key: cord-0986911-ytfr2pxc
authors: Parvaresh-Masoud, Mohammad; Cheraghi, Mohammad Ali; Imanipour*, Masoomeh
title: Workplace interpersonal conflict in prehospital emergency: Concept analysis
date: 2021-09-30
journal: J Educ Health Promot
DOI: 10.4103/jehp.jehp_213_21
sha: abd274ba2b4fade05bc65380ea5830649b67b563
doc_id: 986911
cord_uid: ytfr2pxc

BACKGROUND: In the turbulent and stressful work environment of prehospital emergencies, the conflict among emergency medical technicians (EMT) and other health-care providers is inevitable. This study aims to examine the concept of workplace interpersonal conflict (WIC) in prehospital emergencies. MATERIALS AND METHODS: The eight-step Walker and Avant's concept analysis approach was adopted to define the concept. Iranmedex, SID, Magiran, ISC, PubMed, Scopus, Embase, and Web of Science searched with keywords such as WIC and hospital emergencies. After an extensive review of online national and international databases, one dictionary, nine books, and 25 articles in English and Persian were retrieved for the purposes of the study. RESULTS: The antecedents, attributes, and consequences of the concept identified. EMT must learn how to eliminate their destructive effects while enhancing constructive effects. CONCLUSION: Conflict is an inevitable part of life, and EMT must learn how to reduce their destructive effects while increasing constructive results.

D ue to the unique and complex workplace of prehospital emergency, conflict is inevitable. Emergency medical technicians (EMT) are in contact with various groups such as administrators, hospital staff, and patients with different cultural, age, and gender backgrounds. EMTs face daily exposure to human tragedy and chronic stressors such as dealing with cardiac arrest, chronic diseases, accidents, and unlike a hospital, they do not work in a well-equipped environment with sufficient medical staff. In this situation, they must make a decision quickly and provide proper care to their patients. [1] [2] [3] [4] [5] [6] [7] Persistent conflict at work is detrimental to the work climate and negatively affects individual's psychological and physical well-being including damaging to a team environment, insomnia, distraction, anxiety, absenteeism, depression, fatigue, frustration, and extreme anger, family problems, and physical illnesses such as heart disease, pain, migraines, headaches, indigestion, and intervertebral disc herniation. [8] [9] [10] [11] [12] [13] [14] Given the importance of this concept, there are few studies in this field. In some research articles and of course, textbooks, workplace interpersonal conflict (WIC) in prehospital emergency has been indirectly mentioned, but what is essential is the need to explain this concept and its features, as well as the antecedents and consequences. This lack of structural and semantic clarity is hardly surprising given the difficulty in distinguishing between episodes of conflict and the regular social interaction. This is to help theorize and do more research in this area.

Concept analysis is the application of a specified method to examine a concept of interest to ascertain its attributes and can be defined as the dissection of a concept into more straightforward elements to promote clarity. [15, 16] The purpose of concept analysis is to analyze, define, develop, and evaluate a concept. If the researcher notes a lack of clarity surrounding the concept, it should undertake to achieve a better understanding of the concept. [15] A concept analysis can elucidate the meaning of the concept in current use, which can contribute to the future development of the concept. [17] This study aims to examine the concept of WIC in prehospital emergency.

A concept often described as a label, expressed as a word or phrase that summarizes the essence of a phenomenon. [18] Concept development is an essential prerequisite for the advancement of knowledge. [19] Among different strategies developed for concept development, concept analysis is a simplified and explicit approach where the attributes of the intended concept initially identified and the concept differentiated from other similar concepts. [20] There are many different approaches to concept analysis. The determining factors in adopting a strategy are the scope of interest and the aim of the analysis. [19] In this paper, Walker and Avant's concept analysis used to examine and clarify the phenomenon of WIC in prehospital emergency. This is a structured, step-by-step approach frequently used in previous studies. The eight steps of the Walker and Avant's approach are as follows: (1) selecting a concept; (2) determining the aim of analysis; (3) identifying all possible uses of the concept in pre-hospital emergency; (4) determining concept defining attributes; (5) identifying a model case; (6) identifying a borderline and a negative case; (7) identifying antecedents and consequences of the concept; and (8) defining empirical referents of the concept. [21] 

