Abstract
Healthcare conflicts are complicated and often dysfunctional in nature. The Indian healthcare system, with its thinning workforce, finds it increasingly difficult to meet the demands and expectations of its healthcare service recipients. Healthcare service providers like physicians, nurses, technical and administrative personnel work in a dynamic and stressful environment with resource and manpower limitations. Healthcare service recipients like patients and their families often face challenges regarding access to care, associated costs, time issues and other situational dynamics. These underlying situations often result in different types of conflicts in the workplace. The purpose of this exploratory study is to understand the factors that serve as primers for healthcare conflicts in the Indian scenario. Data were collected from hospital feedback forms for patients/patient families. The top 10 threads indicating the patient satisfaction factors and conflicting grounds were identified through content analysis, and that formed the basis of the semi-structured questionnaire schedules. Fifty semi-structured interviews were done with healthcare service recipients and healthcare service providers (25 in each set) in private clinical establishments of Kolkata, West Bengal. Four main themes and nine subthemes were identified that illustrated the grounds for healthcare conflicts in Indian settings. The identification of the causes of dissatisfaction and understanding their relationship with healthcare conflicts will go a long way in conflict management.
Introduction
The healthcare establishments around the world cater to the needs of the common man. These are composite systems where teamwork dynamics and effective cooperation are needed for regular operations (Rosen et al., 2018). At the workplace, employees engage in diverse relationships with colleagues, customers (patients and their families) and other acquaintances that have a positive or negative effect on them. The hospital framework is a special environment in itself with its share of vulnerability, emotional outpour, individualism, professionalism, relationship categories, overlapping roles, interdependence and regular conflicts.
Conflicts, in general, turn problematic if they are recurrent or remain unsolved for long spans of time, creating disruptions in the regular functioning of a system (Akman & Yakut, 2019). In clinical settings, the potential for the occurrence of a healthcare conflict is much greater compared to any other condition since it involves not only a financial burden but also severe emotional, practical and chronic implications that often push patients and their immediate family towards a course of downhill movement and test the coping skills to their last extent. On the other hand, the general emotional burden and individual coping skills of healthcare personnel, especially the treating physician, their teams and nursing staff, are often overlooked in scenarios with therapeutic limitations and bad prognosis (Tanner et al., 2015). It could immediately result in conflict of any intensity, frequency and duration within the process, between people, patients and their families. Such situations turn even more intense when they involve paediatric population (Sengupta et al., 2019). Therefore, health conflicts need immediate rectification if they interfere with the treatment regimen or pose any challenge involving therapeutic alliance resulting in possible adherence or compliance issues of patients.
Healthcare conflicts have a direct link with psychosocial and emotional wellbeing of individuals since they depict a range of emotions in an already stressed hospital environment (Koinis et al., 2015). Furthermore, it impacts individual productivity which in turn affects the entire organisation. While conflicts are indispensable in workplace settings, it is important to realise the extent, duration and frequency of conflict on service delivery outcomes. Very few healthcare conflicts have been accounted to be functional for organisations, while majority of them are dysfunctional conflicts affecting the productivity and quality of care (Patton, 2014).
Factors contributing to conflicts are many and vary across regions and countries. While majority of the conflicts are contextual, several researchers have identified a few common areas of healthcare conflicts (Ramsay, 2001; Tosanloo et al., 2019). In particular, due to economic crisis, low healthcare investments, recession and the global COVID-19 pandemic experienced recently, healthcare workers are struggling with personal growth and financial goals (Cullati et al., 2019; Sengupta et al., 2021). Apart from this, poor interpersonal communication is another common source of conflict (Almost et al., 2016).
Healthcare conflicts occur across all hierarchical levels. In areas where teamwork and coordination are required for a successful delivery process like critical care and high dependency areas, vulnerability is high and the roles require coordination, collaboration and control (Attri et al., 2015). Various team members react differently to similar workplace situations thus showcasing a wide array of attitudes and feelings to patients and families that are often contrasting with one another. Many physicians are over involved in the entire system while a few of them keep a perceived safe distance (Lask, 2003). Such behavioural expressions often result in interpersonal conflicts and even confuse the patient. Resolution of conflict depends on many factors and is reflective of failures and deficiencies of the organisation alongside individual personality traits. It is now clear that in order to ensure better patient adherence and commitment, potential causes of conflicts must be minimised for better patient satisfaction.
