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Investigating conflict perceptions among health profession students in an interprofessional education activity
Journal of Interprofessional Education & Practice 18 (2020) 100302
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: www.elsevier.com/locate/jiep
Investigating conflict perceptions among health profession students in an interprofessional education activity
T
Jeffery Kaufman Leadership and Research Marian University, 3200 Cold Spring Road, Indianapolis, IN, 46222, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Conflict management Teamwork Satisfaction Task conflict Relationship conflict
Background: If a goal of interprofessional education (IPE) is to facilitate a culture of collaboration among diverse professionals, then understanding the role of conflict among interprofessional education teams is necessary. Purpose: The study investigated medical and nursing students’ perceptions of conflict and team satisfaction as well as individual performance to identify relationships between these variables. Method: 121 medical and 44 nursing students from a Midwestern college of osteopathic medicine were randomly assigned to teams for a low-stakes, disaster triage activity and measured on their perceptions of task conflict, relationship conflict, team satisfaction, and also their performance on the triage activity. Discussion: There was no statistically significant correlation between performance and any of the other three variables; however, there was a small, negative, significant correlation between relationship conflict and satisfaction, rs = −.181, p = .020, which had an effect size of R2 = .0327. Conclusion: While the effect size is small, the findings raise the question of how the perception of conflict in interprofessional exposure activities might impact students’ willingness to pursue team-based approaches in their professional practice when the stakes are much higher.
1. Introduction
team processes such as communication and conflict management, which then effect outcomes. As such, simply putting people together in teams does not automatically lead to success as teams struggle to utilize their various skills.6 Synergy among members of a task-performing group is not a given, which brings into question the value of those teams.7 When the processes and synergy are lacking within medical teams it can be the patients who suffer given that dysfunctional team dynamics lead to an estimated 70% of medical errors and medical errors were the third leading cause of death in 2013.8,9 The rise of interprofessional education (IPE) offerings for present and future healthcare professionals has correlated with the rise in both team-based heathcare practices and their associated conflict.10 Educators have developed a wide array of methods for addressing potential conflict through IPE such as developing stronger patient and team-directed communication skills among healthcare profession students11 and using authentic, experiential learning models.12,13 These efforts seem to be paying dividends as evidence exists that health profession students may be more inclined or socialized to collaborate with their interprofessional colleagues.14 According to Reeves et al.15; “interprofessional education (IPE) aims to bring together different professionals to learn with, from and about one another in order to collaborate more effectively in the delivery of safe, high quality care for patients/clients” (p. 2). For this reason it
The purpose of this study was to investigate conflict perceptions among medical and nursing students who participated in an interprofessional activity. Additionally, the goal was to determine what, if any, relationship those conflict perceptions had to the participants’ satisfaction working with their team and their individual performance. Teamwork within healthcare settings is common and some would argue a requirement.1 While it seems instinctual to believe that healthcare is delivered through a team, Engeström2 noted that this perspective has only become more prominent over the past 25 years. Medicine has shifted from an individual endeavor on the part of a primary physician, to a group process among professionals from various areas of expertise. The breadth of medical knowledge that comes from teamwork provides myriad benefits to patients, but this knowledge is most effective when those who possess it work together and are well-coordinated.3 Conversely, failure to work effectively as a team can have detrimental effects such as increases in significant medical errors and adverse patient outcomes.4 While high quality patient outcomes and holistic care may the ideal outcome of a team-based approach to healthcare, this may not be the case in actual practice. As Schaefer, Helmreich, and Scheidegger5 noted, team member inputs, such as aptitude and personality, impact
E-mail address: [email protected]. https://doi.org/10.1016/j.xjep.2019.100302 Received 22 May 2018; Received in revised form 22 September 2019; Accepted 26 November 2019 2405-4526/ © 2019 Elsevier Inc. All rights reserved.
Journal of Interprofessional Education & Practice 18 (2020) 100302
J. Kaufman
seems imperative to address conflict as part of that education due to conflict's deleterious effects on team interactions and performance. Baggs and Schmitt16 cited numerous studies pointing to the importance of nurse-physician collaboration and later also found a positive correlation between nurse-physician collaboration and patient outcomes in Intensive Care Units.17 This then implies that conflict should be addressed and that tools should be developed and conveyed in a way that will allow all members of the team to feel safe to communicate openly, especially with reference to issues of patient safety.18 Recognizing the impact of conflict in medical settings and the increasing use of interprofessional education as part of the healthcare education curriculum, it seems worthwhile to investigate how students in healthcare profession programs perceive conflict. At a broad level, Henning, Shulruf, Hawken, and Pinnock19 found that medical students identified constructive relationships as an element of their educational environment that they would change if they could. This might indicate a perception of conflict around their expectations regarding the relationships they encounter in their educational environment. More specifically, the majority of the students in a study by Broukhim et al.20 indicated they believed that conflict would negatively impact patient care and personal wellbeing, while also expressing dissatisfaction with how the conflict they encountered was managed. Equally telling is the finding that medical and nursing students recognize opportunities for behavioral changes in themselves regarding conflict and benefits of conflict resolution skills in their professional interactions.21 What is likely not surprising is that negative personal experiences with perceived group conflict in group learning activities impacts students’ willingness and interest in future group interactions.22 This study evaluated students’ perceptions of conflicts in an interprofessional activity with the goal of better understanding whether these perceptions affected their performance and satisfaction in working with their team. Since conflict is one of the variables that impacts preference or willingness to participate in teams and impacts team effectiveness, understanding conflict perceptions may offer insights into ways to address and/or engage conflict as a part of teamwork processes.
