Journal of Nursing Management, 2016, 24, 211–218
Conflict management style, supportive work environments and the experience of work stress in emergency nurses MARY L. JOHANSEN
PhD, NE-BC, RN
and EDNA CADMUS
PhD, RN, NEA-BC, FAAN
Assistant Clinical Professor, Associate Director, New Jersey Collaborating Center for Nursing, School of Nursing, Rutgers, The State University of New Jersey, 180 University Avenue, Newark, NJ 07102, USA and 2Clinical Professor, Specialty Director, Leadership Tracks, School of Nursing, Rutgers, The State University of New Jersey, 180 University Avenue, Newark, NJ 07102, USA
Correspondence Mary L. Johansen Clinical Assistant Professor. Associate Director NJ Collaborating Center School of Nursing Rutgers, The State University of New Jersey 180 University Avenue, Newark, New Jersey 07102 USA E-mail: [email protected]
JOHANSEN M.L. & CADMUS E. (2016) Journal of Nursing Management 24, 211–218. Conflict management style, supportive work environments and the experience of work stress in emergency nurses
Aims To examine the conflict management style that emergency department (ED) nurses use to resolve conflict and to determine whether their style of managing conflict and a supportive work environment affects their experience of work stress. Background Conflict is a common stressor that is encountered as nurses strive to achieve patient satisfaction goals while delivering quality care. How a nurse perceives support may impact work stress levels and how they deal with conflict. Methods A correlational design examined the relationship between supportive work environment, and conflict management style and work stress in a sample of 222 ED nurses using the expanded nurse work stress scale; the survey of perceived organisational support; and the Rahim organisational conflict inventory-II. Results Twenty seven percent of nurses reported elevated levels of work stress. A supportive work environment and avoidant conflict management style were significant predictors of work stress. Conclusions Findings suggest that ED nurses’ perception of a supportive work environment and their approach to resolving conflict may be related to their experience of work stress. Implications for nursing management Providing opportunities for ED nurses in skills training in constructive conflict resolution may help to reduce work stress and to improve the quality of patient care. Keywords: conflict management style, perceived organisational support, supportive work environment, work stress Accepted for publication: 1 March 2015
Introduction Emergency department (ED) nurses work in high stress, high conflict environments (Emergency Nurses Association (ENA) 2007). How the nurse perceives support may impact his or her work stress level and how they deal with conflict. The purpose of this study was to assess the relationships among supportive work DOI: 10.1111/jonm.12302 ª 2015 John Wiley & Sons Ltd
environments, work stress and conflict management styles in ED nurses.
Overview of the literature Nurses who work in emergency departments are especially susceptible to work stress as they encounter particular work stressors that may not be typical 211
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of most other professions. Emergency department nurses work in an environment that includes the direct involvement in critical incidents such as caring for patients who are critically ill, participating in end-of-life decisions with families, resuscitative efforts and unexpected patient deaths (Institute of Medicine (IOM) 2006, ENA 2007, Pemberton & Turpin 2008, Verhaeghe et al. 2008). Over the past two decades, the role of the emergency staff nurse has expanded to include other care responsibilities that can increase work stress such as serving as the primary provider of health care for many individuals in the community, attending to the urgent and primary care needs of the uninsured; and providing emergent care to acutely ill patients and victims of major trauma. Moreover, the inherently challenging work environment that emergency nurses experience can lead to increased levels of exhaustion and work stress (IOM 2004, 2006, ENA 2007, Li & Lambert 2008) contributing to the 12% registered nurse vacancy rate (IOM 2006). The perception of one’s work environment, that is, the perceived organisational support may likely impact work stress levels in emergency department nurses (Rhoades & Eisenberger 2002). Perceived organisational support also known as a supportive work environment is characterised by perceptions of supervisor support, fairness and open communication (Rhoades & Eisenberger 2002). A supportive work environment contributes to win–win solutions for the employee and the organisation and thereby reduces levels of work stress. Research suggests that nurses in acute care settings such as the ED with greater levels of perceived support from their supervisors