All practicing nurses participate as members of the health care team. Providing health and therapeutic care within healthcare systems, requires cooperation and collaboration with other professionals. Such an environment is easily prone to conflict, particularly under stressful conditions (Chitty, 2005; Vivar, 2006). Different surveys showed that conflicts among nurses are accounted as an important issue in healthcare settings worldwide (Almost, 2006; Farrell, 1997). Recent studies in Australia and Canada indicated an increase in frequency of conflicts among nurses (Farrell, 1997; Hesketh et al., 2003). Even in Japan, there were reports that nurses who experienced conflicts with other nurses expressed willingness to leave their workplace (Lambert et al., 2004). Recently graduated nurses in New Zealand showed a great deal of interpersonal conflicts during the 1st year after graduation (McKenna et al., 2003).
Jhen (1997) used terms task focused and relationship focused conflicts in order to distinguish between task and interpersonal conflicts. Since, task conflicts are often perceived as personal attacks, it is possible that task-related conflicts transform into relationship conflicts (Jhen, 1997). Relationship conflicts interfere with task-related effort because members focus on reducing threats, increasing power and attempting to build cohesion rather than working on task. Relationship conflicts decrease goodwill and mutual understanding, which hinders the completion of organizational tasks. Time is spent on interpersonal aspects of the group rather than on technical and decision making tasks (Jhen, 1997).
In health care services, interpersonal conflicts may be between 2 nurses, the
nurse and physician, a nurse and the agency policies, or a nurse and any other
health care professional (Chitty, 2005). Conflicts take place for different
reasons as different in goals, needs, desires, responsibilities, perceptions,
values and ideas (Stanhope and Lancaster, 2000, 2006; Chitty, 2005; Almost,
2006). Such conflicts could have constructive or destructive effects on team
performance, when conflicts used for solely personal gain or to work out hidden
angers or when directed toward the demise of another person, it plays as a destructive
force (Stanhope and Lancaster, 2000). Based on different studies, continuous
conflicts in workplace not only could have negative effects on physical and
mental health of people, but also leads to deterioration of working environment,
increase in turnover and absenteeism, reduction of cooperation and assistance
in works and in general efficacy (Danna and Griffin, 1999; De Dreu et al.,
1995). Although, numerous studies have focused on conflict management, a few
have examined the nature of nursing conflict in the work place (Cavanagh, 2006)
and explained its causes and effects in nursing (Cox, 2001; Vivar, 2006; McGoawn,
2001; Healy and McKay, 1999).
The studies on nursing conflicts in Iran, limited into 2 quantitative studies, which introduced conflicts management styles of head nurses and its efficacy from the perspective of staffs (Vanaki and Riz, 2005) and types of conflicts felt by staff nurses of medical surgical wards (Phalsafi, 1992). As there is no published research on the nature and source of Iranian nurses conflicts, this investigation aimed at exploring Iranian nurses experience on the interpersonal conflicts with each other at their workplaces. So, the research question posed was: how an interpersonal conflict occurs among nursing personnel on an everyday basis? These guide us to acquire knowledge about the causes and process of Iranian nurses interpersonal conflicts and understanding their reactions and conflict management styles.
The present study is a part of bigger research on conflict resolution process. In this stuay, the process of forming interpersonal conflicts are explained using Grounded Theory (GT) approach introduce by Strauss and Corbin (1998). The initial research question posed was: how does the nurse experience conflict with other nurses on an everyday basis?
MATERIALS AND METHODS
Samples: The study participants were recruited based on the following criteria:
||Holding B.S or upper degrees
||Willingness to take part in the study
||Being able to share their working experiences
The sample size was determined by the data generated and their analysis. Sixteenth interviewees working in teaching hospitals from different cities of Iran (5 Zanjan, 5 Tehran, 3 Tabriz, 2 Mashed and 1 Kerman Shah) participated in this study. Sampling started with a head nurse of 7 years experience presented by the vice president of nursing of a teaching hospital in Zanjan. The next participant was selected based on data generated from previous interview and the maximum variant approach. Therefore, sampling extended to other nurses, managers supervisors in the same citys teaching hospital or others.
This study was conducted in teaching hospitals of Iran between 2006 and 2008. The study design was approved by ethics committees of Tabriz medical sciences university.
