Standards in Focus

Interprofessional Practice: Team Dysfunction and Conflict

October 21, 2022

This edition of Standards in Focus highlights the Standards of Practice and Conduct that speak to interprofessional practice, specifically team dysfunction and conflict, and provides you with the opportunity to reflect on how to apply the Standards in your practice. ¹

Several Standards speak to expectations related to interprofessional practice. Category five (V) of the Standards is focused on collaborative care and states that licensed practical nurses practice in partnership with clients and a team of health care providers using a participatory, collaborative, and coordinated approach. Some of the Standards related to interprofessional practice state the following.

As an LPN, you must:

Document in the client’s record the nursing care you provide with enough information for another health care professional to be sufficiently informed of the care provided. (Standard 41)

Manage differences of professional opinion with colleagues by respectful discussion and informed debate, respecting their views and opinions and by always behaving professionally. (Standard 44)

Choose effective communication tools and techniques that facilitate discussions and interactions that enhance team functioning. (Standard 48)

Treat other healthcare providers with respect. (Standard 49. f.)

Category seven (VII) of the Standards is focused on leadership and states that licensed practical nurses apply leadership competencies in their practice, whether or not they practice in formal leadership positions. A few of the Standards related to interprofessional practice state the following.

As an LPN, you must:

Advocate for and contribute to practice environments which support the mental, physical, and psychological well-being of other registrants and all members of the health care team. (Standard 60)

Advocate for and contribute to practice environments that promote safety, support, and respect for all persons in the practice setting. (Standard 61)

Utilize collaborative and constructive approaches to resolving differences among members of the health care team that affect care. (Standard 63)

The entry-level and full competencies for the profession related to interprofessional practice include: ^{2, 3}

Provides holistic and compassionate care in collaboration with the health care team.
Provides and receives constructive feedback from other healthcare professionals to improve professional practice.
Develops and maintains a partnership with the interprofessional healthcare team based on respect for the unique role and competencies of each member.
Applies the principles of team dynamics and group processes in interprofessional team collaboration.
Applies appropriate conflict resolution strategies to support effective teamwork and positive client outcomes.
Recognizing the necessity for and exhibiting mutual respect for colleagues in the workplace and within the profession.
Integrating evidence-informed practice in collaboration with members of the health care team.

To read more on the competencies related to interprofessional practice and collaborative care, please see:

Entry-Level Competencies for the Licensed Practical Nurse in Manitoba

Nursing Competencies for Licensed Practical Nurses in Manitoba

Interprofessional Practice – Team Dysfunction and Conflict in Nursing Practice

Interprofessional practice in health care occurs when multiple providers from different professions provide comprehensive services by working with clients, their support networks, care providers, and communities to deliver the highest quality of care across all settings. ⁴This partnership between a client and a team of healthcare providers is a participatory, collaborative, and coordinated approach to shared decision-making around health and social issues. ⁴ The six main practice expectations of interprofessional collaborative care are ^{4, 5}:

Client-Centred Care: Practitioners seek out the input and engagement of clients, integrating their information, and valuing them as partners in designing, implementing, and evaluating care/services.
Role Clarification: Practitioners understand their own role and competence, as well as the roles of those in other professions, and use this knowledge appropriately to establish and meet client goals.
Team Functioning: Practitioners acknowledge team dynamics and group processes to enable effective interprofessional team collaboration.
Collaborative Leadership: Practitioners recognize that different team members may assume leadership roles appropriate to the situation.
Interprofessional Communication: Practitioners take responsibility for communicating with others collaboratively and responsively.
Interprofessional Conflict Resolution: Practitioners actively engage themselves and others in dealing effectively with interprofessional conflict.

LPNs are responsible for communicating with others in a collaborative, responsive and responsible manner. ⁶ LPNs must also establish and maintain effective and healthy working relationships with clients and other practitioners, whether or not a formalized team exists. ^{4, 6} Teams that change frequently need more formalized systems to ensure adequate communication between the team members to ensure client needs are addressed. ⁶ The health care providers present on the team may vary depending on the practice setting. As client care needs become less defined, other team members may need to become more involved in the care. LPNs share the accountability for health outcomes with clients, other professions and communities while maintaining accountability for their practice. ^{4, 6}

Different team members may assume leadership roles appropriate to the task, situation, and environment. The team must engage and effectively facilitate respectful interactions and recognize that formal and informal leadership co-exist. ^{4, 6} An understanding of who is most appropriate to take on a lead role, a complementary role and when to refer/consult within the team is essential. The team must actively engage in dealing effectively with interprofessional conflict. As such, each member of the team needs to recognize the potential for conflict, recognize how their behaviour and conduct contribute to the situation, and work effectively to address and resolve disagreements among the team. ⁶

Conflict can be defined as disagreement in which the people involved feel their needs, interests, and concerns are threatened. ⁷ Conflict can arise when two or more people view issues or situations from different perspectives. ⁷ The goals pursued by individual members of interprofessional teams, coupled with the acuity of client health status, resource availability, client preferences, and hierarchy in decision-making, can create conflicting interests among healthcare professionals. ⁸

