Olszewski Aleksandra E, Shah Seema K, Barrera Leonardo, Castillo Leopoldo, Kolaitis Irini, Goodman Denise M, Paquette Erin
Department of Pediatric Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
JAMA Netw Open. 2025 May 1;8(5):e259783. doi: 10.1001/jamanetworkopen.2025.9783.
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.
DESIGN, SETTING, AND PARTICIPANTS: 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.
决策冲突在儿科重症监护病房（PICU）中很常见，并且与患者、家庭和团队的负面结果相关。有报告称冲突结果存在差异，但尚无研究探讨冲突管理方法。
了解PICU中冲突调解和升级的方法。
设计、背景和参与者：这项全国性、多中心、前瞻性、混合方法的调查研究于2023年2月至4月招募了PICU医生和护理主任。
PICU规模、冲突政策、行为合同跟踪。
使用封闭式和开放式调查问题收集有关医院政策、一般冲突方法以及特定场景方法的信息。
总体回复率为57%（120份调查问卷中的68份，其中60份完整到足以进行分析）。总体而言，51名受访者中有30名（59%）为女性，在当前职位的报告年限和临床护理时间百分比方面分布广泛。机构所在地区各不相同，不同规模PICU的机构分布均匀。各机构对冲突策略的使用各不相同。约65%（49份中的32份）报告了冲突管理政策。只有23%（43份中的10份）跟踪冲突及其结果。很少有机构对员工进行冲突管理技术培训。与未跟踪行为合同的机构相比，跟踪行为合同的机构更有可能因冲突管理而寻求伦理咨询（12份中的3份[25%]对20份中的0份；P = 0.04），并且更有可能出于更客观的原因实施行为合同（11份中的8份[73%]对16份中的4份[25%]；P = 0.02）。领导者根据其机构实施的策略提出了多管齐下的冲突预防和应对建议，但也强调了现有方法的需求和问题。
在这项对PICU医生和护士领导者的混合方法调查研究中，冲突和结果的跟踪及内部报告与更客观地应用干预措施相关。我们的受访者提出的广泛方法和升级阈值表明，需要制定标准化的循证流程，以确保临床团队和领导者在解决冲突方面更有效，并减少结果方面的潜在差异。受访者分享了未来可实施和测试的预防及应对流程的想法。从现有管理方法中学习可能有助于开发标准化、可推广的干预措施，以减少冲突、改进干预措施并减少干预应用中的主观性。
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