Conflict management teams in the intensive care unit: A concise definitive review

C in today’s intensive care unit (ICU) is inevitable as multiprofessional providers and multiple teams interact to provide care to increasingly more complex and older patients. In an era of increasing technology, medical providers are able to prolong life and delay the dying process. However, these technological advancements have not been matched with rigorous discussions and uniform recommendations regarding the ethics of providing or withdrawing life-sustaining interventions. Given the numerous potentially disparate sets of values that exist in a culturally diverse society, conflict seems inevitable. Conflict, broadly defined as a disagreement between two parties that can cause harm, may arise from differences in perspectives, beliefs, values, goals, preferences, ideas, or priorities. In the stressful and rapidly paced environment of the ICU, conflict may arise between various parties including but not limited to primary health care teams, patients, their families or other legally authorized representatives, critical care teams, consultants, nurses, as well as administrators, law enforcement agents, and visitors. Conflict in the ICU is not only inevitable but also very common. In a multinational survey of 7,498 ICU staff members, more than 70% of the respondents reported a conflict during the 24-hour reporting period and 53% of the conflicts were considered severe. The most common conflicts occurred between nurses and physicians (32.6%), followed by conflicts among nurses (27.3%), and were only slightly more common than conflict between staff and patient or family members (26.6%). Unsurprisingly, only approximately 40% of the conflicts were considered resolved, and 87% of the respondents felt that the conflict would eventually reoccur. A majority of the respondents also reported that the conflict harmfully impacted team dynamics (92%) as well as relationships with the patient’s family (75%), negatively impacting care quality (70%), patient outcomes (44%), and ultimately patient and staff satisfaction. Conflict is pervasive within medicine and is not limited to the ICU setting. One study of surgical operations observed a minimum of one and a maximum of four conflicts per operation, while another investigation found an average of four conflicts per case among observed operating room (OR) teams. Such conflict may not only impact patient perception of care and potentially increase emotional distress for families but is also associated with significant cost to health care and nonYhealth care organizations, is estimated to exceed $359 billion per year in lost time, and leads to high rates of employee burnout, turnover, and absenteeism. Conflict may also be rather divisive for medical professionals who must work as a team to provide optimal care. For instance, disparate perspectives on end-of-life (EOL) care may create a sharp divide between the physician and nursing care teams that interact dailywith that patient and the remainder of the patients in the ICU. Perhaps, most polarizing are cases involving children or young adults with traumatic brain injury (extra-axial and intra-axial blood and contusion but no herniation) who seem neurologically devastated (Glasgow Coma Scale [GCS] score of 3T, no sedation or analgesia, full ventilator support) but for whom the family holds steadfast hope for a full recovery. The ICU team may believe that there is no credible potential for meaningful recovery, the neurosurgeons cannot make a certain prediction until 6 months have passed, and the nursing staff are themselves divided but believe that they are providing uncomfortable and perhaps painful care that is futile (not reaching the goals of restoration to health). Despite daily rounds that demonstrate no meaningful interaction, the family, hoping for neurologic recovery, wants ‘‘everything to be done. ’’ It is clear that each of the stakeholders has areas of overlap but also occasionally diametrically opposed beliefs. As a result, proactive strategies to avoid, reduce, or mitigate conflict in the ICU are not only appropriate but also essential in such a highly emotionally charged environment. While virtually impossible to avoid, conflict may be successfully managed. Conflict may be characterized as a series of directly related phases (Fig. 1). The conflict life cycle is a dynamic process that may begin without the opposing factions even being aware that the process has begun (latent phase). Emergence of the conflict is typically followed by escalation and, if not successfully resolved at that point, is rapidly followed by stalemate. During stalemate, parties become entrenched in their respective positions without deviation. Resolution embodies deescalation, which can occur through a process of negotiation that leads to dispute settlement. If the settlement is not completely acceptable to both parties, the conflict tends to reoccur. Successful conflict management benefits from a flexible approach to the phase at which management is sought for resolution. While conflict management teams (CMTs) exist in diverse settings, the goal of this review was to define the need, benefits, components as well as the implementation and potential problems with a dedicated CMT in an ICU. The ICU is the focus of this REVIEW ARTICLE