Cooperation and conflict in intra‐hospital transfers: A qualitative analysis

Abstract Aim The purpose of this study was to explore the latent conditions of cooperation and conflict in intra‐hospital patient transfers (i.e. transfers of patients between units in a hospital). Design Secondary qualitative analysis of 28 interviews conducted with 29 hospital staff, including physicians (N = 13), nurses (N = 10) and support staff (N = 6) from a single, large academic tertiary hospital in the Northeastern United States. Methods A two‐member multidisciplinary team applied a directed content analysis approach to data collected from semi‐structured interviews. Results Three recurrent themes were generated: (a) patient flow policies created imbalances of power; (b) relationships were helpful to facilitate safe transfers; and (c) method of admission order communication was a source of disagreement. Hospital quality improvement efforts could benefit from a teaming approach to minimize unintentional power imbalances and optimize communicative relationships between units.

While it is critical to understand the risks posed to patients during transfers, the impact of transfers on hospital staff from a wide array of professional backgrounds is less well-understood (Halvorson et al., 2016;Rosenberg et al., 2018). Research that acknowledges staff experiences in maintaining patient safety during intra-hospital transfers is needed to understand other factors that contribute to adverse events, delays in care and other risks to patients (Hearld, Alexander, Fraser, & Jiang, 2008). To this end, a quality improvement project using an ethnographic approach was conducted to examine the latent conditions that affected how multidisciplinary team members experienced intra-hospital transfers from the Emergency Department and Medical Intensive Care Unit to General Internal Medicine floors at an urban teaching hospital (Rosenberg et al., 2018). Observations of and interviews with team members including clinicians (nurses, physicians and a physician's assistant) and support staff (unit clerks and bed managers and bed associates who assigned patients to beds) informed the development of a taxonomy of intra-hospital transfers (Rosenberg et al., 2018). Cooperation and conflict were two prominent codes that emerged from the primary analysis, leading the research team to suggest further study.
The purpose of this secondary qualitative analysis was to build on findings from a quality improvement project of hospital staff experiences with intra-hospital patient transfers by exploring the latent conditions of cooperation and conflict more deeply. A directed content analysis of data coded for cooperation and conflict was conducted to generate themes about how staff from multiple disciplines experience and view cooperation and conflict during intra-hospital patient transfers (Hsieh & Shannon, 2005).

| ME THODS
The following methods and results are reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ; Tong, Sainsbury, & Craig, 2007).

| Design
The quality improvement project-herein referred to as the parent study-intended to: (a) better understand the process of transferring patients from the emergency department and medical intensive care unit to the general internal medicine floors of an urban teaching hospital; (b) identify challenges and opportunities for improvement in the transition process; and (c) develop interventions to reduce adverse patient events as well as increase staff satisfaction with the transition process. Details of the parent study including the sampling process, data collection (i.e. where the interviews were conducted, who transcribed, how long the interviews were) and data analysis, are well-described in the parent publication (Rosenberg et al., 2018). The parent study identified sending units (units that send patients) and receiving units (units that receive patients) with the greatest number of transfers and staff complaints related to transfers. Participants (N = 29) from the sending and receiving units consisted of 13 physicians (including a unit medical director and an associate medical director), 10 nurses (including staff nurses, a patient services manager and a nurse manager) and six support staff (including a clinical bed manager and a bed associate). The parent study analysis team was surprised by the frequency of cooperation and conflict codes-not only did the codes occur often, but these two seemingly contradictory codes occurred frequently together. Twenty-seven of the original 28 interview transcripts included both the cooperation and conflict codes. The team felt that the prominence of these codes warranted further analysis to understand how cooperation and conflict were experienced during care transfers.

| Sampling
The secondary analysis team had access to the full transcribed and coded interviews in ATLAS.ti (2017) qualitative software, version 7.0 (Scientific Software). The secondary analysis sampled interview data coded with the cooperation and/or conflict codes.

