Case study from "Management Case Book: Insubordination or Advocacy" The Journal of Clinical Systems Management, Volume 4, Number 1.

About 10:30 pm November 12, Joe Doe was admitted with shortness of breath and an irregular heart rate to the Emergency Department of a large teaching hospital. While still being evaluated in the Emergency Department, Doe went into respiratory arrest and was intubated and ventilated manually. Dr. Smith* ordered Doe admitted to the ICU as soon as he was stabilized, and the Emergency Department notified the ICU of the pending admission. The ICU nurse who took the call said "We are very busy. We need more help if we are to admit another patient. We cannot accept another patient." Dr. Smith was notified. Dr. Smith already had called Dr. Roe*, the Intensivist on call, to apprise him of the patient's condition. IT must be noted here that ICU had been short some 6 full time employee's for over a year. Then Dr. Smith called ICU to inform them that the patient was being sent to them despite their objections.

The ICU nurse called the supervisor, and told her that ICU could not safely care for the new admit -- who also was a ventilator patient. The Supervisor told her to "do the best you can" and promised to call the Emergency Department to see fi they could care for the patient until the day shift arrived. She did so, and Dr. Smith made it clear that the Emergency Department would not keep the patient. Smith call Dr. Roe again to tell him that the nurses were giving him a hard time, and he needed Roe's help getting care for this patient. Roe called the ICU and reprimanded the nurse who answered the telephone for giving Smith flack about admitting Joe Doe; she did not know what he was talking about, and assured him that no one was giving Smith any flack, but that ICU was at the saturation point and couldn't take any more patients until they got more help. Roe called the Nursing Supervisor and told her that Doe was being admitted to ICU, and he expected more staff would be there ASAP.

At 5:20 am, Doe was escorted to the ICU by an Emergency Department nurse and Dr. Smith, who transferred Doe to the one empty bed. However, when the nurse attempted to give report to one of the ICU nurses, the ICU nurse refused to take it because ICU staff could not safely care for Doe. The room Doe was admitted to was not equipped for his case, and the Emergency Room nurse and Dr. Smith attempted to assemble the necessary equipment, with the occasional help of one or the other of the ICU nurses--who did, in fact, appear to be swamped. When Dr. Roe arrived, he was furious. Dr. Smith was also very angry. The nurses were angry and overwhelmed. When the day shift arrived, there was more help available, and Patient Doe was formally admitted to the ICU. The physicians went directly to the V.P. of Nursing to complain, and later in the day, all 3 RN's on duty in the ICU were suspended without pay for three days for insubordination.

There are numerous points in this scenario where the application of dispute resolution processes could have prevented the escalation of the conflict, and the resulting suspension of employees badly needed for an already short staffed department.

1. The initial call from Emergency Department to ICU

Some basic training on communication techniques would allow both nurses to provide more information to support their positions. Rather than a "he's coming" statement with a "we won't take him" response, there could be an exchange focused on the need to provide the patient with the best care, and the issues in the ICU regarding the ability of the nurses to provide that care with their case load. In addition, the statement "We need more help if we are to admit another patient" could be expanded on and used as the starting point for generating some care options that would address both the ICU nurses concerns and the Emergency Department desire to move the patient to a location that was better suited to the care needs.

2. The Nurse Supervisor Interaction

The Nurse Supervisor attempted to act as intermediary between the ICU and Dr. Smith, however her call to Dr. Smith only served to escalate the conflict. Dr. Smith's call to Dr. Roe stating the nurses were giving him a hard time illustrates how a party can misinterpret another party's actions and then become entrenched in a negative viewpoint. Based on the eventual outcome, it is likely the ICU Nurses also felt that the Nursing Supervisor let them down, an issue with potential long term effects in that department. With more training, the Nurse Supervisor would have had more tools to deal with the issue beyond just telling the nurses to "do the best you can." She would also have techniques to deal with any morale issues in her department that resulted from the suspensions. If the hospital had access to a third-party neutral, the Nurse Supervisor could have referred the case to the neutral. An external neutral would be immune from any interdepartmental issues affecting interactions.

3. Dr. Smith contacting Dr. Roe

By the time Dr. Smith contacted Dr. Roe a second time, Dr. Smith was clearly frustrated and getting angry as evidenced by his comments to Dr. Roe. Based on the information provided, it does not appear that Dr. Smith was given any information regarding why the ICU was reluctant to take on another patient, therefore he was focusing only on his need to get the patient moved, and not taking into account any other issues. With training, Dr. Smith would know to ask simple yet important questions, such as "what is the patient, nurse ratio in the ICU right now?" In addition, if a third party neutral was available, those questions could be raised without interdepartmental issues coming into play.

4. Roes' Call to ICU

By the time Roe called the ICU, the conflict had escalated to the breaking point. Dr. Roe reprimanded someone not even involved in the initial dispute. While that nurse gave Dr. Roe the needed information that the ICU was at "saturation point," by the time that information was relayed, both Dr. Smith and Dr. Roe were set in their position that the patient had to be transferred out of the ER immediately. Absent formalized training in dispute resolution processes or the introduction of a third party neutral, the conflict would only escalate from that point onward.

5. Roes' Call to Nursing Supervisor

Dr. Roe's demand that more staff be made available ASAP in a department that was chronically understaffed underscores a lack of communication skills and techniques for addressing conflicts.

6. Does' arrival in ICU

At this point the parties are on the road to no return. The ICU nurses would view Dr. Smith's actions as a power play, and Dr. Smith views their refusal to assist or take report as insubordination. Dr. Roe arrives, and his anger fuels Dr. Smith's anger, and the anger and frustration of the nurses. The nurses are focused on the belief that they cannot safely care for another patient, and the doctor's are focused on the nurses' apparent refusal to follow orders. No one, including the patient, is benefiting from the situation, and long term relationships are being seriously damaged.

7. Roe and Smith to Vice President of Nursing

Although the scenario does not supply a significant amount of detail regarding the exchange between the doctors and the V.P. of Nursing, it is unlikely the ICU nurses were given an opportunity to present their version of the early morning's events. If the hospital provided a third-party neutral, the neutral could sit down with the hospital personnel involved to debrief and attempt to repair the damaged relationships. Since the doctors and nurses will be interacting on a regular basis in the future, it is important the issues raised by the events be addressed. A third party neutral could help diffuse the current situation, and also work with the parties to identify whether there are any protocols in place that could have helped in this situation. Absent an existing protocol, the parties could work together to develop a process to deal with similar situations that might arise in the future.

8. Administration Suspension

Imagine the nurses' feelings when they receive notice of their suspension without pay. Imagine the impact on the already understaffed ICU. The affects of the suspension will last far beyond three days, and impact not only the doctors and nurses involved in the scenario, but the patients who will be under their care. The anger and resentment will likely lead to impaired communication, avoidance and additional conflicts which will escalate quickly due to the damage to working relationships that has already been done.

Some basic training on communication techniques and conflict resolution would go a long way in addressing the issues raised by this scenario. In addition, access to a qualified third party neutral would serve to diffuse the situation, and could provide long terms benefits for the interdepartmental relationships impacted by the actions and reactions raised by this case study.

* Names have been changed to protect confidentiality