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Understanding Conflict Management Styles in Anesthesiology Residents

Vasilopoulos, Terrie, PhD*,†; Giordano, Christopher R., MD*; Hagan, Jack D., MD*; Fahy, Brenda G., MD, MCCM*

doi: 10.1213/ANE.0000000000003432
Medical Education: Original Clinical Research Report

BACKGROUND: Successful conflict resolution is vital for effective teamwork and is critical for safe patient care in the operating room. Being able to appreciate the differences in training backgrounds, individual knowledge and opinions, and task interdependency necessitates skilled conflict management styles when addressing various clinical and professional scenarios. The goal of this study was to assess conflict styles in anesthesiology residents via self- and counterpart assessment during participation in simulated conflict scenarios.

METHODS: Twenty-two first-year anesthesiology residents (first postgraduate year) participated in this study, which aimed to assess and summarize conflict management styles by 3 separate metrics. One metric was self-assessment with the Thomas-Kilmann Conflict Mode Instrument (TKI), summarized as percentile scores (0%–99%) for 5 conflict styles: collaborating, competing, accommodating, avoiding, and compromising. Participants also completed self- and counterpart ratings after interactions in a simulated conflict scenario using the Dutch Test for Conflict Handling (DUTCH), with scores ranging from 5 to 25 points for each of 5 conflict styles: yielding, compromising, forcing, problem solving, and avoiding. Higher TKI and DUTCH scores would indicate a higher preference for a given conflict style. Sign tests were used to compare self- and counterpart ratings on the DUTCH scores, and Spearman correlations were used to assess associations between TKI and DUTCH scores.

RESULTS: On the TKI, the anesthesiology residents had the highest median percentile scores (with first quartile [Q1] and third quartile [Q3]) in compromising (67th, Q1–Q3 = 27–87) and accommodating (69th, Q1–Q3 = 30–94) styles, and the lowest scores for competing (32nd, Q1–Q3 = 10–57). After each conflict scenario, residents and their counterparts on the DUTCH reported higher median scores for compromising (self: 16, Q1–Q3 = 14–16; counterpart: 16, Q1–Q3 = 15–16) and problem solving (self: 17, Q1–Q3 = 16–18; counterpart: 16, Q1–Q3 = 16–17), and lower scores for forcing (self: 13, Q1–Q3 = 10–15; counterpart: 13, Q1–Q3 = 13–15) and avoiding (self: 14, Q1–Q3 = 10–16; counterpart: 14.5, Q1–Q3 = 11–16). There were no significant differences (P > .05) between self- and counterpart ratings on the DUTCH. Overall, the correlations between TKI and DUTCH scores were not statistically significant (P > .05).

CONCLUSIONS: Findings from our study demonstrate that our cohort of first postgraduate year anesthesiology residents predominantly take a more cooperative and problem-solving approach to handling conflict. By understanding one’s dominant conflict management style through this type of analysis and appreciating the value of other styles, one may become better equipped to manage different conflicts as needed depending on the situations.

From the Departments of *Anesthesiology

Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida.

Published ahead of print May 17, 2018.

Accepted for publication April 4, 2018.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Brenda G. Fahy, MD, MCCM, Department of Anesthesiology, University of Florida College of Medicine, 1600 SW Archer Rd, PO Box 100254, Gainesville, FL 32610. Address e-mail to bfahy@anest.ufl.edu.

KEY POINTS

  • Question: What are the predominant conflict styles in anesthesiology residents?
  • Findings: Overall, the median scores for anesthesiology residents were highest in the domains of compromising, problem solving, and accommodating, suggesting that they take an overall cooperative approach to conflict.
  • Meaning: Understanding one’s dominant conflict style may allow health care providers to better adapt their approach to conflict management in clinical settings.

