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Conflict resolution

Applying aviation crew resource management in healthcare

Braverman, Ariel BSN, RN, EMT-P

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Nursing Management (Springhouse): September 2021 - Volume 52 - Issue 9 - p 30-34
doi: 10.1097/01.NUMA.0000771740.79361.1c
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In Brief

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Figure

Conflicts are an inseparable part of human nature, and conflicts exist wherever human society exists. However, conflicts can have devastating results, especially in a complex, pressure-filled, multidisciplinary environment.1 By definition, conflict is an interaction where a person feels threatened because of his or her ideas, positions, or perspectives being challenged by another person or persons.2

Because the core of any threat is fear, it naturally sets up the two response traits that are typically seen in conflicts:

  • aggressively attempting to resolve the conflict by forcing another person to accept the position
  • withdrawing from the conflict, hoping it will resolve itself or go away.

The most common and natural response to fear is “fight or flight.” This response fundamentally dictates the conflict's intensity, which, in turn, is in direct proportion to our perception of the threat. The healthcare setting is a stressful environment, and almost any conflict may be augmented in a disproportional manner.3

To model a healthcare setting, it's logical to use another relatively stressful environment: aviation. An aircraft is a tight space with plenty of egos inside a flight deck and the cabin. Similar to healthcare, aircrew members work in an environment where conflict-related disruption may literally cost lives.4

One example of a poorly managed argument is a dispute that took place in May 2017 between two Qantas Airlines pilots in the cockpit of Boeing 747-400 at Dallas-Fort Worth International Airport.5 Both the captain and first officer got into an obstinate argument during routine preflight preparations due to a disagreement over the take-off performance calculations. As a contributing factor, the incident occurred when a major thunderstorm rolled across Dallas, disrupting services at the airport. The stressful situation caused calculation mistakes, which were detected by the flight computer and prevented the crew from being ready for departure. As the pilots were close to exceeding their 20-hour duty limits due to delays caused by the weather, the Qantas flight operations managers kept the plane on the ground overnight.

During the overnight grounding, flight operations management found out about the dispute, and their first action was to immediate replace both pilots, causing the flight to be postponed to the next day. The operations managers' response may appear radical, but it's typical in the aviation world when safety-related issues arise. Any conflict inside the flight deck is considered a potential breach of flight safety regulations that should be resolved immediately; several notable airline accidents have happened due to cockpit conflicts.6

Prevention of conflicts between crew members in aviation is a mandatory learning topic for any airline pilot. Conflict resolution skills, especially for captains, are tested every 6 months during recurrent training, and crew resource management (CRM) principles provide solid guidelines to avoid a conflict in the first place or resolve it if it has already happened.

In this article, we explore the fundamental similarities between healthcare and aviation environments to help transfer and adapt conflict prevention and resolution methodologies.

Crew resource management principles

Conflict resolution is a common name for the methods and processes involved in facilitating the peaceful ending of a conflict. Efficient resolution of a conflict requires understanding the fundamental reason for the dispute and follows several tactics to neutralize it, including forcing the opponent into an agreement, collaborating to find a solution (a win-win situation), and compromising or withdrawing.7 There's no one universal solution to resolve disputes.

To simplify aviation's CRM approach, the initial stage of any conflict resolution should be a positive recognition that conflict is present. It may not be intuitive but, in many cases, conflict escalates because the opponents don't recognize that they're in a conflict. The next stage is to freeze the situation before aggravating the dispute. Then, an argument should be presented from low to high hierarchy; the last word will be at the highest rank present and is the final decision. However, others will have a chance to speak up due to an essential CRM principle: “All opinions matter.”

See Table 1 for the components of CRM.

Table 1. - CRM components
Situational awareness
  • Awareness of surroundings

  • Reality versus perception of reality

  • Prevention of fixation

  • Recognition of incapacitation (physical, psychological)

Communication
  • Cultural influence

  • Role in the team

  • Assertiveness

  • Listening

  • Feedback

Leadership/Followership
  • Team building

  • Managerial skills

  • Authority

  • Professionalism

  • Credibility

Interpersonal skills
  • Listening

  • Conflict resolution

  • Mediating

Critique
  • Planning

  • Ongoing review

  • Debriefing

Stress management
  • Ability to perform

  • Fatigue management

  • Mental state monitoring


Humans happen

No methodology can overcome power abuse and power struggle. The phenomenon of power abuse is attributed to humanity from the beginning of documented history, and today is no different. Those in dominant positions often abuse their power to reduce criticism.8 The famous proverb, “With great power comes great responsibility,” is sometimes interpreted as an absolute monopoly on knowledge.

