JOURNAL OF INTERPROFESSIONAL CARE
2020, VOL. 34, NO. 2, 259–268
https://doi.org/10.1080/13561820.2019.1639645
ORIGINAL ARTICLE
Intra versus interprofessional conflicts: implications for conflict management
training
Nadia M. Bajwa a, Naïke Bochatay b, Virginie Muller-Juge c, Stéphane Cullati d, Katherine S. Blondon
Noëlle Junod Perron f, Fabienne Maîtreg, Pierre Chopardh, Nu V. Vui, Sara Kimj, Georges L. Savoldellik,
Patricia Hudelsonl, and Mathieu R. Nendaz m
e
,
a
Department of General Pediatrics at the Children’s Hospital, University Hospitals of Geneva, Unit of Development and Research in Medical
Education (UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland; bUnit of Development and Research in Medical Education
(UDREM), Faculty of Medicine, Institute of Sociological Research, University of Geneva, Geneva, Switzerland; cUnit of Primary Care (UIGP), Faculty of
Medicine, University of Geneva, Geneva, Switzerland; dQuality of Care Unit, Medical Directorate, University Hospitals of Geneva, Institute of
Sociological Research, University of Geneva, Geneva, Switzerland; eMedical Directorate, University Hospitals of Geneva, Geneva, Switzerland;
f
Institute of Primary Care, University Hospitals of Geneva, and faculty member at the Unit of Development and Research in Medical Education
(UDREM), Faculty of Medicine, University of Geneva, Geneva, Switzerland; gDivision of General Internal Medicine, University Hospitals of Geneva,
Geneva, Switzerland; hQuality of Care Unit, Medical Directorate, University Hospitals of Geneva, Geneva, Switzerland; iFaculty of Medicine,
University of Geneva, Geneva, Switzerland; jDepartment of Surgery at the School of Medicine, University of Washington, Seattle, Washington, USA;
k
Division of Anesthesiology at the University Hospitals of Geneva and in the Unit of Development and Research in Medical Education (UDREM),
Faculty of Medicine, University of Geneva, Geneva, Switzerland; lDepartment of Community Medicine, Primary Care and Emergency Medicine,
University Hospitals of Geneva, Geneva, Switzerland; mUnit of Development and Research in Medical Education (UDREM), Faculty of Medicine,
University of Geneva, and Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland
ABSTRACT
ARTICLE HISTORY
Interprofessional collaboration and conflict management training are necessary in health sciences curricula.
Characteristics of conflicts occurring within intraprofessional or between interprofessional teams can vary
and are poorly understood. We sought to compare and contrast characteristics of intra- versus interprofessional conflicts to inform future training programs. An exploratory study was conducted through semistructured interviews with 82 healthcare professionals working in a tertiary hospital. Interviews focused on
sources, consequences, and responses to conflicts. Conflict situations were analyzed with conventional
content analysis. Participants shared more intra- than interprofessional situations. Intraprofessional conflicts
were caused by poor relationships, whereas interprofessional conflicts were associated with patient-related
tasks and social representations. Avoiding and forcing were the most commonly mentioned responses to
intraprofessional conflicts. The theme of power impacted all aspects of conflict both intra- and interprofessional. Intraprofessional conflicts were found to be as important as interprofessional conflicts. Differences in
the sources of conflict and similarities regarding consequences of and responses to conflicts support
integration of authentic clinical situations in interprofessional training. Understanding similarities and
differences between intra- and interprofessional conflicts may help educators develop conflict management
training that addresses the sources, consequences, and responses to conflicts in clinical settings.
Received 30 October 2018
Revised 25 June 2019
Accepted 28 June 2019
Introduction
Effective interprofessional collaboration has been described as the
foundation for delivering safe, high quality patient care in the
health care setting. The practice of interprofessional collaboration
is has been defined as “the process by which different health and
social care professional groups working together to positively
impact care” (Reeves, Pelone, Harrison, Goldman, &
Zwarenstein, 2017) and leads to demonstrated improvement of
patient outcomes in several patient care settings (Baggs & Schmitt,
1997; Liberati et al., 2019; Martin, Ummenhofer, Manser, & Spirig,
2010; Reeves et al., 2017; Szafran, Kennett, Bell, & Green, 2018).
