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RESEA RCHARTICL E Workplace interpersonal conflictsamongthe healthcare workers:Retrospective exploration from theinstitutional incidentreporting system ofauniversity-affiliated medical center Jih-Shuin Jerng 1,2 , Szu-Fen Huang 1,3 , Huey-Wen Liang 1,4 , Li-Chin Chen 1 , Chia-Kuei Lin 1 , Hsiao-Fang Huang 1 , Ming-Yuan Hsieh 1 , Jui-Sheng Sun 1,5 1 Center forQuality Managemen t,National TaiwanUniversity Hospital,Taipei,Taiwan, 2Departm entof Interna lMedicine, NationalTaiwanUniversity Hospital,Taipei,Taiwan, 3Department ofNursing, National Taiwan University Hospital,Taipei,Taiwan, 4Departme ntofPhysical Medicine &Rehabilitation, National Taiwan University Hospital,Taipei,Taiwan, 5Departme ntofOrthopedi cSurgery, NationalTaiwanUniversity Hospital, Taipei,Taiwan drjssun@nt uh.gov.tw Abstract Objective There havebeen concerns abouttheworkplace interpersonal conflict(WIC)among health- care workers. Ashealthcare organizations haveapplied theincident reporting system(IRS) widely forsafety-related incidents,weproposed thatthissystem mightprovide achannel to explore theWICs.

Methods We retrospectively reviewedthereports tothe IRS from July2010 toJune 2013 inamedical center. Weidentified theWICs andtyped theseconflicts according tothe two foci(task con- tent/process andinterpersonal relationship)andthethree properties (disagreemen t,inter- ference, andnegative emotion), andanalyzed relevantdata.

Results Of the 147 incidents withWIC, themost common relatedprocesses werepatient transfer (20%), laboratory tests(17%), surgery (16%)andmedical imaging (16%).Allofthe 147 inci- dents withWIC focused ontask content ortask process, but41(27.9%) alsofocused onthe interpersonal relationship.Wefound disagreement, interference,andnegative emotionin 91.2%, 88.4%, and55.8% ofthe cases, respectively. Nurses(57%)weremost often the reporting workers,whilethemost common encounter wasthenurse-doctor interaction (33%), andthemajority (67%)ofthe conflicts wereexperienced concurrentlywith theinci- dents. Therewasasignificant differenceinthe distribution ofworker jobtypes between cases focused onthe interpersonal relationshipandthose without (p=0.0064). Thedoctors PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 1/13 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 2 3 ( 1 $ & & ( 6 6 Citation: JerngJ-S,Huang S-F,Liang H-W,Chen L-C, LinC-K, Huang H-F,etal. (2017) Workplace interpersona lconflicts amongthehealthca re workers: Retrospecti veexploration fromthe institutional incidentreporting systemofa university -affiliated medicalcenter.PLoSONE12 (2): e0171696. doi:10.1371/journal.pone .0171696 Editor: Stanley J.Robboy, DukeUnivers ity, UNITED STATES Received: July6,2016 Accepted: January6,2017 Published: February6,2017 Copyright: 2017 Jerng etal. This isan open access articledistributed undertheterms ofthe Creative Commons Attribution License,which permits unrestricte duse, distribu tion,and reproduction inany medium, providedtheoriginal author andsource arecredited.

Data Availabilit yStatement: Allrelevant dataare within thepaper anditsSupport ingInformation files.

Funding: Theauthors received nospecific funding for this work.

Competing Interests:The authors havedeclared that nocompeting interestsexist. were more frequently asthe reporter whentheconflicts focusedonthe interpersonal rela- tionship (34.1%) thannotonit(17.0%). Thedistributions ofworker jobtypes weresimilar between thosewithandwithout negative emotion(p=0.125).

Conclusions The institutional IRSisauseful placetoreport theworkplace interpersonal conflictsactively.

The healthcare systemsneedtoimprove thechannels tocommunicate, manageand resolve theseconflicts.

