Conflict Between Providers and Family Members
Most of the research in this area is focused on circumstances within which family members make critical decisions regarding the patient’s care. This occurs when the patient is a dependent or is temporarily or permanently incapable of making his or her own health care decisions.
Several studies address issues in pediatric care, while others involve residential care and/or palliative care. Sources of conflict in these situations are similar to the sources identified in the provider-patient section. These sources are summarized briefly below, along with the unique factors that contribute to conflict when family members are acting on behalf of the patient.In Moore and Kordick’s study (2006), parents of children with cancer reported on five types of conflict with health care providers. The most common concerns of parents are (1) data conflicts, which involve receiving discordant or inappropriate amounts of information. While receiving too little or too much information was common at the point of diagnosis, a felt lack of information was also common at the point of survivorship. Families felt unprepared and abandoned when moving into this new stage of their life. (2) Interest conflicts typically relate to policies and procedures, such as rotating medical personnel and delays in receiving laboratory results or getting checked in, while (3) s tructural conflicts concern issues of unequal power, authority, and control between parties. Cancer patients and their families particularly felt this lack of power over their lives, their medical care, and their bodies as the disease progressed, and they became increasingly reliant on medical personnel and technology. (4) Relational conflict occurs in cases where the patient or the patient’s family felt disrespected, disregarded, or discriminated against by the provider. Finally, (5) value conflicts reveal divergent goals.
For instance, a treatment regimen perceived as appropriate or effective by the provider may cause medical side effects that are unacceptable to family members (e.g., weight loss). We review a few of these conflict sources in the sections that follow.Information-Based Conflicts. Similar to patients, families describe conflicts with providers based on the lack of adequate or timely information and an unmet desire for involvement in health care planning and decision making (Majerovitz et al., 2009).
Norton and associates (2003) argued that the need for effective communication between health care providers and patients’ families is rarely greater than during decisions about lifesustaining treatments, yet Baker et al. (2000) report that 30% of patients’ families are typically dissatisfied with communication during this time. The stress and anxiety associated with end-of-life decisions contribute to and make conflict particularly distressing for the involved parties. Communication problems during end of life include lack of information about the prognosis and life-sustaining treatment options, absence of clinician-initiated discussions, poor access to clinicians, inconsistency in information—especially when multiple providers are involved, and failure to include family members in all stages of the decision making (Norton et al., 2003). Families frequently reported that information was withheld about the seriousness of the condition and that they lacked adequate and timely information on which to make an informed decision regarding life-sustaining treatments. Some families felt purposefully deceived and made various attributions about the providers’ behaviors, such as the provider did not want to admit that he or she could not “save” the patient, believed that the family could not handle the truth, or thought that the family would make a decision he or she disagreed with. Others described situations within which they came to understand that the death of their loved one was eminent only during the discussion about withdrawing life support.
Family members also expressed the need for information in lay terms and the need for consistent information from the health care team. Other researchers have noted problems with providers and patients’ families holding discrepant meanings for certain medical terms (e.g., do not resuscitate [DNR]; Jezewski & Finnell, 1998). Moreover, families resent having to repeat or rehash information as nurses and physicians rotated in and were confused by different assessments from attending and consulting physicians (Norton et al., 2003). In some cases, family members felt that their comments and requests went unheeded and felt guilty when they could not advocate for or honor the patient’s wishes (i.e., DNR orders). From the perspective of the provider, patients may avoid or be resistant to discussions of death, and providers may struggle with balancing clear, straightforward communication with timing, patient preferences, and the need to offer realistic hope (Wenrich et al., 2001).Differing expectations regarding roles in the care of the loved one (Kirk, 2001), power dynamics based on medical knowledge and expertise (Heath, 1992), and a lack of understanding about the health care system (Clarke & Fletcher, 2003) or health care stages and procedural changes over time are also information-based contributors to conflict between providers and family members. For instance, nursing homes’ environments are rife with conflict based on these sources. Nursing home residents tend to enter this type of care arrangement permanently, requiring family members to acquiesce their role as primary caretakers to the nursing home staff (Majerovitz et al., 2009). This shift can result in guilt, relief, anxiety, sadness, anger, and uncertainty. Families may feel ill prepared and inexperienced with navigating residential care procedures and, as a result, may hold false expectations regarding the degree of personalized care that his or her loved one will receive. As the residents’ health inevitably declines, families may experience conflicts with staff over timing of information, medications or treatments, and standards of care.
