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The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members
Accepted Manuscript Title: The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members Author: Karemah Francois Elizabeth Lobb Sarah Barclay Liz Forbat PII: DOI: Reference:
S0738-3991(17)30110-6 http://dx.doi.org/doi:10.1016/j.pec.2017.02.019 PEC 5596
To appear in:
Patient Education and Counseling
Received date: Revised date: Accepted date:
1-9-2016 16-2-2017 20-2-2017
Please cite this article as: Francois K, Lobb E, Barclay S, Forbat L, The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members, Patient Education and Counseling (2017), http://dx.doi.org/10.1016/j.pec.2017.02.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Highlights (for review)
Highlights
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Conflict occurs in specialist palliative care Different ideas of syringe drivers and providing fluid/nutrition cause conflict Staff and relatives identified systemic causes Compassion and empathy were employed by staff and relatives in explaining conflict Conflicts were not always proactively resolved
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*Manuscript Click here to view linked References
The Nature of Conflict in Palliative Care: A Qualitative Exploration of the Experiences of Staff and Family Members Karemah Francoisa, b, Elizabeth Lobbc, Sarah Barclayd and Liz Forbata, b a
Calvary Centre for Palliative Care Research, Calvary Health Care ACT, Canberra, Australia. School of Health Sciences, Australian Catholic University, Canberra, Australia. C Calvary Health Care Kogarah and Cunningham Centre for Palliative Care, Sydney, Australia. d School of Medicine, Univeristy of Notre Dame, Darlinghurst, Australia e Medical Mediation Foundation, London, UK.
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Email addresses: [email protected] [email protected] [email protected] [email protected]
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* Corresponding author at 5 Menindee Drive, Barton, ACT, 2602, Australia; Australian Catholic University, Antill Street, Watson, Canberra, 2612, Australia. Tel: +61 (0)47 597 8476, [email protected]
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Abstract
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Objectives: Conflict is a significant and recurring problem in healthcare. This study aimed to understand staff and relatives’ perspectives on the characteristics of conflict and serious disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care. Methods: Qualitative study of 25 staff and seven bereaved relatives using individual interviews, recruited from a multidisciplinary specialist palliative care setting in Australia. Data were analysed thematically. Results: Communication was frequently cited as a cause of conflict. Further, different understandings regarding disease process, syringe drivers and providing nutrition/hydration caused conflict. Staff applied empathy to moderate their responses to conflict. Relatives’ reactions to conflict followed a trend of anger/frustration followed by explanations or justifications of the conflict. Relatives identified systemic rather than interpersonal issues as triggering conflict. Conclusions: The data illustrate connections with conflict literature in other clinical areas, but also points of convergence such as the compassion shown by both families and staff, and the identification of systemic rather than always individual causes. Practice implications: Family meetings may fruitfully be applied to prevent and de-escalate conflict. Clinical audits may be useful to identify and provide support to families where there may be unresolved conflict impacting grief process.
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Introduction
Conflict is a significant and recurring problem in health care [1-4] [5,6]. Commonly identified causes/triggers of conflict include breakdown in communication [4], relatives’ involvement in decision-making [7], patient and family mistrust of the healthcare system [8], religious beliefs and cultural differences about treatment goals [4,9,10], refusal of treatment [9] and misunderstanding of prognosis [11]. A recent integrative review of conflict identified a lack of emotional intelligence alongside systemic organisational issues as key antecedents [12].
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The triadic healthcare relationships (involving patient-relative-healthcare team) [13] in settings where conflict has been documented adds complexity to the dynamic and increases the potential for disagreement and conflict. The combination of very sick patients, high mortality, multiple specialities and a frequent need for decisions on complex matters are recognised as factors in conflict [14]. Consequently adult palliative care, which exhibits these characteristics, is likely to experience conflict.
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Although conflict in palliative care is a recognised phenomenon, there has been little primary research, and the few papers reporting conflict are based on anecdotal clinical reports [11]. One exception to this paucity of data is a recent study comparing intensivist and specialist palliative care clinicians’ responses to conflict [15]. The authors identified that specialist palliative care clinicians used language which was less task-oriented and slightly more focussed on relationship building. Palliative care is intended as a holistic, multidisciplinary approach to relieve suffering, for both patient and families [16]. Therefore, attending to suffering within the clinical relationships is particularly pertinent.
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Little has been established through robust empirical work about the causes and outcomes of conflict in specialist palliative care. This study sought to understand staff and relatives’ perspectives on the characteristics of conflict and serious disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care. The study focused solely on conflict between staff and patients/relatives, rather than intra-staff or intra-familial conflict.
Methods
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A qualitative inductive design was applied using semi-structured individual interviews.
Setting
Participants were recruited from a multidisciplinary specialist palliative care service located in [city] Australia. The service has a 19 bed in-patient unit, with an average of 268 admissions per annum, and a community service component, which at time of the study had a caseload of 125 patients.
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Sample and recruitment
Purposive sampling was used to identify staff with varying levels of experience in a palliative care service, exposure to serious disagreement/conflict, gender, and in-patient and out-patient location. The service supports patients whose disease is not responsive to curative treatment, offering care for months or years, as well as end-of-life and terminal care. Staff names were derived from discussion with senior clinicians to ensure that the sampling frame was achieved. Twenty-nine staff
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members were sent email invitations to participate.
Table 1: Inclusion criteria Family members
Staff member in adult palliative care team
No severe/enduring mental health problem or cognitive impairment
Identifies as having experience of conflict with patients/families, defined as “when two or more people perceive opposition of toward other, and a process whereby one’s interests, norms and values are opposed by another” Able to communicate in English
Relative (aged >18) of someone receiving inpatient or outpatient services from specialist palliative care, of a patient who was over 18 years old,
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Bereaved greater than three months [following evidence from a recent study, 17], but less than 18months to reduce recall bias Service manager indicated that there was no current complaint to the hospital about the care received (to avoid interfering with a formal complaint process) Able to communicate in English
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Willing and able to give informed consent
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132 family members met the inclusion criteria. The postal invitation asked relatives to opt-in if they self-identified as having serious disagreement or conflict with specialist palliative care staff.
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A sample size of 25 was sought for staff, and 25 for relatives, to achieve theoretical sufficiency and thematic saturation [18,19].
Data collection
Audio recorded one-to-one interviews were conducted and transcribed verbatim. All participants provided written consent.
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The interview schedule drew from previous work on conflict in healthcare settings, with adaptations for the context of the adult palliative care service. Staff questions focused on definitions of conflict, perceived causes, consequences, triggers and risk factors, and impact on staff and patients/family members. Questions posed to families focused on descriptions of conflicts, causes of conflicts, trust in the service and resolution of conflict. Recruitment commenced in December 2015 and data collection ceased in May 2016. Interviews were conducted by two female researchers including a junior research assistant and an experienced qualitative health researcher. Interviews lasted between 25-90 minutes (mean: 43; mode: 30mins). The researchers regularly work alongside the staff interviewees, but had no prior relationship with families.
