The article explores the sources and experiences of conflict among Iranian hospital nurses through qualitative interviews with 30 nurses and managers. Seven main themes were identified: 1) Nurses perceive conflict in various negative ways and react with emotions like anger or resignation. 2) Organizational structures in hospitals contribute to conflict, such as relationships with teaching universities, inadequate facilities, and issues with staffing levels. 3) Management styles can breed conflict when there are slow processes or lack of support for nurses. 4) Job conditions cause tensions when responsibilities are beyond nurses' control or do not match expectations. 5) Individual traits of nurses and patients influence conflicts. 6) Mutual understanding between staff is

1. Nursing Administration Quarterly:
April/June 2003 - Volume 27 - Issue 2 - p 153-163
Original Article
The Effects of Intrapersonal, Intragroup, and Intergroup
Conflict on Team Performance Effectiveness and Work
Satisfaction
Cox, Kathleen B. PhD, RN
Abstract
Although numerous studies have focused on conflict management, few have considered the
effects of unit technology and intrapersonal, intragroup, and intergroup conflict on team
performance effectiveness and work satisfaction. The model was tested using a nonexperimental
design. Path analysis using multiple regression was used to test the model. The nonrandom
sample consisted of 141 nurses employed on 13 inpatient units at a state-supported, 597-bed
academic medical center in a southeastern city. Findings indicated that intrapersonal conflict had
a direct negative impact on intragroup conflict and work satisfaction. Intragroup conflict had
direct negative effects on work satisfaction and team performance effectiveness. Unit technology
had a direct negative impact on work satisfaction. Findings have implications for administrators
to implement strategies to decrease a stressful work environment and increase team-building
activities.
22
Health Care Manager:
October/November/December 2003 - Volume 22 - Issue 4 - pp 349-360
Article
The Causes and Consequences of Conflict and Violence in
Nursing Homes: Working Toward a Collaborative Work
Culture
Nelson, H. Wayne PhD, FGSA; Cox, Donna M. PhD
Abstract

2. Interpersonal conflict, often spiraling to violence and abuse, is one of the most daunting
challenges facing nursing home administrators and their departmental heads. Mounting evidence
documents how they spend an inordinate amount of time dealing with angry families, adversarial
ombudsmen, regulators, and other hostile parties as well as handling the aftermath of the
ubiquitous conflict between the residents and their direct caregivers. All this is in addition to
coping with the normal interdepartmental and line staff forms of conflict that typify any
organization. This paper details the special dynamics that accelerate dysfunctional conflict in
nursing homes and presents strategies, tactics, and style recommendations that will help nursing
home leaders build more collaborative work cultures to minimize the effects of dysfunctional
conflict.
WORKPLACE CONFLICT IS pervasive. Managers spend as much as 20% of their time either
trying to minimize dysfunctional conflict or spurring functional conflict to sharpen their
organization's creative edge.1 Conflict is "a major responsibility of all administrators,"2(pp.13,14)
and health service conflict is a growing concern, especially regarding its most extreme
expression-workplace violence.3 Although emergency room violence draws the greatest public
attention, mounting evidence suggests that nursing home staff face even tougher conflict
challenges. Correspondingly, there is a growing concern that the training of nursing home
administrators (NHAs), while adequate on the operations side, is sorely lacking in more "abstract
skills such as assessment, communication, negotiation, and resolution of problems" and conflict
management generally.4,5(p.72)
Achieving a collaborative work environment requires an understanding of the causes and
accelerants of conflict that are unique to the nursing home. This paper focuses on 5 such
accelerants: (1) goal incompatibilities that are routinely noted in nursing home environments, (2)
managerial approaches that breed dysfunctional conflict, (3) organizational structure effects
including extreme regulation, functional departmentation, rigid staff status distinctions, and
influence of third-party advocates, (4) biomedical institutional cultural influences, and (5)
emotional and psychologic factors that spur family-enacted conflict. Where applicable, we will
include qualitative data derived from personal interviews with NHAs in the Baltimore
metropolitan area1 that offer some insight into the unique characteristics of nursing home conflict
and the way in which this conflict is perceived by administrators. Finally, recognizing that
mitigating factors (ie, limited resources and regulatory constraints) will continue to influence
relationships within these organizations, specific recommendations based on well-established
principles of conflict control and resolution will be presented to offer practical strategies for
turning conflict into a tool for building collaborative long-term care environments.
©2003Lippincott Williams & Wilkins, Inc.
333
Conflict among Iranian hospital nurses: a qualitative study
Nahid Dehghan Nayeri and Reza Negarandeh*

3. * Corresponding author: Reza Negarandeh rnegarandeh@tums.ac.ir
Author Affiliations
School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
For all author emails, please log on.
Human Resources for Health 2009, 7:25 doi:10.1186/1478-4491-7-25
The electronic version of this article is the complete one and can be found online at:
http://www.human-resources-health.com/content/7/1/25
Received: 4 November 2008
Accepted: 20 March 2009
Published:20 March 2009
© 2009 Nayeri and Negarandeh; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Background
This study aims to explore the experience of conflict as perceived by Iranian hospital nurses in
Tehran, Islamic Republic of Iran. Although conflict-control approaches have been extensively
researched throughout the world, no research-based data are available on the perception of
conflict and effective resolutions among hospital nurses in Iran.
Methods
A qualitative research approach was used to explore how Iranian hospital nurses perceive and
resolve conflicts at work. A purposive sample of 30 hospital nurses and nurse managers was

4. selected to obtain data by means of in-depth semi structured interviews. Data were analysed by
means of the content analysis method.
Results
The emerging themes were: (1) the nurses' perceptions and reactions to conflict; (2)
organizational structure; (3) hospital management style; (4) the nature and conditions of job
assignment; (5) individual characteristics; (6) mutual understanding and interaction; and (7) the
consequences of conflict. The first six themes describe the sources of the conflict as well as
strategies to manage them.
Conclusion
How nurses perceive conflict influences how they react to it. Sources of conflict are embedded in
the characteristics of nurses and the nursing system, but at the same time these characteristics can
be seen as strategies to resolve conflict. We found mutual understanding and interaction to be the
main factor able to prevent and resolve conflict effectively. We therefore recommend that nurses
and nurse managers encourage any virtues and activities that increase such understanding and
interaction. Finally, as conflict can destroy individual nurses as well as the nursing system, we
must act to control it effectively.
Background
Conflict is one of many issues found in any organization, including hospitals, where constant
human interaction occurs [1,2]. The potential for conflict to arise in a hospital setting is
considerably higher due to the complex and frequent interactions among the nurses and other
employees and the variety of roles they play. Specialization and organizational hierarchy often
add to the territorial conflicts in hospitals [3,4]. Although a reasonable amount of conflict in the
form of competition can contribute to a higher level of performance and a conflict-free work
environment is an exception, how conflict is addressed is of paramount importance [5]. The
sources of conflict among hospital nurses and health care personnel include authority positions

