Perception of interprofessional conflicts and interprofessional education by doctors and nurses.

PURPOSE: This study aimed to collect information that is needed to develop interprofessional education curricula by examining the current status of interprofessional conflicts and the demand for interprofessional education.
METHODS: A total of 95 doctors and 92 nurses in three university hospitals in Seoul responded to a survey that comprised questions on past experience with interprofessional conflicts, the causes and solutions of such conflicts, past experience with interprofessional education, and the demand for interprofessional education.
RESULTS: We found that 86% of doctors and 62.6% of nurses had no interprofessional education experience. Most of them learned about the work of other health professions naturally through work experience, and many had experienced at least one interprofessional conflict. For doctors, the most popular method of resolving interprofessional conflicts was to let the event pass; for nurses, it was to inform the department head. Further, 41.5% of doctors and 56.7% of nurses expressed no knowledge of an official system for resolving interprofessional conflicts within the hospital, and 62.8% of doctors and 78.3% of nurses stated that they would participate in interprofessional education if the opportunity arose.
CONCLUSION: In Korean hospital organizations, many doctors and nurses have experienced conflicts with other health professionals. By developing an appropriate curriculum and educational training system, the opportunities for health professionals to receive interprofessional education should expand.

INTRODUCTION

Collaboration and teamwork between health professionals are crucial in providing high-quality patient care [1,2]. This allows a holistic approach to treatment [3] and ultimately improves patient outcomes [4].

There have been criticisms that “learning together” does not necessarily mean “working together” [1], and some doubts about the effectiveness of early interprofessional education (IPE). Nevertheless, interprofessional education is regarded as an effective method for removing barriers and conflicts between different types of professionals [5,6]. IPE can promote a team-based approach to treatment by removing stereotypes against other professions [7], instilling the right values and attitudes toward all professions (including one’s own), and creating a culture of mutual respect between different professions [8,9].

Due to these reasons, many countries around the world have built a healthcare system that guarantees effective cooperation between health professionals. They are also making investments and policies aimed at strengthening such IPE between health professionals [6]. However, IPE is an unfamiliar concept in South Korea’s organizational culture and clinical environment. The Korean organizational culture is based on a pre-modern Confucian patriarchal system, which is characterized by collectivism and a high degree of uncertainty. In this type of organizational culture, there is an inherent lack of understanding of IPE and almost no effective method to resolve interprofessional conflicts.

Therefore, this study investigated the present status of interprofessional conflicts and the demand for IPE in order to inform the development and implementation of IPE curricula. Specific problems addressed in this study are as follows:

(1) Have physicians and nurses received IPE in the past? How do they learn about other health professions?

(2) Have physicians and nurses experienced conflict with other health professionals? What do they believe was the cause of such conflict and how did they resolve it?

(3) Do physicians and nurses wish to receive IPE? If so, when do they believe would be the most appropriate time for this?

SUBJECTS AND METHODS

1. Participants

The participants were selected from a random sample of doctors and nurses working at three different university hospitals in Seoul. A total of 210 surveys were distributed to 105 doctors and 105 nurses. The response rate was 89.5% (n=94) for doctors and 87.6% (n=92) for nurses, resulting in a total of 186 responses available for analysis. Of the doctors, 64.9% were male and 35.1% were female. In terms of age, 26.6% of doctors were 25 or younger, 54.3% were between 26 and 30, and 17.0% were 31 or older. By occupation, 53.2% were interns, 38.3% were residents, and 8.5% were professors. Of the nurses, 100% were female. In terms of age, 43.3% were between 26 and 30, 20.7% were between 31 and 35, and 24% were 36 or older. A total of 51.1% were charge nurses, 39.1% were staff nurses, and 9.8% were head nurses (Table 1).

Table 1.

