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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Medical Education 2011:45: 939–945

CONTEXT  Conflict management has been identified as an essential competence for surgeons as they work in operating room (OR) teams; however, the optimal approach is unclear. Social science research offers two alternatives, the first of which recommends that task-related conflict be managed using problem-solving techniques while avoiding relationship conflict. The other approach advocates for the active management of relationship conflict as it almost always accompanies task-related conflict. Clarity about the optimal management strategy can be gained through a better understanding of conflict transformation, or the inter-relationship between conflict types, in this specific setting. The purpose of this study was to evaluate conflict transformation in OR teams in order to clarify the approach most appropriate for an educational conflict management programme for surgeons.

METHODS  A constructivist grounded theory approach was adopted to explore the phenomenon of OR team conflict. Narratives were collected from focus groups of OR nurses and surgeons at five participating centres. A subset of these narratives involved transformation between and within conflict types. This dataset was analysed.

RESULTS  The results confirm that misattribution and the use of harsh language cause conflict transformation in OR teams just as they do in stable work teams. Negative emotionality was found to make a substantial contribution to responses to and consequences of conflict, notably in the swiftness with which individuals terminated their working relationships. These findings contribute to a theory of conflict transformation in the OR team.

CONCLUSIONS  There are a number of behaviours that activate conflict transformation in the OR team and a conflict management education programme should include a description of and alternatives to these behaviours. The types of conflict are tightly interwoven in this setting and thus the most appropriate management strategy is one that assumes that both types of conflict will exist and should be managed actively.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

Contemporary surgical therapy requires contributions from a variety of professionals who work together in what has traditionally been called an operating room (OR) ‘team’. Patient safety research shows that patients suffer negative outcomes when there is dysfunction, including conflict mismanagement, in this type of health care team.1–3 Optimal conflict management requires the participation of all team members, but is likely to fail without a substantial contribution by surgeons as they wield ‘tremendous organisational power’ in this team setting.4 Recommendations for conflict management for surgeons have been offered based on research in stable non-medical groups.5,6 However, the OR team has been described as a ‘…working group of siloed individuals who, in the best circumstances, act as a potential team and, in the worse situations, function more like a pseudoteam’.7 Thus, management strategies developed in stable work teams may prove ineffectual or even counterproductive in the OR setting. This is not to say that what has been found to be true of conflict in non-medical work teams may not be useful in understanding conflict in OR teams. In fact, research focused on OR team member communication shows that both task- and relationship-related conflicts occur in OR teams, as they do in stable work teams.5 This finding is important for this investigation because contemporary management recommendations are based on these types of conflict.

Task-related conflict is principally cognitive in nature8 and has been defined as a ‘perception of disagreements among group members about the content of their decisions… [involving] differences in viewpoints, ideas and opinions’.9 Relationship-related conflict is emotional in nature and has been described as a ‘perception of interpersonal incompatibility’ and as typically including ‘tension, annoyance and animosity among group members’.8 Task- and relationship-related conflicts have differing consequences for the team. Task-based conflict is thought to improve group performance in specific situations, such as in the evaluation of potential problems in non-routine tasks,10,11 but generally it reduces team member satisfaction.12 Relationship-based conflict has profoundly negative effects on both team performance and team member satisfaction.11 This has led to the recommendation that conflict be managed in such a way that the group enjoys the benefits of the outcomes of task-related conflict without experiencing the negative outcomes associated with relationship-based conflict.13 This involves emphasising problem solving in dealing with task-related conflict while avoiding relationship conflict.5 This recommendation is consistent with the ‘separation perspective’, which holds that the conflict types are distinct.14 The alternative view is described as the ‘complexity perspective’, which treats conflict as a unitary process that involves both task- and relationship-related attributes and which considers that these attributes interact to effect group outcomes.14 A management approach consistent with this perspective advocates for the active management of relationship conflict as it almost always accompanies task-based conflict.15 The debate about the appropriate perspective and related management approach then hinges on the degree to which the conflict types are connected; this is an area of recent investigation in the social sciences. The most recent study evaluated this inter-relationship between conflict types in longitudinal investigations and described it as involving a process of ‘conflict transformation’.16 Other research has focused on the behaviours that are responsible for these shifts between conflict types. A study of hotel management executives showed that both misattribution and the use of harsh language would result in a shift from task-related conflict to relationship conflict.9 Misattribution occurs when group members assign a motive to an individual’s observed conflict response. When this attribution takes the form of a personal attack, task-related conflict can shift to relationship conflict. The same transformation can occur when harsh language (e.g. insults) is used because it is interpreted as disrespectful.

