Conflicts Between Colleagues

Written by on May 31, 2013 in Practice tips - No comments

What to Do When Work Relationships Stop Working

Given the stress of having lives hanging in the balance and the often ill-defined hierarchy of the multiple physicians and staff that might be “touching” each patient, the medical workplace can be a breeding ground for interpersonal conflict.

Yet few medical professionals have the inclination or skill set to wade into difficult conversations when confronted with unacceptable behavior or situations, including:

  • Nurses and medical techs who are perceived as overstepping their bounds, inappropriately questioning medical decisions, having poor listening skills and repeatedly asking for clarification or unnecessarily disturbing on-call physicians.
  • Physicians who dismiss input or sarcastically respond to questions from colleagues, nurses and medical techs, or who engage in disruptive behaviors such as bullying, throwing items or abusing the power differential their MD provides them.
  • Healthcare administrators who provide arbitrary on-call schedules or work loads, productivity goals that compromise quality, introduce new systems (such as electronic medical records) without sufficient time for training, and who lack appreciation for physician and staff contributions.
  • Nurses who engage in what is often called “horizontal hostility” and are uncooperative or undermine their peers.
  • Physician peers who refuse to return consult calls, have turf issues regarding care of patients and staffing, or who have unusually demanding or assertive personalities.
  • Medical professionals, in general, whose lack of competency, skills or work ethic impacts patient safety or continuity of care

When medical professionals aren’t called on inappropriate behavior, it breeds fear, resentment and disrespect.  Over time, employees will avoid certain co-workers even if their skill set is essential to patient care—for example, the night shift nurse who won’t wake an on-call physician who’s been abusive in the past.

The research clearly demonstrates that when medical professionals can’t communicate effectively and honestly, the workplace becomes unnecessarily stressful and patient safety is put at risk.

Physicians under stress have a tendency to act out in disruptive behaviors.  According to a recent survey of more than 800 physicians conducted by the American College of Physician Executives 1:

  • More than 70% said that disruptive physician behavior occurs at least once a month at their organizations—and more than 10% said that such incidents occur on a daily basis.
  • More importantly, 77% of respondents said they were concerned about disruptive behavior at their organizations—and 99% believed that disruptive behavior ultimately affects patient care.

Nurses under stress are more apt to either suffer in silence—or engage in stealthy, passive-aggressive forms of disruptive behaviors that, while harder to detect than physician outbursts, can be equally damaging.

  • In a 2005 survey of more 1,700 nurses, physicians, clinical-care staff and administrators, more than half reported seeing their co-workers break rules, make mistakes, fail to support others, demonstrate incompetence, show poor teamwork, act disrespectfully or micromanage. 2

Most concerning—despite the risk to patients, less than 10% of physicians, nurses and other clinical staff directly confronted their colleagues about their concerns.

However, silence isn’t an option anymore.  Since 2008, when the Joint Commission issued Sentinel Event Alert #40 titled, “Behaviors that undermine a culture of safety,” healthcare organizations have became responsible for taking action when disruptive outbursts or workplace conflicts that put patient safety at risk.

Negative Side Effects of Unresolved Conflict

Conflict in and of itself isn’t bad—it often leads to new ideas, processes, improved communication and development of new skills.  Refusal to acknowledge and address conflict is where the trouble begins.

  • When a staff member sees a colleague berating another staff member and doesn’t step in, there can be an assumption that they condone their colleague’s behavior, even if that’s not the case.
  • One disruptive physician or nurse can make the workplace feel hostile.  Recruiting and retaining skilled staff often becomes more difficult—even if the majority of doctors and nurses are blameless.
  • Patients who sense conflict or witness disrespectful confrontations are apt to seek care from another source—at a time when HCAHPS scores are taking on increasing importance, and the healthcare environment is becoming more competitive.
  • Malpractice suits and insurance costs are typically higher for medical groups that refuse to confront disruptive behavior.

Given the demands on time that everyone experiences, at what point should an organization step in to address a workplace conflict?  In general, a conflict rises to the point where there should be an intervention when:

  • Patient safety or satisfaction is compromised
  • The conflict is affecting the morale or changing the attitudes of staff or colleagues
  • Staff members are changing behavior or rearranging their schedules because of the conflict
  • Employees not directly involved in the conflict are becoming caught up in it (the smaller the medical group or work group, the more likely this is to happen)
  • Significant amounts of time and energy are being devoted to dealing (or not dealing) with the conflict

Best Practices:  Productively Addressing Workplace Conflict

There are a variety of approaches all staff members can take to address workplace conflicts, including:

  • Speaking up immediately whenever unacceptable behavior is witnessed
  • Engaging in a private conversation where you point out what you’ve witnessed and express concern
  • Having a consultation with Human Resources or submitting a formal complaint
  • Pushing for guidelines around civil communications at the next staff meeting

For those who are uncomfortable dealing with conflict, are uncertain about which approach to take or don’t know how to begin a difficult conversation, there may be resources available to help.  For organizations with an Employee Assistance Program (EAP), that can be a good starting point.  Organizations can also provide training, mentors, or identify someone in the office or practice as a go-to resource and coach.

