Background

The operating room's hierarchical culture and leadership expectations contribute to negative emotions and communication challenges (1). Conflict in surgical teams is common and can negatively impact healthcare professionals, team effectiveness, and patient safety (2). Conflict in surgical environments can arise from a range of factors, including individual differences, communication styles, and professional hierarchies (3). Surgical residents face significant interpersonal conflicts within healthcare teams. These conflicts contribute to stress, burnout, and job dissatisfaction among healthcare professionals (4). Surgical resident training programs often overlook soft skills like conflict management, despite their importance in healthcare settings (5). Recent research highlights the critical need to incorporate conflict management and communication training into surgical residency programs, addressing a longstanding gap in curricula that have traditionally focused on clinical and technical competencies (6). Conflict management competencies are essential in various contexts, including organizational performance, local governance, and educational settings (7).

While conflict management is recognized as an essential competency across diverse settings, the surgical environment—with its steep hierarchies, high-pressure operative dynamics, and interprofessional teamwork—creates a particularly unique and critical area for focused study (8). Competency-based medical education (CBME) represents a paradigm shift in medical training, centering on learners' ability to demonstrate essential competencies rather than advancing based on time spent in training. This model prioritizes integrating theoretical knowledge with clinical practice, ensuring that students develop practical, evidence-based skills in real-world settings (9). Clive Chappell et al. (10) and Nazik Hammad (11) emphasize the importance of competency-based education in designing training programs that accurately diagnose educational needs and improve the applicability of learning. Despite some studies in the field of conflict in healthcare settings, especially in nursing and health management (12-14), given the complexity of the surgical environment and the critical role of teamwork in achieving successful treatment outcomes, identifying and developing competencies in conflict management for surgical residents is an undeniable necessity (10). However, there has been limited targeted and coherent research on the specific roles, challenges, and competencies required of surgical residents in managing conflict. This review focused on surgical residents because conflict dynamics in surgical training are shaped by unique factors, including steep hierarchies, high-pressure operative environments, and multidisciplinary team interactions. These conditions differ significantly from other residency programs (2). The study aims to map conflict management competencies essential for surgical residents in clinical settings. Findings provide valuable insights for researchers, educators, and policymakers to enhance surgical education and professional performance.

Objectives

This review aims to identify the essential competencies in conflict management required of surgical residents.

Methods

Scoping reviews are designed to map the existing body of literature on a broad topic area, offering an overview of potentially extensive and diverse research (11). This scoping review was conducted following Arksey and O’Malley’s (11) iterative five-stage framework, as outlined Figure 1.

1. Identifying the Research Question

The research question was developed using the PCC framework (Population, Concept, and Context), as follows:

Population: Surgical residents

Concept: Conflict management competencies

Context: Clinical environment

This structured approach ensured the scope of the review remained focused and clinically relevant, addressing the specific needs of surgical trainees who encounter conflict in real-world healthcare contexts.

The main research question was as follows:

What are the required competencies for clinical conflict management in surgical residents?

The specific questions are:

1. Which conflict management competencies are essential for surgical residents in the clinical setting?
2. What strategies are effective for teaching and developing conflict management competencies in the clinical setting?
3. What contextual factors (e.g., cultural, institutional, hierarchical) influence conflict situations and their resolution in a clinical setting?
4. Identifying Relevant Studies

A comprehensive search strategy was developed using MeSH and standardized keywords to ensure broad and accurate retrieval across databases. Searches were conducted in both national (SID, Magiran, Irandoc, Civilica) and international databases (PubMed, Scopus, Web of Science, ProQuest, ERIC, EBSCO, Emerald, and Google Scholar). All retrieved records were screened using predefined eligibility criteria to include only studies involving surgical residents, with keywords summarized in Table 1.

Table 1. Keywords and Search Terms used in this study

3. Study Selection and Screening

All retrieved articles were imported into EndNote (Version 18), and duplicates were removed. Study selection proceeded with title and abstract screening, followed by full-text review of potentially relevant studies. To ensure methodological rigor and maintain relevance, predefined inclusion and exclusion criteria—based on the research objectives—were applied during article selection (Table 2). The final selection of articles included in the review was independently assessed by two authors (Z.S. and S.N.). Any disagreements or discrepancies were resolved through discussion with a third author (Sh.B.) to reach a consensus, ensuring a rigorous and unbiased screening process.

Table 2. Eligibility Matrix: Inclusion and Exclusion Criteria

4. Data Extraction

To ensure transparent and comprehensive data reporting, this scoping review adhered to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist (12). This form was used to extract data from the included studies. A team meeting was held to ensure a shared understanding of terminology before distributing articles. The initial studies were assigned to two authors, and the data from the articles were then entered into the form. The data extraction table included items such as the year of study, article language, country, authors, conflict management competencies, and educational strategies for conflict management.

5. Collecting, Summarizing, and Reporting Results

After extracting data from the included studies, inductive content analysis was used to analyze the findings. The process began with coding, where key concepts were identified from the extracted data. Similar or related codes were then grouped into broader categories. This step helped organize the data by identifying patterns and conceptual similarities among the codes.

Process for Data Synthesis:

Data were extracted from included studies using a structured PRISMA-ScR form covering Dimension, Main Components, Subcomponents, Key Findings, Objective, Study Type, Country, and Authors (Appendix 1).

