- Email: [email protected]
Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict
EDUCATION
Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict Julia Kfouri, MD;1 Patricia E. Lee, MD, CM, LLM2 1
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto,
Toronto, ON 2
Division of Urogynecology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of
Toronto, Toronto, ON J. Kfouri
Abstract Objective: In the health care sector, intercollegial conflict is inevitable. Such conflict may have an adverse effect on employee turnover, workplace morale, and patient safety and care. Conversely, skillful management of conflict may result in beneficial change and improvement. Improved conflict management (CM)/ dispute resolution (DR) knowledge for health care professionals (HCPs) has been shown to reduce the negative impacts of conflict. This study aimed to determine whether HCPs feel equipped to manage collegial workplace conflict and whether they feel there is a need for CM training. Methods: An electronic survey was developed to determine the attitudes, experience, and background training HCPs have had with CM, as well as whether respondents felt they needed CM/DR training. The survey was emailed to 660 HCPs in 2013 at Sunnybrook Health Sciences Centre, Toronto, Ontario. Results: The response rate was 46% (303 of 660). Of 303 respondents, 128 (42%) reported previous formal training in CM/DR, but only 80 of 303 (26%) felt adequately trained to manage conflict and resolve disputes in the workplace, with 59% believing they need more conflict training. Among respondents, 76% wanted to see these skills incorporated into their own career training opportunities, but only 34% were aware of courses Key Words: Collegial conflict, conflict management, surveys, questionnaires Corresponding Author: Dr. Patricia Lee, Division of Urogynecology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON. [email protected] Competing interests: The authors declare that they have no competing interests. Presented as “Conflict in the Health Care Sector at the Society of Obstetricians and Gynecologists of Canada Annual Clinical Meeting, June 2014, Niagara Falls, ON; and as “Conflict in the Health Care Sector: Why can’t we all get along?” at University of Toronto’s Obstetrics and Gynecology Annual Research Day, May 2013, Toronto, ON, where it was awarded best resident presentation. Received on January 14, 2018 Accepted on March 26, 2018
available to improve their CM/DR skills, and 50% stated they would be interested in taking such courses; 79% wanted to see these skills incorporated into medical school curricula. Conclusion: This needs assessment survey found that most HCPs did not believe that they have adequate training to manage workplace conflict comfortably, and they felt more training is needed in CM/DR.
Résumé Objectif : Dans le milieu des soins de santé, les conflits interprofessionnels sont inévitables. Ces conflits peuvent cependant avoir des conséquences négatives sur le roulement des employés et le moral au travail, ainsi que sur la sécurité des patients et les soins qui leur sont prodigués. En revanche, la capacité à gérer les conflits peut entraîner des changements positifs. En effet, il a été démontré que l’amélioration des connaissances en gestion de conflits (GC) et résolution de conflits (RC) chez les professionnels de la santé permettait d’atténuer les conséquences négatives des conflits. Cette étude avait pour but de déterminer si les professionnels se sentaient bien outillés pour gérer des conflits interprofessionnels en milieu de travail, et s’ils jugeaient avoir besoin de formation en la matière. Méthodologie : Nous avons créé un sondage électronique visant à déterminer les attitudes, l’expérience et la formation de base des professionnels de la santé en matière de GC. Les répondants devaient également indiquer s’ils estimaient avoir besoin de formation en GC/RC. Le sondage a été envoyé par courriel à 660 professionnels, en 2013, au Sunnybrook Health Sciences Centre, à Toronto. Résultats : Le taux de réponse a été de 46 % (303 répondants sur 660 sondages envoyés). Parmi les répondants, 128 (42 %) ont mentionné avoir déjà suivi une formation structurée en GC/RC, mais seulement 80 (26 %) se sentaient adéquatement formés pour gérer et résoudre des conflits en milieu de travail; 59 % des répondants jugeaient d’ailleurs qu’ils auraient besoin de formation supplémentaire. Parmi les répondants, 76 % désiraient que les compétences de GC/RC soient ajoutées à leurs occasions de formation professionnelle, mais seulement 34 % connaissaient des cours offerts sur ces compétences. De plus, 50 % des répondants ont indiqué qu’ils souhaiteraient suivre des cours dans ce domaine. Enfin, 79 % désiraient que ces compétences soient ajoutées aux programmes d’études de médecine.
JANUARY JOGC JANVIER 2019 • 15
EDUCATION
Conclusion : Ce sondage a révélé que la plupart des professionnels de la santé estimaient ne pas posséder la formation nécessaire pour bien gérer des conflits en milieu de travail et qu’ils auraient besoin de formation supplémentaire en matière de GC/RC. Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2019;41(1):15–20
tively and to result in increased malpractice and liability costs for the organization.3,4 Conflict in a large, complex health care organization is unavoidable; however, conflict is not intrinsically negative. For people with the proper training or experience, conflicts often may be managed to avoid any of the negative consequences, and the conflict may even be used as an agent of change if properly channeled.
