# Pediatric Intensive Care Unit Conflict Management Perspectives Among Physician and Nurse Leaders

## TL;DR

This study explores how conflicts between families and medical teams in pediatric intensive care units are managed and finds a need for standardized, evidence-based approaches.

## Contribution

The study identifies variability in conflict management practices and proposes the need for standardized, evidence-based processes in PICUs.

## Key findings

- Only 23% of institutions track conflicts and their outcomes.
- Institutions that track behavior contracts are more likely to use objective reasons for interventions.
- Respondents suggest multipronged strategies for conflict prevention and response.

## Abstract

How is decisional conflict between families and clinical teams managed?

In this survey study of 60 pediatric intensive care unit (PICU) physician and nurse leaders, there was wide variability in approaches and opinions about best practices for conflict prevention, mediation, and management.

Our findings indicate a need to develop standardized, multipronged, and evidence-based processes to prevent and address conflict between clinical teams and families.

This survey study among physician and nurse leaders in pediatric intensive care units (PICUs) across the United States examines how decisional conflict between families and clinical care teams is handled.

Decision-making conflict is common in the pediatric intensive care unit (PICU) and associated with negative outcomes for patients, families, and teams. Disparities in conflict outcomes are reported, yet no studies have explored conflict management approaches.

To understand approaches to conflict mediation and escalation in the PICU.

This national, multicenter, prospective, mixed-methods survey study recruited PICU physician and nursing directors from February to April 2023.

PICU size, conflict policy, behavior contract tracking.

Closed- and open-ended survey questions were used to collect information on hospital policies, general conflict approaches, and specific approaches to scenarios.

The overall response rate was 57% (68 of 120 surveys, with 60 complete enough for analysis). Overall, 30 of 51 respondents (59%) identified as female, with a wide distribution of reported years in current role and percentage of time spent in clinical care. Institution regions varied, with an even distribution among institutions with different PICU sizes. Conflict strategies were used variably across institutions. Approximately 65% (32 of 49) reported policies for conflict management. Only 23% (10 of 43) tracked conflicts and their outcomes. Few institutions trained staff in conflict management techniques. Compared with institutions that did not track behavior contracts, those that did were more likely to call ethics consults for conflict management (3 of 12 [25%] vs 0 of 20; P = .04) and to implement behavior contracts for more objective reasons (8 of 11 [73%] vs 4 of 16 [25%]; P = .02). Leaders offered ideas for multipronged conflict prevention and response based on strategies implemented at their institutions but also highlighted needs and concerns with existing approaches.

In this mixed-methods survey study of PICU physician and nurse leaders, tracking and internal reporting of conflicts and outcomes were associated with more objectively applied interventions. The wide-ranging approaches and thresholds for escalation voiced by our respondents indicate a need to develop standardized and evidence-based processes to ensure greater effectiveness by clinical teams and leaders in addressing conflict and reduce potential disparities in outcomes. Respondents shared ideas for preventive and responsive processes that could be implemented and tested in the future. Learning from existing management approaches may help develop standardized, generalizable interventions to reduce conflict, improve interventions, and reduce subjectivity in the application of interventions.