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2.4
Analysis
Inductive analysis proceeded through a five-stage process of thematic analysis [20]. Stage 1 involved familiarisation with the dataset. Stage 2 involved identifying a thematic framework. Stage 3 involved indexing the data with reference to the thematic framework. In Stage 4, responses were synthesised from across respondents into a working grid of themes. Stage 5 focused on data interpretation and finalisation of key emergent themes. Data were coded and analysed in the software package Nvivo version 10.
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Analysis was conducted by the study research assistant and study PI. More than a third of transcripts were double-coded to ensure themes derived from the data were highly refined, and to ensure coding disagreements were discussed and the analytic strategy was robust and valid. The staff and family data were analysed separately, and then jointly to identify convergent and divergent areas.
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Core themes from the staff data were presented to the clinical team to elicit feedback on the validity and fit of the findings. Participant checking was not conducted with family members, although the interview process incorporated a technique of on-going checking about understanding of core themes and issues.
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Ethical approval was provided by [details to be added after peer review]. Anonymity has been achieved by not reporting identifiable demographic or other identifiable information alongside quotations. The quotes used in this paper were shared with interviewees to verify their confidence that the data is not identifiable or attributable. The initial S is used to indicate a staff interviewee and F to denote a family member.
Results
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25 staff members and seven relatives participated in the study. Table 1 illustrates participant role. Staff length of service in specialist palliative care services (including experience prior to the current service) ranged from five months to twenty years, with a mean duration of 10 years (mode: 12 years, median: 11years). Participants were mainly female (n=21/25 staff, 84%) and worked in both inpatient and out-patient contexts (n=7 and n= 13 respectively), with five staff working across both inpatient and out-patient services. All family member participants were female (n=7/7). The majority of the relatives recruited were a spouse/partner (n=5/7 relatives, 71%). Four invited staff members declined participation, and did not provide reasons for their decision. One of the participants declined verbally while the other three booked interviews but did not follow through with the interview. Attempts to reschedule the interviews were unsuccessful. Of the 132 family invitations, five letters were returned to sender, and seven relatives opted in to the study.
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Relative role Spouse Son/Daughter Sibling
n 5 1 1
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n 9 3 3 3 2 2 1 1 1 25
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Table 2: Role of participants Staff role Community RN In-patient RN Doctor Social worker Clinical nurse consultant Allied health Acute hospital liaison nurse Pastoral care Service manager Total
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The data indicate key emergent themes, reported below, which are described in Figure 1. The data point to conflict as emotional expression, which is managed by validating but not internalising emotions and responding systemically, such as through use of family meetings.
Definitions: Mismatched expectations and suboptimal communication
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Participants were not offered an a priori definition of conflict or serious disagreement, instead they were encouraged to articulate their own:
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“If a patient or a family member became aggressive and highly emotional, that would be classed as serious to me.” (S1)
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“Where a family’s expectations are different to the care team’s expectations.” (S8)
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Definitions of conflict involved staff being ‘sacked’ by families (being asked not to return and have another member of the team provide care), raised voices, aggression, verbal threats and erratic behaviour: “A patient felt he wasn’t being given his medication […..] And he became aggressive and wanted to leave so he became quite threatening and yelling” (S11)
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By contrast, families were not explicitly asked to provide a definition. Their views of conflict were distilled from the narrative of their experience, and were understandably focused on single experiences rather than being able to more broadly define conflict itself, for example feeling that the service had inadequate resource to care for their relative, or that staff were dismissive toward them: “This particular nurse came and she said to me … you’re the wife, you’re not the nurse” (F1). “The difficulty was continuity [there wasn’t] any really continuous person who got to know us and got know my mother” (F4) Other relatives cited conflict as involving lack of communication about advance care planning
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Staff indicated that conflict frequently involved the relative, rather than the patient, which may point to perceptions in care rather than the care itself being problematic. While lack of conflict with patients may also be explained by patients being too unwell to engage in communicating annoyance, it is likely that the relative takes on a role as advocate. As noted below, the causes of conflict often pertain to emotional distress, and consequently signal difficulties in coping.
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Causes: not feeling prepared for death
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Many participants’ accounts focused on perceived causes of conflict. Communication was implicated in numerous underlying causes of conflict, for example, use of misjudged words:
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“I was trying to explain to him […] if you were to take enough medication so you didn’t have pain when you got up to walk, it would make you like a zombie and he took exception to the word zombie.” (S21) Family members also recounted similar experiences where mis-judged words caused conflict:
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“This lady who I don't have any doubt that she is a top nurse […] she decided the best thing was to joke to break the ice and she said, "You know what, not everybody who comes here leaves in a coffin". That joke has stayed in my mind forever and ever and ever, and my husband as well.” (F3)
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Different understandings regarding disease process were cited frequently. The provision of fluid/nutrition were called upon as examples of clashes in assumptions about care which cause conflict. The disjuncture between relatives wishing to give the patient food/fluids contrasted with clinician prioritisation of the potential risks of aspiration or choking:
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“Hydration is a big thing and that ties back to … level of expectation of the loved ones and really having being told what is happening.” (S11) Family members described experiences where different understandings of care caused conflict. Administration of pain relief was a concern to one family:
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“It’s just it wasn’t a matter of our expectations it wasn’t of, “Your sister will have pain or your sister won’t have pain”. It was purely that [the palliative care team] kept saying “she doesn’t have to have this much pain. The pain can be managed”, but it wasn’t. So it was always like she was under – the dose was too low, and it was us [the family] ringing up to say, “It’s not good at the moment. We need a higher dose. We need more pain management”. (FP6)
A lack of shared understanding of the dying process and goals of care were also triggers for conflict: “There can sort of be an assumption that you come here [to the hospice] and you’re automatically going to die so people are worried what you’re going to do to their loved one. So you know they’re really guarded about you giving any pain control no matter how much you try to explain.” (S11)
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Syringe drivers (a needle inserted under the patient’s skin to deliver medication, including strong analgesia such as morphine) were noted as frequently activating conflict “[The family] agreed to the commencement of a syringe driver for management of symptoms. The next day the daughter came back to visit and her father remained alive but was no longer conscious. Her understanding of the situation was that he was starving to death […] she was very distressed.” (S18)
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Syringe drivers and morphine are frequently construed by families as a signifier of impending death, and become imbued with unintended meanings around terminal decline. Consequently conflict be triggered by clinical activities which imply the nearness of death, thereby provoking an emotional response to approaching bereavement.
