A Multilevel Analysis of Professional Conflicts in Health Care Teams: Insight for Future Training

Conflict in emergency medicine: A systematic review

BACKGROUND

The emergency department (ED) is a demanding and time-pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual-, team-, and systemic-level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research.

METHODS

Online databases PubMed and Web of Science were systematically searched for relevant peer-reviewed journal articles in English with keywords relating to "conflict" and "emergency department," yielding a total of 29 articles.

RESULTS

Narrative analysis showed that conflict often occurred during referrals or admissions from ED to inpatient or admitting units. Individual-level contributors to conflict include a lack of trust in ED workup and staff inexperience. Team-level contributors include perceptions of bias between groups, patient complexity, communication errors, and difference in practice. Systems-level contributors include high workload/time pressures, ambiguities around patient responsibility, power imbalances, and workplace culture. Among identified solutions to mitigate conflict are better communication training, standardizing admission guidelines, and improving interdepartmental relationships.

CONCLUSIONS

In emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.

Stress and conflict from tacit culture forges professional identity in newly graduated independent physicians

To transition successfully into independent practice, newly graduated independent physicians (new "attendings") undergo a process of professional identity formation (PIF) as a clinician within a new community of practice (CoP). PIF is crafted by socialization within a CoP including transfer of tacit knowledge. While certain tacit knowledge is critical for professional identity, we understand little how it shapes PIF. We set out to describe the tacit knowledge acquired by new attendings within a CoP and how it contributes to PIF. Informed by constructivist grounded theory, we interviewed 23 new attendings about the tacit knowledge they acquired in early practice. Data collection and analysis occurred iteratively. We identified themes using constant comparative analysis and generated a theory that underwent member checking and feedback. Implicit standards from group culture imparted high expectations on new attendings and led to internal stress. New attendings also encountered a tacit code of conduct as behavioral elements of group culture. These elements created external conflict between new attendings and group members such as departmental colleagues, consulting physicians, and other health professionals. Depending on the support they received, new attendings responded to the stress and conflict in three ways: they doubted, adjusted, or avoided. These strategies molded their professional identity, and moved them towards or away from the CoP as they navigated their transition and PIF. We describe a novel theory of how tacit group culture shaped new attending physicians' professional identity in a new community of practice. Internal stress and external conflict occurred due to high expectations and tacit culture elements. New attendings' doubt, adjust, or avoid responses, shaped by support they received, in turn crafted their professional identity. Education leaders should prepare graduating trainees to navigate aspects of transition to independent practice successfully.

Exploring the Concept of Spiritual Sensitivity from the Perspectives of Healthcare Providers in Iran

Spiritual sensitivity (SS) is defined as attention to the available spiritual values in a conflicting situation and awareness of one's roles and responsibilities in that situation. It helps differentiate between the right and the wrong and leads to sound practice. This study explored the concept of SS from the perspectives of healthcare providers in Iran. This qualitative study was carried out in 2017-2019 using conventional content analysis. Twenty-two physicians, faculty members with clinical work experience, and healthcare providers were purposefully recruited. Data were collected using unstructured interviews and were analyzed using conventional content analysis. Participants' experiences of the concept of SS were grouped into three main themes, namely sense of value, spiritual growth and morale boosting, and SS as a motivator for purposeful service delivery. The findings of the present study will help healthcare managers develop programs for improving healthcare providers' spiritual sensitivity and also will help healthcare providers develop spirituality-based holistic care plans.

