Leadership DIMENSION
Conflict Management Styles Among Iranian Critical Care Nursing Staff A Cross-sectional Study Mohammad Reza Ahanchian, PhD; Amir Emami Zeydi, MSN, CCRN; Mohammad Reza Armat, MSN
Background: Conflict among nurses has been recognized as an extremely important issue within health care settings throughout the world. Identifying the conflict management style would be a key strategy for conflict management. Objective: The aim of this study was to evaluate the prevalence of conflict management styles and its related factors among Iranian critical care nursing staff. Methods: In a descriptive cross-sectional study, a total of 149 critical care nurses who worked in the critical care units of 4 teaching hospitals in Sari (Iran) were evaluated. A 2-part self-reported questionnaire including personal information and Rahim Organizational Conflict Inventory II was used for data collection. Results: Although Iranian critical care nurses used all 5 conflict management styles to manage conflict with their peers, the collaborating style was the most prevalent conflict management style used by them, followed by compromising, accommodating, avoiding, and competing. Male gender was a predictor for both compromising and competing styles, whereas position and shift time were significant predictors for compromising and competing styles, respectively. Discussion: Based on the results of this study, nurse managers need to take these factors into account in designing programs to help nurses constructively manage unavoidable conflicts in health care setting. Keywords: Conflict management style, Critical care unit, Iran, Nurse [DIMENS CRIT CARE NURS. 2015;34(3):140/145]
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Dimensions of Critical Care Nursing
Vol. 34 / No. 3
DOI: 10.1097/DCC.0000000000000106
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Conflict Management in Iranian Critical Care Nurses
Conflict, as a natural result of human communication, is commonly defined as an internal misunderstanding that occurs from the differences in goals, opinion, needs, values, ideas, and feelings between 2 organizations or people.1,2 It is an inevitable issue in any work environment, including hospitals.3 Complex and constant interactions among nurses and other health care professionals along with their diverse roles increase the possibility of conflict occurrence in hospitals.1 Conflict among nurses and other health care providers has been recognized worldwide as an important issue within health care settings.3,4 The hierarchical structure of hospital organizations, team working, interpersonal relationship, and the expectations of performing different tasks or roles are the potential sources of conflicts among hospital nurses and other health care providers.1 Persistent interpersonal conflict, as the most common and challenging type of conflicts in the workplace, is disadvantageous to the work climate and deleteriously affects individuals’ physical and psychological well-being. Consequently, this can lead to accelerating absenteeism and turnover rate and reducing interprofessional collaboration, coordination, and efficiency.3,4 Interpersonal conflicts may also affect the health care quality.5 In critical care units, the most stressful places in hospitals, conflict is much more common.6 Patients admitted to the critical care units have great demands for complex care, whereas their successful management depends on multiple disciplines’ collaboration. Nurses, along with other experts from various specialties involved in intensive care, work together and apply their knowledge to provide a coordinated patient care. This multidisciplinary team working probably increases the likelihood of conflict occurrence among health care professionals.6-8 Unresolved or poorly managed conflicts have negative influences on individuals, organizations, and, most importantly, patient outcomes.9 The result of a multicenter and international study showed that more than 70% of intensive care unit (ICU) staff perceived at least 1 professional conflict over the last working week, which was severe, and associated with job strain, and consequently decreased the quality of their care and affected the patient survival.5 Considering that the nurses are the largest group of health care professionals in critical care units10 and high level of conflict occurrence among them, nurse managers need to assess how these conflicts are dealt with, in an effort to develop and implement efficient conflict resolution strategies.4 To achieve this, identifying the conflict management style would be a key approach.11 The 5 common conflict management styles are collaborating, accommodating, competing, avoiding, and compromising. In collaborating style, a direct and cooperative manner is used to reach a fully satisfactory solution for both parties. Users of this style show high concern for priorities and
preferences of themselves and others equally. Assertiveness and cooperation are involved in the collaboration style.9,11 Those who use accommodating style face conflicts passively and follow the decisions of other parties. They show low concern for themselves and high concern for others and tend to accept the other party’s purpose. This approach enhances conformity and involves cooperative but unassertive responses. Users of this style achieve credits with the hope of using it in a later time.11,12 Individuals who use competing style oblige others and have much more concern for themselves. They strive to impose their will on others, using an aggressive and uncompromising approach to the conflicts, and may use threats and bluffs, persuasive arguments, and positional commitment. This power-driven approach is used in emergency situations or when a prompt or unusual decision needs to be made or to protect self or others from an aggressive person.11,13 Avoiding style, users have a tendency to sidestep conflicts. They show low concern for self and others, tending to reduce the importance of the issues and to suppress thoughts about them. As an unassertive and uncooperative response, it is more appropriate when the other party is more authoritative. Nurses with compromising style aim to reach mutually agreed decisions between parties. They show moderate concern both for themselves and others. This style contains intermediate levels of assertiveness and cooperation and aims on rapid, reciprocally agreeable decisions that partly satisfy both parties. It is applied when negotiation or interchange exists.12,13 Although nurses may dominantly use 1 specific style, their gender, age, culture, workload, and position in the organizational hierarchy can influence it.11 By understanding the nurses’ conflict management style in a specific context, the managers can develop effective strategies to help nurses constructively manage unavoidable conflicts within health care workplaces.14 Considering the aforementioned issues and the paucity of published study on conflict management styles among critical care nurses in Iran, the aim of this study was to assess the prevalence of conflict management styles and related factors among Iranian critical care nursing staff.
