Conflict Resolution Styles and Skills and Variation among Medical Students

doi:10.21203/rs.3.rs-1840192/v1

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Conflict Resolution Styles and Skills and Variation among Medical Students

https://doi.org/10.21203/rs.3.rs-1840192/v1

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published 14 Apr, 2023

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Background: Conflict is inevitable on healthcare teams, yet few professional school curricula teach or assess conflict resolution skills. Little is known about the variation in conflict resolution styles across medical students and how these styles might impact conflict resolution skills.

Methods: Graduating medical students completed a mandatory conflict resolution session with standardized patients acting as nurses during a transition to residency course. Coaches reviewed videotapes of simulated student-nurse encounters, focusing on students’ conflict resolution style (assessed with the Thomas-Kilman Instrument (TKI)) and student skills with negotiation and emotional intelligence. We also assessed the impact of knowing one’s conflict resolution style, student gender, race and intended field of practice on conflict resolution skills.

Results: One hundred and eight students completed the simulated conflict session. Sixty-seven students completed the TKI before the simulated patient (SP) encounter and 41 after. The most common conflict resolution style was accommodating (n=40). Knowing one’s conflict resolution style in advance of the simulation and one’s identified race/ethnicity did not impact skill as assessed by faculty coaches. Students pursuing diagnosis-based specialties had higher negotiation (p=0.04) and emotional quotient (p=0.006) scores than those pursuing procedural specialties. Females had higher emotional quotient scores (p=0.02).

Conclusions: Conflict resolution styles vary among medical students. Male gender and future practice in a procedural specialty impacted conflict resolution skills, but knowing conflict resolution style did not.

conflict resolution

undergraduate medical education

entrustability

conflict resolution style

The healthcare environment is a complex system of relationships. The interplay amongst different professionals, staff, and trainees allows for the successful care of patients most of the time, but with daily stressors, it can also be a source of conflict. While conflict may improve the quality of decisions and enhance the understanding of diverse viewpoints,[1, 2] relationship conflicts negatively impact productivity, creativity, satisfaction, and task-related effort.[1, 3] Rudeness in the NICU decreased diagnostic and procedural performance.[4] Conflict also contributes to burnout.[5] In healthcare, poor working relationships correlated to higher levels of burnout in critical care nurses and physicians and general hospital staff.[6–8] However, personal conflict style and emotional intelligence have been found to have an impact on work environment, and subsequently, burnout.[5, 9, 10]

As a result, many professional training programs, including law and business schools, provide training in conflict resolution.[11–13] The need for formal training in conflict management in healthcare is highlighted in studies from both the emergency department and operating rooms, where continued negative conflicts can lead to high staff turnover, and thus, loss of experiential knowledge that could effect patient outcomes.[14, 15] While many health professions’ curricula focus on interprofessional communication, there are few that address conflict resolution specifically.[16–20]

We created a conflict resolution simulation for graduating medical students as part of their transition to residency course.[21] The objectives of this study were to 1) evaluate conflict resolution styles amongst graduating medical students, 2) assess if conflict resolution skills as judged by trained faculty coaches were impacted by knowing one’s conflict resolution style or by other personal characteristics (e.g. intended specialty, gender, and/or under-represented minority (URM) status, and 3) assess the value to students of practicing conflict resolution skills while considering one’s conflict resolution style.

Conflict Resolution Curriculum in Capstone

Duke University School of Medicine has a mandatory, longitudinal transition to residency course for fourth-year medical students. Individual students are assigned faculty coaches (1 faculty: 8 students) at the start of the course and coaches provide individual feedback to students across several exercises, such as a discharge summary, informed consent, managing difficult conversations, handoffs, simulated paging, triage, and high-fidelity simulation. In 2016, we introduced a conflict resolution simulation session as part of the transition to residency course.[21] The conflict resolution session is mandatory for all students and consists of three parts: pre-work, a standardized patient (SP) encounter, and post-work. During the exercise, students review videos of conflict resolution, reflect on their own conflict resolution styles and complete a simulated conflict with another healthcare provider. During the simulation, students’ conflict resolution skills are evaluated by their assigned transition-to residency coaches using a rubric that is shared in advance of the session. This study was reviewed by the Duke University School of Medicine Institutional Review Board and assigned exempt from further review. Informed consent was obtained from all students at the start of the session.

