Journal of Palliative Care & Medicine
Open Access

Abstract

Objectives: The conflicts that occur in the ICUs seem to have their sources in the structure of tasks, because their patients have a high risk of systemic complications and mortality. However, the existing workload of medical staff and the assessment of one's own situation may generate further conflicts.

Methods: The analyzed material is the result of a survey conducted among the ICUs staff from 12 hospitals in the Pomeranian Voivodeship (Poland). The surveys were self-filled by the respondents.

Results: The ICUs staff locates the causes of conflicts in organizational factors clearly more often than in the attitudes and activities of the staff. The vast majority refer directly to the frustration associated with low pay. There is a statistically significant difference between the answers of doctors and nurses also. The conflicts resulting from the necessity to make decisions in case of critical condition of patients are rarely observed.

Conclusions: The ICU employees are more strongly affected by the physical workload than by the psychological burden and they also pay attention to the fact that there is not enough staff employed in the units. The burden that they experience is not compensated by financial rewards and the work organization does not support the medical staff in the work they perform.

Keywords: Phytocannabinoid; CB2 Receptor; Acmella oleracea; Palmitoylethanolamide; Diindolylmethane; Colostrum ultrafiltrate

Introduction

The regulations regarding the functioning of the intensive care units (ICUs) define primarily the requirements that these units should meet in professional and sanitary respect, as well as the quality and equipment of the rooms in which the units are located. Thus, they refer to the formal and material conditions of the ICUs functioning, leaving the problems of internal relations in the units outside the regulations. It is about the phenomena that can appear and build up in staff teams as a result of actions in crisis conditions or difficulties in cooperation. The conflicts that often arise in such circumstances, have their source both in social processes and organizational conditions. In an international multi-centre study, embracing 323 ICUs from 24 countries, as many as 71.6% of the respondents noticed the occurrence of at least one conflict situation in their ward within seven days preceding the examination. The conflicts occurred most often between nurses and doctors (32.6%), then among the nursing team (27.3%) and between the staff of the ward and family members (26.6%). The degree of the conflict intensity was rated as ‘serious’ by 53% of respondents, ‘dangerous’ by 52% and 'harmful’ by as many as 83%1. Analyzing the state of affairs from the perspective of the task teams organization and functioning theory, it should be noted that the appearance of a conflict in the team may be influenced by improper work organization, inefficient communication, as well as the structure of the situation itself that causes the interests of certain groups or people to be perceived as contradictory2. The basis of conflicts in the ICU may stem from limited material or personnel resources, but also from the complexity of dependencies and internal relations: numerous parties involved in the treatment process (directly and indirectly) and the special position of the patient3. The context of the conflict is also important, which includes not only the history of relations between the parties of the conflict and the interdependencies existing between them, but primarily the struggle for human life combined with the pressure of the environment and the pressure of time4. It should be emphasized that Intensive care patients are admitted to the units when they suffer from a severe medical condition, caused by failure of one or more organs or systems of the human body. These are patients characterized by a high risk of systemic complications and mortality, although in a potentially reversible situation. The emergence of tensions in task groups is usually associated with decision-making processes (the authorities) or world-view/ ideological differences, which in the work of intensive care teams may take the form of rivalry or latent conflict. These kinds of phenomena evoke various emotional reactions (blaming others, anger, feeling of injustice) and have a strong influence on the reinforcement of the emerging tensions. Individual groups of employees may assess the existing situation differently and at the same time lose the necessary professional solidarity5. In turn, the need to reduce costs, improve efficiency, quality and security enforces the creation of various types of alliances and cooperation between people with various types of medical preparation, without which the team's work becomes impossible.

Methods

After doing research on the nature of ICUs conflicts, their potential causes have been divided into several areas. They are the following:

• Organization of work in the unit and the nature of the work performed,

• Professional preparation and interpersonal communication among the employees of the unit,

• Personality issues and personal causes of conflicts,

• Worldview and ethical issues,

• External conditions and financial conditions of work.