Ethical consideration: The ethical committee of Tabriz University of Medical Sciences and health services approved the research proposal. Official permission was obtained from 5 educational hospital directors, nursing managers and head nurses in order to conduct the study. Ethical issues were concerned with the participants autonomy, confidentiality and anonymity during the study period. All participants were informed of the purpose and design of the study and also the voluntary nature of their participation. Informed consent was obtained from the participants in writing and signed by them for all stages of the study.
Data collection: Unstructured interviews were used to collect data. The interviews began by allowing each nurse to describe her/his experience along with a recent day work. In the process of the study more specific questions were posed on the conflicts experience e.g., what are the effective causes triggering an interpersonal conflict in your work place? and how nurses interpret them? During the interview, the interviewer verified and checked veracity of her perception by posing of clarifying questions.
With interviewees permission all the interviews were audio taped and transcribed verbatim for analysis after each interview. Interviews lasted between 40-120 min.
Also, notes were taken during field observations. Data from the interviews and field observations were integrated and analyzed continuously.
Data collection ended when no new categories or subcategories emerged. So, interviews ended with sixteenth. This was considered as saturation point. Family members, patients and other health care team members were not included, as the focus of this study was the interpersonal conflicts among nurses.
Data analysis: In this study, for generating and developing theory, Grounded Theory approach (GT) and constant comparison method of Strauss and Corbin (1998) was used. Grounded theory is well suited for studies that explore basic social processes and how they vary among actors within a defined context (Strauss and Corbin, 1998). In this study, the context was nursing units in the teaching hospital of Iran and nurses were the actors.
According to Strauss and Corbin (1998), scheme of open, selective and theoretical
coding and sorting each transcribed interview was analyzed line by line. The
purpose of the coding was to look for social processes and meanings in the data,
what was happening and how the actors interacted with each other. The data analyses
and qualitative comparative interpretations are organized and discussed along
the elements of emergent model for conflict and their relation to simulation
The transcripts were reviewed in order to validate the codes and categories. Regarding trustworthiness, credibility was established through member check, peer check and prolonged engagement. For the purpose of reliability, supplementary comments and memos of colleagues was studied through member check. Presenting transcripts and memo to 3 nursing professor and getting similar feedback the reliability of data was established.
In this study, to further contribute to the validity, data was scrutinized through observation, integration of the sources of data, data reviewing and scrutiny of opposite extant literature. The dependence indicates reliability of data. Generalization of the study is also possible through providing rich description of data.
Sixteen nurses, 12 women and 4 men, were included. All had B.S degree expect two with M.S degrees and were employed in hospital settings (9 staff nurses, 2 head nurses, 2 supervisors and 2 clinical mentors) with a working experience of 1-29 years, recording an average working experience of 10.5 years. From the 16 interviews, 310 codes were extracted, which showed conflict in relation to the influencing factors. Codes with similar meanings were grouped into the same categories. Categorization of these codes led to the emergence 3 themes in related to different phases of the interpersonal conflict process: Preliminary phase, subjective phase and objective phase. Preliminary phase starts with an unwanted or unexpected event. Marginal issues rise from extra and intra organizational elements besides personal factors provide the antecedents for creating the conditions, which lead to interpersonal conflicts. Based on subjective premise followed by a one way judgment, negative feelings formed as the stages of subjective phase of conflict process. Last phase start when one party manifests her/his feelings by verbal or nonverbal reactions. Nature of event, offensive behavior, individual and organizational characteristics determined type and intensity of negative feelings. In following model, the emerged process of interpersonal conflict is shown (Fig. 1).
Preliminary phase: This phase started with unwanted or unexpected events.
The primary codes related to events caused most nurses experience various form
of conflicts were: Incomplete handling over process of the ward, negligence
of the assigned duties, carelessness, divergence of opinions, imposed changes
on working schedule, rejection of the requests, lack of cooperation, authoritative
and offensive behavior or statements, error reporting, accusing others or being
accused, interference, preference in favor of the other party and being criticized.
||The process of interpersonal conflicts among nurses
These events categorized into two main subcategories: person-related and organization-related
events. This meant that some of these events were imposed by nurses behavior
at a personal level and others by organizational functions. These events were
commonly unwanted and sometimes unexpected.