https://doi.org/10.1016/j.jogc.2018.03.132
INTRODUCTION
C
onflict can be defined as a “disagreement between two individuals that causes or has the potential to cause harm.”1 Conflict is an inevitable, natural, and normal occurrence when individuals with differences in opinions, beliefs, roles, cultures, and languages interact. The health care system involves a complex, dynamic, and frequently changing mix of people working together for the common goal of excellent patient care at the highest level of efficiency. Not surprisingly, this environment is rich with the ingredients for conflict. Within the hospital setting there are many potential sources of conflict: (1) personality conflicts (personal differences), (2) role incompatibility (differences in goals and responsibilities), (3) information deficiencies (missing or partial information leading to differences in opinions), and (4) environmental stress (resource allocation),2 all of which could lead to conflict among health care professionals. Some examples include the allocation of on-call, providing or receiving feedback, informing a colleague that he or she is not meeting expectations, dealing with disruptive behaviour, resource allocation or the use of data, transparency or accountability regarding a process, and more. It is a given that conflict occurs in health care organizations. The negative consequences of conflict can be quite dramatic and stressful for people, but they can also lead to direct and indirect effects on the organization by adversely affecting morale, sick time, employee turnover, efficiency, costs, medical management, patient safety, and patient care.3 Additionally, conflict within health care teams has been shown to affect hospital administration and economics nega-
ABBREVIATIONS CM
conflict management
DR
dispute resolution
Ob/Gyn
obstetrics and gynecology
16 • JANUARY JOGC JANVIER 2019
Many hospitals now offer conflict management and leadership courses to their employees, and conflict resolution and prevention are recognized by the Royal College of Physicians and Surgeons of Canada as a key competency to be learned in medical school.5 Despite this, there are currently no available studies reporting on the preparedness and comfort of individuals working within Canadian health care institutions in managing conflict in their professional environment. The objective of this study was to determine health care professionals’ comfort level regarding CM and dispute resolution at our hospital (Sunnybrook Health Sciences Centre, Toronto, ON) and to determine whether these professionals felt they required more formal training in this area. MATERIALS AND METHODS
A cross-sectional online survey was carried out at a single tertiary care academic health science centre (SHSC) to determine the attitudes, experience, and background training of health care professionals in CM. Research Ethics Board approval was obtained from both SHSC (University of Toronto, project # 040–2013) and Osgoode Hall Law School (York University, Toronto). An electronic survey was created using the SurveyMonkey.com web survey system. The 27-question survey was pre-tested by several health care providers in the Department of Obstetrics and Gynecology at SHSC for content, clarity, and ease of flow. Consent was implied if the participant completed and submitted the electronic survey. The survey was strictly anonymous and confidential for the participant. No personal health data were collected. Program chiefs of the following departments at SHSC were contacted to request permission to distribute the questionnaires to their members: Departments of Medicine, Surgery, Ob/Gyn, Emergency Medicine, Family Practice, and Neonatology. The following nursing units were approached: obstetric, perioperative, and OR. Recruited trainee groups included medical students on an Ob/Gyn rotation, Ob/Gyn residents and fellows, and anaesthesia fellows.
Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict
Table 1. Conflict management styles
Table 2. Survey questions 15–27
Avoiding
Conflict is not addressed or deferred to avoid the possibility of loss.
Question number
Both parties work to find a solution that is fully satisfactory to both.
15
There is a lot of conflict at my workplace.
16
I find conflict situations stressful.
17
I enjoy conflict situations.
18
I am adequately trained to manage conflict and resolve disputes in the workplace.
19
CM/DR is something I need to learn more about.
20
I am comfortable managing conflict in the workplace.
21
I am satisfied with my ability to resolve workplace disputes.
22
I feel CM/DR is an important skill for me to have in my workplace.
23
I feel CM/DR is an important skill for others to have in my workplace.
24
I believe formal CM/DR teaching sessions should be incorporated into the medical trainee’s curriculum.
25
I believe formal CM/DR teaching sessions should be incorporated into my career training.
26
I am aware of courses that are available for CM/DR training.
27
I would like to take a course in CM and DR.
Collaborating Competing Compromising
Accommodating
Competition occurs to overcome opposition and ensure individual’s position prevails. Both parties involved make trade-offs to reach a mutually acceptable solution that is partially satisfactory to both. One party subordinates own interests for the sake of preserving the relationship.
Adapted from Kilmann and Thomas.6
Once approval was received, the Survey Monkey questionnaire link was emailed to each department’s members. In total, 660 potential participants, including staff physicians, nursing teams, medical trainees, and support and administrative staff, received the survey invitation between February and May 2013. Three reminders were sent electronically at monthly intervals. There was no monetary incentive for completing the survey. Survey response data were compiled, codified, and entered into a survey database. The survey was in English. The survey was divided into the following components: 1. Participant’s demographic background. 2. Participant’s exposure to CM/DR to date: “In your post high school training, did you receive any training in CM/DR?” 3. Conflict experience: A description of a conflict situation was elicited with the question: “Think of a recent conflict situation at your work place that involved a colleague (not a patient or client). What was it? (describe in a few words).” 4. Conflict responses: The participant’s management style in response to a conflict situation described at work was explored with the following question and response choices (Table 1’6): “What did you do? Avoidance (ignoring it), collaborate (“let’s work it out together”), fight back (“my way or the high way”), compromise (“split the difference”), or accommodate (“do whatever you want”).” 5. Conflict outcome: The outcome of the conflict was assessed with the following questions: “Did you feel equipped to deal with the conflict?” (response choices: yes, no, or not sure), “Did you feel the outcome of the conflict situation was satisfactory?” (response choices: yes, no, or not sure), and “Did you receive help/advice in order to manage your conflict situation?” (response choices: yes, no, or not sure).
Question
CM: conflict management; DR; dispute resolution.
6. Participant’s attitudes towards CM and CM/DR training: Participants were polled with 13 questions (see Table 2 for questions 15–27) regarding their comfort in dealing with conflict and their attitudes to formal training in CM/DR. Responses to this group of questions were determined on the basis of a Likert scale of 1–7 (1 = no agreement with statement; 7 = complete agreement with statement). For the analysis, we presented quantitative data as percentages on the basis of the numbers of responses received to each individual question. The narrative responses to the open-ended questions were reviewed and categorized into one of the following four groups, according to recurring themes observed (adapted from Whetten’s and LemieuxCharles’ identified sources of conflict2,7): (1) personal differences, (2) role incompatibility (reflecting differences in goals and responsibilities), (3) information deficiencies (reflecting differences in opinions regarding treatment plans or other patient care–related issues), and (4) environmental stress (reflecting disagreements on budget allocation, scheduling concerns, and other resource-related issues). RESULTS
Of the 660 various department members invited to participate in the survey, there were 303 participants (response
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were planning on future CM/DR training compared with 17 (14%) physicians.