Extracted data were summarized through tables and figures showing publication year, study type, and country distribution. An inductive content analysis was then conducted to identify key codes, subcategories, and categories related to conflict management competencies in surgical settings. Final results, limitations, and recommendations for future research were comprehensively reported.

Results

The number of retrieved articles from each database is shown in Table 3.

Table 3. Number of retrieved articles from each database

A total of 9,252 articles were retrieved in the database search. After duplicate article removal and screening, 35 articles were selected for final analysis. The characteristics of the final extracted articles are included in Appendix 1. The PRISMA flow diagram for the study is shown in Figure 2 below.

Among the included studies, the subspecialties represented were general surgery (30 studies), orthopedics (1 study), and mixed surgical cohorts
(4 studies). This breakdown provides additional insight into the contexts in which conflict management competencies have been studied.

Distribution of Studies by Publication Year

The 35 included studies were published between 2011 and 2024. The most studies were published in 2011 (13-16) and 2012 (17-20), with 4 studies each. The distribution of studies by year of publication is presented in Figure 3.

Type of Studies

The 35 included studies were classified into four main categories; the types of the final included studies are presented in Table 4.

Table 4. Types of the final included studies

Distribution of Studies by Country

A total of 35 studies were included in the review, originating from various countries. The United States contributed the largest number of studies, with 15
(6, 13, 15, 18-29). The distribution of studies by continent is presented in Figure 4.

 Content Analysis of Extracted Data

An inductive content analysis approach was employed to analyze the extracted data.

The process began with identifying codes and their frequency. Similar codes were grouped into subcategories, which were further refined into broader categories. The codes and their corresponding categories are presented in Tables 5 and 6.

Table 5. Codes and their frequency

 Table 6. Codes, sub-category, category, and themes obtained from articles

Discussion

This scoping review aimed to map the essential conflict management competencies for surgical residents in clinical settings. As a result of the content analysis process, three main categories were identified that reflect the multifaceted nature of conflict in clinical settings:

(1) Educational Approaches to Conflict Competency Training.

(2) Conflict Management Competencies.

(3) Contextual Factors of Conflict Formation.

1. Educational Methods: Bridging Theory and Practice

The first category includes formal and informal instructional strategies focused on experiential and reflective learning approaches—such as simulations, role-playing, case studies, and continuous feedback—to prepare learners for real-world conflict management effectively. The diverse teaching strategies—from formal courses and workshops to experiential learning through simulations and role-playing—highlight the complexity of preparing healthcare professionals for conflict resolution. These findings align with Kolb’s experiential learning theory (30), emphasizing that active engagement with real-life-like scenarios enables learners to internalize and apply conflict management skills more effectively. Conflict simulation with feedback underscores Ericsson’s concept of deliberate practice (31), reinforcing the importance of feedback and iterative learning in mastering conflict competencies. Such approaches not only develop cognitive understanding but also foster emotional readiness and behavioral adaptability, critical for navigating the unpredictable, high-stakes nature of clinical conflicts.

2. Conflict Management Competencies: Interpersonal and Emotional Foundations

The second category highlights the central competencies required for conflict resolution, including emotional regulation, communication, empathy, role clarity, and collaborative problem-solving as fundamental to resolving clinical conflicts. The competencies identified are consistent with established psychological and organizational theories. Empathy and perspective-taking facilitate mutual understanding and reduce miscommunication, resonating with Johnson and Johnson's Social interdependence theory (32). Emotional regulation’s prominence reflects current evidence linking healthcare workers’ stress management capacity with conflict outcomes (33).

3. Social Context and Organizational Factors: The Systemic Lens

The third category underscores the influence of systemic and contextual factors that shape conflict dynamics beyond individual interactions. Contextual factors such as hierarchical power imbalances, organizational culture, and political dynamics emerge as fundamental in shaping conflict patterns. These findings support Schein’s model of organizational culture (34) and Coser’s structural conflict theory (35), which articulate how embedded power relations and cultural norms create fertile ground for conflict. The identification of the political and social context extends the analysis to Jackson's social conflict resolution (36), emphasizing that conflict cannot be fully understood without considering the broader socio-cultural environment. Role ambiguity’s influence on conflict supports role theory (37), highlighting how unclear expectations increase interpersonal tension.

Thus, conflict management requires not only skill acquisition but also clarity in professional roles. This systemic perspective underscores the need for organizational interventions alongside individual skill development. As Bronfenbrenner’s (38) socio-ecological model suggests, effective conflict management must operate across multiple levels—individual, team, and organizational—to produce sustainable change.

Our integrative findings extend prior studies (39-41) by demonstrating the interconnectedness of educational, interpersonal, and organizational domains. While earlier research often examined these factors separately, our analysis shows their dynamic interplay and cumulative impact, underscoring that isolated interventions may fail to address the root causes of clinical conflict.

Strengths and Limitations of the Study

The key strengths and limitations of this scoping review are summarized in Table 7, providing an overview of its methodological rigor and contextual boundaries.

Practical Implications

The practical implications of this review for education, training, and organizational leadership are summarized in Table 8.

Table 7. Strengths and Limitations of the Review

Table 8. Recommendations for Education, Training, and Organizational Leadership

Conclusion

This scoping review synthesizes evidence that effective conflict management for surgical residents is a multifactorial competency requiring integrated development through tailored education and supportive organizational structures. Embedding these principles into CBME frameworks is essential for fostering resilient surgical teams and safeguarding patient safety. Future research should explore how these principles can be embedded into competency-based medical education to cultivate collaborative, resilient healthcare teams.