Patient satisfaction is an important indicator of healthcare quality (Prakash, 2010). Workplace conflicts often affect quality of care, patient perception and general satisfaction. Thus, healthcare organisations strategise their goals and objectives for better patient engagement and clinical management. For effective patient satisfaction, it is important to identify the causes of conflict and dissatisfaction amongst healthcare service providers (doctors, nurses and hospital staff) and recipients (patients and family/accompanying members) (Overton & Lowry, 2013). This knowledge will be instrumental in plugging the gaps and effectively managing and preventing healthcare conflicts for better outcomes.
This study aimed to investigate the various conflict primers between healthcare service providers and recipients. The issues have been explored from the perspective of patients, their families and healthcare service providers that include doctors, nurses, receptionists and allied services personnel, hospital managers and ward staff, to understand conflict and factors of patient satisfaction.
Methodology
Design
First, the hospital feedback forms in the preceding 12 months (March 2018–March 2019) were analysed to identify the threads that serve as potential patient satisfaction and/or conflict primers (n = 410). Once the questionnaire schedule was designed based on the feedback, data collection, analysis and interpretation through individual in-depth interviews and thematic analysis were done to investigate the causes of conflict between healthcare service providers and recipients. This study utilised inductive method for extracting relevant themes and working on theoretical explanation based on the experiences shared by both respondent sets.
Sample
For this research, only those patients, families and healthcare service providers were recruited who faced some type of conflict during healthcare service provider–recipient interactions. Specifically, healthcare service recipients were in-patients in private clinical establishments and voluntarily agreed to participate. Pending medico-legal cases were excluded from the study. Quota sampling was used with 25 participants in each group, that is, patient and their families (healthcare service recipients) as well as healthcare providers comprising doctors, nurses, hospital managers, front office and laboratory technicians. A total of 50 interviews were done. All the demographic details of participants are noted in Table 1.
Socio-demographic Details of Respondents (n = 50).
Ethical Consideration
We ensured all forms of ethicality in the current research which was duly approved by the Institutional Ethics Committee. Participants were told about the research process and their consent was taken prior to the beginning of data collection. They were also assured of confidentiality regarding identity and responses.
Data Collection
Semi-structured interview schedules were used to interview patients, their families and healthcare practitioners. These interviews were conducted from April 2019 to July 2020 in Kolkata, West Bengal (Appendix 1). The focus of the healthcare service recipient interviews was the description of their perception, experiences and perceived causes of conflict; whereas the focus of healthcare practitioner’s interviews was the description of challenges, limitation and their perception of conflict cause. All these interviews were audio recorded. These interviews ranged between 30 and 45 minutes and once completed, all information for identification was removed and each was assigned a code number. These interviews were transcribed verbatim by the first authors and a back translation method was used to transcribe them to English from Bengali and Hindi.
Data Analysis
The first stage consisted of reviewing hospital feedback forms (approx. 2,000) where 410 patient/next of kin feedback forms with ‘needs improvement’, ‘poor’ feedback or dissatisfactory remarks were analysed. The top 10 threads were identified using content analysis (Table 2) and the questionnaires for semi-structured interviews were based on them.
Analysis of Hospital Feedback Data (n = 410).
Braun and Clarke’s method (2014) of thematic analysis was used to develop the initial codes and the first authors cross-checked it. Initially, both the first authors independently read the transcribed interviews multiple times for familiarisation with the data. Using inductive approach, the interesting features of gathered data were pinpointed as the initial codes. These codes were eventually organised to form potential themes relevant to the study. They were further reviewed and discussed with another co-author, refined and the final themes were generated. The selected themes were explained and the corresponding extracts from interviews are presented in the subsequent section.
In order to gain a deeper understanding of the subject matter, the analysis was done separately for healthcare service recipients and providers. Separate themes and sub-themes were generated for each category. The common themes identified for both respondent sets were clubbed. The themes and sub-themes based on the descriptions from the respondents (healthcare service providers, recipients) are given in Table 3.
Different Themes and Sub-themes Contributory Towards Healthcare Service Provider–Recipient Conflicts.