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Cultural and language differences were cited by multiple respondents, both staff and families, as contributors to conflict:
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“Some particular cultural groups, they still try and feed their family members and they just think that we're starving mum or dad or their husband or wife and that could cause quite a bit of conflict.” (S13)
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“[The specialist palliative care nurse] probably meant well but we weren’t prepared to give up […] You're just declared palliative by Western society, but a person may not want to die, may not want to give up. We were living every day, we didn't give up.” (F3)
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Many of the participants indicated awareness that patients and families are under significant strain, and that this emotional fragility combined with poor communication, differences in opinion about goals of care, or culture would be sufficient to trigger conflict with staff:
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“Times of distress are when disputes in families come out…so there’s a lot of previous baggage going on” (S10) Expectations of the service also led to conflict, for example the availability of specialists overnight or weekends in the community, and delays in accessing care:
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“[Patients/relatives] want us there in an hour and we can’t get there straight away […] they might think that our role is to coordinate every aspect of that person’s care and we can’t always do that [….] they think we should be able to get [them] a bed at [the hospice] immediately even if there’s not one available or they’re not the most suitable candidate at the time.” (S21).
Family members approached the palliative care service with expectations, such as the number of staff available to provide care. Services failing to meet their expectations led to conflict and/or serious disagreements. Disappointment with care provision was channelled into frustration with what was perceived as inadequate resourcing to attend to the growing, complex and intricate needs of patients and relatives. “I was left with…just that anger with the system, the not being able to provide a better service…I was gobsmacked right from the beginning when I was told there was one nurse on an evening shift for the entire [area] and I couldn’t believe that, 8 Page 9 of 17
and I still think that is the worst thing I’ve ever heard of in pretending to be offering a service when you’re really not.” (F1) Suboptimal communication about disease progression (including managing pain, and nutrition/hydration) alongside insufficient clarity regarding the level of care provided by the service, create a context where conflict can flourish. Not being prepared or ready for the relative’s death underpinned each of these data-points.
3.3
Warning signs: Concerns about care
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Asked to identify warning signs of conflict, staff referred to relatives documenting the care they were receiving, for example taking photographs of the patient’s posture to evidence poor quality care. Other staff reported that relatives and patients were sometimes suspicious of the goals of palliative care:
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“If they’re suspicious to start with and you don’t get past that suspicious phase you know they have a pre-conceived idea of what palliative care is…it’s sort of like terminal care…if they think that you’re coming in with narcotics, and that it can contribute to the death of their loved one…the alarm bells start going off.” (S19)
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Tone of voice, being uncommunicative or dismissive were all described as signs of disgruntlement and early flags for conflict. Further, a history of difficulties with other clinicians were all signifiers to staff respondents that conflict was fermenting: “If people tell me X clinician was not good [I] realise that [the family are] going to criticise me too, because no one’s ever going to be good enough.” (S25)
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A history of drug and alcohol use, and severe and enduring mental health problems were also considered warning signs by staff.
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Warning signs were not mentioned in the family interviews. Relatives appeared not to identify a build-up, but rather spoke of a single incident which was an unexpected shift into conflict. Thus for staff, feeling under scrutiny was a warning sign. These warning signs indicate that conflict can be identified in advance (or in the early stages) and therefore be open to de-escalation strategies.
Consequences: a hurtful experience not to be internalised
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The repercussions of conflict included immediate reactions and long term consequences. For staff, reactions seemed to follow a trend of feeling hurt, then excusing the actions of the other party: “I step back to be calm inside, but I’m usually angry. It depends what it is […] what I try to do is I think ‘well it’s not that personal to me. They’re just questioning something because there might be ten things that are causing the, worry and this is just one small part of it’” (S11)
However, for more junior members of staff, responses followed a different trend. Reactions followed a cycle of feeling hurt because of the conflict, justifying and excusing the actions of the other party and then withdrawing from the conflict situation. Resolution was less proactive and relied on allowing the situation to settle and sort itself out: “I think I left it for other staff to deal with that particular situation.” (S14) 9 Page 10 of 17
From the family’s perspective the consequences of conflict also seemed to follow a trend of emotional response followed by explanations or justifications of the conflict. Family members reported distress, annoyance, anger, disappointment, upset, offence, disrespect and puzzlement. The following quotation also illustrates a commonality of relatives presenting an understanding of why services sometimes failed to meet their expectations due to systemic rather than personal failings:
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“You can’t blame the staff, they’re working under pressure for inadequate staffing and inadequate funding.” (F1)
Family members cited writing complaint letters to politicians as a consequence of the conflict:
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“I’ve told a couple of politicians, I haven’t had a real response but I was trying to, I went out and spoke to [a staff member] and you know all their hands are tied but I just wanted to let people know how I felt.” (F1)
Staff described placing their own emotional reactions in the background, in order to foreground the patient and family as their main priority:
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“I listened to him and I tried to see where he was coming from which is a little tricky so I just waited for him to finish as best I could, so I could hear his frustration and I just explained that our role is to relieve suffering. I felt comfortable in my own skin saying that […] listening to him, listening to the family’s concerns.” (S7)
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Some staff reactions pointed to the gulf between their personal reaction (upset) and the usual sense of gratitude expressed by patients and families:
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“Nobody really talked to me about it or nobody ever said ‘how did that make you feel?’ and I was embarrassed because you know it’s not an everyday occurrence that your patients don't feel grateful for any of your input.” (S16) While conflict was upsetting for both staff and families, both parties avoided internalising blame, and recruited compassionate discourses to explain the conflict, or their hurt.
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3.5 Resolving and managing conflict: A proactive and systemic approach to conflict resolution The majority of both staff and family respondents indicated that conflicts ended either when a new member of staff was allocated to look after the family, or when the patient died and the family was no longer in touch with the service. Consequently, in many cases, families felt that the conflict was never directly resolved, but ceased being a concern because contact between families and service stopped at point of death: “When my mother died we never saw them again.” (F4) Senior staff (managers and senior clinicians) displayed a more proactive approach in their responses to conflict; they were more likely to address the issues and attempt a resolution. One senior respondent indicated that discussing the situation with the individuals involved was routine, and cited the strategy of reallocating patients to other staff: 10 Page 11 of 17
“My job is to find out what’s upset the person […] ‘I want to find out what’s wrong and can you explain it to me and what can we do to sort it out’ so I think that’s just the approach.” (S10) Behaviour contracts and boundary-setting were rarely used, and referred to only in a historical sense of strategies which were no longer applied.
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Family meetings were often used as a management approach, and are prioritised for families where the staff have concerns about conflict occurring:
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“If we think there’s any problem with the family, and we’ve got limited time, that’s the family meeting we’ll have first” (S6)
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Family members’ accounts of managing conflict tended to be systemic. Their comments focused on requests for more support for relatives, and additional training of specialist palliative care staff which would enable them to provide a better service:
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“I felt that often relatives of, and carers of, the person that’s dying need coaching and encouragement.” (F4)
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“They need to be told look yes it’s okay for you to do that, yes this is how you do it – so a bit of training around what you can and can’t, what you can do and how you can do it.” (F1)
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Staff avoided internalising conflict, and families often proffered systemic explanations thereby resisting internalising the conflict to individual nurses. Both strategies permit the expression and acknowledgment of hurt or harm, while allowing adaptation to allow for care to continue to be provided and/or received.