Table 3. Survey participants’ demographics Participant positions/roles Position
N (%)
Staff physician
124 (41)
Nurse
102 (34)
Medical trainee
46 (15)
Hospital administrator
10 (3)
Support staff
21 (7)
Years worked in position Number of years
N (%)
<5
96 (32)
5–10
65 (21)
11–20
73 (24)
>20
69 (23)
Participants’ department affiliations Department Obstetrics and gynecology
N (%) a
Surgeryb
113 (37) 95 (31)
Internal medicine
28 (9)
Emergency department
20 (7)
Anesthesia
20 (7)
Psychiatry
13 (4)
Family medicine
9 (3)
a
Includes physicians and labour and delivery nurses.
b
Includes physicians and operating room nurses.
Recent Conflict Experience – Open Comments
Narrative free-text comments describing a recent conflict experience with a colleague were provided by 284 of 303 (94%) respondents. Some examples of submissions are included in Table 4. Comments were categorized as being the result of personal differences in 89 of 284 (31%) of cases, whereas 81 of 284 (29%) were related to environmental stress, 62 of 284 (22%) were related to role incompatibilities, and 52 of 284 (18%) were related to information deficiencies. When asked to explore their perceived CM style 123 of 253 (48.5%) chose to “collaborate.” Other choices were “avoidance” in 43 (17%), “compromise” in 37 (14.5%), “accommodation” in 35 (14%), and “competition” in 15 (6%) of cases (Table 5). When asked “Did you feel equipped to deal with the conflict?” 146 (49%) stated that they did feel equipped, 82 (28%) were not sure, and 70 (23%) felt unprepared. To resolve the conflict, 138 (46%) sought advice from another source, such as a colleague or manager. In total, 128 (44%) were satisfied, 72 (25%) were not sure, and 90 (31%) were unsatisfied with the outcome of the conflict. Opinion Statements
rate, 46%). Participants’ demographic information is described in Table 3.
Training Experience in Conflict Management
Of our participants, 128 of 303 (42%) reported previous formal training in CM/DR, with 51% (65 of 128) having attended workshops, 46% having attended lectures, and 59% having taken part in small group sessions. This exposure was a formal component of the individual’s training program’s curriculum for 49% of respondents. Of nurse participants, 62 of 102 (60%) had previous CM/DR training, with 35 of 62 (56%) stating this was part of their training. Physicians reported they had received prior CM/DR training in 38 of 128 (30%) of cases, with only 12 (32%) indicating that this was a part of their medical curriculum. When asked about future CM/DR skill development, only 56 of 303 (18%) participants planned on enrolling in a course in this area, whereas 235 of 303 (78%) had no current intent of exploring more training, and 12 (4%) chose not to answer. Of the nursing respondents, 28 (27%)
18 • JANUARY JOGC JANVIER 2019
When asked their opinion on the statement “there is a lot of conflict in my workplace,” 163 of 303 (54%) of participants responded 5–7 on a Likert scale of 1–7 (indicating strong agreement); 223 (74%) indicated that they found conflict situations stressful (Likert scale 5–7, question 16). Only 80 (26%) respondents believed they were adequately trained to manage conflict and resolve disputes in the workplace (question 18), and 114 (38%) were comfortable managing such conflict situations (question 20). A total of 122 (40%) were satisfied with their CM skills (question 21), whereas 180 (59%) believed they need to learn more about CM/DR (question 19). Finally, we were interested in understanding our survey respondents’ opinions regarding the importance of CM/DR skills: 260 respondents (86%) believed CM/DR skills are important for them to have in their workplace (question 22), and 270 (89%) believed these skills are important for others to have in their workplace (question 23). A total of 238 (79%) and 229 (76%) wanted to see these skills incorporated into medical school curricula (question 24) and their own career training opportunities (question 25), respectively. Although only 103 of 303 (34%) were aware of
Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict
Table 4. Selected respondents’ descriptions of a recent conflict Personal differences: interpersonal conflict – personality differences, bullying, gossip, yelling “It was my first day as a scrub nurse in the OR and the surgeon lost it on me because I didn’t properly load the laparoscopic needle driver.” “Resident was condescending to nurses, stating he/she was in charge.” “Academic bullying resulting in me having to switch to a different research niche” “Shunning because of whistleblowing” “I felt a colleague was belittling my role on our team.” “Colleague being rude to me in front of a patient” Environmental stress: resource scarcity and uncertainty, budget and resource allocation, scheduling concerns, on-call coverage, clinic bookings “Distribution of departmental finances” “Vacation allotments and on-call not being uniform among physicians” “Doctor kept telling me to book patients in to see her sooner but then complained when the clinic was overbooked and ran late.” “Conflict over strategic priorities and leadership” “Disagreement about policy direction and planning resource allocation” “Surgeon’s last OR case was cancelled due to time constraints and surgeon became angry and disrespectful.” Role incompatibilities: differences in roles/expectations: surgeon-anesthetist, physician leader-physician, physician-nurse, staff-trainee, charge nurse-RN “Anesthetist was disappearing between OR cases, slowing down the process and threatening my ability to get the entire OR list completed.” “Working with allied health care colleagues to develop standards of care” “L&D nurse paged me overhead stat to come back to labour floor – I was in Emerg seeing a consult and ran upstairs thinking there was an emergency. When I got there, she just wanted her primip examined for progress and told me she thought I had gone to bed.” “Charge nurse kept sending everyone else on breaks before me” “dealing with contrary staff members” Information deficiencies: consultations, treatment plans, discharge planning, medication administration “Oncology team refused to see a patient in the emergency department with an obvious malignancy until the patient had proof of tissue diagnosis.” “Different judgment on patient care” “Surgical staff disagreed with anesthesia regarding need for patient-controlled analgesia (PCA) pump in post-op patient.” “Dispute over medical management” “The consultant was rude and refused to see the patient in Emerg.” L&D: labour and delivery; Emerg: emergency department; primip: primipara.
available CM/DR courses (question 26), 151 (50%) stated they would be interested in taking such courses (question 27). DISCUSSION
This survey is the first specifically to investigate the background training and comfort in CM/DR of health care workers in a Canadian medical institution.