Using the keywords "conflict, pre-hospital emergency, emergency medical services (EMS), and WIC" published articles in English and Persian by 2019 in Iranmedex, SID, Magiran, ISC, PubMed, Scopus, Embase, and Web of Science databases, were extracted. No concept analyses of WIC conflict in prehospital emergency found. English-language dictionaries were also used to further define the concept. The inclusion of articles in the review was based on the relevancy of content regarding background, definition, use, defining attributes, and consequences of WIC in prehospital emergency. Articles that did not refer to the foreword conflict were excluded. Initially, 137 documents were retrieved met the inclusion criteria. We extracted and read the full texts of all these documents. Finally, one dictionary, nine books, and 25 original research articles were used for data analysis. The research team had a full agreement on the inclusion of these documents in the final analysis. They started the process by reading each record at least three times. For the third time, we identified words and phrases that stood for the attributes of the WIC in prehospital emergency. After that, we arranged identified words and phrases in descending order according to their frequency to determine the attributes of the concept. Finally, we categorized the attributes according to their differences and similarities to identify the defining attributes of the WIC.

This study was part of a PhD dissertation in nursing approved by the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran (code: IR.TUMS.VCR. REC.1397.642). The agreement of the authorities of the study setting was gotten for the study.

Steps 1 and 2 explained in the Introduction. Steps 3-8 described below.

Researchers identified all applications of the concept by reviewing the related literature. [21] Conflict is difficult to define because it occurs in many different settings. The essence of conflict seems to be disagreement, contradiction, or incompatibility. Thus, conflict refers to any situation in which there are incompatible goals, cognitions, or emotions within or between individuals or groups that lead to opposition or antagonistic interaction. Conflict is a complex behavior. It can occur on various levels -intrapersonal, interpersonal, intragroup, or intergroup. Intrapersonal conflicts occur within the person, whereas interpersonal conflict takes place between people. Similarly, intragroup conflict happens within one group of people, and intergroup conflict occurs between two or more groups of people. [22] [23] [24] [25] In Webster's Dictionary, mentioned that conflict is a battle, contest, or opposing forces existing between primitive desires and moral, religious, or ethical ideas. [26] Organizations based on interpersonal interactions, and where there is interaction, there is conflict. Interpersonal conflict is an essential type of conflict and defined as a disagreement between two persons or subgroups of an organization involving significant bitterness and dissatisfaction. [27, 28] Interpersonal conflict is a mild form of aggressive behavior. It can be overt, such as being rude to a coworker, or covert, such as spreading rumors about a coworker. Interpersonal conflict is an essential stressor in the workplace and is associated with career consequences and negative psychological states. Stress caused by interpersonal relationships endangers the mental and physical health of the employee. [29] Because individual interests are understood to be opposed or negatively affected, this type of conflict often seen as a negative term. [30] Conflicts are more common in stressful work environments, which have a complex network of interpersonal relationships, and in situations that are associated with decisions about health, illness, death, and life such as those in the health-care system. [11, [31] [32] [33] In recent years, attention and focus on WIC and its effect on the health-care system and the workers has increased. [34] WIC refers to negatively charged interactions with others at the workplace and often reported as one of the most stressful aspects of the job by employees. [29, 35] A variety of individuals, including doctors, nurses, coworkers, managers, and administrative workers might have experienced conflicts. [31] In the workplace setting, it often involves personal agendas, insights, or goals versus the plans, ideas, or goals of the group or team. [36] Frequent interpersonal conflicts create an unpleasant working atmosphere and adverse effects on the body and mind. And increase workload, stress, absenteeism, higher turnover intentions, reduce cooperation, unprofessional and counterproductive work behavior, mistreatment of colleagues and clients, reduce job satisfaction, and the effectiveness diminished. [5, 8, 37, 38] Some researchers have also used the term in the field of ethics as a challenge that emergency technicians face in complex emergency work environments. [12, 39] Concerning the nature of the prehospital emergency work environments, conflict is inevitable, and in this study, we were going to look at that WIC.