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Discussion and conclusion
4.1
Discussion
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While dictionaries define conflict as active disagreement, these data indicate the emotional undertow of conflict in palliative care. Communication difficulties underpinned many conflict scenarios. Although communication issues varied, the majority centred on difficulties in reaching a shared understanding of palliative care or goals of care. Communication difficulties often plague clinical practice, and dominate patient experience feedback, despite a considerable body of work in communication training and education [21,22]. Conflict was also identified as mis-matched expectations of care, for example around providing nutrition and hydration. Cultural values may take on greater salience at times of existential crises [10]; finding time to understand a patient/family’s motivations around their goals of care [23] could be a significant step in lessening conflict. The hegemony of the western-medical model currently serves to undermine valuing differences in goals of care. Conversely, conflict over nutrition and hydration may be signifiers of underlying communication difficulties where there is not a shared understanding about what constitutes compassionate caring at end-of-life. Cultural relativism in palliative care is not new [24], but its place in understanding conflict occurrence and conflict resolution is not well understood. Since it is established that providing food is an enactment of 11 Page 12 of 17
caregiving and a social transaction [25], there is a need to support families to provide safe nurturance.
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The consequences of the conflicts described in this paper were predominantly emotional. Physical violence which has been reported in other areas such as ED [1] and paediatrics [6] was not apparent in the data from this study. This may be an artefact of the service itself, or point toward the unique specialist palliative care context, with different stressors, mediators and moderators. Further studies in palliative care should seek to establish the frequency and severity of conflict in this setting. This approach has been adopted in other specialities, such as ICU [2] and paediatrics [5], and allows for mapping of the scale of the problem.
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Data saturation was not achieved for the family interviewees, so the data indicate areas for further exploration. Low uptake of the opportunity to discuss conflict may indicate an unrepresentative sample and a limitation of the sampling frame (3-18months post-bereavement).The dominance of staff voices has resulted in a model which relies more heavily on staff perspectives on the causes and consequences of conflict. Not including current service users (due to concern from staff about burden and impacting the dynamic) will also have impacted the number and type of families responding, a gate-keeping feature well documented in the palliative care literature [26]. Since the research team have on-going working relationships with the clinicians, there is a risk of bias to the data; however to mitigate this, two authors (SB and EL) have no such relationship and independently scrutinised the analysis and reporting.
Conclusion
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Practice implications
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This study reports experiences of conflict from the perspective of staff and relatives in palliative care services. The data illustrate connections with conflict literature in other clinical areas, but also highlighted points of convergence. The data indicated compassion for families by staff. Further, both families and staff identify systemic rather than always individual causes.
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Identifying and managing conflict in its early stages is important in reducing the burden to families, patients, staff and systems. Methods and theories from restorative healthcare practice may be fruitful to apply. Restorative practice, which stems from the legal approach of restorative justice, seeks to limit blaming and offer a more collaborative model of shared responsibility and shared concern has been used in healthcare [27] and could be adapted from staff-staff conflict to staffrelative conflict. Further, techniques from within palliative care, such as family meetings, aid communication, reduce blaming and create space for a shared understanding of goals of care and responsibilities. Interviewees raised them as a mechanism to prevent or reduce conflict [28]. Conflict training can also increase staff confidence in identifying and de-escalating conflict [29] and could be usefully applied in palliative care services. Many of the conflicts ended when the patient died. Consequently, there was no follow-up or resolution for family or staff. Not resolving conflict may be problematic in terms of complicated grief/bereavement [30]. Findings from this study suggest that audits may be required to identify and provide support to families where there may be unresolved conflict over goals of care, since lack of preparedness for death negatively impacts grief [31]. Further, an audit of formal complaints would augment understandings of the causes and consequences of conflict in specialist palliative care.
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Acknowledgments: Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest: None of the authors have any conflicts to declare.
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Chan, T.C., F. Bakewell, D. Orlich, and J. Sherbino, Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations, Acad Emerg Med 21 (2014) 308-13. Azoulay, E., J.F. Timsit, C.L. Sprung, M. Soares, K. Rusinová, A. Lafabrie, R. Abizanda, M. Svantesson, et al., Prevalence and factors of intensive care unit conflicts: The conflicus study, Am J Respir Crit Care Med 180 (2009) 853-60. Schuster, R.A., S.Y. Hong, R.M. Arnold, and D.B. White, Investigating conflict in ICUs: Is the clinicians perspective enough?, Crit Care Med 42 (2014) 328-35. Studdert, D.M., M.M. Mello, J.P. Burns, A.L. Puopolo, B.Z. Galper, R.D. Truog, and T.A. Brennan, Conflict in the care of patients with prolonged stay in the ICU: types, sources, and predictors, Intensive Care Med. 29 (2003) 1489-97. Forbat, L., C. Sayer, P. McNamee, E. Menson, and S. Barclay, Conflict in a paediatric hospital: a prospective mixed-method study, Arch Dis Child 101 (2016) 23-7. Forbat, L., B. Teuten, and S. Barclay, Conflict escalation in paediatric services: Findings from a qualitative study, Arch Dis Child 100 (2015) 769-73. Marziali, E., C.S. Mackenzie, and I. Tchernikov, Acceptability of an e-learning program to help nursing assistants manage relationship conflict in nursing homes, Am J Alzheimers Dis Other Demen. 30 (2015) 55-60. Back, A.L. and R.M. Arnold, Dealing with conflict in caring for the seriously ill: "it was just out of the question", J Amer Med Assoc. 293 (2005) 1374-81. McDougall, R., L. Notini, and J. Phillips, Conflicts Between Parents and Health Professionals About a Child's Medical Treatment: Using Clinical Ethics Records to Find Gaps in the Bioethics Literature, J Bioeth Inq. 12 (2015) 429-36. Johnstone, M.J., Bioethics, cultural differences and the problem of moral disagreements in end-of-life care: a terror management theory, J Med Philos. 37 (2012) 181-200. Weissman, D.E., T.E. Quill, and R.M. Arnold, The family meeting: Causes of conflict #225, Journal of Palliative Medicine. 13 (2010) 328-9. Almost, J., A.C. Wolff, A. Stewart-Pyne, L.G. McCormick, D. Strachan, and C. D'Souza, Managing and mitigating conflict in healthcare teams: an integrative review, J Adv Nurs. 72 (2016) 1490-505. Greene, M. and R. Adelman, Beyond the Dyad: Communication in Triadic (and more) Medical Encounters, in The Oxford Handbook of Health Communication, Behavior Change, and Treatment Adherence M.L. DiMatteo, Editor. 2013, Oxford Handbooks,: Oxford. pp. 136-54. Fassier, T. and E. Azoulay, Conflicts and communication gaps in the intensive care unit, Curr Opin Crit Care. 16 (2010) 654-65. Chiarchiaro, J., D.B. White, N.C. Ernecoff, P. Buddadhumaruk, R.A. Schuster, and R.M. Arnold, Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists, Crit Care Med 44 (2016) 934-42. World Health Organisation. WHO definition of palliative care. [cited 2017 09/01/2017]; Available from: http://www.who.int/cancer/palliative/definition/en/. Bentley, B. and M. O'Connor, Conducting Research Interviews with Bereaved Family Carers: When Do We Ask?, J Palliat Med. 18 (2015) 241-5. O'Reilly, M. and N. Parker, ‘Unsatisfactory Saturation’: a critical exploration of the notion of saturated sample sizes in qualitative research Qualitative Research. 13 (2013) 190-7. Baker, S.E. and R. Edwards, How many qualitative interviews is enough? Expert voices and early career reflections on sampling and cases in qualitative research. 2012, National Centre for Research Methods Review Paper: London. Braun, V. and V. Clarke, Using thematic analysis in psychology, Qualitative Research in Psychology. 3 (2006) 77-101.