METHODS A descriptive cross-sectional study was performed between August and September 2014, at 4 teaching hospitals affiliated to Mazandaran University of Medical Sciences. The population of the study consisted of all nurses who worked in the critical care units (medical and surgical ICUs, cardiothoracic ICUs, and coronary care units) of Sari teaching hospitals, Iran. The whole population was considered for the study, and working in the critical care units for at least 6 months was accounted as inclusion criterion. As a primary instruction, the purpose of the study was explained May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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Conflict Management in Iranian Critical Care Nurses
to respondents. They were assured that study participation was voluntary. Data were collected anonymously using a self-report questionnaire. Returning the completed questionnaire was considered as informed consent to participate. The questionnaire consisted of 2 parts. The first part devoted to demographic characteristics including age, gender, marital status, job position, educational level, and years of experience. The second part included Rahim Organizational Conflict Inventory II (ROCI II) to measure the nurses’ predominant conflict management styles they usually use during interaction with their peers. It consists 28 items with a 5-point Likert type rating scale (5 = strongly agree to 1 = strongly disagree) to measure the conflict-handling behaviors. A higher score indicates the greater use of the style in conflict situations. The ROCI II was designed to measure 5 styles of resolving conflicts. The numbers of items for collaborating, accommodating, competing, avoiding, and compromising styles were 7, 6, 5, 6, and 4, respectively. The reliability and internal consistency of the 5 subscales of ROCI II have been established in previous studies. Also, its convergent and discriminate validity have been approved previously.11,12 The content validity of Persian version of the questionnaire was assessed by 10 experts in this field. To assess the reliability of the questionnaire, we examined the internal consistency coefficient and achieved a Cronbach ! of .78. Values of .7 or higher are appropriate and acceptable.15
Statistical Analysis Data were analyzed using SPSS (SPSS Inc, Chicago, Illinois). Results present frequencies, means, and SEs. After checking for outliers and removing them, basic assumptions of regression analysis including normality, linearity, and homoscedasticity were checked using scatter plots and Kolmogorov-Smirnov test. Stepwise linear regression analysis were used to determine the effects of gender, age, marital status, ward, educational level, position, and shift time on nurses’ 5 conflict management styles, all of which except age were used as dummy variables. The input criterion of P G .05 and output criterion P 9 .1 were selected. The significance level for the model and each variable was set at P G .05.
RESULTS A total of 180 nurses were invited to participate. Among whom, 149 (82%) answered the questionnaire. The mean and SE for age and years of experiences were 33.15 (0.62) and 8.87 (0.57), respectively. Other participants’ demographic characteristics are shown in Table 1. Descriptive statistics of participants’ conflict management style scores are shown in Table 2. As shown in Table 2, there was a significant difference between nurses’ conflict management style scores, so that 142
Dimensions of Critical Care Nursing
TABLE 1
Nurses’ Demographic Characteristics
Variable
Sex
Marital status
Frequency
Percent
24
16.1
Female
125
83.9
Single
36
24.2
Male
Married Ward
Educational level
Position
Shift time
113
75.8
Intensive care unit
95
63.8
Coronary care unit
54
36.2
129
86.6
Master
Bachelor
20
13.4
Nurse
138
92.6
Head nurse
11
7.4
Fixed day
30
20.2
Rotational
2
1.3
117
78.5
Fixed night
the highest scores belonged to the collaborating and compromising styles, respectively. The Figure shows the box plots of conflict management scores according to management style, gender, and working shifts. A linear regression analysis was used for each conflict management style separately. The models for predicting collaborating, accommodating, and avoiding styles were not significant (P 9 .05), whereas the model for compromising and competing styles showed an R2 of 0.079 (P e .003) and 0.108 (P G .001), respectively. The regression model constructed for compromising style included gender (P e .043) and position (P e .004), whereas the model for competing style included gender (P e .001) and shift times (P e .017). Gender in the competing style was the first variable in the model, whereas in the compromising style, it was the second. The " weights of gender in the model for compromising and competing styles were j0.163 and j0.284, respectively. This means that in both styles male nurses have higher scores as compared with their female colleagues. In compromising style, position as a predictive variable showed " of j0.236. This denotes a decrease of j0.236 in conflict management score in case of changing the position from a nurse to a head nurse. For competing style, shift times as predictive variable showed " weight of 0.190. This means that if a nurse changes his/her fixed shift into rotational shift, his/her conflict management score will increase by 0.19.