The goal of this study was to select the conflict management approach most appropriate for an education programme for surgeons. This involved evaluating those behaviours responsible for progression within a conflict type and those associated with a shift between conflict types. An analysis of the behaviours responsible for a shift between conflict types would allow for an estimate of the degree to which the conflict types are related in this setting, which would clarify the selection of the optimal management approach. A constructivist grounded theory approach was adopted for this study on the basis that it would allow for the use of sensitising concepts or guiding interests derived from the conflict literature, as well as an investigation of the features of conflict unique to the OR team.17

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

A multi-institutional, multidisciplinary research team was developed. The core research team was composed of a surgeon, two nurses and a social scientist; this group was responsible for the data analysis and preliminary development of themes. This core team was joined by three surgeons from different institutions in order to support a review of the results emerging in the context of diverse local experiences and to consider the educational implications of the findings. Institutional ethics approval was obtained at all five participating sites and informed consent was obtained from all study participants. Participating institutions were purposely selected so that they were geographically and organisationally diverse, although all were regional referral centres affiliated with residency training programmes. A semi-structured question script was developed prior to initiating the focus groups based on the previously developed conceptual framework.5 This included queries about the source of conflict, specific behavioural responses and consequences in each conflict episode. Operating room nurses and surgeons were recruited at each institution and assigned to discipline-specific focus groups that ranged in size from three to nine participants. The participants constituted a convenience sample of individuals who were able to make time for the focus group discussion and all received the same financial stipend as compensation for their participation in the study.

Within the nursing group, purposeful sampling was used to ensure that the nurses had at least 2 years of experience in the OR environment. This sampling strategy was not used in the surgeon group as all had completed residency training and thus had at least 5 years of experience in the OR. The number of focus groups conducted was determined through theoretical sampling, in which data collection occurred alongside preliminary analysis and collection ceased when no new themes were arising from the focus group discussions. Focus group interviews were audio-recorded, anonymised and transcribed with standard linguistic conventions to yield 223 pages of transcription for analysis.

In the grounded theory tradition,18 transcripts were read iteratively by the members of the core research team and a process of open and axial coding was conducted. The codes were applied to the entire transcript using NVivo Version 7.0 (QSR International Pty Ltd, Doncaster, Vic, Australia). During the coding process, it became obvious that some of the narratives identified the source of the conflict and its consequences and described the behaviours involved. The core research team then attended to this subset of narratives to evaluate the process of conflict transformation. The behaviours responsible for conflict transformation both within and between types were grouped by type of source and consequence. A theory or explanation of conflict transformation was developed using these groupings, as well as by evaluating all of the behaviours described in the narratives. The analysis was revised and refined through the constant comparison of instances from the dataset by the core research team members in a series of three, day-long meetings. The analysis was refined with input from the entire research team until consensus was achieved.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