| Analysis
The secondary analysis occurred between February and November 2017. The secondary analysis of the cooperation and conflict codes took place in Atlas.ti. Two researchers (disciplines of nursing-andhealth services research and quality improvement) immersed themselves in the interview data coded with conflict and cooperation (Patton, 2015). The two-member team was not part of the original coding team, but had access to the data through a formal research relationship with the project's principal investigator (Heaton, 2004).
Both members of the team had prior qualitative research experience including coding and analysis. The researchers used directed content analysis, whereby they analysed data coded for cooperation and conflict in the parent study and synthesized the qualitative data to identify patterns and develop themes across experiences (Hsieh & Shannon, 2005). A new code structure was created for this analysis.   (Corden & Sainsbury, 2006). Quotes were italicized to indicate the participant's own words and followed by a general label to identify the speaker while still ensuring anonymity. Quotes were presented as close to verbatim with as little editing as possible. Ellipses (…) were inserted to indicate places where words or phrases were omitted (such as verbal hesitations to enhance readability and avoid the repetition and false starts heard in conversational speech). General or explanatory terms were placed within square brackets [ ].
regularly to discuss and refine definitions for open codes, continuously updated the coding structure to reflect the emerging data, refine code definitions and organize findings. Once coding of the data set was complete, the team analysed code reports and developed themes.
Analytic rigour was supported through coding procedures, including maintaining an audit trail through memos kept in Atlas.ti to document the analytic process. The trustworthiness of data analysis was established by reviewing themes in a series of feedback sessions between the secondary analysis team and the parent study team (Creswell & Miller, 2000). During these sessions, the study team shared themes that emerged from the secondary analysis and incorporated insights from the parent study team to deepen interpretation. Disagreements were resolved through discussion with the parent study's three-member research team until consensus was reached. Final code structure was reviewed with the study's PI's in two meetings with the secondary analysis study team.

| Ethical considerations
The

| RE SULTS
The research team identified three themes in the data: (a) patient flow policies created imbalances of power; (b) relationships were helpful to facilitate safe transfers; and (c) method of admission order communication was a source of disagreement (Figure 1). Illustrative quotes are displayed in Table 1.

| Patient flow policies
Senders, receivers and support staff identified several hospital policies that complicated the transition process by creating imbalances of power and conflict among groups. These patient flow policies epitomize the struggle of working within the mandates of a complex system that staff perceived as sometimes impeding high-quality and safe care transfers. policy-as a passive receiver awaiting patients on his unit-to those providers who had an active role in the transfer process (Table 1).
The same general medicine physician described how this policy had a negative impact on patient disposition. The general medicine physician's perception was that this patient would be more appropriately placed on a specialty unit where he could be treated for his primary presenting problem, namely kidney stones and kidney failure. The same policy, which the emergency department experienced as cooperative, generated conflict when imposed on the general medical staff.
Another contested policy was the four-hour mark, wherein the responsibility of patient care was automatically transferred from the emergency department physician to a general medicine physician after the patient had been in the emergency department for 4 hr. This policy was implemented in response to a Joint

| Admission order communication
Admission orders are essential to any intra-hospital transfer. They  (Table 1). This nurse did not value the mode of communication that providers from other units found critical to safe transfers.
In addition to mode of communication being a source of disagreement, the content of admission orders hindered transfers. lack of knowledge about variation in policies contributed to transition inefficiencies and were marked by more conflict than cooperation. Sending providers were sometimes unaware of limitations in receiving units' scope of practice and therefore did not always include pertinent patient care in the admission orders. Receivers described receiving patients that they were unable to treat, such as patients requiring additional telemetry monitoring for specific cardiac medications. Often, this resulted in a re-booking of the patient to a different unit. Occasionally, scope of practice policy was interpreted as lack of confidence in caring for specific patients. While a sending physician interpreted units not accepting patients as within the control of the receiving nurses, a receiving nurse described having to serve as an arbiter for the frequent conflicts that arose when sending teams were unaware of these unit-specific policies and did not understand limitations in scopes of practice.

