Conflict in emergency medicine: A systematic review

The emergency department (ED) is a demanding and time‐pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual‐, team‐, and systemic‐level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research.

Emergency department (ED) doctors operate within an increasingly demanding, stressful, and time-pressured healthcare environment, where they must manage numerous interpersonal and team interactions. 4,5Conflicts over clinical decisions and actions often arise from this complex setting, leading to potential adverse patient events and exacerbating access block issues. 6While individual studies have identified contributing factors to conflict, a comprehensive review that explores and summarizes these issues is either lacking, or not specific to the ED (cf.general health care, see Kim et al. 1 ).This review aims to provide a comprehensive examination of individual, team-level, and systemic factors that contribute to conflict between clinicians within the ED setting.
Ultimately, we hope to provide a more nuanced understanding of the complex ED environment and valuable insights to aid ED clinicians in effectively managing conflict.
Conflict is defined as a "process that begins when an individual or group perceives differences and opposition between oneself and another individual or group about interests, beliefs or values that matter to them."(p.8) 7 In the workplace, conflict often encapsulates task issues and/or relationship (socioemotional) issues. 8Task issues arise from disparities in procedures, priorities, or resource allocation when performing work-related tasks and also involves process, whereas relationship (socioemotional) conflict revolves around breakdowns in interpersonal interactions, often resulting from miscommunication or personality clashes. 7 health care, conflict has been attributed to multiple factors, including incompatible personal motivations, high workload, stress, role ambiguity, and poor leadership. 9Clashing personality traits and work-related factors such as team size and tenure are also associated with high-intensity conflict between physicians and their superiors. 10In a field where effective multidisciplinary teamwork is essential, unresolved conflicts extend beyond the immediate disagreement, shifting the focus from patient care, 11 hindering cohesive teamwork and decision making, and potentially compromising patient safety. 9nflict itself may hold potential for positive outcomes by fostering trust and cohesiveness among team members, enriching clinicians' perspectives and decision-making processes around patient care. 11Importantly, conflict may differ across health care contexts; a physician's experience and perceptions of workplace conflict may differ significantly from a surgeon's (e.g., personality clashes vs. communication and performance issues, respectively). 10,12Hence, it is vital to examine conflict specific to the ED environment, to uncover the nuances of how and why it is experienced as well as specific strategies for addressing it.This review identifies contributing factors along individual, interpersonal, and organizational lines, in tandem with existing frameworks on conflict in health care. 1 By incorporating multiple levels of analysis, this additionally aligns with the literature on the various workplace identities that people hold, be they personal (as an individual), relational (within a group), or collective (as part of an organization). 13 summary, these are the questions addressed by this review: 1. What constitutes conflict in the ED?
2. What factors contribute to conflict in the ED?
3. What strategies are employed to address and resolve conflict in the ED?

Search strategy
The first two authors (TET, LYW) performed a systematic search through the online databases PubMed and Web of Science from June to August 2023.The methodology adhered to PRISMA guidelines 14 (with the exception of comparing effect measures, which were not relevant to this review).Search terms included "emergency medicine," "emergency department," and "emergency care" as well as "conflict" and synonymous terms such as "misunderstanding," "dispute," "communication breakdown," "miscommunication," and "disagreements" (outlined in Table 1, along with inclusion/exclusion criteria).There were no time filters specified.Conflicts regarding article selection were resolved through a process of review and TA B L E 1 Inclusion and exclusion criteria and search terms.

Inclusion criteria
Full-text empirical, peer-reviewed journal articles written in English Articles related to conflict in the ED context Studies that address at least one of the research questions (outlined above)

RE SULTS
We summarize the various dimensions of conflict in the ED and provide a narrative overview of the underlying individual, interpersonal (i.e., team-level), and organizational (i.e., system-level) factors contributing to the conflict, along with identified strat- articles is reported in Table S1.