Table 1 Participant demographics. Age Group
Female (n = 103)
Male (n = 62)
Nursing (n = 44)
Medicine (n = 121)
18-21 (n = 2) 20-25 (n = 101) 26-29 (n = 45) 30-33 (n = 8) 34-37 (n = 4) 38-41 (n = 3) 42+ (n = 2)
2 70 21 5 0 3 2
0 31 24 3 4 0 0
2 33 4 1 0 2 1
0 68 41 7 4 1 0
was voluntary although encouraged, and faculty promoted participation in various classes. Given the voluntary nature of participation, the mood of the participants may have been impacted such that either the potential for conflict could be increased or decreased, but it is difficult to know. Group one consisted of 64 medical students and 17 nursing students and took place on a Tuesday, and 57 medical students and 27 nursing students participated in group two on Thursday of the same week. IRB approval was received from the institution where the study was conducted and participants were only measured on their levels of perceived conflict and satisfaction at the end of the activity. They were informed that the information gathered was part of a study to better understand their team processes. Table 1 provides the demographic information of the participant group. Task and relationship conflict perceptions were measured as part of this study; however, process was excluded. This was done for two reasons. First, the process by which the students would accomplish the task was relatively static and consistent across all groups as it was largely dictated by the educators. Second, given the time constraints that the students faced in already using several hours of their day in the activity and because they were completing surveys from the activity facilitators, it was decided that the process conflict indicators on the Intragroup Conflict Scale24 would be removed to shorten the survey. The interprofessional activity focused on emergency triage and included a pre-test, group instruction by the IPE providers, a post-test, and the completion of an instrument to measure perceptions of conflict and participant satisfaction with their team. Pre- and post-test data related to the actual triaging of the simulated patients was used as the measure of performance to be compared to the other variables to determine correlations. The participants began by meeting in a large lecture hall where they were introduced to the staff and agenda for the morning. Immediately following the introductions the participants completed a pre-test on diagnosing triage injuries. The pre-test consisted of a series of 30 slides showing various injuries with basic patient information including respiration, perfusion, and mental status. The participants then selected the appropriate triage category. At the conclusion of the pre-test a representative from the IPE organization led a presentation on triage medicine. After completing the pre-test and listening to the presentation on triage medicine, the nursing and medical students were dispersed into pre-determined, randomly-assigned groups where they were given large, laminated cards of the same injuries from the pre-test. The participants were given a scenario explaining that they were attending a basketball game on campus together and an active shooter entered the gymnasium and randomly fired into the crowd. The shooter was subdued and as medical students and nurses they were now to begin the process of triaging the injured. In these groups the participants discussed each of the injuries and triaged them, which meant to prioritize them based on the severity of the injury. During the course of the group discussions on triaging of the injured, step-in guides would enter the group and provide insight into their roles and what they might be doing during such an emergency situation. These step-in guides included clergy, emergency medical technicians, police officers, and medical school faculty. These guides
2. Methods This descriptive study was undertaken to respond to two primary questions. First, what is the prevalence of perceived conflict of students participating in an IPE activity? Second, what correlation(s) exists between IPE participants’ perceptions of conflict and their individual performance and satisfaction with their team? The definitions for the various types of conflict in this study were derived from the work of Guetzkow and Gyr23 and advanced by Karen Jehn.24 They separated team conflict into three types; task, relationship, and process conflict. Jehn and Mannix25 provided definitions for each of these types of conflict. Task conflict is, “an awareness of differences in viewpoints and opinions relating to a group task” (p. 238). Relationship conflict is defined as, “an awareness of interpersonal incompatibilities, includes affective components such as feeling friction and tension” (p. 238). Finally, process conflict centered on, “controversies about aspects of how task accomplishment will proceed” (p.239). For the sake of this study, only task and relationship conflict were included. Process was excluded as the process for this task was determined by the interprofessional education providers. Also, due to time constraints on the part of the participants, those statements related to process conflict were removed from the survey. 2.1. Methodology The study included 121 medical students and 44 nursing students from a private, faith-based, Midwestern university. The medical students were second year osteopathic medicine students and both the nursing and medical schools resided in the same building. Participation 2
Journal of Interprofessional Education & Practice 18 (2020) 100302
J. Kaufman
would also respond to any questions the group might have for them. Once the groups triaged all the injured from the disaster and met all the step-in guides, they reconvened in the lecture hall to complete the post-test as well as various surveys related to the study and their reactions and experiences related to the activities. Upon completion of the post-test they were presented with the two scales for this study and asked to fill them out based on their group experience working through the interprofessional activity. The percentage correct from the pre-test and post-test were compared to determine performance with the expectation that after working in groups their percent correct would increase. Performance was then compared to task conflict, relationship conflict, and satisfaction to determine what relationships existed among those variables.
Table 3 Correlations between levels of conflict, team performance and team satisfaction.
1. 2. 3. 4.
3. Findings This study investigated the conflict perceptions of 121 second-year, osteopathic medical students and 44 nursing students after they engaged in an IPE session. Data was initially analyzed to determine general mean scores for levels of task conflict, relationship conflict, satisfaction, and performance. Performance was defined as the difference between the pre-test and post-test percentage of correct responses. Table 2 provides the mean scores across all participants for task conflict, relationship conflict, satisfaction, and performance. In reviewing the mean scores for the variables a few things become evident. First the task and relationship conflict instrument used a fivepoint scale and the mean scores for both were low at 1.77 and 1.19 respectively. Additionally, the satisfaction instrument also used a fivepoint scale and was relatively high at 4.34. This suggests that participants perceived very little task and relationship conflict within their groups and were generally satisfied in the teams with which they worked. The average performance, which again was the difference between the pre- and post-triage activity scores, was strong with the average growth being a 34% increase in correct responses. Table 2 Mean scores for task conflict, relationship conflict, satisfaction, and performance. Performance
Mean Score
1.77
1.19
4.34
34.82
-.050 -.181* -.043
.535** -.060
.047
-
The prevalence of perceived conflict among participants in this study was low. It appeared that the teams and individual team members did not sense much conflict and were generally satisfied with their team interactions. While the data indicated differences in the variables of the study, only two were statistically significant. Those statistically significant correlations can offer insight on the effects of conflict on IPE, but are far from definitive. A good example of significant findings that may not offer much actual insight was the strong, positive correlation between reported perceptions of task and relationship conflict (rs = .535), which is interesting but perhaps not surprising. It suggests that as one type of conflict increased, so too did the other. One possible explanation for this might be that students were unable to separate task conflict surrounding the goals of the exercise from relationship conflict wherein personality differences occurred. It may also be argued that students were unable to differentiate between the two because they are either not distinct constructs or because the students cannot or do not perceive them that way. High correlations between task conflict and relationship conflict are also not uncommon. In fact it was addressed by De Dreu and Weingart29 in their meta-analysis of studies of task and relationship conflict and their effect on performance and satisfaction. In their meta-analysis they found a positive correlation (r = .52) among the 23 studies that were included. Likewise, de Wit, Greer, and Jehn30 found the correlation between conflict types to be a moderating variable in their meta-analysis such that “if task conflicts can occur without relationship conflicts also occurring, task conflicts are less likely to be emotional,31 escalate,32 and impair group performance33–35” (p. 373). The negative correlation between satisfaction and relationship conflict was also not a complete surprise as the meta-analyses by De Dreu and Weingart29 and de Wit, Greer, and Jehn30 both found similar negative correlations between relationship conflict and team member satisfaction (r = -.54) across the studies included in their meta-analysis. More recent research on conflict experiences, performance, and satisfaction among health profession students found negative correlations between both task and relationship conflict and team member satisfaction.36,37 However, when considering the goal of IPE, the finding could cause some concern. Satisfaction and relationship conflict were negatively correlated, rs = -.181, p = .020 with an effect size of R2 = .0327. While this is a small effect size indicating only about a 3%
Spearman correlation was used to determine the nature and strength of the relationships between the four variables: task conflict, relationship conflict, member satisfaction, and performance.