Subjects: Doctors and Nurses (N=186)

DoctorsM		Nurses
Subject	Frequency (valid %)	Subject	Frequency (valid %)
Gender		Gender
Male	61 (64.9)	Male	-
Female	33 (35.1)	Female	92 (100.0)
Age (yr)		Age (yr)
≤25	25 (26.6)	≥25	11 (12.0)
26-30	51 (54.3)	26-30	40 (43.3)
31-35	8 (8.5)	31-35	19 (20.7)
≥36	8 (8.5)	≥36	22 (24.0)
No response	2 (2.1)
Occupation		Occupation
Intern	50 (53.2)	Nurse	36 (39.1)
Resident	36 (38.3)	Charge nurse	47 (51.1)
Professor	8 (8.5)	Head nurse	9 (9.8)
Total	94 (100.0)	Total	92 (100.0)

2. Questionnaire

In order to investigate the perception of interprofessional conflict and IPE, a preliminary version of the survey, consisting of thirteen questions, was developed by reviewing related works [10-12]. To examine the validity of the assessment tool, focus group interviews were conducted with a group of 13 residents and five nurses (two ward nurses, two outpatient nurses, and one nurse specialist).

The final version of the survey was completed by discussing the results of focus group interviews and referring to the preliminary version of the survey. The survey consisted of questions about interprofessional conflict (e.g., experience of interprofessional conflict, number of conflicts, cause of the conflict, and how it was resolved) and IPE (e.g., IPE experience, wish to participate in IPE, the appropriate time to receive IPE). For questions regarding experience of interprofessional conflict and experience of interprofessional education, the response scale was simply “yes/no.” A nominal scale was used for all other questions. The nominal scale was developed on the basis of the information obtained from focus group interviews. A general category of “other” was included in the scale in order for people to freely describe any additional information.

3. Collection and analysis of data

A total of 210 physicians and nurses working in three different hospitals in Seoul were surveyed during October and November of 2011. The purpose of this study and instructions regarding the survey were explained to one medical school professor and one nursing school professor of each university. These professors were then requested to carry out the survey by randomly distributing the survey forms to physicians and nurses working in their respective universities, and then collecting the completed forms. In order to protect the rights and safety of the participants, the survey was approved by the Korea University Ethics Review Board (approval number: KU-IRB-11-36-P-1).

All statistical analyses, including frequency analysis and descriptive statistics output, were performed using SPSS version 12.0 (SPSS Inc., Chicago, USA).

RESULTS

1. Experience of interprofessional education

A total of 86% of doctors and 62.6% of nurses reported that they had no past experience of IPE. A total of 64.5% of doctors and 55% of nurses reported that they learned naturally about the work of other professions through work experience, and 18.5% of doctors and 22.5% of nurses learned from personal communication with colleagues in the same profession. Only 3.9% of doctors and 13.8% of nurses had acquired this knowledge through undergraduate lectures/courses or postgraduate hospital-sponsored programs. These results show that both doctors and nurses mainly learn about other health professions via informal routes rather than through formal education (Table 2).

Table 2.

Experience with Interprofessional Education (Multiple Responses)

Item	Doctors (n= 130)	Nurses (n = 138)	Total (n = 268)
Formal education
Undergraduate: lecture or course	1 (0.8)	4 (2.9)	5 (1.9)
Postgraduate education: hospital-sponsored programs	4 (3.1)	15 (10.9)	19 (7.1)
Informal education
Natural learning via work experience	84 (64.5)	76 (55.0)	1 60 (59.6)
Personal communication and learning from colleagues in the same profession	24 (18.5)	31 (22.5)	44 (20.5)
Personal communication and learning from other professions	16 (12.3)	5 (5.8)	24 (9.0)
Others	1 (0.8)	4 (2.9)	5 (1.9)

2. Experience of interprofessional conflict

A total of 76.6% of doctors and 96.7% of nurses reported that they had experienced at least one interprofessional conflict while working at the hospital. When asked about the cause of their previous interprofessional conflict, 33.3% of doctors and 43.4% of nurses chose “ignorance of those from other occupations about my occupation.” A total of 28.8% of doctors thought that this was due to a systemic failure to cooperate with other occupations, while 19.5% of nurses thought that their own ignorance of other occupations was the cause. Only 16.7% of doctors and 12.4% of nurses felt that personality problems were to blame (Table 3).

Table 3.

