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Survey of Canadian critical care nurses' experiences of conflict in intensive care units.

In his landmark book about decision-making in health care, Katz (1984) identified that health is "an ambiguous state" about which people and their health care providers may have "conflicting expectations" (p. 98). Given the nature of patients' illnesses and the decisions required in an intensive care unit (ICU), it is not surprising that it is a place where disagreements about the plan of care can arise. Despite the fact that critical care nurses are an integral part of the team providing care to patients and families, relatively little is known about their experiences with conflict situations. Increasing our knowledge in this area will assist us to better understand conflict in the ICU and to identify strategies for preventing and/or dealing with it.

Background to the problem

To date, studies on conflict in ICUs, defined by researchers as disagreements over patient care, have focused on the rates, causes and types of conflict experienced. Reported rates of conflict have varied between 32% and 78% of patient situations in the presence of a prolonged length of stay in ICU (Studdert, Burns, et al., 2003; Studdert, Mello, et al., 2003) or discussions regarding withholding or withdrawing treatment (Abbott, Sago, Breen, Abernethy, & Tulsky, 2001; Breen, Abernethy, Abbott, & Tulsky, 2001). In a large multi-national survey (Azoulay et al., 2009), 72% of health care providers (n=7,358 in 24 countries) reported at least one perceived conflict in their last week of work in ICU. In that survey, Azoulay et al. (2009) defined conflict more broadly than other researchers, including interpersonal conflict in the definition, even if unrelated to patient care.

From these studies and research on both end-of-life care and families' experiences in ICU, it is known that conflict can arise for a number of reasons, including unclear, insufficient, or inconsistent communication, perceived inappropriate behaviours, unrealistic family expectations, inattention to patient wishes, differing perspectives regarding patient prognosis or goals of care, and/or family stress (Abbott et al., 2001; Azoulay et al., 2009; Breen et al., 2001; Danjoux Meth, Lawless, & Hawryluck, 2009; Kirchhoff et al., 2002; Nelson et al., 2006; Norton, Tilden, Tolle, Nelson, & Eggman, 2003; Studdert, Burns et al., 2003; Studdert, Mello et al., 2003). Conflict can lead to anxiety and distress for family members (Abbott et al., 2001; Kirchhoff et al., 2002), strained relations between family members and health care providers (Abbott et al., 2001; Breslin, MacRae, Bell, Singer, & the University of Toronto Joint Centre for Bioethics Clinical Ethics Group, 2005; Robichaux & Clark, 2006), strained team relations (Melia, 2001), and distress or burnout for health care providers (Danjoux Meth et al., 2009; Heland, 2006; Poncet et al., 2007; Workman, McKeever, Harvey, & Singer, 2003). Clearly, situations of conflict can create emotional burden for patients, families, and caregivers.

Study purpose and objectives

Given the rates of conflict reported in previous studies and the potential impact on all involved, and given nurses' proximity to patients (Malone, 2003), it would be useful to gain an understanding of the current situation for registered nurses working in ICUs in Canada. The purpose of this study was to enhance our understanding of Canadian critical care nurses' experiences of and responses to situations of conflict in the ICU. The research objectives were to: 1) identify the types, causes, and frequency of conflict experienced by critical care nurses in ICU settings; 2) identify the nursing interventions critical care nurses find most helpful in situations of conflict; 3) describe the knowledge and skills required by critical care nurses when working in situations of conflict; and 4) identify the resources critical care nurses find helpful in responding to situations of conflict. Objectives 1, 2, and 4 will be examined in this article.

Methods

Based on an extensive review of the literature, a questionnaire was developed for this descriptive study. The questionnaire was reviewed by a sample (N=11) of critical care nurses, advanced practice nurses, educators, and researchers with expertise in survey design to assess readability, relevance, and appropriateness of the questions, and then revised based on their feedback.

After obtaining research ethics board approval, the 35-item questionnaire was loaded on Survey Monkey[C], an online platform. The Canadian Association of Critical Care Nurses (CACCN) agreed to send out an email message on our behalf to members with an email contact address, inviting them to complete the questionnaire. Three additional reminder messages were sent out at one week intervals during the month of April 2010. Data were entered in the Statistical Package for the Social Science (SPSS 18) program and means, percentages, and scores were calculated as appropriate. Qualitative responses were analyzed using content analysis (Weber, 1990); categories were identified and responses were sorted into appropriate categories.