Results
We analysed 50 interviews in total from different stakeholders that represented ‘healthcare service providers’ and ‘healthcare service recipients’. We identified 4 major themes and 9 sub-themes after thematic analysis of 25 interviews in each category (healthcare service recipients—patients and their families; healthcare service providers—doctors, nurses, hospital managers, front office and laboratory technicians). The thematic analysis has been depicted in Figure 1.
The participant’s views have been elaborated in light of their individual personal factors, perceptions, experiences and external factors. We explored each of these themes by comparing the viewpoints of healthcare providers and service recipients.
Thematic Analysis of Primers of Healthcare Conflicts in Indian Scenario.
Individual Factors
Personality Facets
Type of personality is contributory towards behavioural outcome that in turn decides the possible implications. This theme includes personality facets that seem to trigger conflicts in health settings.
Disruptive Behaviour
Lack of systematic and timely information with poor communication leads to disruptions in daily practices. Disruptive behavioural outcomes have been documented for both healthcare service providers and recipients. With the COVID-19 pandemic in the background, any disconnect resulted in negative escalations. Many such incidents reported regular workflow disruptions due to behavioural issues.
As experienced by some hospital personnel,
‘We all are stressed. Sometimes, I have seen people (physicians) inside the OT shout at the nurses and ward boys. They even throw some instruments out of disgust. While, we silently observe and let it pass, somewhere it does hurt us… We are tensed and sometimes end up committing unintentional mistakes’ (OT personnel; 27 F).
Another doctor noted,
‘I have faced the wrath of such behaviour. I remember, once a patient’s relative started behaving rudely and was very angry after the patient died. When after repeated requests, he was passing lewd comments, I reported to the hospital security who took steps and this person was out of bounds. I forgot about this until after about two weeks, I saw him standing near my residence with people armed with sticks… I just avoided going out that day, but will never forget this’ (Consultant doctor; 44 M).
Disagreement and Delayed Decision-making
Disagreements often result in communication failure, misunderstanding and conflicts with serious implications (Jerng et al., 2017). Perceptual differences make way for disagreements and delay important decisions. Patients, their families and healthcare practitioners have experienced such conflicting antecedents.
An excerpt from a nursing staff,
‘There are times when the patient party does not comply with the given instructions. They question the treatment regimen. They don’t let us do our duty. We are already stressed with so much work and it further increases our woes’ (Nursing personnel; 26 F).
The next of kin shared,
‘I had asked the doctor to admit my father. His condition had deteriorated in the last 3 days.. The doctor said, “The medicines will work”. He gave some tests and didn’t admit him despite our repeated plea. He finally breathed his last after 2 more days of struggle’ (Next of kin; 34 F).
As described by a doctor,
‘The pandemic was a real eye opener. I never felt so miserable before. Despite working so hard, for almost 40-45 hours at a stretch, sometimes we knew that it was too late and we couldn’t do anything to save the patient… yet, the families shouted at us and other staff’ (Doctor, 39 M).
Communication Facets
Communication serves as the main pathway to describe one’s feelings and emotions. This theme includes different sides of communication as sub-themes that highlight the conflict antecedents in healthcare service provider–recipient relationship.
Communication Adequacy
Communication adequacy is an important tool of patient satisfaction (Ha & Longnecker, 2010). Patients and their families highlighted the use of technical jargons with little explanation to be a source of worry. They also reported poor explanation at the reception and billing counters with their query. Designated people believed these questions were unnecessary. Thus they avoided them to reduce the average handling time of their customers. This issue has taken a serious turn in light of the COVID-19 pandemic where healthcare professionals are extremely busy. Additionally, wearing of mask, face shield and other personal protective equipment (PPE) further creates a barrier during verbal communications.
A respondent who is a regular patient in that hospital noted,
‘The explanation on next course of action is very poor. The doctor is too busy to tell what are the options available and the team uses complex words, which I find difficult to understand’ (Patient; 53 M).
Another respondent noted,
‘I couldn’t follow what the nurse said.. I wanted to ask her again but she got busy with another person.. with all the masks and all, it is indeed difficult to follow what they are saying… they get irritated if I ask multiple times.. What should I do? .. Tell me’ (Next of kin, 36 F). ‘Billing department is very bad here. All they are concerned is about payment. They don’t want to answer anything’ (Next of kin; 47 M).
