NU 726 Unit 4 conflict case analysis example

A 2 a.m. Refusal: Conflict Case Analysis of an Escalation Between a Nurse Practitioner and an On-Call Surgeon

Student Name

Department of Nursing, Herzing University

NU 726: Professionalism and Leadership for Advanced Practice

Instructor Name

February 12, 2026

A 2 a.m. Refusal: Conflict Case Analysis of an Escalation Between a Nurse Practitioner and an On-Call Surgeon

The Exchange

This case is a de-identified composite drawn from common patterns in overnight escalations. I was the night nurse practitioner covering the surgical floor. At 1:50 a.m., the bedside nurse called me about Mr. H., a 67-year-old man on the second day after a colon resection, whose heart rate had risen from 88 to 118 over four hours, whose abdominal pain had increased despite his analgesic regimen, and whose lactate, drawn at my request at 1:15, was 3.4 mmol/L. I examined him: he was diaphoretic and his abdomen was more tender than on the previous evening. I suspected an anastomotic leak and called the on-call surgeon at 2:05 a.m.

I said, "I'm calling about Mr. H., post-op day two from a colectomy. His heart rate is 118 and his lactate is 3.4. I'm worried about a leak." The surgeon replied, "Lactate goes up after surgery. Give him a liter of fluid and call me in the morning if he's actually sick." I said, "I think he's sick now." The surgeon said, "You're not a surgeon. Fluids and morning labs," and ended the call. I gave the fluid bolus. At 4:30, Mr. H.'s blood pressure fell to 92/54. I called the surgeon again, who came in, ordered a computed tomography scan, and took Mr. H. to the operating room at 6:40 a.m. for a leak. He recovered after an intensive care stay and a second operation, and went home on the fourteenth day after his original surgery. The surgical team's own review later concluded that earlier imaging would probably have allowed a smaller operation. For roughly three hours between the first call and the second, Mr. H. was in severe pain, frightened, and deteriorating; he told me later that he thought he was dying and that no one believed him.

Contributing Conditions

Workload: the surgeon was covering three hospitals by phone and had been called six times that night. Hierarchy: in this hospital, overnight calls from nurse practitioners to surgical attendings were uncommon, and the surgeon's comment about my role suggested that my assessment carried less weight than a surgical resident's would have. History: two weeks earlier, a call I had made about a different patient had turned out to be a false alarm, which the surgeon mentioned the next day. My own communication: my first sentence opened with background and led to my concern only at the end, and I did not state what I wanted the surgeon to do.

Reading the Exchange Through a Conflict Framework

The Thomas-Kilmann framework classifies conflict-handling behavior along two dimensions, assertiveness, the attempt to satisfy one's own concerns, and cooperativeness, the attempt to satisfy the other's concerns, producing five modes: competing, collaborating, compromising, avoiding, and accommodating (Thomas, 1992).

The surgeon's behavior was competing: high in assertiveness and low in cooperativeness. He dismissed the concern, cited role rather than data, and ended the conversation. Behavior of this kind, which nurses and physicians describe as disruptive, has been associated in surveys of clinicians with perceived adverse events, errors, and compromises in patient safety (Rosenstein & O'Daniel, 2005).

My own behavior was accommodating. I stated my concern once, accepted the plan, and did not escalate. I told myself I had done what I could, but the framework makes clear that I gave up my concern, the patient's safety, to avoid further conflict. That was the more consequential behavior of the two, because I was the person at the bedside with the information. The collaborating mode, which would have meant pressing my concern while asking what the surgeon needed in order to act on it, was available to me and I did not use it. A compromise, such as agreeing to the fluid bolus with a repeat lactate and a call-back in one hour, would also have kept the patient's safety in view.

What a Better Exchange Would Have Sounded Like

Two tools would have changed the exchange. The SBAR format, which structures a call as situation, background, assessment, and recommendation, gives the listener the concern and the request up front (Haig et al., 2006). My opening should have been: "I'm calling about Mr. H., post-op day two, who I think has an anastomotic leak. His heart rate has gone from 88 to 118, his lactate is 3.4, and his abdomen is worse. I'd like you to evaluate him now or order a CT." The second tool is escalation language. The CUS approach from the TeamSTEPPS program, in which the caller names being Concerned, then Uncomfortable, then flags a Safety issue, together with the two-challenge rule, voicing a concern at least twice and escalating through the chain of command if it is still disregarded, give clinicians agreed words for exactly this moment (Agency for Healthcare Research and Quality, 2023). Had I used them, the chain of command, in this hospital the surgical chief on call, would have been the next step at 2:15, not at 4:30.

A Repair the Nurse Practitioner Can Carry Out

First, with the surgeon: I asked for a 15-minute conversation the following week, framed around the patient, not the insult. I said that I should have made my request clearer, that I needed him to hear my concern as a clinical assessment, and asked what would help him act on overnight calls from nurse practitioners. He said that he gets many calls about lactate alone and that a clear request and exam findings would help. We agreed that I would open calls with my assessment and request, and he would tell me directly if he disagreed and why.

Second, with the system: I brought the case, de-identified, to the hospital's patient safety committee, proposing that the escalation policy name nurse practitioners explicitly as able to call the surgical chief directly after a second unresolved concern, and that the policy be included in surgeons' onboarding.

Third, with myself: I now write down my request before I dial, and I have decided that a second call within 30 minutes, if my concern is unchanged, is not a failure of politeness but my responsibility to the patient.

References

Agency for Healthcare Research and Quality. (2023). TeamSTEPPS 3.0 pocket guide. Agency for Healthcare Research and Quality.

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Rosenstein, A. H., & O'Daniel, M. (2005). Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. American Journal of Nursing, 105(1), 54-64. https://doi.org/10.1097/00000446-200501000-00025

Thomas, K. W. (1992). Conflict and conflict management: Reflections and update. Journal of Organizational Behavior, 13(3), 265-274. https://doi.org/10.1002/job.4030130307