While interactions of healthcare professionals include cooperation
and a shared commitment to patient care, the need for constant
communication and negotiation can undoubtedly lead to conflict
in the form of minor disagreements to major disputes (D’Amour,
KEYWORDS
Intraprofessional;
interprofessional; conflict;
interprofessional
collaboration; power; postgraduate training
Ferrada-Videla, San Martin Rodriguez, & Beaulieu, 2005). Poorly
understood roles and responsibilities, power differentials, and
a lack of conflict management skills can all create an environment
where conflicts among team members may flourish (Bochatay
et al., 2017a).
Conflicts between healthcare providers can directly lead to
medical errors. In the United States, the Joint Commission
reported that, between 2004 and 2014, human factors, leadership,
and communication difficulties were the main reasons for root
causes of sentinel events (The Joint Commission, 2015).
Unresolved conflicts can also result in devastating consequences
for healthcare professionals in the form of decreased job satisfaction and increased turnover (Read & Laschinger, 2013; Strachota,
Normandin, O’Brien, Clary, & Krukow, 2003). Residents undergoing post-graduate medical training are especially vulnerable to
CONTACT Nadia M. Bajwa
Nadia.Bajwa@hcuge.ch
Département de l’enfant et de l’adolescent, Rue Willy-Donzé 6, 1211 Genève 14, Switzerland
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ijic.
© 2019 Taylor & Francis Group, LLC
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N. M. BAJWA ET AL.
such conflicts, validating efforts to implement conflict management training in curricula (Baldwin & Daugherty, 2008) .
Understanding the relationships between healthcare professionals is complex as each profession has been socialized to
adopt distinct professional identities that are based upon the
theoretical role of their profession and on supervisors’ rolemodeling (Weller, Boyd, & Cumin, 2014; Yardley, Teunissen,
& Dornan, 2012). The necessity to collaborate requires a shift in
understanding that allows for professionals to favor partnership
over competition, to accept a certain level of interdependence
and role fluidity, to integrate the expertise of others into patient
care plans, and to communicate their opinions in a participative
manner (Bochatay et al., 2017b; D’Amour, Sicotte, & Lévy, 1999;
Muller-Juge et al., 2014). Such changes challenge the importance
placed upon individual competence. In complex patient care
situations the ability to optimize the contributions of multiple
healthcare team members requires “role fluidity” and “collective
competence” (Lingard, 2016).
Difficulties and breakdowns in communication can also
occur within a profession. Until now, much of the focus in
the health professions literature has been on interprofessional
conflict and little is known about conflicts that may occur
within intraprofessional groups. We define intraprofessional
conflict as a difficult interaction between colleagues of the
same professional group, e.g., physician to physician or
nurse to nurse (Almost, 2006; Zwarenstein, Rice, GotlibConn, Kenaszchuk, & Reeves, 2013); representing incompatibilities or differences among group members with sources of
conflict being described as related to relationships, tasks, or
processes(De Wit, Greer, & Jehn, 2012) . Intraprofessional
conflicts may be triggered by a power differential when individuals in a professional group have more power than others
(Janss, Rispens, Segers, & Jehn, 2012). For example, studies
have shown that trainees in medical residency fail to speak up
when they recognize an error made by a supervisor for fear
that their action might negatively impact their career (Bould,
Sutherland, Sydor, Naik, & Friedman, 2015; Friedman et al.,
2015). The imbalance of power may also limit help-seeking
behaviors and lead to competition between team members
seeking to gain power (Janss et al., 2012).
Currently, interprofessional collaboration is frequently
learned in an idealized context that may ignore the realities of
the clinical working environment. Curricula do not adequately
address the suboptimal practices that have become the norm and
the competing demands on learners’ time that can hinder collaboration (Bainbridge & Regehr, 2015) . Residents may be challenged to implement the collaborative practices learned in
training when they are confronted with a dysfunctional work
culture, for example, when due to a lack of resources a new
colleague does not receive adequate orientation. Addressing
these complexities in interprofessional education may allow for
conflict management training to be more relevant to actual
practice.
Interventions in the literature to improve interprofessional
collaboration are still limited in evidence; there is a growing
need to better understand the underpinnings of conflict that
may occur both between and within professions to better
adapt future training interventions(Reeves et al., 2017). Our
previous study demonstrated the relationship between the
sources, consequences and responses to conflict (Bochatay
et al., 2017a). Conflict was found to be a cyclical phenomenon
with sources, consequences, and responses occurring at individual, interpersonal, and organizational levels with supervisors having an overarching role in each aspect of conflict.
However, this framework does not account for differences
between intraprofessional and interprofessional conflicts. In
this study, we sought to compare and contrast characteristics
of intra- versus interprofessional conflicts in the clinical setting, so as to inform our conceptual framework and future
conflict management training programs.