DISCUSSION The results showed that although Iranian critical care nurses used all 5 styles to manage conflicts with their peers, the
Vol. 34 / No. 3
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Conflict Management in Iranian Critical Care Nurses
TABLE 2
Comparison of Nurses’ Conflict Management Style Scores
Conflict Management Style n Mean SE
Collaborating
149
3.95
#2
P
0.03 253.376 G.0001
Accommodating
149
3.13
0.04
Competing
149
2.81
0.05
Avoiding
149
3.11
0.04
Compromising
149
3.46
0.04
P G .05 (Friedman test).
collaborating style was dominant, after compromising, accommodating, avoiding, and competing styles. Also, findings suggest that gender was a significant predictor for both compromising and competing styles. The result of a study by Al-Hamdan et al,9 aimed at examining the Omani nurse managers’ conflict management styles, showed that the dominant conflict management style was collaborating, after compromising, accommodating, competing, and avoiding. Also, the study demonstrated that men were more likely to use compromising style than women. A study conducted in Turkey showed that collaborative style was the most frequently used conflict management style among nurse managers, followed by the compromising style.16 These are concordant with our study findings. Likewise, it was evidenced that the undergraduate nurse students preferred collaborating style.13 Another study has suggested that although compromising was the most commonly style used by nurses, collaborating style was the dominant con-
flict management style.17 It seems that collaboration is an efficient approach in conflict management within the nursing profession, irrespective of individual seniority and culture.13 Although it was demonstrated that Asians are less likely to verbally and directly express the feelings of conflict,18 our study showed that most Iranian nurses use this style. Collectively, the collaborating style as a win-win strategy focuses on problem solving. In this style, once the conflict is encountered, the individuals focus on the needs of both sides, enabling them to find new and creative solutions.19 A study by Losa Iglesias and Becerro de Bengoa Vallejo,20 aimed at identifying the predominant conflict management styles among Spanish nurses, has shown that compromising was the most commonly used style. Also, Hendel et al21 confirmed this in their study. Another study found that compromising was the only style associated with nurses’ job satisfaction.22 Nevertheless, overdependence on this style may be dysfunctional.19 The compromising style, a lose-lose strategy, may be appropriate when the objectives of conflicting parties are mutually exclusive or when both parties with equal power have reached an impasse in their negotiation.19 This style emphasizes quick, mutually acceptable decisions that somehow satisfy both parties.9 Our study showed that male nurses had higher scores of compromising style than did their female colleagues, which is in line with the results of the studies of Al-Hamdan et al9 and Chan et al.13 This difference in conflict management approaches among male and female nurses confirms the socializing effects of gender role expectations in Iran. For instance, men are generally expected to develop masculine
Figure. Conflict management scores according to management style, gender, and working shifts. May/June 2015
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Conflict Management in Iranian Critical Care Nurses
characteristics, including aggression, independence, competitiveness, and assertiveness, whereas women are supposed to develop feminine characteristics such as emotiveness and sentimentality. Therefore, competitive behavior is more consistent with a masculine gender role.23 The result of a meta-analysis demonstrated that men use competing conflict management style more than do females.24 This indicates that nurse managers may need to consider gender differences when they plan for conflict management. In line with the result of our study regarding the predictive role of nurses’ position in their conflict management style, it was suggested that an individual’s behavior in an organization may vary according to their position in the organizational hierarchy.25 We believe that because head nurses face different types of conflicts, they would be different from their subordinate nurses in managing conflicts. On the other hand, they tend to rely on their organizational authority instead of conflict management skills. Therefore, they use compromising style less than do the others. A study by Cavanagh26 conducted on American female ICU staff nurses showed that avoiding was their predominant conflict management style in workplace. This study demonstrated that there was no significant relationship between the avoiding style and variables such as age, years of experience, and educational background, which is concordant with our study. Also, another study on Egyptian nurses showed that the most and least preferred conflict management style was avoiding and competing, respectively. In this study, a positive correlation between turnover intension and avoiding styles has been identified.27 Accommodating was the fourth conflict management style used by critical care nurse staff in our study. The results of a study conducted in Thailand showed that the majority of nurses used accommodating style to manage conflicts.28 Also, this style was the fourth preferred one among Spanish nurse,20 which is in line with the result of our study. This conflict management style can be used as a strategy when a party is willing to give up something with the hope of getting something in exchange from the other party when needed.19 In our study, competing style was the least utilized style among critical care nurses. This advocates the results of the studies of Cavanagh,26 El Dahshan and Keshk,27 Kunaviktikul et al,28 and Woodtli.29 The present study has some strengths and limitations. Although the response rate in this study was high, the participants were limited to critical care nursing staff of 4 university affiliated hospital in north of Iran, which restricts the generalizability of the results. Also, no inference about causality in the relationships between nursing staff factors and conflict management styles can be made because of adopting a cross-sectional design. 144
Dimensions of Critical Care Nursing
IMPLICATIONS FOR PRACTICE The results of our study imply the demand that nurse managers are supposed to acquire a good recognition of their staff nurses’ behavioral patterns, particularly their conflict management styles. This would help nurse managers to insightfully and creatively assign nurse staff to specific tasks or positions with certain conditions or likely conflicts, according to their dominant conflict management style, which best matches with those particular situations. For instance, a nurse manager may consider this when scheduling shift times to avoid possible conflicts between senior or junior working nurses by assigning a nurse who use compromising, collaborating, or accommodating style with a nurse whose dominant conflict management style is avoiding or competing. Also, our study suggests the need for considering gender, shift times, and position of working nurses in task assignments. In addition, the findings may encourage nurse staff to reflect on their conflict management styles to amend them based on the context they are working within.