Introduction Interpersonal conflictisan important typeofconflict [1]that avariety ofits nomenclature exists, suchastask, process, information, emotionalandrelationship conflicts[2±4].Thiskind of conflict isoften regarded asanegative termbecause individual interestsareperceived tobe opposed ornegatively affected[5].Recently, therehavebeen concerns aboutworkplace inter- personal conflict(WIC)anditsimpact onthe healthcare systemandtheworkers [6].Avariety of individuals, includingdoctors,nurses,co-workers, managersandadministrative workers might haveexperienced conflicts[7].The WICs werealsocommonly encountered inintensive care units [8],operating rooms[9]and emergency rooms[10,11].These high-risk healthcare areas often require intensive patientcaring,timelydecision-making, andmultidisciplinary coordination amongtheworkers [12].WICs might bethe consequence ofpoor communica- tion [13], excessive workstress [14]orunsolved competing prioritiesoftasks [15].Once devel- oped, theWIC might, inturn, possess deleterious effectsonthe workers, suchasinterference with theteam performance andreduction ofstaff satisfaction [16].Furthermore, reportshave associated WICswithlower-quality patientcare,higher ratesofmedical errors,ahigher level of staff burnout, andgreater directandindirect costsofcare [17].

Since theseconsequences mightcompromise patientsafety,weproposed thattheworkers of the healthcare systemmightreport interpersonal conflictsinthe process ofpatient care when theyreport patient safetyevents. Manyhealthcare systemsworldwide haveimplemented the incident reporting system(IRS)tounderstand theoccurrence ofpatient safetyevents [18].

Since 2000,ourinstitution hasestablished anIRS forthe workers inthe hospital toreport safety-related eventsinthe hospital. Previous reportsofthe studies onthe WIC inthe health- care settings appliedmainlyquestionnaire investigations andsurveys [12,19]while real-life case-specific descriptionsofthe WIC werelacking, probably becausereporting directlyfrom the workers mightrequire anadequate channel.Whether orno the IRS might alsobeapossi- ble channel forreporting theWIC hadremained unclear.

Materials andmethods Study design andsettings This retrospective studywasconducted atthe National TaiwanUniversity Hospital(NTUH) to analyze thecollected datafrom theincident reporting system(IRS)ofthe institution from July 2010 toJune 2013. TheResearch EthicalCommittee Aof the National TaiwanUniversity Hospital approved thestudy andexempted theinformed consents.

The NTUH wasa2,300-bed, university-affiliated medicalcenter,containing about6,400 full-time employees, whichincluded morethan1,000 doctors and2,700 nurses. In2000, the Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 2/ 13 hospital established theinstitutional IRSforsafety-related events.Itinitially operated through a paper-based reportingprocess,andthen adopted on-linereporting mechanism in2005 by integrating intothehospital's intranet.Thereporting ofthe safety incident wasvoluntary and non-punitive, focusedonsafety-related eventsorconcerns tothe patients, workersandvisi- tors. Inaddition tostructured checkboxes fordata entry, theonline pagealsoprovided afree text field forthe reporter todescribe theevents. Afterthereporting, theCenter forQuality Management managedthedata. Thestaff ofthis centralized unitofthis institution verifiedthe incidents, collectedandanalyzed pertinent information, performedimportantdiscussions with theworkers fromwhere theevents occurred, andparticipated inthe improvement activities. The definition andseverity ofthe safety-related incidentswereclassified aspreviously described inthe literature [20±22].Briefly,asafety incident orevent isan unexpected orunin- tended event,which couldhaveledtoor did result inharm ofthe involved person.Anadverse event wasaninjury caused during thehealth careprocess ratherthanbythe underlying disease or condition ofthe individual. Ano-harm eventwasanevent, which resulted inno harm to the person, orthe effect wasminor thattheindividual couldnoteven feelit.Anear miss event was anevent thatmay cause accident, injuryorillness, butdidnot happen because ofuninten- tional ortimely intervention [20±22].Weexcluded thereports fromthedatabase ofIRS ifthe incidents werenotrelated toany health careorservice process forthe patients, ornot relevant to the health careenvironment providedforthe care ofthe patients.