The survey identifies a need for, and an interest in, further training in CM/DR. The work, however, is far from done. In fact, it is our hope that this questionnaire will serve as a catalyst for the serious examination of opportunities at each of the undergraduate, post-graduate, and post-licensing levels for increased exposure and more formal training in CM/DR to allow for access to more trainees, thus serving to raise awareness on the issue early in their professional career. Some of this type of training is already a mandatory component
Table 5. Conflict management styles of survey respondents (N = 253) Collaborate Avoid Compromise
48.5% (123/253)
Both parties work to find a solution that is fully satisfactory to both.
17% (43/253)
Conflict is not addressed or deferred to avoid the possibility of loss.
14.5% (37/253)
Both parties involved make trade-offs to reach a mutually acceptable solution that is partially satisfactory to both.
Accommodate
14% (35/253)
One party subordinates own interests for the sake of preserving the relationship.
Compete
6% (15/253)
Competition occurs to overcome opposition and ensure individual’s position prevails.
JANUARY JOGC JANVIER 2019 • 19
EDUCATION
of medical training in some Canadian programs (e.g., the University of Toronto Faculty of Medicine’s pre-clerkship course), but it is unclear whether this is sufficient to improve trainees’ comfort level and ability in managing workplace collegial conflict.8 Some studies do show promising results with formal CM/DR training for employees. Steinert et al.9 concluded that participants in faculty development leadership programs reported increased confidence in and awareness of their CM skills. Zweibel et al.10 and Zweibel and Goldstein11 showed, in a study of participants in conflict resolution training programs, that learners gained a positive outlook on their ability to apply CM/DR skills and were able to transfer the skills gained in the classroom to the workplace both immediately and one year after completion of the workshops. Although this questionnaire serves as an assessment of the current state of CM skills and training among health care professionals at one institution, the Royal College of Physicians and Surgeons of Canada reinforces that this is but the first step in the multifaceted approach needed to develop CM processes in health care facilities and recommends that the next task be a careful examination of hospital resources available to assist with implementing CM/DR training modules at the staff level.12 Our study has some limitations. Most of the literature describes an expected response rate to conventional surveys of 70% to 75%, but these high rates are often affected by the use of registered mail services and monetary incentives.13,14 Although our survey did adhere to some of the other recognized methods for increasing response rates, including shortening the questionnaire and sending multiple reminders, we chose to use an electronic survey system to reach our recipients in an effective, efficient, low-cost, and convenient manner.15 Web surveys, however, often result in lower response rates, described as ranging from 34% to 56%.16,17 The response rate of 46% is in keeping with the reported response rates of electronic surveys. The survey was distributed locally, at SHSC only, thus resulting in a limited number of participants invited overall. The crosssectional survey method is potentially biased, with the possibility that health care professionals were more likely to respond to the questionnaire if they had experienced unprofessional and non-collaborative interactions in their workplace.
outcome of a recent conflict situation. This needs assessment survey identifies a need for and interest in additional training in CM/DR for those who work in health care institutions. REFERENCES 1. Saltman DC, O’Dea NA, Kidd MR. Conflict management: a primer for doctors in training. Postgrad Med J 2006;82:9–12. 2. Lemieux-Charles L. Physicians in health care management: 10. Managing conflict through negotiation. CMAJ 1994;151:1129–32. 3. Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual 2011;26:372–9. 4. Forte PS. The high cost of conflict. Nurs Econ 1997;15:119–23. 5. Frank JR, Snell L, Sherbino J. CanMEDS 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available at: http://canmeds.royalcollege.ca/uploads/en/ framework/CanMEDS%202015%20Framework_EN_Reduced.pdf. Accessed on October 24, 2018. 6. Kilmann RH, Thomas KW. Developing a forced choice measure of conflict management behavior: the MODE instrument. Educ Psychol Measures 1977;37:309–23. 7. Whetten DA, Cameron KS. Developing management skills. 2nd ed. New York: Harper Collins; 1991. 8. MD Program, University of Toronto. Leader 3. Key Competency 3. Demonstrate Leadership in Professional Practice. Toronto: MD Program, University of Toronto; 2017. Available at: http://www.md.utoronto.ca/ content/leader-3. Accessed on October 24, 2018. 9. Steinert Y, Naismith L, Mann K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME guide no. 19. Med Teach 2012;34:483–503. 10. Zweibel EB, Goldstein R, Manwaring JA, et al. What sticks: how medical residents and academic health care faculty transfer conflict resolution training from the workshop to the workplace. Conflict Resolution Q 2008;25:321–50. 11. Zweibel EB, Goldstein R. Conflict resolution at the University of Ottawa Faculty of Medicine: the Pelican and the sign of the triangle. Acad Med 2001;76:337–44. 12. Marshall P, Robson R. Conflict Resolution. Ottawa: Royal College of Physicians and Surgeons of Canada; 2017. Available at: http:// www.royalcollege.ca/rcsite/bioethics/primers/conflict-resolution-e#top. Accessed on October 24, 2018. 13. Raziano DB, Jayadevappa R, Valenzula D, et al. E-mail versus conventional postal mail survey of geriatric chiefs. Gerontologist 2001;41:799–804. 14. Thorpe C, Ryan B, McLean SL, et al. How to obtain excellent response rates when surveying physicians. Fam Pract 2009;26:65–8. 15. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002;324:1183.
CONCLUSION
16. Braithwaite D, Emery J, De Lusignan S, et al. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract 2003;20:545–51.
Most survey participants did not feel equipped to handle collegial or workplace conflict and were dissatisfied with the
17. Seguin R, Godwin M, MacDonald S, et al. E-mail or snail mail? Randomized controlled trial on which works better for surveys. CanFam Physician 2004;50:414–9.