Satisfaction
4
4. Discussion
2.3. Data analysis
Relationship Conflict
3
To answer the questions about the relationships that existed between conflict, satisfaction and performance, Spearman's rho was used. While most of the correlations such as those between task conflict and satisfaction were both small and not statistically significant, the correlation between relationship conflict and task conflict was positive, moderately strong, and statistically significant, rs (163) = .535, p < .01. Performance was not significantly correlated with any of the other three variables, but there was a weak, negative correlation between relationship conflict and satisfaction, which was statistically significant, rs (163) = -.181, p < .05. This indicates that as the perception of relationship conflict increased, member satisfaction with their team decreased. Table 3 provides all correlations.
The Intragroup Conflict Scale was developed by Karen Jehn24 to measure team member perceptions of conflict experienced within a team function. The instrument measures task, relationship, and process conflict using a five point Likert-type scale with options ranging from “None or Hardly” to “A Great Deal.” For this study, a 6 question version was used as it has been found to have similar psychometric properties as the original 9 question version,26 but did not include the statements to identify process conflict. Satisfaction was measured using a two item scale utilized by DeChurch and Marks.27 The scale included the two questions “working with this group has been an enjoyable experience” and “I would like to work with this group in the future,” and used a five-point Likert scale ranging from “strongly agree” to “strongly disagree.” The satisfaction scale was chosen as it showed a strong item correlation of .94 in prior studies on conflict and satisfaction.28
Task Conflict
2
**. Correlation is significant at the 0.01 level (2 tailed). *. Correlation is significant at the 0.05 level (2 tailed).
2.2. Data collection instruments
N = 165
Satisfaction Task Conflict Relationship Conflict Growth
1
3
Journal of Interprofessional Education & Practice 18 (2020) 100302
J. Kaufman
interprofessional collaboration, but it is recognized that interprofessional interactions can lead to conflict. That being the case, then preparing healthcare professionals with the skills needed to resolve differences and a personal awareness of their own instincts towards conflict is critical. IPE seeks to help professionals from various areas of expertise learn to work together, and is being used at the university level to begin to introduce healthcare professionals to the wide array of colleagues with whom they may work. There may be benefits to teaching healthcare professionals how to reduce conflict, but there may also be some benefits that team conflict can provide. Perhaps rather than a focus on removing conflict, education on separating relationship conflict and task conflict is worth considering. In the meta-analysis by de Wit, Greer, and Jehn,30 top management teams showed more positive correlations between task conflict and performance than members of other organizational levels in their studies. They noted that, “an alternative explanation for why task conflicts in top management teams are more positively related to group performance is that members of top management teams are better able to prevent task conflict from turning into relationship conflict” (p. 373). Similar to the notion of separating the person from the problem,42 the key may rest in helping medical professionals differentiate between conflict towards the problem (task conflict) and conflict towards other members of the team (relationship conflict). While the effect sizes in this study were low, they still suggest that relationship conflict is negatively correlated with participant satisfaction, a finding consistent with other studies on the topic. If satisfaction is lower, there is the potential for participants to elect not to engage in teamwork strategies in actual practice.22 At that point it is customers, or patients, who can suffer the most, which both supports the benefits of IPE and also indicates areas for further consideration and development.
variance in satisfaction that can be attributed to relationship conflict, it is worth noting that it occurred in a low-stakes interaction. The participants were not being graded on their performance and participation in the IPE unit was voluntary. Kaufman36,37 encountered a similar condition in his study on conflict and the use of the micronegotiation technique. Future research would be wise to investigate these correlations and effect sizes in high stakes scenarios. The concern then becomes the possible negative impact that relationship conflict can have on satisfaction and whether that reduced satisfaction could lead to hesitancy on the part of these students to engage in collaborative, team-based care as professionals. This may be especially relevant when the stakes become higher and the pressure greater. And yet IPE may be addressing these concerns. Research suggests that participation in IPE activities can reduce the likelihood of utilizing an avoidance response when conflict arises among health profession students.38 Boros, van Gorp, Cardoen, and Boute39 found that group emotional awareness, a skill that can be developed and fostered within teams, can mitigate conflict and improve team performance. And goal orientation has been found to be a key factor in moderating the relationship between task conflict and team innovation.40 These studies and others like them suggest opportunities for conflict management and moderation that can benefit teams and their performance. While it is certainly possible that the low levels of reported perceptions of task and relationship conflict were a product of a low-stress, low-stakes experience, it is also possible that there are cultural changes at work in the health profession community. Jones, Jennings, Higgins, and de Waal41 studied the social behavior of team members in operating rooms. Of the 200 surgeries and 6,348 spontaneous social interactions observed by the researchers only 2.8% were classified as conflict while 59% were classified as cooperative. Gender appeared to be an important factor in these interactions as “cooperation tended to increase with a rising proportion of females in the OR” (p. 29). While gender was not part of this specific study, it is worth noting that the participant group was made up of 103 females and 62 males. This ratio may have led to a higher level of cooperation among the participants and therefore lower perceived levels of both task and relationship conflict, as well as satisfaction within the teams. The study encountered limitations, most noteworthy appeared to be the lack of emotional investment due to the low-stakes nature of the activity. Pressure to perform in a team is a key catalyst for potential conflict. For medical and nursing students who face highly competitive learning environments and are being trained to make life and death decisions, an activity with no consequence or reward may not elicit an emotional reaction making measurement of the impact conflict has on performance and satisfaction difficult. Given that the findings indicated only a small effect size in a low stakes interprofessional interaction, a natural iteration of this study would be in a setting where the stakes hold greater weight. Another limitation was the timing of the measurements of conflict perceptions and satisfaction. The measurements were the last thing the participants did at the end of the activity. At this point they had already been engaged in the activity for 2 hours and may have been hasty in trying to complete the survey as it was the last thing to complete before leaving. As such, participants may not have been reflecting on their experience and providing an accurate representation of that experience as much as simply trying to finish.