On the basis of their own observations, the surveyed staff was to determine the importance of particular factors as a source of the frequency of conflicts in the ICUs. At the same time, they used a five-point scale: very rarely, quite rarely, sometimes, quite often, and very often. The results presented in the tables have been grouped in 3 degrees only: rarely, sometimes, and frequently. The survey was carried out on a 232 staff sample of intensive care units from 12 hospitals in the Pomeranian Voivodeship (all hospitals where intensive care units are located) between September and December 2018. The study included nursing and medical staff, regardless of the position or length of employment. Professional status of respondents: doctors with specialization – 69, doctors without specialization – 10, nurses with specialization – 70, nurses without specialization – 83 (Tables 1-4). Bearing in mind the subject of the survey (sensitive issues concerning the entire team) and the specificity of the teams (differentiation), as well as a relatively low response rate achieved in the survey conducted among specialists, it was considered necessary to include all the ICUs staff members in the study, without the selection procedure. The employees were invited to participate in the study by the management of the unit, while the procedure of returning the questionnaire ensured confidentiality of responses (closed boxes for inserting completed questionnaires). The survey used a questionnaire technique - a paper form for self-filling. The respondents were offered full anonymity  and the opportunity to respond at their own convenience without the participation of third parties. We have obtained a high response rate: 48.8%. The initial research material was questionnaire forms filled in by the respondents, which were then entered into the electronic database. All statistical procedures and analyses were carried out using the IBM SPSS Statistics 25 programme. A statistical description was made and a comparison of the results between separate categories (professional group: doctors vs nurses, ICU work experience: 1-10 years vs 11-20 vs>20 years) by using chi-square test (comparison of proportions, for analytical purposes, on a five-point scale, two extreme values from each end of the scale were combined into one category). The test probability was assumed to be significant at the level of p<0.05 (for p<0.05 the differences between the compared groups are statistically significant, while the differences that did not meet this condition were considered statistically insignificant).

Results

Our survey shows that the causes of conflicts are clearly more often attributed by the medical personnel to external factors, which determine the working conditions in the ICUs, rather than to the attitudes and actions of the employees themselves or the specificity of the work of the units. The most common cause of conflicts is - in the opinion of the respondents - the financial conditions of work combined with a simultaneous large load of tasks. Inadequate financial conditions of work being defined as a quite frequent or a very frequent cause of conflicts were indicated by 76.7% of the respondents. At the same time, 69.4% of the respondents point out directly to the frustration associated with low pay, although there is a significant difference between the ratings of doctors and nurses. The former perceive the impact of this factor on the conflicts occurring in the ward in 55.7%, while the percentage in case of nurses reaches 76.5% (statistically significant difference, p<0.05). Also, the salary disproportions of individual intensive care unit employees are perceived as a clear cause of conflicts. 63.4% of the respondents express such an opinion, although we again observe differences in the answers of doctors and nurses: 54.4% and 68.0%, respectively (statistically significant difference, p<0.05). There was also a difference of opinion between employees with the employment time length of 11- 20 years and people working for over 20 years (72.6% versus 49.2% - a statistically significant difference, p<0.05). As many as 71.4% of the respondents perceive a fairly frequent or very frequent source of conflicts in too heavy a physical workload, and if the answer sometimes is added, the percentage increases to 91.3% On the other hand, the stress itself is psychogenic - the psychological burden that usually accompanies work in the ICUs is conflictogenic. This burden results from the need to constantly monitor and assess sudden changes in the patients' health and to make numerous and immediate decisions, being incapable to save a life or to relieve suffering3. However, the response rate describing stress situations as a source of conflicts in the ICUs is nearly 12% lower than that associated with physical load, hence it can be assumed that physical exhaustion generates conflict situations more frequently than the experiences related to critical situations. The need to act under time pressure is also conflictual. Over half of the respondents see quite frequent or very frequent reasons for conflicts because of this, and when we include sometimes answers, this ratio increases to 82.3%.