experience less work stress (Hall 2007, Verhaeghe et al. 2008). Due to the nature of the emergency department, conflict is an inevitable characteristic of the work environment and a common work stressor that emergency nurses encounter in the unpredictable workplace where nursing responsibilities are driven by patient needs that are often complex and dynamic (Laschinger et al. 2008). The style that the individual utilises to manage conflict may be directly shaped by the task at hand or by the interpersonal relationships between peers, physicians and supervisors and may directly affect the level of work stress (Laschinger et al. 2006). Conflict management style (CMS) is a multidimensional concept consisting of five styles of managing conflict (integrating, obliging, dominating, avoiding and compromising) (Rahim 1983). These styles are 212
complex and while an individual may use one style more than others, the style that is used is dependent upon the situation and the players (Rahim 1983, Friedman et al. 2000). According to the seminal work by Rahim (1983) integrating involves exchanging information, examining differences to solve the problem, and looking for alternatives to solve the issue in a manner that is acceptable to all parties involved. Obliging involves an attempt to minimise differences and to emphasise commonalities to satisfy the concerns of the other parties. The dominating style involves one party satisfying their needs or concerns at the expense and the needs and concerns of the other party. In contrast, when avoiding conflict, there is often no attempt to satisfy needs and concerns of any of the parties. Lastly, compromising involves both parties giving up something to make a mutually acceptable decision (Rahim 1983). Individuals who have a high concern for themselves have personal internal resources and are more skilled in ensuring that their interests are represented when urgent needs arise and as a result, these individuals experience lower levels of work stress. These individuals tend to use a dominating or integrating (problem-solving) conflict management style. Conversely, individuals who have a low concern for themselves lack personal internal resources and fall short of representing their own interests, making them passive receivers of others’ actions that lead to higher levels of work stress. These individuals usually are avoiders or obligers (Friedman et al. 2000). Thus, the conflict management style rendered in response to conflict may directly affect the level of work stress and may be an important determinant of work stress in emergency department nurses (Friedman et al. 2000, Montoro-Rodriguez & Small 2006, Vivar 2006, Sportsman & Hamilton 2007). Although findings in the literature indicate that supportive work environments and conflict management styles are directly related to work stress, it is thought that the individual’s perception of their work environment may lessen the negative effects of conflict management style on overall work stress (Friedman et al. 2000, Rhodes Rhoades & Eisenberger 2002). The aim of this study was not only to examine the relationships among conflict management style, supportive work environment and work stress in staff nurses who work in hospital-based emergency departments but also to determine whether a supportive work environment support minimises the negative effects of obliging and avoidant conflict management style on work stress in emergency department nurses. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 211–218
Conflict management, work environment & stress
Method Research design A descriptive, correlational design was used to investigate the relationships among supportive work environment, conflict management style and work stress and to answer the following research questions: (1) How does conflict management style contribute to the level of stress experienced by the ED nurse? (2) Does a supportive work environment moderate or lessen the effect of conflict management styles on stress? Participants were recruited through the use of a mailing list of registered nurses who were current members of the Emergency Nurses Association (ENA) and work in the USA. Systematic sampling was used to select 1000 nurses from this list who were mailed questionnaires and follow-up reminders using a modified Dillman method (Dillman 2007). The data were collected in 2009–2010 over a 4 month period. Sample inclusion criteria included current membership in the ENA, current employment as a staff nurse in a hospital based emergency department in the USA and a direct patient care provider. Sample exclusion criteria included nurses employed in education, nurse practitioner and management roles.
Human subjects protection This study was approved by the Institutional Review Board (IRB) at the Office of Research and Sponsored Programs at Rutgers, The State University of New Jersey. IRB number 09-600M.