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Fallowfield, L. and V. Jenkins, Communicating sad, bad, and difficult news in medicine, Lancet. 363 (2004) 312-9. Turner, M., S. Payne, and T. O'Brien, Mandatory communication skills training for cancer and palliative care staff: does one size fit all?, Eur J Oncol Nurs. 15 (2011) 398-403. Doane, G.H. and C. Varcoe, Relational practice and nursing obligations, Advances in Nursing Science. 30 (2007) 192-205. Hanks, G., N.I. Cherny, N.A. Christakis, and S. Kaasa, Oxford Textbook of Palliative Medicine. 2011, Oxford: Oxford University Press. Hughes, N. and R.D. Neal, Adults with terminal illness: a literature review of their needs and wishes for food, J Adv Nurs. 32 (2000) 1101-7. Kars, M.C., G.J. van Thiel, R. van der Graaf, M. Moors, A. de Graeff, and J.J. van Delden, A systematic review of reasons for gatekeeping in palliative care research, Palliat Med. 30 (2016) 533-48. Hutchinson, M., Restorative approaches to workplace bullying: Educating nurses towards shared responsibility, Contemporary Nurse. 32 (2009) 146-55. Meeker, M.A., D.P. Waldrop, and J.Y. Seo, Examining family meetings at end of life: The model of practice in a hospice inpatient unit, Palliative and Supportive Care. 13 (2015) 128391. Forbat, L., J. Simmons, C. Sayer, M. Davies, and S. Barclay, Training paediatric health care staff in recognising, understanding and managing conflict with patients and families: Findings from a survey on immediate and six-month impact, Arch Dis Child forthcoming (2016). Shear, M.K., A. Ghesquiere, and K. Glickman, Bereavement and complicated grief, Curr Psychiatry Rep. 15 (2013) 406. Hebert, R.S., Q. Dang, and R. Schulz, Preparedness for the death of a loved one and mental health in bereaved caregivers of patients with dementia: findings from the REACH study, J Palliat Med. 9 (2006) 683-93.
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Figure
Conflict as emotion
Warning signs: concern about care provided
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Causes: insufficiently prepared for death
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Defining conflict: mis-matched expectations and sub-optimal communication
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Consequences: hurt, where internalising is resisted
Acknowledgment of emotion and adaptation to allow continued care
Resolution: proactive and systemic
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Figure 1: A model of conflict in palliative care between staff and relatives in palliative care
S0738-3991(17)30110-6 http://dx.doi.org/doi:10.1016/j.pec.2017.02.019 PEC 5596
To appear in:
Patient Education and Counseling
Received date: Revised date: Accepted date:
1-9-2016 16-2-2017 20-2-2017
Please cite this article as: Francois K, Lobb E, Barclay S, Forbat L, The nature of conflict in palliative care: A qualitative exploration of the experiences of staff and family members, Patient Education and Counseling (2017), http://dx.doi.org/10.1016/j.pec.2017.02.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
*Highlights (for review)
Highlights
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Conflict occurs in specialist palliative care Different ideas of syringe drivers and providing fluid/nutrition cause conflict Staff and relatives identified systemic causes Compassion and empathy were employed by staff and relatives in explaining conflict Conflicts were not always proactively resolved
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*Manuscript Click here to view linked References
The Nature of Conflict in Palliative Care: A Qualitative Exploration of the Experiences of Staff and Family Members Karemah Francoisa, b, Elizabeth Lobbc, Sarah Barclayd and Liz Forbata, b a
Calvary Centre for Palliative Care Research, Calvary Health Care ACT, Canberra, Australia. School of Health Sciences, Australian Catholic University, Canberra, Australia. C Calvary Health Care Kogarah and Cunningham Centre for Palliative Care, Sydney, Australia. d School of Medicine, Univeristy of Notre Dame, Darlinghurst, Australia e Medical Mediation Foundation, London, UK.
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Email addresses: [email protected] [email protected] [email protected] [email protected]
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* Corresponding author at 5 Menindee Drive, Barton, ACT, 2602, Australia; Australian Catholic University, Antill Street, Watson, Canberra, 2612, Australia. Tel: +61 (0)47 597 8476, [email protected]
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Abstract
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Objectives: Conflict is a significant and recurring problem in healthcare. This study aimed to understand staff and relatives’ perspectives on the characteristics of conflict and serious disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care. Methods: Qualitative study of 25 staff and seven bereaved relatives using individual interviews, recruited from a multidisciplinary specialist palliative care setting in Australia. Data were analysed thematically. Results: Communication was frequently cited as a cause of conflict. Further, different understandings regarding disease process, syringe drivers and providing nutrition/hydration caused conflict. Staff applied empathy to moderate their responses to conflict. Relatives’ reactions to conflict followed a trend of anger/frustration followed by explanations or justifications of the conflict. Relatives identified systemic rather than interpersonal issues as triggering conflict. Conclusions: The data illustrate connections with conflict literature in other clinical areas, but also points of convergence such as the compassion shown by both families and staff, and the identification of systemic rather than always individual causes. Practice implications: Family meetings may fruitfully be applied to prevent and de-escalate conflict. Clinical audits may be useful to identify and provide support to families where there may be unresolved conflict impacting grief process.
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1
Introduction
Conflict is a significant and recurring problem in health care [1-4] [5,6]. Commonly identified causes/triggers of conflict include breakdown in communication [4], relatives’ involvement in decision-making [7], patient and family mistrust of the healthcare system [8], religious beliefs and cultural differences about treatment goals [4,9,10], refusal of treatment [9] and misunderstanding of prognosis [11]. A recent integrative review of conflict identified a lack of emotional intelligence alongside systemic organisational issues as key antecedents [12].
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The triadic healthcare relationships (involving patient-relative-healthcare team) [13] in settings where conflict has been documented adds complexity to the dynamic and increases the potential for disagreement and conflict. The combination of very sick patients, high mortality, multiple specialities and a frequent need for decisions on complex matters are recognised as factors in conflict [14]. Consequently adult palliative care, which exhibits these characteristics, is likely to experience conflict.
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Although conflict in palliative care is a recognised phenomenon, there has been little primary research, and the few papers reporting conflict are based on anecdotal clinical reports [11]. One exception to this paucity of data is a recent study comparing intensivist and specialist palliative care clinicians’ responses to conflict [15]. The authors identified that specialist palliative care clinicians used language which was less task-oriented and slightly more focussed on relationship building. Palliative care is intended as a holistic, multidisciplinary approach to relieve suffering, for both patient and families [16]. Therefore, attending to suffering within the clinical relationships is particularly pertinent.