5. and hierarchy, the ability to work as a team, interpersonal relationship skills, and the
expectations of performing in various roles at various levels [6].
Researchers believe that functional conflict can turn into emotional conflict if not managed
properly, which in turn disrupts collaborative efforts [7]; leads to unprofessional behaviors [8];
results in under commitment to the organization [9]; increases psychological stress [10] and
emotional exhaustion [11,12]; results in mistreatment of patients [12]; elevates anxiety and work
resignation [13]; and decreases altruistic behaviors [14]. This is only a short list of negative
consequences of poorly managed conflict. Nevertheless, some researchers argue that conflict, if
treated with wisdom and creativity can result in positive performance in the organization [15].
Finally, conflict influences clinical decision-making as much as collaboration and positive
relationships do [7].
The first step for the effective management of conflict would be the recognition of conflict and
its sources from the viewpoints of nurses/caregivers and then understanding how to moderate
and control them according to those viewpoints [16,17]. Once the conflict and its source are
identified, addressing the conflict would be instrumental in enhancing professional development
and reducing the burnout rate among nurses [2].
A literature review points to the paucity of information relevant to this study and reveals many
studies from industrial and political entities. Considering how much hospital and industrial
settings differ, the suggested strategies seem inadequate for conflict resolution among hospital
nurses. Our experiences as a clinical nurse, nurse manager and researcher indicate that conflict is
a daily problem in the hospital setting, especially for nurses. Therefore, we conducted an inquiry
to explore Iranian hospital nurses' experiences with conflict in the hospital setting. We aimed to
identify the sources of conflict and how nurses and nurse managers deal with conflicts daily.
Health care in Iran
The Islamic Republic of Iran is a country of 70 million people, more than two thirds of whom are
under the age of 30. Culturally, Iranians are Muslims (98%); their official language is Farsi, or

6. Persian. According to the World Health Organization, Iran's literacy rate is 82%; life expectancy
for men is 70 years and 73 years for women [18].
In Iran until 1915, hospitalized patients received care from untrained personnel. Subsequently
foreign missionaries came to Iran, and as they performed their religious duties they introduced
the modern form of nursing and provided health care services. Missionaries trained a small
number of Iranian women to care for hospital patients.
In 1916, the first three-year nursing programme was established, in the city of Tabriz. Currently
there are approximately 70,000 nurses employed in the Iranian health care system. Male and
female nursing students are enrolled at various universities to study nursing at the bachelor's to
doctoral level. Today, nursing in Iran is a recognized profession with its own Nursing
Organization of the Islamic Republic of Iran (NOIRI), founded in 2000. This organization is
charged to improve and promote the Iranian nursing profession.
Methods
A qualitative research method was used to explore sources of conflict for nurses and nurse
managers and how they handle it in daily practice. Thirty hospital nurses and nurse managers
were selected purposively and interviewed by the first researcher with aim of capturing their
experiences in the area of conflict on the job. The inclusion criterion for staff members was a
minimum of three years' work experience. After giving their informed consent, nurses and nurse
managers were given an appointment according to their schedule and preferred date and time.
The time and place were planned according to the participant's preference in a private place in
the ward. Each interview began with a broad question, such as: "Could you explain your
experiences with conflict?", or, "Tell me about how you have resolved a conflict in the past".
The interviews lasted between 40 and 75 minutes, but on the average it took one hour if the
participant was interested in elaborating on his or her experience. Interviews were tape-recorded
and transcribed verbatim.

7. Content analysis was based on scrutiny of the transcripts. Meaningful segments of data were
identified and coded with appropriate labels in the transcribed text. These codes were clustered
under the categories of sources of conflict and the ways in which participants managed conflict,
by means of comparative analysis. For example, participants 2, 6, 13, 24 and 26 expressed
disjuncture between how they conceived their role and what they actually did, which we
categorized under "the nature and conditions of the job". Similarly, numerous participants spoke
about the effect of conflict on nurses' physical and spiritual health. Concurrent analysis and
sampling continued until saturation was reached and researchers arrived at a meaningful
description of what was occurring among nurses regarding conflict. This took place after 30
interviews.
Trustworthiness and data credibility were established via face-to-face discussions with individual
participants and fellow researchers and by prolonged engagement. The researcher made every
effort to clarify participants' perceptions and the emergent themes to determine whether the
codes and themes identified were appropriate to their experiences. The participants were
contacted for verification of analysed data from the full interview transcript and the summary.
Maintaining long-term communication with the participants helped the researcher to establish
trust and reach a better understanding of participants in the field.
Three faculty members served as peer reviewers to ensure that no data were lost in transcription
and content analysis. If any disagreement occurred, group discussion was conducted to let them
to reach general agreement. Approximately 60% of the transcripts, codes and categories were
rechecked for group consensus
Ethical considerations
The research proposal was approved by the Tehran University of Medical Sciences Research
Committee. All participants were informed about the purpose of the study and assured of
confidentiality and anonymity. Participants signed an informed consent indicating that their
participation in this study was voluntary and without any obligation to continue.

8. Results
Among the 30 staff members and nurse managers who participated in the study, there were 19
nurses, five head nurses, four supervisors and two nurse managers (matrons). All the participants
worked in various wards – such as orthopaedics, neonatal intensive care, intensive care,
medicine, obstetrics, urology, coronary care – and the emergency department at university
hospitals in Tehran. The participants' ages ranged from 28 to 56 years, with a mean age of 36.5).
The nurses' experience ranged from three to 28.5 years, with a mean of 14 years. Twenty-six
participants were female and four were male. Twenty-eight had bachelor's degrees and two had
master's degrees.
Seven themes were identified during the data analysis process: (1) the nurses' perception of and
reaction to conflict; (2) organizational structure; (3) hospital management style; (4) the nature
and conditions of job assignment; (5) individual characteristics; (6) mutual understanding and
interaction; and (7) the consequences of conflict.
The nurse's perception and reaction to conflict
Participants interpreted conflict as any form of verbal aggression, disagreement, discrimination,
psychological stress, interpersonal differences, violence, anger and non-coping behaviour. Some
participants perceived conflict as the disparity between expectations and realities.
Different views were expressed regarding the existence and control of conflict among nurses.
Some participants believed that there not should be any conflict in nursing as a humanistic
profession. Others contended that conflict cannot be eliminated and is a normal occurrence in
every work environment. Several participants shared that conflict emanates mainly from an
individual's behaviour and personality, while the majority of participants believed in multiple
sources of conflict. For example, one of the participants said:
"It seems to me conflict means everything that we expect from nursing and then we saw what
they expected from us as a nurse."

9. "The first thing that comes to my mind about conflict is two contrary things or people."
The types of reaction to conflict also varied according to the participant's perception of conflict.
Reactions such as anger and aggression, shouting at team members and colleagues, a tearful
feeling of resignation and sorrow, apology, self-control, calming behaviour, forgiveness,
flexibility and coping with oneself were enumerated by the participants.
About ways of reacting, participants said:
"If I experience conflict with my colleague I would try to ignore it, if possible, whereas if it was
severe enough that I felt it hurt me, I would warn them."
"the other day ... I faced a lot of stress, so I got a nervous breakdown ... I had the feeling of going
home and starting to yell and shout to get everything off my mind... or to confide in my
family..."
Organizational structure
Participants pointed out some of their experiences with conflict in the workplace. One of the
recurring criticisms related to the hospital affiliation with the universities (teaching hospitals)
was the slow process of management, numerous and redundant medical orders written by
medical interns, residents and attending physicians and the presence of unskilled and
inexperienced medical students contributed to the rising level of conflict.
A subcategory of this variable is the hospital facilities. Budget deficits, the hospitals' self-
governance policy and the lack of sufficient medical equipment and medicines created much
stress and conflicts for the patients, families and staff.
"All the companions of the patient demand more care for their patients and when they are told
about the lacks, shortages and inadequacies of facilities they turn a deaf ear to us. This has often
led to severe conflicts."