Review ofincidents andidentification ofworkplace interpersonal conflicts Our team oftwo doctors, threenurses andtwoquality managers fromtheInstitution's Center for Quality Management reviewedallavailable incidentreports.Allteam members hadat least oneyear's training inthe process. Fourofthe seven reviewers independently selectedthe reports theyconsidered tocontain thedescriptions compatiblewithworkforce conflictand recorded thetype using theclassification inTable 1below. Thethree other members thenpar- ticipated inthe assessment ofselected reportsandauthenticated theconsensus results.Records were de-identified andanalyzed anonymously.

Interpersonal conflict We classified workplace conflictsusingamodified BarkiandHartwick typologybasedscheme [4] (Table 1).We defined interpersonal conflictasªa dynamic processthatoccurs between interdependent individuals,groups,orboth, asthey experience negativeemotional reactions Table 1.Workplace InterpersonalConflicts: SummaryofDefinitions .

Property ofthe WIC Focus ofthe WIC Task Content orTask Process InterpersonalRelationshi p Disagreem entDisagreem entwith other about whatshould bedone orhow should bedone in a task Disagreem entwith theother's personalvalues, views, preferen ces,etc.

Interferenc ePreventing theother fromdoing whattheythink should bedone inatask or how atask should bedone Preventing theother fromdoing things unrelated toa task Negative emotion Angerandfrustration directedtothe other about whatshould bedone inatask or how atask should bedone Anger andfrustration directedtothe other asa person Adopted fromBarki andHarwick[4 ].

doi:10.137 1/journal.pone. 0171696.t001 Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 3/ 13 to perceived disagreements andinterference withtheattainment oftheir goals.º Thetwotypes of focus ofthe interpersonal conflictidentified includedtheconflicts relatedtotask content or process, andtheconflicts relatedtothe interpersonal relationship.Weexplored eachfordis- agreement, interference, andnegative emotion asthe property ofthe WICs. Disagreement reflects cognitive difference basedonadivergence ofvalues, needs,interests, opinions, or goals. Interference indicatesconflictduetobehavioral differenceandused byone party to interfere withoroppose another party'sattaining itsinterests, objectives orgoals. Suchbe- haviors include debate,argumentation, competition,politicalmaneuvering, backstabbing, aggression, hostility,anddestruction. Negativeemotions produceconflictandunderlie fear, jealousy, anger,anxiety, andfrustrations [4].Table 1depicts thetypology ofthe classification of WICs usedthroughout thisstudy. Ineach incident, theinvestigators identifiedatleast one focus andproperty ofconflict. Basedonthe text descriptions fromthereporters andconsensus after discussions, theinvestigators classifiedtheincident-related processesthatwere related to the WICs andthen identified thetasks thatwere considered mostclosely related tothe occur- rence ofWICs.

Collection ofdata The investigators collectedthefollowing dataforanalysis: dates,times, place,anddepartments where theincidents andconflicts occurred, typesandcategories ofthe reported incidents, job types ofthe reporting workersandemployees involvedinthe WIP, andworking experience of the reporting workers.Recordswerede-identified andanalyzed anonymously. Wealso included thedata regarding thetypes ofthe conflicts intoanalysis together withthecollected data.

Statistical analysis We first analyzed thehealth carecharacteristics relatingtothe development ofWICs found in the reported incidents, suchashealth carerelated processes, workertypesinvolved inthe development ofWIP, andseverity ofthe reported incidents. Wethen described thetyping of the WICs, basedonthe focus ofthe conflicts. Wethen further explore thepossible association of job scenario andthedevelopment ofWIP bycomparing differentcharacteristics among groups. Results aresummarized andexpressed ascounts andpercentage fornominal variables, or median withrange forages. Thechi-square testwas used tocompare acrossdifferent catego- ries, such asincident types,jobtypes ofthe workers. TheMann-Whitney U-testwasused to compare theage between groupsofworkers. Statistical analysiswasperformed usingtheSPSS 22 Software (SPSSCorp., Chicago, IL,USA). AP<0.05 wasconsidered statistically significant.

