Khadija Waheed  ( King Edward Medical University, Lahore )
Mohamed Al-Eraky  ( University of Damam, Saudia Arabia )
Noor-i-kiran Naeem  ( Aziz Fatima Medical University, Faisalabad, Pakistan )
Sara Ejaz  ( Crescent Medical College, Lahore, Pakistan. )
Amna Khanum  ( King Edward Medical University, Lahore )

Objective: To explore the patterns in research and underlying factors of conflicts in obstetrics and gynaecology and its effect on restricting the quality of education and training of residents.

Methods: The narrative study was conducted at the Obstetrics and Gynaecology Department, Lady Aitchison Hospital, King Edward Medical University, Lahore, Pakistan, from October 2018 to January 2019, and comprised narrative essays by residents associated with the department. Data was subjected to thematic analysis.

Results: Of the 27 residents, 26(96.3%) were females and 1(3.7%) was male. Overall, 19(70.3%) were aged 25-30 years and 8(29.6%) were aged 30-35 years. Three levels of conflict were identified: organisational, interpersonal and individual. Causes of organisational conflict included inadequate facilities, poor security and unclear duty appointments. Interpersonal factors included lack of communication, lack of patient autonomy, non-cooperative co-workers, illiteracy of attendants and unprofessional behaviour. Individual factors were overburdening duty hours and duty negligence.

Conclusion: There was found to be a need to design education programmes, like workshops, that may enable post-graduate residents in obstetrics and gynaecology to handle conflicts at workplace.

Keywords: Conflict, Work, Hospital, Gynaecology, Residents, Patients, Doctors. (JPMA 71: 514; 2021)

DOI: https://doi.org/10.47391/JPMA.797

 

Introduction

 

Inter-personal conflicts exist in every organisation, including challenges of minor and major degrees.¹ These challenges commonly lead to conflicts between patients and hospital staff, and this situation is observed increasingly now-a-days.²

Conflicts can occur due to difference in interests, needs, desires, responsibilities, perceptions, values, ideas and objectives.^3-4 There can be positive and negative aspects to conflict or in technical terms, conflict can be destructive or constructive.⁵ Conflicts at workplace are defined as disagreements, differences or incompatibility between an individual and his/her superiors, subordinates, patients, administrative staff or peers. Conflict can be task conflicts, emotional conflicts and process conflicts.⁶ Conflicts are quite common at workplace, especially in hospitals, as it involves interactions of many individuals with varying backgrounds during time of stress, pain and anxiety.⁷ Doctors have long duty hours and they spend long time with their seniors, colleagues, peers, subordinates, patients and administrative staff, and have more chances of interpersonal conflicts. Workplace conflicts can occur in labour room, outpatient department (OPD), intensive care units (ICUs), and wards and even in duty rooms, and may lead to compromising patient safety.⁸

Previously studies have been conducted on inter-personal conflicts among residents, but no study has completely focussed on scope and varieties of conflicts which hospital staff encounters on a daily basis⁹ which has been cited as an important area of concern.¹⁰

The current study was planned to explore the range and varieties of conflicts which arise during daily working in a gynaecology and obstetrics department.

 

Materials and Methods

 

The qualitative narrative study was conducted at the Lady Aitchison Hospital, Lahore, Pakistan, from October 2018 to January 2019. After approval from the institutional ethics review board, residents at the Department of Obstetrics and Gynaecology (OB-GYN) were enrolled using purposive sampling method. All the post-graduate (PG) residents were included and written informed consent was obtained from all of them. Data was collected using narrative essays as the instrument of choice because it allows participants to tell their experiences, which, in turn, allows researchers to make meaning out of reflective essays.¹¹ First-hand data about conflicts arising in the daily working of the department was observed and narrated by the participants in the form of reflective essays. The tool was selected because of ease of collecting data as working in the department as consultant for several years makes residents hesitant to talk in face-to-face interviews about conflicts, while direct observation could have made them uncomfortable. Presentations were made for all the subjects and they were assured about confidentiality and anonymity. They were explained what was expected of them. To make it easy for them, templates were provided to them according to which they could describe their story (Figure).

In the morning, questions were asked about conflicts in the preceding 24 hours from the batch on duty, and if there was any conflict, the resident concerned used to present that conflict in detail after which the narrative was done by the resident. Confirmation about the episode was subsequently got done from the senior registrar on call. The essays were obtained till data saturation as the analysis was being done manually simultaneously.

Data was subjected to thematic analysis done by manual analysis. Codes were identified through open coding process which means “working intensively with data line by line, identifying themes and categories that seem to be of interest”, and then explicated themes from the interconnection of these categories, which is selective coding. Finally, by the merger of the open and axial codes, sub-categories were made and arranged under a core category/theme.