Study Design

We utilized the Thomas-Kilmann Instrument (TKI) to assess students’ predominant conflict resolution style. The TKI is a validated and widely used tool to describe and study behavior in conflict scenarios.[22, 23] Based on a series of questions, the instrument determines the respondent’s primary conflict style(s). The five described styles are accommodating, avoiding, collaborating, competing, and compromising. All differ on the scales of assertiveness and cooperativeness as shown in Fig. 1.[24]

To evaluate if awareness of conflict resolution style effected conflict resolution performance, we randomized the groups of students to taking the TKI before the SP encounter and taking the TKI after the SP encounter; these will henceforth be referred to as the “before” or “after” groups. Randomization was completed as groups because students rotated in groups through the clinical skills lab, and students completing the TKI as part of the post-work, immediately following their encounter, needed longer time allocated for the post-work that was completed within the clinical skills lab. While the clinical skills lab director was aware of randomization for the purpose of scheduling students, this randomization did not affect the duration of time for the SP encounter. SP and faculty coaches were blinded to the students’ groups. See Fig. 2 for the study design.

Skill Assessment

Coaches within a transition to residency course developed a scoring rubric for the conflict resolution within the simulated nurse-student interaction. This rubric was developed from a review of the literature and a discussion in faculty development sessions where faculty reviewed videos of conflicts and identified behaviors that contributed to the success of the encounter. The rubric was then trialed with six videotaped student/nurse encounters so that faculty could agree on how to score student encounters. Specifically, the coaches discussed as a group what skills, if present or absent, would influence a decision of the student as entrustable based on this encounter.

Two scores determined conflict resolution skills: ability to negotiate and emotional quotient (which include control of and understanding of emotion). The negotiation score was the sum of scores from four 10-point assessments on the student’s ability to: (1) identify/acknowledge there was a problem, (2) break the problem into smaller pieces, (3) acknowledge a shared goal, and (4) summarize a plan that worked for both parties. The maximum amount of points for this section was 40. The emotional quotient score was the sum of scores from six 100-point assessments of the student’s: (1) ability to listen, (2) ability to acknowledge concerns, (3) ability to ask questions effectively, (4) appropriate body language, (5) emotional intelligence, and (6) patient-centered conversation. The maximum amount of points for this section was 600.

Entrustability was determined based on the Association of American Medical Colleges (AAMC)’s Core Entrustable Professional Activities (EPA) for Entering Residency #9: Collaborate as a member of an interprofessional team.[25]

To determine the impact of gender, URM status and intended field of practice with faculty determinations of entrustability, we utilized the gender, race and ethnicity identified by students on their admission application, and the student’s residency placement as reported by students for the graduation bulletin. Specialties were identified as diagnosis-based (medicine, internal medicine, psychiatry, pediatric, neurology, community and family medicine), procedure-based (surgery, anesthesiology, emergency medicine, dermatology, and obstetrics and gynecology), or other (pathology, radiology, radiation oncology, physical medicine and rehabilitation, and consulting).

Students rated the value of the exercise at its conclusion using Likert-item questions. Students also answered questions about the usefulness of the exercise in regards to (1) having information from the TKI prior to the SP encounter, (2) learning the background to conflict resolution, (3) reviewing the pre-work videos, and (4) self-assessing their own performance in conflict resolution by viewing a video of the encounter.

Statistical Analysis

Students were randomized into two groups: those who took the TKI before SP encounter and those who took TKI after the SP encounter. Conflict resolution skills were assessed by the negotiation score, emotional quotient score, and entrustability. Conflict resolutions styles were reported from the TKI. Other explanatory variables included gender, URM status, and intended field of practice.