Sample The sample size for the study was estimated based on power analyses for correlational and regression analysis that was used to test the research questions. For correlational analysis, using a moderate effect size (r = 0.30) based on the literature (Rhoades & Eisenberger 2002, Tabak & Koprak 2007), a sample size of 84 was needed to obtain a power of 0.80 at a 0.05 significance level. Using a moderate effect size (f2 = 0.30), based on a review of the literature (Hall 2007, Tabak & Koprak 2007, Verhaeghe et al. 2008) and 14 predictor variables (the total number of subscales in the instruments), a minimum sample size of 135 was needed to obtain a power of 0.80 at a significance level of 0.05 (Cohen 1992) for regression analysis. Based on Dillman’s (2007) estimate of mailed ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 211–218
survey response rates with repeated mailings, a minimum sample size of 290 nurses was anticipated to yield more than sufficient power for statistical analyses. Three hundred surveys were returned for a 40% response rate. Seventy-eight of these surveys were excluded because responders identified their current position as educators, nurse practitioners or nurse managers. The final sample size for this study was 222 staff nurses who worked in hospital-based emergency departments.
Instruments All data were collected using a demographics questionnaire developed by the investigator; the expanded nursing work stress scale (ENSS) (French et al. 2000); the abbreviated survey of perceived organisational support (SPOS) (Eisenberger et al. 1986); and the Rahim organisational conflict inventory-II (ROCI-II) (Rahim 1983). The expanded nurse work stress scale (ENSS) is a 57 item self-report survey with nine subscales and measures the nurses’ experience of work stress as perceptions of sources and frequency of work stress experienced in the workplace rather than general work stress (French et al. 2000). The ENSS subscales consist of items related to the following sources of stress: (1) death and dying, (2) conflicts with doctors, (3) inadequate emotional preparation, (4) problems with peer support, (5) problems with supervisors, (6) workload, (7) uncertainty concerning treatment, (8) patients and families and (9) discrimination. The ENSS is a 5-point Likert response scale. Each item is scored from 1 to 5. The responses are (1) ‘never stressful’, (2) ‘occasionally stressful’, (3), ‘frequently stressful’, (4), ‘extremely stressful’ and (5) ‘doesn’t apply’. The ENSS yields a total score of 228 in the nine subscales. The higher the score, the more the respondent agrees that the situation is stressful. The ENSS has demonstrated an acceptable reliability (a = 0.96) (French et al. 2000). The reliability for the ENSS subscales has ranged from 0.65 to 0.88 (French et al. 2000). The abbreviated survey of perceived organisational support (SPOS) (Eisenberger et al. 1986) was used to measure a supportive work environment in this study. This widely accepted 16-item, self-report instrument measures the extent to which nurses perceive that their employer values them. Using a 7-point Likert scale respondents are asked to rate the extent to which they disagree or agree with statements concerning the organisation’s value of the individual such as ‘The 213
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organisation values my contributions and well-being’ and ‘The organisation shows very little concern for me’. Each item is scored from 0 to 6. The responses range from (0) strongly disagrees to (6) strongly agree. The possible range of SPOS scores is 16 to 96, with a higher score reflecting a higher level of organisational support perceived by the respondent. Cronbach’s alpha coefficient of 0.90 has been reported for the SPOS. The reliability for the SPOS subscales was 0.97 (Eisenberger et al. 1986). The Rahim organisational conflict inventory-II (ROCI-II) is a 28-item self-report instrument with five subscales and was used to measure five styles of handling interpersonal conflict with the ‘people at work’ (dominating, obliging, avoiding, integrating and compromising). The ROCI-II is a 5-point Likert scale. Individual items are scored from 1 to 5 with responses ranging from (1) strongly agrees to (5) strongly disagrees. Reliability for all ROCI-II subscales ranged from 0.72 to 0.74 (Weider-Hatfield 1988).
Data analysis A descriptive analysis of the demographic data was conducted to describe the sample characteristics. Correlation and linear regression analysis were used to test relationships among study variables. Hierarchical multiple regression analysis was used to test the affect of supportive work environment on the relationship between conflict management style and work stress. All data were analysed using Statistical Package for the Social Sciences (SPSS) version 16.0 for Windows (SPSS Inc. Released 2007, SPSS for Windows, Version 16.0; SPSS Inc, Chicago, IL, USA).