Residency is a demanding and stressful time in a clinician’s career.1–3 Each specialty, including anesthesiology, has a unique set of stressors. One major and common contributor to work-based stress is interpersonal conflict.4 There are many potential sources of interpersonal conflict in the workplace, including with superiors, peers, and patients,5 and reducing this conflict, via improved communication, could lead to a reduction in stress for residents during their training.4 The Accreditation Council for Graduate Medical Education recognizes the importance of reducing interpersonal conflict with their inclusion of communication and professionalism as competencies (Table 1).6 Thus, there is a need to better understand different conflict management styles and use this knowledge to teach effective conflict management.7

Table 1

Table 1

A common source of conflict among staff members is the breakdown in communication.8 Poor communication can readily compromise patient safety9 and is identified as a common root cause of sentinel events related to anesthesia.10 Successful conflict resolution is recognized as a key component of effective teamwork required for quality patient care,11 especially when it requires interprofessional communication.12 Thus, learning skills that can help resolve conflict is an important step for providing optimal patient care.13

One popular and validated self-assessment for conflict management styles is the Thomas-Kilmann Conflict Mode Instrument (TKI). In 1974, Kilmann and Thomas14 built on a preexisting business managerial grid to develop a self-assessment instrument that measures 5 conflict management styles (accommodating, avoiding, collaborating, competing, and compromising) across 2 dimensions (assertiveness and cooperativeness) (Figure 1).14–16 Some studies have assessed TKI conflict styles in residents in other fields and how they relate to performance and communication.17 , 18 To the best of our knowledge, there are no similar studies published specifically regarding TKI conflict management styles in anesthesiology residents.

Figure 1

Figure 1

Another validated conflict management style assessment tool is the Dutch Test for Conflict Handling (DUTCH). The DUTCH allows self-assessment and assessments of others’ conflict management style. The DUTCH (Figure 2) also assesses 5 conflict scales: avoiding, compromising, forcing, problem solving, and yielding,19 , 20 which are also a function of 2 dimensions (concern for others versus concern for self) and have been shown to converge with the behaviors observed during conflict.19 Higher TKI and DUTCH scores would indicate a higher preference for a given conflict style. A key difference between the TKI and the DUTCH is that while the TKI measures responses to proposed conflict scenarios, the DUTCH assesses conflict response after actual interactions.

Figure 2

Figure 2

With a cohort of anesthesiology residents, the goals of the present study were to (1) assess and summarize conflict management styles using the TKI self-assessment; (2) assess and summarize conflict management styles using the DUTCH assessment of both self- and resident counterpart after simulated conflict scenarios; (3) compare self- and counterpart ratings of conflict management styles using the DUTCH; and (4) correlate self-assessment of conflict styles with the TKI and the DUTCH.

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METHODS

This study was approved by the University of Florida Institutional Review Board, and written informed consent was obtained from all subjects.

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Thomas-Kilmann Conflict Mode Instrument

The TKI was administered to 20 first postgraduate year (PGY-1) anesthesiology residents enrolled in a 4-year anesthesiology training program during a dedicated 4-week education rotation that they all participated in during the month of November. The selection of PGY-1 residents allowed a baseline assessment of each resident’s predominant conflict management style that could later be followed during their residency. The TKI is a validated instrument and contains 30 statements pertaining to conflict situations that are used to assess 5 conflict modes/styles: accommodating, avoiding, collaborating, competing, and compromising.14 , 21 (Figure 1). For each statement, participants are required to choose 1 response of 2 that best reflects how they would handle that particular situation. Responses correspond to one of the 5 conflict modes, with each conflict mode being assessed by choosing conflict style options within each of the 30 questions. Scores on the TKI are then converted to percentile scores (0%–99%) based on a normative sample; higher percentile scores indicate high use of that particular conflict mode (and vice versa).14 , 22

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Conflict Scenarios and DUTCH

The DUTCH was used to assess conflict management styles through self-assessment and counterpart assessment after each of the 2 different conflict scenarios. The DUTCH is a validated, 20-item instrument that assesses 5 conflict scales: avoiding, compromising, forcing, problem solving, and yielding.19 , 20 (Figure 2). Each scale contains 5 statements to which participants respond using a 5-point scale regarding their agreement: 1 = not at all to 5 = very much19 , 20; thus, scores for each scale could range from 5 to 25 points.