Chief Cause of Conflicts with Other Occupations (Multiple Responses)

Item	Doctors	Nurses
My ignorance of other occupations	29 (18.5)	53 (23.4)
Ignorance of those from other occupations of my occupation	52 (33.3)	98 (43.4)
Personality problems	26 (16.7)	28 (12.4)
Systemic failure of cooperating with other occupations	45 (28.8)	44 (19.5)
Other	4 (2.7)	3 (1.3)
Total	156 (100.0)	226 (100.0)

Data are presented as frequency (valid %).

When asked about the method they used to resolve interprofessional conflicts, 51.1% of doctors said that they would “let the event pass,” while 23.4% stated that they would consult a colleague in the same profession. About 8.5% expressed a preference for meeting the source of conflict and resolving the issue, while 7.4% would inform the department head of the person who caused the conflict. Only 5.3% said that they would inform their own department head and a mere 3.2% stated that they would report to the hospital authorities.

In contrast, 46.7% of nurses would inform their own department head, while 26.1% would let the event pass. About 18.5% of nurses said they would consult a colleague in the same profession, and 5.4% would choose to meet the source of conflict to resolve the issue. Only 3.3% said they would inform the department head of the person who caused the conflict, and no one said they would report to the hospital authorities (Table 4).

Table 4.

How Interprofessional Conflicts Should Be Solved

Item	Doctors (n = 93)	Nurses (n = 92)
Let the event pass	48 (51.1)	24 (26.1)
Consult a colleague in the same profession	22 (23.4)	17 (18.5)
Inform my department head	5 (5.3)	43 (46.7)
Meet the source of conflict and resolve the issue	8 (8.5)	5 (5.4)
Inform the department head of the person who caused the conflict	7 (7.4)	3 (3.3)
Report person to hospital authorities	3 (3.2)	-

Data are presented as frequency (valid %).

Of those who said they would let the event pass, 51% of doctors and 68% of nurses explained that speaking out on the issue would not resolve anything. About 23.5% of doctors and 16.0% of nurses chose this option because they felt they were too busy, and 19.6% of doctors and 12% of nurses felt that they did not possess the authority or status to speak out. A total of 41.5% of doctors and 56.7% of nurses reported that they did not know the official way to resolve a conflict with another profession or department. About 55.3% of doctors and 31.1% said they were not sure. Only 3.2% of doctors and 12.2% of nurses said that they did know.

3. Needs for interprofessional education

A total of 62.8% of doctors and 78.3% of nurses stated that they would like to broaden their understanding of other health professions through IPE, if given the opportunity. A total of 64.7% of doctors and 64.7% of nurses cited the overwhelming amount of work as a reason for not being able to engage in extra education; 23.5% of doctors and 29.4% of nurses did not feel that the content of such education would be helpful for them. The remaining participants (2.9% of doctors and 5.9% of nurses) did not feel it was necessary to know about other occupations. A total of 55.3% of doctors thought that interprofessional education becomes necessary during internship, while 30% thought that it was necessary during medical school. For nurses, 70% thought it was necessary at entry-level (less than 3 years of experience) and 19% chose undergraduate level (Table 5).

Table 5.

When Does Interprofessional Education Become Necessary?

	No. (%)
Doctors
Undergraduate	28 (29.8)
Internship	52 (55.3)
Residency	5 (5.3)
Specialist	7 (7.4)
No response	2 (2.2)
Total	94 (100.0)
Nurses
Undergraduate	17 (18.5)
Entry level <3 yr	64 (69.5)
Midlevel >3 yr	10 (10.9)
No response	1 (1.1)
Total	92 (100.0)

DISCUSSION

The fundamental reason why collaboration between health professionals is necessary is that the common goal of all health professionals working at hospitals is to provide high-quality care to patients. Doctors and nurses have different duties in their respective areas of medical treatment and nursing, but all of these duties are connected with patients’ health. As a part of the overall hospital environment, the provision of medical treatment and nursing is affected by both the hospital’s overall organizational culture and the subcultures of each profession. This study highlights some of the realities of interprofessional conflict and IPE and provides a number of implications regarding the South Korean hospital organizational system, its culture, and IPE in healthcare.

