Hello, and welcome to Crucial Conversations, Difficult Encounters with Interdisciplinary Professionals in the ICU. I'm Dr. Marilyn Bullock. I'm an Associate Clinical Professor and Director of Strategic Operations at the Auburn University Harrison School of Pharmacy. And today we're gonna talk about how you can avoid or deal with conflict that occurs between people who work together in the ICU. The intensive care unit has been one of the best environments for teamwork and collaboration in the healthcare system. And that's the way we want it to be. We want to enjoy the people we work together. We wanna collaborate and get along with all of those that we encounter in our care for our patients. Unfortunately, you can't always get along with every personality. And sometimes there are acute situations that bring high tensions and conflict is bound to arise. But at the end of the day, we have to remember it's about our patients. These are some of the most complex, medically needy patients in the healthcare system. And we have to put aside our own interests to do what's best for them. Or the ICU is a prime environment for conflict, particularly since we're dealing with the most acutely ill and high stakes patients in the healthcare system. Many of our resources are costly or scarce. We've learned that a lot over the past two years. And this isn't just equipment, it's also human capital as well. Most of the conflicts in the ICU center around goals of care. This can be something like, what medication is best for the patient? Or when should we wean them from the ventilator? But many conflicts also involve end of life care decisions. And in fact, we know that those tend to be the most stressful that occur in our clinical environment. There are six key catalysts that influence collaboration or conflict within our ICU teams. These include authority, education, patient needs, knowledge, resources, and time. Anytime there's a challenge or deficiency in one of these six areas, you have an increased likelihood for conflict to arise. Unfortunately, there's not a lot of literature out there about interprofessional communication and conflict in the ICU overall. What does exist seems to be siloed in the disciplines that are involved and doesn't truly capture all of the members of our modern healthcare ICU teams. One factor that can contribute or even mitigate conflict in the ICU is known as the perception of ownership. You may think of this more colloquially as what someone's role is. These are perceived values and constructs and commodities, including knowledge, technical skills, and equipment that we think a person has ownership of. They have the most expertise in. It also may be clinical territory. For example, I'm a pharmacist. I tend to think about medications as being my primary clinical domain. But it may also involve a patient, particularly if you worked very closely with that patient for an extended duration of time, you may have a lot invested in that patient's outcome and feel very protective of what happens to them. Perception of ownership can be both positive and negative, and it can be collective, meaning that it's team-based or individual. Collective ownership tends to be good overall. It fosters team identity and collaboration, while individual perception of ownership can be both positive or negative. This is where one is thought to have priority over a specific area. For example, pharmacists are tend to thought to be primarily knowledgeable about medications, and respiratory therapists tend to be, tend to have a perception of ownership involving the ventilators because that is their clinical area of expertise. The perception of ownership in an individual doesn't have to be negative. It can be positive if it's recognized by others within the team, and that use of knowledge and skills and expertise that one has improves collaboration and overall care in the patient. Unfortunately, if a person's skillset and expertise is not recognized or appreciated by others within the team, it can lead to tension. Perception of ownership can also be negative if we tend to pigeonhole people. We think that the knowledge that they have only exists within a certain area. As I mentioned before, I'm a pharmacist. Most of my recommendations during rounds involve medications, but I've been working with my team for a very long time. I've gotten to a comfort level with them that sometimes I make recommendations that don't involve medications. For example, several times this past year, I've made recommendations that involve social issues of the patient, such as maybe recommending that we consult a chaplain to see them. One of the things that I think is going to help, and maybe not entirely eliminate, the negative outcomes of perception of ownership is that all health discipline schools are required to participate in interprofessional education. And this means that people, while they're still in school, are learning what the other disciplines know, what they're being taught, and what they're capable of bringing to the team. Social structurization theory is a helpful way to think about the construct of professional identity, especially when you're in an environment where there's a lot of different professions in conflict, such as the ICU. We conceptualize professions as a social system, and each profession's role is determined by its position in relation to others and its access to certain commodities. What can that profession bring to the table? What can it bring to the care of our patient? It recognizes that individuals within a profession, or even between professions, are in a constant process of trying to distinguish themselves. They're always trying to prove what can they do for this patient? How can they improve patient care? And how long can they stay part of this team? Precious little literature about conflict between professions in the ICU. One of the best studies was published over a decade ago. The Conflicus Study was put on by the Ethics Section of the European Society of Intensive Care Medicine, SCCM's European counterpart. The section developed a survey that was then distributed by 240 of their intensivists and nurse members at their home institutions. It involved just under 400 ICUs in 29 countries. They had a very good response rate. Just under 7,500 people completed the questionnaires. Now, 60% of these were nurses. They were asked to think about what kind of conflicts occurred in their work environment and how did it impact patient care? 53% said that they perceived them as being severe and 52% said they were dangerous and 83% said they were downright harmful to patient care in their ICUs. Thankfully, respondents seemed to think that conflicts could be easily resolved. 