The effectiveness of task teams increases when the work is well organized, i.e.: the knowledge and skills of group members complement each other and are both effectively communicated and tailored to the task. However, this results not only from the attitudes of the employees themselves, but also from the health policy and the organization of the work of hospitals. This general dependence is clearly noticed by the ICUs staff and many of them see the reasons of tensions and conflicts in the ward in the currently adopted solutions - 60.3% associate them with the implemented health policy of the state, and 63.8% with hospital and financial policy, which has a direct impact on the functioning of the ICUs. The causes of conflicts are seen even more often in the excessive bureaucratization of the work, which directly burdens the medical personnel. This factor is indicated by 72.8% of the respondents.

The respondents point to too few medical staff (61.5%) in the wards, which they think makes it difficult to perform tasks. It is worth noting that the number of these answers is nearly twice as high as the number of answers indicating the conflicts resulting from the necessity to make decisions in critical situations. The occurrence of conflicts in the context of the necessity of making decisions in critical situations was mentioned by only 32.9% of the respondents. However, there is a statistically significant difference between the percentage of the responses of doctors and nurses: 46.8% against 25.7%, respectively (p<0.05). This reflects the fact that difficult decisions are most frequently made by doctors, and that the decisions also involve the patient’s family and other doctors4,6. A relatively lower level of responses in the nurses' answers is confirmed by the results of comparative studies on occupational burnout of nurses in various hospital wards. They showed that the nurses from the intensive care units do not belong to the groups that are most prone to stress in this profession and they have a statistically significantly lower level of overload than, for example, the nurses from surgery wards 7.

According to management theoreticians, mutual trust is the foundation of teamwork. Only then can employees concentrate on tasks and achieve group goals instead of allocating energy to deal with difficult relationships in the team2,8. It is emphasized that mutual trust does not give rise to fears of engaging in a conflict, which then takes on rather constructive character and does not create barriers that threaten the achievement of goals or leads to team disintegration2,9. In general, 15.5% of the respondents indicate a lack of trust as a cause of the observed conflicts. For example, the occurrence of the problem of the lack of personal culture of colleagues, which, according to 18.6%, is quite often or very often the reason of conflicts, is noticed more often. At the same time, 22.1% note that the causes of conflicts lie in the lack of mutual respect between the ICUs staff and, in the same dimension, seem to be personal, being a result of mutual animosity - 22.0% state that conflicts against this background occur quite often or very often. Among the personality factors, the most frequent reason for the accumulation of conflicts is seen in the so-called difficult nature of some colleagues (33.6%). On the other hand, a comparatively less significant reason for tensions are such attitudes and behaviors of the ICU staff, which manifest themselves in the lack of respect for patients and their families - 8.2%.

The professional preparation and qualifications of its members are very important for the balance of the teams’ work. 23.3% of the respondents indicate to inadequate qualifications of the ICU staff as the reason of conflicts, which is a significant value and only in the context of other results does not have to be treated as a problem of the firstrate importance. It is also interesting that employees relatively seldom point to the importance of training held in the units, including, among others, joint training and instruction on new devices or procedures. Only 17.2% of the respondents are of the opinion that too little intragroup trainingis quite frequent or very frequent cause of conflicts in the wards.

The flow of information has a different meaning for the work of task teams. The shortcomings of communication can make the overall atmosphere in the team discouraging from a joint action10. The insufficient information flow as a cause of conflicts is indicated by 38.4% of the respondents. A similar percentage of the answers refer to the situations in which inappropriate manners of conveying information are indicated which in turn leads to the build-up of tensions and conflicts - 36.2%. Such situations occur, for example, when the staff uses the wrong tone of voice during conversations or when they use inappropriate vocabulary.

It seems that the necessity itself of working in a team is not a significant difficulty for the ICU staff - only 13.0% of them see this as a frequent cause of conflicts, and nearly 60% of the respondents do not think that this is a significant cause. The relatively high response rate of sometimes (28.1%) can be considered as a signal of the need to improve some elements of the organization of activities in the ICUs. The distribution of the responses regarding the occurrence of conflicts resulting from the shift nature of the ICUs work should be interpreted somewhat differently. Shift work in the context of the types of conflicts distinguished by Christopher Moore11 and their functionality or dysfunctionality should be considered as conflictual. Shift work involves taking over the responsibility for patients by subsequent shifts of medical personnel, hence the percentage of answers saying that it causes conflicts in the ICUs quite often or very often in 19.0%, and in the opinion of 55.2% of the respondents it causes them rarely or rather rarely, can be considered as a manifestation of a fairly efficient transfer of duties.

