The head nurse is the first line manager in a working unit who is responsible for preventing and solving conflicts. Unmanaged interdisciplinary conflicts can result in decline quality of the healthcare service. This study explores the head nurses’ experiences in preventing interdisciplinary conflicts.
MethodThis study was a qualitative study using descriptive-phenomenological approach. Data were collected through in-depth interviews with twelve head nurse of a central hospital in Jakarta, Indonesia. The data were then analyzed by employing Colaizzi's method.
ResultThe results of this research revealed four themes: (1) integrated-effective communication is a form of interdisciplinary conflict prevention; (2) a head nurse need to have wide insights and supple character to prevent conflicts with doctors; (3) a head nurse is responsible for coordination and negotiation to prevent interdisciplinary conflicts; and (4) a head nurse creates conducive working environment to prevent interdisciplinary conflicts.
ConclusionsA head nurse can prevent conflicts and direct interdisciplinary conflicts to be positive to provide quality healthcare service.
Interdisciplinary collaboration is an inherent part of nursing profession.1 As the first line manager in a working unit, head nurses have a pivotal role to manage interdisciplinary collaboration.2 The head nurses also navigate the care for the patients and the healthcare team.3
An interdisciplinary team consists of skilled-professional staffs, including doctors, nurses, midwives, pharmacists, nutritionists, and other healthcare staffs.4 In Indonesia, nurses’ collaborative work within the interdisciplinary team is regulated in the Accreditation Standards for Hospital known as Patient-based services. In practice, however, the healthcare team collaboration has the potential to induce an interdisciplinary conflict.
Conflict among health staffs is a common problem.5,6 It frequently occurs in a multidisciplinary team due to role limitation and differences of practice fields.7 Organization and communication problems are also the prominent cause of interdisciplinary conflicts.8,9 Conflicts can be a global threat for an organization. Therefore, Interdisciplinary conflicts must be prevented and managed well.
Studies found that a manager spends 20% of his/her working hour to solve conflict and loses 25% of the working hour to manage conflicts.10,11 Meanwhile, medical staff experience conflict for 60% of their working hour and solve the conflicts for 19% of their working hour per day.5 Given the preoccupying nature, interdisciplinary conflicts can influence the quality of nursing services for the patient.
Conflicts can create negative working environment and decrease productivity.10 Furthermore, conflicts within the interdisciplinary team may interfere with the nursing care.12 Ineffective conflict prevention may lead to deprived working condition, power gambling, patients’ dissatisfaction, decreased nursing quality, and inefficient health cost.13 However, conflicts were either entirely negative and positive. The output of conflict depends on individual's ability to manage them.14 Interdisciplinary conflict may hamper the collaboration between the health care team member that eventually impact the patient’ satisfaction of overall healthcare service.15
The head nurse is responsible for coordinating team members and interdisciplinary conflicts.10 In case of occurring conflict, it also under the head nurse's responsibility for managing conflict and adjusting his/her leadership model to the situation.16,17 To this end, a head nurse must understand the strategies of interdisciplinary conflict prevention.18 This study, therefore, aimed to explore the head nurses’ experiences in preventing interdisciplinary conflict.
MethodThis research employed qualitative design with descriptive-phenomenological approach. Data were collected through in-depth interview. The participants of this research were 12 head of a central hospital in East Jakarta, Indonesia, who had been assuming the position for at least three years.
The participants were selected from various wards. In Indonesia, the type of wards normally divided according to the hospital charge from the highest class (Very very Important Person/VVIP). In this study, head nurses from all classes of inpatient wards, as well as those from the emergency departments, outpatient unit, hemodialysis unit, Intensive Care Unit (ICU), and Intensive Cardiology Care Unit (ICCU) were invited and agreed to participate. Interviews were conducted from March to April 2018. Data analysis was done using Collaizzi's method of qualitative analysis.
ResultsThe participants were mostly middle-aged female (91.6%) and had bachelor of nursing degree (58.4%). As the third class wards made up the majority of the inpatient wards in the hospital, most head nurses were from the third-class inpatient wards. Four themes were identified to describe the head nurses’ experiences in preventing interdisciplinary conflicts.
Integrated-effective communication is a form of interdisciplinary conflict preventionThis theme consists of three categories: (1) effective, direct communication, (2) written communication media, and (3) online communication media. These three communication categories can work together to prevent interdisciplinary conflicts. The following is a participant's statement: “…Communication is a vital element to keep in touch with others, for example with radiology staffs, laboratory staffs, and other staffs…” (P5)
The theme of having wide insight and supple character to prevent conflicts with doctors is derived into five categories: (1) head nurses must have a thorough understanding of the patients’ need before a doctor's visit; (2) head nurses must have clear reasoning or judgment in communicating with doctors; (3) head nurses should understand the personal characters of the doctors; (4) head nurses should have ambition for continuing education; and (5) doctors have positive perception of nursing profession. The following is a short excerpt that represents the second theme: “… So a head nurse is required to know the patients’ condition …” (P7)
Two categories of: (1) head nurses’ coordination and (2) head nurses’ negotiation explain how the head nurses are deemed responsible for coordination and negotiation in preventing interdisciplinary conflicts. A participant mentioned the following statement: “…As a service management, I only conduct coordination to ensure that all services run well…” (P2)
Creating conducive working environment means that in order to prevent interdisciplinary conflicts the head nurse is responsible to: (1) maintain attitude and harmony in collaboration; (2) think positively toward other professions; (3) be unresentful to any solved problems; and (4) keep multidisciplinary staffs feel comfortable with the presence of the head nurse. The following is a participant's statement: “…because of us, I see other health care professions as a team; we do team work. So synergy, dependability, and relationship will occur. We cannot work in silos…” (P5)
Miscommunication is a frequent cause of interdisciplinary conflicts.19 Some examples of communication-related conflicts are misunderstanding and distorted communication channel.20 Errors in interdisciplinary communication, which are very likely to happen given the diverse background of the health care team, may bring fatal results in the healthcare service.21 Whereas, effective communication is the key in interdisciplinary collaboration and can eventually improve the quality of nursing care and service.22
The present study results reveal that interdisciplinary communication can run effectively through integrated communication, either in direct, written, or correlated forms. An example of integrated communication is through proper documentation in the patient's medical records, the main communication media within the health care team. Illegible or incomplete documentation is a form of ineffective written communication in the multidisciplinary health care team that may disrupt care delivery and create conflicts.23,24 Effective communication requires clarity, openness, accuracy, and timeliness.23 To communicate in such manner, all team members, and most importantly the head nurse, need interpersonal competency.25 Head nurses must have the skills to articulate the daily report, plan, and all communication needs not only to the staff nurses under their coordination but also to other health care professionals as a team.