Results During the3-year studyperiod, atotal of8,555 safety-related incidents(Table2)were reported hospital-wide, withanaverage of237 events everymonth. Among the8,555 safety-related inci- dents, 147(1.7%) hadWIC. Strikingly noneinvolved fallevents andtubing/line events,and few involved medication. 96%involved healthcareorservice processes (Table3).Most com- monly, theyinvolved thetransfer ofpatients between unitsordepartments (20%),laboratory tests (17%), surgery (16%)andmedical imageexamination andinterventions (16%).Foreach category ofthe incident-related processes,thefirst tasks werethemost frequent (64incidents, 44%) inthese processes associated withtheconflict, suchasthe decision tostart theprocess, the requesting forthe care process andthescheduling forthe process. (Table3).

Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 4/ 13 Table 4summarizes thecharacteristics ofthe workers andworking condition. Mostcom- monly, thenurses werethereporter (57%),inanurse-doctor encounter(33%).TheWICs occurred mostfrequently duringtelephone communication (63%),atthe same timewhen the incident developed (60%),during thedaytime nursingshift(51%) (Table 4).We didnot find any WIC inthe same unit.Themedian ageofthe reporters was7years (range 0±31years).

The working experience wassimilar among different typesofworkers (p=0.055), although the doctors tendedtohave lessworking years(median, 4years; range, 0±31years).

Table 5shows thetypes ofWIC. Allofthe 147 incidents withWIC focused ontask content or task process, but41(27.9%) alsofocused onthe interpersonal relationship(Table5).Fig 1 shows theVenn diagram toindicate different combinations ofWIC properties inthese inci- dents. Most(85.7%) ofthe cases focused onthe task content ortask process hadamixed property ofconflicts. Thisincluded especially theªdisagreement +interference +negative emotionº combination (66cases, 44.9%) andtheªdisagreement +interferenceº combination (54 cases, 36.7%) (Fig1A). Onthecontrary, themajority (25cases, 61.0%) theWIC focusing on the interpersonal relationshiphadasingle property ofnegative emotion withoutany description ofdisagreement orinterference (Fig1B). Forallofthe 147 cases, 82(55.8%) hada negative emotion. Theseincluded 42(28.6%) focusedontask content orprocess, 7(4.8%) on the interpersonal relationship,and33(22.4%) onboth. Table 6shows examples ofreporting descriptions fromtheworkers considered ashaving theWIC indifferent categories.

As shown inTable 7,there wasasignificant differenceinthe distribution ofworker job types between caseswithorwithout afocus onthe interpersonal relationship(p=0.0064).

Nurses accounted foralower proportion ofthe reporters ofcases withinterpersonal relation- ship than thecases without thistype ofconflict (34.1%vs.66.0%). However, caseswithinter- personal relationship hadmore doctors involved thanthose without thisconflict (34.1%vs.

17.0%). Thereworking experience ofthe employee whoreported interpersonal relationship (n =41; median, 6years; range, 1±31years) wassimilar tothose whodidnot (n=106) (median, 8years; range, 0±31years) (p=0.397).

In the 82incidents withnegative emotion, 45(54.9%) weredescribed bythe reporters, while 15(18.3%) bythe counterpart workersand22(26.8%) byboth sides involved inthe con- flict. Also, 26(31.7%) described disruptive languageswhereas9(11.0%) haddisruptive physi- cal behaviors. Althoughthejob types weresimilar between incidents withnegative emotion and those without (p=0.125), thereweremore doctors asthe reporters forWIC incases with a negative emotion thanthecases without (28.0%vs.13.8%) (Table8).This result wasin Table 2.Safety-rela tedincidents duringthestudy period.

Type Number(%) Fall 2,041(23.9%) Indwellin gtubes andlines 1,577(18.4%) Medicati on 1,504(17.6%) Transfus ion 827(9.7%) Diagnost icprocedu res 503(5.9%) General bedsidecare 184(2.2%) Self hurting 164(1.9%) Unexpec tedcardiop ulmonary resuscitation 139(1.6%) Medical device 45(0.5%) Anesth esia 10(0.1%) Others 876(10.2%) Total 8,555 doi:10.13 71/journal.pone .0171696.t002 Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 5/ 13 contrast tothe finding thatthere werefewer nurses asthe reporter inthe case with anegative emotion (50.0%vs.66.2%). Therewasnodifference ofwork experience betweentheemployee who reported negativeemotions (n=82; median, 5years; range, 1±25years) andwho didnot (n =65) (median, 8years; range, 0±31years) (p=0.265).

