Conflict Resolution in Emergency Medicine

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209 Conflict Resolution in Emergency Medicine

Gus M. Garmel

image      Key Points

• Conflict is the result of discordant expectations, goals, needs, agendas, communication styles, and backgrounds between or among individuals. At least two perspectives contribute to conflict.

• Conflict in emergency medicine (EM) may occur with patients, family members, nurses, consultants, residents, students, hospital administrative staff, or agents inside and outside the emergency department.

• The goals of effective conflict resolution are to optimize immediate outcomes and to establish a solid foundation for subsequent interactions. Success depends on one’s communication style, awareness of other’s needs and psyche, and understanding of relationship dynamics.

• Successful conflict resolution requires a systematic and structured approach. Recognizing each participant’s principal interests and underlying positions is important. Having a strong BATNA (best alternative to a negotiated agreement) is beneficial. Possessing a “win-lose” attitude interferes with successful conflict resolution.

• Not all conflict in EM can be resolved immediately, if at all; some resolutions require the assistance of a third party.

• Efforts to prevent conflict before it happens are recommended whenever possible.

The problem with conflict is not its existence, but rather its management.1

Conflict is inevitable. Opportunities for conflict in emergency medicine (EM) are numerous because individuals with different backgrounds and divergent agendas interact over important concerns (e.g., patient care or resource use). By nature, these interactions take place under time constraints, which often exacerbate conflict. Many interactions between emergency physicians (EPs) and patients, family members, staff members, or consultants occur with limited or no previous working relationship or when prior interactions have been problematic. As such, involved parties may be unable to reflect on prior successful interactions, an approach that often decreases the likelihood of intense exchange.2

Controversy exists about the value of conflict. Many believe that, at its best, conflict is disruptive. Most agree that, at its worst, conflict is destructive to team harmony and patient outcomes. However, conflict also serves as a creative force, providing both initiative and incentive to solve problems.

This chapter describes conflict in general, identifies contributing factors, and offers several examples specific to EM. The importance of effective communication in conflict resolution is presented, as well as its role in de-escalating, limiting, and preventing conflict. This chapter offers strategies to facilitate successful conflict resolution. Conflict resolution ultimately benefits patients, staff, and EPs by optimizing patient care, decreasing patient morbidity, improving patient safety, and maximizing an individual’s or health care team’s overall satisfaction.

Communication, in the form of language and interaction, and power, in terms of how conflict is managed (or mismanaged), are tremendously important in the dynamics of groups. EM is very much about group dynamics because physicians, nurses, and other staff members must consistently demonstrate successful teamwork to offer patients the best possible outcomes. Louise B. Andrew, MD, JD, stated “… conflict is often the result of miscommunication, and may be ‘fueled’ by ineffective communication.”3

Three important sources of conflict have been identified: resources, psychological needs of individuals or groups, and values. Resource-based conflicts relate to limited resources, common in EM. Psychological needs include power, control, self-esteem, and acceptance. These needs often exist under the conflict’s surface and can be difficult to identify or address. Values (beliefs) are fundamental to conflict. Core values, such as religious, ethical, financial, or those involving patient care are difficult to change and therefore generally assume a large role in conflict. Value differences among people or groups (e.g., health care professionals and physicians with different training) may result in repeated conflicts. The expectations that EPs have of hospital and emergency department (ED) staff regarding work ethic or efficiency, for example, often result in conflict (perceived or real). Under these circumstances, people feel as if their integrity is being questioned, and this is one reason that value-based conflicts are extremely difficult to resolve.

For additional information about sources and types of conflict, see the online version of this chapter at www.expertconsult.com

Conflict in medicine is relatively easy to understand if one considers physician attributes, such as a tendency toward perfectionism and delayed social development. These characteristics are highly adaptive to doctoring, reinforced by training, and rewarded by society. These traits may be maladaptive when it comes to communicating and interacting with nonphysicians, however, with resulting conflict and poor conflict management.

