Political Conflict in Health Care Teams
Somewhere between the managerial control and pluralistic perspectives on politics falls a large body of work on health care teams in which conflict is a persistent theme. Differences in power and status among different professions—physicians, nurses, social workers, psychologists, psychiatrists—and within each profession—among different physician specialties and different types of nurses—both foment and are involved in the management of conflict in health care groups.
The complexity of medical care forces health care teams to adapt constantly, often leaving room for negotiation of roles and power (Schatzman & Bucher, 1964).Several factors in the interactions of health care teams, including the complex and pressing work, the strong authority position of the physician, and hesitancy to confront professionals outside one’s own discipline, encourage avoidance or suppression of conflict (Drinka, 1996; Folger et al., 2011). Sands, Stafford, and McClelland (1990) found that conflict within interdisciplinary teams was expressed both overtly and covertly within a format that required the team to reach consensus in a short period of time. On the other hand, Simon (1999) analyzed how neurosurgeons and biophysicists jockey for professional prominence in sharp, public arguments over the interpretation of images. Keith (1991) described how physiologists and orthopedic surgeons contend for leadership in geriatric rehabilitation units.
Negotiations over division of labor in a group can be triggered by resistance of those whose voice was silenced by the ideology, problems with patients, or coalitions of lower status members (Schatzman & Bucher, 1964). Many of these negotiations occur “tacitly” as members work together. Abramson and Mizrahi (1996) reported that social workers (typically a lower power profession) focused more on interaction with physicians, while physicians focused more on competence of social workers, indicating that the higher status of physicians allowed them to judge the competence of social workers while social workers emphasized collaboration. The numerous articles (e.g., Fountain, 1993) advising nurses, social workers, and mental health professionals about how to interact with physicians effectively testify to the importance and potential impact of style differences in health care teams.
They also indicate that resistance to the presumption of physician control and advocacy for increased input is an explicit part of the discourse of these professions.The interdisciplinary team literature in health care emphasizes the need for mutual respect and power sharing among members of health care groups (e.g., Clark, 1997; Drinka, 1996). However, countervailing forces, including the assertiveness of professions and established status and power structures, tend to lead to the reassertion of physician dominance as teams progress (Freidson, 1970). Feiger and Schmitt (1979) found that even in teams initially committed to interdisciplinary collegiality, status differences reasserted themselves over time.
Another type of exceptional behavior, whistle-blowing, is a sensitive subject in the health care literature. Erde (1982) noted that professional norms require reporting incidents that represent negligence or harm patients; however, group norms grounded in collegial decisions about care and in collegial relationships provide disincentives to do so. Erde argued that the ideology of teamwork is often used to suppress dissent and curtail or punish whistle-blowers as “uncommitted” members. The dynamics of team communication surrounding ethically driven behavior such as whistle-blowing offer an important horizon for future research.