages (New York:AICPA,1999), p. 1-15
IY Valmenustalo Itsensäylittäjät Oy
Leader Manager whom people want to lead them and the organization
Leadership All entities that steer the people in an organization
Manager A person in a leading position responsible of the processes more than he feels
responsibility towards people
Management All entities that steer the organization
MBA My set group in MBA
MI Marketing Intelligence
Mobbing Scandinavian-German speaking countries name for bullying (English speaking)
according to Zapf
MSAH Ministry of Social Affairs and Health
MSOC Managerial Span of Control (=proportion managers/employees or degree of
hierarchy of authority in organization)
non-juridical this doesn’t include litigation or arbitration methods, but methods, that do have a
law to indirectly or directly back them up (mediation, employees’ health care and
working safety) as well as other in-house methods (like solving the conflicts in a team)
Nursing staff Doctors and nurses who work in a clinical setting
Ontology Studies being and existence
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Outside of court room The line between juridical – half-juridical – and non-juridical is not a clear cut.
Outside of court room means, that the process is not handled by the authority of law
Perceptual conflicts Conflicts one can more easily find
Phenomenology The reflective study of the essence of consciousness
Porter’s model Model by Michael Porter on marketing penetration
R&D Research and development
Resilience The capacity of individuals to cope successfully in a face of significant change,
adversity or risk
Resolution Act that stops a dispute
SCB Superior Customer Benefit
SMB Small and Medium size Businesses (less than 250 employees)
TEKES Teknologian Edistämiskeskus (The Centre of Technological Achievements)
TENTTU Public Library database of The Helsinki University of Technology
Teleology Learning based on meaning that points to a target or end result as explanation.
Formative Teleology (norms and rules), Transformative Teleology (builds up
with the help of dialogue)
Transitivity Someone is friends with persons who is friends with another person and creates
thus pressure for the first person to become friends with that other person as well
Literature
Burns J.M. Leadership, Harper&Row, New York (1978)
Terttu Grönfors, Action Learning, e-learning, Espoo, Facile Publishing (2002)
Pehrman T. Studie, that I’ve been taking part with and that is at the same time part of his thesis work
Laitinen P. Implemented Change Laboratory™ in Oulu University Hospital