Resolve conflicts between ED and other departments
December 1, 1999 5 minutes read
Resolve conflicts between ED and other departments
(Editor’s note: This is the second part of a two-part report on resolving conflicts. In last month’s issue, we discussed conflicts between emergency departments and consultants. This month, we cover conflicts between EDs and other hospital departments.)
ED managers are not always prepared for the strained collegial relationships they encounter.
"You often have to learn through trial and error how to effectively handle these conflicts," notes Tamara Thomas, MD, FACEP, associate professor of emergency medicine at Loma Linda (CA) University and attending physician in the ED at Loma Linda University Medical Center and Children’s Hospital. Strained relationships are centered on the fact that other services have no idea how the ED operates, says Thomas. "They are convinced that they can do better and often make a blood sport of second-guessing what you do."
Physicians and nurses have a tendency to avoid conflict if possible, says Thomas. "This may allow anger to build and does not provide constructive solutions," she says.
Avoidance of conflict should be used only as a last resort because it does nothing to solve the conflict and often can escalate it, she advises. "Dealing directly rather than passively with conflict may require breaking lifelong habits."
Here are common causes of conflicts that arise and suggestions for how to deal with each:
• Disputes over what service a patient should see.
In this scenario, the conflict is not over whether patients should be admitted but whether they should go to another admitting service, Thomas explains. "These are the classic turf battles’ that are very commonly seen at academic centers between resident services."
However, private institutions are not immune to this problem. "Very often, the admitting physician will request the patient to be admitted to another service with ED physicians as the conduit for the bad news,’" she explains.
For example, a classic turf battle occurs when a colleague says, "Please have OB-GYN see this patient with right lower quadrant pain. I’m sure this is a gynecological problem," Thomas says. "In turn, OB-GYN angrily sees the patient and is certain that the patient has appendicitis."
This makes the manager the middleman with a sick patient that everyone has signed off on, she says. "In this scenario, have the two services discuss the case with each other and take responsibility for the patient," she recommends.
• Disagreement over whether a patient should be admitted or discharged.
This conflict is becoming more common with the pressures of capitated medicine, says Thomas. For example, physician gatekeepers might refuse to authorize an admission to keep their admission percentage down. "In these cases, they state the ED physician should do what they have to do,’" she says. "This places the ED physician into acting as the conscience.’"
• Micromanagement by physician colleagues.
This conflict usually centers around control issues, Thomas says. "Overworked, on-call physicians often focus on peripheral issues in patient care. This may be trivializing or patronizing."
A typical comment would be, "What do you mean ANA has not been done? Call me when the work-up is complete," she notes. "This tends to happen at night when someone wants to stay in bed a little longer or if they want to establish a small piece of control."
Realize that every time you allow someone to stall, the patient suffers, she stresses. "Always have a plan B for ammunition in your back pocket. Tell them, I’ll be happy to add the order on, but since the result will not change this patient’s need for admission, we can A) get a bed for the patient and have you see them upstairs, or B) you can come to see the patient now."
• Ineffective communication.
Miscommunication is often the root of conflict, says Colleen Bock-Laudenslager, RN, MSN, a Redlands, CA-based consultant with Bock-Laudenslager and Associates, which specializes in ED issues. For example, if radiology has not communicated its need to have a chest X-ray sent along with a patient’s CT scan, conflict occurs, she says.
Another common example of miscommunication occurs when reports are given to floor nurses. "You may have the impression the nurse is ready to accept the patient, but when the patient arrives, the nurse is surprised and may react differently than you expect," says Bock-Laudenslager.
In a private conversation, deal directly with the person you have a conflict with. If there is something you are frustrated about, privately share it with your colleague, Bock-Laudenslager suggests. "For example, you can explain that you feel concern for the patient who suffered a potential bad outcome due to the conflict."
Communicate clearly and succinctly, she advises. "Sometimes we have expectations, but we haven’t communicated them."
• Increased workload.
When other departments receive calls from the ED, it typically means more work. "From that standpoint, EDs are considered demanding and imposing," says Bock-Laudenslager. "Quite frankly, some of our nursing colleagues on other units just do not want more work to do."
Staff might think they can’t accommodate their current workload. For instance, in radiology, the CT scanner may hooked up all day with outpatients. "When the ED calls, they are forced to accommodate the patient urgently," she says. These issues are often a source of conflict.
Educate staff about the importance of the ED admissions to their job security, she advises. "A hospital without an ED would have 30% to 40% fewer admissions, and that might close the hospital down."
• Different organizational structures.
Often, staff working in other departments report through another organizational structure, and that structure can cause conflicts, Bock-Laudenslager notes. "You commonly hear staff say, I’m sorry, but my boss won’t allow me to do that,’" she notes. "Many conflicts arise because there are different immediate supervisors on both sides giving different directives to their staff."
Find ways to reorganize to reduce conflicts, she recommends. "For example, if there are conflicts between the ED and the courier dispatch service, consider having several FTEs provide that function to ED primarily so you don’t have to wait for someone to come from a centralized department."
Similarly, if ED nursing leadership reports to the same nursing director as critical care nurses, there is a better chance of having shared goals for both departments, Bock-Laudenslager adds.
• Colleen Bock-Laudenslager, RN, MS, P.O. Box 7303, Redlands, CA 92375. Telephone/Fax: (909) 798-4969. E-mail: [email protected].
• Tamara Thomas, MD, Loma Linda University Medical Center and Children’s Hospital, Emergency Medicine, 11234 Anderson St., Room A108, Loma Linda, CA 92354. Telephone: (909) 824-4344. Fax: (909) 478-4121. E-mail: [email protected].
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