Continuous variables were summarized with the median and 25th and 75th percentiles, and categorical variables were summarized with frequencies and percentages. The outcomes were compared between groups using the Wilcoxon rank-sum test for scores and chi-square or Fisher’s exact test where appropriate for survey questions with categorical values. All tests were two-sided and the level of statistical significance was set to 0.05 without adjusting for multiple comparison. Statistical analyses were performed using SAS 9.4 (SAS Institute, Cary, NC).

One-hundred and eight students participated in the conflict resolution course. There were 67 students randomized into the before group. There were 41 students randomized into the after group. The groups had similar distributions of age, gender, URM status, or specialty. Table 1 summarizes the students’ characteristics.

Table 1

Student characteristics.
Student Characteristics	TKI After (n = 41)	TKI Before (n = 67)	Total (n = 108)
Age
Median (25th, 75th percentiles)	27 (26, 30)	27 (26, 28)	27 (26, 29)
Not reported	6	10	16
Gender
Male	19 (46.3%)	31 (46.3%)	50 (46.3%)
Female	14 (34.1%)	27 (40.3%)	41 (38%)
Other or Unknown	8 (19.5%)	9 (13.4%)	17 (15.7%)
Under-represented minority (African/Native American, Hispanic, Latino)
Yes	6 (14.6%)	9 (13.4%)	15 (13.9%)
No	24 (58.5%)	43 (64.1%)	67 (62.0%)
Other or prefer not to answer	11 (26.8%)	15 (22.4%)	26 (24.1%)
Specialty*
Diagnosis-based specialty	15 (36.6%)	23 (34.3%)	38 (35.2%)
Procedure-based specialty	18 (43.9%)	34 (50.7%)	52 (48.1%)
Other or unknown	8 (19.5%)	10 (14.9%)	18 (16.7%)

* Diagnosis-based specialties included internal medicine, pediatrics, family medicine, psychiatry, and neurology. Procedure-based specialties included surgical specialties, anesthesia, emergency medicine, dermatology, and obstetrics and gynecology. Other included pathology, radiation oncology, radiology, physical medicine and rehabilitation, and consulting.

Conflict Resolution Styles

Table 2 summaries the primary conflict resolution styles found amongst the students as reported from the TKI instrument itself. Students could have more than one primary style.

The most common styles were accommodating followed by compromising. As part of the curriculum, students also self-determined their primary conflict style prior to taking the TKI. Only 56.0% (n = 56/100) of students had accurate self-awareness of their predominant conflict resolution style as that determined by the TKI.

Table 2

Conflict resolution style assessed by TKI; note that 8 out of the 108 students had missing values for conflict resolution style assessed by TKI. A student could have more than one primary style.
Conflict Resolution Modes	Total (N = 108)
Accommodating	37 (34.3%)
Compromising	20 (18.5%)
Avoiding	15 (13.9%)
Collaborating	15 (13.9%)
Competing	7 (6.5%)
Accommodating/Collaborating	2 (1.9%)
Collaborating/Avoiding	2 (1.9%)
Accommodating/Compromising	1 (0.9%)
Collaborating/Compromising	1 (0.9%)
* Eight patients did not report conflict resolution styles (7.4%)

Student characteristics and impact on conflict resolution skills

Table 3 summarizes differences between gender, URM status, and intended specialty in conflict resolution skills as evaluated by faculty at the time of reviewing each students’ videotaped encounter. Faculty gave higher emotional quotient scores to females (p = 0.02). Students pursuing diagnosis-based specialties had higher negotiation (p = 0.04) and higher emotional quotient (p = 0.006) scores.