On being probed regarding the situations faced by the billing team, one of them responded,
‘So many people are in the queue. If we keep on answering them, it will be endless and other people start shouting on us. What do we do?’ (Billing executive, 31 F).
Empathy and Psychosocial Expression
Patients and their families noted a lack of empathy and poor redressal of their psychosocial needs during hospital interactions. The frequency of such instances increased during the COVID-19 pandemic when the hospital machinery was severely overworked with little preparation and know-how on dealing with the same. The next of kin recounted the experience of receiving difficult news without any empathy or emotional support and limited soft skills.
‘My daughter has leukaemia. This doctor is very renowned. We went with lot of expectations. He just checked the reports and said that we just have a few months. He didn’t even care how shocking it was for a mother’ (Next of kin; 34 F).
Another respondent noted,
‘The technician was so rude. While doing X-ray she was so harsh with her instructions. I am a senior citizen and can’t follow fast instructions’ (Patient; 71 F). ‘We are following whatever the doctors are asking us to do.. In fact spending money is not also the concern.. Yet, there is no assurance from the doctor whether our patient will recover or not.. Feeling so helpless’ (Next of kin, 52 M).
On the other hand, the medical practitioners highlighted,
‘Many times, our softness is considered as some mistake. Patients just file complaint against us without our fault. That’s why we remain professional and to the point’ (Consultant doctor; 43 M).
Previously Unresolved Conflicts
Previously neglected and unresolved conflicts affect regular operations in health settings. The presence of such conflicts might create problems in optimal healthcare delivery.
As opined by a hospital manager,
‘Problem are with ego clashes. Generally, we face this with senior consultants where multidisciplinary specialists are needed. We have to channelize it so that patients don’t feel anything but sometimes it delays processes’ (Hospital manager; 44 M).
Perceptions and Expectations
The healthcare services providers and recipients have some perceptions, impressions and experiences in healthcare settings that impact their viewpoints and subsequent dealings. These are also shaped by direct and indirect exchanges in the past and affect provider–recipient interactions.
Perceived Portrayal of Healthcare and Costs
In the era of information technology, various news items become viral resulting in public backlash, media trials and perception-based judgements. As a result of the general negative portrayal of the Indian health system and associated costs coupled with huge out-of-pocket (OOP) expenditure, there are grounds for commotions that result in conflicting episodes during interactions.
As noted by a patient,
‘They (hospitals) are just doing business. The bill escalates when they see you can pay. Irrelevant tests and list of medicines, gloves, injection…., I doubt they use so many’ (Patient, 43 M).
The health personnel remarked,
‘Many patient party charge us, as if we are taking this money in our pockets.. They ask us to reduce the bill citing different reasons. When we ask them to talk to doctors, they are furious on us’ (Billing staff; 34 M). ‘Complaints on excess bills these days have become so common. The people don’t understand that giving individual life support during these pandemic times incur huge infrastructure costs’ (Hospital manager, 45 F).
Expectation Gap
Both healthcare providers and service recipients identified this as one of the most common reasons for conflict. While attributes of disorganisation, process protocols and coordination issues were common, the underlying causes varied across the respondent sets. With the COVID-19 pandemic, there was limited planning, infrastructure reallocation issues, lack of resources and skewed demand and supply of essential commodities; the expectations of both healthcare service recipients and service providers were far away from the real scenario.
One of the doctors highlighted,
‘Despite telling the ward nurses regarding protocols, they don’t keep things organized during rounds. It wastes our time and when asked, they pass on the blame and tell unwarranted things’ (Doctor; 45 F).
The next of kin reported,
‘The discharge process is pathetic. They take about by 5-6 hours. They keep on sending requests from one floor manager to admin to others without any resolution. I am very irritated with this whole thing’ (Next of kin; 57 M).
Another patient’s family said,
‘I am a regular visitor to this clinic. The doctor definitely knows by now. However, I have never seen him smile or even show some expression which will make me feel valued. I am paying the fees and everything, but it seems he is doing me a favour.. I think doctors should be welcoming.. …’ (Next of kin; 38 F).