Results Demographics The demographic characteristics of the sample are presented in Table 1. The mean age of the sample was 43.75 years (SD = 10.41) with a range of 22 to 69 years. Eighty six percent of the nurses were female, 73% were employed full time. One-third of the nurses had less than 4 years’ experience (n = 69); another one third of nurses had 5 to 11 years of emergency department experience (n = 75) and the remaining third had 12 to 34 years of emergency department experience (n = 78). The mean years of emergency department experience was 10.68 (SD = 9.10). Fiftynine percent of the respondents had at least a baccalaureate degree in nursing (n = 130) and 36% were 214
Table 1 Sample characteristics (n = 222) Variable
Gender Male Female Age 18–30 31–49 50 and above Race African-American/Black Alaskan Native or American Indian Asian Hispanic Caucasian/White Mixed race Highest nursing degree Diploma Associate degree Baccalaureate degree Masters degree Years of experience 0–4 5–11 12–34 Board Certification in Emergency Nursing Yes No Work status Full time Part time Per diem
28 117 77
13 53 34
3 2 12 9 190 5
1.4 0.9 5.4 4.1 86 2
15 77 122 8
6 35 55 4
69 75 78
33 33 33
163 47 12
73 21 5
board certified in emergency nursing (n = 81). A majority of nurses (74%) worked in facilities not designated as Magnet hospitals.
Work stress Regarding work stress, a large majority, 73% of nurses experienced stress occasionally and reported low levels of work stress (n = 161), while the remaining 27% (n = 54) experienced stress frequently with moderate to high levels. Sixty-six percent (n = 147) of the sample perceived low levels of organisational support (Table 2). A little more than one in four nurses (28%) reporting used an avoidant conflict management style; 7% reported using a dominating conflict management style; and the remaining two thirds reported using integrating and obliging conflict management styles.
Supportive work environment and work stress When testing the relationship between supportive work environments and work stress, there was an inverse, weak negative relationship. This suggests that ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 211–218
Conflict management, work environment & stress
Table 2 Work stress and perceived organisational support (supportive work environment) Variable Level of work stress Low Moderate to high Perceived organisational support Low Moderate to high
ED nurses experienced less work stress in a supportive work environment (r = 0.292, P = 0.000).
Conflict management style and work stress There was a moderate positive, relationship between avoidant conflict management style and work stress (r = 0.300, P = 0.000) indicating that ED nurses who avoided conflict experienced less work stress (Table 3). No significant relationships were found between integrating, dominating and obliging dimensions of conflict management styles and work stress.
Supportive work environment, conflict management style and work stress Regression analysis revealed that both supportive work environment and avoidant conflict management style were significant independent predictors of work stress (b = 0.262, P = 0.003, b = 0. 209, P = 0.018, respectively). That is, a supportive work environment had an independent effect on work stress while controlling for the effects of avoidant conflict management style and avoidant conflict management style had an independent effect on work stress while controlling for the effects of a supportive work environment. Hierarchical regression analyses revealed that there were no significant relationships between conflict management style and a supportive work environment, on Table 3 Relationships between perceived organisational support (supportive work environment), conflict management style (CMS) and work stress r Perceived organisational support Integrating CMS Dominating CMS Avoidant CMS Obliging CMS
0.292** 0.024 0.012 0.300** 0.129
*P < 0.05 **P = 0.002. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 211–218
the level of work stress in staff nurses who worked in hospital-based emergency departments.
