Intensive Care Med

DOI 10.1007/s00134-014-3517-z UNDERSTA NDING THE DISEASE

Christiane S. Hartog
Julie Benbenishty
Understanding nurse–physician conflicts
in the ICU

C. S. Hartog ()) C. S. Hartog

Received: 17 September 2014
Accepted: 8 October 2014
Ó Springer-Verlag Berlin Heidelberg and
ESICM 2014
Department for Anesthesiology and
Intensive Care, Jena University Hospital,
Erlanger Allee 101, 07743 Jena, Germany
e-mail: Christiane.hartog@med.uni-jena.de
Tel.: ?49 3641 9323171
Center for Sepsis Control and Care, Jena
University Hospital, Jena, Germany
J. Benbenishty
Hadassah Hebrew University Medical
Center, Jerusalem, Israel

The modern approach to critical care delivery is the
multidisciplinary model where collaboration and respon-
sibility is shared between ICU physicians and nurses.
Effective collaboration is considered fundamental to
optimize the medical care provided to critically ill
patients and improve staff outcomes [1–3]; there is a
positive relationship between collaboration and ethical
climate and job satisfaction [4]. Conflicts between nurses,
physicians and other clinicians threaten to disrupt team
collaboration and negatively influence patient and family
well-being, job satisfaction, staff burnout, intention to
quit and health expenditure [5, 6]. Intra-team disagree-
ments commonly occur about goals of care and the role of
life-sustaining interventions [7]. Given the complex and
dynamic nature of critical illness, decision-making should
be collaborative but often is not, due to different attitudes,
perceptions, experience and responsibilities.
How big is the problem
Nurse–physician conflicts in the ICU are common.
A French multicenter survey found that conflicts in gen-
eral were perceived by 72 % of staff at least once during
the previous week, and nurse–physician conflicts were the
most common types of conflict noted (33 %), closely
followed by nurse–nurse and staff–relative conflicts
(27 % each) [8]. In a recent nation-wide US survey, 43 %
of 912 responding surgeons reported sometimes or always
experiencing conflicts with ICU nurses about the goals of
post-operative care, and a similar percentage (43 %)
reported such conflicts with ICU physicians [9]. Nurse–
physician conflicts in the ICU commonly arise about
goals of care, particular at the end of life. The change
from curative to end-of-life care is demanding and may be
aggravated if there is poor collaboration, communication
and lack of support. Nurses who spend more direct time
with the patient and family often feel unsupported and
that their opinions about end-of-life care processes are not
respected [10].
Factors that drive nurse–physician conflicts
in the ICU
Nurse–physician conflicts in the ICU can be grouped into
four main categories which are interconnected and may
overlap (Fig. 1). The personal level concerns personality
traits, for instance personal animosity or mistrust [8].
Procedural factors relate to team processes, such as lack
of clarity about one’s tasks or responsibilities, lack of
guidance by superiors, unclear or nontransparent deci-
sion-making processes, inadequate sharing of knowledge,
lack of respect and poor communication. Common sour-
ces of conflicts for instance are communication gaps, lack
of regular interdisciplinary meetings, misunderstandings
and lack of leadership [2, 8]. Organizational factors may
contribute to conflicts on the unit or hospital level. For
instance, the disparity of power between nurses and
physicians has historical roots in the differences in
income and gender, but many of our pre-conceived
notions and expectations are related to the manner in
which each profession is currently being educated. Most
physicians first meet nurses on their initiation as new
interns. The same occurs in nursing school. There has
been no joint socialization for our collaborative roles.
Nurses expect physicians to have all the answers and
‘‘know what to do’’ when a problem arises and interns
expect nurses to fulfill their ‘‘orders’’. Lack of adminis-
trative guidelines and protocols which regulate
interprofessional collaboration, deficits in professional
education, financial constraints and lack of staffing which
increase work load, and planned performance directed at
patient throughput at the expense of team-strengthening
measures may contribute to conflicts. Lastly, the larger
political, legal, social and cultural context can drive
conflict-enhancing perceptions and expectations, such as
gender roles, ethical norms, cultural values or traditional
hierarchies.
All of the above may come to bear on conflicts, mis-
understandings and frustrations that are experienced daily
as nurses and physicians work side by side in the ICU.
Studies consistently show that physicians and nurses
differ in their expectations, attitudes and perceptions
about interprofessional collaboration and communication.
Perception of teamwork is related to status in the team
[11]. Nurses consistently rate the quality of interprofes-
sional collaboration lower than doctors [4]. Thomas et al.
found that, relative to physicians, nurses give lower rat-
ings, report that it is difficult to speak up, disagreements
are not appropriately resolved, more input into decision-
making is needed, and nurse input is not well received.
The authors linked these findings to suboptimal conflict
resolution and explained them as the result of the
Fig. 1 Factors which can drive
nurse–physician conflicts
differences in status/authority, responsibilities, gender,
training, and nursing and physician cultures [12].
How to prevent conflicts and improve
interprofessional collaboration
Key to effective team collaboration is good communica-
tion on all levels. Conflicts were less likely to occur in
ICUs that held regular staff meetings [8]. An increase in
interdisciplinary activities like daily interprofessional
rounds or multidisciplinary team meetings has a positive
impact on patient outcomes [13]. Other suggestions are
integrated patient records, joint practice committees, joint
ICU leadership, scheduled interdisciplinary meetings,
scheduled joint patient bedside rounds, written policies
supporting collaboration, interprofessional orientation of
new providers in the unit, and interdisciplinary in-services
[14].
To achieve sustainable change, modifications should
occur on more than one level (Fig. 1). On the personal
level, nurses and residents can be trained together to
learn to speak up and value each others’ statements; on
the procedural, unit and hospital level, regulations and
protocols are necessary to ensure that interprofessional
meetings, rounds or audits are scheduled and carried
out. For instance, nurses may find that the resident does
not insert CVP lines according to evidence-based stan-
dards. To personally ‘‘challenge’’ this physician may
cause conflict. The nursing and physician team can
together perform an up-to-date literature search, finding
the benchmarking guidelines on central line insertion,
then implement the collaborated consensus-agreed
guidelines throughout the unit. Lastly, we need to
develop a culture that values and acknowledges the
contributions of nurses and physicians as different but
equally important.
Towards nurse–physician synergy collaboration to occur, all disciplines within the health
care team must be considered equal partners but with
Nurse–physician conflicts in the ICU are common and different roles and knowledge. The nursing role is going
unavoidable. They can be viewed as both positive and through change and moving away from hierarchy to more
negative–positive in that conflicts can be constructive and independent roles. More research is needed to conceptu-
lead to improvements and progress, negative in that they alise and measure good and healthy collaboration [15].
influence patient outcomes, family well-being, and staff
job satisfaction and health. Either way, understanding Acknowledgments No external funding.
what drives conflicts or how they may be resolved is
Conflicts of interest The authors declare that no conflict of
important to achieve and sustain the ICU as a satisfying, interest exists.
healthy and restorative work place which is effective at
saving lives and supporting families. For true

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