10. In addition, inadequate facilities, improper functioning of other departments and neglected
responsibilities created pressure and conflict among the personnel. These inadequacies
eventually reduced the tolerance threshold, which in turn contributed to the conflict experienced.
"Too much pressure on this shift... Scanty facilities... very meager...you feel really
exhausted...amounting to tensions and conflicts which are often displaced onto people
around...you know...yelling at colleagues..."
The workforce structure is another subcategory regarded by participants as having a significant
role in causing and controlling conflicts. An excessive number of patients, lack of personnel,
failure to recruit new personnel according to standards and obligatory overtime work left nurses
feeling angry, violated and exploited without any control over the situation. Participants believed
that unskilled staff failed to meet patients' needs, harmed the patient-nurse relationship and
damaged staff morale. Meanwhile, the patients expected good nursing care and no one could
explain the situation for them.
The individual and cultural characteristics of the patient population and their family members
were another workplace issue in various teaching hospitals. Because teaching hospitals are
economically accessible to a low-income, non-local and less-educated patient population that is
often unfamiliar with how a teaching hospital operates, conflicts can and do occur.
"The conflicts we face mostly occur due to encounter with the patient's companions because in
this ward companions are not allowed in...yet they insist on accompanying the patient...which
makes trouble for us...because we have to face the matron, supervisors and other staff in charge."
Hospital management style
Participants believed that flaws in management styles at different levels contributed to conflict
and its ineffective resolution. Authoritarian bearing, abuse of power, illogical actions and failure
to support the staff were some of the weak points that participants recounted from their
experiences. One participant provided this example:

11. "We told our problems to the supervisor and asked him to see to them. For example, I asked the
supervisor to intervene but to my surprise not only didn't he help solve the problem, he added to
it."
Participants contended that planning, clarifying objectives, supporting the staff, fairness, tending
to staff rights and understanding the staff, along with other appropriate leadership measures, can
have a significant role in controlling conflicts and preventing resignations and loss of motivation.
Participants believed that some managers' behaviour influenced an increase in conflict
occurrence. Some managers were seen to have mistreated staff, shown unreasonable behaviour,
discriminated, suddenly changed style, failed to understand and support the staff, violated staff
rights, aggravated conflict intensity, discouraged teamwork and ignored nurses' problems.
Moreover, participants expressed some of their experiences for reduction of conflict through
taking their concerns to upper management levels.
"We can't ignore the fact that heavy workload and shortage of skilled human resources affect our
performance; despite our effort to get used to the situation, we are limited in coping. When you
see that the supervisor stops backing us up and never steps into the ward to listen to us it makes
us feel our rights have been violated."
"Now I see nobody is advocating for me as a nurse, I am alone on this ward up to this hour of the
night and I need support... but who supports me?"
The nature and conditions of job assignment
Another theme or category that emerged from data analysis was the nature and conditions of the
job. Participants contended that this theme had double effects on the occurrence and control of
conflict. Although nursing has always been regarded as a valuable and important profession, the
current lack of professional regard for nurses has caused several internal and external conflicts.
The importance of the work, responsibility, continuous contact with the patient, long working
hours, night shifts, inadequate vacation time, high rate of staff turnover, heavy workload and

12. excessive stress are all inherent to the nursing profession, affecting the threshold for rising
conflicts.
"Most conflicts between my colleagues and me have been due to working shifts or hours
clashing with our plans...arguing 'why does this colleague of mine have very light working hours
but mine are so heavy?..."
"Well, if you are very exhausted, have been under pressure, have had a crowded shift, have been
with patients all in bad conditions...sure you will develop conflict and an aggressive behaviour."
Therefore, it can be said that suboptimal working conditions can lead to exhaustion, mental
pressure, tension and nervous breakdown, which in turn can result in leaves of absence and
ultimately resignation, energy and motivation loss, and psychological problems for the nurses.
Individual characteristics
The individual characteristics of participants involved specific situations at work where the
potential source of conflict was more obvious and its resolution required management skills.
These characteristics included an individual's personality, work commitment and moral
characteristics. Any of these could play a role in creating or controlling conflict. Some of the
participants recalled their experiences about the occurrence or control of conflict.
"Since I am a very easy-going person I rarely face conflict; I don't argue a lot."
"Conflict depends on the individual; there are some matters that may be important for me but not
for others, or they may be important for others and not significant for me."
Mutual understanding and interaction
Shared understanding and interaction was one of the most important categories. The majority of
the participants regarded misunderstanding in interpersonal interactions as one important source
of conflict. This inadequate mutual understanding occurs between nurses with other individuals

13. and staff, such as patients, patient companions, managers and nursing and non-nursing
colleagues at different position levels.
"I expect my manager to understand me...no matter if he does nothing for me...I just expect to
hear a 'thank you', or 'yes, you're right on this, I understand you...it's a tough job, I know..."
"The patients' companions are not well informed ...their expectations don't fall into our area of
responsibility...we can't meet their wants...it's difficult to make them understand that our services
are directed at the patients not their companions."
Other factors that emerged from the collected data may increase or decrease this
misunderstanding. Furthermore, the nature and conditions of the job, the teaching atmosphere
and the structure of the hospital, management style and individual characteristics may have a
double effect on this issue, thus improving or worsening the situation. Participants confirmed
psychological stress arising from misunderstanding and emphasized the importance of mutual
understanding between nurses and other staff.
Nevertheless, experiences of the participants indicated that they felt that patients and their
families did not understand the nursing dilemma and work conditions. Also, participants
emphasized the role of colleagues in the occurrence and intensity of conflict. These conflicts
arose from sources such as doctors' influence on decision making, unwarranted interference of
doctors and their inappropriate treatment of nurses. Other participants pointed out the role of
colleagues other than doctors in the occurrence of conflict in clinical environments. Moreover,
displacement of responsibilities onto nurses and other staff members who neglected their duties
contributed to the occurrence of conflict.
"Patients have some expectation from us, but they don't understand that it isn't nursing duties.
Today some drug must be purchased from outside of hospital. Many interns and residents visit
patients, and nurses actually can't make any changes in these affairs."