An important element of conflicts in the ICU teams - even more than in other types of task groups, including the medical ones - may be world-view/ideological differences. What is meant by these differences are, among others, values and attitudes towards dilemmas related to the end of life as well as the observance of ethical principles and readiness to act in accordance with them. The concerns about the occurrence of such conflicts in activities carried out to protect health and life are the reason for establishing procedural safeguards and professional ethics of the medical personnel. The situation in which a person has to choose between values which he/she considers equally important is for him/ her an ethical dilemma, and its resolution is most often associated with the sacrifice of one value for another. However, what results from the conducted survey is that the conflicts occurring against the background of ideological viewpoints are observed very rarely. Only 4.3% of the respondents notice a frequent occurrence of this problem in the ICUs. Furthermore, the lack of compliance with professional ethics3,12, which in turn leads to conflicts between the staff, is perceived by only 6.9% of the respondents and together with the world-view issues is the least-recognized conflictogenic factor in the intensive care units.

Discussion

Work overload13 is a dangerous phenomenon in working circumstances, which means difficult tasks that exceed an employee's capabilities, high responsibility, and the need to make difficult decisions. It is also noted in the theory of organization that a high probability of conflict occurs when there may be a mismatch of goals, and at the same time there are a lot of common resources and a large interdependence of activities between individuals2,9,14. All these elements can be found in the work of the medical personnel in the intensive care units. It seems that there is a clear overload of work in the physical as well as psychological sense. The latter aspect consists of both the responsibility for securing the basic life functions of the patients, acting under time pressure as well as under the pressure of the environment. A separate issue is the burden resulting from the fact that the medical staff also gives emotional support to the patients' family members15.

We do not know how high is the level of stress among the ICU employees and how often it rises to a very high level, which does not allow determining when this stress becomes a factor hindering the activities. H. Selye16 points to both mobilizing stress (eustress) and debilitating stress (dystres).

On the basis of the answers given in the questionnaire we can conclude, however, that the stress that is experienced is not compensated by the remuneration for the work, or even that it can be a factor that intensifies this stress (financial problems in the household, the need to obtain additional income from other sources, reducing the time needed to rest and regenerate after work). Similarly, organizational determinants and regulations regarding the work performed, may significantly affect the work of the team. Of course, one should be aware that the frequent indication by the respondents to the external conditions as the reasons for the conflicts that occur in the units may be the staff’s way of pushing aside the responsibility for the conflicts that occur in the wards.

Conclusion

When analysing conflicts in the intensive care units, specific conditions that occur in this area of therapy and medical care as well as staff attitudes should be taken into account. These are not conflicts that occur in structures free of consciousness, but ones that occur between individuals who conduct conscious actions and are capable of emotional engagement. Conflict situations are therefore co-shaped by both objective and subjective conditions. The assumption that the worldview differences and professional ethics issues are an important reason for conflicts in the ICUs17,18 has not been confirmed, although ethical dilemmas of medical staff in this area of medicine18,19,20,21 often affect the ideals and ideological systems they profess. In the light of the results obtained, work teams in the ICUs seem to be primarily task groups, and the number of conflicts on the background of the worldview is only incidental.

The employees themselves often attribute the causes of conflicts to external factors that determine the working conditions of the ICUs, including: excessive bureaucracy, but also hospital policy and state health policy. What is of much significance, however, are the attitudes of the employees themselves, who clearly indicate that they are underestimated - above all financially, and badly tolerate the existing differences in remuneration. The frustration related to low pay creates divisions among the employees. This is clearly visible from the differences in the answers of doctors and nurses. The problem seems to lie in the remuneration system as well as in the absence of sufficiently objectified evaluation criteria, especially those that allow a relatively precise determination of the actual participation of individual units in the implementation of the desired work. In addition, too low a rate of the ICU staffing causes difficulties in the division of tasks and overloading of individual employees. This is confirmed by the distribution of answers to the questions probing the impact of the physical load on the emergence of conflict situations in the team. Should be noted that, the opinions and assessments made by the respondents cannot be directly related to their level of professional experience, because we do not observe statistically significant differences - except for one case - in the responses rates of employees with different job seniority.