Table 3

Conflict resolution skills in relation to gender, intended specialty, and URM status.
	Gender			Specialty				URM-status
	Female	Male	p-value	Diagnosis-based	Procedure-based	Other	p-value	Yes	No	p-value
Negotiation Score Median (25th, 75th percentiles)	33.1 (28.1, 36.1)	30.2 (24.2, 33.7)	0.14	33.3 (28.2, 36.5)	29.6 (24.2, 33.1)	31.2 (24.5, 33.5)	0.04	31.3 (23.0, 35.4)	31.6 (25.0, 35.4)	0.61
Emotional Quotient Median (25th, 75th percentiles)	533.0 (505.0, 553.5)	510.0 (458.0, 540.0)	0.02	540.0 (505.0, 555.0)	507.0 (480.0, 530.0)	525.0 (471.0, 540.0)	0.006	506.5 (449.0, 544.0)	529.0 (492.0, 545.0)	0.3
* P-values were calculated from Kruskal-Wallis tests.

Entrustability and Conflict Resolution

Table 4 summarizes conflict resolution skills as judged by faculty after review of each students videotaped encounter (n = 98). There was no difference in conflict resolution the before and after groups. The majority of students, 92.8% (n = 91), were evaluated as entrustable and 7.2% (n = 7) as pre-entrustable. Among students evaluated as pre-entrustable, a common theme in faculty comments was the need to be more assertive.

Table 4

Conflict resolution skills and entrustability between after and before groups
	After TKI (n = 41)	Before TKI (n = 67)	p-value
Entrustability
Entrustable	35 (97.2%)	56 (90.3%)	0.26¹
Pre-entrustable	1 (2.8%)	6 (9.7%)
Not evaluated	5	5
Total Negotiation Score (Max 40)
Median (25th, 75th percentiles)	31.7 (28.2, 36.5)	31.3 (24.5, 34.9)	0.29²
Range	(13.7–39.0)	(8.2–40.0)
Missing	2	0
Total Emotional Quotient Score (Max 600)
Median (25th, 75th percentiles)	529.5 (501.0, 545.0)	514.5 (479.0, 546.0)	0.58²
Range	(395.0-580.0)	(301.0-600.0)
Missing	3	1
¹Fisher’s exact test. ²Wilcoxon rank-sum test

Value of the Exercise

A majority of students thought the TKI promoted self-reflection (81/108, 75.0%). A higher proportion of students who took the TKI before their encounter with the SP (65/67, 97.0%) found the TKI found it more useful in reviewing the pre-work videos than the group who took the TKI after the encounter.

The most common conflict resolution style amongst fourth-year medical students was accommodating. The accommodating style focuses on satisfying the other person’s needs or concerns over one’s own. While there is no “correct” primary conflict resolution style, execution of patient care may require an intern to advocate for and/or compromise more rather than simply giving in to the needs of the other healthcare professionals.[26–28] The “student” mindset most likely contributes to conflict styles focused on appeasing the other party; medical students are often the junior members of a medical team. A course that focuses on communication skills that foster use of different conflict resolution styles and using the most effective style for a situation or scenario may be useful for graduating medical students.

Diagnosis-based specialties and female students had significantly higher negotiation and emotional quotient scores than procedure-based specialties and male students, respectively. These differences may warrant further curriculum development; others have also described differences in communication by specialty and gender that impacted patient outcomes.[29–32] Ambady et al. showed that surgeons’ tone of voice during routine visits were associated with malpractice claims.[30] Levinson et al. showed that surgeons infrequently expressed empathy towards patients and focused more on operational information compared to internists.[31] Female physicians have been shown to be better communicators through active partnership behaviors.[33] These differences in specialty and gender indicate that different curricula may be needed to target specific skills for different student groups.

We were delighted to find no differences in the faculty evaluation of URM and non-URM students especially in light of known racial disparities in student performance evaluations, grades and membership in the Alpha Omega Alpha Honor Society.[34–39] We believe faculty development sessions to develop the evaluation rubric and to practice the rubric contributed to the lack of racial disparities in evaluation by coaches. As the number of medical schools assigning students to coaches increases, we believe that schools should undertake similar evaluations to look for unconscious bias in coach evaluation and to take the time for faculty development to set consistent expectations and to practice group evaluation.

