Conflict and resolution

In addition to the conflicts directly observed during the observation stage of the study, a number of stories of conflict arose during interviews with participants. There were differences in how participants viewed conflict and the function they ascribed to it in terms of individual and organisational learning and

106 change. However, there were also commonalities in the outcomes of conflict on the activity systems and learning.

One of the common stories told was that of verbally aggressive clashes

between consultant obstetricians, being repeated in one form or another to me by four different interviewees. In this tale, individual consultants, or small factions of consultants, set themselves up against other consultants; leader against leader. This led to disagreement and argument over a number of matters; from the care of patients, to the agreement of departmental policy, to the training of junior staff. The different consultants used a combination of factors, such as their clinical experience, their experience elsewhere or their external leadership roles, to assert their opinion over the wider department and draw them into the conflict. This led to work carrying on in the same way it always had and the department learned to cope with and manage the

disruption rather than learning to change it. Individual staff in the department tried to achieve resolution with the individual consultants in order to make working life easier and more manageable.

An example was given by one of the key informants, who had been tasked by the Board with improving patient flow. She spoke of how two of the

consultants disagreed on the responsibilities of the consultant in discharging patients and how this led to a complete refusal to agree a new pathway of care and to a number of heated arguments in meetings. This conflict led to

continued delays and the failure to implement any change. The conflict was widely recognised by midwifery staff and junior doctors, but many expressed to her that they found it easier to adapt their day to day practice depending on the consultant, rather than conform to a shared way of working.

“ When [Dr A] is on, she just won‟t even go there, you know. She just says it isn‟t in her job plan, her clinical priority is the sickest patients on antenatal ward. The midwives, when it‟s her on, they know that there will be delays so, so they tell me they can‟t get anything done and the discharge is delayed so they let labour ward know to reduce patients as they can‟t get women up. [Dr B] has fought with her over this so many times, so many…she‟s totally

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way we want and …she tells [Dr A] this but it‟s like she‟s banging her head against a brick wall sometimes. She has tried taking it to the different

meetings, trying to get other people on side, but they just end up all shouting at each other and we get nowhere going forward as the consultants can‟t agree” (Key informant C, Nursing).

This story seems to be one of fragmentation, with different interpretation of clinical priorities by different team members and resulting ambiguity and confusion. Staff views changed as the tasks and leadership changed, leading to co-existing practices and beliefs but no agreed change. However, when examined from a differentiation perspective this story can also be seen in terms of power. The consultants are positioned powerfully and this places other members in a different, lower, subculture where they share values based on their status. Integration was apparent at a subcultural level, as more junior team members adapted their work patterns to manage the change in

leadership moment to moment. Through this subcultural working, the power of the consultants was reinforced and organisational members learned through their practice that the culture is hierarchical and divided. From an integration perspective, the key informant can be seen striving for consensus in order to achieve cultural change. She is clearly aligning herself with one side through her narrative, talking of “the way we want” and “we get nowhere”. In her story telling to me, she makes clear what she sees as the integrated and effective way of working and paints the other consultant as a barrier to this. Her sense of this situation is that consensus has to be achieved. Without this, no shift in policy or practice can happen and organisational change is not possible. For her, the conflict is a barrier and learning is not possible while the conflict continues. However, my interpretation is that organisational learning is taking place and that cultural change is occurring, but in a way that reinforces

dominant beliefs about hierarchy and power and furthers subcultural division.

Priya, a consultant obstetrician, told a number of stories of difficult working relationships with her colleagues. These experiences contributed to her learning about both herself and others. In the story below she stepped in to break up a conflict between colleagues.

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“Two days ago we had this situation where we wanted good teamwork and we had hugely complicated cases around. And each one didn‟t want to listen to each other and, you know, the attitude was different, the behaviour was

different and a few of them, you know, it can affect the whole team. But it, kind of, works as a team. For example elective sections that are complicated ones, you need midwives, you need theatre staff, you need anaesthetists,

obstetricians to work together…and we had a cardiac patient as well,

so…the…cardiologist input. But I saw that, that day, everything fell apart and they… it was chaos and emotions went up and up, they couldn‟t get…errr….oh my god, everyone got really upset. We really tried to get the other person to

talk and what had upset them and I was open and I was trying to understand and I said, „Yes but does it work? For that moment you‟re showing a stern face and it plays with people‟s emotions and you want a team work, you don‟t want at that time just the work being done‟. Ermm…I think…you know, I think it doesn‟t work in this one, I think you need to keep talking and building up the relationship . But I realised that myself and the CD at that moment, we came in to help the situation. I volunteered, and he was called as the CD, and we had help from the management and we went and spoke to the people and gently calmed the situation” (Priya, consultant obstetrician).

From an integration perspective, in this story Priya constructs herself as a voice of calm and reason in the midst of a sea of chaos, aiming to unite through “teamwork” and achieve the organisation‟s overarching goal. She speaks of how “we” wanted good team working but it is not clear who „we‟ are. She sees the conflicting behaviour of a few individuals as affecting overall integration and excludes them from the team. My impression was that this was partly done for my benefit and that she saw me as a similarly rational person, the researcher, who would understand her desire for calm. However, from a fragmentation perspective, the complexity of the work and the different roles and views of team members leads to dissent. In achieving successful practice, these conflicting views and systems of meaning had to be acknowledged as the situation was calmed down. Therefore, change was only possible through an active effort to confront and accept apparently irreconcilable differences. Priya viewed the conflict as cathartic, and once it had been confronted and acknowledged, everyone could learn to carry on. It is interesting, though, that Priya resorts to hierarchical understandings of how conflict should be

109 managed, noting that the Clinical Director was called due to his role and how the two consultants resolved the matter “with help from the management”. This more subcultural understanding again reinforces dominant beliefs around power and status.