Table 9summarizes thecomparison ofthe distributions ofincident typesbased onthe severity ofoutcome betweenthetwo groups thatcontained (n=147) ordid not contain (n =8408) WIC,which wasstatistically different(P<0.0001). Theincidents withWIC hadless Table 3.Workplace interpersonalconflicts: Relatedprocesses andtasks (n=147).

Incident-re latedprocess Number(%) Con¯ict-associat edtasks inthe process Number(%) Patient transfer 28(20) Decision ontransfer 25(17) Preparation fortransfer 2(1) Handoff 1(1) Laborato rytests 25(17) Testordering 1(1) Sample preparat ion 11(7) Sample transport ing 2(1) Turnaround time 10(7) Report maintenanc e 1(1) Surgery 24(16) Scheduling 10(7) Preoperative preparation 5(3) In-hospital transport 6(4) Intraoperative care 1(1) Postoperative care 1(1) Operation noteentry 1(1) Medical imageexaminat ionsandinterventi ons 23(16) Scheduling 9(6) Preparation forexaminatio n 3(2) In-hospital transport 6(4) Continuity ofcare 2(1) Patient identi®c ation 1(1) Post-exami nationcare 1(1) Result reporting 1(1) Consulta tions 13(9) Request forconsultation 10(7) Equipmen tpreparation 2(1) Consultation response 1(1) Maintenanc eof facility andequipment 12(8) Supply turnarou ndtime 5(3) Facility &equipm entmaintenan ce 7(5) Transfusi ons 6(4) Request fortransfusio n 6(4) Medicatio n 6(4) Medication order 1(1) Dispensing 2(1) In-hospital transportofmedicatio n 2(1) Adverse reactionreporting 1(1) Resuscita tions 3(2) Decision onresuscit ation 1(1) Cooperation duringresuscit ation 2(1) Outpatie ntclinic 3(2) Scheduling 2(1) Medical recordmaintenanc e 1(1) Emergency RoomVisit 1(1) Patient identi®c ation 1(1) Dialysis 1(1) Equipmen tmaintenanc e 1(1) Other 2(1) Patient monitorin g 1(1) IT system maintenan ce 1(1) doi:10.137 1/journal.pone. 0171696.t003 Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 6/ 13 harm tothe patients thanthose without reported conflicts(Table9).None ofthe patients asso- ciated withtheevents containing WICdiedinthe hospital; thiswas incontrast withthat18 patients linkedtothe incidents thatdidnot have WIC diedathospital discharge.

Discussion The main finding ofthis study wasthat theemployee ofthe hospital appliedtheincident reporting system(IRS)toactively reporttheworkplace interpersonal conflicts(WICs) although theIRS was originally designedforthe reporting ofsafety events.

Our study provided theevidence ofWIC asthe dedicated workersofthe institution described thescenarios andencounters relatedtothe conflicts inthe incident reporting sys- tem. Although weidentified only1.72% ofthe reported safetyincidents ashaving theWIC, there might beahigh probability ofunderestimation. Oneofthe explanations isthat theinsti- tution originally designedtheIRS forthe reporting ofsafety incidents thatthedescriptions by the reporters focusedmainlyonthe events ratherthantheconflicts. Moreover, theseWICs were theinterpersonal conflictsbetweenpeopleofdifferent units.Individuals inthe same unit or department mightreport theconflicts tothe same onesupervisor, ratherthantothe IRS. In fact, wedid not find anintra-unit WICinthis study. Also,theculture ofthe healthcare envi- ronment, aswell asthe social background, mightalsoinfluence thereporting ofWICs. In Table 4.Workpla ceinterperso nalconflicts: Summaryof 147 inciden ts.