The ED environment is particularly predisposed to conflict for many reasons. Differences in professional opinion and value systems among staff members and patients are contributing factors. EPs must interact with individuals in all areas of health care, at any time of day or night, and during periods of great stress. EPs are unlikely to know everyone on every service with whom they must interact. This challenges EPs because they are not familiar with each medical staff members’ idiosyncrasies, preferred practice pattern, or communication style. These interactions create even greater difficulties for new EPs, who lack histories of favorable reputations or successful relations with hospital staff, thus significantly increasing the likelihood of conflict.

Examples of Conflict

Conflict in EM results from a mismatch of expectations among patients, family members, providers, or consultants, as well as among nurses, ED staff, or ancillary staff outside the ED. Patients and family members may have unrealistic expectations about their ED experience, not to mention the pain or fear that brought them to the ED. Nurses may have unrealistic expectations of physicians and generally have widely differing backgrounds. Although gender representation of EPs has become more equal, older EPs tend to be male, whereas nurses are predominantly female. Misunderstandings and communication problems exist in the workplace between genders and age groups. Additionally, each time a consultant is contacted, his or her practice, social life, or sleep is disrupted. This added workload alone may ignite conflict.

Numerous additional factors further explain the high likelihood of conflict in EM. Diversity in training, experience, and perspective often result in differences of opinion between EPs and colleagues from other areas of medicine, including nursing. For example, conflict arises simply because EPs do not want to send someone home who should not go home, whereas hospital-based physicians or specialists may prefer not to admit (or may be pressured not to) patients who do not require admission. These two opposing “forces” create conflict.

The responsibility of patient advocacy assumed by EPs and ED staff often creates conflict because it may not coincide with the interests of the patient or family members. If a patient’s decision-making capacity is impaired or their legal advocate is not present, EPs have the duty to act in the best interest of the patient, state, or society, regardless of the patient’s wishes. One common challenge occurs when a patient with a history of substance abuse and chemical dependency demands narcotics for “pain.” An EP’s refusal to prescribe narcotics is certain to create conflict. Conflict also occurs when a patient or family member desires admission to the hospital without medical justification, a test that is not indicated or available (or may be harmful), or consultation with a specialist that is medically unnecessary or inappropriate at that time. Other times, an EP may believe that it is in the patient’s best interest to be admitted to an inpatient medical service even if hospitalization may not influence the ultimate outcome, and this creates conflict with the admitting service. Conflict may also develop between two services over which service will admit a patient. The EP must mediate this dispute while keeping the patient’s needs and interests at the discussion’s forefront.

Perhaps the area most likely to create conflict is ineffective or incomplete communication between or among two or more parties. Given cultural and language differences among patients, families, nurses, staff, and consultants, communication challenges prime the ED for conflict. Frustration, unmet expectations, time constraints, and limitations on staffing, equipment, space, and privacy may be overwhelming if communication is suboptimal or barriers to effective communication exist.

Because the specialty of EM is so complex and has tremendous liability associated with its practice environment, many areas of potential conflict have been addressed at federal, state, and local levels. Hospital policies and bylaws have established guidelines addressing these issues, in an attempt to prevent conflict before it occurs. Despite these policies, conflict still occurs. EM organizations are addressing these and other areas of potential conflict, based on the needs of emergency patients and professionals. As health policy and the specialty of EM evolve, new challenges will be identified, with more issues requiring resolution (Box 209.1).

Box 209.1 Areas of Conflict Related to Emergency Medicine

1. Differences in education, background, values, belief systems, and interpersonal styles of communication between EPs and others

2. Commitment to patient satisfaction

3. Final patient disposition (and who determines this)

4. Timing of follow-up care and outpatient tests for released patients

5. Telephone conversations required for patient care issues

6. Lack of professional respect from primary physicians or consultants

7. Dual advocacy expected by others for the EP

8. Teaching hospitals with house staff who may lack communication and conflict resolution skills, have less commitment to the hospital, patients, or ED staff because of temporary scheduling at that hospital or ED, and sense a lack of input, ownership, and control over patients’ (or their own) lives

9. Patient transfers to or from the ED

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