 

Results

 

There were 49 narrative essays contributed by 27 residents; 26(96.3%) females and 1(3.7%) male. Overall, 19(70.3%) subjects were aged 25-30 years and 8(29.6%) were aged 30-35 years (Table 1).

Themes identified in the study categorised conflict into organisational, interpersonal and individual levels (Table 2).

The themes were coded according to sub-themes (Table 3) and residents’ year-wise pattern of conflict (Table 4)

 

Discussion

 

The study revolved around three main areas of research which were conflicts on an organisational level and what caused them; conflicts on an interpersonal level and what caused them; And conflicts on an individual level and what caused them.

One interesting finding was that organisational conflicts were more common in senior residents so there was a need to bridge the gap between administration and clinical departments by capacity-building. On the other hand, interpersonal conflicts were more common among junior residents so there was a need to improve professionalism and communication skills at that level.

The immediate manifestations of these conflicts included delay in patient treatment, verbal exchanges in case of interpersonal conflict, threats, punishments and confrontation, involvement of media and defaming of the organisation by angered patients and their attendants, and mistakes while giving treatment leading to increased chances of patient mortality.

Lack of adequate facilities has proven to be a major problem for workplace efficiency in all fields of work, not just healthcare, including business professionals who admitted to a correlation between workplace conflict and lack of tools and resources available to them.^12-14 CEO of a hospital in Zimbabwe mentioned in a report that lack of drugs and essential medical equipment was a major contributing factor to the workers’ accelerating frustration with their jobs.¹⁵ This sentiment was shared by a healthcare assistant working at a health facility in New Zealand who said it was ‘soul-destroying’ to see the lack of funding compromising patient health.¹⁶

A study aimed at discovering the conditions of public hospitals in Africa concluded that poor infrastructure and lack of resources further aggravated the already skyrocketing workload due to flooding of hospital with patients of human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS).¹⁷

Organisational deficit was also seen to result from a poor security system. A case of security breach at Jinnah Hospital, Lahore, was reported in January 2016 when an assailant opened fire in the emergency department (ED), injuring patients. Working doctors were interviewed and they mentioned that the highly unpleasant security situation of the hospital included absolutely no guards or walkthroughs. Cases of harassment of female doctors were also reported due to the same cause.¹⁸

Research suggests that both doctors and nurses were in many cases seen to be misinformed of their own as well as the other party's duties, leading to occurrence of conflicts.¹⁹ Similar outcomes appeared in a hospital as alarming conflict, the worst being delay in patient treatment because unclear professional roles contribute to work-related stress and consequent poor performance.²⁰

On the interpersonal level, the study revealed involvement of doctors, nurses, patients, attendants, administrative staff and paramedics in such conflict arising due to factors like work overload, poorly set priorities and lack of communication amongst team members.²¹

Duties of the doctor also include maintaining a healthy doctor-patient relationship.²² The third theme focussed on conflict that occurred due to individual factors. Participants mentioned working excessively without any clearly-defined duty hours, and that too on bare minimum wages. In one incident reported from Newham General Hospital, London, an anaesthetist accidently gave a three-year-old patient nitrous oxide instead of oxygen, leading to her death. The cause for this blunder was the stressful and busy hospital environment the physician was coping with.²³ Physician ‘burnout' was seen to target around 40% of doctors in the developed country, ultimately interfering with patient wellbeing.²⁴ This proved to be a vital contributor to conflict on an individual level in the shape of stress and burnout, and on an interpersonal level as strained relationships due to burnout.

Further strengthening the findings of the current study, one study suggested that health care workers are more particularly susceptible to work-induced stress.²⁵ According to a survey, the data was alarming when they were asked to answer questions regarding their levels of burnout: 45.8% doctors displayed at least one sign of work-induced burnout; 37.9% had high levels of mental exhaustion; 29.4% displayed excessive existentialism; and 12.4% had poor self-appreciation.²⁶

Some narratives further explained how individual factors contributed to interpersonal conflict. Some of the temper outbursts of the doctor on duty were either due to workload or other reasons like personal differences. A disruptive physician exacerbates the stress in the work environment which affects the morale of other workers around him.²⁷

The current study has limitations as sampling was limited to one department and one specialty in a single centre. This limits the scope of the study. A larger sample size involving all medical specialties in various medical schools is recommended.

 

Conclusion

 

The conflicts were mainly categorised into three types: organisational, interpersonal and individual. Contributing factors included lack of security, lack of communication, inadequate facilities, unclear duty appointments and lack of awareness regarding maternal healthcare.

 

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

 

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