Descriptio n Number(%) Total number ofsafety-rela tedincide ntswith WIC 147(100) Reporting workerjobtype Nurse 84(57) Doctor 32(22) Other healthcare professional 24(16) Support ingdepartment worker 7(5) Workin gexperie nceofthe incident reporter (year,mean, range) 9.3(0.2±30 .9) Job types ofthe workers encountered inthe WIC Nurse-do ctor 48(33) Nurse-ot herhealthcare professional 36(24) Doctor-d octor 18(12) Nurse-nu rse 14(10) Nurse-s upporting department worker 10(7) Doctor-o therhealthcar eprofessi onal 6(4) Doctor-s upporting departmen tworker 5(3) Other encoun ters 10(8) Interacti onand commun icationscenario ofthe WIC Face-to-f aceinteraction 54(37) Teleph onecommuni cation 93(63) Timing ofthe occurrenc eof con¯ict inrelation tothe incident Con¯ic toccurred beforetheincident 4(3) Con¯ic toccurred atthe same timewiththeincident 89(60) Con¯ic toccurred aftertheincident 54(37) Timing ofthe incident occurrence inrelation tonursing shift Day shift 75(51) Evenin gshift 53(36) Night shift 19(13) doi:10.13 71/journal.pone .0171696.t004 Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 7/ 13 some cultural contexts, theorganization mightnotencourage thereporting ofconflicts because ofthe emphasis onharmony toavoid conflict[23]. Nevertheless, wesuggest thehealth- care system shouldpromote thereporting ofthe conflicts. Otherauthors alsosuggested that the organizations askedtheirpeople todiscuss conflicts openlyandproductively tostrengthen the interpersonal relationships[24].

Traditionally, interpersonalconflictsamongnurseswerecalled `horizontal violence'[25].

However, wefound asubstantial numberofWICs focusing oninterpersonal relationship across different disciplines andunits. Thisfinding suggests thathorizontal violencemightbe Table 5.Workplace interpersonalconflicts: Typesofthe 147 incidents.

Property ofthe WIC Focus ofthe WIC Task Content orTask Process (147 [100%]) Interperso nalRelationshi p(41 [27.9%]) Either Focus Combined Number(147 [100%]) Disagreem ent 134(91.2%) 16(10.9%) 134(91.2%) Interferenc e 130(88.4%) 8(5.4%) 130(88.4%) Negative emotion 75(51.0%) 40(27.2%) 82(55.8%) doi:10.137 1/journal.pone. 0171696.t005 Fig 1.Venn diagrams ofthe workplace interpersonalconflict s.(A) Conflicts focusedonthe task process/ task content. (B)Conflicts focusedonthe interpers onalrelationship. D=disagre ement; I= interferenc e; N =negative emotion.

doi:10.13 71/journal.pone .0171696.g001 Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 8/ 13 more common thanpreviously perceived.Althoughresearchers reportedthatnewly graduated in the first year oftheir practice mightencounter horizontal violence[25],weshowed thatthe occurrence ofWICs focusing onthe interpersonal relationshipwasnotrelated toworking Table 6.Workplace interpersonalconflicts: Examples.

Focus Categor yFocus Property Summariesof Text Description s Task content ortask process Disagreem ent The nurse reported thatthelabtechnician insistedonnot having received thesample, butthenurse had checked thetracking systemandwas sure thatthey hadsubmitted thesample.

The nurse reported thatthepatient shouldnotstay atthe emerge ncyroom because thepatient shouldbe transport eddirectly tothe ICU.

The technici ansaid thatthedoctors shouldnotcancel theorder ofblood transfusion bytelephone despite knowing thatthey might bebusy inthe Operation Room.

Interferenc e The nurses transporte dthe patient tothe general ward,butonarrival, theywere asked totransport this patient tothe operati onroom without con®rmed message.

The anesthes iologistwasunable tokey inassessment datatothe electronic recordsystem because the reques tingdepartme ntdid not establish aneligible patientlist.

The doctor askedthatthenurse should stayatthe bedsid eduring theexaminatio n,which wasdeclin edby the nurse.

Negative emotion The nurses expresse dtheir anger abouttheoperation schedulethatresulted inprolonge dwaiting forthe patients .

The nurse wassurprised andupset about thatthestaff transported thepatient tothe ICU before con®rmat ion of the transfer timing.