14. Participants conceded that the existence of a cooperative environment could well prevent
conflict, resolve the existing conflicts and prevent displacement of conflict onto hierarchical
superiors. In all cases, participants agreed that mutual understanding and interaction can affect or
be affected by other themes.
"We and our colleagues understand each other more, and we know that we have to work
alongside each other peacefully, because if any tension is added, we may not be able to manage
and control the working environment properly."
Expectations, viewpoints and cultures of the individuals were important from the participants'
viewpoint. Expectations can definitely affect interpersonal interactions. Other highlighted issues
were differences in cultures and belief that influenced conflict in the workplace.
"Conflict is meaningless in nursing because our primary purpose is caring for the patient to
recover; so there should be no room for conflict."
The consequences/outcomes resulting from conflict
An important category found in this study was the consequence/outcomes of the experience of
conflict. Participants expressed several outcomes for conflict. Conflict can cause many
psychological problems; agitation, loss of peace of mind, unhappiness, nervousness, sleep
disorders and depression were identified by the participants. As well, conflict can lead to
physical problems and occasionally the hospitalization of the affected individual.
"I remember once a patient's companion had such a blatant behaviour with me that I got
hospitalized for the mental and nervous pressure inflicted on me...I got nervous breakdown."
In addition to these psychological and physical problems, the affected individual may lose
motivation and become discontented, leading to indifferent and irresponsible behaviour at work
and even a decision to resign.
"The main cause of our job dissatisfaction is these encounters and conflicts."

15. "When I experience a lot of stress I decide to change my job and choose another one, but when
conflict is resolved I feel that I like my job and I love to work as a nurse."
Work-related outcomes are another aspect of this category. These consequences lie on a
continuum with no outcomes on work at one end to resignation from work at the other. Some
participants said that in their experience, despite existing conflicts, patient care was not affected
and those internal conflicts did not affect meeting the patient's needs. Work-related outcomes of
conflict are not limited to the individual; they also affect colleagues, managers and patients and
their companions.
Some participants cited poor performance and neglect of patients as instances of unresolved
conflicts. Other outcomes involve indifference or intolerance towards colleagues. Moreover, if
not discharged progressively, the accumulated conflict can burst explosively and more
destructively. Other experiences include disrupted performance, decrease in service quality,
absenteeism, job dissatisfaction, forgetting care tasks, disrupted work routine, neglect of the
patient, reluctant caring, conflict displacement onto the patient and a negative attitude towards
the patient.
"Well...they are patients...and I know they need help...but sometimes you can't help it...those
conflicts affect you...you get the feeling of discontent,...you don't work heartily...with
reluctance...I give them the shots, serum, medicine...take their vital signs...all with reluctance and
unwillingness."
"When I was in conflict with a patient or her/his companion, I couldn't focus on anything
because I became nervous and I couldn't write a plain report, and my performance was affected."
Conflict can also affect the individual's family life. Participants' viewpoints ranged from lack of
influence to adverse effects on family life. Displacement and inappropriate behaviour with
family members and the disruption of the regular flow of life were some of the problems
participants mentioned as having affected their family lives. They also suggested that nurses,

16. during their education and training, be oriented about how to avoid transfer of work-related
problems into the family.
"Surely it affects our lives...when you leave for home with a troubled mind you will make
trouble for the family members...and this affects children and your whole life..."
Discussion
The findings of this study reveal that issues such as the perception of and reaction to conflict,
organizational structure, hospital management style, the nature and conditions of job assignment,
individual characteristics, and mutual understanding and interaction are important factors
contributing to the occurrence and control of conflict. Furthermore, the consequences/outcomes
resulting from conflict were also discussed. Therefore, managers need to take these variables into
account to increase efficiency.
In line with the findings of the current study, other research findings confirm the variability of
the perception of and reaction to conflict as being affected by different variables. Jahoda and
Wanless found that when facing conflict, employees would react with verbal or physical
aggression such as yelling and hitting [19]. Researchers as well found relationship-destructive
reactions such as criticism, faulting, humiliation, defensiveness and job resignation in conflict
situations [20].
Organizational structure – such as the training nature of the hospitals, hospital equipment and
facilities, hierarchy in organization, patients and patient companions – was another issue
expressed in various ways by the participants. Other researchers have noted that competition for
limited organizational resources can be a potential source of conflict [4]. When institutional
priorities must be juggled against individual and departmental priorities in the face of limited
time and other resources, conflict can result. Conflict increases with the number of levels in
organizational hierarchy [4]. When employees work in very crowded settings, their interactions
with colleagues and patients increase and potentially lead to stress, exhaustion, conflict and high
turnover [2].

17. Research has also revealed the role of hospital management style adopted by managers in
conflict control. Nelson and Cox found management approaches to be one of the conflict
enhancers, contending that since autocratic managers try to prevent challenges and suppress
conflict by force and coercion, they aggravate dysfunctional conflict [21].
The nature and conditions of job assignment, which was one of the major themes expressed by
participants, has been investigated in various ways by different researchers. Cox and Kubsch
concluded that task structures, task-based environments controlled by medical practitioners,
group combination and size, and limited resources available to nursing managers can all function
as conflict sources [22,23]. Overloading can lead to conflicts for most individuals [24]. One
important strategy in reduction of conflict is a balanced nurse-patient ratio [21] and clear task
descriptions [4]. Working conditions may bring about conflicts that induce nurses to resort to
routine task performance, thus possibly negatively affecting health care, as is evident among
Iranian nurses.
Regarding individual characteristics, we found that they are involved in the specific work
situation as potential sources of conflict and its efficient resolution. Similarly, researchers
contend that personal characteristics, attitudes and situational behaviors play significant roles in
conflict issues [24].
Mutual understanding and interaction was found to be the most frequent and important category
in the research, comprising different aspects such as mutual understanding between colleagues,
managers, personnel, patients and patient companions. Other studies have shown that conflict
can occur and be controlled through interactions and communication. Conflict arises because of
misinformation or misunderstanding [21]. Inadequate communication between medical
practitioners and nurses can lead to conflicts [25]. In his ultimate research model, Cox proposed
that good personal interrelationships and a higher understanding of the spirit of others are
negatively correlated with within-group conflict and can function as buffers [22].
Some participants believed that as nursing is a humanistic profession, conflict could not therefore
affect nurses' performance. Cox did not find any direct relationship between conflict and

18. performance and turnover [22], although some researchers [2,21,22,26] argued that a "good
nurse should leave her/his personal life matters behind the hospital doors". However, by now it
has been revealed that personal and life experiences can influence professional life and vice
versa [27]. Further research has also revealed the outcomes of conflict on different individual
aspects, the health of family life, poor performance and relationships, increase in patient care
cost, imprecise and counterproductive care, and eventually an increase in turnover [2,21,26].
Generally it can be argued that not all the outcomes of conflict are negative; conflict can be
constructive if it enhances decision-making quality [22].
Other finding in this study was that conflict can also affect the individual's family life. On the
other hand, family life and multiple roles of the individual can also give rise to conflicts.
Chandola et al. contend that both directions of conflict – work conflicts disrupting one's personal
life and life conflicts disrupting work – affect health [26]. These conflicts can arise from the
individual's inability to adopt multiple roles, which can lead to stress and illness. On other hand,
conflict has arisen between nurses' perceived professional roles and the roles that the
organization has imposed on nurses [28].
Organizational culture, task-oriented nursing experiences, unbalanced nurse-patient ratios and
physician-centered organizations were found to be the main themes in other Iranian qualitative
research [29-33]. Nikbakht found that Iranian nurses were confronted with many difficulties in
two domains: (1) difficulties relating to work settings, such as personnel shortages, heavy
workloads, unclear tasks, lack of registered and auxiliary nurses, equipment deficiencies and low
salary; and (2) difficulties relating to a poor public image and a low social status of nurses [29].
Salsali also wrote that the role of nurses is unclear and largely unknown, even by the educated
public [33]. It is clear that under these circumstances, the conditions that cause conflict are
increased. Thus, nurses and nurse managers should be alert in order to prevent and control
conflict effectively.
Limitations