Determining defining attributes is the heart of concept analysis. [21] Working in the health-care system is emotionally and physically demanding and can be exacerbated by long hours and teams competing for resources. Concerns have recently raised about the WIC and its impact on the health-care system and workers. [34] Various people, including doctors, nurses, coworkers, managers, and office workers, may be involved. [31] A review of literature revealed the following attributes: conflict-generating workplace due to challenging and unpredictable nature of referred cases, quality of equipment, dispatching systems, structure and functions on patients' admission, and interactions with family of patients during entering the patients' home, [4, 10, 32, [40] [41] [42] [43] [44] conflict with administration's agenda, insights, and goals, [11, 32, 39, 43, 45, 46] conflict with coworker and team member, [4, 10, 11, 14, 32, 39, 43] conflict with patient/ family/bystander, [32, 39, 43, 46, 47] harmful types of conflict (dysfunctional/destructive), and positive kinds of conflict (functional/constructive). [2, 10, 32, 40, 43] Some of these positive and negative consequences mentioned in sections 3.7.

Various stages have taken to form a conflict, for example, Thomas [48, 49] describing five steps of conflict (awareness, thoughts, and emotions, intentions, behavior, and outcomes). Here, we refer to Pondy's opinion. The Pondy described five stages to the formation of conflict. Latent conflict in which the factors that could become a cause of potential conflict exist; perceived conflict, where people become aware of a conflict; felt conflict, where the conflict is not only understood but felt, cognized and personalized; manifest conflict, where the existence of the conflict becomes evident to other people not involved; and conflict aftermath, or the outcome of the conflict episode, where conflict stopped by some method and new conditions established. The result of conflict may have positive or negative repercussions for the organization, depending on how conflict is resolved. [50] Conflict management based on the principle that not all conflicts are necessarily solvable, but gaining skills in conflict management can reduce the likelihood of escalating inefficiencies. Conflict management requirements include conflict-related skills, self-awareness about a variety of conflict situations, communication skills in the face of conflict, and the ability to create a practical framework for managing conflict in the environment. All members of the organization need to know how to minimize the potential for conflict and be able to address the problems that arise before these conflicts become a severe problem in the work process. [51] [52] [53] [54] Thomas et al. have introduced five styles of conflict resolution: competing, accommodating, avoiding, compromising, and collaborating, among which the collaborative style introduced as the most effective way to resolve conflicts in the work environment. [49, 55] In summary, there are several vital attributes of WIC including its types, stages, and effects. Although the interaction between at least two people is the main attribute, where one or both perceive the opposition of the other. The role of perception is vital. For example, regardless of whether goals are incompatible, if either of the people believes them to be inconsistent, then the conditions are set for conflict.

Step 5: Identifying a model case A model case is an example of the concept of interest, which includes all defining attributes. [21] The model case is an example that has all the defining attributes of a concept and is, in fact, a classic example of the concept analyzed. One of the best ways to do this is to find a case that is an example of the concept under study. Such a model should choose clearly.

Mr. Rezaei (This is a pseudonym), 25-year-old, is an EMT. In one of the missions, he transferred the acutely ill patient, who had suffered multiple trauma due to a car accident, to a general hospital. When he intends to deliver the patient to the triage department, the triage nurse, without greeting Mr. Rezaei, angrily tells him why he did not establish an IV line for the patient and that his cervical collar did not fix. Mr. Rezaei explains that the scene of the accident was very crowded and that the patient had to rush to the hospital due to his poor health; as a result, he has not been able to provide complete treatment for the patient. At this time, the emergency physician enters, and he also supports the triage nurse and does not s sign and confirm Mr. Rezaei's mission report. Mr. Rezaei, who was also under a lot of stress at the scene of the accident and treated at the hospital, has an accident while returning to the base while driving an ambulance.

This model case represents an ideal example of the concept of "WIC" and includes most of the defining attributes. The hustle and bustle of the scene caused Mr. Rezaei has transferred the patient to the hospital without any full medical treatment. In the hospital, there is a conflict between him and the triage nurse and then the emergency physician due to inadequate professional communication, which results in an accident on his way back.