According to the results of this study, about 80% of doctors and 97% of nurses had experienced at least one interprofessional conflict. Despite this, the findings revealed that an official system for resolving such conflict did not exist in the hospital, and the majority of the respondents were simply not aware of the presence or the lack of such a system.

If the team-based approach to treatment is seen as a collaborative process between different health professionals with different goals, values, and cognitive structures, then interprofessional conflict is somewhat inevitable. The important thing, however, is not so much the conflict itself, but the ability to resolve conflicts using rational solutions, using these to improve the hospital organization and induce changes within it. The establishment of a system for officially reporting, investigating, and resolving conflicts between health professionals is necessary; such conflicts may function as a driving force for organizational development.

The fact that the majority of doctors and about a quarter of nurses of nurses chose to remain silent in the event of an interprofessional conflict shows that the culture of healthcare organizations in South Korea is being dominated by a hierarchical, Confucian, patriarchal tradition.

As one study indicates, in Korean organizational culture, which emphasizes collectivism over individualism and has its basis in Confucian patriarchal tradition and familial values [13], social status and class are important, and reticence and patience are considered noble attributes. In order to adjust to and survive in the group they belong to, health professionals naturally internalize societal norms and learn to remain silent and patient [14]. In this type of culture, conflicts are often resolved in an irrational manner, and outcomes can depend on one’s social status. This type of atmosphere can make people think that speaking out on an issue will not change anything or that they are not in a position to speak out about something. While hospitals in Western countries have a culture that resolves interprofessional conflicts in a reasonable way through an official organization of the hospital, Korean hospitals tend to handle the conflicts unofficially, mainly attributable to collectivism based on the hierarchical relations. Changing a culture is not easy, but the hierarchical organizational culture in South Korean healthcare systems should be reformed through gradual progress.

According to the results of this study, a majority of doctors and nurses learn about other health professions through personal experiences or other unofficial ways, and not through official educational programs or courses. This implies that learning to understand and collaborate with other health professionals can be very situation-dependent, rather than organizational or systematic. In other words, differences in the capacity to understand and collaborate with other health professionals can result from environmental factors, such as the people that an individual meets at work, the types of situations that they encounter, and their inclination and determination to understand other professions. To overcome the limits of such situation-dependent education, it is necessary to formalize IPE in the college curriculum, which is the initial stage of a health professional’s training [15]. There is also a need to make it mandatory for health professionals to receive official IPE when they begin to work at hospitals after graduation.

In this study, participants identified personal, rather than systemic, factors as being more important in causing interprofessional conflict. This suggests that strengthening IPE educational programs could be as effective in resolving interprofessional conflicts as improving hospital collaboration systems. There is a need to provide information about the work of other health professions in the IPE curriculum [2] in order to correct stereotypes and encourage positive attitudes toward all professions [16].

An encouraging fact is that a significant proportion of the participants (62.8% of doctors and 78.3% of nurses) expressed a strong intention to receive IPE when the opportunity becomes available. This kind of optimistic attitude shows that these health professionals recognize the need for IPE, and its value. It also suggests that an IPE curriculum suitable to the Korean healthcare system will need to be developed to meet the needs of health professionals. In addition to considering the development of an IPE curriculum for medical students, an appropriate educational program for new interns and nurses is also desirable.

Since the study sample is limited to physicians and nurses of the three university hospitals, the results may not be representative of the entire physicians and nurses.

In South Korean hospital organizations, where individualism and Confucian patriarchal tradition coexist, many doctors and nurses have experienced conflict with other health professionals. However, an official hospital system for resolving these conflicts has not yet been developed, and health professionals are not given enough opportunities to receive IPE. Nevertheless, the fact that many doctors and nurses express a strong wish to participate in IPE is very encouraging. In order to expand IPE opportunities, an appropriate educational system, and a curriculum will need to be developed. As an important method of breaking down intellectual and cultural barriers between different health professionals, IPE may help to convert the traditional and patriarchal organizational structure into an integrative, cooperative system, helping to improve patient outcomes.