19. The main disadvantage of the qualitative approach is that the findings cannot be replicated for a
larger population with the same degree of certainty that quantitative analyses provides. However,
the results can be judged based on the criteria of transferability or applicability. This study
provides a comprehensive understanding about factors that influence occurrence and control of
organizational conflict. It is recommended that further research be carried out to explore conflict
management in clinical settings.
Conclusion
Iranian nurses experience conflict as a frequent incident in their work. According to our findings,
how nurses perceive conflict influences how they behave or react concerning it. Conflict sources
are embedded in nurses' and the nursing system's characteristics; at the same time, these
characteristics can be considered as the strategies to resolve conflict. We found "mutual
understanding and interaction" to be the main factor able to prevent and resolve conflict
effectively. We therefore recommend that nurses and nurse managers encourage any virtues and
activity that enhances such understanding and interaction. This approach will benefit the quality
of patient care through a healthy work environment. Finally, as conflict can destroy individual
nurses and the nursing system as a whole, it is advisable that we take action to control it
effectively.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
NN planned the study, carried out the interviews, and carried out data analysis. RN and NN
jointly developed an outline for the paper and wrote the initial draft, which they revised in
accordance with comments from reviewers. Both authors have read and approved the final
manuscript.

20. Acknowledgements
The authors wish to thank all the nurses and nursing administrators who participated in this
study. It was their willingness to share their experiences made this study possible. We also
extend our gratitude to Tehran University of Medical Sciences for its financial support.
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4444
eptember 2003, Volume 29, Issue 9, pp 1489-1497
Conflict in the care of patients with prolonged stay in the ICU: types,
sources, and predictors
David M. Studdert,
Michelle M. Mello,
Jeffrey P. Burns,
Ann Louise Puopolo,
Benjamin Z. Galper,
Robert D. Truog,
Troyen A. Brennan
Look Inside Get Access
Abstract

24. Objective
To determine types, sources, and predictors of conflicts among patients with prolonged stay in
the ICU.
Design and setting
We prospectively identified conflicts by interviewing treating physicians and nurses at two
stages during the patients' stays. We then classified conflicts by type and source and used a case-
control design to identify predictors of team-family conflicts.
Design and setting
Seven medical and surgical ICUs at four teaching hospitals in Boston, USA.
Patients
All patients admitted to the participating ICUs over an 11-month period whose stay exceeded the
85th percentile length of stay for their respective unit (n=656).
Measurements and results
Clinicians identified 248 conflicts involving 209 patients; hence, nearly one-third of patients had
conflict associated with their care: 142 conflicts (57%) were team-family disputes, 76 (31%)
were intrateam disputes, and 30 (12%) occurred among family members. Disagreements over
life-sustaining treatment led to 63 team-family conflicts (44%). Other leading sources were poor
communication (44%), the unavailability of family decision makers (15%), and the surrogates'
(perceived) inability to make decisions (16%). Nurses detected all types of conflict more
frequently than physicians, especially intrateam conflicts. The presence of a spouse reduced the
probability of team-family conflict generally (odds ratio 0.64) and team-family disputes over
life-sustaining treatment specifically (odds ratio 0.49).
Conclusions
Conflict is common in the care of patients with prolonged stays in the ICU. However, efforts to
improve the quality of care for critically ill patients that focus on team-family disagreements
over life-sustaining treatment miss significant discord in a variety of other areas.
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Nursing Administration Quarterly:
April/June 2003 - Volume 27 - Issue 2 - p 153-163
Original Article
The Effects of Intrapersonal, Intragroup, and Intergroup
Conflict on Team Performance Effectiveness and Work
Satisfaction
Cox, Kathleen B. PhD, RN
Abstract
Although numerous studies have focused on conflict management, few have considered the
effects of unit technology and intrapersonal, intragroup, and intergroup conflict on team
performance effectiveness and work satisfaction. The model was tested using a nonexperimental
design. Path analysis using multiple regression was used to test the model. The nonrandom
sample consisted of 141 nurses employed on 13 inpatient units at a state-supported, 597-bed
academic medical center in a southeastern city. Findings indicated that intrapersonal conflict had
a direct negative impact on intragroup conflict and work satisfaction. Intragroup conflict had
direct negative effects on work satisfaction and team performance effectiveness. Unit technology
had a direct negative impact on work satisfaction. Findings have implications for administrators
to implement strategies to decrease a stressful work environment and increase team-building
activities.
© 2003 Lippincott Williams & Wilkins, Inc.
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Conflict and professionalism: perceptions among nurses in Saudi Arabia
1. N.M. Zakari phd, rn1,*,
2. N.I. Al Khamis msn, rn2,
3. H.Y. Hamadi bcs 3
Article first published online: 19 MAR 2010

26. DOI: 10.1111/j.1466-7657.2009.00764.x
© 2010 The Authors. International Nursing Review © 2010 International Council of Nurses
Issue
International Nursing Review
Volume 57, Issue 3, pages 297–304, September 2010
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Keywords:
Academia;
Conflict;
Government;
Health-care Sectors;
Hospitals;
Nurse Managers;
Nurses;
Professionalism;
Saudi Arabia
Abstract
ZAKARI N.M., AL KHAMIS N.I. & HAMADI H.Y. (2010) Conflict and professionalism:
perceptions among nurses in Saudi Arabia. International Nursing Review57, 297–304
Aim: To examine the relationship between nurses' perceptions of conflict and professionalism.
Background: In Saudi Arabia, health-care sectors are constantly undergoing major changes
because of social, consumer-related, governmental, technological and economic pressures. These
changes will influence the nature of health-care organizations, such as hospitals' work
environment. The ability of nurses to practise in a professional manner may be influenced by
their work environment and conflict level.
Methods: A cross-sectional design was conducted in this study. A simple random selection of
three health-care sectors in Saudi Arabia was performed and 346 nurse managers, as well as
bedside nurses participated to provide information about conflict levels and professionalism. The
Perceived Conflict Scale was used to assess the level of conflict, and the Valiga Concept of
Nursing Scale was used to assess the professionalism perception among nurses.
Results: The intragroup/other department type of conflict had a statistically significant
correlation with the perception of professionalism. In addition, the findings point to a low
perception among the participating nurses regarding their professionalism.