What constitutes conflict in the ED?
The primary conflict type in the reviewed papers (n = 12) is conflict emerging between clinicians during handovers, referrals, or admissions between ED and admitting/consulting staff such as IM, general medicine, and surgical teams.These conflicts revolve around adverse events/near misses; disagreements regarding patient disposition, priorities, and perspectives; and miscommunication.For example, Kanjee et al. 17 noted that IM physicians express apprehension about unwarranted hospital admissions, whereas their ED counterparts emphasize reasons for admission, such as comprehensive outpatient care guidance.[30] Conflict is also portrayed as a contributing factor to occupational burnout and stress. 31,32Avelino-Silva and Steinman 33 presented conflict as diagnostic discrepancy, i.e., disparities between initial ED diagnoses on admission and final diagnoses on discharge.Lastly, Pun et al. 34 explored communication challenges in a multilingual setting.

What factors contribute to conflict in the ED?
Individual-level factors

Lack of trust: poor reputation, personality clashes, and unfamiliarity
Eleven of the included studies highlight the substantial role of distrust in driving conflict at the individual (personal) level, stemming from unfavorable reputation, incongruent personal attributes/attitudes/motivations, and a lack of familiarity.

Poor reputation
Several studies emphasized the detrimental influence of poor or unknown reputations of ED clinicians impacting on their perceived level of trust.These include being perceived as a nonexpert, having an unfavorable reputation (e.g., being unhelpful or unreliable), or even having an unknown reputation. 35,36Additionally, historical experiences of poor relationships between ED doctors and inpatient doctors, along with a reputation for "aggressive" or "unapproachable" behavior during high-stress situations, are also factors that heighten distrust. 19,28,36,37compatibilities in personal attitudes and motivations Poor engagement, arrogance, rudeness, and avoidance are examples of personal behaviors of doctors that erode trust, 25,35 along with poor listening skills among different parties 38 and antagonistic conflict management strategies. 21Individual biases and discrimination also play a role, such as when female consultants with more youthful and softer voices are perceived as having lower seniority. 38saligned interests can lead to doubts around underlying motives. 21,35For example, Lawrence et al. 38 showed that the likelihood of receiving specialist teams accepting the ED referral increases if the patient has a condition of particular interest to them.In other words, effective two-way communication occurs more frequently when both teams perceive tangible benefits.

Unfamiliarity
A lack of familiarity may breed suspicion and skepticism between health care professionals. 20,22This stems from limited collaborative interactions over time, compounded by large and varying team sizes, time constraints, and changing junior medical staff. 20,23,35familiarity with colleagues' workflows and varying preferences for communication timing can create misunderstandings. 17,20r instance, regarding the optimal time for contacting inpatient teams, some accepting doctors favor early contact, whereas others believe contact should occur only after investigations have been completed 38 ; such perplexing variability increases the perceived workload for ED staff. 17,38experience and lack of self-confidence Lastly, inexperience, lack of self-confidence, and a fear of making mistakes hinder optimal interprofessional communication and increases the difficulty for making inpatient referrals, especially among junior ED doctors. 6,20,37terpersonal (team-level) factors

In-group/out-group bias
Group identification significantly shapes the dynamics within a health care environment, especially in the ED with its multiple interactions across and between teams.Individuals naturally favor their own group (in-group) while exhibiting less favorable attitudes or perceptions toward other groups (out-group). 39,40The influence of specialty identity primes conflicts through a twofold process; first, in-group/out-group biases lead to a divisive "us versus them" mentality. 40This phenomenon of "tribalism" hinders positive relationships from being fostered within the ED as well as between the ED and other departments. 19cond, generalizations and stereotypes about approaches to patient care erode trust and cooperation.For instance, ED physicians perceive IM doctors as less skilled at navigating uncertainty, whereas IM doctors view ED practitioners as less thorough and thoughtful in their assessments. 40Horwitz et al. 39 explored the skepticism of IM physicians toward the competence, judgment, or professionalism of ED physicians.Unsurprisingly, ED doctors report a sense of condescension and distrust from specialty doctors. 37,41de Bekkink et al. 20 also noted perceived disparities in experience, expertise, and qualifications between ED doctors and nonphysician staff.