The nurse expressed avery frustratin gsituatio nto wait forsuch along time forgathering allofthe team members totransport thepatient forradiolog icexaminat ionand intervention .

Interperson al relationshi p Disagreem ent The nurse atthe ICU received thecomments fromadoctor unrelat edtothe care team forthe indicated patient anddisagreed withthecomment bystating thatthedoctor hadnoright tointervene thecare forthat patient.

The nurse reported thatthey didnot need toperform thejobthey arenotsupposed todo, such asexplain to the patients abouttheoperation procedure.

The nurse reported thattheway theindica teddoctor spoketothe nurse wasnotacceptab le.

Interferenc e The doctor askedthestaff todo more works thatanothe rdisciplin eshould do,which bothered thenurses.

A doctor whowasunrelated tothe care team forthe patien ttried toput opinions intothepatient care.

The doctor unrelate dto the Emerge ncyRoom andthepatient careteam asked theEmergency Roomstaffto admit thepatient tothe ward.

Negative emotion The nurse reported herstaff members wereveryupset about thepoor attitude andinteraction fromthe transferri ngunit.

The labtechnician statedthefrustration andlack ofrespect duringthecontact withnurses forlaboratory sample issue.

The doctor expresse dhis anger aboutthenurse repeatedly askedhimtocorrect themedication order without con®rmat ion.

Translate dfrom theoriginal Chinese texts.

doi:10.137 1/journal.pone. 0171696.t006 Table 7.Personnel involvedandinterperso nalrelationsh ip.

Worker jobtype Con¯ictsfocusedonthe interperson alrelation ship Present (n=41) Absent(n=106) p-value Reporter ofthe con¯ict inthe incident Doctor 14(34.1%) 18(17.0%) 0.0064 Nurse 14(34.1%) 70(66.0%) Other healthcare professions 10(24.4%) 14(13.2%) Supporti ngworker 3(7.3%) 4(3.8%) Doctor reported lyinvolved inthe con¯ict Yes 27(65.9%) 51(48.1%) 0.053 No 14(34.1%) 55(51.9%) doi:10.137 1/journal.pone. 0171696.t007 Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 9/ 13 experience. Thereforethehealthcare organization mightneedtopay attention tothe possibil- ity ofhorizontal violenceinworkers withanylevel ofworking experience.

Because allofthe WICs inthis study focused onthe task content ortask process, wesuggest the need forencouraging theconflict reporting forinthe improvement ofthe process ofhealth care. From theteamwork's pointofview, goalorientation moderatestherelationship between conflict andteam performance [26].Therefore, whiletheworkers reportconflicts, theyshould have themutual understanding onthe goal ofcare, andcommunication undoubtedlyplaysa vital roleinthe management ofconflicts. However, adequatecommunication iswarranted, since toomuch interaction mightalsocontribute tomisunderstanding becauseofperceived words, bodylanguage, andexpressions leadtointent [5].For situations thateffective communi- cation mightnotbefeasible duringthecare process, reporting WICsfocusing ontask content and task process through theIRS might beseen asaform ofmoderate wayofcommunication to avoid moreconflicts, asthe reporter hadperceived. Sincemany WICs alsofocused onthe interpersonal relationship,wealso suggest thatthese types ofreports shouldbedeemed asan internal informal complaint process[27].Conflicts inthe interpersonal relationshipmightneg- atively affectpatient carebyinterfering withone's ability towork withtheother members ofthe health careteam [28],especially whenthereisdisruptive behavior[29].Inasurvey, morethan 50% ofhealthcare workerswitnessed thedisruptive behaviors, and18% reported thatthey were aware ofaparticular adverseeventthatoccurred asadirect result[30].Forabetter working environment, theorganization shouldencourage thehealthcare workerstoreport theconflicts.

The useofIRS asachannel forreporting interpersonal conflictmighthavethepotential of providing achance tosystemic improvement. Previousreportssuggesting controversial con- clusions aboutthebenefits ofconflicts andperformance andemployee satisfaction [16,31± 35]. The application offormal reporting systemsuchasIRS might provide thechance to improve interpersonal conflicts.Management ofthe reported eventsaremainly task-oriented, therefore mightreduce thetension between theworkers withinterpersonal conflictsandfocus more onthe goal ofthe task andtheexpected provided care.