Team conflicts may be viewed constructively when used to clarify misunderstandings and disagreements about roles and tasks; however, if not addressed respectfully and professionally, team conflicts can negatively alter team dynamics and communication, decrease trust and overall team performance, and lead to poor mental health among professionals. ⁹ Healthcare team dysfunction may threaten client safety and the quality of client care because healthcare professionals’ attention may be directed toward team conflicts and away from clients’ needs. ⁹ In addition, clients may be put at risk as a result of the breakdown in effective communication and consultation between colleagues which can result from dysfunction within the team. Nurses who deal with conflict effectively demonstrate respect for their clients, colleagues, and the profession. ⁷

Nursing Practice Scenario

The following scenario shows how even subtle interprofessional team dysfunction and conflict can influence the therapeutic nurse-client relationship and affect client care:

Bella Hernandez, LPN, works in a hospital’s busy medical/surgical unit. This week, Bella is caring for Mr. Penner, a 65-year-old client with a venous leg ulcer requiring a daily dressing change. A few days into the week, Mr. Penner tells Bella that another nurse (Joe, LPN) was in his room complaining about how Bella had changed his leg wound dressing the last couple of days. Mr. Penner had never voiced any concerns to Bella about how she had cared for him in the past, and Bella followed the wound dressing protocol as written in Mr. Penner’s care plan. No changes to the client’s care plan, including dressing changes, had been made by the physician or the other nurses since Mr. Penner’s admission to the unit several weeks ago.

Today, Mr. Penner questions Bella’s every move and all of her decisions as she is caring for him, especially when she is changing his wound dressing. Bella becomes flustered, and her confidence in her skills is shaken. As a result, Bella inadvertently uses the wrong kind of occlusive dressing on the wound, and the wound drainage oozes out and soaks into Mr. Penner’s pant leg a few hours later. Mr. Penner is upset and hastily says to Bella, “I guess nurse Joe was right. You don’t know what you’re doing.” Bella apologizes to Mr. Penner and applies a new dressing using the correct supplies. She documents her error and her interactions with the client in the chart so that the healthcare team is aware of the context of the situation and the care she has provided to Mr. Penner.

Bella is hurt and frustrated that her nursing skills were openly criticized by her colleague in front of a client. She is also frustrated that Joe didn’t speak to her directly to share his observations about her dressings, which might have been helpful feedback. As a result, she is left wondering what, if anything, she could have done differently. After reflecting on the situation and her feelings, Bella decides to speak to her nurse manager about the situation. They mutually agree to set up a team/staff meeting to discuss the causes of team dysfunction and conflict, such as incivility, gossip, and unconstructive criticism.

At the meeting, Bella and her colleagues are encouraged to discuss the situation civilly and openly. Bella explains that Joe’s remarks made in front of the client created an unintended snowball effect: Mr. Penner lost trust in Bella’s nursing skills; Bella lost confidence in herself; and Mr. Penner was upset with his care. Joe apologizes to Bella. Bella reinforces her openness to hearing feedback directly from her colleagues to help her develop her competence and confidence, and each healthcare team member commits to using collaborative and constructive approaches to resolving differences or conflicts among the team going forward. Bella hopes that the staff meeting has helped the healthcare team discuss and address these issues in helpful ways so that therapeutic relationships and client care are negatively affected as little as possible in the future.

Bella’s behaviour in the practice scenario is an example of an LPN meeting several of the Standards of Practice and Conduct in the face of team dysfunction and conflict. In particular, Standard 44 states that LPNs must manage differences of professional opinion with colleagues through respectful discussion and informed debate by respecting their views and opinions and always behaving professionally. ¹ Similarly, Standard 63 speaks to the expectation that LPNs use collaborative and constructive approaches to resolving differences among members of the healthcare team that affect care. ¹ Standard 48 goes on to say that LPNs must choose effective communication tools and techniques that facilitate discussions and interactions that enhance team functioning, and Standard 49 f. states that LPNs must treat other healthcare providers with respect. ¹ Additionally, Standard 41 says that LPNs must document in the client’s record the nursing care they provide with enough information for another healthcare professional to be sufficiently informed of the care provided. Furthermore, Standards 60 and 61 state that LPNs must advocate for and contribute to practice environments which support the mental, physical, and psychological well-being of all members of the healthcare team, and they must advocate for and contribute to practice environments that promote safety, support, and respect for all persons in the practice setting. ¹

In the practice scenario, Bella met her Standards of Practice and Conduct when she handled team dysfunction and conflict professionally. She was accountable for the care she provided to Mr. Penner through her apology to him and her documentation, and she did not involve the client in the team conflict. Instead, Bella discussed her concerns with her nurse manager, and the healthcare team had a constructive and collaborative meeting to help resolve their issues. Overall, Bella treated her colleagues with respect and was able to advocate for a practice environment that promotes safety, support, and respect for all people on the medical/surgical unit.