Institutional Factors
Service Standards and Practices
Hospitals in current times are struggling with the upcoming challenge to maintain a competitive environment that shall prove advantageous for them to ensure their sustainability (Agwunobi & Osborne, 2016). It is thus essential to identify ways of improving service standards, practices and overall functioning so as to ensure a good doctor–patient relationship. This theme includes different dimensions of organisational standards and practices reflecting on provider–recipient interactions and conduct in healthcare service provider–recipient relationship.
Time Constraints
Time limitations and associated challenges due to time constraints have been identified by both the respondent sets as one of the vital conflicting causes.
As mentioned by a senior medical practitioner,
‘We have to see a lot of patients in OPD on a regular basis. Occasionally, time becomes a constraint when there are scheduled OTs and a long queue in OPD. If case of emergency, the schedule goes haywire’ (Senior consultant; 57 M).
One of the patient family members told,
‘I took leave just to see the doctor since my mother’s chemotherapy will start shortly. After waiting for 2 hours, when my turn came, the doctor simply talked for a minute and left hurriedly. I had many questions that went unanswered. I simply wasted my time waiting’ (Next of kin; 38 M).
Interdepartmental Coordination and Overall Stress
Poor multilevel coordination, work pressure and lack of clear instructions result in communication fallacies and stress. Moreover, the healthcare providers were also scared of COVID-19 infections and the lives of their immediate family members. Isolation from family and tremendous work pressure affected their physical and mental health. The same has been identified in the following interviews:
‘Operation/procedure delay by doctor without informing us happens quite often. Patient is NPM, sometimes they are dehydrated or condition is serious. The patient party fights with us. We try to contact OT and they say that Doctor is busy. We are at the receiving end’ (Nursing staff; 40 F). ‘We were anxiously waiting for the main doctor, I heard the nurse saying, that patient is critical and needs ITU. I didn’t like the way my father became the topic of discussion at the nursing station. I would expect the doctor to tell me the implications’ (Next of kin; 25 M). ‘We always send samples as per schedule. The lab technicians don’t document and receive samples properly. That creates the problem. Patient party complains about us. It is not our problem’ (Nursing staff; 24 F). ‘My father is a diabetic. I am so scared to go home since I might carry the infection. Last 1 month, I am staying in the ladies hostel. I miss my family’ (Nursing staff; 31 F).
Discussion
Interpersonal conflicts are validations of the presence of more than one value system, perspective or opinion that are different from one another and have not yet reached a common agreement. The success of a conflict mitigation technique is normally done by effectively listening to the points raised by the concerned people and providing requisite opportunities that meet the overall needs and address the individual interests to obtain a satisfactory outcome. Conflicts and dissatisfaction raise issues and energise stakeholders thereby helping them to identify limitations in the current set of differences.
Healthcare conflicts are everyday events occurring in clinical settings between physicians, team members, other health personnel, as well as patients and their families (Ramsay, 2001). The situation becomes complex in the light of disagreements, impaired trust, misunderstandings and expectation differences thus challenging the healthcare service provider–recipient relationship. Whenever paediatric and geriatric patients are involved, due to the possible involvement of parents/children, the conflict potential gets even more intensified (Sengupta et al., 2019; Van Keer et al., 2015). It is thus clear that conflicts are to be managed effectively in health settings for better patient satisfaction.
Conflicts become progressively entrenched and difficult to resolve when overlooked, resulting in significant damage and costs on the overall healthcare system (Forbat & Barclay, 2019). The extent to which various healthcare organisations can smoothly integrate the different frequently encountered competing issues related to task and relationship is also an indication of effective identification of conflicting areas and their quick redressal. While, few most common practices towards workplace conflict resolution include conciliation, compromise, force, withdrawal and confrontation, in case of healthcare organisations, it is seen that withdrawal is commonly used to resolve interpersonal conflicts (Fowler et al., 1993). It further complicates the scenario and presents long-term negative outcomes like working for less duration, changing work settings or workplace and sometimes even a career change. Therefore, it calls for ways to equip healthcare professionals to mitigate underlying conflicts and build trust. In this regard, effective and open communication has been considered to be pivotal in minimising conflict episodes (Durbin et al., 2012).