Table 8.Personnel involvedandnegative emotion.

Worker type Negativeemotioninthe report Present (n=82) Absent(n=65) p-value Reporter ofincidents Doctor 23(28.0%) 9(13.8%) 0.125 Nurse 41(50.0%) 43(66.2%) Other healthcare professions 13(15.9%) 11(16.9%) Support ingworker 5(6.1%) 2(3.1%) doi:10.13 71/journal.pone .0171696.t008 Table 9.Workplace interpersonalconflicts andseverities ofincidents.

Severity Incidentswithoutreported WIC(n=8408) Incidentswith reporte dWIC (n=147) Pvalue According toevent type Near miss 1184(14.1) 24(16.3) 0.0001 No harm event 4660(55.4) 107(72.8) Mild adverse event 2256(26.8) 10(6.8) Moderate adverseevent 270(3.2) 5(3.4) Severe adverse event 20(0.2) 0(0) Very severe adverse event 18(0.2) 1(0.7) doi:10.137 1/journal.pone. 0171696.t009 Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 10/ 13 Our study hasseveral limitations. First,sincethisstudy wasretrospective andtheIRS of this hospital didnot provide astructured formforreporting WICs,wewould missapropor- tion ofWICs experienced bythe healthcare workerswhoencountered theincidents. Itwas also difficult tovalidate theseWICs mainly basedonthe report contents; thiswas incontrast to the reports ofincidents, whichmightbefollowed byfurther investigations asindicated. Sec- ond, wedid not know thepresence ofWICs during thepatient careprocesses ifthere wasno incident reported. Although theestablishment ofaformal process forinternal complaints might benecessary, webelieve thatatleast some ofthe WICs would beconsidered notsub- jected foraformal reporting ascomplaints. Third,wedid not investigate howtheworkers coped withWICs. Researchers hadsuggested avariety oftypes ofbehaviors formanaging con- flicts inthe context ofªconflict management strategiesº(i.e.arepertoire ofreactions toacon- flict that individuals mayadopt depending onthe situations) orªconflict management stylesº (implying afixed tendency) [36].Furthermore, approachestomanaging conflictinorganiza- tions havebeen suggested [37].Understand theconflict-managing behaviorsofthe workers was beyond thescope ofthis study andmight require otherapproaches inaddition tothe inci- dent report system hereweused.

In conclusion, theinstitutional incidentreporting systemisauseful placetoactively report the workplace interpersonal conflicts(WICs)relatedtotask content andtask process, and interpersonal relationship.Thehealthcare systemsneedtoimprove thechannels tocommuni- cate, manage andresolve interpersonal conflicts.

Supporting information S1 Dataset. CaseFile.Thecase data related tothe workplace interpersonal conflictsretrieved from theincident reporting systemofthe institution.

(XLSX) Acknowledgmen ts The authors wouldliketothank Chia-Shun Chang,M.D.,Ph.D., Department ofInternal Med- icine, National TaiwanUniversity Hospital,Taipei,Taiwan, forhisexpertise onstatistical anal- ysis. Wealso thank Li-Hong Liand Yu-Tsu Li,Center forQuality Management, National Taiwan University Hospital,Taipei,Taiwan, fortheir kindassistance inthe preparation of reporting data.

Author contributions Conceptualization: JSJ.

Data curation: JSJSFH HWL.

Formal analysis: JSJ.

Investigation: JSJLCC CKL HFH MYH.

Methodology: JSJSFH HWL JSS.

Project administration: JSJ.

Resources: JSJSFH HWL JSS.

Software: JSJLCC.

Supervision: JSJJSS.

Workplace interpersona lconflicts andincident reporting system PLOS ONE|DOI:10.137 1/journal.po ne.0171696February 6,2017 11/ 13 Validation: JSJSFH HWL.

Visualization: JSJJSS.

Writing ±original draft:JSJ.

Writing ±review &editing: JSJJSS.

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