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Little has been established through robust empirical work about the causes and outcomes of conflict in specialist palliative care. This study sought to understand staff and relatives’ perspectives on the characteristics of conflict and serious disagreement in adult palliative care, including triggers, risk factors and the impact on themselves and clinical care. The study focused solely on conflict between staff and patients/relatives, rather than intra-staff or intra-familial conflict.
Methods
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A qualitative inductive design was applied using semi-structured individual interviews.
Setting
Participants were recruited from a multidisciplinary specialist palliative care service located in [city] Australia. The service has a 19 bed in-patient unit, with an average of 268 admissions per annum, and a community service component, which at time of the study had a caseload of 125 patients.
2.2
Sample and recruitment
Purposive sampling was used to identify staff with varying levels of experience in a palliative care service, exposure to serious disagreement/conflict, gender, and in-patient and out-patient location. The service supports patients whose disease is not responsive to curative treatment, offering care for months or years, as well as end-of-life and terminal care. Staff names were derived from discussion with senior clinicians to ensure that the sampling frame was achieved. Twenty-nine staff
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members were sent email invitations to participate.
Table 1: Inclusion criteria Family members
Staff member in adult palliative care team
No severe/enduring mental health problem or cognitive impairment
Identifies as having experience of conflict with patients/families, defined as “when two or more people perceive opposition of toward other, and a process whereby one’s interests, norms and values are opposed by another” Able to communicate in English
Relative (aged >18) of someone receiving inpatient or outpatient services from specialist palliative care, of a patient who was over 18 years old,
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Bereaved greater than three months [following evidence from a recent study, 17], but less than 18months to reduce recall bias Service manager indicated that there was no current complaint to the hospital about the care received (to avoid interfering with a formal complaint process) Able to communicate in English
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Willing and able to give informed consent
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132 family members met the inclusion criteria. The postal invitation asked relatives to opt-in if they self-identified as having serious disagreement or conflict with specialist palliative care staff.
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A sample size of 25 was sought for staff, and 25 for relatives, to achieve theoretical sufficiency and thematic saturation [18,19].
Data collection
Audio recorded one-to-one interviews were conducted and transcribed verbatim. All participants provided written consent.
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The interview schedule drew from previous work on conflict in healthcare settings, with adaptations for the context of the adult palliative care service. Staff questions focused on definitions of conflict, perceived causes, consequences, triggers and risk factors, and impact on staff and patients/family members. Questions posed to families focused on descriptions of conflicts, causes of conflicts, trust in the service and resolution of conflict. Recruitment commenced in December 2015 and data collection ceased in May 2016. Interviews were conducted by two female researchers including a junior research assistant and an experienced qualitative health researcher. Interviews lasted between 25-90 minutes (mean: 43; mode: 30mins). The researchers regularly work alongside the staff interviewees, but had no prior relationship with families.
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2.4
Analysis
Inductive analysis proceeded through a five-stage process of thematic analysis [20]. Stage 1 involved familiarisation with the dataset. Stage 2 involved identifying a thematic framework. Stage 3 involved indexing the data with reference to the thematic framework. In Stage 4, responses were synthesised from across respondents into a working grid of themes. Stage 5 focused on data interpretation and finalisation of key emergent themes. Data were coded and analysed in the software package Nvivo version 10.
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Analysis was conducted by the study research assistant and study PI. More than a third of transcripts were double-coded to ensure themes derived from the data were highly refined, and to ensure coding disagreements were discussed and the analytic strategy was robust and valid. The staff and family data were analysed separately, and then jointly to identify convergent and divergent areas.
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Core themes from the staff data were presented to the clinical team to elicit feedback on the validity and fit of the findings. Participant checking was not conducted with family members, although the interview process incorporated a technique of on-going checking about understanding of core themes and issues.
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Ethical approval was provided by [details to be added after peer review]. Anonymity has been achieved by not reporting identifiable demographic or other identifiable information alongside quotations. The quotes used in this paper were shared with interviewees to verify their confidence that the data is not identifiable or attributable. The initial S is used to indicate a staff interviewee and F to denote a family member.
Results
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25 staff members and seven relatives participated in the study. Table 1 illustrates participant role. Staff length of service in specialist palliative care services (including experience prior to the current service) ranged from five months to twenty years, with a mean duration of 10 years (mode: 12 years, median: 11years). Participants were mainly female (n=21/25 staff, 84%) and worked in both inpatient and out-patient contexts (n=7 and n= 13 respectively), with five staff working across both inpatient and out-patient services. All family member participants were female (n=7/7). The majority of the relatives recruited were a spouse/partner (n=5/7 relatives, 71%). Four invited staff members declined participation, and did not provide reasons for their decision. One of the participants declined verbally while the other three booked interviews but did not follow through with the interview. Attempts to reschedule the interviews were unsuccessful. Of the 132 family invitations, five letters were returned to sender, and seven relatives opted in to the study.
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Relative role Spouse Son/Daughter Sibling
n 5 1 1
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n 9 3 3 3 2 2 1 1 1 25
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Table 2: Role of participants Staff role Community RN In-patient RN Doctor Social worker Clinical nurse consultant Allied health Acute hospital liaison nurse Pastoral care Service manager Total
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The data indicate key emergent themes, reported below, which are described in Figure 1. The data point to conflict as emotional expression, which is managed by validating but not internalising emotions and responding systemically, such as through use of family meetings.
Definitions: Mismatched expectations and suboptimal communication
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Participants were not offered an a priori definition of conflict or serious disagreement, instead they were encouraged to articulate their own:
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“If a patient or a family member became aggressive and highly emotional, that would be classed as serious to me.” (S1)
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“Where a family’s expectations are different to the care team’s expectations.” (S8)
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Definitions of conflict involved staff being ‘sacked’ by families (being asked not to return and have another member of the team provide care), raised voices, aggression, verbal threats and erratic behaviour: “A patient felt he wasn’t being given his medication […..] And he became aggressive and wanted to leave so he became quite threatening and yelling” (S11)
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By contrast, families were not explicitly asked to provide a definition. Their views of conflict were distilled from the narrative of their experience, and were understandably focused on single experiences rather than being able to more broadly define conflict itself, for example feeling that the service had inadequate resource to care for their relative, or that staff were dismissive toward them: “This particular nurse came and she said to me … you’re the wife, you’re not the nurse” (F1). “The difficulty was continuity [there wasn’t] any really continuous person who got to know us and got know my mother” (F4) Other relatives cited conflict as involving lack of communication about advance care planning
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Staff indicated that conflict frequently involved the relative, rather than the patient, which may point to perceptions in care rather than the care itself being problematic. While lack of conflict with patients may also be explained by patients being too unwell to engage in communicating annoyance, it is likely that the relative takes on a role as advocate. As noted below, the causes of conflict often pertain to emotional distress, and consequently signal difficulties in coping.