Self-awareness of one’s conflict resolution style(s), as determined by TKI, was not associated with conflict resolution skills as judged by standardized faculty. Students found the TKI useful in multiple aspects of the exercise and reported that it made their experience more valuable. The TKI did not affect conflict resolution skills in the SP encounter—at least what could be discerned from the coaches scores. This makes the cost ($35/student) of the TKI difficult to justify.

Faculty assigned high levels of entrustment to our students for collaborating in an interprofessional team. The high rates of entrustability despite lack of prior explicit training, specifically in conflict resolution, may be related to a leadership thread in our medical school that includes patient-centeredness and emotional intelligence. Although the number was small, the students who were pre-entrustable may require more sessions with an SP to practice their skills or more feedback to recognize their weaknesses, for example, focusing on respectful assertion.

Our study had several limitations. While our sample size was adequate to look at the primary question of entrustability and types of conflict resolution styles, it might not have been adequate to analyze specialty, gender, and URM differences. We did not evaluate whether gender or specialty-concordance between student, SP, and faculty coach played any role in scoring. We had several female SPs for this study; this could have impacted the session and subsequent evaluation of the interaction, and in the future, we plan to include a male SP as well. Further, our faculty coaches are largely physicians (though we have one physical therapist and one nurse practitioner); we could have different members of the healthcare team assessing entrustability.

The most prominent conflict resolution style among graduating medical students is accommodating. While knowing conflict resolution style in advance of a simulated conflict was of value to students, it did not influence their skill as judged by faculty coaches. Student gender and intended field of practice did effect conflict resolution skills. This may allow for future targeted curricula in conflict resolution.

Thomas-Kilman Instrument (TKI)

Simulated Patient (SP)

Neonatual Intensice Care Unit (NICU)

Under-represented Minority (URM)

Association of American Medical Colleges (AAMC)

Entrustable Professional Activities (EPA)

Declarations of Interest: None

Ethics Approval and Consent to Participate: This study was reviewed by the Duke University School of Medicine Institutional Review Board and assigned exempt from further review.

Consent for Publication: Not applicable

Availability of Data and Materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing Interests: The authors declare that they have no competing interests.

Funding: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (Award Number UL1TR002553) and the Duke Clinical and Translational Science Award from the National Institutes of Health supported the collaboration between the Biostatistics, Epidemiology, and Research Design (BERD) Core and the Department of Surgery. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author Contributions: RG was involved in conceptualization, Methodology, Project Administration, Writing – Original draft, Writing – reviewing and editing.

HL was involved in methodology, Formal Analysis, and Writing – Reviewing and editing. CZ was involved in Methodology, Formal Analysis, and Writing – Reviewing and editing. AC was involved in the Conceptualization, Methodology, Project Administration, Writing – Original draft, and Writing – reviewing and editing.

Acknowledgements: Not applicable

Authors’ Information: RG is a resident in the Department of Surgery at Walter Reed National Military Medical Center. HL is a Senior Biostatitician in the Department of Biostatistics and Bioinformatics in the Duke University School of Medicine. CZ is a Biostatitician II in the Department of Biostatistics and Bioinformatics in the Duke University School of Medicine. AC is an Associate Adjunct Professor in the Department of Medical Education, Duke University School of Medicine.

Disclaimers: The contents of this publication are the sole responsibility of the author(s) and do

not necessarily reflect the views, opinions or policies of Uniformed Services

University of the Health Sciences (USUHS), the Department of Defense (DoD), and the

Departments of the Army, Navy, or Air Force. Mention of trade names, commercial

products, or organizations does not imply endorsement by the U.S. Government.

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published 14 Apr, 2023

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Editorial decision: Major revision
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Conflict Resolution Styles and Skills and Variation among Medical Students

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Journal Publication

Version 1

Abstract

Figures

Introduction

Methods

Conflict Resolution Curriculum in Capstone

Study Design

Skill Assessment

Statistical Analysis

Results

Conflict Resolution Styles

Student characteristics and impact on conflict resolution skills

Entrustability and Conflict Resolution

Value of the Exercise

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1