28. Conclusion: A number of factors might explain the low level of perception of professionalism.
These relate to the workplace itself, as well as to the personal background of the nurses, which
includes the personal interest in the nursing profession, as well as the family's, society's and the
consumers' views of the profession. Given the findings of this study, nurse managers are
encouraged to create a work environment that supports professionalism and minimizes conflict.
Introduction
In Saudi Arabia, health-care sectors are constantly undergoing major changes because of social,
consumer-related, governmental, technological and economic pressures. These changes will
influence the nature of health-care organizations, such as hospitals. By nature, hospital
environments are complex, combining many different professional groups within an intricate
administrative structure. Saudi Arabian hospitals in particular are extremely complex, as they
rely on a nursing workforce is composed primarily of international expatriates. These
complexities often lead to conflict.
Background
Conflict is an integral part of the fabric of a post-modern society that is litigious, competitive,
complex and alienating. Hospital environments are exposed to many types of conflict
compounded by increasing demands on an ever-limited staffing supply, a decrease in available
resources and a period of profound changes (Gardner 1992; Kelly 2006). These complexities and
tensions in hospital settings will undoubtedly continue, and even escalate, providing a fertile
ground for conflict among health-care professionals (Saulo & Wegener 2000).
The forms of conflict are highly diverse and occur in four categories: (1) intrapersonal, which
arises within the individual from two competing demands, (2) interpersonal, which occurs
between two or more individuals arising from miscommunication or a difference in values, (3)
intergroup/support, which occurs between two or more groups that are supportive in work when
differences in competition for resources, power or status arise, and (4) intergroup/other
departments, which occurs between two or more groups for resources or services, and where the
conflict may be competitive or disruptive or may centre around control (Yoder-Wise 2007).
Intergroup conflict is common in an organization. Such conflict is generated from system
differentiation, task interdependence, scarce resources, jurisdictional ambiguity and separation of
knowledge from authority (Xu & Davidhizar 2004).
Conflict within a supervisory relationship can range from mild tension to very extreme forms. It
can originate from differences in personality, style, expectations, knowledge, experience or
world view. In some cases, conflict can be constructive, that is when it improves the quality of
decisions, stimulates creativity, encourages interest and curiosity among group members,
provides the medium through which problems can be aired and tensions released, and fosters
self-evaluation. Interpersonal conflict can serve as the impetus for needed change and can
accelerate innovation (Hagel & Brown 2005).
Conflict within the nursing profession, however, has traditionally generated negative feelings. It
has been seen to drain energy, reduce focus and cause discomfort and hostility (Wilson 2004).

29. Nurses experience conflict in many forms. Piko (2006) indicated that the main form of conflict
that nurses are vulnerable to is role conflict. Role conflict among nurses can include the
following: role overload, in which they are required to perform the work of other health-care
professionals; role ambiguity, in which their duties expand without a job description change; or
role stress, in which a non-nursing supervisor has different ideas about the nurse's job (Forte
1997). As with any health manager, nursing managers spend an average of 20% of their time
dealing with conflict. Nurses are known more for their use of avoidance, as opposed to open
acknowledgment, of the factors contributing to the issues causing the conflict (Cavanagh 1988).
For nurses, conflict management skills are rated as important as, or even more important than,
planning, communication, motivation and decision-making skills (McElhaney 1996).
Professionalism is the extent to which an individual identifies with a profession and adheres to
its standards. In nursing, a profession comprises of a system of roles that is socially defined.
Professions hold contracts to provide services for the public good, and in return, the
professionals gain higher prestige and autonomy in their work (Adams & Miller 2001).
Professionalism in nursing is represented by leaders of various nursing organizations. For nurses,
professionalism is primarily depicted and encouraged by nurse administrators and middle
managers in the agencies in which they are employed (Spooner & Patton 2007). Therefore, nurse
executives and middle managers can create work atmospheres free of conflict in which staff
nurses perceive opportunities to increase their professionalism and improve professional practice
(Adams 1991). To perform these functions, managers need to understand the nature of conflict
and the concept of professionalism. This is essential to demonstrate and model the behaviours
that denote professionalism and, consequently, encourage similar behaviours among staff (Sand
2003). The most common criteria needed for the nursing professionalism are knowledge, service
and autonomy. Nursing knowledge is the strong base of specialized education from which a
professional practises. Professional service is providing society with essential activities.
Professional autonomy is having authority over and accountability for one's decisions and
activities (Manojlovich & Ketefian 2002). Nursing requires both a high level of expertise and a
sophisticated decision-making process, which are characteristics of strong leadership. Strong
nursing leadership is required to assist in the professionalization of nursing, and to act in a
professional manner when dealing with conflict situations (Delgado 2002).
As the professional code of ethics guides nursing practice, a good working environment guides
and encourages nurses to work in a professional manner to reduce the impact of conflict. The
organizational and workforce structure of many hospitals is in conflict with the practice of
professional nursing, such as in an academic teaching hospital. Nayeri & Negarandeh (2009)
demonstrated that slow management processes, several and redundant medical orders, unskilled
medical interns, lack of personnel and failure to recruit qualified health personnel in academic
teaching hospital contribute to the rising level of conflict.
The ability of nurses to practise in a professional manner may be influenced by the
organizational culture and conflict levels of their work environment (Wynd 2003).

30. Significance of the study
A serious nursing shortage is creating a crisis in health care. Many experienced nurses are
leaving the field, and young people are not selecting nursing as a potential career. One reason is
the conflict that nurses encounter in their work. Considerable researches on conflict and its
impact on nursing outcomes have been conducted worldwide, but no such study has been
performed in hospitals in Saudi Arabia. Moreover, there is very little research on the relationship
between conflict and nurses' perceptions of their professionalism. Thus, a reassessment of
professionalism in nursing is indicated. Therefore, this study was an attempt to identify the
relationship between conflict and professionalism.
Purpose
This study was designed to explore the nature of the relationship between conflict and nurses'
perceptions of their professionalism. The study addressed the following research questions:
1
What is the level of conflict among nurses working in different health-care sectors?
2
What is the level of perception of professionalism among nurses working in different health-care
sectors? and
3
What is the relationship between the level of conflict and the perception of professionalism
among these nurses?
Methods
Research design
This study was carried out using an analytic cross-sectional design.
Setting and sample
A simple random selection of three different health-care sectors in Saudi Arabia was performed
from government, military and academic health sectors, and 346 nurse managers in first-line and
mid-level positions, as well as bedside nurses participated to provide information about conflict
level and professionalism. Statistically, the sample size was calculated to determine any expected
level of conflict or professionalism of ≥35%, with a 15% standard error and a 95% level of
confidence, using spss 13.0 statistical software package (Statistical Package for the Social
Sciences, SPSS Inc. Chicago, IL, USA). The required sample size estimated by power analysis

