17.3 Conflict Resolution & Interprofessional Communication

17.3 Conflict Resolution & Interprofessional Communication

SNB Core Competency Focus: Section 17.3 addresses SNB Registered Nurse Core Competency Domain 3 (Collaborative Practice and Teamwork) and Domain 1 (Legal and Ethical Nursing Practice). Communication failure is recognized globally and by the Singapore Ministry of Health (MOH) as a primary root cause of sentinel events, adverse drug events, and compromised patient safety. RNs must master structured communication protocols, assertive communication tools, and evidence-based conflict resolution strategies.

In high-complexity clinical environments—such as operating theatres, intensive care units (ICUs), and busy medical-surgical wards—interprofessional conflict and communication breakdowns frequently arise from hierarchical power dynamics, competing clinical priorities, role ambiguity, and high stress. The SNB Code for Nurses and Midwives (2023) mandates that nurses communicate effectively, maintain collegial relationships, and escalate patient safety concerns assertively without fear of retribution.

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1. Structured Clinical Communication: ISBAR Framework

Standardized handover protocols eliminate ambiguity and ensure critical clinical information is accurately conveyed during shift changes, intra-hospital transfers, and urgent physician notifications. In Singapore healthcare institutions, the ISBAR framework is the standardized standard of communication:

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2. Standardized Conflict Resolution Strategies: Thomas-Kilmann Model

Conflict within interprofessional teams can be productive if managed constructively, leading to improved care pathways and team cohesion. The Thomas-Kilmann Conflict Mode Instrument (TKI) categorizes conflict resolution behaviors along two dimensions: assertiveness (satisfying one's own concerns) and cooperativeness (satisfying others' concerns):

HIGH  ^
      |    COMPETING                       COLLABORATING
      |   (Assertive, Uncooperative)      (Assertive, Cooperative)
 A    |
 S    |
 S    |                  COMPROMISING
 E    |             (Intermediate Both)
 R    |
 T    |    AVOIDANCE                       ACCOMMODATING
      |   (Unassertive, Uncooperative)    (Unassertive, Cooperative)
LOW   +---------------------------------------------------------->
      LOW                  COOPERATIVENESS                   HIGH

Application of Conflict Modes in Clinical Practice:

1. Collaborating (High Assertiveness, High Cooperativeness): The gold standard for non-emergent interprofessional care planning. Team members pool expertise to create win-win solutions that fully satisfy clinical and patient goals (e.g., negotiating a joint rehabilitation schedule between nursing wound care and physiotherapy).
2. Competing (High Assertiveness, Low Cooperativeness): Necessary when immediate patient safety is compromised or in acute emergency resuscitation (e.g., an RN stopping an incorrect blood transfusion or unsterile procedure immediately).
3. Compromising (Moderate Assertiveness, Moderate Cooperativeness): Useful when time is limited and a temporary, mutually acceptable trade-off is required without compromising safety (e.g., agreeing to split medication administration times to accommodate therapy schedules).
4. Accommodating (Low Assertiveness, High Cooperativeness): Appropriate when the issue is far more critical to the other party, or when the nurse recognizes their own knowledge gap on a specific minor detail.
5. Avoiding (Low Assertiveness, Low Cooperativeness): Generally unhelpful in healthcare, but may be used temporarily to allow emotions to cool down during non-urgent inter-personal friction before a formal resolution meeting.

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3. Graded Assertiveness & Safety Escalation: The CUS Model & DESC Script

When patient safety is threatened by communication barriers, hierarchical resistance, or clinical oversight, Registered Nurses must use graded assertiveness tools to escalate concerns effectively.

The CUS Assertion Framework:

• Step 1: C — I am CONCERNED: State your clinical observation clearly ("Dr. Lee, I am concerned about the prescribed 50 units of IV short-acting insulin dose for this patient.").
• Step 2: U — I am UNCOMFORTABLE: Elevate the concern if ignored ("I am uncomfortable administering this dose because the standard protocol maximum single dose is 10 units, and the patient's blood glucose is 11.1 mmol/L.").
• Step 3: S — This is a SAFETY issue: Halt the procedure or action explicitly ("This is a critical patient safety issue. We need to pause and re-verify this order with the senior registrar immediately.").

The Two-Challenge Rule:

Under safety culture guidelines in Singapore hospitals, an RN is obligated to voice a safety concern at least twice if the initial challenge is dismissed. If the clinician fails to acknowledge or rectify the safety risk after two challenges, the RN must immediately activate the formal Chain of Command escalation pathway (notifying the Nurse Clinician, Nurse Manager, or Consultant-on-Call).

The DESC Script for Interpersonal Conflict:

• D — Describe: Describe the concrete behavior or situation objectively without emotional judgment.
• E — Express: Express your clinical concern and how the situation impacts patient care or team function.
• S — Suggest: Suggest specific, actionable alternatives or compromise solutions.
• C — Consequences: Outline the positive outcomes of consensus (or consequences regarding safety reporting).

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4. Professional Ethics & Zero Tolerance for Incivility

Under SNB Code for Nurses and Midwives (2023), nurses must foster a respectful work environment free from lateral violence, bullying, and verbal abuse. Lateral violence (nurse-to-nurse incivility) and interprofessional hostility undermine psychological safety, leading to unreported errors and burnout. Singapore healthcare institutions enforce zero-tolerance policies for workplace harassment under the Protection from Harassment Act (POHA). Nurses who experience or witness incivility are required to report incidents through internal hospital incident reporting portals (e.g., Risk Management / Safety Reporting Systems).

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5. Clinical Scenario: Medication Safety Escalation

Patient Scenario: During a hectic night shift in an acute medical ward, a junior House Officer (HO) verbally orders 100 mg of IV morphine for an opioid-naive patient experiencing severe pain.

Nursing Conflict Resolution & Escalation:

• Initial Challenge: RN recognizes that 100 mg IV morphine is a 10-fold overdose (standard single IV dose is 2.5–5 mg). The RN states: "Doctor, I am Concerned. The standard IV morphine dose is 2.5 to 5 mg. A 100 mg dose could cause fatal respiratory depression."
• Provider Resistance: The HO dismisses the nurse, stating: "I am the doctor here, just give what I ordered."
• Second Challenge & CUS Escalation: The RN applies the Two-Challenge Rule and CUS framework: "Doctor, I am Uncomfortable and this is a critical Patient Safety issue. I cannot administer this medication order as written because it is unsafe."
• Chain of Command Activation: The RN immediately halts administration, holds the medication, and contacts the Senior Registrar on call. The Senior Registrar reviews the order, confirms the arithmetic error (HO intended to write 10 mg oral syrup), thanks the RN for preventing a fatal adverse drug event, and logs a clinical incident report.