SCCM Resource Library-Conflict Management

Video Transcription

Welcome to our session at the 51st Critical Care Congress.  I'm delighted to have been invited to present this talk, Conflict Management.  Firstly, I have no conflicts of interest related to this topic.  The objectives for today are to identify factors associated with conflict in the ICU and identify their sources, understand conflict management models  and discuss some outcomes related to conflicts in the ICU.  So conflict takes on all kinds of types. There's personal conflict, so within yourself or between you and others, professional conflict within your professional team  or between professional teams or within your team of people.  So let's start with this first study, the Conflicus study that was published in 2009. So it's a little bit old, but the fact of the matter is it's the primary conflict  in the ICU study that's been done to date. So the objective of this study was to examine the prevalence, characteristics and factors of ICU conflicts reported by ICU staff  that recurred in the prior week. They sought to assess the burden on ICU staff members and focused on perceived conflicts without trying to achieve  any objective standardization of responses.  The questionnaire was designed within the ESICM ethics committee using a modified Delphi approach and was validated using three hospital ICUs.  It's important to know that they defined conflict as a dispute, disagreement, incompatibility, opposition or difference of opinion involving more than one individual  and related to the patient's management or to interpersonal conflict.  The ICU conflicts were described according to three categories of perceived characteristics. One, the parties involved in the conflict, two, the source of the conflict  and three, the clinical impact and severity of the conflict. The survey was sent out through the membership of the ESICM ethics committee.  And since this is a palliative care session, I'm gonna focus on the end of life data. It's important to know that it was done over one day and there were 7,358 surveys returned  representing 323 ICUs.  So let's look at some of the results. So there was an 80% return rate for the survey which is substantial with regards to a survey. Of those who replied to the survey,  two thirds of them worked in med-surg adult ICUs and 45% of them had ethics consultants available to them.  So of the over 7,000 respondents, over 5,000 reported at least one perceived conflict in the week prior with 409 of them responding  that there was greater than one perceived conflict in the prior week.  So let's look at how the intensive care unit is organized. So nurses being involved in end of life discussions and nurses being involved in end of life decisions,  you can see in both cases, the majority of the respondents said that they were rarely or never involved.  When you then look further, you can see that implementing end of life decisions and making symptom control decisions at the end of life, both nurses and physicians,  more than half the time in both cases were involved in these processes.  So let's look at characteristics of the respondents.  Of the 5,200 that reported at least one conflict, you can see a very low number of conflicts between the ICU staff and family and the ICU staff and patients.  That's not commonly what we think about when we think about conflict in the ICU. The majority of all the other conflicts happened either within the teams or between the teams.  It is important to note that 80% of the conflicts were identified as severe or dangerous and that conflicts were thought to be related  to prior conflict and that they would occur again, but 70% felt that the conflict could have been avoided.  So the types of conflict, there were general types of conflict as reflected here on this bar graph with personal animosity, mistrust, communication gaps, no regular staff meetings,  misunderstandings among staff, and so on and so forth.  The other conflicts that arose specific to this study were end-of-life conflicts, including no psychological support, suboptimal decision-making processes,  suboptimal symptom control, family preference being disregarded, futile treatment, and so on and so forth.  Lastly, they looked at a multivariate hierarchical analysis of the factors that were associated with intensive care unit conflicts. So conflict was associated with both modifiable  and non-modifiable factors. So things like sex and age, and as well as prior training and ethics.  What we can see here though, is that four factors were associated with the highest conflict. So working more than 40 hours per week, caring for at least one patient  who died within the last week,  and involved in pre-mortem or post-mortem care of at least one dying patient in the last week. And lastly, more than 15 ICU beds.  We can also see that there are two factors that are associated with fewer conflicts, and those include symptom control in dying patients  was ensured jointly by physicians and nurses, and routine ICU unit level meetings.  Another study was done in 12 ICUs in Poland,  involving 232 employees.  They looked at the type and the side of conflict. And we can see that conflict was common in answer to based on your observations and experience,  assess the frequency of ICU conflict. So a third thought that they were common. When we look at the type of conflict, are they overt or hidden?  45% of them felt that they were commonly hidden, and rarely overt.  We can see that the majority of conflicts in this study were between physician and nurse. So within teams.  When we look at causes of conflict, you can see high conflict with regards to salaries, bureaucracy, job overload, frustration with low salary, and other financial policies.  At the low end though, were things like insufficient flow of information, inappropriate information, being communicated with tone of voice and language,  some difficult personalities, and the necessity to make decisions in critical situations. Overall, this study concluded that the main sources of conflict are external,  including financial issues and physical overload.  So really sources of ICU conflict are unavoidable.  Change is one of them. I commonly say to people who are thinking about coming to work in the ICU, think very hard about how you feel about change. Because if change is hard for you,  then the ICU is not the place for you. Since care is commonly changing, processes are commonly changing, and the people are commonly changing. Everyone has their own individuality,  and one's individuality contributes to a source of conflict in the ICU. People aren't necessarily troublemakers, but may be unaware of how they present themselves to the group.  And we'll talk about that a little bit later. Level of experience can only be changed over time. And certainly when people have varying levels of experience,  conflict may arise from that.  So what makes conflict so challenging in the ICU? Well, you can see here's this list, and you can identify any one of them for your own purposes. And I'm sure you've had experience  in a variety of these topics. So people's personal beliefs, their biases, ethics, the amount of stress that they either feel at work or have at home and bring to work,  the complexity of care that presents itself in the ICU, the intensity. In fact, it's in our name, Intensive Care Unit. The rapidity of change, the variety of therapeutic options  with all the pros and cons, and just the simple number of decisions that need to be made over time in the ICU.  