Methods
Research design
We conducted an exploratory and cross-sectional qualitative study
using semi-structured interviews, in accordance with the
Standards for Reporting Qualitative Research (O’Brien, Harris,
Beckman, Reed, & Cook, 2014), involving healthcare professionals
working in four departments of a 1,700-bed Swiss teaching hospital: internal medicine, family medicine, pediatrics, and surgery,
representing specialties with different levels of acuity, both inpatient and outpatient. To develop a deeper understanding of
professional conflict, we interviewed different professional groups:
medical residents (physicians completing post-graduate training),
fellows (physicians completing subspecialty training after board
certification), certified nursing assistants (professionals that assist
patients with activities of daily living under the supervision of
a nurse), nurses (licensed professionals that provide care for
patients in both the hospital and ambulatory settings), and nurse
managers (licensed professionals that manage and supervise teams
of nurses in both the hospital and ambulatory settings). We
selected these professional groups because they are the main
groups involved in first-line patient care in the Swiss context.
Other groups involved in patient care include attending physicians
(physicians that supervise the healthcare team), physiotherapists,
social workers, and dieticians. Concerning attending physicians,
we did not include them in our study for two reasons: 1) There
were not enough individuals in each department to ensure the
confidentiality of the responses, and 2) The attending physician
usually provides only indirect supervision and is considered
a secondary resource in our context. This study was part of
a larger study conducted to examine the characteristics of conflict
at our institution (Bochatay et al., 2017a). Our study was inductive
and informed by the literature on organizational conflicts (De Wit
et al., 2012; Greer, Saygi, Aaldering, & de Dreu, 2012).
Data collection
Given the sensitive nature of our research topic, we paid particular
attention to researchers’ relationships with participants. Four
social scientists with experience in qualitative methods (NBo,
VMJ, PH, SC) and who did not have departmental associations
with participants conducted the interviews, to ensure that participants felt more at ease to speak about difficulties with coworkers. Department heads provided us with lists of potential
participants (all fellows, residents, and nursing professionals
working in the four departments included in our study) that we
JOURNAL OF INTERPROFESSIONAL CARE
transferred into Excel. We randomly selected participants using
an Excel formula (= RAND()) to ensure equal representation of
professional groups (approximately 10 individuals of each group
from each department). Three interviewers (NBo, VMJ, and SC)
telephoned or emailed selected participants to invite them to
participate. Participants had the option to decline the invitation.
We conducted the interviews between the fall of 2014 and early
2016. We adapted the interview guide from Kim and colleagues’
study (Kim et al., 2016) and piloted the French version of the
guide with professionals working in our study departments but
who did not participate in the study. We made minor adjustments
to clarify the questions. During the interviews, we prompted
participants to describe a conflict (we also used the words difficult
interaction, tension, frustration) with coworkers that they had
experienced or witnessed. Follow-up questions aimed to explore
what participants perceived to be the sources, consequences, and
responses to conflicts, as well as how participants had felt. Our
questions were broad to ensure that participants would share any
situation that they had viewed as a conflict (Bochatay et al., 2017a).
All interviews were audio-taped and transcribed verbatim. Two of
the interviewers (NBo, VMJ) de-identified and assigned identification numbers for all transcripts prior to the analysis.
For each conflict situation that was reported, we coded whether
they occurred within one professional group (intraprofessional),
or between professional groups (interprofessional). Conflict characteristics included sources, consequences, and responses to conflicts that were first identified through conventional content
analysis (Hsieh & Shannon, 2005). Conflict sources were derived
from the De Wit and Greer classification (De Wit et al., 2012)
identifying sources as relationships, patient-related tasks, other
tasks, team processes, structural processes, and social representations. Conflicts caused by poor relationships were due to individual characteristics and interpersonal differences. Patient-related
tasks refer to disagreements between professionals on how to care
for patients, or which treatment to administer. Team processes
represent communication and coordination issues. Structural
processes refer to conflicts that arose because of resource allocation, professional roles and responsibilities, and disagreements
over vacation time and shifts. Finally, social representations refer
to general viewpoints of a group to which one does not belong.
Consequences of conflict were characterized as having an
impact on the individual (personal, professional), interpersonal (team), organizational (work organization, clinical environment), or patient care levels (Bochatay et al., 2017a).
Responses to conflict were characterized as problem solving
(collaborating to find a solution that is satisfactory to all
parties), forcing (seeking to impose one’s opinion), avoiding
(pretending that a conflict does not exist), and yielding (surrendering to the other’s point of view) (Greer et al., 2012).