CONCLUSION Collaborating style was the dominant conflict management style used by Iranian nurses followed by compromising, accommodating, avoiding, and competing. Gender was the predictor for both compromising and competing styles, whereas position and shift time were the significant predictors for compromising and competing styles, respectively. Therefore, based on the results, nurse managers need to take factors such as type of conflict and its relative importance, position of involved parties, the emphasis put on relationships versus goals, and time constraint into account when they design programs to help nurses constructively manage unavoidable conflicts in health care. Moreover, training programs for conflict management are recommended for all nurses to promote their communication skills and enhance interpersonal environment, for the advantage of the clients and health care professionals. Furthermore, studies to examine the relationship between personality factors and conflict management styles are warranted. Also, as the conflict is a culturally specific phenomenon, and conflict management styles can be affected by cultural contexts, conducting further studies to assess the conflict management styles among critical care nursing staff in different countries is suggested.
Acknowledgments The authors thank the nurses who participated in the study. Also, the authors are grateful to Mrs Fatemeh Bozorg Sohrabi, a nurse anesthetist, for participating in data collection.
Vol. 34 / No. 3
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Conflict Management in Iranian Critical Care Nurses
References 1. Dehghan Nayeri N, Negarandeh R. Conflict among Iranian hospital nurses: a qualitative study. Hum Resour Health. 2009;7:25. 2. Kantek F, Gezer N. Conflict in schools: student nurses’ conflict management styles. Nurse Educ Today. 2009;29(1):100-107. 3. Almost J. Conflict within nursing work environments: concept analysis. J Adv Nurs. 2006;53(4):444-453. 4. Johansen ML. Keeping the peace: conflict management strategies for nurse managers. Nurs Manage. 2012;43(2):50-54. 5. Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and factors of intensive care unit conflicts: the Conflicus study. Am J Respir Crit Care Med. 2009;180:853-860. 6. Savel RH, Munro CL. Conflict management in the intensive care unit. Am J Crit Care. 2013;22:277-280. 7. Epp K. Burnout in critical care nurses: a literature review. Dynamics. 2012;23(4):25-31. 8. Strack van Schijndel RJ, Burchardi H. Bench-to-bedside review: leadership and conflict management in the intensive care unit. Crit Care. 2007;11(6):234. 9. Al-Hamdan Z, Shukri R, Anthony D. Conflict management styles used by nurse managers in the Sultanate of Oman. J Clin Nurs. 2011;20(3-4):571-580. 10. Gholipour Baradari A, Hoseini SH, Zamani Kiasari A, et al. Effect of zinc supplement on job stress of ICU nurses. J Babol Univ Med Sci. 2013;15(1):38-45. 11. Al-Hamdan Z. Nurse managers, diversity and conflict management. Divers Health Care. 2009;6(1):31-43. 12. Rahim MA. A measure of styles of handling interpersonal conflict. Acad Manag J. 1983;26:368-376. 13. Chan JC, Sit EN, Lau WM. Conflict management styles, emotional intelligence and implicit theories of personality of nursing students: a cross-sectional study. Nurse Educ Today. 2014;34(6):934-939. 14. Sportsman S, Hamilton P. Conflict management styles in the health professions. J Prof Nurs. 2007;23(3):157-166. 15. Streiner LD, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 4th ed. New York, NY: Oxford University Press; 2008. 16. Kantek F, Kavla I. Nurse-nurse manager conflict: how do nurse managers manage it? Health Care Manag (Frederick). 2007;26(2): 147-151. 17. Hendel T, Fish M, Berger O. Nurse/physician conflict management mode choices: implications for improved collaborative practice. Nurs Adm Q. 2007;31(3):244-253. 18. Xu Y, Davidhizar R. Conflict management styles of Asian and Asian American nurses: implications for the nurse manager. Health Care Manag (Frederick). 2004;23(1):46-53. 19. Lee KL. An examination between the relationship of conflict management styles and employees’ satisfaction with supervision. Int J Bus Manage. 2008;3(9):11-25. 20. Losa Iglesias ME, Becerro de Bengoa Vallejo R. Conflict resolution styles in the nursing profession. Contemp Nurse. 2012;43(1):73-80. 21. Hendel T, Fish M, Galon V. Leadership style and choice of strategy in conflict management among Israeli nurse managers in general hospitals. J Nurs Manag. 2005;13(2):137-146. 22. Montoro-Rodriguez J, Small JA. The role of conflict resolution styles on nursing staff morale, burnout, and job satisfaction in long-term care. J Aging Health. 2006;18(3):385-406. 23. Brewer N, Mitchell P, Weber N. Gender role, organizational status, and conflict management styles. Int J Confl Manage. 2002; 13(1):78-94.