So there are a variety of approaches for conflict management, and we'll discuss a couple of them on this slide. So there's this first model, the Rahim model,  that was published in 1983, and it involves dominating, obliging, avoiding, compromising, and finally integrating. The Thomas-Kilman conflict model,  which looks similar to the Rahim model with avoiding, accommodating, competing, collaborating, and compromising, followed by the GRPI model that reflects goals,  roles, processes, and interpersonal skills. And finally, the history and physical model,  the H is listening, the P is collecting objective data, and DD are the reasons and the solutions.  So let's look at the Thomas-Kilman conflict mode instrument that's been around since the early 1970s, and reflects use in a variety of professionals and a variety of groups,  and recognizing that individuals have their own styles and that groups tend to aggregate around certain styles. So in some research, we know that directors of nursing in units,  otherwise known as head nurses in the past, in one study used more collaborating when compared to physicians. PGY-1 residents used more compromising and accommodating.  And yet another study of OB-GYN and radiology residents chose avoiding mode. Yet the OB-GYN chief residents used more competing and collaborating, less avoiding and accommodating.  And when we look at the modified TKI, we can see as assertiveness and cooperativeness increases, we get to this point of collaborating, ultimately leading to compromising,  depending on where you fall in how cooperative or assertive you're being.  So the common themes in conflict management models include communication, bringing the group together, identifying the goals of what you're trying to achieve,  really honing in on the value of the relationship within the team, allowing time for decisions to be made, sureness of the action, and commonly a third party may be involved  to sort of facilitate the group to make sure that things are moving forward. So teams need to be prepared for conflict management. And oftentimes, healthcare providers  receive inadequate formal training on how to manage conflict. And frankly, those who receive conflict training remain unprepared when conflicts come up,  because typically, each conflict has its own unique set of circumstances. And these styles oftentimes will differ between specialties.  So what do we need to be prepared for conflict management? Between specialties.  So there are a variety of types of education for conflict management. The first and typical one is a formal curriculum and didactic, really just teaching about it,  using simulation, using didactic with sim, or didactic with role playing, and teaching people more about nonverbal communication as part of conflict management.  This whole idea of the hot seat  was described by a group training residents on how to facilitate conflict management. And the hot seat was the spot for the person to sit to be the facilitator.  So not only is it important to know how to manage conflict as a team member, but how to manage conflict potentially as a facilitator. And when the person sat in the hot seat,  they were charged with facilitating the management of the conflict.  So what is the impact of conflict in the ICU? What really are the outcomes? So as you can see in the schematic on the left, conflict leads to workplace stress,  burnout, reduced quality outcomes, and those all feed one another. Unfortunately, right now, we don't have any data on whether or not burnout leads to more conflict.  Although intuitively, we would imagine that that's the case.  When we think about conflict from a positive perspective, we can see that conflict may lead to innovation and creativity, which then feeds less workplace stress,  less burnout, and improved quality outcomes. The critical piece of both pieces, whether conflict is good or bad, is remember patient outcomes are relying  on the way we manage our conflict within our ICUs.  So one way to preempt conflict is by building teams. And the Harvard Business Review published this in 2016 and talked about these five steps to build team to preempt conflict.  So the first step is spotting the difference. And really, the goal of the conversation that you're having for spotting the difference is to help team members really think about  how they come across to others and how they actually do. So for example, does one person on the ICU team always dress in business attire when they come to work  when the rest of the team dresses in scrubs? Does that then lead to the team in scrubs perceiving that the person thinks they're more important than those that are wearing scrubs?  So again, it's about how are you perceived and teaching people how they're perceived. So thinking about what the first thing is that people notice about others,  their dress, their speech, their demeanor, and spotting that difference. The second one is misjudging behavior. And one of the things that we know for sure  is that clashing behavioral norms are a common source of trouble. And oftentimes, trivial gestures can have a disproportionate impact that can aggravate or alienate people  and disrupt communication flows. So some of the questions when you're building your teams are to ask what behaviors for the team are valued, helping others, not complaining,  and are there consequences of being late or missing deadlines? So ensuring that everybody is giving everybody else the benefit of the doubt,  but then setting standards of what the behavior should be. Dividing by language. So we already talked about communication being a source of conflict in the ICU.  And communication has many dimensions. The words that are chosen, the way they're expressed, how the team tolerates candor, humor, pauses, interruptions,  and the possibility for misunderstandings are endless, not to mention the least of which is we operate in multicultural teams. So communication using language  that's appropriate for one culture may be terribly inappropriate for another culture. So for example, you should ask your team, are interruptions a signal of interest or rudeness?  And then building the team based on that answer. Next, occupying different mindsets. So often a big source of conflict is the way in which members think about what they're doing.  We all bring something different to the table in the way that we think, in the way that we behave. And because of that, we have experiences that alert us to varied signals,  making different approaches to problem-solving and decision-making. So this could result in working at cross-purposes on the team.  So for example, a question that your team could be asked in a team building exercises is uncertainty viewed as a threat or an opportunity?  So it's important to come to some conclusion on that within your team. Even if you don't have absolute buy-in, everybody knows where everybody else stands.  And lastly, charting emotionals. So we all differ in the intensity of our feelings depending on the topic. We all differ in how we display compassion,  I'm sorry, passion in the group, and the way each of us manages our emotions in the face of disagreement or conflict. So it's important for the team to have an understanding  of what emotions, both the positive ones and the negative ones, are acceptable and unacceptable to display in the business context in the meeting  so that you're working together to preempt conflict.  Okay.  So I will leave you with this image to think about whether conflict is good or bad in the ICU. If you're sitting in a chair in the bright sunshine  and this bee is buzzing around this flower, that may be a conflict that you don't like. But if you're the flower, you may love the bee coming to work with pollinating other flowers.  So is conflict good or bad? Do we grow and learn from it? Are patient outcomes better or worse? Something for you to think about.  I thank you for your kind attention and I'm happy to take questions via email or in the chat.