Pharmacist trainees narrow scope of interprofessional collaboration and communication in hospital practice

Early curricular exposure to interprofessional education (IPE) is intended to acclimatize health professional trainees to shared-care in the practice settings they will ultimately join. However, IPE activities typically reside outside actual organizational and social systems in which interprofessional care is delivered. We aimed to explore how pharmacist trainees experience collaborator and communicator competency roles during team-based workplace-based learning. Participants maintained written diaries reflecting on interprofessional collaboration and communication during an eight-week hospital clerkship. Diary entries and transcripts from semi-structured follow-up interviews were analyzed from the social constructivist perspective using reflective thematic analysis. Participant accounts of on-ward activities represented most collaborator and communicator roles outlined in pharmacy and interprofessional competency frameworks, but were predominantly between the pharmacist trainee and physicians. Pharmacist trainees did not routinely engage with other health professions on a daily basis. Additionally, reported encounters with other team members were typically information exchanges and not episodes of authentic interdependent or shared care. Interactions were almost completely devoid of perceived interpersonal or role conflict. These findings offer insight into how pharmacist trainees perceive and develop competencies for team-based care. Further work is required to understand how such limited scope of interprofessional communication and collaboration might ultimately impair quality patient care.

From ideal to real: a qualitative study of the implementation of in situ interprofessional simulation-based education

BACKGROUND

Despite the widespread adoption of interprofessional simulation-based education (IPSE) in healthcare as a means to optimize interprofessional teamwork, data suggest that IPSE may not achieve these intended goals due to a gap between the ideals and the realities of implementation.

METHODS

We conducted a qualitative case study that used the framework method to understand what and how core principles from guidelines for interprofessional education (IPE) and simulation-based education (SBE) were implemented in existing in situ IPSE programs. We observed simulation sessions and interviewed facilitators and directors at seven programs.

RESULTS

We found considerable variability in how IPSE programs apply and implement core principles derived from IPE and SBE guidelines with some principles applied by most programs (e.g., "active learning", "psychological safety", "feedback during debriefing") and others rarely applied (e.g., "interprofessional competency-based assessment", "repeated and distributed practice"). Through interviews we identified that buy-in, resources, lack of outcome measures, and power discrepancies influenced the extent to which principles were applied.

CONCLUSIONS

To achieve IPSE's intended goals of optimizing interprofessional teamwork, programs should transition from designing for the ideal of IPSE to realities of IPSE implementation.

Work Climate Scale in Emergency Services: Abridged Version

This study is based on a 40-item work climate scale in hospital emergency services (WCSHES). Teams working in these emergency services experience a heavy workload and have a limited amount of time with each patient. COVID-19 has further complicated these existing issues. Therefore, we believed it would be helpful to draft an abridged version of the 40-item WCSHES, considering both validity and reliability criteria, but giving greater weight to validity. One hundred and twenty-six workers between the ages of 20 to 64 (M = 32.45; standard deviation (SD = 9.73)) years old participated voluntarily in the study. The validity, reliability, and fit model were evaluated in an iterative process. The confirmatory factor analysis yielded appropriate global fit indices in the abridged 24-item version (Χ²(248) = 367.84; p < 0.01, RMSEA = 0.06 with an interval of 90% from 0.05 to 0.07, SRMR = 0.08, GFI = 0.9, AGFI = 0.96, CFI = 0.98, NFI = 0.95, and NNFI = 0.98), along with test criteria validity (ρ_XY = 0.68, p < 0.001) and excellent reliability (α = 0.94 and ω = 0.94), maintaining the same conceptualization and usefulness of the original scale. The abridged 24-item version was used to measure four work climate factors (work satisfaction, productivity/achievement of aims, interpersonal relations, and performance at work). Evidence of the usefulness of the new abridged scale is provided along with a description of our study limitations and future areas for development.

Examining the average scores of nursing teamwork subscales in an acute private medical ward

BACKGROUND

Healthcare is delivered by multidisciplinary healthcare teams who rely on communication and effective teamwork to ensure safe patient care. Teamwork builds on employee cohesion and reduces medical and nursing errors, resulting in greater patient satisfaction and improved healthcare. Effective teamwork not only improves efficiency and patient safety but leads to a healthier and happier workplace, reducing burnout among healthcare professionals. The purpose of this paper is to describe the findings of a pilot project on an acute medical ward in Western Australia. The aim was to understand the participants perceived level of teamwork to support future work practices and ultimately patient care.