Data analysis
Each shared conflict story was summarized to include the main
protagonists, their characteristics (gender, professional group and
status, specialty), the sources, consequences, and responses to
conflicts. To enable a comparison between conflict stories, we
then analyzed our data using conventional content analysis
(Hsieh & Shannon, 2005). This step enabled us to gain a broad
understanding of the patterns, similarities, and differences
261
between intra- and interprofessional conflicts and guided the
organization of categories and subcategories that we (NBa, NBo,
MN) used to understand these patterns (Hsieh & Shannon, 2005).
Each author read six interviews leading up to the discussion of
major themes used to develop an initial list of codes. Based on this
list, a sample of 15 interviews were coded in an iterative fashion to
ensure the relevance and applicability of the codes. Codes were
then classified into three major categories: sources of conflict,
consequences of conflict, and responses to conflict. All data were
coded (NBo) using ATLAS.ti software 7.5 (ATLAS.ti Scientific
Software Development GmbH, Berlin, Germany). Authors met
regularly to review the results and to identify additional directions
of analysis. For this article, we analyzed differences between intraand interprofessional conflicts using descriptive statistics that are
reported in frequency percentages, means, and medians.
Representative quotes were selected from our interviews
and translated from French into English. Two authors who
are native English speakers (NB, a pediatrician, and PH
a medical anthropologist) translated the quotes into English.
The research team then performed back translations to ensure
the content and conceptual equivalence of the translation
(Helmich, Cristancho, Diachun, & Lingard, 2017).
Ethical considerations
This study was exempted from a full review from the local
Institutional Review Board. The chairs of the departments represented in the study also approved the project. Interviewers
explained the research project to participants at the beginning of
each interview and provided them with a written summary of the
study and consent form which participants were asked to sign.
Participants could ask to read transcripts from their interviews,
have information removed if they wanted to, or withdraw from
the study altogether.
Findings
A total of 170 individuals were contacted by the research group to
participate in the study. Ultimately, semi-structured interviews
were conducted with 82 participants (43 physicians and 39
nurses). Reasons for refusal to participate in the study included:
participants lack of time, lack of interest in the study, or researchers’ inability to reach the individual after three attempts by email.
The characteristics of participants are displayed in Table 1.
Interviews lasted on average 38 minutes with a range of 23 to
69 minutes. Participants shared 130 situations involving conflicts,
of which 57% (74/130) of conflict situations were intraprofessional
and 43% (56/130) of conflict situations were interprofessional. For
intraprofessional conflicts, 42% (31/74) of stories involved protagonists at the same level of hierarchy, and 58% (43/74) of stories
involved protagonists at different levels of hierarchy. Most of the
conflict situations that participants reported involved physicians
and nursing professionals, with only a few mentions of other
professionals (e.g., two conflicts with midwives, one with
a secretary), which reflects team dynamics in the Swiss context.
Sources of conflict
Sources of conflict were coded for both intra- and interprofessional situations; see Figure 1(a). Poor relationships triggered
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N. M. BAJWA ET AL.
Table 1. Participant Characteristics (Bochatay et al., 2017a).
Age (mean; range)
Male:Female
Department
Internal Medicine
Family Medicine
Pediatrics
Surgery
Years of clinical experience (median; range)
Training in Switzerland, n (%)
Nurse Supervisors
(n = 6)
49 (39; 58)
1:5
Nurses
(n = 27)
46 (29; 61)
10:17
Nursing Assistants
(n = 6)
51 (43; 62)
0:6
Fellows
(n = 21)
36 (32; 44)
11:10
Residents
(n = 22)
34 (29; 45)
10:12
Total
(n = 82)
41 (29; 62)
32:50
2
2
2
27 (16; 35)
1 (17)
6
8
7
6
18 (4; 35)
7 (26)
2
2
2
19 (15; 34)
2 (33)
4
4
5
8
9 (4.5; 19)
14 (67)
6
6
5
5
5 (1; 18)
12 (55)
20
20
21
21
11 (1; 35)
36 (44)
more intra- than interprofessional conflicts (62% vs 41% of
sources of conflict). Intraprofessional conflicts related to poor
relationships occurred within groups of nurses as well as within
physician groups as demonstrated by these quotes:
A nurse in the group had the reputation of being a pathological liar, it’s
what they would call her. She is a woman who tells a lot of stories, that’s
true. In fact, the team started to doubt her a little bit and started
verifying everything that she said. They started talking about her behind
her back a lot. On top of that, it was a period where she wasn’t doing
very well. Anyways, I had to call the team together for an emergency
meeting just to tell them “look, stop with all of this, whatever is going on
you are not reacting appropriately.”