24. Holta JL, DeVore CJ. Culture, gender, organizational role, and styles of conflict resolution: a meta-analysis. Int J Intercult Relat. 2005;29(2):165-196. 25. FagensonEA. perceived masculine and feminine attributes examined as a function of individuals sex and level in organizational power hierarchy: a test of four theoretical perspectives. J Appl Psychol. 1990;75:204-211. 26. Cavanagh SJ. The conflict management style of intensive care nurses. Intensive Care Nurs. 1988;4(3):118-123. 27. El Dahshan MEA, Keshk LI. Managers’ conflict management styles and its effect on staff nurses’ turnover intention at Shebin El Kom Hospitals, Menoufiya Governorate. World J Med Sci. 2014; 11(1):132-143. 28. Kunaviktikul W, Nuntasupawat R, Srisuphan W, Booth RZ. Relationships among conflict, conflict management, job satisfaction, intent to stay, and turnover of professional nurses in Thailand. Nurs Health Sci. 2000;2:9-16. 29. Woodtli A. Deans of nursing perceived sources of conflict-handling modes. J Nurs Educ. 1987;26:272-277.
ABOUT THE AUTHORS Mohammad Reza Ahanchian, PhD, is graduated with Bachelor of Science Degree in Educational Management and Planning in 1987, from Isfahan University. He completed his Master’s of Science Degree in Educational Management in Tehran University in 1990 and his PhD in Philosophy of Educational Management in Tehran University for Teacher Training, Iran, in Companion with Education School of Sheffield University, UK, 2002. Currently, he is an associate professor of Educational Management at the School of Education and Psychology, Ferdowsi University of Mashhad, Iran. Amir Emami Zeydi, MSN, CCRN, is graduated with Bachelor of Science Degree in Nursing in 2008, and Master’s of Science Degree in Critical Care Nursing in 2011, from Mazandaran University of Medical Sciences, Sari, Iran. Currently, he is a PhD candidate in Nursing at the Mashhad School of Nursing and Midwifery, Mashhad University of Medical Sciences, Iran. Mohammad Reza Armat, MSN, is graduated from Mashhad University of Medical Sciences in 1991 with a Bachelor of Science Degree in Nursing. He completed his Master’s of Science Degree in Nursing in Tarbiat Modarres University in 1995. He is an instructor in North Khorasan University of Medical Sciences, Bojnourd, Iran. Currently, he is a PhD candidate in Nursing at the Mashhad School of Nursing and Midwifery, Mashhad University of Medical Sciences, Iran. No funding was received for this study. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Amir Emami Zeydi, MSN, CCRN, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Ebne-Sina St, Mashhad, Rszavi Khorasan, Iran ([email protected]).
May/June 2015
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145
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Conflict Management Styles Among Iranian Critical Care Nursing Staff A Cross-sectional Study Mohammad Reza Ahanchian, PhD; Amir Emami Zeydi, MSN, CCRN; Mohammad Reza Armat, MSN
Background: Conflict among nurses has been recognized as an extremely important issue within health care settings throughout the world. Identifying the conflict management style would be a key strategy for conflict management. Objective: The aim of this study was to evaluate the prevalence of conflict management styles and its related factors among Iranian critical care nursing staff. Methods: In a descriptive cross-sectional study, a total of 149 critical care nurses who worked in the critical care units of 4 teaching hospitals in Sari (Iran) were evaluated. A 2-part self-reported questionnaire including personal information and Rahim Organizational Conflict Inventory II was used for data collection. Results: Although Iranian critical care nurses used all 5 conflict management styles to manage conflict with their peers, the collaborating style was the most prevalent conflict management style used by them, followed by compromising, accommodating, avoiding, and competing. Male gender was a predictor for both compromising and competing styles, whereas position and shift time were significant predictors for compromising and competing styles, respectively. Discussion: Based on the results of this study, nurse managers need to take these factors into account in designing programs to help nurses constructively manage unavoidable conflicts in health care setting. Keywords: Conflict management style, Critical care unit, Iran, Nurse [DIMENS CRIT CARE NURS. 2015;34(3):140/145]
140
Dimensions of Critical Care Nursing
Vol. 34 / No. 3
DOI: 10.1097/DCC.0000000000000106
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Conflict Management in Iranian Critical Care Nurses
Conflict, as a natural result of human communication, is commonly defined as an internal misunderstanding that occurs from the differences in goals, opinion, needs, values, ideas, and feelings between 2 organizations or people.1,2 It is an inevitable issue in any work environment, including hospitals.3 Complex and constant interactions among nurses and other health care professionals along with their diverse roles increase the possibility of conflict occurrence in hospitals.1 Conflict among nurses and other health care providers has been recognized worldwide as an important issue within health care settings.3,4 The hierarchical structure of hospital organizations, team working, interpersonal relationship, and the expectations of performing different tasks or roles are the potential sources of conflicts among hospital nurses and other health care providers.1 Persistent interpersonal conflict, as the most common and challenging type of conflicts in the workplace, is disadvantageous to the work climate and deleteriously affects individuals’ physical and psychological well-being. Consequently, this can lead to accelerating absenteeism and turnover rate and reducing interprofessional collaboration, coordination, and efficiency.3,4 Interpersonal conflicts may also affect the health care quality.5 In critical care units, the most stressful places in hospitals, conflict is much more common.6 Patients admitted to the critical care units have great demands for complex care, whereas their successful management depends on multiple disciplines’ collaboration. Nurses, along with other experts from various specialties involved in intensive care, work together and apply their knowledge to provide a coordinated patient care. This multidisciplinary team working probably increases the