A total of 31 circulating OR nurses participated in the focus groups. Of these, 29 were women and two were men. Thirty-five surgeons participated in focus group sessions; this group included eight women and 27 men. A total of 40 narratives met the criteria for inclusion in the analysis of conflict transformation. Twenty-nine of the narratives came from nurses, all but one of whom were female. The source of the conflict was task-related in 34 instances, relationship-related in five, and both task- and relationship-related in one case. The most common, specific, task-related sources of conflict referred to equipment needs and scheduling. Relationship-related sources of conflict concerned bad moods or attitudes, rudeness and inexperience on the part of staff members. The most common positive consequence of task-related conflict was improved working efficiency. Positive consequences of relationship-associated conflict included increased satisfaction on the part of the team and an improved working relationship between parties. Negative consequences of task-related conflict included an increase in the incidence of mistakes made by staff, an increase in the time required to perform tasks and a decrease in the contribution of team members towards the completion of a task. Negative consequences of relationship-related conflict included feelings of incompetence or misery on the part of staff and a decrease in willingness to communicate with the team. A permanent negative consequence of relationship-associated conflict occurred when a team member was dismissed from the team, a team member refused to work with that team or an individual resigned from his or her position.

There were sufficient narratives to allow us to examine the transformation processes in three of the four possible combinations of conflict source and consequence. The exception belonged to the category in which the source of the conflict was relationship-related and the consequence was task-related. Three of the narratives included mixed-type consequences in which both types of conflict consequences occurred and were integrally related. The behavioural themes for each process type are presented here with an illustrative example for each group. These examples are referenced by the professional identity of the individual and the coded identity of the institution.

Conflict transformation behaviours

Task-related source, task-related consequence

A total of 10 narratives described a task-related source and consequence. The overall pattern showed that negative task-related consequences occurred when a surgeon lost his or her composure in a conflict in which the source was task-related. Surgeons described instances in which these types of behaviours seemed to be effective in accomplishing task-related goals, but acknowledged that even then, these responses often also had negative effects. Nurses never reported instances in which surgeon behaviours associated with a loss of composure produced positive results and described only negative task consequences:

‘I think he [the scrub tech student] wanted to see everything up close and he would nudge my arm. I asked him not to do this but after the third time, I lost it. After that, he decompensated and I was basically doing the case by myself. It took much longer.’ (Surgeon, Institution D)

Relationship-related source, relationship-related consequence

Five narratives described conflict in which the source and consequence were relationship-related. All of these were reported by nurses. A review of these narratives showed the emotional toll associated with this type of conflict. Nurses described feeling dread and long-term anger. In some cases the consequence was that the nurse would request not to work with the surgeon again:

‘...and if somebody that’s not worked with him before, I mean, he’ll come in the room, look at them and immediately get in a bad mood... Well, I think when they see him act like that, they don’t want to be in there. And we have staff now that don’t want to work for him.’ (Nurse, Institution A)

Task-related source, relationship-related consequence

Twenty narratives reported conflict in which the source was task-related and the consequence relationship-related. Almost all of these were contributed by nurses. The first behavioural pattern revealed that verbal outbursts by surgeons evoked frustration and feelings of incompetence on the part of nursing staff. The second pattern related to personal attacks made by surgeons, including blaming, insulting or threatening, which created a strong emotional response from the nurses and would cause nurses to resign their positions or to take steps to avoid working with a particular surgeon again:

‘So, I go back to the surgeon and he asked if I had ordered the suture and I told him that we needed to sit down and talk about it and he said, “There’s no reason to talk about it, just order it.” And I told him at that point that I was not allowed to order it. And he stopped what he was doing, he turned around and he looked at me and he said, “If you don’t order that suture, I’m going to have you f***in fired.” Of course, I was upset by it because when you work really hard for these surgeons... it’s very disconcerting to have surgeons that act like that.’ (Nurse, Institution A)

Task-related source, mixed outcomes

Five of the narratives involved mixed outcomes. The first illustrative narrative described an episode of conflict that began with a task-related source, led to an outburst and an incident of blaming and resulted in negative task-related consequences for the patient and relationship-related consequences for the nurse. The second narrative began with a task-related source and involved the public blaming of a nurse. In this case, the task-related consequences were mitigated, at least from the perspective of the surgeon who wanted a specific piece of equipment, but at the cost of accompanying negative relationship-related consequences for the staff.