-P73, Pediatrics nurse supervisor
The attending is from the South, in the largest sense of the word (laughs).
So, sometimes he can overreact. There is this resident who started
working on the service and who would always be stressed out because
of this attending. At every interaction, every time the two of them were
together, the stress rose, and in the end the resident ended up leaving the
service.
-P39, Surgery fellow
On the contrary, disagreements on patient-related tasks
generated more interprofessional than intraprofessional conflicts (48% vs 27% of sources of conflict). As related in this
conflict between a pediatric resident and a nurse:
So, I just came back to reexamine the child and I thought he was
going downhill. So I said, “OK, let’s give him another aerosol of
adrenaline.” And I will always remember, it was 3:15 in the afternoon, the nurse tells me, “No, I am refusing your order, for me, the
patient is doing just fine. By the way, I already OK’d it with your
attending.” She had already gone directly to my boss to say that she
wasn’t in agreement with me without even telling me first. Even
though it was my patient.
-P19, Pediatric resident
Conflicts related to social representations also occurred
more frequently in interprofessional situations (27% vs 3%
of sources of conflict). The lack of recognition of the professional identity of other groups can provoke conflict:
We nurses have a very long history going all the way back to Catholic
nuns, and later came our role in serving physicians, and all of that, it’s
a significant history. We are well trained; so, we want our professional
identity recognized. And it is from there that the conflict comes into play.
It’s because we are not recognized by this team of physicians. You could
say that they don’t delegate us certain tasks because we are not deserving.
-P14, Family medicine nurse supervisor
Both interprofessional and intraprofessional conflicts could
result from conflicts over structural processes:
This year there were 131 days where our unit surpassed the maximum number of patients allowed. For example, we have 21 beds,
but this weekend we had 26 patients. There were definitely adverse
consequences linked with this overflow of patients. In general, we
don’t work well under such difficult conditions.
-P79, Pediatric fellow
More than half (58%) of intraprofessional conflicts included
protagonists at different levels of hierarchy. The influence of power
differentials played a major role in many conflict stories by being
the source of the conflict, by having an impact on the consequences, and by determining the response to the conflict. The
influence of power is highlighted in this story told by a nurse
anesthetist in surgery about his supervisor with whom he entered
into a conflict about how to prepare the equipment for an operation:
“OK, maybe I don’t have as much experience as she does, but I thought
she was abusing her power. She was like a little, yappy dog that would
just bark at me to scare me. I should have just let her keep barking.”
-p43, Surgery nurse anesthetist
Consequences of conflict
We did not find differences between intra- and interprofessional
conflicts for some consequences such as work organization.
However, intraprofessional conflicts tended to have more influence on individuals’ professional mobility, compared to interprofessional situations (20% vs 9% of consequences of conflict);
see Figure 1(b). The following quote highlights the impact that
conflict may have on staff turnover; in the following example
a family medicine resident recalled a conflict with his supervisor
about his evaluation and had asked for a mediation session:
This mediation session was so futile. Afterwards, I just left that
meeting and started to look at other job options … I absolutely have
to find another way, other opportunities.
-P6, Family medicine resident
Intraprofessional conflicts were also more likely to have an
impact at the personal level than interprofessional conflicts (74%
vs. 61% of consequences of conflict). Many participants related
feelings of emotional distress or burnout as shown in this quote by
JOURNAL OF INTERPROFESSIONAL CARE
80
263
a. Intra - and interprofessional sources of conflict
70
Percent
60
Intraprofessional
conflicts
Interprofessional
conflicts
50
40
30
20
10
0
80
b. Intra - and interprofessional consequences of conflict
70
Percent
60
50
40
Intraprofessional conflicts
30
Interprofessional conflicts
20
10
0
Personal
80
Professional
Team
Work organization
Patients
c. Intra - and interprofessional responses to conflict
70
Percent
60
50
40
Intraprofessional conflicts
30
Interprofessional conflicts
20
10
0
Forcing
Yielding
Avoiding
Problem solving
Figure 1. Intraprofessional (N = 74) versus interprofessional (N = 56) percent frequencies of conflict sources, consequences, and responses.
a resident in internal medicine after the death of a patient where
the resident felt that there was a lack of supervision:
In this situation, to be honest, I was completely devastated during
a very long time. During a very, very, long time. I was debriefed by
many of my supervisors, and I really needed it because, sincerely, I was
really affected by the situation. I wasn’t at the breaking point because
I’m more resistant than that, but I was in a really bad place.