likelihood of conflict occurrence among health care professionals.6-8 Unresolved or poorly managed conflicts have negative influences on individuals, organizations, and, most importantly, patient outcomes.9 The result of a multicenter and international study showed that more than 70% of intensive care unit (ICU) staff perceived at least 1 professional conflict over the last working week, which was severe, and associated with job strain, and consequently decreased the quality of their care and affected the patient survival.5 Considering that the nurses are the largest group of health care professionals in critical care units10 and high level of conflict occurrence among them, nurse managers need to assess how these conflicts are dealt with, in an effort to develop and implement efficient conflict resolution strategies.4 To achieve this, identifying the conflict management style would be a key approach.11 The 5 common conflict management styles are collaborating, accommodating, competing, avoiding, and compromising. In collaborating style, a direct and cooperative manner is used to reach a fully satisfactory solution for both parties. Users of this style show high concern for priorities and
preferences of themselves and others equally. Assertiveness and cooperation are involved in the collaboration style.9,11 Those who use accommodating style face conflicts passively and follow the decisions of other parties. They show low concern for themselves and high concern for others and tend to accept the other party’s purpose. This approach enhances conformity and involves cooperative but unassertive responses. Users of this style achieve credits with the hope of using it in a later time.11,12 Individuals who use competing style oblige others and have much more concern for themselves. They strive to impose their will on others, using an aggressive and uncompromising approach to the conflicts, and may use threats and bluffs, persuasive arguments, and positional commitment. This power-driven approach is used in emergency situations or when a prompt or unusual decision needs to be made or to protect self or others from an aggressive person.11,13 Avoiding style, users have a tendency to sidestep conflicts. They show low concern for self and others, tending to reduce the importance of the issues and to suppress thoughts about them. As an unassertive and uncooperative response, it is more appropriate when the other party is more authoritative. Nurses with compromising style aim to reach mutually agreed decisions between parties. They show moderate concern both for themselves and others. This style contains intermediate levels of assertiveness and cooperation and aims on rapid, reciprocally agreeable decisions that partly satisfy both parties. It is applied when negotiation or interchange exists.12,13 Although nurses may dominantly use 1 specific style, their gender, age, culture, workload, and position in the organizational hierarchy can influence it.11 By understanding the nurses’ conflict management style in a specific context, the managers can develop effective strategies to help nurses constructively manage unavoidable conflicts within health care workplaces.14 Considering the aforementioned issues and the paucity of published study on conflict management styles among critical care nurses in Iran, the aim of this study was to assess the prevalence of conflict management styles and related factors among Iranian critical care nursing staff.
METHODS A descriptive cross-sectional study was performed between August and September 2014, at 4 teaching hospitals affiliated to Mazandaran University of Medical Sciences. The population of the study consisted of all nurses who worked in the critical care units (medical and surgical ICUs, cardiothoracic ICUs, and coronary care units) of Sari teaching hospitals, Iran. The whole population was considered for the study, and working in the critical care units for at least 6 months was accounted as inclusion criterion. As a primary instruction, the purpose of the study was explained May/June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
141
Conflict Management in Iranian Critical Care Nurses
to respondents. They were assured that study participation was voluntary. Data were collected anonymously using a self-report questionnaire. Returning the completed questionnaire was considered as informed consent to participate. The questionnaire consisted of 2 parts. The first part devoted to demographic characteristics including age, gender, marital status, job position, educational level, and years of experience. The second part included Rahim Organizational Conflict Inventory II (ROCI II) to measure the nurses’ predominant conflict management styles they usually use during interaction with their peers. It consists 28 items with a 5-point Likert type rating scale (5 = strongly agree to 1 = strongly disagree) to measure the conflict-handling behaviors. A higher score indicates the greater use of the style in conflict situations. The ROCI II was designed to measure 5 styles of resolving conflicts. The numbers of items for collaborating, accommodating, competing, avoiding, and compromising styles were 7, 6, 5, 6, and 4, respectively. The reliability and internal consistency of the 5 subscales of ROCI II have been established in previous studies. Also, its convergent and discriminate validity have been approved previously.11,12 The content validity of Persian version of the questionnaire was assessed by 10 experts in this field. To assess the reliability of the questionnaire, we examined the internal consistency coefficient and achieved a Cronbach ! of .78. Values of .7 or higher are appropriate and acceptable.15
Statistical Analysis Data were analyzed using SPSS (SPSS Inc, Chicago, Illinois). Results present frequencies, means, and SEs. After checking for outliers and removing them, basic assumptions of regression analysis including normality, linearity, and homoscedasticity were checked using scatter plots and Kolmogorov-Smirnov test. Stepwise linear regression analysis were used to determine the effects of gender, age, marital status, ward, educational level, position, and shift time on nurses’ 5 conflict management styles, all of which except age were used as dummy variables. The input criterion of P G .05 and output criterion P 9 .1 were selected. The significance level for the model and each variable was set at P G .05.
