NUR 7610 Module 6 Conflict Resolution Paper: Disagreeing With a Psychiatrist Over Polypharmacy Example

Five Medications, Two Prescribers, One Patient: Working Through a Disagreement With a Senior Psychiatrist About Polypharmacy

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7610: Psychiatric Mental Health Nurse Practitioner Roles and Contemporary Issues

Mentor Name

Month Day, Year

Five Medications, Two Prescribers, One Patient: Working Through a Disagreement With a Senior Psychiatrist About Polypharmacy

Introduction

Six months after certification, I took over the care of Ms. K., a 52-year-old woman with schizoaffective disorder whose previous prescriber, a senior psychiatrist at our center, had moved to inpatient work but remains on staff. Ms. K. takes two antipsychotics, two antidepressants and clonazepam 1 milligram three times daily. She has gained 25 pounds in two years, has prediabetes, falls asleep during group therapy and told me she feels "foggy all the time." I believe the regimen should be simplified, starting with a slow taper of the benzodiazepine and eventually one antipsychotic. When I raised this, the psychiatrist said firmly that the regimen took years to stabilize and that changing it would put her at risk of hospitalization. This paper analyzes the conflict and plans how to resolve it in her interest.

Sources of the Conflict

Almost et al. (2016) combined 44 studies of clashes inside health care teams. They identified antecedents at three levels: individual characteristics, such as communication style and emotional intelligence; interpersonal conditions, such as poor communication and lack of trust; and contextual factors, such as role ambiguity, hierarchy, workload and a poor work environment. They found few tested interventions but concluded that awareness of these antecedents, accountability and active participation are each team member's responsibility.

Several antecedents are present here. Role ambiguity is the most obvious: it is not clear whether I, as the current prescriber, or the psychiatrist, as the senior clinician who knows her history, should decide. Hierarchy adds pressure; I am new and a nurse practitioner, and he is an experienced psychiatrist. And each of us holds a different view of risk: he sees the danger of relapse, I see the danger of metabolic disease, falls and sedation. Neither view is wrong.

The clinical facts support taking both seriously. Two antipsychotics together add metabolic and sedative burden without strong evidence of greater benefit for most patients, and a benzodiazepine taken three times a day for years adds fall risk, sedation and dependence. Yet Ms. K. has not been hospitalized in two years, after several admissions before that, and the psychiatrist has watched her relapse when earlier changes were made too quickly. A plan that ignores either set of facts would be a poor plan.

The Barriers to Teamwork

Weller et al. (2014) list what good teams rest on, a common picture of the patient, respect, trust and messages that are confirmed back, and sort the obstacles into gaps in training, in attitude and in organization. Our disagreement reflects a missing shared mental model: we have never discussed Ms. K.'s goals together, and each of us is working from a different picture of what success looks like. The psychological barrier of professional hierarchy may make me defer or make him dismiss, and the organizational fact that he now works elsewhere in the building limits our chances to talk.

Planning the Conversation

Overton and Lowry (2013) offer practical guidance for difficult conversations. They recommend preparing by separating the problem from the person, identifying one's own goals and emotions, listening first to understand the other's view, focusing on shared interests rather than positions and agreeing on concrete next steps. They also note that the setting matters: a private, unhurried meeting is better than a corridor exchange.

Following that guidance, I will ask for a 30-minute meeting at a time that suits him. I will begin by asking about Ms. K.'s history, since he knows it better than I do, and listen for what made the current regimen necessary. I will then share what I see now, her weight gain, prediabetes, falls asleep in group and her own words about feeling foggy, as observations rather than criticisms. I will name our shared interest: keeping her out of the hospital while protecting her physical health and quality of life.

I will also be ready to hear that I am missing something. He may know of a relapse after an earlier attempt to stop clonazepam, or a reason the second antipsychotic was added that the chart does not explain. Entering the conversation willing to change my plan is what makes it a conversation rather than a negotiation.

A Shared Approach

Instead of debating the whole regimen, I will propose a small, reversible step: a slow taper of clonazepam by 0.25 milligrams every two weeks, with weekly symptom checks and an agreed signal, such as return of insomnia or paranoia, to pause the taper. I will ask whether he would review her progress with me monthly. This approach respects his knowledge of her relapse pattern, addresses the risk I see and creates the shared mental model we lack. Most important, I will ask that we bring Ms. K. into the decision. She has said she wants to feel clearer, and her goals should guide both of us.

If We Still Disagree

If the psychiatrist still objects, I remain her prescriber and responsible for her care. I would document both views and my reasoning, consult the medical director as our center's policy allows, and continue to involve Ms. K. I would not make changes against his advice without that consultation, nor would I continue a regimen I believe is harming her without raising it further. Conflict handled through proper channels protects the patient and the team.

Conclusion

The disagreement over Ms. K.'s medications arises from role ambiguity, hierarchy and different views of risk, all recognized sources of team conflict. Planning a respectful conversation that listens first, focuses on shared interests and proposes a small, reversible step offers a way through, with the patient's own goals at the center. As a PMHNP, my role in conflict is the same as in care: to keep the patient's interest in view and to build the relationships that make good care possible.

References

Almost, J., Wolff, A. C., Stewart-Pyne, A., McCormick, L. G., Strachan, D., & D'Souza, C. (2016). Managing and mitigating conflict in healthcare teams: An integrative review. Journal of Advanced Nursing, 72(7), 1490-1505. https://doi.org/10.1111/jan.12903

Overton, A. R., & Lowry, A. C. (2013). Conflict management: Difficult conversations with difficult people. Clinics in Colon and Rectal Surgery, 26(4), 259-264. https://doi.org/10.1055/s-0033-1356728

Weller, J., Boyd, M., & Cumin, D. (2014). Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal, 90(1061), 149-154. https://doi.org/10.1136/postgradmedj-2012-131168