eISSN: 1731-2531
ISSN: 1642-5758
Anaesthesiology Intensive Therapy
Current issue Archive Manuscripts accepted About the journal Editorial board Journal's reviewers Abstracting and indexing Subscription Contact Instructions for authors Ethical standards and procedures
SCImago Journal & Country Rank

 
5/2019
vol. 51
 
Share:
Share:
more
 
 
Original paper

Potential sources of conflict in intensive care units – a questionnaire study

Anna Paprocka-Lipińska
1
,
Małgorzata Drozd-Garbacewicz
2
,
Janusz Erenc
3
,
Maria Wujtewicz
4
,
Janina Suchorzewska
1
,
Marek Olejniczak
1
,
Magdalena Wujtewicz
4
,
Henryk Aszkiełowicz
5
,
Astryda Dończyk
6
,
Jacek Furmanik
7
,
Andrzej Gadomski
8
,
Tomasz Kołacki
9
,
Ewa Lenkiewicz
10
,
Andrzej Małek
11
,
Joanna Sawicka
12
,
Bartosz Suchanowski
13
,
Jolanta Wawrzyniak
14
,
Jerzy Węgielnik
15
,
Radosław Owczuk
4

1.
Department of Ethics, Faculty of Medicine, Medical University of Gdańsk, Poland
2.
University of Gdańsk, Poland
3.
Department of Sociology, Public Affairs and Economy, University of Gdańsk, Poland
4.
Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Medical University of Gdańsk, Poland
5.
Department of Anaesthesiology and Intensive Therapy, Hospital in Malbork, Poland
6.
Department of Anaesthesiology and Intensive Therapy, Specialist Hospital in Chojnice, Poland
7.
Department of Anaesthesiology and Intensive Therapy, Tczew Hospitals PLC, Poland
8.
Department of Anaesthesiology and Intensive Therapy, Specialist Hospital in Kościerzyna, Poland
9.
Department of Anaesthesiology and Intensive Therapy, Hospital in Stargard Gdański, Poland
10.
Department of Anaesthesiology and Intensive Therapy, Department of Hyperbaric Medicine and Sea Rescue, University Centre for Maritime and Tropical Medicine in Gdynia, Poland
11.
Department of Anaesthesiology and Intensive Therapy, Specialist Hospital in Wejherowo, Poland
12.
Department of Anaesthesiology and Intensive Therapy, Children’s Hospital in Gdańsk, Poland
13.
Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Kartuzy, Poland
14.
Department of Anaesthesiology and Intensive Therapy, Regional Specialist Hospital in Słupsk, Poland
15.
Department of Anaesthesiology and Intensive Therapy, Hospital in Gdańsk, Poland
Anaesthesiol Intensive Ther 2019; 51, 5: 357–360
Online publish date: 2019/10/29
Article file
- Potential sources.pdf  [0.10 MB]
Get citation
ENW
EndNote
BIB
JabRef, Mendeley
RIS
Papers, Reference Manager, RefWorks, Zotero
AMA
APA
Chicago
Harvard
MLA
Vancouver
 
 
Conflicts are common, inevitable and conflicts associated with social life. They concern interpersonal relationships and may result from differences in opinions, attitudes, values or conflicts of interest. Modern medicine is predominantly based on teamwork; in some hospital wards, e.g. intensive care units (ICUs), the teams of specialists representing various medical fields are particularly large, which is likely to increase the risk of conflict situations. An international multi-centre study involving 323 intensive care units from 24 European countries, including Poland, has confirmed that such phenomena occur [1]. About 70% of respondents reported ICU conflicts during the workweek preceding the study. The most common causes of conflicts were found to be job overload and strain, inadequate communication and controversies regarding end-of-life care strategies. Except for one review [2], the Polish literature lacks any reports on ICU conflicts; therefore, we decided to determine the prevalence and the most common causes of such conflicts.
The findings of an anonymous questionnaire study carried out among the teams of physicians and nurses, essential for the interdisciplinary model of work followed in Polish ICUs, were presented.

METHODS

The study design was approved by the Bioethics Committee for Research of the Medical University of Gdańsk. An original questionnaire was used in the intensive care units of the Pomerania Province whose heads gave their consent for participation, taking all measures to ensure anonymity of the participants and confidentiality of their responses. The respondents were asked about the difficulties in ICU work, frequency, types and sides of conflicts, potential causes of conflicts, including work organisation and nature, financial and substiantive issues. Moreover, interpersonal communication, personal characteristics, values followed by participants, and external work-related determinants were considered.
Statistical analysis was based on IBM SPSS Statistics 25. Descriptive statistics and subgroup comparisons (the 2 test for comparing proportions) were used to analyse the data obtained. P < 0.05 was considered statistically significant.