RESULTS A total of 180 nurses were invited to participate. Among whom, 149 (82%) answered the questionnaire. The mean and SE for age and years of experiences were 33.15 (0.62) and 8.87 (0.57), respectively. Other participants’ demographic characteristics are shown in Table 1. Descriptive statistics of participants’ conflict management style scores are shown in Table 2. As shown in Table 2, there was a significant difference between nurses’ conflict management style scores, so that 142
Dimensions of Critical Care Nursing
TABLE 1
Nurses’ Demographic Characteristics
Variable
Sex
Marital status
Frequency
Percent
24
16.1
Female
125
83.9
Single
36
24.2
Male
Married Ward
Educational level
Position
Shift time
113
75.8
Intensive care unit
95
63.8
Coronary care unit
54
36.2
129
86.6
Master
Bachelor
20
13.4
Nurse
138
92.6
Head nurse
11
7.4
Fixed day
30
20.2
Rotational
2
1.3
117
78.5
Fixed night
the highest scores belonged to the collaborating and compromising styles, respectively. The Figure shows the box plots of conflict management scores according to management style, gender, and working shifts. A linear regression analysis was used for each conflict management style separately. The models for predicting collaborating, accommodating, and avoiding styles were not significant (P 9 .05), whereas the model for compromising and competing styles showed an R2 of 0.079 (P e .003) and 0.108 (P G .001), respectively. The regression model constructed for compromising style included gender (P e .043) and position (P e .004), whereas the model for competing style included gender (P e .001) and shift times (P e .017). Gender in the competing style was the first variable in the model, whereas in the compromising style, it was the second. The " weights of gender in the model for compromising and competing styles were j0.163 and j0.284, respectively. This means that in both styles male nurses have higher scores as compared with their female colleagues. In compromising style, position as a predictive variable showed " of j0.236. This denotes a decrease of j0.236 in conflict management score in case of changing the position from a nurse to a head nurse. For competing style, shift times as predictive variable showed " weight of 0.190. This means that if a nurse changes his/her fixed shift into rotational shift, his/her conflict management score will increase by 0.19.
DISCUSSION The results showed that although Iranian critical care nurses used all 5 styles to manage conflicts with their peers, the
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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Conflict Management in Iranian Critical Care Nurses
TABLE 2
Comparison of Nurses’ Conflict Management Style Scores
Conflict Management Style n Mean SE
Collaborating
149
3.95
#2
P
0.03 253.376 G.0001
Accommodating
149
3.13
0.04
Competing
149
2.81
0.05
Avoiding
149
3.11
0.04
Compromising
149
3.46
0.04
P G .05 (Friedman test).
collaborating style was dominant, after compromising, accommodating, avoiding, and competing styles. Also, findings suggest that gender was a significant predictor for both compromising and competing styles. The result of a study by Al-Hamdan et al,9 aimed at examining the Omani nurse managers’ conflict management styles, showed that the dominant conflict management style was collaborating, after compromising, accommodating, competing, and avoiding. Also, the study demonstrated that men were more likely to use compromising style than women. A study conducted in Turkey showed that collaborative style was the most frequently used conflict management style among nurse managers, followed by the compromising style.16 These are concordant with our study findings. Likewise, it was evidenced that the undergraduate nurse students preferred collaborating style.13 Another study has suggested that although compromising was the most commonly style used by nurses, collaborating style was the dominant con-
flict management style.17 It seems that collaboration is an efficient approach in conflict management within the nursing profession, irrespective of individual seniority and culture.13 Although it was demonstrated that Asians are less likely to verbally and directly express the feelings of conflict,18 our study showed that most Iranian nurses use this style. Collectively, the collaborating style as a win-win strategy focuses on problem solving. In this style, once the conflict is encountered, the individuals focus on the needs of both sides, enabling them to find new and creative solutions.19 A study by Losa Iglesias and Becerro de Bengoa Vallejo,20 aimed at identifying the predominant conflict management styles among Spanish nurses, has shown that compromising was the most commonly used style. Also, Hendel et al21 confirmed this in their study. Another study found that compromising was the only style associated with nurses’ job satisfaction.22 Nevertheless, overdependence on this style may be dysfunctional.19 The compromising style, a lose-lose strategy, may be appropriate when the objectives of conflicting parties are mutually exclusive or when both parties with equal power have reached an impasse in their negotiation.19 This style emphasizes quick, mutually acceptable decisions that somehow satisfy both parties.9 Our study showed that male nurses had higher scores of compromising style than did their female colleagues, which is in line with the results of the studies of Al-Hamdan et al9 and Chan et al.13 This difference in conflict management approaches among male and female nurses confirms the socializing effects of gender role expectations in Iran. For instance, men are generally expected to develop masculine
Figure. Conflict management scores according to management style, gender, and working shifts. May/June 2015
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Conflict Management in Iranian Critical Care Nurses