METHODS

This study used a descriptive survey research method to measure nursing teamwork in a clinical environment. The Nursing Teamwork Survey (NTS) measures the levels of nursing teamwork in acute healthcare facilities. Items for the NTS were generated on theoretical grounds, based on teamwork behaviours, offering a practical explanation of teamwork dynamics.

RESULTS

The survey incorporated five subscales. The response rate to the survey was 90 % (n = 45) with an overall average result on the survey being (m = 2.97) on a 0-4 Likert scale. The validated NTS has provided participants the opportunity to consider nursing teamwork with regards to their position and perceived responsibilities towards patients and team members.

CONCLUSION

The findings highlight areas for consolidation and improvement in teamwork. Introducing teambuilding strategies and acting on results of this survey may support enhanced communication and teamwork influencing nursing care and patient outcomes. Findings recommend that activities to improve teamwork and ensuring teambuilding strategies are implemented to improve effective communication in an acute medical care setting would have significant impacts on staff satisfaction.

The Role of Power in Health Care Conflict: Recommendations for Shifting Toward Constructive Approaches

PURPOSE

The combination of power and conflict is frequently reported to have a detrimental impact on communication and on patient care, and it is avoided and perceived negatively by health care professionals. In view of recent recommendations to explicitly address power and conflict in health professions education, adopting more constructive approaches toward power and conflict may be helpful. This study examined the role of power in conflicts between health care professionals in different cultural contexts to make recommendations for promoting more constructive approaches.

METHOD

The authors used social bases of power (positional, expert, informational, reward, coercive, referent) identified in the literature to examine the role of power in conflicts between health care professionals in different cultural settings. They drew upon semistructured interviews conducted from 2013 to 2016 with 249 health care professionals working at health centers in the United States, Switzerland, and Hungary, in which participants shared stories of conflict they had experienced with coworkers. The authors used a directed approach to content analysis to analyze the data.

RESULTS

The social bases of power tended to be comparable across sites and included positional, expert, and coercive power. The rigid hierarchies that divide health care professionals, their professions, and their specialties contributed to negative experiences in conflicts. In addition, the presence of an audience, such as supervisors, coworkers, patients, and patients' families, prevented health care professionals from addressing conflicts when they occurred, resulting in conflict escalation.

CONCLUSIONS

These findings suggest that fostering more positive approaches toward power and conflict could be achieved by using social bases of power such as referent power and by addressing conflicts in a more private, backstage, manner.

The Hidden Curriculum: Strategies for Preparing Residents for Practice

PURPOSE OF REVIEW

The goal of this paper was to identify areas of importance in modern urology education that are not currently emphasized in current urological curricula.

RECENT FINDINGS

We identified curricular deficits in robotic surgical simulation, transgender health, leadership, business management, and social media training. Few practicing urologists feel comfortable managing transgender-specific needs, and most training programs do not adequately address transgender health. Urology programs also do not sufficiently emphasize topics in leadership, business management, or appropriate social media usage. With respect to simulation, while it is currently included in the Accreditation Council for Graduate Medical Education (ACGME) program requirements, it is currently under-utilized for training in robotic surgery. It is important for urologists to receive adequate training for the modern practice landscape. Where knowledge gaps among early practicing urologists arise, programs should adapt their curricula to address them.

Predictors and triggers of incivility within healthcare teams: a systematic review of the literature

OBJECTIVES

To explore predictors and triggers of incivility in medical teams, defined as behaviours that violate norms of respect but whose intent to harm is ambiguous.

DESIGN

Systematic literature review of quantitative and qualitative empirical studies.

DATA SOURCES

Database searches according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in Medline, CINHAL, PsychInfo, Web of Science and Embase up to January 2020.

ELIGIBILITY CRITERIA

Original empirical quantitative and qualitative studies focusing on predictors and triggers of incivilities in hospital healthcare teams, excluding psychiatric care.

DATA EXTRACTION AND SYNTHESIS

Of the 1397 publications screened, 53 were included (44 quantitative and 9 qualitative studies); publication date ranged from 2002 to January 2020.