When researchers defined attributes of related concepts overlap with the analyzed concepts, it was challenging to identify the most representative defining attributes. Therefore, identifying a case that is contrary to a model case can help researchers determine the most representative attributes of studying a concept. [56] The contrary case "does not meet any of the attributes of the concept. It is an example of what the concept did not demonstrate." [21] An example based on the researcher's working experience provided here. Mr. J is a paramedic with 10 years of experience working in prehospital emergency. His colleague is a technician with 8 years of experience. At 2 p.m., they dispatched to a crowded bank. A case is a 45-year-old male who has chest pain and a history of heart disease. The patient is sitting on the floor in the main hall of the bank, complaining of chest pain. Many people have gathered around him and are continuously shouting at the technicians to take the unfortunate patient to the hospital sooner. When Mr. J is assessing and caring for the patient, his colleague, with the help of the bank's security guard, immediately disperses the people and quickly brings the transport equipment to the patient's bedside. In the hospital, Mr. J calls the medical director inside the ambulance and during the patient's transfer. While performing the care according to the approved instructions, he delivers the patient to the triage nurse by presenting a complete history. This patient is now in better condition, thanks to him and his colleague. Mr. J and his colleague say goodbye to the triage nurse with a smile.

In this case, experienced technician, with the help of a colleague, try to reduce all the factors that cause conflict so that they can achieve their primary task of patient care, and the excellent result is that both the patient and the hospital staff and of course himself. The technicians leave the hospital feeling satisfied and wish each other success.

Step 7: Identifying antecedents and consequences of the concept A limited number of articles and textbooks deal directly with the conflict in prehospital emergencies. Still, some documents address the specific conditions of the prehospital emergency work environment and cite factors as antecedents for conflict, as well as its consequences. Some of them mentioned.

According to Walker and Avant's explanation, antecedents are those events or incidents that must occur before the occurrence of the concept. [21] In the searched documents, some of the antecedents of WIC were personality and/ or value differences, blurred job boundaries, the fight for scarce resources, decision-making, poor communication, competition amongst departments, unreasonable work expectations (policies, rules, deadlines, time restriction), unmet and/or unrealistic expectations (regarding salary, advancement, or workload). Most conflict research reveals that the majority of health care conflict arises from "interpersonal or professional communication difficulties." [1] [2] [3] 5, 11, 13, 39, 43, [45] [46] [47] [57] [58] [59] [60] Based on Walker and Avant, the consequences are those events or incidents that occur as a result of the occurrence of the concept. [21] The consequences of conflict can be destructive or constructive. Conflict is constructive when it supports the group's goals and improve its performance, explains, and clarifies the problems and challenges, contributes to the problem solving, gets individuals involved in resolving matters that are important to them, helps individuals to develop understanding and skills, contributes to communication, makes sense of participation among people by making a difference them to urge to know more approximately each other. [61] [62] [63] [64] Moreover, conflict is destructive when it hinders the work of the group, undermines self-esteem, distracts attention away from essential activities, polarizes individuals and decreases participation, leads to harmful and irresponsible behavior. [62, 65, 66] In the searched documents, some of the destructive consequences of WIC were depressive disorders and poor mental health, physical ailments such as pain, job dissatisfaction, burnout, higher absenteeism, and diminished teamwork. [1] [2] [3] 11, 13, 39, 43, [45] [46] [47] [57] [58] [59] [60] Step 8: Defining empirical referents of the concept The last step of concept analysis is defining empirical referents. Walker and Avant state that "empirical referents are classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself." [21] Based on our concept analysis, the proposed definition of WIC in prehospital emergency is as follows: WIC in the prehospital emergency is the disagreement between the EMT and others coworkers, management, patients, etc.) for a variety of reasons, including complex work environment conditions, competitive environment, unclear rules, and interpersonal or professional communication difficulties that can have physical and psychological consequences (various mental and physical illnesses, absenteeism, Intention to Leave, etc.). A theoretical model of the antecedents and consequences is presented, with implications for further development [ Figure 1 ].