20 • JANUARY JOGC JANVIER 2019
Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict Julia Kfouri, MD;1 Patricia E. Lee, MD, CM, LLM2 1
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto,
Toronto, ON 2
Division of Urogynecology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of
Toronto, Toronto, ON J. Kfouri
Abstract Objective: In the health care sector, intercollegial conflict is inevitable. Such conflict may have an adverse effect on employee turnover, workplace morale, and patient safety and care. Conversely, skillful management of conflict may result in beneficial change and improvement. Improved conflict management (CM)/ dispute resolution (DR) knowledge for health care professionals (HCPs) has been shown to reduce the negative impacts of conflict. This study aimed to determine whether HCPs feel equipped to manage collegial workplace conflict and whether they feel there is a need for CM training. Methods: An electronic survey was developed to determine the attitudes, experience, and background training HCPs have had with CM, as well as whether respondents felt they needed CM/DR training. The survey was emailed to 660 HCPs in 2013 at Sunnybrook Health Sciences Centre, Toronto, Ontario. Results: The response rate was 46% (303 of 660). Of 303 respondents, 128 (42%) reported previous formal training in CM/DR, but only 80 of 303 (26%) felt adequately trained to manage conflict and resolve disputes in the workplace, with 59% believing they need more conflict training. Among respondents, 76% wanted to see these skills incorporated into their own career training opportunities, but only 34% were aware of courses Key Words: Collegial conflict, conflict management, surveys, questionnaires Corresponding Author: Dr. Patricia Lee, Division of Urogynecology, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON. [email protected] Competing interests: The authors declare that they have no competing interests. Presented as “Conflict in the Health Care Sector at the Society of Obstetricians and Gynecologists of Canada Annual Clinical Meeting, June 2014, Niagara Falls, ON; and as “Conflict in the Health Care Sector: Why can’t we all get along?” at University of Toronto’s Obstetrics and Gynecology Annual Research Day, May 2013, Toronto, ON, where it was awarded best resident presentation. Received on January 14, 2018 Accepted on March 26, 2018
available to improve their CM/DR skills, and 50% stated they would be interested in taking such courses; 79% wanted to see these skills incorporated into medical school curricula. Conclusion: This needs assessment survey found that most HCPs did not believe that they have adequate training to manage workplace conflict comfortably, and they felt more training is needed in CM/DR.
Résumé Objectif : Dans le milieu des soins de santé, les conflits interprofessionnels sont inévitables. Ces conflits peuvent cependant avoir des conséquences négatives sur le roulement des employés et le moral au travail, ainsi que sur la sécurité des patients et les soins qui leur sont prodigués. En revanche, la capacité à gérer les conflits peut entraîner des changements positifs. En effet, il a été démontré que l’amélioration des connaissances en gestion de conflits (GC) et résolution de conflits (RC) chez les professionnels de la santé permettait d’atténuer les conséquences négatives des conflits. Cette étude avait pour but de déterminer si les professionnels se sentaient bien outillés pour gérer des conflits interprofessionnels en milieu de travail, et s’ils jugeaient avoir besoin de formation en la matière. Méthodologie : Nous avons créé un sondage électronique visant à déterminer les attitudes, l’expérience et la formation de base des professionnels de la santé en matière de GC. Les répondants devaient également indiquer s’ils estimaient avoir besoin de formation en GC/RC. Le sondage a été envoyé par courriel à 660 professionnels, en 2013, au Sunnybrook Health Sciences Centre, à Toronto. Résultats : Le taux de réponse a été de 46 % (303 répondants sur 660 sondages envoyés). Parmi les répondants, 128 (42 %) ont mentionné avoir déjà suivi une formation structurée en GC/RC, mais seulement 80 (26 %) se sentaient adéquatement formés pour gérer et résoudre des conflits en milieu de travail; 59 % des répondants jugeaient d’ailleurs qu’ils auraient besoin de formation supplémentaire. Parmi les répondants, 76 % désiraient que les compétences de GC/RC soient ajoutées à leurs occasions de formation professionnelle, mais seulement 34 % connaissaient des cours offerts sur ces compétences. De plus, 50 % des répondants ont indiqué qu’ils souhaiteraient suivre des cours dans ce domaine. Enfin, 79 % désiraient que ces compétences soient ajoutées aux programmes d’études de médecine.
JANUARY JOGC JANVIER 2019 • 15
EDUCATION
Conclusion : Ce sondage a révélé que la plupart des professionnels de la santé estimaient ne pas posséder la formation nécessaire pour bien gérer des conflits en milieu de travail et qu’ils auraient besoin de formation supplémentaire en matière de GC/RC. Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2019;41(1):15–20
tively and to result in increased malpractice and liability costs for the organization.3,4 Conflict in a large, complex health care organization is unavoidable; however, conflict is not intrinsically negative. For people with the proper training or experience, conflicts often may be managed to avoid any of the negative consequences, and the conflict may even be used as an agent of change if properly channeled.