RESULTS

Based on the Medical Education Research Study Quality Instrument (MERSQI) scores, the quality of the quantitative studies were relatively low overall (mean MERSQI score of 9.93), but quality of studies increased with publication year (r=0.52; p<0.001). Initiators of incivility were consistently described as having a difficult personality, yet few studies investigated their other characteristics and motivations. Results were mostly inconsistent regarding individual characteristics of targets of incivilities (eg, age, gender, ethnicity), but less experienced healthcare professionals were more exposed to incivility. In most studies, participants reported experiencing incivilities mainly within their own professional discipline (eg, nurse to nurse) rather than across disciplines (eg, physician to nurse). Evidence of specific medical specialties particularly affected by incivility was poor, with surgery as one of the most cited uncivil specialties. Finally, situational and cultural predictors of higher incivility levels included high workload, communication or coordination issues, patient safety concerns, lack of support and poor leadership.

CONCLUSIONS

Although a wide range of predictors and triggers of incivilities are reported in the literature, identifying characteristics of initiators and the targets of incivilities yielded inconsistent results. The use of diverse and high-quality methods is needed to explore the dynamic nature of situational and cultural triggers of incivility.

Factors Affecting Interprofessional Teamwork in Emergency Department Care of Polytrauma Patients: Results of an Exploratory Study

Considering that traumatic injuries are the leading cause of death among young adults across the globe, emergency department care of polytrauma patients is a crucial aspect of optimized care and premature death prevention. Unfortunately, many studies have highlighted important gaps in collaboration among different trauma team professionals, posing a major quality-of-care challenge. Using the conceptual framework for interprofessional teamwork (IPT) of , the aim of this qualitative descriptive exploratory study was to better understand IPT from the perspective of health professionals in emergency department care of polytrauma patients, specifically by identifying factors that facilitate and impede IPT. Data were collected from a sample of 7 health professionals involved in the care of polytrauma patients through individual interviews and a focus group. In the second phase, 2 structured observations of polytrauma patient care were conducted. Following a thematic analysis, results revealed multiple factors affecting IPT, which can be divided into 5 broad categories: individual, relational, processual, organizational, and contextual. Individual factors, a category that is not part of the conceptual framework of , also emerged as playing a major part in IPT.

Patient Safety Over Power Hierarchy: A Scoping Review of Healthcare Professionals' Speaking-up Skills Training

Communication failures in healthcare constitute a major root cause of adverse events and medical errors. Considerable evidence links failures to raise concerns about patient harm in a timely manner with errors in medication administration, hygiene and isolation, treatment decisions, or invasive procedures. Expressing one's concern while navigating the power hierarchy requires formal training that targets both the speaker's emotional and verbal skills and the receiver's listening skills. We conducted a scoping review to examine the scope and components of training programs that targeted healthcare professionals' speaking-up skills. Out of 9,627 screened studies, 14 studies published between 2005 and 2018 met the inclusion criteria. The majority of the existing training exclusively relied on one-time training, mostly in simulation settings, involving subjects from the same profession. In addition, most studies implicitly referred to positional power as defined by titles; few addressed other forms of power such as personal resources (e.g., expertise, information). Almost none addressed the emotional and psychological dimensions of speaking up. The existing literature provides limited evidence identifying effective training components that positively affect speaking-up behaviors and attitudes. Future opportunities include examining the role of healthcare professionals' conflict engagement style or leaders' behaviors as factors that promote speaking-up behaviors.

