Michele Gelfand finds inspiration for new projects all around her: taking in the banter in a boardroom, speaking with taxi drivers when traveling, observing the interactions between physicians and nurses during an unexpected trip to the doctor. The idea for one of her most recent papers was sparked years ago when she had to go to the hospital in Jordan and later when she received care for a broken foot in Dubai.
“Going into any unfamiliar setting, it’s important to be an anthropologist,” Gelfand says. “It’s a window into the context of another culture.”
As she watched the doctors, nurses, and other staff interact around her, Gelfand wondered: How does employees’ behavior in a high-stress hospital unit impact patients’ health? “Anytime you have interdependencies, you have conflict, and conflict needs to be managed,” she says.
Gelfand, a professor of organizational behavior at Stanford Graduate School of Business and an expert on cross-cultural psychology, has documented the nature and effects of conflict in the workplace and how to negotiate such conflicts in a variety of settings around the world. If corporate employees can’t get along, it can affect the bottom line. In hospitals, the stakes are even higher: Medical errors cause an estimated one million deaths annually.
Just before the COVID-19 pandemic, Gelfand conducted research in a large hospital complex in the Northeast. She and her research team zeroed in on how medical staff members assigned to the same care teams interfaced with each other. She then examined these units’ patient outcome data, seeking connections to how employees navigated diversity and conflict. The results, cowritten with Ren Li of the Hong Kong Polytechnic University and Virginia Choi of the University of Maryland College Park, were published in Proceedings of the National Academy of Sciences.
Faultlines in Hospital Hierarchies
Gelfand was particularly interested in how rank and diversity within hospital hierarchies influenced employees’ attitudes toward one another. She defines the natural alignments and splits within work groups as “faultlines.” These faultlines become stronger when people with multiple things in common — expertise, gender, or race — form subgroups; for example, a medical unit where all the doctors are white men and all the nurses are Black women. This split may elicit an us-versus-them mentality, resulting in miscommunication and distrust in a close working environment.
Altogether, the researchers observed 38 hospital units, including surgical departments, emergency rooms, and pediatric and psychiatric wings. Over three years, they collected data on more than 1,100 employees and more than 4,100 patients (with a brief pause due to the pandemic). To gauge group dynamics, the team distributed surveys to employees that asked how peers responded during conflicts and how often they experienced rudeness from their coworkers. The researchers combined this data with patient information about adverse outcomes such as hospital-acquired infections and mortality rates and then performed a series of analyses.
The results showed that units with strong faultlines had much higher levels of incivility — where employees reported feeling disrespected and experiencing hostile behavior from coworkers. Moreover, staff dynamics had “ripple effects” on hospital patients. Higher levels of incivility were linked to higher rates of medical errors and mortality rates among patients. Hostile work units, the researchers found, were associated with a nearly 11% increase in patient mortality rates and a 9% uptick in infection rates.
Gelfand can only make inferences about why that is. “Instability and disrespect make it hard to trust other people and rely on them,” she says. “Taking care of patients is a team effort, and if there’s a lack of trust, the important glue that helps people coordinate, it could very well impact the quality of care.”
Conflict and Cooperation
Gelfand and her colleagues theorized that “collaborative conflict cultures” with norms for active, cooperative discussion of conflicts could help mitigate the incivility that stems from faultlines. Indeed, they found that teams with strong faultlines plus a tendency to collaborate were linked to lower incivility and better patient outcomes than those with weak faultlines.
This suggests that identity-based faultlines do not have to be a source of division. As the paper explains, “When teams have strong faultlines that facilitate communication and trust within subgroups and are simultaneously embedded in a unit culture that encourages cooperation, these teams may exhibit high-functioning capabilities.” Encouraging listening skills, open dialogue, and understanding the importance of the collective group’s interests may go a long way in cultivating better outcomes.
Gelfand recommends that hospitals build on this takeaway by providing collaborative conflict training to their employees. “Learning the appropriate way to approach conflict in a hospital if you’re a doctor or a nurse is just as important as any medical training,” she says. This lesson is relevant not just for hospital executives but any organization that relies on teamwork to avoid dangerous mistakes and avert potentially life-threatening outcomes; Gelfand’s paper cites aviation and the military.
Organizations seeking more collaboration within their ranks should also consider hiring or training charismatic managers. “People who are in charge have a big imprint on the culture that evolves,” Gelfand says. Previous research has shown that agreeable, transformational leaders tend to facilitate the development of more collaborative conflict cultures.
As global workplaces continue to become more diverse, Gelfand says she would like to replicate the hospital conflict-culture experiment in medical complexes around the world, especially in the Middle East and East Asia, where she has worked extensively. “You wonder if these problems we found are universal themes,” she says.
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