Consider the following example. In early 2021, the Czech Republic Civil Aviation Authority (CAA) published a final report about an August 2019 incident with a Boeing 737 belonging to the Czech airline Smartwings, which experienced uncontained engine failure midflight. Instead of immediately landing, the captain decided to continue to Prague on one engine. During the flight, the captain ignored the first officer's suggestions to divert and land. The report describes a “toxic cockpit environment,” and the captain's behavior was called a “God complex” and an “inflated sense of invincibility.”9 The incident was labeled as serious due to a lack of appropriate CRM, misjudgment, and the captain's lack of leadership skills.

Situations similar to the Czech aircraft incident can happen in the OR, clinic, or ED. Power abuse can occur in any place where organizational seniority is combined with experience and knowledge but not with openness and an ability to accept criticism. Any conflict situation may harm appropriate decision-making and directly hinder effective patient care.

The initial and most fundamental factor influencing power struggles in healthcare is the historical hierarchy that divides healthcare into physicians and nonphysicians, with physicians being considered an ultimate authority. Due to the development of additional healthcare specialties, healthcare hierarchy has become even more complex, with a subhierarchy among physicians (residents, consultants, interns, and so on) and within other groups, such as NPs versus RNs or LPNs. However, experience and knowledge are critical in decision-making and may cross hierarchical groups. The situation where more than one opinion exists may lead sides into a power struggle over the principle of “who's right” instead of “what's right.”

The healthcare setting has specific features that differ from aviation and may contribute even more to conflict development. For example, conflict may develop between professional groups rather than individuals. Disagreements might be rooted not only in professional differences, but also because of differences in social status, salaries, and scope of practice.

Practical implications

Effective prevention of power struggles in healthcare following aviation's CRM principles starts with setting two initial conditions that each team member, without reference to rank or experience, must see as fundamental: “Mistakes can kill” and “You don't know everything.” The second may be harder to establish. Senior management should provide a personal example, such as letting junior members of the team talk first.10 Otherwise, they might feel muted and won't engage in conversation to avoid being overpowered, insulted, or even abused. Switching from the importance of titles and formal experience to an environment where all opinions have a place isn't intuitive, so managers need to make sure this is part of the organizational culture.

The stressful environment of the healthcare setting is also a significant contributing factor to tensions and conflicts.11 Leaders need to monitor stress levels, detect evolving conflicts, and isolate the causes as fast as possible. An effective mechanism to monitor stress levels is educating midlevel management to recognize increased stress and address the situation. An additional measure is risk management. Personnel involved in an active conflict should be removed from the work environment due to the potential danger their behavior may present to patients, and the reasons for the dispute should be addressed. Consider changing the schedule to prevent conflicting parties from working together as a temporary measure while seeking long-term resolution of the conflict. Such preventive steps should be done carefully and thoughtfully to avoid further aggravation of the conflict.

Another factor that can create a conflict situation is low self-esteem and self-efficacy, leading to envy toward more “successful” colleagues.12 Healthy and employee-oriented organizational culture can effectively reduce the number of frustrated nurses; however, this is probably the most complex situation to recognize early and prevent conflict from arising.

See Table 2 for a summary of factors that can contribute to work-related conflicts in the healthcare environment and possible actions to reduce them.

Table 2: - Conflict contributing factors and solutions
Contributing factor Possible solution
A significant gap of experience or ranking within the team Allow junior and lower-ranked team members to speak first in the discussion and let all team members talk before making decisions.
High workload combined with insufficient staffing Identify increased workload and resolve the situation with additional staffing. If no extra personnel are available, make all efforts to reduce the administrative workload to allow more time for patient care, supply food and drinks, and offer financial compensation (if available).
A lawsuit against a healthcare team member or fear of a possible lawsuit due to medical/nursing error causing blame within the team Build a reliable personnel protection system (such as employer-sponsored access to legal counseling) and promote legal literacy among nurses. Engage in risk management by encouraging voluntary error self-reporting and a just culture.
Career stagnation, lack of promotion options, and pathologic envy toward peers Build a study-at-work system by allowing compensated study time and transparent merit promotion mechanisms. Additionally, a proactive separation of team members who develop envy-related tensions can be an effective conflict prevention solution. Such separation can be achieved by changing the work/shift roster or repositioning the employees in different departments/divisions.

Effective conflict resolution

Conflicts are a normal phenomenon, and they'll continue to appear. However, any organization that doesn't address internal conflicts is doomed to fail. Proactive, fast recognition of workplace conflicts is fundamental for effective resolution and practical conflict management skills remain a mandatory item in your leadership toolbox.

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