The key points

• The context of conflicts in intensive care units includes formal and material working conditions

• The ICU staff locates the causes of conflicts in physical work overload

• There are statistically significant differences between opinions doctors and nurses.

• Conflictsituations are co-shaped by both objective and subjective conditions.

Conflict of interest

The authors declare they have no conflicts of interests.

References

1. Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, et al. (2009) Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J RespirCrit Care Med 180: 853−860.
2. Robbins SP (2001) Organizational behavior. 9th ed. Upper Saddle River, N.J: Prentice Hall.
3. G?owacka MD, Mojs E (2010) Law and Psychology in Health Protection. Warszawa:Wolters Kluwer.
4. Fr?czkiewicz-Wronka A (2009) Public Management in the Theory and Practice of Health Protection. Warszawa: Wolters Kluwer.
5. Carson J, Fagin L, Ritter S,Nicolette DV, Heather B, et al. (1995)Stress and Coping in Mental Health Nursing. London: Chapman & Hall. Int. J. Soc. Psychiatry 42: 102-111.
6. Prendergast TJ (1997) Resolving Conflicts Surrounding End-of-Life Care. New Horiz 5: 62−71.
7. D?bska G, Pasek M, Wilczek-Ru?yczka E, Zwierzchowska M. (2014) Psychological Burdens and Burnout in Nurses Working in Various Professional Specialties. Hygeia Public Health 49:113−119.
8. Lencioni MP (2012) Overcoming the Five Dysfunctions of Teamwork. A Practical Guide for Leaders, Managers and Moderators, MT Biznes.
9. Deutsch M (1977) The Resolution of Conflict: Constructive and Destructive Processes. New Haven: Yale University Press.
10. MarsdenC (1990)Ethics of the ‘Doctor-Nurse’ Game. Heart and Lung19:422– 424.
11. Moore Ch (1996) The Mediation Process: Practical Strategies for Resolving Conflict. San Francisco: Jossey-Bass Publication`.
12. Drozd-Garbacewicz M, Erenc J (2013) Examination of the Needs and Expectations of Patients as a Practical Dimension of the Idea of Humanism in Medicine. In: Basi?ska K, Halasz J, editors. Ethics in Medicine Yesterday and Today. Selected Issues. Kraków: Impuls 223−234.
13. Kami?ska M, Siewierski B, Skwara A, Szóstek A (2003) Control over Stress. Gliwice: Wydawnictwo Helion.
14. McKenn E, Beech N (1997) Human Resourses Management. Warszawa: WydawnictwoGebethner.
15. P?aszewska-?ywko L, Gazda D (2012) Emotional Reactions and Needs of Family Members of ICU patients. Anaesthesiol Intensive Ther 44: 145−149.
16. Selye H (1977) Stress Restrained. Warszawa: Pa?stwowy Instytut Wydawniczy.
17. Stevens L, Cook D, Guyatt G,Griffith L, Walter S, et al. (2002) Education, Ethics, and End-of-Life Decisions in the Intensive Care Unit. Crit Care Med 30: 290−296.
18. Karnik S, Kanekar A (2016) Ethical Issues Surrounding End-of-Life Care: A Narrative Review Healthcare (Basel) 4:24.
19. Borsellino P (2015) Limitation of the Therapeutic Effort: Ethical and Legal Justification for Withholding and/or Withdrawing Life Sustaining Treatments. MultidiscipRespir Med 10: 5.
20. Suchorzewska J, Basi?ska K, Olejniczak M (2008) Difficult Decisions against a Dying Man – Reflections of a Clinician. In: Chyrowicz B, editor. Extending Life as a Moral Problem. Lublin: Towarzystwo Naukowe KUL 59−76.
21. Arnold RM, Kellum J (2003) Moral Justifications for Surrogate Decision making in the Intensive Care Unit: Implications and Limitations. Crit Care Med; 31: 347−353.