Results

At the time the survey was carried out, CACCN informed us that they had approximately 1,100 members, with email addresses for 990 people. A total of 325 nurses responded to at least a part of the survey, with 241 nurses completing the survey. Demographic data for these nurses can be found in Tables 1 and 2. Approximately 51% (122) of the nurses reported being involved in at least one situation of conflict, defined as a disagreement or dispute related to the management of a patient (Studdert, Mello, et al., 2003), in the last week worked; 26.1% (63) reported being involved in more than one conflict situation in that week. The most common types of conflict encountered by the nurses in their practice are found in Table 3, with disputes or disagreements between the team and family (46.5%) and within the team (35.3%) ranked highest.

The nurses identified factors associated with conflict through an optional open-ended question; 162 responses were provided. Conflict was reported to be associated with patients where end-of-life discussions had been initiated (n=13), with a prolonged length of stay (n=7), or facing a serious, sudden, and unexpected illness (n=5). Family factors included culture and religion (n=29), pre-existing family conflict (n=13), the absence of pre-admission family discussions about patient wishes (n=8), language barriers (n=6), and estranged family members (n=6). The most frequently reported team factors were the involvement of multiple physicians in a patient's care (n=13) or poor team-family communication (n=8).

Nurses were asked to describe the feelings they experienced when involved in a situation of conflict related to the management of a patient. The most common feeling described was frustration (n=108/209 responses), manifested across various scenarios and arising from the situation or the actions of the team, physician, or family, as illustrated in the examples below.

* I feel frustrated because arguments between team members sometimes extend over many hours or days and detract from the team's ability to make decisions about patient care in a timely manner. Arguments between team members detract from keeping the patient/family as the focus of care, and can hinder the patients clinical progress.

* Frustrating when dealing with poor decision-making on the part of the lead physician and, at times, morally distressing to witness the patient and family suffering when faced with an inevitable poor outcome while we sustain life and watch the patient deteriorate and decline.

* Frustration that feelings of the family of guilt or inability to adjust to the reality of what is happening skew their objectivity in decision-making leading to the patient not being the focus of the issues.

Other feelings reported included sadness (n=9), anger (n=8), or helplessness (n=6), while some nurses felt isolated or dismissed in the situation (n=6). Eleven nurses described feeling "caught in the middle" or "torn" between the patient and family, the family and the team, or between various members of the health care team.

The nurses were asked to identify the most helpful nursing interventions (exclusive of providing quality care to the patient) in situations of conflict involving the patient and/or family (Table 4) and the most helpful resources (exclusive of the bedside nurse) for patients and families when conflict arises (Table 5). Clear, consistent, and honest communication was ranked as the most important nursing intervention, followed by arranging for informal or formal family meetings with physicians in attendance. The top three ranked resources for patients and families in conflict situations were attending physicians, social workers, and charge nurses.

Questions were also asked regarding supports for the nurse in situations of conflict (Table 5) and access to and use of resources to assist with addressing conflict. The top three ranked sources of support for nurses were other general duty nurses, attending physicians, and charge nurses. The majority of nurses (80.9%) identified that they had access to an ethics committee, 64.3% had access to an ethics consultant or ethicist, and 22.4% had access to a mediator or mediation services. Approximately half of the respondents who had used each of these services expressed satisfaction with the consult/service; dissatisfaction was associated with, for example, time delays or the lack of clear guidance from the people involved.

Discussion

The results of this study provide a snapshot of the frequency with which a sample of critical care nurses from across Canada encountered conflict in their practice, the types of conflict encountered, factors perceived to be associated with conflict, and the resources used to support families and/or health care providers in situations of conflict. The relatively low response rate (24%) and the limitations of web-based surveys, particularly of an open survey and a non-random sample, need to be acknowledged (Couper, 2000). The mean age of respondents was similar to the national average for critical care nurses: 43 years in our sample and 41.7 years (N=19,096) nationally (Canadian Nurses Association [CNA], 2011). Our sample differed in terms of education, with 50.2% of our sample baccalaureate prepared and 14.1% having completed a graduate program, compared to 37.5% of critical care nurses in Canada reporting degree preparation and 1.7% reporting master's preparation (CNA, 2011).