Conflict Resolution: A Case Study

A clinic that was part of a larger health system was experiencing increasing conflict between its physicians and nursing staff, and with concerns that the resulting breakdown in collaboration was having a negative impact on patient safety.

They brought in consultants who could help pinpoint the major issues and then devise strategies to address both the specific issues that were identified, and help the clinic staff communicate and work more productively with each other.

The clinic staff was invited to one of four 90-minute discovery sessions, ensuring that both doctors and nurses were represented in each group.  After completing a brief survey designed as both a basis for conversation and a benchmarking tool, the session then turned to brainstorming and dialogue around the following topics:

  • The most important thing for doctors to know about working well with nurses
  • The most important thing for nurses to know about working well with physicians
  • What was working well on the team
  • What areas could benefit from improvement
  • Current stressors

The small group sessions offered insight into the team’s perceptions of issues and potential solutions, and allowed participants to hear perspectives that differed from their own.

Regarding the most important things each group wanted the other to know, several thoughts emerged.  Nurses wanted the doctors to know:

  • They were working hard, although due to multiple work demands and patient flow, this might not always be visible.
  • They needed respectful communication, ranging from “don’t shoot the messenger” to more constructive criticism and input on working better together—and giving positive feedback, too.
  • They needed better cooperation in things ranging from improved work flow to helping to train and educate new staff.

The doctors, for their part, wanted nurses to know:

  • They tended to be more research- or process-driven, a result of being very conscientious about the possibility of litigation regarding patient care.
  • They wanted more proactive support, including anticipating patient needs and doing whatever was possible to keep them on schedule within the scope of the nurses’ jobs.
  • They made assumptions about nurses’ availability, lacking other ways of knowing what they were doing if not in the exam room.

While there were shared expectations and assumptions about a focus on patient care and safety, competence and high standards, areas for improvement included some work processes and, more centrally to the conflicts, better communication and also clarity on roles, especially with regard to the nursing staff.  Underlying it all was a perceived failure on the part of both the physicians and nurses to understand the scope of each other’s work, and stressors related to things which were largely outside of the clinic’s control.

The clinic moved ahead with several of recommendations, which included:

  • Developing a multi-disciplinary team focused on strengthening communication, building staff resiliency and increased efficiencies
  • Promoting the use of the EAP, including coaching and counseling to assist with stress management, conflict resolution and work/life balance
  • Developing more vehicles for communication, information exchange, relationship building, problem solving and team building, including:
    • Daily work team huddles to plan for the day ahead and/or debrief at the end of the day
    • One-on-one meetings between leaders and direct reports on at least a quarterly basis to manage individual issues and provide support
    • Quarterly all-staff meetings to discuss topics such as clinic issues, pending  health system initiatives, teamwork and communications, and opportunities for improved operational efficiencies
    • Opportunities for social time (e.g., lunch)

MacDonald, Owen, et al, Disruptive Physician Behavior, ACPE American College of Physician Executives / Quantia MD, May 15, 2011, accessed http://www.quantiamd.com/q-qcp/quantiamd_whitepaper_acpe_15may2011.pdf, April 1, 2012
2  Maxfield, David, Grenny, Joseph, Lavandero, Ramón and Groah, Linda, The Silent Treatment  Why Safety Tools and Checklists Aren’t Enough to Save Lives,  VitalSmarts, Association of periOperative Registered Nurses (AORN), & American Association of Critical Care Nurses (ACCN) 2010. http://www.silenttreatmentstudy.com/, accessed March 29, 2012.

Liz Ferron, MSW, LICSW, is Senior Consultant and Manager of Clinical Services and Matt Steinkamp, MSW, LICSW, is Vice President of Service Delivery at Workplace Behavioral Solutions, Inc. and its Midwest EAP Solutions and Physician Wellness Services divisions.

Leave a Comment

Please type the characters of this captcha image in the input box

Please type the characters of this captcha image in the input box