Are Physician Associates Less-defined Force Multipliers? Comparative Role Definition of Physician Associates within the Hierarchy of Medical Professionals

Medical field has changed considerably with pressures added on mainly by soaring costs, a decline in the workforce strength and patient expectations. The solution that healthcare systems have come up with is the induction of physician associates (PAs) into the workforce. We aim to compare and contrast PAs with other members of the healthcare teams such as nurses, doctors and assistant physicians to demonstrate the vital role PAs play in the current healthcare environment. With the increased patient load and shrinking medical workforce, there are fears that chronic disease management in primary and secondary care will be threatened. Therefore, health policymakers thought of developing a new mid-level practitioner role (such as PAs, ANPs and APs) that will augment physicians to cater for ever-growing complex medical needs of the patients. The role of PAs is comparable to many healthcare professionals, and one can say that the success of PA programmes has paved the way for the development of different other mid-level practitioner development initiatives. All these roles are there to support primary and secondary care physicians in both inpatient and outpatient settings in helping the patients. PAs are a force multiplier within the healthcare sector and can be seen as a valid solution to staff shortages faced by the healthcare systems around the world. We recommend further studies looking into different aspects of the role of a PA that could further provide our readers with clarity with regard to PAs.

Exploring group boundaries and conflicts: a social identity theory perspective

CONTEXT

In the clinical environment, health care professionals self-categorise into different groups towards which they develop positive attitudes, whereas they view other groups less favourably. Social identity theory purports that these attitudes influence group processes and may foster conflicts that impede collaborative practice, although this relationship is poorly understood. This study used concepts from social identity theory to examine the interplay between group processes and conflicts, as well as the consequences of these conflicts, with the goal of identifying educational strategies to favour teamwork.

METHODS

Semi-structured interviews with 82 randomly selected physicians and nursing professionals working at a Swiss academic medical centre explored participants' experiences of conflicts. Data analysis was informed by social identity theory and focused on interviews where group processes were highlighted by participants. The analysis sought to uncover how group processes were intertwined with conflicts and how they affected health care professionals.

RESULTS

A total of 42 participants out of the initial pool of 82 interviews shared 52 stories of conflicts involving group processes. Most of these stories were shared by physicians and involved groups of physicians at different hierarchical levels. Conflicts and group processes were linked in two ways: (i) through processes of group membership when individuals struggled to join a relevant group, and (ii) through intergroup boundaries, such as when participants perceived that power differentials disadvantaged their own groups. Conflicts could lead to difficult experiences for clinicians who questioned their abilities, became disillusioned with their professional ideals and developed negative perceptions of other groups.

CONCLUSIONS

This study suggests that conflicts involving group processes may lead to stronger intergroup boundaries, challenging current educational efforts to favour teamwork in health care. Taking steps to create more inclusive groups and to encourage perspective taking may help manage intergroup conflict.

Intra versus interprofessional conflicts: implications for conflict management training

Interprofessional collaboration and conflict management training are necessary in health sciences curricula. Characteristics of conflicts occurring within intraprofessional or between interprofessional teams can vary and are poorly understood. We sought to compare and contrast characteristics of intra- versus interprofessional conflicts to inform future training programs. An exploratory study was conducted through semi-structured interviews with 82 healthcare professionals working in a tertiary hospital. Interviews focused on sources, consequences, and responses to conflicts. Conflict situations were analyzed with conventional content analysis. Participants shared more intra- than interprofessional situations. Intraprofessional conflicts were caused by poor relationships, whereas interprofessional conflicts were associated with patient-related tasks and social representations. Avoiding and forcing were the most commonly mentioned responses to intraprofessional conflicts. The theme of power impacted all aspects of conflict both intra- and interprofessional. Intraprofessional conflicts were found to be as important as interprofessional conflicts. Differences in the sources of conflict and similarities regarding consequences of and responses to conflicts support integration of authentic clinical situations in interprofessional training. Understanding similarities and differences between intra- and interprofessional conflicts may help educators develop conflict management training that addresses the sources, consequences, and responses to conflicts in clinical settings.

When Team Conflicts Threaten Quality of Care: A Study of Health Care Professionals' Experiences and Perceptions

OBJECTIVES

To explore professionals' experiences and perceptions of whether, how, and what types of conflicts affected the quality of patient care.

