Conflict Within and Among Health Care Groups and Teams
The outer two circles of Figure 16.1 illustrate the potential for intraorganizational conflicts across and within groups of providers. Key contributors to conflict include perceptions of status inequities, organizational and professional culture, cross-disciplinary communication, and communication structure.
Perceptions of Status and Hierarchy. Graham’s (2009) ethnographic study of interdisciplinary discharge rounds (meetings held among a group of providers before discharging patients) described competing views of hospital hierarchy that reinforce ambiguous power structures. A belief that power is based on rank (institutional hierarchy) suggests that physicians are at the top, followed by interns, residents, medical students, and then nurses. A rival system, the social/expertise hierarchy, is based on tenure and the amount of time the provider spends with the patient, suggesting that nurses often have more power and credibility due to cumulative years of experience and time spent with patients. Graham found that providers who perceived themselves as subordinate to physicians used politeness strategies to have their professional opinions included in decisions about follow-up health care. Through interviews and observations of team meetings, Graham illustrated how the institutional culture complicated provider communication and became a source of conflict. Several other studies using a discourse analytic approach have reported similar findings, demonstrating that nurses (Riley & Manias, 2007) as well as interns (Erickson, 1999) and other providers (Kerosuo, 2007) struggle to balance the tension between respect for the physician’s authority and confidence in their own knowledge and contributions to patient care.
Organizational and Professional Culture. Perceptions of organizational rank and status are also affected by organizational and professional culture in the hospital setting.
Kressel, Kennedy, Lev, Taylor, and Hyman’s (2002) study of an urban teaching hospital emphasized a culture that privileged doctors’ voices, resulting in conflict avoidance. Specific intergroup conflicts described in this study were often related to economic issues or treatment decisions. While hospital administrators have interests in cost-effectiveness and must ensure that insurance information is on file, doctors have an economic incentive to see patients quickly so they can move onto the next one. Because nurses spend more time with the patient and family members, nurses were found to go “behind the doctor’s back” to make sure patients’ needs were met. Conversely, a study of the negotiation of unplanned emergency surgeries found that doctors may also “tell fibs about what might be an emergency” to satisfy their own interests (Lum & Fitzgerald, 2007, p. 101). Conflict also erupted between departments when they either battled for or refused to treat certain patients, either to meet teaching/ research needs or to minimize their department’s liability (Kressel et al., 2002). Because several aspects of hospital culture can reduce trust, each of these authors recommended improved communication and coordination among hospital units and personnel.Cross-Disciplinary Communication. A third category of conflict among health care providers comes from the need for cross-disciplinary communication and the challenge of competing discourses. Lammers and Krikorian (1997) observed that surgical teams might be characterized by stable or constantly changing membership. The degree to which the team members have previous history with each other and have negotiated status distinctions is likely to affect how well conflict is managed in these high-stress settings.
In their examination of the operating room list (which governs the surgery schedule), Riley and Manias (2007) found competing discourses of medicine and management. These discourses created ambiguity around what constituted an emergency, and nurses were found to navigate this difficulty based on their local knowledge of different surgeons and their expectations.
In another study of surgical scheduling, Lum and Fitzgerald (2007) also reported ambiguity about the definition of “emergency” as well as the tension resulting from ambiguous power structures among doctors. While surgeons are generally perceived to have highest status, informants in Lum and Fitzgerald’s study found that patient care is sometimes sidelined while surgeons, anesthesiologists, and other specialists address “tribal differences” and “power struggles” (p. 100).Communication Structure. A more holistic approach advocated by some (e.g., Kerosuo, 2007) may be hindered by limited structural opportunities for interprovider communication. Long, Iedema, and Lee (2007) claimed that informal “corridor conversations” represented the majority of interactions among providers of different specialties. These conversations are critical to effective care for patients with multiple illnesses as they reduce the negative impact of status differences on interprovider communication. The disadvantage of reliance on corridor conversations is that they are often undocumented (not recorded on the patient’s chart), potentially leading to miscommunication with the patient, lack of clarifying communication between providers, and/or compromised continuity of care.
The studies reported in this section point to cultural and structural causes of conflict among health care professionals who are expected to work together in teams. Issues of power and status require constant negotiation as medical specialists from multiple units and professional cultures attempt to coordinate patient care. Ambiguities surrounding health care, such as how to define an emergency and how to treat patients with multiple illnesses, further exacerbate the problem. The difficulties of competing professional cultures and identities are further revealed in studies that examine the dyadic relationship between and among doctors, residents, and nurses. This directs our attention back to the bottom center of the health care system portrayed in Figure 16.1.