A power technique to effectively manage healthcare conflicts is through Johari window. It can serve as an effective self-disclosure and feedback tool that will enhance the knowledge of the stakeholders (healthcare providers and service recipients) regarding one another and also identify their individual process-based boundaries (Fowler et al., 1993). The main intention is to enhance the ‘open arena’ which will make room for mutual understanding and knowledge about one another. In order to initiate this, it is essential to create a positive perception of healthcare providers and acceptors for one another so that the ‘hidden self’ gradually diminishes. It is important that both providers and acceptors in health settings are responsive and proactive towards constructive feedback and experiment on their individual personality attributes to lessen the ‘blind self’. Gradually, with a positive environment and knowledge about one another, the ‘open arena’ shall increase thus building a platform that nurtures mutual trust, respect and acceptability. It covers not only the immediate issues of conflict but also the underlying conditions responsible for them.
The present study examined the perspectives of both healthcare service providers and recipients to gain insights into conflict primers and dissatisfaction. With patient-centric approach, it is important to reduce conflicts and make the overall experience satisfactory. The themes and subthemes identified in this exploratory study have been classified into individual factors and institutional factors. The individual factors have been studied under three main themes and seven subthemes highlighting their presence in both healthcare providers and service recipients. The institutional factors include one theme and two subthemes.
The personality facet theme includes disruptive behaviour and disagreement and delayed decision-making as their subthemes.
Personality issues and disruptive behaviour with little emotional quotient and limited interpersonal training have created a lot of workplace conflicts (Ramsay, 2001). The previous image of medical professionals, especially doctors, has undergone a sea change and are a part of the healthcare team where people should be treated with respect. Dysfunctionality can be costly for healthcare teams where productivity and outcome are associated with emotions (Patton, 2014). The presence of a disruptive physician increases stress and decreases efficiency in a working environment. It mostly leads to a dysfunctional team where team spirit and overall morale of the people have been found to suffer. As interpersonal communication remains poor, there is a tendency to withhold any information since there is always a fear for the generation of a potential conflict (Overton & Lowry, 2013). There is a greater chance for physicians to end up losing the support of staff. Similarly, disruptive personalities might turn violent whenever their interests are unmet. Similar results have also been obtained in the current study where respondents were fearful of the person concerned (Maddineshat et al., 2017). The participants revealed their experiences with disruptive behaviour and interference that highlighted negative healthcare outcomes.
It is imperative to have a sound professional code of conduct in practice that covers the medico-legal bylaws for the staff. In majority of the conflict episodes, since personality happens to be the root cause for all issues, easily understandable, clearly written rules are to be implemented without the interference of individual personality traits (Patton, 2014). Detailed organisational functioning and disciplinary structure in practice shall create awareness regarding the degree of behavioural inappropriateness that shall be tolerated. Accordingly, in situations of specific conflicts, resolution becomes easier.
Delay in making important decisions during crucial hours often creates longstanding conflicts. Socio-cultural differences and emotional reactions result in disparity in healthcare settings (Lask, 2003). General code of conduct on acceptable behaviour as well as expression of feelings and thoughts are different across different cultural contexts. Often, feeling of hopelessness, anger, fear and despair have been noted, especially in the context of the recent COVID-19 pandemic where a similar range of expressions was noted for healthcare providers and recipients at large (Van Keer et al., 2015). During COVID-19 infections, a significant downhill despite the best of efforts gradually impaired the trust and positivity of the patients and their families towards the healthcare system/physician. Disagreements regarding treatment regimen or decision-making process have been frequently noted in this study which has resulted in conflicts of different degrees. The emotional outbursts result in painful conflicts amongst patient, their family and the healthcare personnel, especially the doctors and nurses.
The communication facet theme includes communication, adequacy, empathy and psychosocial expectation and previously unresolved conflict as their sub-themes.
Communication limitations pose serious risk of miscommunications (Ramsay, 2001). In Indian settings, the busy physician often has to rush through the files and necessary information provisions thereby communicating often insufficient information or contributing towards misunderstanding. Sometimes, in an attempt to provide enough information, there is a possible risk of information overload or inability to make a note of vital points. This can create different degrees of assumption amongst physicians, patients and their families regarding the knowledge that they perceive to possess about one another and the underlying situation.