Reflection Exercises

Recognition, prevention, and management of team dysfunction and conflict are important because nursing is a profession based on collaborative relationships with both clients and colleagues. ⁷ Reflecting on the situation and your behaviour may help you understand your feelings and motives and may help you recognize the effect of team dysfunction and conflict on the client. ⁷

Consider engaging in self-reflection about interprofessional team dysfunction and conflicts you may have encountered or are currently encountering in your nursing practice. To aid in this reflection, please ask yourself the following questions:

Is/was my behaviour in the client’s best interest?
Are/were my actions in the client’s best interest?
Whose needs are/were being served in this situation?
What impact will/did this team dysfunction and conflict have on the client and their care?
Am/was I comfortable documenting my behaviour or nursing care in the client’s chart?
Do/did I feel comfortable telling a colleague or supervisor about this conflict?
How could this team dysfunction and conflict be viewed by the client’s family or others?
Am I in breach of CLPNM’s Code of Ethics or Standards of Practice and Conduct?

To help ensure that your actions reflect client-centred care, professional behaviour, and collaborative communication, please consider: ^{4, 5, 7, 10}

recognizing and valuing the potential for conflict to occur;
recognizing that the client’s well-being is affected by your ability to recognize, prevent, and manage team dysfunction and conflict effectively;
identifying common situations that are likely to lead to disagreements or conflicts, including role ambiguity, power gradients, and differences in goals;
engaging self and others to be an active part of conflict management, and recognizing how one’s behaviour and conduct contribute to the situation;
reflecting on interactions with clients and the health care team, and investing time and effort to improve your communication skills;
working effectively to address and resolve disagreements, including analyzing the causes of conflict and working to reach a mutually acceptable solution;
acknowledging biases and feelings that have developed through life experiences and that these attitudes could affect the nurse-client relationship and healthcare team dynamics/interactions;
reflecting on how stress can affect the nurse-client relationship and health care team functioning; and,
appropriately managing the cause of stress so that collaborative client care is not negatively affected.

Conclusion

As per the CLPNM Standards of Practice and Conduct, nurses are expected to work collaboratively with the other members of the interprofessional team, including clients. ¹ This means that LPNs are responsible for ensuring they are advocating for and contributing to practice environments that support the overall well-being of clients and members of the healthcare team in any practice setting. ¹ As seen in the practice scenario above, interprofessional team dysfunction and conflict can lead to errors and/or near misses in client care, especially if conflict is left unresolved. ¹⁰ Many root causes of team dysfunction and conflict exist (e.g., poor communication, lack of effective teamwork, incivility, disrespectful behaviour, mistrust among team members, unfair treatment, and power dynamics). ^{7, 8, 9, 10} Unresolved conflict can have far-reaching effects that ultimately influence every aspect of client care. ⁷ Therefore, engagement in self-reflection and the use of collaborative and constructive approaches to conflict resolution are important strategies that nurses can put into practice to help reduce actual and potential interprofessional team dysfunction and conflict. ^{1, 4, 5, 7, 10}

For further reading about interprofessional practice, specifically team dysfunction and conflict, consider accessing the resources listed in the references section below.

References

College of Licensed Practical Nurses of Manitoba (CLPNM). (2021) Standards of practice and conduct for Manitoba’s practical nurses.
College of Licensed Practical Nurses of Manitoba (CLPNM). (2021) Entry-level competencies for the licensed practical nurse in Manitoba.
College of Licensed Practical Nurses of Manitoba (CLPNM). (2021). Nursing competencies for the licensed practical nurse in Manitoba.
College of Licensed Practical Nurses of Manitoba (CLPNM). (2020). Practice direction: Interprofessional collaborative care.
Canadian Interprofessional Health Collaborative (CIHC). (2010). A national interprofessional competency framework, 1-36. Retrieved from https://drive.google.com/file/d/1Des_mznc7Rr8stsEhHxl8XMjgiYWzRIn/view
College of Licensed Practical Nurses of Manitoba (CLPNM). (2020). Practice guidance: Nursing in a team environment.
College of Nurses of Ontario (CNO). (2018). Practice guideline: Conflict prevention and management. Retrieved from https://www.cno.org/globalassets/docs/prac/47004_conflict_prev.pdf
Kim, S., Bochatay, N., Relyea-Chew, A., Buttrick, E., Amdahl, C., Kim, L., Frans, E., Mossanen, M., Khandekar, A., Fehr, R., & Lee, Y. (2017). Individual, interpersonal, and organisational factors of healthcare conflict: A scoping review. Journal of Interprofessional Care, 31(3), 282-290. doi: 10.1080/13561820.2016.1272558. Retrieved from https://www.abetternhs.com/wp-content/uploads/2012/06/conflicts-in-healthcare-work-settings-review-2017.pdf
Cullati, S., Bochatay, N., Maitre, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Perron, N. J., Bajwa, N. M., Vu, N. V., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43-51. doi: https://doi.org/10.1016/j.mayocpiqo.2018.11.003 Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408685/pdf/main.pdf
Zajac, S., Woods, A., Tannenbaum, S., Salas, E., & Holladay, C. L. (2021). Overcoming challenges to teamwork in healthcare: A team effectiveness framework and evidence-based guidance. Frontiers in Communication, 6(606445), 1-20. doi: 10.3389/fcomm.2021.606445 Retrieved from https://www.frontiersin.org/articles/10.3389/fcomm.2021.606445/full