A third party who had no knowledge of the residents randomly assigned participants to groups and roles. For each of the conflict scenarios, participants were assigned as groups of 2 to a resident dyad. Each participant was then assigned a role in the particular scenario; the role was further elucidated in a brief description and background to support their unique perspectives of the clinical situation as well as some potential outcomes for the event. The scenarios entailed a resident–resident negotiation concerning professional responsibilities, which provided the participants the opportunity to have a vested self-interest in the outcome of the conflict. Because the residents were PGY-1s and had very little anesthesiology acumen or practice, the conflicts were peer to peer and focused on professionalism: staying late to cover cases and evaluating a do-not-resuscitate order. Each scenario had 2 designated outcomes for the simulated conflict solution. One version of the conflict scenario was assigned to each of the dyadic partners to create the conflict, and each was instructed to treat this as a realistic event. Each dyad then entered into a closed office that had a table with seats on either side, and the individuals were instructed to best interact with their counterpart as though they were experiencing the described situation. The participants had total flexibility and autonomy to achieve or progress toward their goals as they saw fit, with no requirement for any particular final resolution to signal completion of the activity. Each group of 2 residents had 10 minutes to review and prepare their approach to the scenario and 8 minutes to address the scenario in any fashion with their counterpart. A complete resolution of the conflict was an acceptable option within the time constraints allotted. After resolution of the conflict scenario or the time allotted for the scenario was reached, each resident completed the DUTCH regarding self- and their counterpart’s conflict management style. Each resident was then randomized into a different dyad with another conflict scenario. As a result, each resident participated in 2 different conflict management scenarios with 2 different counterparts.

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Statistical Analysis

Results from the TKI and DUTCH assessments were summarized as medians with first and third quantiles (Q1–Q3). Sign tests (for paired data) were used to compare DUTCH scores between self- and counterpart ratings. Spearman correlations were used to assess the association between ratings on the DUTCH with TKI self-assessment. A P value < .05 was considered statistically significant.

Power analyses were conducted using G*Power (Universität Düsseldorf, Germany).23 All power analyses were calculated for 80% and α = .05. For nonnormally distributed paired data, comparing self- and counterpart DUTCH scores, n = 20 would be needed to detect a difference of 0.7 points (standard deviation = 1.5),19 assuming 0.5 correlation between factors. This sample size would be able to detect a statistically significant correlation of 0.55.

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RESULTS

Twenty-two (n = 22) PGY-1 anesthesiology residents participated in this study. Summaries of TKI and DUTCH scores are reported in Figures 3 and 4. For these anesthesiology residents, the highest median percentile scores on the TKI were reported for accommodating (69th percentile) and compromising (67th percentile), with the lowest median percentile scores for competing (20th percentile) (Figure 3). Furthermore, nearly all residents (82.8%, 18/22) scored in the 75th percentile or higher in either accommodating or compromising. On the DUTCH, the highest median scores were reported for compromising and problem solving, and the lowest median scores were reported for avoiding and forcing, for both self- and counterpart ratings (Figure 4).

Figure 3

Figure 3

Figure 4

Figure 4

Self- and counterpart ratings for each DUTCH scale were also compared with Wilcoxon signed-rank tests. For avoiding (P = 1.0), compromising (P = 1.0), forcing (P = .115), problem solving (P = .057), and yielding (P = 1.0), there were no statistically significant differences between self- and counterpart ratings.

Table 2

Table 2

Table 2 reports Spearman correlations between percentile scores of each TKI style with scale scores on DUTCH (self-ratings only). High median percentile scores for the avoiding style on the TKI were positively associated with self-reported avoiding on the conflict scenarios using DUTCH scores. Competing style as measured by the TKI was associated with DUTCH scores, with inverse, negative associations with compromising (nonsignificant) and avoiding, and a nonsignificant positive association with forcing.