-P57, Internal medicine resident
Interprofessional conflict situations were more likely to
affect patient care (48% vs 36.5% of consequences of conflict).
These conflicts notably led to treatment delays or to professionals’ disagreeing in front of patients and their relatives:
The ICU stuck to their position and did not admit our patient. So,
we did our best with antibiotics and everything, but we told the
family that there was no guarantee that it would go well. And that’s
what ended up happening: 24 hours later, the patient passed away.
-P3, Internal medicine fellow
Responses to conflict
Individuals involved in intraprofessional conflicts tended
more towards actively avoiding management of conflicts
than those involved in interprofessional conflict situations
(47% vs. 30% of responses to conflict); see Figure 1(c). The
avoiding mechanism of dealing with conflict is highlighted in
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N. M. BAJWA ET AL.
the following quotation told by a resident in pediatrics who
didn’t feel comfortable telling her supervisor that she felt
overwhelmed by administrative work:
There’s a lot of paperwork to do, and it can get really frustrating.
But we can’t tell our supervisor: “Look, I’m not your secretary!”
That’s impossible, so we end up doing all the paperwork, which
means that we have less time to spend with patients and less time to
learn about new cases.
-P72, Pediatrics resident
In intraprofessional conflicts, forcing was also used more
frequently as a response to conflict (50% vs 36%) for example,
when an anesthesiology fellow disagreed with his/her supervisor on the patient’s treatment plan:
Anyways, I said what she didn’t want to hear because she doesn’t
know the patient and her argument wasn’t true. I thought that my
choice was the right one. She ended up getting really angry, and
said “Do what I say, and that’s the way it is, you are going to do
exactly what I say.”
-P26, Anesthesiology fellow
Discussion
This study compares and contrasts the differences between
intra- and interprofessional conflicts in order to identify the
salient features of sources, consequences, and responses to
conflicts to inform future training efforts. It identifies two
main areas where conflicts differ. While intraprofessional
conflicts are more likely to be related to relationship difficulties, interprofessional conflicts tend to focus more on patient
care issues and social representations. The majority of conflicts in our study represented intraprofessional conflicts (57%
vs 43% of conflict stories). Intraprofessional conflicts were
more likely to arise from poor interpersonal relationships
and in turn more likely to result in both personal and professional consequences. Factors that may contribute to poor
interpersonal relationships include busyness, poor or inappropriate communication, or underlying resentment from
past unresolved conflict (Duddle & Boughton, 2007). The
predominance of intraprofessional conflict in our study
demonstrates that this category of conflicts is as important
as interprofessional conflicts and should not be neglected in
conflict management training. Conflict management training
would be able to address the communication aspects of poor
interpersonal relationships, but it would also be necessary to
familiarize participants with institutional conflict mediation
resources and to provide individual support when necessary.
Notably, 58% of intraprofessional conflicts in our study
involved protagonists at different levels of hierarchy. This
power differential manifested itself in conflicts between individuals with lower statuses (e.g., residents, nurses) and individuals
with higher statuses (e.g., attending physicians, nurse supervisors). It prevented individuals with lower statuses from discussing their difficulties with their hierarchy. Although the interplay
of power and conflicts is rarely discussed in the medical education literature (Paradis & Whitehead, 2015), acknowledging it in
training may lead those with more power to create
a psychologically safe environment to allow for speaking up
and lead those with less power to feel safer in doing so
(Appelbaum, Dow, Mazmanian, Jundt, & Appelbaum, 2016).
Physicians have been shown to be less aware of the power that
they influence in the team (Lingard et al., 2012). Training physicians to use simple gestures such as using first-names during
communications may help break down the power differential
(Lingard et al., 2012). Physicians also need to be trained to
acknowledge the expertise of other team members as described
in the construct of “shared leadership” where power is distributed based on the expertise required for the specific situation
and not solely based on hierarchy (Freeth & Reeves, 2004;
Lingard et al., 2012).
Interprofessional conflicts were more likely to arise from
patient-care related tasks. Task-related conflict may not
always be perceived as negative if group decision making
results in innovative ideas to deal with the problem. Conflict
in this case may prevent premature consensus and stimulate
critical thinking (De Wit et al., 2012) This phenomenon
reflects the concepts of convergence and divergence, which
refer to team members’ shared understanding of patient needs
and plan for patient care, or lack thereof (Lingard et al., 2017).