Discussion A significant weak relationship was found between a supportive work environment and work stress, indicating that nurses who work in emergency room settings with greater levels of perceived support from their organisation experience less work stress. In this study, 27% reported moderate to high levels of work stress and 73% of nurses experienced low levels. These findings from this study are similar to previous findings in the literature that revealed 39% of staff nurses working in hospital-based inpatient units reported frequent experiences of work stress (Rhoades & Eisenberger 2002, Parikh et al. 2004, Hall 2007). Moreover, while this relationship has been previously tested in nurses who work in hospital-based, inpatient settings (Hall 2007), findings from this study indicate that a supportive work environment may be an important antecedent to preventing work stress for nurses who work in emergency department environments as well. A significant moderate relationship was found between an avoidant conflict management style and work stress, suggesting that emergency department nurses who use this conflict management approach are likely to experience work stress. In this study more than 25% of emergency nurses used an avoidant approach to manage conflict, suggesting that more emergency nurses may experience some level of work stress. These findings are congruent with previous studies, which demonstrated that nurses using an avoidant approach to managing conflict have higher levels of stress (Friedman et al. 2000, Tabak & Koprak 2007). The findings of the present study also underscore the importance of the recommendations of The Joint Commission (TJC) and the National Institute of Occupational Safety and Health (NIOSH). Lack of effective conflict management skills has been identified as a root cause and contributing factor to behaviours that can undermine the quality of patient care and a culture of safety in the health care environment (Joint Commission 2008). No direct relationship was found between an integrating conflict management style and dominating conflict management style and work stress, indicating that emergency nurses who used these behavioural approaches to managing conflict may have experienced less work stress. These findings differ from previous research that found significant relationships between integrating and dominating conflict management styles and work stress in nurses in 215
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hospital settings (Tabak & Koprak 2007). An explanation might lie in the complex relationship between conflict management style and work stress. There is an overall tendency of the individual to respond to a conflict situation in a predictable way and hence the approach to managing conflict is often chosen to match the situation at hand (Sportsman & Hamilton 2007). Conflict management style may be related to work stress through conflict experiences such as task conflict or relationship conflict with a physician, supervisor or a peer. There was no significant relationship between an obliging conflict management style and work stress, suggesting that emergency nurses who used an obliging conflict management approach may not experience high levels of work stress. Echoing previous studies the results from this study appear to confirm that people using the obliging conflict management style faced a unique situation as they attempt to decrease work stress by addressing the interests of others (Friedman & Tidd 2002). This paradox may solve the immediate conflict: however, for emergency nurses placating a conflict can lead to increased work stress as they abate their ability to assert their own interests. The relationship between conflict management style and work stress is complex. Empirical findings suggest that conflict management style may be shaped by both the task at hand as well as the interpersonal relationship (Rahim 1983, Friedman et al. 2000). This study demonstrated that there is a relationship between an avoidant conflict management style and work stress. These findings underscore the priority that the Joint Commission (TJC) (2008) has placed on the use of effective conflict management strategies in hospitals. In fact, TJC recommendations suggest that nursing administrators including those in emergency departments should provide an opportunity for staff nurses to examine or become aware of conflict management styles and should provide skills based training and coaching in constructive conflict resolution to resolve these differences between peers, physicians and supervisors.
Limitations There are several limitations in this study. For example, nurses self-reported their style of managing conflict, experience of work stress and perceived support by their organisation. Self-reporting measures run the risk of potential common method variance which could inflate or deflate the reported correlational relationships. There may also be unmeasured variables in 216
the analysis such as task and relationship conflict which could affect the results. In addition, more objective organisational variables such as hospital type (urban, rural and suburban), trauma level and hospital size, staffing levels and shift work could affect relationships. Selection bias may have occurred during the data collection process as this study used only registered nurses who were current members of the ENA. This also decreases the generalisability of these study findings. Lastly, it should be noted that the data for this study were collected approximately four years ago.