PATIENTS AND METHODS

We conducted 82 semistructured interviews with randomly selected health care professionals in a Swiss teaching hospital (October 2014 and March 2016). Participants related stories of team conflicts (intra-/interprofessional, among protagonists at the same or different hierarchical levels) and the perceived consequences for patient care. We analyzed quality of care using the dimensions of care proposed by the Institute of Medicine Committee on Quality of Health Care in America (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity).

RESULTS

Seventy-seven of 130 conflicts had no perceived consequences for patient care. Of the 53 conflicts (41%) with potential perceived consequences, the most common were care not provided in a timely manner to patients (delays, longer hospitalization), care not being patient-centered, and less efficient care. Intraprofessional conflicts were linked with less patient-centered care, whereas interprofessional conflicts were linked with less timely care. Conflicts among protagonists at the same hierarchical level were linked with less timely care and less patient-centered care. In some situations, perceived unsatisfactory quality of care generated team conflicts.

CONCLUSION

Based on participants' assessments, 4 of 10 conflict stories had potential consequences for the quality of patient care. The most common consequences were failure to provide timely, patient-centered, and efficient care. Management of hospitals should consider team conflicts as a potential threat to quality of care and support conflict management programs.

Internists' and intensivists' roles in intensive care admission decisions: a qualitative study

BACKGROUND

Intensive care Unit (ICU) admission decisions involve collaboration between internists and intensivists. Clear perception of each other's roles is a prerequisite for good collaboration. The objective was to explore how internists and intensivists perceive their roles during admission decisions.

METHODS

Individual in-depth interviews with 12 intensivists and 12 internists working at a Swiss teaching hospital. Interviews were analyzed using a thematic approach.

RESULTS

Roles could be divided into practical roles and identity roles. Internist and intensivists had the same perception of each other's practical roles. Internists' practical roles were: recognizing signs of severity when the patient becomes acutely ill, calling the intensivist at the right moment, having the relevant information about the patient and having determined the goals of care. Intensivists' practical roles were: assessing the patient on the ward, giving expert advice, making quick decisions, managing access to the ICU, having the final decision power and, sometimes, deciding whether or not to limit treatment. In complex situations, perceived flaws in performing practical roles could create tensions between the doctors. Intensivists' identity roles included those of leader, gatekeeper, life-death decision maker, and supporting colleague doctors (consultant, senior and helper). These roles could be perceived as emotionally burdensome. Internists' identity roles were those of leader and partner.

CONCLUSIONS

Despite a common perception of each other's practical roles, tensions can arise between internists and intensivists in complex situations of ICU admission decisions. Training in communication skills and interprofessional education interventions aimed at a better understanding of each other roles would improve collaboration.

Implementing Frontline Worker-Led Quality Improvement in Nursing Homes: Getting to "How"

BACKGROUND

Despite emerging frameworks for quality improvement (QI) implementation, little is known about how the implementation process works, particularly in nursing home settings. A study was conducted to describe "how"' a complex frontline worker-led QI program was implemented in nursing homes.

METHODS

Six focus groups were conducted in February 2017 with participants of a year-long, multicomponent, unit-level QI intervention in seven nursing homes in the Canadian province of Manitoba. Constant comparative analysis was used to examine perspectives of different groups of QI program participants-35 health care aides, health professionals, and managers.

RESULTS

Five themes important to the implementation process were identified: (1) "supportive elements of the QI program structure," (2) "navigating the workplace," (3) "negotiating relationships," (4) "developing individual skills," and (5) "observable program impact." Data on theme integration suggest that "supportive elements of the QI program structure" (Theme 1), "developing individual skills" (Theme 4), and "observable program impact" (on residents, health care aides, and leaders; Theme 5) operated as part of a reinforcing feedback loop that boosted team members' ability to navigate the workplace, negotiate relationships, and implement the QI program.

CONCLUSION

Health care aide-led QI teams are feasible. However, a leadership paradox exists whereby worker-led QI programs also must incorporate concrete mechanisms to promote strong leadership and sponsor support to teams. The findings also point to the underexplored impact of interpersonal relationships between health care aides and professional staff on QI implementation.