Research has shown that collective competence in health care
team may be achieved both through team members having
a shared mental model of the task at hand defined as convergence and when team members have conflicting views defined
as divergence (Lingard et al., 2017). To enable teams to reach
competence through divergence teams need to be trained with
authentic clinical conflict situations and given concrete strategies for managing conflict in a constructive manner.
Familiarizing teams with these concepts in conflict management training may allow for teams to optimize their communication and to recognize when differing points of view may
be beneficial to the team.
The similarities between intra- and interprofessional conflicts
with regard to consequences of and responses to conflicts support
the importance of developing interprofessional conflict management training that address both intra- and interprofessional differences in conflicts. Creating resources and support for
professionals dealing with conflict may lessen the burden of the
conflict and promote proactive conflict management. While it is
encouraging that professionals involved in interprofessional conflicts used problem solving more, this type of response should be
favored in intra-professional situations as well. The other
approaches such as yielding, forcing, and avoiding may set the
stage for future conflicts and result in weakened team morale. The
latter responses can result in alliances and behaviors that lead to
mobbing and negatively impact team cohesion (Richardson,
1995). Poor conflict management perpetuates a vicious cycle
that can lead to further conflict escalation, inefficient workflows,
and a poor work climate. The ultimate decrease in staff morale has
been shown to negatively affect patient satisfaction and patient
outcomes (Vahey, Aiken, Sloane, Clarke, & Vargas, 2004), while
effective conflict resolution training favors patient safety,
improved quality of care, and professional self-efficacy in conflict
management (Sexton & Orchard, 2016).
The sources, consequences, and responses to conflicts have
varying degrees of impact depending on whether the conflict
is intraprofessional or interprofessional. We have adapted our
JOURNAL OF INTERPROFESSIONAL CARE
initial conceptual framework based on the results of this study
to highlight these differences; see Figure 2. Notably, the element of power has been added as an influence on conflict
sources. This is based upon our observation that power differentials in both intra and interprofessional conflicts created
sources of conflict, could have an impact on the resulting
consequences, and ultimately mediated the choice of response
in dealing with the conflict.
Our results bring forward the differences between intra and
interprofessional conflict that may have an impact on the way that
conflict management training is constructed. The aspects of training that we have mentioned should also be combined with factors
favoring interprofessional collaboration including addressing fundamental differences between the professions, addressing conflicting agendas, acknowledging resource difficulties, giving extra
attention to complex communication demands, and regular evaluation of the quality of the collaboration (Freeth, 2001). Efforts to
sustain interprofessional collaboration may profit from the promotion of a team identity that can lead to the perception of
collective ownership (Lingard, Espin, Evans, & Hawryluck,
2004). Supporting socialization during interprofessional education before post-graduate training may favor collaboration as
most physicians first work directly with nurses during the beginning of their post-graduate training. Structured time and places to
communicate may diminish conflict as units that had regular staff
meetings were less likely to report conflicts (Azoulay et al., 2009;
Glauser, 2011; Savel & Munro, 2013). Otherwise, breakdowns in
interprofessional collaboration are likely to lead to negative social
representations or stereotypical views of the professions (Lingard,
Reznick, DeVito, & Espin, 2002; Sargeant, Loney, & Murphy,
2008). In addition, healthcare teams are often changing membership on a daily basis. Creating explicit structural processes that
facilitate integration of new members to the team may create the
basis for effective communication, shared expectations, and identification with the community of practice.
Our study comes with limitations. Even though our research
design enabled us to collect rich data and to gain a deeper understanding of health care professionals’ experiences of conflicts, it
may have led participants’ recollection to be skewed to the most
impactful events rather than mundane daily disagreements.
Participants also were not specifically asked to relate both types
of conflict: intra- and interprofessional. This may have limited the
breadth of conflict situations related. In addition, our study was
limited to four departments and to only physicians and nursing
professionals. Our participants shared conflict stories from when
they worked in other departments (e.g., intensive care, emergency
department, geriatrics), which suggests that our findings may
apply to specialties that were not involved in our study.