One interviewee mentioned: When I come for delivering my shift and again see a crowded ward and uncompleted duties, the first thing comes into my mind is that my colleague neglected to carry out her/his duties. This makes me angry with her. This informant referred to her coworkers repetitious negligence about completing tasks. Negligence here is a personal factor, while in following comments from another interviewee compulsory change is an administrative factor resulted in interpersonal conflict. As a result of personnel transfer by the vice president of nursing, a participant stated: We are dissatisfied due to insulting treatment to the staff of this ward due to imposed change of our personnel by management.
Marginal issues rise from extra and intra organizational elements with personal characteristics provide the antecedents for creating the conditions, which lead to interpersonal conflicts.
Individual characteristics: Based on the emerged model events, incited sentiments and external manifestations all are affected by individual differences. Difference in age, gender, ideas, belief, aims and intentions, working experience, passed experiences, personality and health status of both parties were extracted codes, which categorized as personal characteristics. During an interview, one informant explained, Annoying behavior only happened to me once when I just started working, inexperienced and too young. Statements like this reveal nurses have faced unpleasant and disturbing conflicts when they started working. These unpleasant experiences had a long time effect on nurses and remain with them many years. According to observational field note nearly all nurses by remembering their annoying memories were agitated.
Personality typology of people plays an important role in the way they feel and behave. Statements like I am very punctual and precise, when my colleague leaves sooner or arrives late, naturally I feel uneasy and annoyed or I am generally a calm person thus, when a colleague is in a hurry to leave, I just say to myself let him leave after a busy shift by two different informants indicate people with different personalities have unique characteristics of their own, that is why a similar event for each of them might have different feeling and implications.
Physiological changes with ageing were extracted from the following comment stated by an informant with 28 years job experience I have 2 years left until retirement. Suffering from foot ache, backache, varicose and menopause made me inpatient but nobody care. Changes in temper following periodic hormonal changes and during menopause play a significant role in outbreak of conflicts, which its effects on interactions with people are often left unnoticed.
Difference in understanding and perspectives as well as gender differences
was the reasons for outbreak of nurses interpersonal conflicts. In following
experience task conflict arose regarding manner of doing and prioritizing tasks
as the triggering issue. But the authoritative, strongly worded tone of male
nurse objecting his female colleague fomented the conflict. There were many
other works to do. My colleague went to help doctor. The doctor could do the
job himself so there was no need for her. With my strongly objection she was
annoyed and started crying. Based on commentary memos authoritative behaviors
of men nurses have roots in male dominated Iranian society in, which men are
in a position to order. These social contracts indirectly influence occupational
interactions. It is also possible that the mental background of male nurses
towards characteristics of their female colleagues resulted in such unfriendly
behavior. Difference in working style of male and female nurses was among other
factors, which resulted in outbreak of conflict among nurses. While, male nurses
focused on speed and practical skills, female nurses preferred discipline in
work. Female nurses, described male nurses as people with no discipline that
do their tasks carelessly. In the same vein, another male participant pointed
out, female nurses are not working accurate and precise enough. Based on the
above points, we can conclude that passed experiences, as well as social and
occupational culture caused sets of mental backgrounds, which could lead to
an outbreak of a conflict.
Sometimes, necessary information was given inaccurately, or sufficient information was not provided on time whether intentionally or unintentionally, which could result in occurrence of a conflict. Informant No. 5 describes his experience as follows:
when I first arrived in the ward, there were no training at all for me as a newcomer. They didnt even show the place of instruments. Consequently, I became angry and told I would not work there. Based on the above experience intentional misinformation, in order to achieve specific aims or objectives was related to personal intentions, different perceptions of the significance of an issue or if unintentionally occur to absence of communicative skills. Sending contradictory orders and not receiving any appropriate feedbacks were among other instances of conflict outbreak. The individual who took note of feedback results less negative conflict could be extracted from their experience.
Organizational characteristics: Intra and extra organizational factors were 2 main subcategories of this theme as shown in Fig. 2.