RESULTS

The questionnaire study was carried out in 12 intensive care units of the Pomerania Province. The questionnaire was completed by 232 employees, including 79 male and female physicians and 153 female and male nurses. More than one-third of respondents had up to 10 years of ICU experience, including 19% with up to 3 years of ICU job seniority. The percentages of ICU staff members with experience between 11 and 20 years as well as above 20 years were comparable (in both cases about 30%). Almost all the participants assessed ICU work as relatively or very difficult.
The occurrence of conflicts was confirmed by about 30% of respondents who reported that conflicts among ICU employees were “common”. About 43% of employees found conflicts to be occasional and 25% – “rare”. The distribution of responses to the questions concerning the frequency, types and sides of conflicts was presented in Table 1. The respondents reported a higher frequency of hidden conflicts, which did not turn into public confrontations. In our questionnaire, conflicts were divided into overt and hidden. Some authors, however, have accepted the concept of six stages developing dynamically in each conflict. According to this concept, an overt conflict is a successive stage of a hidden conflict [3]. Physician-nurse, nurse-nurse, and nurse-head nurse conflicts were found to occur most commonly. Physician-physician and physician-head as well as physician-head nurse conflicts were identified as relatively rare; the rarest conflicts were those between head nurse-ICU head and between ICU team and physiotherapists.
Based on the analysis of the questionnaire answers, the most common causes of conflicts perceived by the ICU staff were identified; 28 possible answers concerning potential sources of conflicts were listed in Table 2. The results were ranked according “common” answers (in descending order). The first 10 table positions were chosen by > 50% of respondents.
According to the responses regarding potential sources of conflicts, the financial issues were found to be the most conflictogenic factor. Moreover, 76.7% of respondents reported inadequate salaries as the common source of conflicts – 80.4% of nurses and 69.6% of physicians.
Excessive bureaucracy was ranked second of the most relevant sources of conflicts (72.8%) – 75.9% of physicians and 71.2% of nurses (in the group of physicians this source was most commonly chosen).
The next factors identified as the common sources of conflicts were associated with the nature of ICU work, including work overload (physical), shortage of workers, work under time pressure, and mental strain related to work. Furthermore, the other two relevant conflictogenic factors included frustration related to low salaries (this factor was statistically significantly more frequently reported by nurses, as compared to physicians, P < 0.05) and external determinants – hospital and financial policy as well as government health policy.

DISCUSSION

An intensive care unit is a special hospital facility abounding in specific everyday challenges faced by ICU personnel. Despite novel therapeutic strategies and technologies, the challenges seem similar to those faced in the 50ties when the first intensive care units were organised [4, 5]. The intensive care units employ many professionals, which translates into more common differences in opinions (informally defined as conflicts). The literature contains many reviews regarding conflicts [6, 7] yet only few research studies [1, 8]. The study regarding American ICUs carried out in 2006 emphasised a slightly different perception of conflicts by the ICU personnel and patients’ families [8] – the latter reported a significantly higher incidence of conflicts (42.3%) compared to clinicians (27.8%). In our study, both physicians and nurses stated that conflicts with patients’ families were occasional (about 40% of physicians and nurses). The limitation of our study was that the questionnaire was carried out only among ICU staff; therefore, the comparison with the incidences of conflicts perceived by patients’ families is impossible.
Detailed analyses of our findings confirmed that both nurses and physicians of ICUs perceived the phenomenon of conflicts and their extent was comparable to literature data (about 30%). In one of the studies among nurses, the nurse-physician conflicts were considered a significant stressogenic factor in everyday work [9]. Our study results did not confirm the frequency of conflicts between the other professional groups employed in intensive care units or between ICU staff and patients’ families (i.e. conflicts which have been considered relevant by many authors) [7, 8].
According to the multi-centre study, job strain was found to be one of the common causes of conflicts [1]. The above factor was also identified by nurses as a significant cause of stress related to everyday work [9–11]. In 2020, the guidelines of the Ministry of Health on standards of management in anaesthesiology and intensive therapy for therapeutic centres were launched [12], which should considerably reduce job overload and strain among ICU workers.
The analysis of the questionnaire responses did not demonstrate a significant frequency of conflicts with patients’ families concerning discontinuation or abandonment of new intensive care strategies. The above issues are one of the essential problems described in literature reviews [13–15]. Our findings are consistent with the specificity of Polish ICUs, i.e. patients’ families are informed about the discontinuation of futile therapy without discussing the wishes of patients [16].
Almost 40% of positive answers were related to inadequate flow of information as a common source of conflicts. This source of conflicts was also identified as a relevant factor in reviews [6, 17, 18] and in the multi-centre study [1].
Half of respondents reported that the common factors of interpersonal conflicts are related to mental strain and work under time pressure. The above factors, frequently discussed in literature [19, 20], are associated with the specificity of ICU work and any changes in this respect are rather difficult to be expected.