https://doi.org/10.1016/j.jogc.2018.03.132
INTRODUCTION
C
onflict can be defined as a “disagreement between two individuals that causes or has the potential to cause harm.”1 Conflict is an inevitable, natural, and normal occurrence when individuals with differences in opinions, beliefs, roles, cultures, and languages interact. The health care system involves a complex, dynamic, and frequently changing mix of people working together for the common goal of excellent patient care at the highest level of efficiency. Not surprisingly, this environment is rich with the ingredients for conflict. Within the hospital setting there are many potential sources of conflict: (1) personality conflicts (personal differences), (2) role incompatibility (differences in goals and responsibilities), (3) information deficiencies (missing or partial information leading to differences in opinions), and (4) environmental stress (resource allocation),2 all of which could lead to conflict among health care professionals. Some examples include the allocation of on-call, providing or receiving feedback, informing a colleague that he or she is not meeting expectations, dealing with disruptive behaviour, resource allocation or the use of data, transparency or accountability regarding a process, and more. It is a given that conflict occurs in health care organizations. The negative consequences of conflict can be quite dramatic and stressful for people, but they can also lead to direct and indirect effects on the organization by adversely affecting morale, sick time, employee turnover, efficiency, costs, medical management, patient safety, and patient care.3 Additionally, conflict within health care teams has been shown to affect hospital administration and economics nega-
ABBREVIATIONS CM
conflict management
DR
dispute resolution
Ob/Gyn
obstetrics and gynecology
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Many hospitals now offer conflict management and leadership courses to their employees, and conflict resolution and prevention are recognized by the Royal College of Physicians and Surgeons of Canada as a key competency to be learned in medical school.5 Despite this, there are currently no available studies reporting on the preparedness and comfort of individuals working within Canadian health care institutions in managing conflict in their professional environment. The objective of this study was to determine health care professionals’ comfort level regarding CM and dispute resolution at our hospital (Sunnybrook Health Sciences Centre, Toronto, ON) and to determine whether these professionals felt they required more formal training in this area. MATERIALS AND METHODS
A cross-sectional online survey was carried out at a single tertiary care academic health science centre (SHSC) to determine the attitudes, experience, and background training of health care professionals in CM. Research Ethics Board approval was obtained from both SHSC (University of Toronto, project # 040–2013) and Osgoode Hall Law School (York University, Toronto). An electronic survey was created using the SurveyMonkey.com web survey system. The 27-question survey was pre-tested by several health care providers in the Department of Obstetrics and Gynecology at SHSC for content, clarity, and ease of flow. Consent was implied if the participant completed and submitted the electronic survey. The survey was strictly anonymous and confidential for the participant. No personal health data were collected. Program chiefs of the following departments at SHSC were contacted to request permission to distribute the questionnaires to their members: Departments of Medicine, Surgery, Ob/Gyn, Emergency Medicine, Family Practice, and Neonatology. The following nursing units were approached: obstetric, perioperative, and OR. Recruited trainee groups included medical students on an Ob/Gyn rotation, Ob/Gyn residents and fellows, and anaesthesia fellows.
Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict
Table 1. Conflict management styles
Table 2. Survey questions 15–27
Avoiding
Conflict is not addressed or deferred to avoid the possibility of loss.
Question number
Both parties work to find a solution that is fully satisfactory to both.
15
There is a lot of conflict at my workplace.
16
I find conflict situations stressful.
17
I enjoy conflict situations.
18
I am adequately trained to manage conflict and resolve disputes in the workplace.
19
CM/DR is something I need to learn more about.
20
I am comfortable managing conflict in the workplace.
21
I am satisfied with my ability to resolve workplace disputes.
22
I feel CM/DR is an important skill for me to have in my workplace.
23
I feel CM/DR is an important skill for others to have in my workplace.
24
I believe formal CM/DR teaching sessions should be incorporated into the medical trainee’s curriculum.
25
I believe formal CM/DR teaching sessions should be incorporated into my career training.
26
I am aware of courses that are available for CM/DR training.
27
I would like to take a course in CM and DR.
Collaborating Competing Compromising
Accommodating
Competition occurs to overcome opposition and ensure individual’s position prevails. Both parties involved make trade-offs to reach a mutually acceptable solution that is partially satisfactory to both. One party subordinates own interests for the sake of preserving the relationship.
Adapted from Kilmann and Thomas.6
Once approval was received, the Survey Monkey questionnaire link was emailed to each department’s members. In total, 660 potential participants, including staff physicians, nursing teams, medical trainees, and support and administrative staff, received the survey invitation between February and May 2013. Three reminders were sent electronically at monthly intervals. There was no monetary incentive for completing the survey. Survey response data were compiled, codified, and entered into a survey database. The survey was in English. The survey was divided into the following components: 1. Participant’s demographic background. 2. Participant’s exposure to CM/DR to date: “In your post high school training, did you receive any training in CM/DR?” 3. Conflict experience: A description of a conflict situation was elicited with the question: “Think of a recent conflict situation at your work place that involved a colleague (not a patient or client). What was it? (describe in a few words).” 4. Conflict responses: The participant’s management style in response to a conflict situation described at work was explored with the following question and response choices (Table 1’6): “What did you do? Avoidance (ignoring it), collaborate (“let’s work it out together”), fight back (“my way or the high way”), compromise (“split the difference”), or accommodate (“do whatever you want”).” 5. Conflict outcome: The outcome of the conflict was assessed with the following questions: “Did you feel equipped to deal with the conflict?” (response choices: yes, no, or not sure), “Did you feel the outcome of the conflict situation was satisfactory?” (response choices: yes, no, or not sure), and “Did you receive help/advice in order to manage your conflict situation?” (response choices: yes, no, or not sure).
Question
CM: conflict management; DR; dispute resolution.
6. Participant’s attitudes towards CM and CM/DR training: Participants were polled with 13 questions (see Table 2 for questions 15–27) regarding their comfort in dealing with conflict and their attitudes to formal training in CM/DR. Responses to this group of questions were determined on the basis of a Likert scale of 1–7 (1 = no agreement with statement; 7 = complete agreement with statement). For the analysis, we presented quantitative data as percentages on the basis of the numbers of responses received to each individual question. The narrative responses to the open-ended questions were reviewed and categorized into one of the following four groups, according to recurring themes observed (adapted from Whetten’s and LemieuxCharles’ identified sources of conflict2,7): (1) personal differences, (2) role incompatibility (reflecting differences in goals and responsibilities), (3) information deficiencies (reflecting differences in opinions regarding treatment plans or other patient care–related issues), and (4) environmental stress (reflecting disagreements on budget allocation, scheduling concerns, and other resource-related issues). RESULTS
Of the 660 various department members invited to participate in the survey, there were 303 participants (response
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were planning on future CM/DR training compared with 17 (14%) physicians.