Patient complexity and disposition disagreements
Eight studies noted patient complexity and disposition disagreements as team-level contributors to conflict, especially during the referral and admission process. 17Patient complexity itself is multifactorial, because of preexisting comorbidities and acute illness, 6 uncertain clinical trajectory, and incomplete test results. 41These factors disrupt a shared understanding of the patient, impeding efficient and collaborative decision-making regarding disposition or further management. 23,25For example, in Iwata et al., 42 conflict arose between emergency physicians advocating for discharge with close follow-up versus inpatient teams recommending hospital admission.
Regarding patient factors, older patients with diagnoses such as urinary tract infections, pneumonia, and congestive heart failure are more frequently implicated in team-level conflict. 33

Communication errors
Closely related to patient complexity is miscommunication, where conflict is generated from omission of crucial information such as medication history, examination and investigation outcomes, and the ED course. 39Some articles point to the variability in ED providers' training and expertise as reasons for miscommunication, leading to missing information during handovers or a lack of closedloop communication around ED outpatient referrals. 25,26Sequential handovers, where there is no direct communication between the first and final caregivers, also contributes to miscommunication. 41e-way communication during handovers-simply transferring information instead of co-constructing a mental model of the patient and their clinical course-adds to conflict. 25Conflict may also revolve around inadequacies in communicating diagnostic uncertainty.
For example, ED physicians prefer provisional diagnoses over definitive diagnoses, but IM doctors perceive that ambiguous diagnostic labels potentiate diagnostic error and inappropriate care. 17,39Lastly, a multilingual environment potentiates information loss through translation errors. 34

Differences in priorities, perspectives, and expectations
Nine papers highlighted competing priorities, perspectives, and expectations between ED physicians and other specialists as contributors to conflict.These are intimately linked to interdisciplinary culture differences, as highlighted by Rixon et al., 19 Smith et al., 41 and Gifford et al. 23 ED physicians tend to focus on rapid, uncertain diagnoses, disposition decisions, stabilization, and referrals, while having to navigate through a high patient load, requiring swift transfers. 17,39Conversely, admitting physicians emphasize comprehensive assessments, definitive diagnoses, and detailed treatment planning. 17,19IM doctors are often concerned about unnecessary admissions and may perceive the workup standards of the ED to be subpar, thus introducing delays to the admission process. 6,17,18,41,43This disparity is exemplified in the study from Horwitz et al. 39 where a patient initially diagnosed with pneumonia in the ED was later found to have a pulmonary embolism.The IM physician categorized this as a diagnostic error that led to improper care, while ED physicians view their role as stabilization and disposition and considered the patient suitable for admission with a provisional diagnosis.
ED and IM doctors also differ in opinion on the barriers to efficient admission and the "right way" of managing common presentations. 40IM specialists view patient instability, inadequate workup, and suboptimal initial treatment in ED as more prominent barriers to the admission process, while ED physicians highlight excessive IM registrar workload, slow admission process, overly detailed patient work-up, and delays due to timing of referrals near the end of shifts. 38,43ganizational (system-level) factors

High volume, workload, and time pressures
Excessive workload and time constraints are important sources of stress, pressure, and subsequent conflict at the systemic level. 28,36,37,43These may lead to rushed handovers, delayed evaluations, inadequate medical notes, and reduced opportunities to develop relationships. 19,34,39Compounded by staff shortages, the high patient volume necessitates multitasking and passive listening, potentially increasing errors and miscommunication. 24,41Moreover, this makes reevaluating admission decisions challenging, even when patients improve in the ED. 17 Additionally, patient flow issues such as crowding and unnecessary utilization of ED beds propagate conflict. 30,39High patient volumes also skew perceptions of reasonable requests, as both ED and admitting teams seek to offload work. 17tergroup conflict arises as staff tend to discard accommodating attitudes in times of resource scarcity, 21 further fueling burnout and occupational stress. 31,32biguous responsibility after handover

Smith et al. and Horwitz et al. documented scenarios of staff un-
certainty regarding clinical responsibility after handover, as in the case of investigations initiated by ED physicians but at the request of admitting physicians.This practice creates ambiguity about followup 39,41,44 especially in situations where leadership roles and responsibilities are unclear. 23

Lack of feedback and training
The absence of posthandover feedback between the receiving physician and ED provider prevents quality improvement practices 39 and reduces the effectiveness of a learning environment that relies on trial and error. 20This may result in ED staff lacking knowledge on the receiving unit's scope of practice as well as wrongly attributed/ misplaced admissions (where patients need to be rebooked under a different unit).