31. was 317 subjects. The actual sample size was increased to 420 to compensate for an anticipated
dropout or non-response rate of 25%.
Instruments
Data were collected via a questionnaire containing the following two instruments:
•
The Perceived Conflict Scale, which was designed to measure the level of conflict. It consists of
16 items on a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree). The items
are classified into four subscales (intrapersonal, interpersonal, intergroup/support, and
intergroup/other departments). Scores of 1, 2, 3, 4, or 5 were given to the responses of ‘strongly
disagree,’‘disagree,’‘uncertain,’‘agree’ and ‘strongly agree,’ respectively. The scores of the items
were summed, and the total score was divided by the number of items giving a mean score for
perceived conflict. These scores were converted into a percent score, and the means and
standard deviations (SD) were computed. The conflict was considered high if the percent score
was ≥60%, and low if <60% (Huber 1996). The Cronbach's alpha coefficient in this study was
0.67, which indicates good reliability.
•
The Valiga Concept of Nursing Scale was used to assess nurses' professionalism. It includes 25
items to measure the ideas held by the nurse about nursing as a profession, the role of the
nurse, and the relationship of the nurse to the client, the physician, and other health team
colleagues. The responses are on a 5-point Likert-type scale (strongly agree to strongly
disagree). The negative statements are scored negatively. Therefore, the total minimum score
was −50 and the maximum score was +50 (Valiga 1996). The Cronbach's alpha coefficient for this
study was 0.79, which indicates a high degree of reliability. An additional section was added,
which included eight questions for the demographic characteristics, such as nursing qualification
and years of experience.
Procedures
Prior to data collection, an institutional review board at each of the three health-care sectors
granted approval for the study. Before the study was conducted, the research team met with the
directors of the research centres in the selected hospitals and explained the study procedures.
Questionnaires were handed out to supervisors in the selected hospitals who then gave them to
nursing professionals on the wards. A letter to each participant accompanied the questionnaire
explaining the objective of the research. All questionnaires were self-administered; paper-and-
pencil instruments were distributed, completed and collected on the hospital wards. Throughout
the study, protection of human rights was assured and adherence to ethical principles was
secured. Thus, the researcher ensured that each individual's autonomy was supported.
Participation was voluntary, and there was no penalty for withdrawal from or termination of the

32. study. In addition, the research methodologies were non-invasive, and there were minimal or no
anticipated risks to participants. A written consent form was obtained from all participants. Total
confidentiality of information was also ascertained.
Statistical analysis
Data entry and analysis were done using the spss 13.0 statistical software package. Pearson
correlation analysis was used for assessment of the inter-relationships among quantitative
variables. The Cronbach's alpha coefficient was calculated to assess the reliability of the
developed tools through internal consistency. To identify the independent predictors of the score
of professionalism, multiple stepwise backward linear regression analysis was used, and analysis
of variance for the full regression models were performed. Statistical significance was
considered at a P-value < 0.05.
Results
Of 420 questionnaire forms distributed, 346 were completed, returned and validated, with a
response rate of 82.4%. The responding sample consisted mainly of staff nurses (86.4%), with
higher percentages from internal medicine departments (43.9%). The results indicated that
around 43% nurses were participated from governmental hospitals while 28% and 29% nurses
participated from military and academic hospital, respectively. The sample age ranged between
20 and 60 years, with a mean ± SD of 37.0 ± 8.7 years. The majority of participants were
females (92.8%), married (74.6%) and had a bachelor's degree in nursing (63.6%). The
experience in nursing ranged between 1 and 40 years, with a mean ± SD of 11.4 ± 7.4 years.
Slightly more than one-third of the sample (37.3%) had a high perception of nursing
professionalism. The mean ± SD percent score was 53.8 ± 16.7. With respect to the types of
conflict, the finding indicates that the interpersonal type was the most common (82.1%), whereas
the intrapersonal type was the least common (38.4%).
The relationship between nurses' perception of professionalism and conflict is displayed in
Table 1. Only the intragroup/other department type of conflict had a statistically significant
association with the perception of professionalism (P = 0.03). It is evident that a higher level of
professionalism is associated with a higher level of such conflict. A similar relationship existed
with intrapersonal conflict, although it had only borderline significance (P = 0.054).
Table 1. Relationship between nurses' perceptions of professionalism and conflict
Perceptions of professionalism
High Low X2 P
No. % No. %
*
P < 0.05.

33. Table 1. Relationship between nurses' perceptions of professionalism and conflict
Perceptions of professionalism
High Low X2 P
No. % No. %
Interpersonal conflict:
High (60%+) 111 86.0 173 79.7
Low (<60%) 18 14.0 44 20.3 2.20 0.14
Intrapersonal conflict:
High (60%+) 58 45.0 75 34.6
Low (<60%) 71 55.0 142 65.4 3.70 0.05
Intergroup/support conflict:
High (60%+) 84 65.1 133 61.3
Low (<60%) 45 34.9 84 38.7 0.51 0.48
Intergroup other department conflict:
High (60%+) 71 55.0 93 42.9
Low (<60%) 58 45.0 124 57.1 4.82 0.03*
Similarly, Table 2 points to statistically significant positive correlations between the scores of
nurses' perception of their professionalism and intrapersonal (R = 0.12) and intragroup/other
department (R = 0.35) types of conflict. The Table also indicates that the four types of conflict
were positively inter-correlated, with the strongest correlations between intrapersonal conflict
and both types of intergroup conflicts.
Table 2. Correlation matrix of nurses' perception of professionalism and conflict scores
Scores 1 2 3 4 5
*

34. Table 2. Correlation matrix of nurses' perception of professionalism and conflict scores
Scores 1 2 3 4 5
P < 0.01;
**
P < 0.05.
Perception of professionalism 1. 1.00
Interpersonal conflict 2. 0.02 1.00
Intrapersonal conflict 3. 0.12* 0.12* 1.00
Intergroup/support conflict 4. 0.06 0.12* 0.44** 1.00
Intergroup/other departments conflict 5. 0.15** 0.17** 0.41** 0.35** 1.00
Multivariate analysis was carried out to identify the independent predictors of the score of
nursing professionalism. The best fitting model is presented in Table 3. It is evident that the only
statistically significant independent predictors of this score were years of experience and the
score of the intra group/other department type of conflict, with the former being a negative
predictor. These were adjusted for the nurse's age, gender, qualifications, job position, marital
status, as well as hospital and department of work, and other types of conflict scores. However,
as indicated from the value of the R-square, the model only explains 4% of the variation in the
professionalism score.
Table 3. Best fitting multiple linear regression model for the score of perception of professionalism
Unstandardized
coefficients Standardized
t-test P-value
coefficients
Beta SE
*
The experience in nursing ranged between 1 and 40 years, with a mean ± SD of
11.4 ± 7.4 years.
R-square = 0.04.
Model analysis of variance: F = 4.53, P = 0.01.
Variables excluded by model (non-significant): age, sex, nursing qualification, marital
status, job position, department, hospital, other conflict scores.