References 1. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet. 2010;376(9756):1923–1958. 2. Engeström Y. From Teams to Knots: Activity-Theoretical Studies of Collaboration and Learning at Work. Cambridge University Press; 2008. 3. Thibault GE. Interprofessional education in the USA: current activities and future directions. J Interprofessional Care. 2012;26(6):440–441. https://doi.org/10.3109/ 13561820.2012.704778. 4. Baldwin D, Daugherty S. Interprofessional conflict and medical errors: results of a national multi-specialty survey of hospital residents in the US. J Interprofessional Care. 2008;22(6):573–586. https://doi.org/10.1080/13561820802364740. 5. Schaefer H, Helmreich R, Scheidegger D. Human factors and safety in emergency medicine. Resuscitation. 1994;28(3):221–225. https://doi.org/10.1016/03009572(94)90067-1. 6. Mayo A, Woolley A. Teamwork in health care: maximizing collective intelligence via inclusive collaboration and open communication. Ama J Ethics. 2016;18(9):933–940. https://doi.org/10.1001/journalofethics.2016.18.9.stas2-1609. 7. Larson JR. In Search of Synergy in Small Group Performance. Psychology Press; 2010. 8. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. Bmj. 2016;353:i2139. 9. Mitchell R, Parker V, Giles M, Boyle B. The ABC of health care team dynamics: understanding complex affective, behavioral, and cognitive dynamics in interprofessional teams. Health Care Manag Rev. 2014;39(1):1–9. 10. Barrow M. Conflict in context: designing authentic teamwork education. Med Educ. 2012;46(10):926–927. 11. Chou CL, Ainsworth A, O'Brien BC. An assessment strategy for interprofessional interactions of primary care practitioner trainees. J Interprofessional Educ Pract. 2016;2:1–3. 12. Coleman MT, McLean A, Williams L, Hasan K. Improvement in interprofessional student learning and patient outcomes. J Interprofessional Educ Pract. 2017;8:28–33. 13. Waynick-Rogers P, Hilmes M, Cole S, et al. Design and impact of an orientation for an interprofessional education program. J Interprofessional Educ Pract. 2018;13:8–11. 14. Moll A, Lambert S, Visker J, et al. A case study activity to assess nursing students' perceptions of their interprofessional healthcare team's collaborative decisionmaking process. J Interprofessional Educ Pract. 2019;14:18–21. 15. Reeves S, Fletcher S, Barr H, et al. A BEME systematic review of the effects of interprofessional education: BEME Guide No. 39. Med Teach. 2016;38(7):656–668. 16. Baggs JG, Schmitt MH. Collaboration between nurses and physicians. Image - J Nurs Scholarsh. 1988;20(3):145–149. 17. Baggs J, Schmitt M, Mushlin A, et al. Association between nurse-physician collaboration and patient outcomes in three intensive care units. Crit Care Med.
5. Conclusions This study was undertaken to understand the interaction between perceived conflict, performance, and satisfaction among medical and nursing students working together, it did not attempt to investigate resolution of conflict that arose. However, looking for methods for managing conflict is a practical and necessary step in this vein of research. One goal of IPE is to improve patient care through developing 4
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31. Yang J, Mossholder KW. Decoupling task and relationship conflict: the role of intragroup emotional processing. J Organ Behav. 2004;25:589–605. 32. Greer LL, Jehn KA, Mannix EA. Conflict transformation: an exploration of the interrelationships between task, relationship, and process conflict. Small Group Res. 2008;39:278–302. 33. Peterson RS, Behfar KJ. The dynamic relationship between performance feedback, trust, and conflict in groups: a longitudinal study. Organ Behav Hum Decis Process. 2003;92:102–112. 34. Shaw JD, Zhu J, Duffy MK, Scott KL, Shih HA, Susanto E. A contingency model of conflict and team effectiveness. J Appl Psychol. 2011;96:391–400. 35. Simons TL, Peterson RS. Task conflict and relationship conflict in top management teams: the pivotal role of intragroup trust. J Appl Psychol. 2000;85:102–111. 36. Kaufman J. Effect of conflict on team performance and satisfaction among health profession students. Online J Workforce Educ Develop. 2015;8(1). 37. Kaufman J. The effect of a" micronegotiation" technique on team interactions. J Organ Cult Commun Confl. 2015;19(3):31. 38. Dominguez DG, Sanchez-Diaz PC, Fike DS, et al. A pilot study to examine the conflict handling preferences of health professional students before and after participation in an interprofessional education and collaborative practice (IPECP) initiative. Health Interprofessional Pract. 2016;3(1):6. 39. Boroş S, Van Gorp L, Cardoen B, Boute R. Breaking silos: a field experiment on relational conflict management in cross-Functional teams. Group Decis Negot. 2017;26(2):327–356. https://doi.org/10.1007/s10726-016-9487-5 Published in Cooperation with the Institute for Operations Research and the Management Sciences and Its Section on Group Decision and Negotiation. 40. DeGeest D, Kristof-Brown A. Conflict can make your team innovate: goal orientation moderates the task conflict-team innovation relationship. Proceedings of NIDA International Business Conference 2017–Innovative Management: Bridging. 2017; 2017:10. 41. Jones LK, Jennings BM, Higgins MK, de Waal FB. Ethological observations of social behavior in the operating room. Proc Natl Acad Sci. 2018;115(29):7575–7580. 42. Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Agreement without Giving in. second ed. New York: NY: Penguin Books; 1991.