Extent of involvement of healthcare providers, most importantly, the physicians in the treatment of their patients has always attracted attention (Chipidza et al., 2015). The importance of soft skills, empathy and other psychological domains of satisfaction has been explored by numerous researchers (Ranjan et al., 2015). It is important to note that while there is no set benchmark regarding the depth of involvement of doctors with their individual patients, there are situations where doctors are over involved and walk that extra mile during the course of treatment. Contrastingly, another set of doctors does not endorse the same citing grounds of remaining professional due to varied understanding and experiences of the clinical environment. These differences are grounds for impending conflicts and dissatisfaction affecting doctor–patient relationship.
Participant interviews have highlighted that inadequate communication, lack of perceived empathy and presence of previously unresolved conflicts pose detrimental implications in clinical settings. Poor communication, empathy, accountability issues and decision delays irk the provider–recipient relationship (Forbat & Barclay, 2019; Moudatsou et al., 2020). It is important to realise that patient-centric care needs interprofessional and intraprofessional conflicts within the limits of tolerance, the failure of which would result in unnecessary delays, critical clinical complications, increased costs, bad news and diminished satisfaction (Jerng et al., 2017). The healthcare service recipients opined communication adequacy, interdepartmental communication issues and empathy to be contributory towards conflicts and providers specifically identified previously neglected or unresolved conflict as a precursor.
Experiences shape perceptions which affect relationships and patient care (Cullati et al., 2019). The situation becomes complex when finances become a source of worry for the patient and their families. In the Indian context, despite significant developments in health policy and practices, there is a noteworthy healthcare cost that is borne by the common man which is commonly described as OOP (Chowdhury et al., 2018). A drastic increase in health costs, especially in private clinical establishments, and complications that magnified with the onset of the COVID-19 pandemic created negative perceptions associated with costs and enhanced the expectation–reality gap. The outcomes remain far-fetched in situations when the illness (acute or chronic) despite the best of efforts does not meet the expectations of individuals. This eventually results in impairment of trust and overall confidence in the front-line medical practitioners. The therapeutic relationship becomes the ground for conflict when the perceptions and expectations of patients/families regarding the illness course and content are different from the real scenario. The immediate reflexes end up in shock, resentment, disagreement, trust issues, disappointment, conflict and violence (Levinson et al., 1999).
Our findings identified perceptual negativities to be contributory to health dissatisfaction. Some patients do turn up to their physicians to discuss costs and finances associated with treatment. However, the doctors might perceive this as a wasteful activity in an already burdened clinical setting. They may feel stressed out that they are devoting time to discussions that are essentially not medical in nature, which, in turn, has long-term effects on patient satisfaction and increases the chance of a conflict. Instead, physicians may seek to establish a ground rule for dialogue alongside developing a platform for honest discussions, their limitations and managing expectations. Also, the mindset shift coupled with trials, opinions and judgements in media creates a rift amongst everyone which affects working relationships. However, negativities surrounding healthcare practices and costs get escalated promoting hostility and trust issues in healthcare relationships (Branning & Vater, 2016).
There are situations when the cause of conflict or dissatisfaction cannot be described only in terms of individual factors and involves the process and delivery systems. Our study has identified a key theme on service standard and practices. Thorough deliberations with stakeholders on this theme that included time constraints and interdepartmental coordination and laxity as their sub-themes revealed that organisational factors and processes need to be worked upon for avoiding scenarios of conflict and dissatisfaction.
Previous studies have identified communication breakdown, manpower constraints, resource limitation, work stress, long work hours, high employee turnover and poor professional support to be the common indicators of conflicts and dissatisfaction (Cullati et al., 2019; De Dreu & Weingart, 2003; Ferens, 2008; Goetz et al., 2018). Poor work conditions and ambiguous functional protocols create unnecessary disturbances that can otherwise be avoided (Lahana et al., 2019). Early interventions are crucial in conflicting scenarios. A similar type of result was also obtained in the current context where interpersonal conflicts amongst stakeholders resulted in poor outcome, delayed processes, high turn-around time, mismanagement and intermittent care, issues with patient safety, ineffective utilisation of valuable resources, unnecessary work time for personnel and patient dissatisfaction. Healthcare institutions must avoid them to ensure minimal disruption at work. Our study revealed that general disorganisation as a dimension of personality, working style or simply process flow often creates coordination issues which further complicates events and affects satisfaction.