Negative hierarchy/power imbalances
As identified earlier, the dynamics of hierarchy and power imbalances are prominent, with ED doctors often being perceived as "nonspecialists" and lacking discretionary power when making admission decisions. 23More commonly, specialty teams hold authority to accept or reject referrals, although some centers institute an "ED unit transfer privilege" (allowing patient transfer to the ward without consultation).However, both approaches create a sense of power imbalance that hinders two-way communication and collaborative decision making 22,38 and, instead, produces discontent in admitting clinicians on the receiving end of this process. 22These hierarchical structures may exacerbate misunderstandings, such as when junior staff perceive that their seniors are too busy to assist them. 28Such power imbalances are also seen in physician-nurse, inexperienced intern-experienced nurse, and nurse-medical student interactions. 20,31ift culture and physical separation Two other systemic-level factors contributing to conflict are the workplace culture surrounding night shifts and end-of-shift referrals 38 as well as the spatial separation of services in the hospital. 23mited senior staff availability during night shifts can lead to prioritization of managing current patients over accepting new admissions.
Additionally, referrals made near the end of a shift are often less likely to be accepted due to impending shift changes. 38Moreover, the physical separation and limited coordination between specialists and ED can lead to delays in communication and an underappreciation for ED operations.Furthermore, sequential consultations lead to repeated examinations and diagnostics, further delaying patient care. 23These contributing factors to conflict within ED are summarized in Table 2 below.
What strategies are employed to address and resolve conflict in the ED?

Communication training and handover standardization
Proposed solutions to decrease conflict in handovers and referrals include using standardized elements around communicating patient information, such as content guidelines 39 and protocols 17 and frameworks like SBAR 38 and I-PASS. 26,27Standardized communication protocols increase verbal handover quality and reduce ambiguity concerning patient responsibility. 27,44Other recommendations include formal teaching and training around communication, 20,28,34,37,38 especially around interdisciplinary roles and boundaries. 17,24,41,44In addition, a shared mental model facilitates efficient and effective collaboration by bridging gaps in understanding, which contributes to a more comprehensive and nuanced insight of the patient. 25

Improved admission guidelines
Some studies recommend enhancing referral guidelines and establishing protocols to aid disposition decisions. 6,17In addition, granting ED doctors expanded admitting rights, especially for undifferentiated patients, may improve patient flow and bed availability. 23As shown in Charbonneau et al. 29 where investigation requests and disposition disagreements remained constant despite end of shift and surge events in the ED, patients need to receive a universal high standard of care that is not reliant on ED clinicians adapting well to time and surge constraints but on strong, robust, and consistent admission policies and systems.

Communication system changes
Various articles suggest improvements to how providers involved in patient care communicate, such as real-time updates for the responsible physician and means of contact to facilitate closed-loop communication, role-based pager forwarding, automated alerts to admitting teams for new patients, and centralized notes to minimize sequential handovers. 26,39,41Other recommendations include using technology (e.g., walkie-talkies) to improve communication, 30 designated notice boards to signify staff whereabouts, 28

Improving interpersonal and interdepartmental relationships
Building interpersonal relationships across different units helps facilitate transfers 22 and can be developed through shared academic programming, multidisciplinary conferences, and interdepartmental social events. 17,35,40Other recommendations to improve team dynamics include increasing face-to-face discussions, simultaneous bedside evaluation between specialties, providing positive feedback, motivating junior staff, and involving nurses in updates. 17,20,28,40Conflict is also reduced through increasing engagement, understanding other teams' interests, and focusing on patient-centred goals. 20,36,43Finally, colocation of specialists and ED doctors may improve teamwork by reducing structural boundaries. 23

