#KeyLIMEPodcast 308: Six Flavours of Power on the Menu of Healthcare Conflict

This week, KeyLIME presents the question, “how can we make healthcare conflict better?” The authors of this paper, which Jason calls the “most unusual one I have read using qualitative interviews”, took a look at the role of power in conflicts between health care professionals. They conclude their article with 4 recommendations to making conflict in healthcare more constructive.

Listen here to learn more.


KeyLIME Session 308

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Reference

Bochatay et. al., The Role of Power in Health Care Conflict: Recommendations for Shifting Toward Constructive Approaches Acad Med 2021 Jan 1;96(1):134-141.

Reviewer

Jason R. Frank (@drjfrank)

Background

Conflict. Does it go together with healthcare like peanut butter and jam? Like pineapple on pizza? It certainly seems like conflict is an absolutely everyday occurrence, from the moment we enter our health professional careers to the day we retire (hopefully less conflict on the latter). As an ER doc, conflict seems continuous: angry worried patients waiting, overworked consultants refusing consults, spontaneously assembled teams of semi-strangers, disagreements between clinical services, only small scrubs in the dispenser (that one is more of a conflict with my waistline). It seems humans have a tendency to use their power in disagreements in healthcare settings.

But what is a “conflict” in healthcare exactly? What is “power” in healthcare? Given the evidence that healthcare conflict is so pervasive and damaging to the wellness of professionals and patients, how can we make healthcare conflict better?

Purpose

Enter Bochatay et al in this paper from Academic Medicine from the January 2021 issue, entitle: The Role of Power in Health Care Conflict: Recommendations for Shifting Toward Constructive Approaches. The authors “examined the role of power in conflicts between healthcare professionals in different cultural contexts…”

Key Points on the Methods

This paper is one of the most unusual ones I have read using qualitative interviews. This is a secondary analysis of 249 interviews performed in the US (92), Switzerland (82) and Hungary (75) involving healthcare professionals, mostly physicians and their experience of conflict in the workplace. The original work from those interviews was published separately. Interview subjects were selected “randomly” from lists of local professionals, though there is not more detail about how that was done.

Using the data from those 3 settings, the authors performed another analysis on the interviews using the lens of “social power” as operationalized by French and Raven (1959). This theory posits that social power draws on 6 “resources” or “social bases”, namely:

  1. Position/title
  2. Expertise
  3. Information/situational knowledge
  4. Reward
  5. Coercion, and
  6. Charisma/inspiration.

To the authors’ credit, they provide definitions for their constructs:

  • Power: “having influence or control over the beliefs, behaviours, and values of individuals, groups, or institutions”.
  • Power distance: “the perception of unequal statuses between individuals”.
  • Conflicts: “perception of differences, discrepancies, and incompatible goals among team members”.

The authors describe their approach as “qualitative exploratory research”, involving “directed approach to content analysis”. Conflicts were identified from the interviews, then screened to find those involving power issues. The most relevant power type was identified and coded. They also added 2 codes informed by “impression management” as to whether the conflict involved witnesses (“Frontstage”) or 1 on 1 (“Backstage”).

Note that the original interviews did not specifically involve asking about power, only conflict.

Key Outcomes

The authors identified 367 conflicts, all of which involved the interview subject being the victim and was always viewed negatively. Of these 53% were identified as involving one of the 6 types of Power (194). While these power conflicts were present in about 39% of the US & Swiss interviews, they made up 97% of those from Hungary.

The authors found that 3 of the social bases accounted for all the power conflicts:  positional, expertise, and coercive. They provide illustrative examples of each. The 3 bases were consistent across sites.

The authors also found that most conflicts analyzed involved “frontstage” scenarios (81.5%), and the presence of an audience (eg a patient and their family), made the conflicts worse. Interviewees reported that it was easier to speak up and address conflicts when they were “backstage”.

Key Conclusions

The authors conclude that healthcare conflict is viewed negatively, involving the misuse of power, primarily of 3 types. The frequent presence of an audience was a barrier to making the conflict constructive.

The authors offer 4 recommendations to improve healthcare conflict and make them more constructive:

  1. Those with positional power should take steps to decrease power distances and hierarchies for better patient care.
  2. Interprofessional education should be used to help learners identify and manage conflict and the uses of power.
  3. Collaboration champions should be trained to promote constructive conflict.
  4. Frontstage conflicts should be avoided.

Spare Keys – Other take home points for Clinician Educators

  1. This is an unusual qualitative study due to enormous size of the interview database.
  2. The authors do a better job than most at making their definitions of terms explicitly

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