CONCLUSIONS

The major sources of ICU conflicts, such as inadequate salaries or shortages of staff, require further in-depth analyses and studies to determine possible measures to mitigate or counteract them at the systemic as well as ICU level.
The conflicts perceived by respondents should be carefully and continuously monitored in order to limit them by improving work organisation, communication between staff members and skills to cope with stress situations.
The prevalence of hidden conflicts, which do not escalate to the level of public confrontations, require comprehensive assessment of their effects on the quality of performance of ICU personnel.

ACKNOWLEDGEMENTS

1. Financial support and sponsorship: none.
2. Conflict of interest: none.

REFERENCES

1. Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and factors of Department of Anaesthesiology and Intensive Therapy conflicts: the conflictus study. Am J Respir Crit Care Med 2009; 180: 853-860. doi: 10.1164/rccm.200810-1614OC.
2. Wujtewicz M, Wujtewicz MA, Owczuk R. Conflicts in the intensive care unit. Anaesthesiol Intensive Ther 2015; 47: 360-362. doi: 10.5603/AIT.20155.0055.
3. Strack van Schijndel RJM, Burchardi H. Bench-to-bedside review: leadership and conflict management in the intensive care unit. Crit Care 2007; 11: 234-240.
4. Luce JM, White DB. A history of ethics and law in the intensive care unit. Crit Care Clin 2009; 25: 221-237. doi: 10.1016/j.ccc.2008.10.002.
5. Luce J. Conflicts over ethical principles in the intensive care unit. Crit Care Med 1992; 20: 313-315.
6. Fassier T, Azoulay E. Conflicts and communication gaps in the intensive care unit. Curr Opin Crit Care 2010; 16: 654-665. doi: 10.1097/MCC.0b013e32834044f0.
7. Luce JM. A history of resolving conflicts over end-of-life care in intensive care units in the United States. Crit Care Med 2010; 38: 1623-1626.
8. Schuster RA, Hong SY, Arnold RM, et al. Investigating conflict in ICUs – Is the clinicians’ perspective enough? Crit Care Med 2014; 42: 328-335. doi: 10.1097/CCM.0b013e3182a27598.
9. Kwiecień-Jaguś K, Mędrzycka-Dąbrowska W, Małecka-Dubiela A. Źródła stresu zawodowego a sposoby radzenia sobie w sytuacjach stresogennych pielęgniarek pracujących na wybranych oddziałach szpitalnych – doniesienia wstępne. Pomeranian Life Sci 2018; 64: 53-60.
10. Kelly J. An overview of conflict. Dimens Crit Care Nurs 2006; 25: 22-28.
11. Condra JM. Nursing conflict: diagnosis and treatment. Nurs Manag 1988; 19: 78.
12. Rozporządzenie Ministra Zdrowia z dnia 16 grudnia 2016 r. w sprawie standardu organizacyjnego opieki zdrowotnej w dziedzinie anestezjologii i intensywnej terapii. Dz.U. 2016, poz. 2218. Available at: http://dziennikustaw.gov.pl/DU/2016/2218.
13. Long AC, Curtis JR. The epidemic of physician-family conflict in the ICU and what we should do about it. Crit Care Med 2014; 42: 461-462. doi: 10.1097/CCM.0b013e3182a525b8.
14. Breen CM, Abernethy AP, Abbott KH, et al. Conflict associated with decisions to limit life-sustaining treatment in intensive care units. J Gen Intern Med 2001; 16: 283-289.
15. Norton SA, Tilden VP, Tolle SW, et al. Life support withdrawal: communication and conflict. Am J Crit Care 2003; 12: 548-555.
16. Kübler A, Siewiera J, Durek G, et al. Guidelines regarding the ineffective maintenance of organ functions (futile therapy) in ICU patients incapable of giving informed statements of will. Anaesthesiol Intensive Ther 2014; 46: 215-220. doi: 10.5603/AIT.a2014.0038.
17. Azoulay E, Sprung CL. Family-physician interactions in the intensive care unit. Crit Care Med 2004; 32: 2323-2328. doi: 10.1097/01.CCM.0000145950.57614.04.
18. Ervin JN, Kahn JM, Cohen TR, et al. Teamwork in the intensive care unit. America Psychologists 2018; 73: 468-477. doi: http://dx.doi.org/10.1037/amp0000247.
19. Piquette D, Reeves S, LeBlanc VR. Stressful intensive care unit medical crises: how individual responses impact on team performance. Crit Care Med 2009; 37: 1251-1255. doi: 10.1097/CCM.0b013e318 19c1496.
20. Mason V, Leslie G, Clarc K, et al. Compassion fatigue, moral distress, and work engagement in surgical intensive care unit trauma nurses. Dimension of Crit Care Nursing 2014; 33: 215-225. doi: 10.1097/DCC. 0000000000000056.
This is an Open Access journal, all articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0). License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Quick links
© 2020 Termedia Sp. z o.o. All rights reserved.
Developed by Bentus.
PayU - płatności internetowe