Concept analysis not only clarifies the existing state of knowledge about a concept but also identifies directions for further development. The literature provided insights, theoretical elements, and descriptions of the contexts, antecedents, and consequences of conflict. In this study, it found that limited research articles addressed the concept of conflict directly and in some articles, indirectly addressed the challenges and stresses of the emergency work environment. However, some textbooks in prehospital emergency referred to this concept.

In this study, it found that the unique, complicated, and stressful workplace of prehospital emergency is one of the causes of conflict, which it was in line with other health-care system studies that emphasized the role of the workplace in creating conflict. [11, 32, 54] It can say that the prehospital emergency workplace is more complex and stressful due to the unknown nature of missions, long shifts, low staffing, and patient diversity from medical to trauma and as a result, it can be more of a cause for conflict.

According to the findings of the present study, such as other areas of the health system and of course other organizations, poor communication was one of the main reasons for the conflict in the prehospital emergency. [11, 48, 53, [67] [68] [69] [70] There are several possible causes for poor communication in prehospital emergencies, the most important of which is the need for high-speed emergency services, the uncertainty of emergency missions, and the low level of information available to the hospital. Communication fails when trust between two people is lost, and there is no transparency in the exchange of information. The nature of prehospital emergency missions is such that services must provide quick, and this speed can reduce accuracy. In some cases, it is not possible to obtain complete information from the patient, for example, when the patient is unconscious at the scene and has no companion or when the companions are not willing to provide information. When hospital staff feels they have not received enough reports from the emergency technician, there is a loss of trust, which in turn leads to the failure of communications on subsequent missions.

The undeniable fact is that there is a conflict in the prehospital emergency workplace, as in other health care systems, but what is important is how to deal with this conflict, which can have both constructive and destructive consequences. Research shows that conflict in organizations can have positive or destructive consequences. The essential destructive consequences of conflict are the loss of time and energy of the organization, dissatisfaction in the organization, reduction of the group's effectiveness, forgetting the main goals in the organization, people's misjudgment of each other, weakening of harmony, and lack of disagreement between the organizational groups. Loser people get away from each other, and the organization disintegrates instead of integrating. [8, 54, 61, [71] [72] [73] Conflict also has positive consequences, such as making changes, fostering creativity and innovation, clarifying topics, goals, perspectives, and ideas, making communication better and more appropriate. Increasing energy in the organization, assessing the abilities and capacities of employees, resolving stagnant and complicated issues and creating views, pointed out better and more constructive opinions. [73] [74] [75] The consequences of interpersonal conflict necessitate the requirement for healthcare organizations to have evidence-informed guidelines to manage and mitigate conflict. In general, conflict can reduce motivation and satisfaction among EMTs, and this in itself can reduce the communication between health care providers. On the other hand, inappropriate communication creates conflict. Finally, conflict reduces the attention and focus of EMTs from patient care to conflict situations, which can result in inadequate patient care.

One of the limitations of the present study was the texts selected as the source. The larger the volume of data included in the study, the clearer the meaning of the studied concept. Of course, concept analysis never ends; whenever new knowledge or experience regarding the concept in question appears, further development of the concept is required. In this study, we only included documents published in English or Persian languages. Accordingly, documents in other languages and unpublished data on WIC did not include in the analysis.

WIC can affect the quality of service provided by a health-care system. Wherever there are communication and interaction, conflict is inevitable. In a prehospital emergency system, with multiple communications from the patient and his companions to the hospital's coworkers and staff, this possibility is even greater. How to deal with this conflict is essential. Determining the boundary between constructive and destructive conflict is also tricky and ambiguous. No conflict at any level can accept as an acceptable or unacceptable conflict for all circumstances. The conflict that results in a positive, constructive outcome for one group may have detrimental consequences for the other group, or the same group at the end of the day. With proper management and training of conflict management skills can benefit from the positive consequences of conflict, the result of which will be to increase the satisfaction and health of medical staff as well as improve patient outcomes. 

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This article is part of a Ph. D. dissertation in nursing approved by the vice-chancellor in research affairs-Tehran University of Medical Sciences (IR.TUMS.VCR. REC.1397.642). We are proud to present this study to all EMT at the forefront of the fight against COVID-19.

This study was financially supported by Tehran University of Medical Sciences.

There are no conflicts of interest.