CONFLICT SOURCES
Conflict Triggers & Contributing Factors
Individual
Interpersonal
Organizational
Supervisor role
Relationships
Care-related tasks
Other tasks
Team processes
Structural processes
Power
Social representation
CONFLICT
CONFLICT CONSEQUENCES
Individual
Interpersonal
RESPONSES TO CONFLICT
Organizational
Individual
Interpersonal
Supervisor role
Organizational
Supervisor role
Personal
Work organization
Forcing
Team
Professional
Clinical environment
Power
Patient care
265
P
o
w
e
r
Avoiding
Yielding
Problem solving
Figure 2. Framework of conflict: sources, consequences, and responses to conflict at the individual, interactional, and organizational levels.
The grid shading indicates greater importance in intraprofessional conflicts while the slanted line indicate greater importance in interprofessional conflicts.
266
N. M. BAJWA ET AL.
However, participants mostly reported conflict stories involving
physicians and nursing professionals. While this suggests that our
pool of participants reflected typical healthcare teams in our
setting, the framework we developed based on our findings
(Figure 2) may not capture conflicts that would occur with other
healthcare professionals. Future research will need to include
types of healthcare professionals such as physiotherapists, social
workers, chaplains, nurse practitioners, or cleaning crew, to gain
further insight into the complexity of conflict management.
Research is needed in this domain, particularly to understand
how to prevent disagreements from taking a toll on health care
professionals and patient care. Another limitation of our research
is that we did not include patient perspectives. As we found that
conflicts between coworkers had an impact on patient care
(Cullati et al., 2019), future research should explore conflicts that
include patients and elicit patients’ experiences.
Conclusion
Through our comparison of intra- and interprofessional conflicts,
we have identified two main areas in which they differ.
Intraprofessional conflicts were more likely to revolve around
poor relationships and power differentials. Interprofessional conflicts, on the other hand, tended to be more closely related to
patient care, as they arose from disagreements on patient-related
tasks and affected the provision of care. Our results support the
need to prepare learners to work in the clinical setting by providing
them with training combining both intra- and interprofessional
aspects to conflict management that reflect the reality of the
clinical setting.
Acknowledgments
The authors wish to thank all participants who accepted to share their stories
and experiences, as well as the heads of departments who supported this
project. They also extend their gratitude to Ms. Nuria Scherly for her transcription work.
Declaration of Interest
The authors report no declarations of interest. The authors alone are
responsible for the content and writing of this article.
Funding
This study was funded by university funds from the University of
Geneva, Switzerland;University of Geneva, Switzerland.
Notes on contributors
Nadia M. Bajwa is the Pediatric Residency Program Director at the
Geneva University Hospitals and Faculty Member in the Unit of
Development and Research in Medical Education of the University of
Geneva Faculty of Medicine.
Naïke Bochatay is a Research Assistant in the Unit of Development and
Research in Medical Education at the University of Geneva Faculty of
Medicine
Virginie Muller-Juge is a Research Assistant in the Unit of Primary Care
Medicine at the University of Geneva Faculty of Medicine.
Stéphane Cullati is a Medical Sociologist at the Geneva University
Hospitals.
Katherine S. Blondon is an Attending in the Medical Directorate at the
Geneva University Hospitals
Noëlle Junod Perron is the Coordinator for the Institute of Primary Care
and Faculty Member in the Unit of Development and Research in
Medical Education of the University of Geneva Faculty of Medicine.
Fabienne Maître is a Registered Nurse Supervisor at the Geneva
University Hospitals.
Pierre Chopard is the Director of the Quality of Care Unit at the Geneva
University Hospitals.
Nu V. Vu is Professor Emeritus at the University of Geneva Faculty of
Medicine.
Sara Kim is Research Professor of Surgery and Associate Dean for
Educational Quality Improvement at the University of Washington
School of Medicine.
Georges L. Savoldelli is Associate Professor of Anesthesiology and
Faculty Member of the University of Geneva Faculty of Medicine.
Patricia Hudelson is a Medical Anthropologist in the Department of
Primary Care in the Geneva University Hospitals.
Mathieu R. Nendaz is Professor of Internal Medicine and Director of the
Unit of Development and Research in Medical Education of the
University of Geneva Faculty of Medicine.
ORCID
http://orcid.org/0000-0002-1445-4594
Nadia M. Bajwa
http://orcid.org/0000-0002-6098-4262
Naïke Bochatay
http://orcid.org/0000-0002-2346-8904
Virginie Muller-Juge
http://orcid.org/0000-0002-3881-446X
Stéphane Cullati
http://orcid.org/0000-0002-9407-8516
Katherine S. Blondon
http://orcid.org/0000-0002-9124-8663
Noëlle Junod Perron
http://orcid.org/0000-0003-3795-3254
Mathieu R. Nendaz
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