Abstract
<title>Abstract</title> <p>Aim To explore the multiple concurrent causal pathways leading to the occurrence, escalation, and extreme consequences of nurse-patient conflicts in pediatric settings from a configurational perspective. Design: A retrospective case study design using fuzzy-set Qualitative Comparative Analysis (fsQCA). Methods Thirty-three typical cases of nurse-patient interactions in pediatric units were included. Five condition variables were extracted: technical procedure outcome (T), communication and attitude (C), resource and process constraints (R), child and family member state (P), and expectation-perception discrepancy (E). A four-value fuzzy-set calibration (0, 0.33, 0.67, 1) was applied. Double-blinded independent coding was performed by two coders (inter-rater reliability Kappa = 0.87). Necessity and sufficiency analyses were conducted using fsQCA 3.0 software, with a case frequency threshold ≥ 1 and an original consistency threshold ≥ 0.8. Results Necessity analysis showed no single condition was necessary for conflict occurrence (consistency all < 0.9). Sufficiency analysis identified three equivalent configurational pathways leading to conflict, with an overall solution consistency of 0.94 and coverage of 0.72: 1) Structural Constraint Type (T·R): of technical failure and systemic resource limitations (raw coverage 0.36, consistency 0.93); 2) Cognitive-Interactive Dysregulation Type (~ C·E): Poor communication encountering high family expectations (raw coverage 0.32, consistency 1.00); and 3) System-Individual Resonance Failure Type (T·C·R·P·E): A full-blown convergence of problems across all five dimensions (raw coverage 0.20, consistency 1.00). For conflict escalation, family emotional dyscontrol (P) was a necessary condition for extreme outcomes (violence/legal disputes) (consistency 0.92), while the combination of "oppositional communication, emotional dyscontrol, and cognitive discrepancy" (C·P·E) formed a sufficient pathway (consistency 1.00, coverage 0.85). Causal asymmetry analysis indicated that good communication (C) or flawless technical procedures (T) are key protective conditions for avoiding conflict. Conclusion Pediatric nurse–patient conflicts arise from multiple interacting factors rather than a single cause. Three configurational pathways were identified: structural constraint (technical failure combined with resource constraints), cognitive–interactive dysregulation (communication breakdown combined with expectation gaps), and systemic resonance failure involving multiple simultaneous problems. Family emotional dyscontrol was a necessary condition for extreme conflict outcomes. Implications for Nursing Management: Nurse managers should adopt a configurational perspective when designing conflict prevention strategies. Interventions should target not only individual factors but also their interactions, such as improving communication training, strengthening emotional de-escalation protocols, and optimizing staffing and resource allocation. Additionally, establishing early warning systems for high-risk configurations and enhancing organizational support mechanisms may help reduce the likelihood and severity of pediatric nurse–patient conflicts.</p>