Implications for nursing management In this study 73% of emergency nurses reported occasional experiences of work stress. These findings are important since research has shown that there is a significant relationship between work stressful nurses and negative patient outcomes such as, medication errors, IV errors, patient falls, reduced quality and efficacy of care (Jones et al. 2003, Trinkoff et al. 2011). Findings from this study suggest that nursing leadership in acute care hospitals should document the prevalence of work stress among its ED nurses in order to develop administrative strategies for reducing work stress (NIOSH 2010, Shirey et al. 2010). Recommendations may include routine distributions of work stress surveys, analysis of existing employees’ data such as injury and illness logs or worker compensation data, or tracking staffing patterns. Enhancing nursing leadership and staff skills in managing conflict is important to develop and master. Nurse managers and staff need to have strong emotional intelligence (EI), which includes self-awareness, self-management, social awareness and relationship management skills in dealing with emotionally charged situations (Goleman et al. 2002). These are skills that can be taught to nurse leaders and staff. Morrison (2008) conducted a study in three hospitals in Mississippi to determine the relationship between emotional intelligence and preferred conflict handling styles with 94 nurses using three instruments. The results showed that higher levels of emotional intelligence positively correlated with collaborating and negatively with accommodating styles. While this was a small sample it demonstrates the importance of developing nurses’ emotional intelligence as a strategy to employ to improve how conflict is managed. One of the first exercises with staff is to understanding their conflict management style to help determine how best to enhance their emotional intelligence. ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 211–218
Conflict management, work environment & stress
Another approach is to develop conflict coaching skills in nurse managers using the comprehensive conflict coaching model (Brinkert 2011). This model can be used to educate nurses on how to work through conflict. It includes four stages: (1) discovering the story, (2) exploring the perspectives of identity, emotion and power, (3) crafting the best story, and (4) enacting the best story. This curricula includes education on communication skills, conflict management styles, negotiation and dispute resolution; and a parallel process of identifying learning needs and goal setting in the process (Brinkert 2011). Role playing actual events in a safe environment helps the nurse manager refine his/her skill set around conflict management. Brinkert (2011) conducted a study in two healthcare systems using this model. The results demonstrated that this model was an effective means of developing communication skills. While this model holds promise the research is limited. One example of interprofessional education that has been recommended to reduce stress and conflict in the literature is the use of TeamSTEPPs. TeamSTEPPS, developed by the Department of Defense (DOD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ) is an example of one strategy that a nurse leader should consider incorporating into this environment. The DOD developed curricula and tools to improve communication and teamwork skills among health-care professions (AHRQ 2014). TeamSTEPPS modules focus on: teamwork, communications, how to lead teams, situational monitoring and mutual support. These modules provide evidence-based strategies to create an environment that is supportive. This framework has been employed primarily in acute care facilities either at a unit or organisational level. Outcomes demonstrated in the literature include improved interprofessional communication in high stress environments (Harvey et al. 2013), reduced medication errors (O’Byrne et al. 2014) and an improved culture of safety and engagement (Thomas & Galla 2013). Broader evaluation of the impact TeamSTEPPS has been measured using the AHRQ Hospital Survey Patient Safety Culture. The results have shown an improved perception of a safety culture in health-care organisations using TeamSTEPPS (Thomas & Galla 2013). Turner (2012) implemented TeamSTEPPs in an emergency department in the western United States, which treated 65000 patients per year. A TeamSTEPPS leadership team was identified to include three MDs and three RNs who became master ª 2015 John Wiley & Sons Ltd Journal of Nursing Management, 2016, 24, 211–218
trainers. Specific ED vignettes were developed and included staff as part of the videos to demonstrate the TeamSTEPPs application in the ED setting. A wrap up sheet was developed by the team to identify the things that went well and those that could be improved during highly stressful events. These sheets help to keep leadership informed and on issues that needed to be addressed. The outcomes of integrating TeamSTEPPS improved communication between leaders and staff. Many of the TeamSTEPPS studies have a small sample size or are single institutions’ experiences and therefore cannot be generalised. This study also found that 66% of ED nurses perceived their work environment was not supportive suggesting that they are experiencing some degree of work stress.
Conclusions A supportive work environment and avoidant conflict management style were found to be significant predictors of work stress, suggesting that emergency nurses’ perception of a supportive work environment and their approach to resolving conflict may be related to their experience of work stress. The findings of the present study underscore the priority that the Joint Commission and NIOSH have placed on the use of effective conflict management strategies in hospitals. Moreover, a majority of nurses in this study indicated that they perceived a lack of organisational support coupled with the finding that a quarter of the sample rated their work stress level as moderate to high; it appears that conflict management skills training may benefit emergency department nurses.
Ethical approval IRB No. 09-600M, Rutgers, the State University of New Jersey, Office of Research and Sponsored Programs.
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