Negative task and relationship consequences

‘The worst experience I’ve had in the OR, and it’s the only time I’ve come close to crying. We were doing a tendon on a child, a little child, and we didn’t have an instrument that he wanted, ’cause we just, the whole hospital did not have it. We didn’t carry it. He knew that we had it. I said we don’t have it and he had to make another incision and he looked at me and pointed his finger at me and said, “It’s your fault that this child has to have another incision!” And it was unfair, we didn’t have the instrument that he was wanting and he was blaming his own ineptness on me. That was very personal.’ (Nurse, Institution C)

Positive task consequence, negative relationship consequence

‘And this other surgeon whose name is on this piece of equipment asked where was his retractor and they told him it was in his usual OR, rather than the one he was currently working in. Well, he hit the ceiling. He wanted his retractor and he went on for what, a couple of hours or more. And life was miserable for the people. I felt really sorry for the circulator and that scrub tech. She ran and got a retractor that was comparable to it, but he flat out refused. “I want mine.” It took a couple of hours to get it to him. And it didn’t cause that case to have a different outcome either. It was just something that he could continually drive back home to the team in there and that scrub was almost in tears at the end of that. She was worn out after the one case and she needed to spend the time with him and it was just unnecessary.’ (Nurse, Institution C)

A theory of OR team conflict transformation

What emerged from these participant narratives is an explanation for how behaviours contribute to conflict transformation in this health care team. These results confirm that both misattribution and the use of harsh language can cause an episode of conflict to shift across types, as is consistent with the results of quantitative research in stable work groups.9 The qualitative approach used in this study shows that the forms of misattribution and use of harsh language can be extreme. Misattribution involves a personally attacking act of blaming conducted in a public setting; harsh language includes threats, yelling and profanity. All of these behaviours, which range from the act of losing composure to that of dismissing someone from the room, reflect a pervasive and significant effect of strong, negative emotionality on conflict transformation in the OR. One reason why surgeons may behave in this way is that their experience shows that these behaviours are effective strategies for accomplishing immediate task-related goals. Elsewhere, surgeons have indicated that these behaviours are a result of the stress associated with surgery.19 One result of these aggressive responses is that they tighten the connection between the conflict types so that a single behaviour can simultaneously create both task- and relationship-related consequences. Another contribution to this interweaving of conflict types is the fast-paced nature of the work.4 The combination of extreme negative emotionality and the rapid pace of work creates what can be a truly explosive environment. One consequence is that both surgeons and nurses move to end the working relationship. The fact that surgeons end the relationship directly, whereas nurses take a more indirect approach, probably reflects the fact that surgeons have more power. Another reason why both groups choose to terminate a working relationship is that their members lack a sense of belonging to the team. Existing research shows that members of the OR team hold discipline-specific values related to teamwork and team leadership20,21 and these types of value differences are known to decrease cohesion among team members.22 Behaviours such as yelling, insulting and blaming have been previously shown in a human factors study to impair working relationships between nurses and surgeons.23 The results of this study show that this impairment can extend to eliminating the relationship altogether.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References

This study was undertaken as part of a programme of research to develop a conflict management education programme for surgeons who work in OR teams. Our strategy required us to draw from a rich tradition of conflict research and existing conflict management recommendations and to test these concepts prior to beginning an educational process. Ultimately, this led to an examination of conflict transformation in this setting as understanding the inter-relationship between conflict types has significant influence on the selection of the most appropriate management approach. These results suggest that the complexity perspective, which conceptualises conflict as a unitary process with differing attributes, is superior to the separation perspective, which holds that there are differing distinct types of conflict. The tight connection between the task- and relationship-related types or attributes reflects the strong emotional responses and fast-paced nature of the work in this environment. The role of emotions in conflict has received more attention in recent social science research.24,25 Negative emotion is one of the moderators described in the contingency perspective, a model designed to explain how conflict influences organisational group performance. In this model, negative emotion is categorised as an ‘exacerbator’ as it strengthens negative and decreases positive outcomes for the group.26 It has been recently proposed that constraining negative emotionality may be the key to decoupling task- and relationship-related conflict.27