Codes related to Intra-organizational factors categorized into two subcategories:
Ward condition and managerial weakness. The ratio of active beds to the number
of nurses in different working shifts, different medical students and staffs,
having sufficient facilities, having routine directions for current activities,
patients condition and communicative barriers were categorized as ward
condition. Based on data extracted from transcription, condition of the ward
besides mental and physical condition of nurses were among interfering elements
that could lead to occurrence of a conflict even in people with calm and peaceful
personality. Generally, I am a calm person. Nevertheless, when I was working
in emergency ward due to extraordinary circumstances over them when working
pressure increased, I sometimes reprimanded my colleagues for not completing
a task. My colleagues had repeatedly told me when I became angry they were afraid
of me. On the contrary, here (in the heart unit) everything runs smoothly and
||Organizational characteristics subcategories of preliminary
phase of interpersonal conflict
As a result, so far there have never been any cases of annoyance between the
colleagues. Even if such things happen, we will try to solve them peacefully.
Informants respondents have repeatedly referred to autocratic leadership, injustice and discrimination, favoritism, domination of doctors, inaccurate evaluation, developing negative competition atmosphere, unfair use of reward and punishment system, inconsistency rules, job/duties interference, absence of supervision, shortage of personnel and equipment, constant frequent changes made by nursing managers, unpredictable policies, absence of support, inattentiveness toward personnel problems and inconsideration for occupational pressures on staff, as managerial weakness. The said elements comprised a category entitled managerial weaknesses being under influence of individual differences resulted in outbreak of conflict among nurses.
A respondent with 28 years of experience stated: it seems doing your work properly is of less significance than having relations. Similarly, another informant with only 1.5 years of experience stated, I wish we could only focus on doing our task properly, which of course is not important at all in the ward. In the ward everybody only thinks about saving his/her own interests and position. The same perception of two generation of nursing showed that in proper assessment system for evaluation of nurses performance by their superiors and managers is known as a major cause of interpersonal conflict.
Based on the collected transcripts absence of motivation towards nursing tasks as well as authoritarian behaviors among nurses could be the result of in appropriate and weak managing policies.
Interference between working shifts of doctors and nurses were also among other reasons for outbreak of a conflict, which is reflected in below comment.
The visiting hours by the residents fail to match with that of our working hours. At 12.30 residents shifts are changed and the morning shifts of the nurses end at 1.30. We have done our works and ready to handover the shift, while our residents whose shifts start at 12.30 are preparing the records. They change the order, while we are in doubt whether to fulfill the orders or not if so we should stay here until 2.30. If we do otherwise, we are in hesitation to say to the evening shifts that the orders have not been done. This is a source of conflict between the nurses of the 2 shifts. We have raised this issue several times, but to no avail, as our doctors are not willing to change their working hours. Management has also failed to do anything in this respect.
The relevant handwritten notes reflect the working context of nurses in a doctor-dominated system as well. Negligence by doctors of problems imposed on the nursing system under the working style just added to the working pressure intensifying conflict among nurses. Lack of a power balance and negligence of nurses problems and views in the medical system had shaped a significant part of professional beliefs of nurses. In this regard, an informant stated, we see most doctors do not care how to behave toward others and nursing managements don't care.
The growing cases of negative competition, as another part of managerial weaknesses had directed the nurses to quarrel each other instead of concentration on solving their own inter-group conflicts. Based on the memo writings, provoking such conditions by hospital managers might signify their tendency to disturb solidarity of nurses in an attempt to keep a constant power balance in the interests of favored groups.
One respondent with 28 years of experience stated, At this hospital working properly is of secondary importance. An ordinary nurse should always be afraid of his/her rights being denied. Thus, the first thing he/she would do is to attract attention of his/her superiors towards himself. That is why nurses instead of focusing on their tasks, concentrate on strengthening relations to keep their job allowances and benefits. According to memo writings, such a policy by Iranian clinical nurses could be among one of the major reasons for their focusing on non-professional aspects of their job.
Codes related to extra-organizational factors categorized into 2 subcategories: Economical and socio-cultural conditions. These factors at national and international levels were considered as source of individual differences and managerial weaknesses created events breeding ground for the outbreak of conflicts among nurses.
During tour observation the researcher met an informant who has asked the head
nurse for 3 days leave of absence to find a new house following an increase
in current rent. Because of shortage of personnel the head nurse refused to
accept with his request and consequently a conflict took place between the two.