| D ISCUSS I ON
This study sought to understand and characterize the multidisci- This study-along with the parent study-builds on the existing literature that had focused on transfers and communication between only-physicians (Detsky et al., 2015;Hilligoss et al., 2015) or between only-nurses (Shields, Overstreet, & Krau, 2015) by incorporating diverse stakeholder perspectives from across the transfer process. This study continues to expand the scope of intra-hospital transfer literature, which has narrowly focused on failures in communication (Ong et al., 2011;Patterson & Wears, 2010), step for future work in this area (Detsky et al., 2015). Hilligoss et al. (2015) characterized the challenges of between-unit transfers after a 2-year ethnographic study of intra-hospital transfers between emergency and intensive care unit and general medicine physicians at two different medical centres. Those findings include unequal distributions of power among units, infrequent face-toface communication and a lack of awareness of the other unit's state (Hilligoss et al., 2015). However, both studies were restricted to communication of information during transfers and limited to the perspectives of physicians.
This study expands the literature by capturing the voices of multiple staff involved in transfers and applying a systems approach that highlights the impact of hospital policy within a broader social context (Alexander & Hearld, 2012). Our analysis was novel because we characterized the moments when participants felt most frustrated, or most supported and related these characterizations directly to policies and structural barriers at the hospital. Our analysis highlights the importance of examining organizational-wide policies and unit-specific cultural adaptations to those policies. The study also demonstrated that conflict is not necessarily terminal-conflict can be an indicator of a problem or potential risk. In line with literature on group dynamics, conflict is essential to healthy group functioning (Smith & Berg, 1987). Our findings also revealed that cooperation in the transition process can belie the disempowerment experienced by participants as evidenced by the experiences of bed management with the four-hour mark.
We used established approaches (e.g. a multi-member coding team, an audit trail using memos and feedback sessions) to enhance the rigour of our findings (Miles, Huberman, & Saldaña, 2014;Patton, 2015); however, our study is not without limitations.
First, our findings cannot be generalized to all hospitals. However, qualitative study findings can provide insights into areas that have been previously unexplored and can generate hypotheses for future quantitative evaluations (Curry, Nembhard, & Bradley, 2009).
Second, as this study was based on interview data, we must acknowledge the potential impact of social desirability bias (Collins, Shattell, & Thomas, 2005)-participants may have misrepresented their role in transfers to provide desirable answers. Third, as a secondary analysis of qualitative data, the data were limited to what was available in the parent study (Hinds, Vogel, & Clarke-Steffen, 1997).

| CON CLUS ION
Our findings have implications for improving the day-to-day experience of staff navigating transfers of patients between units.
In a report by the Joint Commission Center for Transforming Healthcare (Joint Commission, 2017b), a lack of teamwork and respect was identified as a specific root cause for failures in care transfers. Two of their proposed solutions addressed the culture of transfers and encouraged organizations to make successful transfers an organizational priority. Institutional use of a standardized transfer tool developed by all members of the intra-hospital transition staff in a mutually agreed on medium (e.g. verbal, written or in the chart) could foster a culture of shared responsibility while standardizing critical content for efficient communication.
Recent work by Abraham and Acharya (2016) applied the theory of "common information spaces" to develop evidence-based guidelines for an interdisciplinary handoff framework and embraced the similarities between resident physicians' and nurses' transfer communication. Applying a teaming approach, which includes representation from all involved departments, could minimize unintended consequences of hospital-wide policies. Quality improvement efforts spanning units, with goal-setting that crosses boundaries and optimizes synergies between units, could be an efficient route for solidifying these relationships. Hospital policies should be examined from the perspective of multiple units. Rather than seek to eliminate all conflict, which is likely impossible, future quality improvement efforts should consider how to learn from experiences of conflict as indicators of staff burnout or potential risks to patients.
Hospital staff involved in intra-hospital transfers must navigate a complex healthcare system to get patients to the appropriate site of care. Nurses, physicians and support staff described episodes of cooperation and conflict-some complicated by hospital policy-pervading the relationships and communication that occurred between units. The emergence of these domains across different types of staff underscores the importance of integrating the whole healthcare team in organization-wide problems and solutions.

ACK N OWLED G EM ENTS
The authors would like to thank Beth L. Emerson, MD from Yale University Department of Pediatrics (Emergency Medicine) for her thoughtful contributions to this manuscript.

CO N FLI C T O F I NTE R E S T
The authors declare no conflicts of interest to disclose.