1999;27(9):1991–1998. 18. Boehler M, Schwind C. Power and conflict and the performance of medical action teams: a commentary. Med Educ. 2012;46(9):833–835. 19. Henning MA, Shulruf B, Hawken SJ, Pinnock R. Changing the learning environment: the medical student voice. Clin Teach. 2011;8(2):83–87. 20. Broukhim M, Yuen F, McDermott H, et al. Interprofessional conflict and conflict management in an educational setting. Med Teach. 2019;41(4):408–416. 21. Vandergoot S, Sarris A, Kirby N, Ward H. Exploring undergraduate students' attitudes towards interprofessional learning, motivation-to-learn, and perceived impact of learning conflict resolution skills. J Interprofessional Care. 2018;32(2):211–219. https://doi.org/10.1080/13561820.2017.1383975. 22. Volet S, Mansfield C. Group work at university: significance of personal goals in the regulation strategies of students with positive and negative appraisals. High Educ Res Dev. 2006;25(4):341–356. 23. Guetzkow H, Gyr J. An analysis of conflict in decision-making groups. Hum Relat. 1954;7(3):367. https://doi.org/10.1177/001872675400700307. 24. Jehn K. Enhancing effectiveness: an investigation of advantages and disadvantages of value-based intragroup conflict. Int J Confl Manag. 1994;5(3):223–238. https://doi. org/10.1108/eb022744. 25. Jehn K, Mannix E. The dynamic nature of conflict: a longitudinal study of intragroup conflict and performance. Acad Manag J. 2001;44(2):238–251. https://doi.org/10. 2307/3069453. 26. Pearson AW, Ensley MD, Amason AC. An assessment and refinement of Jehn's intragroup conflict scale. Int J Confl Manag. 2002;13(2):110. 27. Priem RL, Harrison DA, Muir NK. Structured conflict and consensus outcomes in group decision making. J Manag. 1995;21(4):691–710. https://doi.org/10.1016/ 0149-2063(95)90006-3. 28. DeChurch LA, Marks MA. Maximizing the benefits of task conflict: the role of conflict management. Int J Confl Manag. 2001;12(1):4–22. 29. De Dreu C, Weingart L. Task versus relationship conflict, team performance, and team member satisfaction: a meta-analysis. J Appl Psychol. 2003;88(4):741–749. https://doi.org/10.1037/0021-9010.88.4.741. 30. de Wit F, Greer L, Jehn K. The paradox of intragroup conflict: a meta-analysis. J Appl Psychol. 2012;97(2):360–390. https://doi.org/10.1037/a0024844.
5
Contents lists available at ScienceDirect
Journal of Interprofessional Education & Practice journal homepage: www.elsevier.com/locate/jiep
Investigating conflict perceptions among health profession students in an interprofessional education activity
T
Jeffery Kaufman Leadership and Research Marian University, 3200 Cold Spring Road, Indianapolis, IN, 46222, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Conflict management Teamwork Satisfaction Task conflict Relationship conflict
Background: If a goal of interprofessional education (IPE) is to facilitate a culture of collaboration among diverse professionals, then understanding the role of conflict among interprofessional education teams is necessary. Purpose: The study investigated medical and nursing students’ perceptions of conflict and team satisfaction as well as individual performance to identify relationships between these variables. Method: 121 medical and 44 nursing students from a Midwestern college of osteopathic medicine were randomly assigned to teams for a low-stakes, disaster triage activity and measured on their perceptions of task conflict, relationship conflict, team satisfaction, and also their performance on the triage activity. Discussion: There was no statistically significant correlation between performance and any of the other three variables; however, there was a small, negative, significant correlation between relationship conflict and satisfaction, rs = −.181, p = .020, which had an effect size of R2 = .0327. Conclusion: While the effect size is small, the findings raise the question of how the perception of conflict in interprofessional exposure activities might impact students’ willingness to pursue team-based approaches in their professional practice when the stakes are much higher.
1. Introduction
team processes such as communication and conflict management, which then effect outcomes. As such, simply putting people together in teams does not automatically lead to success as teams struggle to utilize their various skills.6 Synergy among members of a task-performing group is not a given, which brings into question the value of those teams.7 When the processes and synergy are lacking within medical teams it can be the patients who suffer given that dysfunctional team dynamics lead to an estimated 70% of medical errors and medical errors were the third leading cause of death in 2013.8,9 The rise of interprofessional education (IPE) offerings for present and future healthcare professionals has correlated with the rise in both team-based heathcare practices and their associated conflict.10 Educators have developed a wide array of methods for addressing potential conflict through IPE such as developing stronger patient and team-directed communication skills among healthcare profession students11 and using authentic, experiential learning models.12,13 These efforts seem to be paying dividends as evidence exists that health profession students may be more inclined or socialized to collaborate with their interprofessional colleagues.14 According to Reeves et al.15; “interprofessional education (IPE) aims to bring together different professionals to learn with, from and about one another in order to collaborate more effectively in the delivery of safe, high quality care for patients/clients” (p. 2). For this reason it
The purpose of this study was to investigate conflict perceptions among medical and nursing students who participated in an interprofessional activity. Additionally, the goal was to determine what, if any, relationship those conflict perceptions had to the participants’ satisfaction working with their team and their individual performance. Teamwork within healthcare settings is common and some would argue a requirement.1 While it seems instinctual to believe that healthcare is delivered through a team, Engeström2 noted that this perspective has only become more prominent over the past 25 years. Medicine has shifted from an individual endeavor on the part of a primary physician, to a group process among professionals from various areas of expertise. The breadth of medical knowledge that comes from teamwork provides myriad benefits to patients, but this knowledge is most effective when those who possess it work together and are well-coordinated.3 Conversely, failure to work effectively as a team can have detrimental effects such as increases in significant medical errors and adverse patient outcomes.4 While high quality patient outcomes and holistic care may the ideal outcome of a team-based approach to healthcare, this may not be the case in actual practice. As Schaefer, Helmreich, and Scheidegger5 noted, team member inputs, such as aptitude and personality, impact
E-mail address: [email protected]. https://doi.org/10.1016/j.xjep.2019.100302 Received 22 May 2018; Received in revised form 22 September 2019; Accepted 26 November 2019 2405-4526/ © 2019 Elsevier Inc. All rights reserved.