Just over half of the nurses in this study (50.6%) reported experiencing at least one situation of conflict in their last week of work prior to completing the questionnaire. This is in keeping with previously reported rates of between 32% and 78% of patient situations (Abbott et al., 2001; Breen et al., 2001; Studdert, Burns et al., 2003; Studdert, Mello et al., 2003), but less than the rate of 72% reported in response to the same question in the Azoulay et al. (2009) study. It is important to note that Azoulay and colleagues used a broader conflict definition, included other health care providers (from 24 countries) in their sample, and did not provide the rate for Canadian respondents alone (Azoulay et al., 2009). As with previous studies (Abbott et al., 2001; Breen et al., 2001; Studdert, Burns et al., 2003; Studdert, Mello et al., 2003), the two most common types of conflict were team-family and within team disagreements.

The nurses' responses regarding helpful nursing interventions in conflict situations highlight the importance of nurse-family communication. Other researchers have identified that good communication is key in preventing and resolving conflict in ICU (Azoulay et al., 2009; Fassier & Azoulay, 2010; Hartwick & Jones, 2010). There are clear implications for education from these findings in terms of the inclusion of content related to effective communication in both undergraduate programs and courses designed for critical care nurses.

The frustration expressed by the nurses related to conflict situations is worrying. Robichaux and Clark (2006) identified that nurses (N=21) experienced "resignation and frustration" when faced with situations where they believed "continued aggressive medical interventions were not warranted" (p. 480). In our study, there were many sources of nurses' frustration (e.g., communication, decision-making processes, the perceived suffering of patients, families' plight, nurses' treatment as team members). Given the consequences of these feelings, more study is needed to enhance our understanding of nurses' frustration in the face of conflict.

Others have written about the in-between position of nurses and the "perils" of nurses' proximity to patients and families (Heland, 2006; Peter & Liaschenko, 2004; Varcoe et al., 2004). For many reasons, not least of which is the potential for conflict situations to become emotionally charged (Breslin et al., 2005), access to resources is essential for families, nurses, and the team. Previous studies have reported that conflict is a trigger for ethics consultations (Aleksandrova, 2008; DuVal, Sartorius, Clarridge, Gensler, & Danis, 2001). More work is needed to understand how resources like ethics committees, ethicists, and mediators are used by nurses and the results of such consultations. The support of nursing colleagues and physicians emerged as important to the nurses in this study. This was also true in our previous work (Edwards, Throndson, & Dyck, 2009) and highlights the value of working together as a team.

In conclusion, conflict is a known concern in ICUs. The results of this study add to our understanding of Canadian critical care nurses' conflict experiences and illustrate the frequency with which conflict arises in practice. More research is needed in this area in order to assist nurses and other health care providers to prevent conflict or address it when it does arise.

Acknowledgements

Thanks to CACCN, the critical care nurses who responded to the survey, and the University of Manitoba University Research Grants Program for funding the study.

REFERENCES

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Edwards, M., Throndson, K., & Dyck, F. (2009). Conflict in the intensive care unit: The roles of critical care nurses [Abstract]. Dynamics, 20(2), 27-28.

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About the authors

Address for correspondence: Marie Edwards, PhD, RN, Assistant Professor, Faculty of Nursing, University of Manitoba, 381 Helen Glass Centre for Nursing, University of Manitoba, Winnipeg, MB R3T2N2. Phone: 204-474-8218; Email: marie_edwards@umanitoba.ca

Karen Throndson, MN, RN, Clinical Nurse Specialist, Cardiac Sciences Program, Health Sciences Centre, Winnipeg, MB. kthrondson@exchange.hsc.mb.ca

Julie Girardin, BN, RN, Children's Hospital, Health Sciences Centre, Winnipeg, MB. juliegirardin1@gmail.com

Edwards, M., Throndson, K., & Girardin, J. (2012). Survey of Canadian critical care nurses' experiences of conflict in intensive care units. Dynamics, 23(3), 15-19.

Marie Edwards, PhD, RN, Karen Throndson, MN, RN, and Julie Girardin, BN, RN
Table 1: Demographics (n=241 nurses)

Characteristic n (%)

Age (mean 43 years)

0-29 years 22 9.1
30-39 years 52 21.6
40-49 years 86 35.7
50+ years 56 23.2
Missing 25 10.4

Gender

Female 215 89.2
Male 13 5.4
Missing 13 5.4

Province/Territory

Quebec and Ontario 129 53.5
Western provinces (MB, SK, AB, BC) 86 35.7
Maritimes & Newfoundland/Labrador 15 6.2
Missing 11 4.6