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DISCUSSION

The present study evaluated conflict management styles in a cohort of anesthesiology PGY-1 residents in the first 6 months of training via the TKI conflict management self-assessment survey and the DUTCH self- and counterpart assessments after 2 simulated conflict scenarios. The DUTCH self- and counterpart assessments revealed higher scores for both compromising and problem solving in addition to lower scores for forcing and avoiding. Similarly, on the TKI, the PGY-1 anesthesiology residents were more likely to select compromising and accommodating styles, while having lower ratings for competing and avoiding. In this study, anesthesiology PGY-1 residents in the TKI assessment were compromising and accommodating, which suggests cooperativeness in both conflict management styles and moderate-to-low assertiveness based on their predominant compromising and accommodating styles.

Interestingly, this pattern for the PGY-1 anesthesiology residents differed from those TKI conflict styles reported by obstetrics and gynecology residents.17 , 18 , 24 For the obstetrics and gynecology residents, the avoiding conflict style was the most selected during the self-assessment, followed closely by compromising and accommodating, with competing and collaborating styles less likely to be selected.24 Similar results have been reported in a study examining radiology residents, with the avoiding style most selected during self-assessment.25 Studies have shown these conflict styles to be related to resident behavior and performance.17 , 18 Although the above studies have linked conflict self-assessment with behavior, few studies have used standardized, observed conflict assessments in residents.26 , 27

Studies of businesses outside of health care have established that those of “lower status” within the organization more often use accommodating styles.28 , 29 Studies are limited on the topic of power and conflict,30 , 31 which may have influenced the ratings on the DUTCH assessments. PGY-1 anesthesiology residents in the first 6 months of training are just beginning their training paradigm, and, as such, also have a “lower status.” Perhaps, this partially accounts for their more accommodating style similar to those of “lower status” in business studies. In addition, the scenario focused on a peer-to-peer discussion in which one resident would ask another to provide additional, undesirable clinical responsibilities. This setup may have encouraged a more compromising and problem-solving conflict management style as the residents are used to working together toward mutually acceptable agreements.

Interprofessional teamwork remains important for quality patient care in the operating room.32 In this setting, the ability to communicate effectively and successfully resolve conflicts is an important aspect in the effective teamwork required for quality patient care.11 Anesthesiology residents may recognize their roles as members of interprofessional teams, which may explain why the avoiding and competing conflict management styles are less prevalent. In a study of health care practitioners, the avoiding conflict management style was identified as a major challenge to advancing toward interprofessional collaboration.33

Scores on the TKI have been associated with workplace behaviors and success. In obstetrics and gynecology residents, TKI conflict styles correlated with workplace compliance, which included attendance at required activities, project completion, and accountability. Specifically, collaborating and competing styles were associated with better compliance, whereas avoiding and accommodating styles were associated with worse compliance.18 Furthermore, TKI styles differed across other metrics of resident performance. Compared to other residents, those residents entrusted with administrative responsibilities had higher competing style scores and lower accommodating and avoiding scores. On the other hand, residents who were under academic remediation had lower collaborating scores and higher avoiding and accommodating scores compared to residents who were not under academic remediation.17 The effects of the potential differences in overall conflict styles used by anesthesiology residents compared to other specialties were not evaluated in this study.

Finally, we compared scores from the TKI to the DUTCH. The associations that existed are consistent with the conflict management styles measured. Those who had high scores on avoiding on the TKI also reported high avoiding on the DUTCH after the conflict scenario. Similarly, those who had high scores on competing on the TKI reported lower avoiding and lower compromising on the DUTCH, as well as higher forcing. However, many of the correlations were not statistically significant. This could be because the study was underpowered to detect moderate correlations. However, the differences in how the TKI and DUTCH are implemented and constructed could also contribute to the lack of differences. Although both assess conflict styles over 2 dimensions, those dimensions differ, with the conflicts styles as a function of assertiveness and cooperativeness in the TKI versus as a function of concern for others and concern for self in the DUTCH. Furthermore, the approach to assessing conflict differs between the instruments. In the TKI, the residents were forced to choose between 2 conflict styles in response to a hypothetical situation. The DUTCH, however, required the residents to assess the use of all 5 conflict styles after their involvement in a single, interactive conflict scenario.