From this note economic problems were extracted as an indirect influential factor
on interpersonal conflict occurrence at work place. Economical problem cause
hospitals restricted employment so nursing shortage is a big problem in whole.
Also, insufficient earning besides high rate of inflation, roots in economic
system at national and international level, salaries not meeting the costs.
Under such conditions, many nurses particularly male nurses considered as family
breadwinner have to works at two jobs. Great deals of the conflicts among Iranian
nurses are due to interference of their working hours with different places.
Different interviewee referred to this subject. One of them said: Many personnel
of this hospital work in 2 places (have two jobs). They suddenly ring and say
they will be absent for the shift just like yesterday while, one of the nurses
himself has asked for that shift, nevertheless in the morning a friend of him
rang and told me he is on a mission and will be absent. Just suppose what would
have happened if it was an afternoon or night shift. It took until noon when
I could hardly manage to find somebody else to replace him. We called this type
of conflicts as forced conflicts this type of conflicts return to an unordinary
situation, which is forced by society, culture and governmental policies. Interactions
of these factors on each other cause a defective cycle, which makes organizing
becomes impossible. Working at two hospitals for example, causes nurses with
two jobs often left their workplace sooner and arrived the next later.
These inconsistencies, were among other factors wasted a significant amount of nurses time and thus change their focus away from their principal tasks towards marginal issues and affairs. On the other hand, shortage of nursing personnel and difficulties in employing further nurses result in shortage of healthcare personnel in almost all hospitals. Problems and difficulties as such weaken the managers position to address such inconsistencies and at the same time cause inter-group conflicts at hospitals.
Subjective phase: Negative perception raised from unilateral judgments
resulted in negative feelings consist different stages of this phase. Pursuant
to unexpected events and the ensuing unilateral judgments, almost all the participants
had expressed a sense of irritation raised in the form of anger, depression,
annoyance, uneasiness, confusion or a state of ambiguity. These are considered
to be the characteristics of feelings lead to group or individual conflicts.
As, it is declared in the first comment negligence was the interviewee's primary
analysis and anger was the consequent feelings.
Another interviewee referred to annoyance during purposeful conflict episode. Purposeful conflict was used by senior staffs in order to making a sense of seniority in juniors. This seems to be a sequence of simulation process in nursing. One interviewee with 29 years of experience stated: When I was a young nurse and worked at night shift I always had to tolerate the nagging of the nurse in charge of the morning shifts who complained of everything. It made me annoyed but now I just do the same with new comers. Initially nurses were trying to explain for different things but gradually they tried to pretend everything was being done normally in such a manner that those in charge of the morning shift could not raise any objection. Subjectivity is the main characteristics of this phase. In this case, making excuses and objections were among the main reasons for outbreak of conflicts among old and new staff. Transcripts of interviews indicated that habitual behaviors inciting conflict entailed particular specifications, which partly include: being stereotyped, painful and imitative. Not taking notes of personnels explanations and repeating critics that are more or less for making excuses are indicative of this perspective that conflicts among newcomers and older staffs are a part of a process, which has led into simulation of behaviors among different generations of nurses. Under this mechanism, it seemed that senior nurses were trying to put the other part into defensive position by making objections beforehand as well as aiming the self esteem of new personnel in order to hold their position.
Two emerged factors influencing on the type and intensity of emotional feelings and reactions were: the nature of event (determined by significance and frequency) and the offensive behavior of each of parties.
Nature of event: From the following comments one of my colleagues usually handed over in a mess. I tried to endure her behavior for several times then protested. Since, I could no longer content myself that her behavior was due to awkwardness or of course these kinds of conflicts are a part of our everyday work repetitive events and habitual conflicts were extracted. The informants indicate that some form of repeated events has intensified personal annoyance unveiling the conflict left hidden before. In other words, daily conflicts on repetitious or platitudinous matters are an integral part of interactions among nurses, which in practice distance them away from their professional objectives in different forms and focus them on marginal issues.
Offensive behavior: In this study, verbal and non-verbal offensive behaviors especially in public, authoritative behavior, objective behaviors and inattentiveness provoked negative sentiments and consequently outbreak of a conflict. Generating tensions, taking offense, unjust and annoying behavior were among distinctive signs of such behavior, which could be the reflection of unresolved conflicts and power imbalance, manifested through expressing violent sentiments and use of violence.