A head nurse needs to have wide insights and supple character to prevent conflicts with doctorsNurses and doctors constitute the largest portion of the healthcare professionals. Power imbalance between these two professions can hinder collaboration, thus necessitates a proper management.26 Conflicts related to this issue should be mitigated by the head nurses, by bridging the nurses’ communication, information, and relation with the doctors’.27 Information on patients’ condition identified by the nurses needs to be passed onto the respective doctor and other health care team members.28 Doctors could be upset when the nurses miscommunicate the clinical information.24 Collaboration needs competence equity of the health care providers to allow mutual appreciation and cooperation. However, as raised in a study finding, doctors feel that nurses are lacking of motivation to improve their knowledge.25 A head nurse holds the responsibility to be the role model of an excellent nurse in the interpersonal and professional relationships with the other health care professionals, especially medical doctors.
A head nurse is responsible for coordination and negotiation to prevent interdisciplinary conflictsA head nurse should act as a facilitator, coordinator, and negotiator in mitigating or overcoming conflicts by taking decision and accommodate the team members in such cases.29,30 Furthermore, the head nurse coordinate with other professions to ensure the service flows or other patient service run properly.
A head nurse conducts interdisciplinary negotiation for example by consulting emergency care, or seeking assistance and approval from other units to address the patients’ service needs. Negotiation is defined as a process involving two or more parties to decide financial budget allocation and to solve any conflicting interest.20 Negotiation typically aims at fair solution acceptable to all parties, or to a greater extent, a stronger working relation for all involved parties.31 Therefore, effective coordination and negotiation can improve team performance and eventually the patients’ satisfaction.32 Coordination and negotiation are part of the head nurse's duty, including preventing or managing conflicts. Coordination which accompanied by sense of collective responsibility is a key element of collaboration.23,32
A head nurse creates a conducive working performance to prevent the occurrence of interdisciplinary conflictsA head nurse prevents the occurrence of conflicts by creating a conducive and supportive working environment. This can be done through several actions: (1) reducing the provocative condition in the immediate surroundings of the workplace, (2) using legitimate authority only for decision making, (3) formally facilitating conflict resolution process, (4) taking responsibility to achieve the organization's goal, and (5) compromising all units’ need.20
Conflicts can give either positive or negative impacts. Effective and constructive conflict management can minimize the negative impacts of conflict.33 The negative impacts of conflicts are abysmal-interpersonal relation which may lead to lower quality of work, difficulty in concentration, anxiety, sleep difficulty, self-withdrawal, and interference in interpersonal communication.34 Another major negative impact of conflict is failure at providing services, hence decreased patients’ satisfaction.35 Conflicts may waste working hours, lower working motivation, create dreadful team work, and even induce staff attrition. It may also harm the relationship of the healthcare staffs and patients.36
Conflict needs to be managed carefully to lessen its destructive impacts, and in some special cases, to create positive changes. Some positive conditions can be stemmed from conflict, such as solid teamwork and improved creativity and innovation.33,37 Conflicts may create changes that enable people to better understand each other and to create the best problem-solving.38 The occurring conflicts can also become a lesson and a reminder for the head nurses to have better team work in the future.
ConclusionThis research reveals four themes describing the head nurse's role in preventing multidisciplinary conflicts: (1) integrated-effective communication is a form of interdisciplinary conflict prevention; (2) a head nurse needs to have wide insights and supple character to prevent conflicts with doctors; (3) a head nurse is responsible for coordination and negotiation to prevent interdisciplinary conflicts; and (4) a head nurse creates conducive working environment to prevent interdisciplinary conflicts. Preventing multidisciplinary conflicts means averting conflicts and directing interdisciplinary conflicts to positive purposes for the healthcare services.
To be able to hold such intriguing roles, head nurses need to hone their communication skills in by attending communication and conflict management training. Formal education is also important for the head nurses to mature their capacity and competence and to balance the educational background with other health care professional especially doctors. On the other hand, nursing and other health science educational institutions should include conflict management and inter-professional collaboration in their curriculum.
Conflict of interestsThe authors declare no conflict of interest.
This work is supported by Hibah PITTA 2018 funded by DRPM Universitas Indonesia No. 1840/UN2.R3.1/HKP.05.00/2018.
Peer-review under responsibility of the scientific committee of the Second International Nursing Scholar Congress (INSC 2018) of Faculty of Nursing, Universitas Indonesia. Full-text and the content of it is under responsibility of authors of the article.