Similar rolebased distress has been noted in mothers of hospitalized children (Callery, 1997a, 1997b). Mothers prioritized their personal knowledge of the child, yet understood that nurse’s held professional knowledge regarding the child’s medical care. Conflict occurred when parental distress about their child’s care ran counter to nurses’ needs to be efficient in the delivery of that care.Institutional- and Structural-Oriented Conflicts. Institutional practices and policies, such as the application of standardized and efficient care, are contributors to conflict between providers and family members. In several studies, interviews with nursing home staff revealed that family members expect individual and personal care of the resident, while the institution values efficiency (Majerovitz et al., 2009). As Abrahamson, Anderson, Anderson, Suitor, and Pillemer (2010) described, staff are expected to deliver care that is “uniform, efficient, and easily documented” (p. 39), while families evaluate staff member quality by their ability to provide personalized care. The staff members are typically left to figure out how to comply with the expectations of both parties, thus role conflict and role overload contribute to distress and dissatisfaction.
Understaffing is often seen as the root cause of other communication issues. Families perceived understaffing as a contributor to inadequate information, noting that they often do not have enough time to communicate with staff members due to the staff members’ patient load and inconsistent schedules (Majerovitz et al., 2009). These high job demands, accompanied with low pay and lack of training, lead to high staff turnover in this field. Ironically, the lack of staff is most visible in the evenings and on the weekends when many families visit.
Social workers represent another group of providers who experience a great deal of conflict within the nursing home environment. One study found that directors of nursing manage conflicts with family members in about 6% of the cases, while social workers mediate conflicts in 43% of the cases (Vinton, Mazza, & Kim, 1998).
Yet social workers’ ability to advocate for residents may be hindered by their status as facility employees (Allen, Nelson, Netting, & Cox, 2007). The social worker is often caught between the resident and facility or between doing what is best for the resident and the resident’s desire for autonomy. For instance, the social worker may try to influence coworkers to accept the resident’s right to noncompliance. Social workers may also mediate conflict between family members and nursing staff when care expectations are incongruent or when biased perceptions are operating. Family members may see nursing staff as uncaring, and nursing staff may see family members as meddlesome and demanding. These perceptions can lead to relational conflicts.Relational Conflicts. Disrespectful, insensitive, or disconfirming messages may be exchanged between providers and family members within the context of these often stressful situations. These messages may lead to conflict or occur within conflicts.
In Majerovitz et al.’s (2009) study, staff members described how family members’ anxiety and guilt over nursing home placement can be projected onto the staff and come off as “second guessing” or “disrespectful.” Even statements such as “Handle her with care” may suggest that the family member does not trust the nursing assistant or believes that the assistant is not trying her best. Despite the time that the nursing home assistants spend with the resident, family members may fail to ask the assistants for their input about the resident’s needs, resulting in the staff members feeling dismissed or unappreciated. From the perspective of the family members, staff members may be perceived as judgmental or uncaring. Staff members who speak in a hurried manner or spend little time with the patient or patient’s family may elicit such perceptions. Comments that reflect cultural differences regarding the institutionalization of family members or religious beliefs about an end-of- life decision have been described within their accounts as well.
Similar findings emerge in other health care environments. For instance, discourse analytic studies of interactions between mothers and nurses (Heritage & Sefi, 1992) and midwives and expecting mothers (Bredmar & Linell, 1999) portray the role of the health care provider as one of support and surveillance. As such, communication that queries care of self or baby or directs the mothering in a certain way is often perceived by the mother as face threatening.
Moore and Beckwitt’s (2003) narrative analysis of parents’ reactions to conflict with health care providers noted that parents employed the five common conflict strategies of (1) problem solving, (2) yielding, (3) withdrawing, (4) inaction, and (5) contending, and they typically used more than one strategy within a conflict. The authors described a turning point process, wherein contending emerged as a strategy following a breach of norms and crisis concerning their child’s health care. These narratives portrayed a transformative experience that resulted in a parent-as-advocate role and, in some cases, led to a social justice activist role.