In addition to clarifying the most authentic perspective and corresponding management schema, the results of this study provide a set of behaviours that cause conflict to progress and shift to have negative consequences for both the surgical task and the relationships among team members. These include misattribution in the form of blaming and the use of harsh language that includes yelling, profanity, threats and personal attacks. One challenge to teaching surgeons to manage conflict differently is illustrated in the finding that surgeons believe that their use of these behaviours is sometimes justified in order to accomplish task-related goals. By contrast, nurses never described any positive task- or relationship-related outcomes arising from these behaviours.

In addition to eliminating negative conflict responses, an education programme should also include alternative effective behaviours. The narratives in the present study included an example of positive task- and relationship-related outcomes when a surgeon maintained calm instead of expressing a strong negative emotion:

Nurse 1: ‘And they’re calm. They’re calm no matter what happens and that’s kind of a…’

Nurse 2 [interrupting]: ‘And that’s better because if you get in a crisis or a situation where things are going wrong, if they’re calm, you’re calm and you can take care of it very easily.’ (Institution B)

The ending of a relationship by both parties was a common theme in these narratives. It would seem obvious to everyone involved that it is not possible to create stable teams if team members are frequently being dismissed or quitting. Some narratives reported instances in which a surgeon had publicly or privately apologised for his or her behaviour in a conflict in response to a threat by a nurse to quit. It is likely that these surgeons recognised the value of that individual’s membership of the team or regretted how they had managed the conflict. Although it would be optimal to avoid allowing conflict to escalate to a point at which nurses threaten to quit the team, the nature of the conflict process suggests that this will continue to happen. Thus, apologising or other relationship-rehabilitating behaviours should also be included in the surgeon education programme.

The main limitations of this work relate to sampling and data collection.28 The ultimate goal of this study was to develop an educational conflict management programme for surgeons. Therefore, a sampling strategy involving focus groups in multiple centres was selected in order to increase the probability that any explanations or theory that developed would be broadly applicable. However, this did not facilitate continued engagement with the study participants and thus limited the depth of the theory developed. Additionally, only nurses and surgeons were selected to participate with the goal of gaining both outsider and insider perspectives on the ultimate learner group. However, the available evidence suggests that there is interpersonal conflict between all possible dyads in the OR team29 and hence the results of this study should not be viewed as representative of the totality of interpersonal conflict in the OR. This project relied exclusively on participants’ recall of episodes of conflict. It is likely that this has had the effect of emphasising the more memorable conflicts, including those that were perhaps more emotional in nature. This may have been compounded by the uni-disciplinary focus group structure, which may have increased the likelihood that participants recounted ‘war stories’ of inter- rather than intra-disciplinary conflict. Finally, this work focused entirely on the conflict process and did not examine the antecedents of conflict. Understanding the antecedents of conflict will be extremely valuable in explaining why conflict occurs in this setting and why team members behave in the ways that they do. A conceptual framework has been developed for conflict in nursing work environments and should be extremely useful for this type of investigation.30

Contributors:  DR and LL were responsible for the study conception and design. LL and MB were responsible for the acquisition of data. All authors contributed to data analysis and interpretation. DR and LL created the draft of the article. MB, SE, MK, JM and NS reviewed the draft manuscript and provided input that facilitated its critical revision. All authors approved the final manuscript for publication.

Funding:  this work was funded by a Center of Excellence in Surgical Education Research and Training grant from the Association for Surgical Education Foundation (PO Box 19655, Springfield, IL, 62794-9655 USA).

Conflicts of interest:  none.

Ethical approval:  this study was approved by the institutional review boards of Southern Illinois University School of Medicine (Springfield, IL, USA), the University of Western Ontario (London, ON, Canada), Washington University (St. Louis, MO USA), Georgia Health Sciences University (Augusta, GA, USA) and the University of Chicago (Chicago, IL, USA).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgments
  8. References