80% said that an informal debriefing would help resolve conflict and 84% saw discussion as a resolution option. If you look over here on the right, they looked at the impact of conflict on job strain according to perceived severity at the top or at the bottom, dangerousness of conflict. Overall, lower demand on a person's time and emotional availability and higher autonomy and social support led to higher scores, which indicates less job strain. The study also looked at risk factors associated with ICU conflicts and they found that male gender being specifically 34 years of age, working more than 40 hours a week were all associated with more conflicts. They also saw that this conflict should vary by job title. It was higher when you were caring for a patient at the end of life and it was higher when it involved government healthcare expenditures. The CONFLICA study also evaluated sources of conflicts that were causing issues within the ICU and behaviors perceived to cause conflicts included personal animosity, mistrust and poor communication. Unfortunately, one fourth of people said that they believe their conflict that was currently occurring was related to a previous conflict and 87% of respondents said they believed conflict was not isolated and would reoccur. Four main categories of conflict within the ICU. Many of them revolve around personality, which also addresses personal aversions and lack of trust. And to be honest, not every person is gonna get along with every other person that they work with and encounter. Some conflicts are procedural. They may arise due to lack of guidelines of what's expected, poor transparency or communication gaps in the ICU working environment or not having a team leader that sets the expectations of what is required and anticipated of all of those working within the ICU. Some conflicts arise out of organization factors, issues that may be specific to a particular unit or at a hospital. For example, you may not have all the adequate staffing that you need. And others are societal in nature, although they can be legal or cultural. These tend to influence our perception and expectations of others. And when things go against what we expect to occur, conflict can arise. There are six main stages of conflict in the ICU. And it's not always possible to distinguish between the six typical stages. When the conflict first occurs, it may be hidden. The people may not even be aware that there's underlying conflict causing an issue. But the time between conflict onset and the time it's recognized can be immediate or it can take a significant amount of time. But eventually, hopefully, it will be recognized. Unfortunately, that conflict will continue to grow until all parties are aware that it exists. Eventually, it will escalate. The recognition of the conflict will be there, but the people involved have their heels dug in and they don't want to change their mind. At some point, you will have stagnation. Where the conflict's left unresolved, everyone still feels offended, but it's not continuing to grow. Eventually, people will become aware of the conflict cost, either to themselves, to their coworkers, their work environment, or even to the patient. And ideally, you will reach a point of de-escalation where you start to think about how you can resolve the process. Now, this can be a laborious process because not only do you have to deal with the acute issues and disagreement at hand, but you have to start building up new interpersonal relations with a person in which you had the conflict. Feelings may be hurt and a lot of trust may have been lost. In the ICU, it is very important to rebuild those interprofessional relationships. Because we know that conflict can have a significant impact on our patients, our families, and our environment. There's a direct impact on patient care. It can lead to delayed care and delayed decision-making. Sometimes, you can see patients continue to receive aggressive therapy when it's not in their best interest. They may receive lower quality of treatment and there's an increased risk of medical error when conflicts occur between team members. Conflict obviously impairs cooperation between the team members, but it also impairs cooperation and contacts with the patient and families. And patients and families, when they see conflicts when they're between team members, don't always know what to think. Sometimes, the families themselves are not always on the same page and seeing conflict among us and disagreements between we think may only contribute or encourage conflict that's already brewing within the families and the patient's social support system overall. And the team impaired by conflict may not provide information that is truly reflective of the patient's present health condition. Thus, even families who are not in conflict with one another that are on the same page can often report being disoriented, anxious, and stressed because they're hearing different pieces of information from different parties and they don't know what is going on with their loved one. Simple methods for preventing conflict in the ICU. First, you wanna stay focused on preventing conflict. It's always easier to prevent than to respond to. You can use communication interventions that facilitate teamwork across world boundaries. For example, ICU goal sheets have been very effective in this matter. But whatever you use, you wanna make sure that you choose an intervention that has inclusive and inclusive outcomes and has inclusive and explicit communication in any of your patient care plans. You wanna try a proactive approach in your task-focused communication rather than a reactive one. If you put it in order and you know that that order may be questioned or may not be slightly unusual, go ahead and take the initiative to reach out to other people that may respond to that order and let them know where you're coming from and have an opportunity to proactively explain your rationale. Get to know other team members and not necessarily think of them as the role that they play. I remember early in my career being known not as Marilyn, but as Pharmacy. And I always hated it because it de-individualized me. People didn't know who I was, how I thought or the way my brain worked. With the team that I'm with now, I've been with them a long time, we know how each other operates. And that makes our collaboration a lot easier. Avoid the trap of being considered excessively polite and differential or even difficult. You don't want to be stereotyped to someone in a particular way where you can either be run over or avoided. And you wanna resolve inter and intro team conflicts prior to engaging the family in any decision discussions, particularly those that will be difficult or involve end-of-life care decisions. Thank you for participating. We hope that this short educational opportunity increased your awareness of conflicts in the ICU, what causes them and how to avoid them.

conflict

ICU

teamwork

collaboration

patient care