Table 3. Survey participants’ demographics Participant positions/roles Position
N (%)
Staff physician
124 (41)
Nurse
102 (34)
Medical trainee
46 (15)
Hospital administrator
10 (3)
Support staff
21 (7)
Years worked in position Number of years
N (%)
<5
96 (32)
5–10
65 (21)
11–20
73 (24)
>20
69 (23)
Participants’ department affiliations Department Obstetrics and gynecology
N (%) a
Surgeryb
113 (37) 95 (31)
Internal medicine
28 (9)
Emergency department
20 (7)
Anesthesia
20 (7)
Psychiatry
13 (4)
Family medicine
9 (3)
a
Includes physicians and labour and delivery nurses.
b
Includes physicians and operating room nurses.
Recent Conflict Experience – Open Comments
Narrative free-text comments describing a recent conflict experience with a colleague were provided by 284 of 303 (94%) respondents. Some examples of submissions are included in Table 4. Comments were categorized as being the result of personal differences in 89 of 284 (31%) of cases, whereas 81 of 284 (29%) were related to environmental stress, 62 of 284 (22%) were related to role incompatibilities, and 52 of 284 (18%) were related to information deficiencies. When asked to explore their perceived CM style 123 of 253 (48.5%) chose to “collaborate.” Other choices were “avoidance” in 43 (17%), “compromise” in 37 (14.5%), “accommodation” in 35 (14%), and “competition” in 15 (6%) of cases (Table 5). When asked “Did you feel equipped to deal with the conflict?” 146 (49%) stated that they did feel equipped, 82 (28%) were not sure, and 70 (23%) felt unprepared. To resolve the conflict, 138 (46%) sought advice from another source, such as a colleague or manager. In total, 128 (44%) were satisfied, 72 (25%) were not sure, and 90 (31%) were unsatisfied with the outcome of the conflict. Opinion Statements
rate, 46%). Participants’ demographic information is described in Table 3.
Training Experience in Conflict Management
Of our participants, 128 of 303 (42%) reported previous formal training in CM/DR, with 51% (65 of 128) having attended workshops, 46% having attended lectures, and 59% having taken part in small group sessions. This exposure was a formal component of the individual’s training program’s curriculum for 49% of respondents. Of nurse participants, 62 of 102 (60%) had previous CM/DR training, with 35 of 62 (56%) stating this was part of their training. Physicians reported they had received prior CM/DR training in 38 of 128 (30%) of cases, with only 12 (32%) indicating that this was a part of their medical curriculum. When asked about future CM/DR skill development, only 56 of 303 (18%) participants planned on enrolling in a course in this area, whereas 235 of 303 (78%) had no current intent of exploring more training, and 12 (4%) chose not to answer. Of the nursing respondents, 28 (27%)
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When asked their opinion on the statement “there is a lot of conflict in my workplace,” 163 of 303 (54%) of participants responded 5–7 on a Likert scale of 1–7 (indicating strong agreement); 223 (74%) indicated that they found conflict situations stressful (Likert scale 5–7, question 16). Only 80 (26%) respondents believed they were adequately trained to manage conflict and resolve disputes in the workplace (question 18), and 114 (38%) were comfortable managing such conflict situations (question 20). A total of 122 (40%) were satisfied with their CM skills (question 21), whereas 180 (59%) believed they need to learn more about CM/DR (question 19). Finally, we were interested in understanding our survey respondents’ opinions regarding the importance of CM/DR skills: 260 respondents (86%) believed CM/DR skills are important for them to have in their workplace (question 22), and 270 (89%) believed these skills are important for others to have in their workplace (question 23). A total of 238 (79%) and 229 (76%) wanted to see these skills incorporated into medical school curricula (question 24) and their own career training opportunities (question 25), respectively. Although only 103 of 303 (34%) were aware of
Conflict Among Colleagues: Health Care Providers Feel Undertrained and Unprepared to Manage Inevitable Workplace Conflict
Table 4. Selected respondents’ descriptions of a recent conflict Personal differences: interpersonal conflict – personality differences, bullying, gossip, yelling “It was my first day as a scrub nurse in the OR and the surgeon lost it on me because I didn’t properly load the laparoscopic needle driver.” “Resident was condescending to nurses, stating he/she was in charge.” “Academic bullying resulting in me having to switch to a different research niche” “Shunning because of whistleblowing” “I felt a colleague was belittling my role on our team.” “Colleague being rude to me in front of a patient” Environmental stress: resource scarcity and uncertainty, budget and resource allocation, scheduling concerns, on-call coverage, clinic bookings “Distribution of departmental finances” “Vacation allotments and on-call not being uniform among physicians” “Doctor kept telling me to book patients in to see her sooner but then complained when the clinic was overbooked and ran late.” “Conflict over strategic priorities and leadership” “Disagreement about policy direction and planning resource allocation” “Surgeon’s last OR case was cancelled due to time constraints and surgeon became angry and disrespectful.” Role incompatibilities: differences in roles/expectations: surgeon-anesthetist, physician leader-physician, physician-nurse, staff-trainee, charge nurse-RN “Anesthetist was disappearing between OR cases, slowing down the process and threatening my ability to get the entire OR list completed.” “Working with allied health care colleagues to develop standards of care” “L&D nurse paged me overhead stat to come back to labour floor – I was in Emerg seeing a consult and ran upstairs thinking there was an emergency. When I got there, she just wanted her primip examined for progress and told me she thought I had gone to bed.” “Charge nurse kept sending everyone else on breaks before me” “dealing with contrary staff members” Information deficiencies: consultations, treatment plans, discharge planning, medication administration “Oncology team refused to see a patient in the emergency department with an obvious malignancy until the patient had proof of tissue diagnosis.” “Different judgment on patient care” “Surgical staff disagreed with anesthesia regarding need for patient-controlled analgesia (PCA) pump in post-op patient.” “Dispute over medical management” “The consultant was rude and refused to see the patient in Emerg.” L&D: labour and delivery; Emerg: emergency department; primip: primipara.
available CM/DR courses (question 26), 151 (50%) stated they would be interested in taking such courses (question 27). DISCUSSION
This survey is the first specifically to investigate the background training and comfort in CM/DR of health care workers in a Canadian medical institution.