Conclusion
Healthcare conflicts are inevitable parts of the giant health system, yet, most of the commonly encountered conflicts can be solved if managed effectively. One of the most reliable ways of conflict management involves effective practices that reduce frequency, intensity and duration of such interpersonal conflicts.
It is important to understand that instead of engaging in a futile attempt of avoiding any conflicting scenario, it is more prudent to look for ways of constructive conflict resolution. It has been identified that effective conflict management enhances regular operations at workplaces, whereas, conflict mitigation strategies promote dysfunctionality.
Healthcare satisfaction is a dominant parameter for the sustainability of clinical establishments. To ensure better patient care and safety, the causes of conflicts and dissatisfaction in healthcare settings need identification, root cause analysis and optimal intervention. Our study has reconfirmed the role of communication metrics, personality facets, perceptions and expectation gap along with organisational service standards to affect conflict, satisfaction and management.
Medical care is engraved upon a trusted and cordial relationship amongst the healthcare provider and their recipients. An important entity of this relationship is the doctor–patient relationship. Decreased public trust, diverse information sources and rapid changes in the overall healthcare system have resulted in a strained relationship between the healthcare provider and its recipient. Innovative approaches towards designing coping and thriving strategies between physicians, teams, patients, their families, healthcare policymakers and administrators are required to preserve the essence of healthcare provider–acceptor relationship.
A few points that front-line healthcare providers, especially the physicians and nursing staff, can keep in mind while dealing with the patient involve understanding the concerns and worries of the patient, expression of empathy during discussions and negotiation of any possible opinion differences which might have cropped up during conversations ensuring mutual respect. Conflict resolutions become effective when decisions are mutually acceptable. It is only possible when the concerns of the patients are considered.
The main contributions of the present study can be summed up as (a) It is the only study that explored the views of both healthcare service providers and recipients in Indian settings. (b) It is one of the pioneering studies in Indian settings that have qualitatively explored the factors of conflicts affecting healthcare service provider–recipient relationship. (c) This study has specifically considered in-patients, their families and providers (doctors and all other medical personnel) who have experienced conflicts to gain first-hand experience on their perceptions, expectations and challenges in real-time settings.
Limitations
This study has a few limitations and scope for further extension. We did not triangulate this data with hospital feedback records. We considered patients, next of kin, staff and practitioners from private medical establishments only. It is assumed that economically stable and literate respondents were part of the study who visited private healthcare establishments and similar results are reflective in socio-demographic dimensions. Involvement of illiterate patients, respondents from lower economic group and government institutions might have provided a wider spectrum.
Despite such limitations, we are confident about data robustness. We have done a significant number of interviews through random selection thereby capturing a remarkable heterogeneity in the conflict stories. The interviews were done by researchers who have thorough experience in doing such interviews thereby involving minimal barriers.
Appendix 1
Questions for Healthcare Service Recipients
Hi, may I know your name please?
Are you the patient? (If no, how are you related to the patient?)
How old are you?
What is your educational qualification?
Could you please tell me how was your experience with the hospital?
Can you please elaborate what exactly happened?
How was your interaction with the doctors? How was the treating physician?
How about the nurses? Will you please share how the interaction was?
How was your experience with the reception and billing department?
Please share your opinion during interactions with other personnel like technicians and others.
Would you like to add anything regarding the overall services?
Can you suggest how you think things can be improved?
Questions for Healthcare Service Providers
Hi, may I know your name please?
What is your age?
Could you please tell me what is your role in the organisation?
What is your educational qualification?
Can you please elaborate what exactly happened?
How was your interaction with the patient and patient family members?
How was your interaction with other doctors with regards to this case?
How about the nurses? Will you please share how the interaction was?
How was your experience with the reception and billing department?
Please share your opinion during interactions with other personnel like technicians and others.
Would you like to add anything regarding the overall services?
Can you suggest how you think things can be improved?
Author Contribution
Mitali Sengupta and Arnab Ganguly contributed equally.
Footnotes
Acknowledgements
The authors would like to thank the University of Engineering & Management, Kolkata for the necessary infrastructure for conducting the research. MS would like to thank the other team members for constructive feedback and discussions.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.