Video Summary

In this talk on conflict management in the ICU, the speaker discusses the prevalence, characteristics, and sources of conflict in the ICU. They highlight a study that found that over 5,000 ICU staff reported at least one perceived conflict in the prior week, with the majority of conflicts occurring within or between teams. The speaker also examines the factors associated with conflict in the ICU and explores conflict management models, such as the Rahim model and the Thomas-Kilman conflict model. They emphasize the importance of communication, teamwork, and understanding individual differences in managing conflict. The impact of conflict in the ICU is discussed, including workplace stress, burnout, and reduced quality outcomes. The speaker suggests that conflict can also lead to innovation and creativity if managed effectively. Finally, the speaker provides insights on how to build teams to preempt conflict, focusing on spotting differences, misjudging behavior, dividing by language, occupying different mindsets, and charting emotions.

Asset Subtitle

Ethics End of Life, Patient and Family Support, 2022

Asset Caption

This session will cover challenging cases of primary palliative care in the ICU and best practices for integration with palliative medicine. Speakers will review causes of conflict and moral distress among the ICU team, family surrogates, and other medical consultants. The session will also cover communication strategies for optimizing family-centered meetings to discuss goals of care and minimize conflict, along with the differences and similarities in providing palliative care for adult versus pediatric populations through case-based presentation (diagnosis, treatment, and communication). Active small group workshops on communication skills for discussing goals of care, empathy, and conflict resolution will allow skills practice for clinicians.

Meta Tag

Content Type Presentation

Knowledge Area Ethics End of Life

Knowledge Area Patient and Family Support

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Palliative Care

Tag Ethics and End of Life

Year 2022

Keywords

conflict management

ICU

prevalence

teams

communication

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