3.2
Causes: not feeling prepared for death
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Many participants’ accounts focused on perceived causes of conflict. Communication was implicated in numerous underlying causes of conflict, for example, use of misjudged words:
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“I was trying to explain to him […] if you were to take enough medication so you didn’t have pain when you got up to walk, it would make you like a zombie and he took exception to the word zombie.” (S21) Family members also recounted similar experiences where mis-judged words caused conflict:
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“This lady who I don't have any doubt that she is a top nurse […] she decided the best thing was to joke to break the ice and she said, "You know what, not everybody who comes here leaves in a coffin". That joke has stayed in my mind forever and ever and ever, and my husband as well.” (F3)
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Different understandings regarding disease process were cited frequently. The provision of fluid/nutrition were called upon as examples of clashes in assumptions about care which cause conflict. The disjuncture between relatives wishing to give the patient food/fluids contrasted with clinician prioritisation of the potential risks of aspiration or choking:
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“Hydration is a big thing and that ties back to … level of expectation of the loved ones and really having being told what is happening.” (S11) Family members described experiences where different understandings of care caused conflict. Administration of pain relief was a concern to one family:
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“It’s just it wasn’t a matter of our expectations it wasn’t of, “Your sister will have pain or your sister won’t have pain”. It was purely that [the palliative care team] kept saying “she doesn’t have to have this much pain. The pain can be managed”, but it wasn’t. So it was always like she was under – the dose was too low, and it was us [the family] ringing up to say, “It’s not good at the moment. We need a higher dose. We need more pain management”. (FP6)
A lack of shared understanding of the dying process and goals of care were also triggers for conflict: “There can sort of be an assumption that you come here [to the hospice] and you’re automatically going to die so people are worried what you’re going to do to their loved one. So you know they’re really guarded about you giving any pain control no matter how much you try to explain.” (S11)
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Syringe drivers (a needle inserted under the patient’s skin to deliver medication, including strong analgesia such as morphine) were noted as frequently activating conflict “[The family] agreed to the commencement of a syringe driver for management of symptoms. The next day the daughter came back to visit and her father remained alive but was no longer conscious. Her understanding of the situation was that he was starving to death […] she was very distressed.” (S18)
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Syringe drivers and morphine are frequently construed by families as a signifier of impending death, and become imbued with unintended meanings around terminal decline. Consequently conflict be triggered by clinical activities which imply the nearness of death, thereby provoking an emotional response to approaching bereavement.
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Cultural and language differences were cited by multiple respondents, both staff and families, as contributors to conflict:
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“Some particular cultural groups, they still try and feed their family members and they just think that we're starving mum or dad or their husband or wife and that could cause quite a bit of conflict.” (S13)
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“[The specialist palliative care nurse] probably meant well but we weren’t prepared to give up […] You're just declared palliative by Western society, but a person may not want to die, may not want to give up. We were living every day, we didn't give up.” (F3)
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Many of the participants indicated awareness that patients and families are under significant strain, and that this emotional fragility combined with poor communication, differences in opinion about goals of care, or culture would be sufficient to trigger conflict with staff:
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“Times of distress are when disputes in families come out…so there’s a lot of previous baggage going on” (S10) Expectations of the service also led to conflict, for example the availability of specialists overnight or weekends in the community, and delays in accessing care:
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“[Patients/relatives] want us there in an hour and we can’t get there straight away […] they might think that our role is to coordinate every aspect of that person’s care and we can’t always do that [….] they think we should be able to get [them] a bed at [the hospice] immediately even if there’s not one available or they’re not the most suitable candidate at the time.” (S21).
Family members approached the palliative care service with expectations, such as the number of staff available to provide care. Services failing to meet their expectations led to conflict and/or serious disagreements. Disappointment with care provision was channelled into frustration with what was perceived as inadequate resourcing to attend to the growing, complex and intricate needs of patients and relatives. “I was left with…just that anger with the system, the not being able to provide a better service…I was gobsmacked right from the beginning when I was told there was one nurse on an evening shift for the entire [area] and I couldn’t believe that, 8 Page 9 of 17
and I still think that is the worst thing I’ve ever heard of in pretending to be offering a service when you’re really not.” (F1) Suboptimal communication about disease progression (including managing pain, and nutrition/hydration) alongside insufficient clarity regarding the level of care provided by the service, create a context where conflict can flourish. Not being prepared or ready for the relative’s death underpinned each of these data-points.
3.3
Warning signs: Concerns about care
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Asked to identify warning signs of conflict, staff referred to relatives documenting the care they were receiving, for example taking photographs of the patient’s posture to evidence poor quality care. Other staff reported that relatives and patients were sometimes suspicious of the goals of palliative care:
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“If they’re suspicious to start with and you don’t get past that suspicious phase you know they have a pre-conceived idea of what palliative care is…it’s sort of like terminal care…if they think that you’re coming in with narcotics, and that it can contribute to the death of their loved one…the alarm bells start going off.” (S19)
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Tone of voice, being uncommunicative or dismissive were all described as signs of disgruntlement and early flags for conflict. Further, a history of difficulties with other clinicians were all signifiers to staff respondents that conflict was fermenting: “If people tell me X clinician was not good [I] realise that [the family are] going to criticise me too, because no one’s ever going to be good enough.” (S25)
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A history of drug and alcohol use, and severe and enduring mental health problems were also considered warning signs by staff.
3.4
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Warning signs were not mentioned in the family interviews. Relatives appeared not to identify a build-up, but rather spoke of a single incident which was an unexpected shift into conflict. Thus for staff, feeling under scrutiny was a warning sign. These warning signs indicate that conflict can be identified in advance (or in the early stages) and therefore be open to de-escalation strategies.
Consequences: a hurtful experience not to be internalised
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The repercussions of conflict included immediate reactions and long term consequences. For staff, reactions seemed to follow a trend of feeling hurt, then excusing the actions of the other party: “I step back to be calm inside, but I’m usually angry. It depends what it is […] what I try to do is I think ‘well it’s not that personal to me. They’re just questioning something because there might be ten things that are causing the, worry and this is just one small part of it’” (S11)
However, for more junior members of staff, responses followed a different trend. Reactions followed a cycle of feeling hurt because of the conflict, justifying and excusing the actions of the other party and then withdrawing from the conflict situation. Resolution was less proactive and relied on allowing the situation to settle and sort itself out: “I think I left it for other staff to deal with that particular situation.” (S14) 9 Page 10 of 17
From the family’s perspective the consequences of conflict also seemed to follow a trend of emotional response followed by explanations or justifications of the conflict. Family members reported distress, annoyance, anger, disappointment, upset, offence, disrespect and puzzlement. The following quotation also illustrates a commonality of relatives presenting an understanding of why services sometimes failed to meet their expectations due to systemic rather than personal failings:
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“You can’t blame the staff, they’re working under pressure for inadequate staffing and inadequate funding.” (F1)
Family members cited writing complaint letters to politicians as a consequence of the conflict:
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“I’ve told a couple of politicians, I haven’t had a real response but I was trying to, I went out and spoke to [a staff member] and you know all their hands are tied but I just wanted to let people know how I felt.” (F1)
Staff described placing their own emotional reactions in the background, in order to foreground the patient and family as their main priority:
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“I listened to him and I tried to see where he was coming from which is a little tricky so I just waited for him to finish as best I could, so I could hear his frustration and I just explained that our role is to relieve suffering. I felt comfortable in my own skin saying that […] listening to him, listening to the family’s concerns.” (S7)
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Some staff reactions pointed to the gulf between their personal reaction (upset) and the usual sense of gratitude expressed by patients and families:
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“Nobody really talked to me about it or nobody ever said ‘how did that make you feel?’ and I was embarrassed because you know it’s not an everyday occurrence that your patients don't feel grateful for any of your input.” (S16) While conflict was upsetting for both staff and families, both parties avoided internalising blame, and recruited compassionate discourses to explain the conflict, or their hurt.