Each person has a predominant conflict management style based on his or her concerns for self (assertiveness) and others (cooperativeness). In clinical settings (as well as general professional settings), this predominant style is not appropriate for all conflict situations. Certain contexts call for different conflict styles based on the situational features: power, hierarchy, experience, safety, harm, timeliness, importance, tension, and so forth. In fact, previous studies have shown that although individuals identify a dominant conflict management style via self-assessment, the individual can still adapt what type of style to use when interacting in real-life scenarios.34 Therefore, our goal was to best equip PGY-1 residents with the capability to detect an emerging conflict, recognize the surrounding context, and, by self-assessment and assessment of others, to recognize and understand their predominant conflict management style as well as that of their counterpart during a conflict and utilize different management styles to reach resolution.

Successful conflict resolution has been identified as a key component of effective teamwork in the operating room.11 On average, 4 conflicts surface between different team members in the operating room during each surgical operation.35 The operating room’s high-pressure environment involves highly trained physician anesthesiologists and surgeons,36 as well as other health care workers simultaneously and interdependently caring for the same patient.13 Conflict is common in this setting due to individual differences in values and beliefs, with studies reporting a minimum of 20% of physician executive time spent dealing with conflicts.32 Being able to appreciate the differences of training backgrounds, individual knowledge and opinions, and task interdependency necessitates skilled conflict management styles when addressing different clinical and professional scenarios. Before one can appreciate which conflict management style is appropriate for a specific encounter, he or she must first recognize his or her own dominant, default conflict management style. We believe with this self-knowledge, residents will become better equipped to adopt other conflict management styles as needed for inevitable team member conflicts.

Overall, the results of our study using a cohort of 22 PGY-1 anesthesiology residents revealed that this group of residents was more likely to use a cooperative approach when handling conflict, which differs from previously reported studies of residents from other specialties. This suggests that perhaps different specialties have different conditions and conflicts, which then may require altered approaches to resolving these conflicts. The notion that certain personality traits gravitate toward particular medical fields can be found throughout the literature; to the best of our knowledge, however, similar studies have not been performed for conflict management styles.35 , 37 , 38

Several limitations should be considered when reviewing these results. Because this study was done at 1 institution, involving only PGY-1 anesthesiology residents in the first 6 months of their training, the results may not be generalizable to represent all PGY levels of anesthesiology residents. The use of a single institution may be a source of selection bias. Also, the use of dyads between 2 residents who may be familiar with each other may have biased discussions toward a more accommodating, cooperative tone. Replacing one of the residents in each dyad with standardized actors could eliminate possible bias introduced by familiarity between peers. Furthermore, although our study was adequately powered to detect group differences in the TKI and the DUTCH, it was underpowered to detect correlations between them. Studies whose primary goals are to compare these instruments require a larger sample size. Potential areas of further investigation include comparing conflict styles of PGY-1 to more experienced PGY-4 anesthesia residents, comparing across specialties using multiple institutions, and examining how conflict styles relate to behaviors important to anesthesiologists.

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CONCLUSIONS

In the operating room, teamwork is critical, and conflict is a common occurrence. Poor management of conflict has been shown to negatively impact patient safety.39 Understanding one’s predominant conflict management style is a first step in the training continuum to better navigate inevitable conflicts. Therefore, our goal was to best equip PGY-1 residents with the capability to detect an emerging conflict, recognize the surrounding context, and understand their predominant conflict management style. Coupling that goal with an appreciation that certain conflict styles are necessary to manage different types of conflicts, along with recognizing a counterpart’s style amid conflict, will enable physicians to best handle a major source of stress, patient endangerment, and burnout.

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DISCLOSURES

Name: Terrie Vasilopoulos, PhD.

Contribution: This author helped design the study, analyze the data, and write the manuscript.

Name: Christopher R. Giordano, MD.

Contribution: This author helped design the study, collect study data, and write the manuscript.

Name: Jack D. Hagan, MD.

Contribution: This author helped design the study, collect study data, and write the manuscript.

Name: Brenda G. Fahy, MD, MCCM.

Contribution: This author helped design the study, collect study data, and write the manuscript.

This manuscript was handled by: Edward C. Nemergut, MD.

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