DISCUSS ION
In this first review of conflict specific to emergency medicine, we identified that for emergency medicine clinicians, conflict generally comprises mainly routine, common task issues of referring patients for admission, handing over, communicating, and diagnosing.
Essentially, the underlying reasons for these task-related conflicts are inherently and intrinsically embedded within the complexity of emergency medicine work 4 : uncertainties with patient diagnosis and disposition, necessity for discussion and negotiation with multiple other health care providers, and fragmentation of the patient care hospital journey.
Examining the contributing factors that stoke the flames of conflict reveals a rich array of relationship (socioemotional) issues.
9 was that "the diagnostic role of the emergency physician is critically important, but it is frequently preliminary, which does not make the diagnosis incorrect per se." Although it is unsurprising that time pressure and resource lack feature as systematic contributors to conflict, the unstable power dynamic between the ED and the rest of the system is noteworthy.
In a Canadian paper examining patient flow, Kreindler 50 problematized the giving of ED more power, as it stressed other parts of the health service.This hints at the notion that power alone is not the simple solution, but, as uncovered by Nugus et al., 51 practicing collaborative power (i.e., interdependence, collegiality) over competitive power (i.e., dominance) may be more helpful at reducing friction between ED and other specialties.
In light of this, while it is reassuring that the identified strategies to mitigating conflict in the ED mainly revolve around systems-level improvements, the biggest challenge is presented by perceptions and prejudices inherent in cultural and professional practice.Improving interpersonal and interdepartmental relationships may remain elusive due to complexities and differences in professional identity and the very nature of ED work. 52Importantly, this could occur between emergency medicine clinicians and nonemergency clinicians, between clinicians themselves within a large emergency medicine team or even between leaders and followers.Attempts to foster unity between these units may paradoxically increase conflict within another, 13,53 such as in the scenario when an ED doctor sides with an inpatient specialist over an ED nurse or vice versa.Hence, we contend that any attempt to improve ED patient care processes (task issues) must firstly, and genuinely, foster collaboration between all parties involved (relationship/socioemotional issues) and consider the various personal, professional, relational, and organizational tensions impacting on emergency clinicians.
In alignment with previously identified research gaps around conflict in health care, 1 this systematic review highlights particular opportunities and needs, given the dynamic, demanding, and data-rich ED environment, namely: (i) involving interprofessional team members; (ii) utilizing conceptual or theoretical bases such as self-evaluation (e.g., identity) or psychological capital (e.g., resource depletion) to better understand the nature of conflict; (iii) examining the role of power and status implicit in ED conflict; and (iv) harnessing organizational metrics to objectify the costs of conflict.
There is a lack of research on specific conflict management interventions and their effectiveness in emergency medicine.Further research is needed to identify effective strategies for preventing and managing conflicts in emergency medicine.Finally, with the prevalence and importance of conflict management and resolutions skills being part of clinicians' capability, it is interesting to note the lack of conflict management and resolution as a particular leadership competency for health leaders within national and international frameworks 54,55 -this points the way toward future opportunities for further research on leadership competencies and the role that health leaders can play in conflict. 56In this regard, scholars are encouraged to build on recent work that contends that, for leaders, the ED work environment itself not only fuels conflict but is threatening to their very identity as leaders. 57

TJAN
egies.(Due to their interconnected nature, and given that individuals operate within team structures, it is often challenging to distinguish between individual and interpersonal-/team-level conflict.As a result, there may be a degree of overlap between the factors contributing to conflict at the various levels.)WhileF I G U R E 1Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) diagram.1254 records identified from databases.Pubmed (n = 585), Web of Science (n = 669) 808 records screened for inclusion 762 non-relevant records excluded 46 reports sought for retrieval 6 reports not retrieved Full-text not available (n = 1) Article not in English (n = 3) Abstract only (n = 2) 40 reports assessed for eligibility 19 reports excluded: Not conflict-specific (n = 10) Not specific to ED (n = 2) Not empirical (n = 7) 29 studies included in review et al. conflict itself tends to center around task issues such as handovers, referrals for admission, and making diagnoses, contributing factors tended to revolve around relationship (socioemotional) issues like distrust, biases, and miscommunication, compounded by working in a challenging, strenuous system.A summary of all 29

34 TA B L E 2 •
and digital translation for medical documentation.Summary of contributing factors to conflict within ED.Inexperience and lack of self-confidence Interpersonal (team-level) factors • In-group/out-group bias • Patient complexity and disposition disagreements • Communication errors • Differences in priorities, perspectives, expectations Organizational (systems-level) factors • High workload and time pressures • Ambiguous responsibility after handover • Lack of feedback and training • Power imbalances • Shift culture and physical separation