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seems imperative to address conflict as part of that education due to conflict's deleterious effects on team interactions and performance. Baggs and Schmitt16 cited numerous studies pointing to the importance of nurse-physician collaboration and later also found a positive correlation between nurse-physician collaboration and patient outcomes in Intensive Care Units.17 This then implies that conflict should be addressed and that tools should be developed and conveyed in a way that will allow all members of the team to feel safe to communicate openly, especially with reference to issues of patient safety.18 Recognizing the impact of conflict in medical settings and the increasing use of interprofessional education as part of the healthcare education curriculum, it seems worthwhile to investigate how students in healthcare profession programs perceive conflict. At a broad level, Henning, Shulruf, Hawken, and Pinnock19 found that medical students identified constructive relationships as an element of their educational environment that they would change if they could. This might indicate a perception of conflict around their expectations regarding the relationships they encounter in their educational environment. More specifically, the majority of the students in a study by Broukhim et al.20 indicated they believed that conflict would negatively impact patient care and personal wellbeing, while also expressing dissatisfaction with how the conflict they encountered was managed. Equally telling is the finding that medical and nursing students recognize opportunities for behavioral changes in themselves regarding conflict and benefits of conflict resolution skills in their professional interactions.21 What is likely not surprising is that negative personal experiences with perceived group conflict in group learning activities impacts students’ willingness and interest in future group interactions.22 This study evaluated students’ perceptions of conflicts in an interprofessional activity with the goal of better understanding whether these perceptions affected their performance and satisfaction in working with their team. Since conflict is one of the variables that impacts preference or willingness to participate in teams and impacts team effectiveness, understanding conflict perceptions may offer insights into ways to address and/or engage conflict as a part of teamwork processes.
Table 1 Participant demographics. Age Group
Female (n = 103)
Male (n = 62)
Nursing (n = 44)
Medicine (n = 121)
18-21 (n = 2) 20-25 (n = 101) 26-29 (n = 45) 30-33 (n = 8) 34-37 (n = 4) 38-41 (n = 3) 42+ (n = 2)
2 70 21 5 0 3 2
0 31 24 3 4 0 0
2 33 4 1 0 2 1
0 68 41 7 4 1 0
was voluntary although encouraged, and faculty promoted participation in various classes. Given the voluntary nature of participation, the mood of the participants may have been impacted such that either the potential for conflict could be increased or decreased, but it is difficult to know. Group one consisted of 64 medical students and 17 nursing students and took place on a Tuesday, and 57 medical students and 27 nursing students participated in group two on Thursday of the same week. IRB approval was received from the institution where the study was conducted and participants were only measured on their levels of perceived conflict and satisfaction at the end of the activity. They were informed that the information gathered was part of a study to better understand their team processes. Table 1 provides the demographic information of the participant group. Task and relationship conflict perceptions were measured as part of this study; however, process was excluded. This was done for two reasons. First, the process by which the students would accomplish the task was relatively static and consistent across all groups as it was largely dictated by the educators. Second, given the time constraints that the students faced in already using several hours of their day in the activity and because they were completing surveys from the activity facilitators, it was decided that the process conflict indicators on the Intragroup Conflict Scale24 would be removed to shorten the survey. The interprofessional activity focused on emergency triage and included a pre-test, group instruction by the IPE providers, a post-test, and the completion of an instrument to measure perceptions of conflict and participant satisfaction with their team. Pre- and post-test data related to the actual triaging of the simulated patients was used as the measure of performance to be compared to the other variables to determine correlations. The participants began by meeting in a large lecture hall where they were introduced to the staff and agenda for the morning. Immediately following the introductions the participants completed a pre-test on diagnosing triage injuries. The pre-test consisted of a series of 30 slides showing various injuries with basic patient information including respiration, perfusion, and mental status. The participants then selected the appropriate triage category. At the conclusion of the pre-test a representative from the IPE organization led a presentation on triage medicine. After completing the pre-test and listening to the presentation on triage medicine, the nursing and medical students were dispersed into pre-determined, randomly-assigned groups where they were given large, laminated cards of the same injuries from the pre-test. The participants were given a scenario explaining that they were attending a basketball game on campus together and an active shooter entered the gymnasium and randomly fired into the crowd. The shooter was subdued and as medical students and nurses they were now to begin the process of triaging the injured. In these groups the participants discussed each of the injuries and triaged them, which meant to prioritize them based on the severity of the injury. During the course of the group discussions on triaging of the injured, step-in guides would enter the group and provide insight into their roles and what they might be doing during such an emergency situation. These step-in guides included clergy, emergency medical technicians, police officers, and medical school faculty. These guides
2. Methods This descriptive study was undertaken to respond to two primary questions. First, what is the prevalence of perceived conflict of students participating in an IPE activity? Second, what correlation(s) exists between IPE participants’ perceptions of conflict and their individual performance and satisfaction with their team? The definitions for the various types of conflict in this study were derived from the work of Guetzkow and Gyr23 and advanced by Karen Jehn.24 They separated team conflict into three types; task, relationship, and process conflict. Jehn and Mannix25 provided definitions for each of these types of conflict. Task conflict is, “an awareness of differences in viewpoints and opinions relating to a group task” (p. 238). Relationship conflict is defined as, “an awareness of interpersonal incompatibilities, includes affective components such as feeling friction and tension” (p. 238). Finally, process conflict centered on, “controversies about aspects of how task accomplishment will proceed” (p.239). For the sake of this study, only task and relationship conflict were included. Process was excluded as the process for this task was determined by the interprofessional education providers. Also, due to time constraints on the part of the participants, those statements related to process conflict were removed from the survey. 2.1. Methodology The study included 121 medical students and 44 nursing students from a private, faith-based, Midwestern university. The medical students were second year osteopathic medicine students and both the nursing and medical schools resided in the same building. Participation 2
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would also respond to any questions the group might have for them. Once the groups triaged all the injured from the disaster and met all the step-in guides, they reconvened in the lecture hall to complete the post-test as well as various surveys related to the study and their reactions and experiences related to the activities. Upon completion of the post-test they were presented with the two scales for this study and asked to fill them out based on their group experience working through the interprofessional activity. The percentage correct from the pre-test and post-test were compared to determine performance with the expectation that after working in groups their percent correct would increase. Performance was then compared to task conflict, relationship conflict, and satisfaction to determine what relationships existed among those variables.
