Conflict Management Education in the Intensive Care Unit

This study was conducted at Baylor Scott & White Health, a level I trauma center with approximately 636 beds in Temple, Texas. Participants were from multiple disciplines. Demographic information, including years of experience, clinical specialty, and area of practice, were collected. The research was approved by the institutional review board (Ref. No. 300999).

An educational session and assessment were designed by the first author (B.A.A.W.) and reviewed by an expert panel of 2 ICU doctors (H.D.W., A.C.A.) and a regionally known conflict management expert. The educational assessment and intervention involved 2 instruments: (1) the Thomas-Kilmann Conflict Mode Instrument (TKI), which was used primarily as an educational tool,^12–15  and (2) a pretest and posttest with Likert-type multiple choice questions (pretest/posttest) (see Supplement). Demographic data and the TKI were analyzed with descriptive statistics, and the pretest/posttests were analyzed with the Wilcoxon test.

The 1-hour conflict management educational intervention for this study was led by the lead author, who has expertise in organizational psychology and medical education, and had 4 overarching objectives: (1) diagnose conflict type and cause; (2) recognize internal dialogue; (3) identify conflict management modes; and (4) develop awareness of self and others. The education session incorporated basic knowledge concepts of conflict management, self-reflection around the TKI, and an emphasis on active learning through reviewing clinical cases. The educational intervention went through several iterations of revision after feedback from experts in the field but continued to include components of literature, conflict management content, and adult learning.

The session opened with discussion of literature that highlighted the importance of conflict management and basic concepts about conflict including conflict types, language, common causes of conflict, perception, cognitive processing of conflict, and resolution hints. Following the background section of the intervention, participants completed the TKI and discussed each conflict management mode. After participants understood the concepts, the leader introduced interprofessional conflict cases and the group discussed the cases as an interprofessional team. Participants used their new knowledge to dissect scenarios and name potential symptoms, diagnoses, and treatment plans for the conflict. The session was intended to educate and enlighten participants and encourage diplomacy and empathy in ICU teams.

Forty-nine providers (10 physicians, 1 advanced practice provider, 18 registered nurses, 8 respiratory therapists, and 12 not specified) participated in the educational intervention and completed the TKI during the intervention. The TKI assessed 5 constructs, with each participant having at least 1 high score and 1 low score. Because the inventory allows for multiple high and low scores, the total number of scores is not the same as the number of participants. The 49 participants had 57 high scores. The high scores (Figure 1) indicate that the most frequently used conflict modes were avoiding (32%), compromising (30%), and accommodating (25%). The low scores (Figure 2) indicate that the least frequently used modes were competing—with 50% of the population scoring lowest in this mode—and collaborating (25%). There was no correlation between conflict management mode scores and specialty or years of experience.

In addition to the quantitative research questions, there were 3 open-ended questions that yielded some insight for future iterations of conflict management education. Participants reported that taking the TKI provided personal insight and taught them about how to work in a team. Participants identified mindfulness as a strategy that they would apply in practice. Most importantly, participants wanted further exposure to concrete skills for conflict resolution and believed that insights about communication were an important part of conflict resolution.

Of the 49 participants in the educational intervention, 31 (5 physicians, 1 advanced practice provider, 17 registered nurses, and 8 respiratory therapists) completed the pretest/posttest. The participants who completed the pretest/posttest represented the cardiothoracic ICU (10 participants), medical ICU (9 participants), surgical trauma ICU (9 participants), and combinations of the 3 ICUs (9 participants). Their clinical experience ranged from less than 1 year to more than 30 years. The Wilcoxon rank sum test showed a significant change in participants’ knowledge (P < .001) with a large effect size (d = 1.47). The difference in perception scores was significant as well (P = .004).

We conclude that conflict management can be taught in a short time frame. Participants gained knowledge, changed their perceptions, and planned to use the gained knowledge in their practice. Additionally, participants believed that the following would improve or reduce conflict: communication, mindfulness, dialogue, interdisciplinary rounds, and awareness.

The competing mode of conflict resolution was the most common low score, which has both positive and negative implications. Competing, which involves high concern for self and low concern for others, is a necessary conflict management mode in medicine because providers must be comfortable competing with one another about what they feel is best for the patient. It may be advisable to coach staff on how to compete in a healthy way. If team members feel that they cannot speak up or contradict perceived leaders, poor patient outcomes can result.¹⁶  The most common high score was in the avoiding mode of conflict resolution. This finding also can have positive and negative implications. Avoidance can be beneficial when a “cooling off” period is needed, but avoidance can lead to unresolved conflict that contributes to poor morale.¹⁷ 

The generalizability of these results is limited by the small sample size. However, the sample was fully powered and there was a large effect size; and thus these results support the use of conflict education as a tool. There have been efforts to include leadership principles in physician education, but there is little continuity across programs.¹⁸  Most programs yield only data on participants’ perception and no real quantifiable results.^6,8,10,11  The effectiveness of this intervention should be reviewed further.

This is the first study to create a conflict management education intervention for teams in the ICU. In the group that completed the pretest and posttest, knowledge and perception scores increased significantly after the educational intervention. Significant findings for knowledge gained and perceptions of conflict point to a need for continued research, as gained knowledge can assist individuals in their daily team interactions. We were surprised by results that showed that compromising and avoiding are preferred conflict management styles within the ICU. Although there is no wrong conflict management mode, there are negative team repercussions of compromising and avoiding. Future investigations around conflict training and management are much needed.

We thank and acknowledge Ms Susan Owens, vice president for human resources at the University of Mary Hardin-Baylor, for contributing her time and expertise to the conflict management educational intervention and tools. Her feedback was invaluable.