When my senior colleague accused me to disobedience loudly and impolitely, I was filled with grief for myself
Objective phase: When the signs of a mental conflict manifested conflict is in objective phase. Verbal and nonverbal reactions to mental analysis cause the other party aware of the conflict situation. Frowning, inattentiveness and indignation were the common nonverbal reactions and verbal reactions included: speaking sarcastically, objecting and making accused. One of interviewee described her experience as fallow: Here is a colleague who used to order and nagging for everything. First this made me so angry but now I learn not listen to her. Of course this made her angry too but less invasive. A reaction may be both a strategy for solving a conflict and a sign, which show a conflict occur.
The findings of this research suggest that: conflict is a process, that triggered by an unexpected or unpleasant event. These events are called as triggering events Braham (2003).
These events are not necessarily disturbing events, nevertheless, it is the initial judgment and perception that could result in feeling of annoyance and consequently outbreak of a conflict. Opposition, threat of territory, unreasonable expectations, sabotage, offensive behavior and evasion of tasks induced a feeling of being insulted, humiliation or unfair led to anger, depression, annoyance, uneasiness, confusion or a state of ambiguity. In a study regarding variety and different dimensions of conflicts in different organizational groups, almost all emerged sentiments and feelings were negative (Jenn, 1997).
The analysis revealed that relational conflicts comprised a significant part of nursing interpersonal conflicts. The nature of these conflicts mostly emerged as result of a territory being under threat, conflict of interests/profits and inconsistency in peoples morale with each other. These findings were consistent with Jehn (1997). In this study, conflict on tasks performance rarely emerged in the data. In other words, task conflicts had nt an important role in interpersonal nursing conflicts. This may be due to inexperienced new graduates dependency on expert personnel as a stage of simulation process. In the simulation, process scientific work is not considered as something of a priority. Under this process a nurses makes progress when he/she follows the existing models. Such approaches have caused nurses become inconsiderate towards scientific nursing and choose methods brought them less conflicts in work place. Based on a study conducted in Iran centrality of senior nurses has been identified as one of the effective elements in transfer of knowledge in clinics. Based on the said research, newly graduated nurses as a result of domination of senior nurses tried to adjust their desires with those of senior nurses (Cheraghi et al., 2007). Authoritative treatment and excessive power of the head nurse are considered as the main cause of conflict in health services (Vivar, 2006). It seems many researches in their studies have referred to simulation process in nursing profession one way or another (Vivar, 2006; Nathaniel, 2006; Cheraghi et al., 2007). In this study, habitual and purposeful conflicts in covert and overt form were part of simulation process to protect personal interest and position in an organization. The result of such conflicts has been a sense of absence of occupational security and shortage of resources. Under such condition, managers weakened solidarity of nurses and undermined their position through disintegration of their power.
This study focus was on interpersonal conflict occurrence within the context of Iranian nursing workplace. The emerged model for this study is describing the process of formation of interpersonal conflicts among clinical nurses in Iran. According to model, nurses pass through 3 phases: Preliminary, subjective and objective phases. Preliminary phase starts with an unwanted or unexpected event. Marginal issues rise from extra and intra organizational elements besides personal factors provide the antecedents for creating the conditions, which lead to interpersonal conflicts. Based on subjective premise followed by a one way judgment, negative feelings formed as the stages of subjective phase. Last phase start when one party manifests her/his feelings by verbal or nonverbal reactions. Type and intensity of negative feelings are determined by nature of event, offensive behavior, individual and organizational characteristics.
The findings of this research show that working conditions is responsible for the outbreak of many relationship conflicts in Iranian nurses working place. Consequently, any attempt to manage these conflicts effectively should be made with due respect to strategies to principally remove the causes of such conflicts as well as changing the working contexts of nurses.
The analysis also revealed that nurses are taking advantage of conflicts purposefully to achieve their goals. This means that nurses often intentionally take advantage of conflicts in order to attain better working conditions and to defend their own territory as well as resolving interpersonal ambiguities as means for compelling others to cooperate. These elements must be considered in conflict management strategies.
This study indicates the need for further research into the subjective, experiential aspect of the process of conflict management from a contextual perspective.
We wish to thank all the nurses who participated in this study and those who had made these experiences possible.