Table 3 Correlations between levels of conflict, team performance and team satisfaction.
1. 2. 3. 4.
3. Findings This study investigated the conflict perceptions of 121 second-year, osteopathic medical students and 44 nursing students after they engaged in an IPE session. Data was initially analyzed to determine general mean scores for levels of task conflict, relationship conflict, satisfaction, and performance. Performance was defined as the difference between the pre-test and post-test percentage of correct responses. Table 2 provides the mean scores across all participants for task conflict, relationship conflict, satisfaction, and performance. In reviewing the mean scores for the variables a few things become evident. First the task and relationship conflict instrument used a fivepoint scale and the mean scores for both were low at 1.77 and 1.19 respectively. Additionally, the satisfaction instrument also used a fivepoint scale and was relatively high at 4.34. This suggests that participants perceived very little task and relationship conflict within their groups and were generally satisfied in the teams with which they worked. The average performance, which again was the difference between the pre- and post-triage activity scores, was strong with the average growth being a 34% increase in correct responses. Table 2 Mean scores for task conflict, relationship conflict, satisfaction, and performance. Performance
Mean Score
1.77
1.19
4.34
34.82
-.050 -.181* -.043
.535** -.060
.047
-
The prevalence of perceived conflict among participants in this study was low. It appeared that the teams and individual team members did not sense much conflict and were generally satisfied with their team interactions. While the data indicated differences in the variables of the study, only two were statistically significant. Those statistically significant correlations can offer insight on the effects of conflict on IPE, but are far from definitive. A good example of significant findings that may not offer much actual insight was the strong, positive correlation between reported perceptions of task and relationship conflict (rs = .535), which is interesting but perhaps not surprising. It suggests that as one type of conflict increased, so too did the other. One possible explanation for this might be that students were unable to separate task conflict surrounding the goals of the exercise from relationship conflict wherein personality differences occurred. It may also be argued that students were unable to differentiate between the two because they are either not distinct constructs or because the students cannot or do not perceive them that way. High correlations between task conflict and relationship conflict are also not uncommon. In fact it was addressed by De Dreu and Weingart29 in their meta-analysis of studies of task and relationship conflict and their effect on performance and satisfaction. In their meta-analysis they found a positive correlation (r = .52) among the 23 studies that were included. Likewise, de Wit, Greer, and Jehn30 found the correlation between conflict types to be a moderating variable in their meta-analysis such that “if task conflicts can occur without relationship conflicts also occurring, task conflicts are less likely to be emotional,31 escalate,32 and impair group performance33–35” (p. 373). The negative correlation between satisfaction and relationship conflict was also not a complete surprise as the meta-analyses by De Dreu and Weingart29 and de Wit, Greer, and Jehn30 both found similar negative correlations between relationship conflict and team member satisfaction (r = -.54) across the studies included in their meta-analysis. More recent research on conflict experiences, performance, and satisfaction among health profession students found negative correlations between both task and relationship conflict and team member satisfaction.36,37 However, when considering the goal of IPE, the finding could cause some concern. Satisfaction and relationship conflict were negatively correlated, rs = -.181, p = .020 with an effect size of R2 = .0327. While this is a small effect size indicating only about a 3%
Spearman correlation was used to determine the nature and strength of the relationships between the four variables: task conflict, relationship conflict, member satisfaction, and performance.
Satisfaction
4
4. Discussion
2.3. Data analysis
Relationship Conflict
3
To answer the questions about the relationships that existed between conflict, satisfaction and performance, Spearman's rho was used. While most of the correlations such as those between task conflict and satisfaction were both small and not statistically significant, the correlation between relationship conflict and task conflict was positive, moderately strong, and statistically significant, rs (163) = .535, p < .01. Performance was not significantly correlated with any of the other three variables, but there was a weak, negative correlation between relationship conflict and satisfaction, which was statistically significant, rs (163) = -.181, p < .05. This indicates that as the perception of relationship conflict increased, member satisfaction with their team decreased. Table 3 provides all correlations.
The Intragroup Conflict Scale was developed by Karen Jehn24 to measure team member perceptions of conflict experienced within a team function. The instrument measures task, relationship, and process conflict using a five point Likert-type scale with options ranging from “None or Hardly” to “A Great Deal.” For this study, a 6 question version was used as it has been found to have similar psychometric properties as the original 9 question version,26 but did not include the statements to identify process conflict. Satisfaction was measured using a two item scale utilized by DeChurch and Marks.27 The scale included the two questions “working with this group has been an enjoyable experience” and “I would like to work with this group in the future,” and used a five-point Likert scale ranging from “strongly agree” to “strongly disagree.” The satisfaction scale was chosen as it showed a strong item correlation of .94 in prior studies on conflict and satisfaction.28
Task Conflict
2
**. Correlation is significant at the 0.01 level (2 tailed). *. Correlation is significant at the 0.05 level (2 tailed).
2.2. Data collection instruments
N = 165
Satisfaction Task Conflict Relationship Conflict Growth
1
3
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interprofessional collaboration, but it is recognized that interprofessional interactions can lead to conflict. That being the case, then preparing healthcare professionals with the skills needed to resolve differences and a personal awareness of their own instincts towards conflict is critical. IPE seeks to help professionals from various areas of expertise learn to work together, and is being used at the university level to begin to introduce healthcare professionals to the wide array of colleagues with whom they may work. There may be benefits to teaching healthcare professionals how to reduce conflict, but there may also be some benefits that team conflict can provide. Perhaps rather than a focus on removing conflict, education on separating relationship conflict and task conflict is worth considering. In the meta-analysis by de Wit, Greer, and Jehn,30 top management teams showed more positive correlations between task conflict and performance than members of other organizational levels in their studies. They noted that, “an alternative explanation for why task conflicts in top management teams are more positively related to group performance is that members of top management teams are better able to prevent task conflict from turning into relationship conflict” (p. 373). Similar to the notion of separating the person from the problem,42 the key may rest in helping medical professionals differentiate between conflict towards the problem (task conflict) and conflict towards other members of the team (relationship conflict). While the effect sizes in this study were low, they still suggest that relationship conflict is negatively correlated with participant satisfaction, a finding consistent with other studies on the topic. If satisfaction is lower, there is the potential for participants to elect not to engage in teamwork strategies in actual practice.22 At that point it is customers, or patients, who can suffer the most, which both supports the benefits of IPE and also indicates areas for further consideration and development.