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3.5 Resolving and managing conflict: A proactive and systemic approach to conflict resolution The majority of both staff and family respondents indicated that conflicts ended either when a new member of staff was allocated to look after the family, or when the patient died and the family was no longer in touch with the service. Consequently, in many cases, families felt that the conflict was never directly resolved, but ceased being a concern because contact between families and service stopped at point of death: “When my mother died we never saw them again.” (F4) Senior staff (managers and senior clinicians) displayed a more proactive approach in their responses to conflict; they were more likely to address the issues and attempt a resolution. One senior respondent indicated that discussing the situation with the individuals involved was routine, and cited the strategy of reallocating patients to other staff: 10 Page 11 of 17
“My job is to find out what’s upset the person […] ‘I want to find out what’s wrong and can you explain it to me and what can we do to sort it out’ so I think that’s just the approach.” (S10) Behaviour contracts and boundary-setting were rarely used, and referred to only in a historical sense of strategies which were no longer applied.
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Family meetings were often used as a management approach, and are prioritised for families where the staff have concerns about conflict occurring:
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“If we think there’s any problem with the family, and we’ve got limited time, that’s the family meeting we’ll have first” (S6)
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Family members’ accounts of managing conflict tended to be systemic. Their comments focused on requests for more support for relatives, and additional training of specialist palliative care staff which would enable them to provide a better service:
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“I felt that often relatives of, and carers of, the person that’s dying need coaching and encouragement.” (F4)
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“They need to be told look yes it’s okay for you to do that, yes this is how you do it – so a bit of training around what you can and can’t, what you can do and how you can do it.” (F1)
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Staff avoided internalising conflict, and families often proffered systemic explanations thereby resisting internalising the conflict to individual nurses. Both strategies permit the expression and acknowledgment of hurt or harm, while allowing adaptation to allow for care to continue to be provided and/or received.
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Discussion and conclusion
4.1
Discussion
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While dictionaries define conflict as active disagreement, these data indicate the emotional undertow of conflict in palliative care. Communication difficulties underpinned many conflict scenarios. Although communication issues varied, the majority centred on difficulties in reaching a shared understanding of palliative care or goals of care. Communication difficulties often plague clinical practice, and dominate patient experience feedback, despite a considerable body of work in communication training and education [21,22]. Conflict was also identified as mis-matched expectations of care, for example around providing nutrition and hydration. Cultural values may take on greater salience at times of existential crises [10]; finding time to understand a patient/family’s motivations around their goals of care [23] could be a significant step in lessening conflict. The hegemony of the western-medical model currently serves to undermine valuing differences in goals of care. Conversely, conflict over nutrition and hydration may be signifiers of underlying communication difficulties where there is not a shared understanding about what constitutes compassionate caring at end-of-life. Cultural relativism in palliative care is not new [24], but its place in understanding conflict occurrence and conflict resolution is not well understood. Since it is established that providing food is an enactment of 11 Page 12 of 17
caregiving and a social transaction [25], there is a need to support families to provide safe nurturance.
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The consequences of the conflicts described in this paper were predominantly emotional. Physical violence which has been reported in other areas such as ED [1] and paediatrics [6] was not apparent in the data from this study. This may be an artefact of the service itself, or point toward the unique specialist palliative care context, with different stressors, mediators and moderators. Further studies in palliative care should seek to establish the frequency and severity of conflict in this setting. This approach has been adopted in other specialities, such as ICU [2] and paediatrics [5], and allows for mapping of the scale of the problem.
4.2
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Data saturation was not achieved for the family interviewees, so the data indicate areas for further exploration. Low uptake of the opportunity to discuss conflict may indicate an unrepresentative sample and a limitation of the sampling frame (3-18months post-bereavement).The dominance of staff voices has resulted in a model which relies more heavily on staff perspectives on the causes and consequences of conflict. Not including current service users (due to concern from staff about burden and impacting the dynamic) will also have impacted the number and type of families responding, a gate-keeping feature well documented in the palliative care literature [26]. Since the research team have on-going working relationships with the clinicians, there is a risk of bias to the data; however to mitigate this, two authors (SB and EL) have no such relationship and independently scrutinised the analysis and reporting.
Conclusion
4.3
Practice implications
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This study reports experiences of conflict from the perspective of staff and relatives in palliative care services. The data illustrate connections with conflict literature in other clinical areas, but also highlighted points of convergence. The data indicated compassion for families by staff. Further, both families and staff identify systemic rather than always individual causes.
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Identifying and managing conflict in its early stages is important in reducing the burden to families, patients, staff and systems. Methods and theories from restorative healthcare practice may be fruitful to apply. Restorative practice, which stems from the legal approach of restorative justice, seeks to limit blaming and offer a more collaborative model of shared responsibility and shared concern has been used in healthcare [27] and could be adapted from staff-staff conflict to staffrelative conflict. Further, techniques from within palliative care, such as family meetings, aid communication, reduce blaming and create space for a shared understanding of goals of care and responsibilities. Interviewees raised them as a mechanism to prevent or reduce conflict [28]. Conflict training can also increase staff confidence in identifying and de-escalating conflict [29] and could be usefully applied in palliative care services. Many of the conflicts ended when the patient died. Consequently, there was no follow-up or resolution for family or staff. Not resolving conflict may be problematic in terms of complicated grief/bereavement [30]. Findings from this study suggest that audits may be required to identify and provide support to families where there may be unresolved conflict over goals of care, since lack of preparedness for death negatively impacts grief [31]. Further, an audit of formal complaints would augment understandings of the causes and consequences of conflict in specialist palliative care.
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Acknowledgments: Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest: None of the authors have any conflicts to declare.
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Figure
Conflict as emotion
Warning signs: concern about care provided
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Causes: insufficiently prepared for death
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Defining conflict: mis-matched expectations and sub-optimal communication
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Consequences: hurt, where internalising is resisted
Acknowledgment of emotion and adaptation to allow continued care
Resolution: proactive and systemic
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Figure 1: A model of conflict in palliative care between staff and relatives in palliative care