The survey identifies a need for, and an interest in, further training in CM/DR. The work, however, is far from done. In fact, it is our hope that this questionnaire will serve as a catalyst for the serious examination of opportunities at each of the undergraduate, post-graduate, and post-licensing levels for increased exposure and more formal training in CM/DR to allow for access to more trainees, thus serving to raise awareness on the issue early in their professional career. Some of this type of training is already a mandatory component
Table 5. Conflict management styles of survey respondents (N = 253) Collaborate Avoid Compromise
48.5% (123/253)
Both parties work to find a solution that is fully satisfactory to both.
17% (43/253)
Conflict is not addressed or deferred to avoid the possibility of loss.
14.5% (37/253)
Both parties involved make trade-offs to reach a mutually acceptable solution that is partially satisfactory to both.
Accommodate
14% (35/253)
One party subordinates own interests for the sake of preserving the relationship.
Compete
6% (15/253)
Competition occurs to overcome opposition and ensure individual’s position prevails.
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of medical training in some Canadian programs (e.g., the University of Toronto Faculty of Medicine’s pre-clerkship course), but it is unclear whether this is sufficient to improve trainees’ comfort level and ability in managing workplace collegial conflict.8 Some studies do show promising results with formal CM/DR training for employees. Steinert et al.9 concluded that participants in faculty development leadership programs reported increased confidence in and awareness of their CM skills. Zweibel et al.10 and Zweibel and Goldstein11 showed, in a study of participants in conflict resolution training programs, that learners gained a positive outlook on their ability to apply CM/DR skills and were able to transfer the skills gained in the classroom to the workplace both immediately and one year after completion of the workshops. Although this questionnaire serves as an assessment of the current state of CM skills and training among health care professionals at one institution, the Royal College of Physicians and Surgeons of Canada reinforces that this is but the first step in the multifaceted approach needed to develop CM processes in health care facilities and recommends that the next task be a careful examination of hospital resources available to assist with implementing CM/DR training modules at the staff level.12 Our study has some limitations. Most of the literature describes an expected response rate to conventional surveys of 70% to 75%, but these high rates are often affected by the use of registered mail services and monetary incentives.13,14 Although our survey did adhere to some of the other recognized methods for increasing response rates, including shortening the questionnaire and sending multiple reminders, we chose to use an electronic survey system to reach our recipients in an effective, efficient, low-cost, and convenient manner.15 Web surveys, however, often result in lower response rates, described as ranging from 34% to 56%.16,17 The response rate of 46% is in keeping with the reported response rates of electronic surveys. The survey was distributed locally, at SHSC only, thus resulting in a limited number of participants invited overall. The crosssectional survey method is potentially biased, with the possibility that health care professionals were more likely to respond to the questionnaire if they had experienced unprofessional and non-collaborative interactions in their workplace.
outcome of a recent conflict situation. This needs assessment survey identifies a need for and interest in additional training in CM/DR for those who work in health care institutions. REFERENCES 1. Saltman DC, O’Dea NA, Kidd MR. Conflict management: a primer for doctors in training. Postgrad Med J 2006;82:9–12. 2. Lemieux-Charles L. Physicians in health care management: 10. Managing conflict through negotiation. CMAJ 1994;151:1129–32. 3. Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual 2011;26:372–9. 4. Forte PS. The high cost of conflict. Nurs Econ 1997;15:119–23. 5. Frank JR, Snell L, Sherbino J. CanMEDS 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available at: http://canmeds.royalcollege.ca/uploads/en/ framework/CanMEDS%202015%20Framework_EN_Reduced.pdf. Accessed on October 24, 2018. 6. Kilmann RH, Thomas KW. Developing a forced choice measure of conflict management behavior: the MODE instrument. Educ Psychol Measures 1977;37:309–23. 7. Whetten DA, Cameron KS. Developing management skills. 2nd ed. New York: Harper Collins; 1991. 8. MD Program, University of Toronto. Leader 3. Key Competency 3. Demonstrate Leadership in Professional Practice. Toronto: MD Program, University of Toronto; 2017. Available at: http://www.md.utoronto.ca/ content/leader-3. Accessed on October 24, 2018. 9. Steinert Y, Naismith L, Mann K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME guide no. 19. Med Teach 2012;34:483–503. 10. Zweibel EB, Goldstein R, Manwaring JA, et al. What sticks: how medical residents and academic health care faculty transfer conflict resolution training from the workshop to the workplace. Conflict Resolution Q 2008;25:321–50. 11. Zweibel EB, Goldstein R. Conflict resolution at the University of Ottawa Faculty of Medicine: the Pelican and the sign of the triangle. Acad Med 2001;76:337–44. 12. Marshall P, Robson R. Conflict Resolution. Ottawa: Royal College of Physicians and Surgeons of Canada; 2017. Available at: http:// www.royalcollege.ca/rcsite/bioethics/primers/conflict-resolution-e#top. Accessed on October 24, 2018. 13. Raziano DB, Jayadevappa R, Valenzula D, et al. E-mail versus conventional postal mail survey of geriatric chiefs. Gerontologist 2001;41:799–804. 14. Thorpe C, Ryan B, McLean SL, et al. How to obtain excellent response rates when surveying physicians. Fam Pract 2009;26:65–8. 15. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002;324:1183.
CONCLUSION
16. Braithwaite D, Emery J, De Lusignan S, et al. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract 2003;20:545–51.
Most survey participants did not feel equipped to handle collegial or workplace conflict and were dissatisfied with the
17. Seguin R, Godwin M, MacDonald S, et al. E-mail or snail mail? Randomized controlled trial on which works better for surveys. CanFam Physician 2004;50:414–9.
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