variance in satisfaction that can be attributed to relationship conflict, it is worth noting that it occurred in a low-stakes interaction. The participants were not being graded on their performance and participation in the IPE unit was voluntary. Kaufman36,37 encountered a similar condition in his study on conflict and the use of the micronegotiation technique. Future research would be wise to investigate these correlations and effect sizes in high stakes scenarios. The concern then becomes the possible negative impact that relationship conflict can have on satisfaction and whether that reduced satisfaction could lead to hesitancy on the part of these students to engage in collaborative, team-based care as professionals. This may be especially relevant when the stakes become higher and the pressure greater. And yet IPE may be addressing these concerns. Research suggests that participation in IPE activities can reduce the likelihood of utilizing an avoidance response when conflict arises among health profession students.38 Boros, van Gorp, Cardoen, and Boute39 found that group emotional awareness, a skill that can be developed and fostered within teams, can mitigate conflict and improve team performance. And goal orientation has been found to be a key factor in moderating the relationship between task conflict and team innovation.40 These studies and others like them suggest opportunities for conflict management and moderation that can benefit teams and their performance. While it is certainly possible that the low levels of reported perceptions of task and relationship conflict were a product of a low-stress, low-stakes experience, it is also possible that there are cultural changes at work in the health profession community. Jones, Jennings, Higgins, and de Waal41 studied the social behavior of team members in operating rooms. Of the 200 surgeries and 6,348 spontaneous social interactions observed by the researchers only 2.8% were classified as conflict while 59% were classified as cooperative. Gender appeared to be an important factor in these interactions as “cooperation tended to increase with a rising proportion of females in the OR” (p. 29). While gender was not part of this specific study, it is worth noting that the participant group was made up of 103 females and 62 males. This ratio may have led to a higher level of cooperation among the participants and therefore lower perceived levels of both task and relationship conflict, as well as satisfaction within the teams. The study encountered limitations, most noteworthy appeared to be the lack of emotional investment due to the low-stakes nature of the activity. Pressure to perform in a team is a key catalyst for potential conflict. For medical and nursing students who face highly competitive learning environments and are being trained to make life and death decisions, an activity with no consequence or reward may not elicit an emotional reaction making measurement of the impact conflict has on performance and satisfaction difficult. Given that the findings indicated only a small effect size in a low stakes interprofessional interaction, a natural iteration of this study would be in a setting where the stakes hold greater weight. Another limitation was the timing of the measurements of conflict perceptions and satisfaction. The measurements were the last thing the participants did at the end of the activity. At this point they had already been engaged in the activity for 2 hours and may have been hasty in trying to complete the survey as it was the last thing to complete before leaving. As such, participants may not have been reflecting on their experience and providing an accurate representation of that experience as much as simply trying to finish.
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5. Conclusions This study was undertaken to understand the interaction between perceived conflict, performance, and satisfaction among medical and nursing students working together, it did not attempt to investigate resolution of conflict that arose. However, looking for methods for managing conflict is a practical and necessary step in this vein of research. One goal of IPE is to improve patient care through developing 4
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31. Yang J, Mossholder KW. Decoupling task and relationship conflict: the role of intragroup emotional processing. J Organ Behav. 2004;25:589–605. 32. Greer LL, Jehn KA, Mannix EA. Conflict transformation: an exploration of the interrelationships between task, relationship, and process conflict. Small Group Res. 2008;39:278–302. 33. Peterson RS, Behfar KJ. The dynamic relationship between performance feedback, trust, and conflict in groups: a longitudinal study. Organ Behav Hum Decis Process. 2003;92:102–112. 34. Shaw JD, Zhu J, Duffy MK, Scott KL, Shih HA, Susanto E. A contingency model of conflict and team effectiveness. J Appl Psychol. 2011;96:391–400. 35. Simons TL, Peterson RS. Task conflict and relationship conflict in top management teams: the pivotal role of intragroup trust. J Appl Psychol. 2000;85:102–111. 36. Kaufman J. Effect of conflict on team performance and satisfaction among health profession students. Online J Workforce Educ Develop. 2015;8(1). 37. Kaufman J. The effect of a" micronegotiation" technique on team interactions. J Organ Cult Commun Confl. 2015;19(3):31. 38. Dominguez DG, Sanchez-Diaz PC, Fike DS, et al. A pilot study to examine the conflict handling preferences of health professional students before and after participation in an interprofessional education and collaborative practice (IPECP) initiative. Health Interprofessional Pract. 2016;3(1):6. 39. Boroş S, Van Gorp L, Cardoen B, Boute R. Breaking silos: a field experiment on relational conflict management in cross-Functional teams. Group Decis Negot. 2017;26(2):327–356. https://doi.org/10.1007/s10726-016-9487-5 Published in Cooperation with the Institute for Operations Research and the Management Sciences and Its Section on Group Decision and Negotiation. 40. DeGeest D, Kristof-Brown A. Conflict can make your team innovate: goal orientation moderates the task conflict-team innovation relationship. Proceedings of NIDA International Business Conference 2017–Innovative Management: Bridging. 2017; 2017:10. 41. Jones LK, Jennings BM, Higgins MK, de Waal FB. Ethological observations of social behavior in the operating room. Proc Natl Acad Sci. 2018;115(29):7575–7580. 42. Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Agreement without Giving in. second ed. New York: NY: Penguin Books; 1991.
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