characteristics, including aggression, independence, competitiveness, and assertiveness, whereas women are supposed to develop feminine characteristics such as emotiveness and sentimentality. Therefore, competitive behavior is more consistent with a masculine gender role.23 The result of a meta-analysis demonstrated that men use competing conflict management style more than do females.24 This indicates that nurse managers may need to consider gender differences when they plan for conflict management. In line with the result of our study regarding the predictive role of nurses’ position in their conflict management style, it was suggested that an individual’s behavior in an organization may vary according to their position in the organizational hierarchy.25 We believe that because head nurses face different types of conflicts, they would be different from their subordinate nurses in managing conflicts. On the other hand, they tend to rely on their organizational authority instead of conflict management skills. Therefore, they use compromising style less than do the others. A study by Cavanagh26 conducted on American female ICU staff nurses showed that avoiding was their predominant conflict management style in workplace. This study demonstrated that there was no significant relationship between the avoiding style and variables such as age, years of experience, and educational background, which is concordant with our study. Also, another study on Egyptian nurses showed that the most and least preferred conflict management style was avoiding and competing, respectively. In this study, a positive correlation between turnover intension and avoiding styles has been identified.27 Accommodating was the fourth conflict management style used by critical care nurse staff in our study. The results of a study conducted in Thailand showed that the majority of nurses used accommodating style to manage conflicts.28 Also, this style was the fourth preferred one among Spanish nurse,20 which is in line with the result of our study. This conflict management style can be used as a strategy when a party is willing to give up something with the hope of getting something in exchange from the other party when needed.19 In our study, competing style was the least utilized style among critical care nurses. This advocates the results of the studies of Cavanagh,26 El Dahshan and Keshk,27 Kunaviktikul et al,28 and Woodtli.29 The present study has some strengths and limitations. Although the response rate in this study was high, the participants were limited to critical care nursing staff of 4 university affiliated hospital in north of Iran, which restricts the generalizability of the results. Also, no inference about causality in the relationships between nursing staff factors and conflict management styles can be made because of adopting a cross-sectional design. 144
Dimensions of Critical Care Nursing
IMPLICATIONS FOR PRACTICE The results of our study imply the demand that nurse managers are supposed to acquire a good recognition of their staff nurses’ behavioral patterns, particularly their conflict management styles. This would help nurse managers to insightfully and creatively assign nurse staff to specific tasks or positions with certain conditions or likely conflicts, according to their dominant conflict management style, which best matches with those particular situations. For instance, a nurse manager may consider this when scheduling shift times to avoid possible conflicts between senior or junior working nurses by assigning a nurse who use compromising, collaborating, or accommodating style with a nurse whose dominant conflict management style is avoiding or competing. Also, our study suggests the need for considering gender, shift times, and position of working nurses in task assignments. In addition, the findings may encourage nurse staff to reflect on their conflict management styles to amend them based on the context they are working within.
CONCLUSION Collaborating style was the dominant conflict management style used by Iranian nurses followed by compromising, accommodating, avoiding, and competing. Gender was the predictor for both compromising and competing styles, whereas position and shift time were the significant predictors for compromising and competing styles, respectively. Therefore, based on the results, nurse managers need to take factors such as type of conflict and its relative importance, position of involved parties, the emphasis put on relationships versus goals, and time constraint into account when they design programs to help nurses constructively manage unavoidable conflicts in health care. Moreover, training programs for conflict management are recommended for all nurses to promote their communication skills and enhance interpersonal environment, for the advantage of the clients and health care professionals. Furthermore, studies to examine the relationship between personality factors and conflict management styles are warranted. Also, as the conflict is a culturally specific phenomenon, and conflict management styles can be affected by cultural contexts, conducting further studies to assess the conflict management styles among critical care nursing staff in different countries is suggested.
Acknowledgments The authors thank the nurses who participated in the study. Also, the authors are grateful to Mrs Fatemeh Bozorg Sohrabi, a nurse anesthetist, for participating in data collection.
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Conflict Management in Iranian Critical Care Nurses
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ABOUT THE AUTHORS Mohammad Reza Ahanchian, PhD, is graduated with Bachelor of Science Degree in Educational Management and Planning in 1987, from Isfahan University. He completed his Master’s of Science Degree in Educational Management in Tehran University in 1990 and his PhD in Philosophy of Educational Management in Tehran University for Teacher Training, Iran, in Companion with Education School of Sheffield University, UK, 2002. Currently, he is an associate professor of Educational Management at the School of Education and Psychology, Ferdowsi University of Mashhad, Iran. Amir Emami Zeydi, MSN, CCRN, is graduated with Bachelor of Science Degree in Nursing in 2008, and Master’s of Science Degree in Critical Care Nursing in 2011, from Mazandaran University of Medical Sciences, Sari, Iran. Currently, he is a PhD candidate in Nursing at the Mashhad School of Nursing and Midwifery, Mashhad University of Medical Sciences, Iran. Mohammad Reza Armat, MSN, is graduated from Mashhad University of Medical Sciences in 1991 with a Bachelor of Science Degree in Nursing. He completed his Master’s of Science Degree in Nursing in Tarbiat Modarres University in 1995. He is an instructor in North Khorasan University of Medical Sciences, Bojnourd, Iran. Currently, he is a PhD candidate in Nursing at the Mashhad School of Nursing and Midwifery, Mashhad University of Medical Sciences, Iran. No funding was received for this study. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Address correspondence and reprint requests to: Amir Emami Zeydi, MSN, CCRN, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Ebne-Sina St, Mashhad, Rszavi Khorasan, Iran ([email protected]).
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