Current position

Direct care provider 160 66.4
Manager/administrative role 22 9.1
Educator 21 8.7
Clinical resource nurse or charge nurse 16 6.6
Clinical nurse specialist or nurse practitioner 11 4.6
Multiple Roles and Other 11 4.6

Total years of nursing experience

Less than 1 year 2 0.83
1-5 years 27 11.2
6-10 years 36 15.0
11-15 years 29 12.0
16-20 years 27 11.2
More than 20 years 118 49.0
Missing 2 0.83

Total years of critical care experience

Less than 1 year 2 0.83
1-5 years 53 22.0
6-10 years 45 18.7
11-15 years 32 13.3
16-20 years 35 14.5
More than 20 years 73 30.3
Missing 1 0.4

Education

Diploma 72 29.9
Baccalaureate degree 121 50.2
Graduate degree 34 14.1
Missing 14 5.8

Table 2: Work settings of nurses (n=241)

Characteristic n (%)

Place of employment

Tertiary care hospital (university affiliated) 123 51.0
Tertiary care hospital (non-university affiliated) 39 16.2
Community hospital 63 26.1
Rural hospital 4 1.7
Multiple facilities 8 3.3
Missing 4 1.7

Type of ICU

Medical/surgical ICU 160 66.4
Pediatric or neonatal 27 11.2
Medical ICU 14 5.8
Surgical ICU 11 4.6
Cardiac ICU 10 4.1
Other Mixed ICU 10 4.1
No specific unit (work in critical care float pool) 3 1.3
Multiple units 2 0.8
Other 4 1.7

Usual shift duration

8 hours 44 18.3
10 hours 7 2.9
12 hours 171 71.0
Mix of 8 and 12 hours 16 6.6
Missing 3 1.2

Daily rounds in unit

Yes 218 90.5
No 18 7.5
Missing 5 2.0

Table 3: Nurses' perceptions of most
common types of conflict (n=241)

Type of conflict n (%)

Dispute or disagreement between the team 112 46.5
and the family

Dispute or disagreement within the team 85 35.3

Dispute or disagreement between family 30 12.4
members (other than the patient)

I have no experience with conflict 4 1.7

Dispute or disagreement between the team 3 1.2
and the patient

Dispute or disagreement between the patient 3 1.2
and family

Missing 4 1.7

Table 4: Most helpful nursing interventions
in situations of conflict

Nursing intervention (n=228) Total
 score

Providing clear, consistent, and honest information 538
to patient/family

Arranging for the physician to meet with the patient/ 294
family at the bedside to answer questions

Arranging a formal family conference 220

Ensuring that other health care team members 151
receive information about the patient's or family's
wishes or concerns when known

Referring patient/family to other resources (e.g., 143
patient advocate, social work, pastoral care)

Other 10

* Participants were instructed to select the most helpful, second
most helpful and third most helpful nursing interventions
(exclusive of providing quality care to the patient). Interventions
selected as most helpful, second most helpful, and third most
helpful were assigned 3 points, 2 points, and 1 point respectively.
Interventions not selected by respondents were given no points.
All points were summed to determine the total score for each
nursing intervention. Interventions in Table 4 appear ranked
from highest to lowest scored.

Table 5: Nurses' perceptions regarding most helpful resources
in conflict situations

For patients/families (n=226)

Resource (excluding staff nurse) Score

Attending physicians 379
Social workers 373
Charge nurses 158
Pastoral/spiritual care providers 115
Manager of the ICU 110
Clinical resource nurses 55
Other 50
Advanced practice nurses 45
Patient advocates 39
Residents 23
Psychiatry/liaison nurses 21

For nurses (n=220)

Resource Score

Other staff nurses 253
Attending physicians 246
Charge nurses 246
Social workers 177
Manager of the ICU 147
Clinical resource nurses 89
Advanced practice nurses 38
Pastoral/spiritual care providers 37
Educators 35
Residents 26
Other 26
Psychiatry/liaison nurses 11

* Participants were instructed to select the most helpful, second
most helpful and third most helpful resources. Resources selected
as most helpful, second most helpful, and third most helpful were
assigned 3 points, 2 points, and 1 point respectively. Resources
not selected by respondents were given no points. All points were
summed to determine the total score for each resource. Resources
in Table 5 appear ranked from highest to lowest scored.
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Author:Edwards, Marie; Throndson, Karen; Girardin, Julie
Publication:Dynamics
Date:Sep 22, 2012
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