35. Table 3. Best fitting multiple linear regression model for the score of perception of professionalism
Unstandardized
coefficients Standardized
t-test P-value
coefficients
Beta SE
SE, standard error.
Constant 53.4 45.47 9.777 <0.001*
Years of experience −0.26 0.12 −0.11 2.075 0.039*
Intergroup/other departments
0.18 0.07 0.14 2.602 0.010*
conflict
Discussion
Nurses have a certain social standing in society, the dimensions of which can be measured by
various indicators pertaining to their socio-economic status and respectability. They occupy a
particular hierarchical and vertical professional location in the division of health-care sectors.
Moreover, nurses work in various health-care sectors in which they occupy particular functional
roles and hierarchical positions. In order to understand the perceptions and experiences of nurses
with their professionalism, we have to assume that nurses' actions and perceptions are taken from
particular positions with specific resources and constraints. These positions are located at three
nested structural levels: society, the field of health care and the organization of the particular
clinic or hospital (Bourgeault et al. 2005).
The present study was designed to examine the relationship between conflict and nurses'
perceptions of their professionalism. The study findings point to low perception among the
studied nurses of their professionalism. Only about one-third of the sample had a high perception
of nursing. A number of factors might explain this low level of perception of professionalism.
These relate to the workplace itself, as well as the personal background of the nurses, which
includes the personal interest in the nursing profession, as well as the family's, society's and
consumer's views of the profession. The workplace factors have been addressed very early in the
literature. It was claimed that employment of professionals in bureaucratic organizations has
typically been thought to result in varying degrees of de-professionalization or the diminishing of
professional autonomy (Armstrong & Armstrong 2002). This phenomenon has been extensively
studied in the profession of nursing.
Nayeri & Negarandeh (2009) explored Iranian hospital nurses' perception about conflict and
identify conflict sources. The finding confirmed that both the hierarchy in the organization and
the condition of nursing assignment have a negative impact on nursing professional practices by
increasing fragmentation, stress and exhaustion.

36. Similar findings were indicated in French hospitals, which showed that increased bureaucracy
and work intensity both led to an equivalent increase in frustration with the inability to provide
care (Bourgeault et al. 2005).
Another workplace-related factor that has been assessed in the literature is the feeling of
professional support, which fosters a nurse's perception of professionalism. This feeling could be
lacking among some of the nurses in the present study who are expatriates and who have to deal
with foreign seniors who may have different perceptions and attitudes regarding the nursing
profession. In this regard, Healy & McKay (2000) and Attree (2001) have demonstrated that
nurses in the ward were better able to accommodate patients' demands on nursing time and
energy when there was a high proportion of senior staff with knowledge, skill and experience in
the specialty area. In addition, the stress experienced by the nursing staff was reduced. Other
researchers supported the fact that both staffing levels and support from other staff were
important factors in the perception of workload and quality of patient care (Jones & Cheek 2003;
Strachota et al. 2003). Additionally, nurses were found to experience a lack of control over
factors that affect practice standards, which generate dissatisfaction, frustration and
demoralization, and consequently, a decreased perception of professionalism (Attree 2005).
Furthermore, the lack of resources, time and manpower affect the caring aspect of nurses'
professional tasks, skills and knowledge. This would have a negative impact on their perception
of nursing professionalism.
Caring is the core of a nurse's professional identity. The individual understanding of caring
directs the choice of nursing as profession. Consequently, when this perception is not supported
by the work environment conflict may arise (Kirpal 2004). This is important to the present study
because of a workforce with diverse nationalities, education and social backgrounds, all of whom
may have different perceptions of caring.
Concerning conflict, the present study findings indicated that the interpersonal type was the most
common, while the intrapersonal type was the least common, and intergroup conflicts were in
between. The findings are incongruent with a study in Egypt (Ahmed 2008), which found that
intergroup conflict was the most common type, whereas interpersonal conflict was the least
common, thus indicating that nurses have no problems in personal relationships, and that the
conflict comes between groups, usually because of competition for the scarce resources needed
to achieve the work. Moreover, the present study findings are not in agreement with another
study conducted in Egypt which demonstrated that intrapersonal conflict was the highest type of
conflict among nurses in Ain-Shams University and El-Demerdash hospitals (El-Berry 2003).
The discrepancies among these studies might be explained by the nature of the setting. In the
present study, the nursing workforce is multinational, while the resources are not comparably
tight. Hence, unsurprisingly, interpersonal conflict is the highest among the four types. This
effect of the factors connecting culture and organizational climate on the incidence of various
types of conflict has been previously reported (Clarke 2006).
The present study findings demonstrated a statistically significant negative correlation between
the scores of perception of nursing professionalism and a nurse's years of experience. This
implies that more years of experience is associated with a decrease in the perception of a nurse's

37. professionalism. This phenomenon was discussed as a division into practical nurses of an older
generation and young academic nurses. These distinctions are potential sources and means of
internal conflict, particularly in the conditions of cost-cutting and lacking resources (Edmunds &
Turner 2005; Eraut 2004). As this phenomenon is common world wide, it is also obvious in
Saudi Arabia with the expansion of academic nursing programmes in the last decade. Goodson &
Norrie (2005) reported the subsequent diminished hierarchies between nurses, with the
experienced nurses noting how it leads to diminished respect for older colleagues. In agreement
with this, in Saudi Arabia, it is common to find a younger nurse with a bachelor's degree in a
managerial position, with more experienced, less educated older nurses as subordinates, a
situation that may contribute to this phenomenon.
Presently in Saudi Arabia, there is no national nursing scope of practice and career ladder, which
may explain this relationship between years of experience and perceived professionalism. Lack
of scope of practice leads to highly diversified job descriptions and specifications for a similar
position. This ultimately results in role conflict, which when prolonged may decrease perceived
professionalism. The absence of a career ladder may be related to the sense of diminished
perceived professionalism as the nurse stays in the profession. A nursing multinational
workforce with diverse perceptions of the nursing profession and the local societal perception of
the nursing profession combined together could drive nurses in Saudi Arabia to lose their
perceived professional commitment. In addition, the perceived lack of control over resources and
constraints associated with nursing positions within the organization hierarchy could also
contribute to the explanation of this finding.
When the relationship between nurses' perceptions of their professionalism and conflict was
examined in the present study, the results indicated that only the intragroup/other department
type of conflict had a statistically significant positive correlation with the perception of
professionalism. The higher the level of professionalism, the greater was this conflict. This was
further confirmed by multivariate analysis, which adjusted for the effect of other variables, such
as age, experience, workplace and other types of conflict. The finding is incongruent with a study
which revealed that intergroup conflict was higher in smaller units with a higher ratio of
registered nurses to total staff, while it was not associated with satisfaction with pay or
anticipated turnover (Cox 2003). Meanwhile, it has been argued that the high perceptions of unit
morale and interpersonal relationships buffered the effect of unit size and skill mix on inter
group conflict. Thus, unit morale and interpersonal relationships might relate to nurses'
perceptions of their professionalism (Cox 2001; Severinsson 2003).
Limitations
The present study has limitations which must be acknowledged. First, self-report questionnaires
were used for data collection with research assumption of trustworthiness of the respondents.
Second, for the majority of the nursing workforce, English is the second language. Perception
concepts may have been difficult for nurses to interpret in concrete terms. Third, the tool was
limited to address the cultural diversity among nurses.

38. Recommendations for further research
Saudi Arabia will continue to experience diversity in its nursing workforce for the foreseeable
future. Therefore, further qualitative research is recommended to focus on to what extent
attitudes and values are a source of promoting nursing professionalism. Replication of this study
should be carried out with nurses in different regions. More studies are needed to examine the
impact of nursing scope of practice on conflict and professionalism.
Implications for nursing practice
The study indicates that a higher level of professionalism is associated with a higher level of
conflict. Organizational training and development models must encourage the proactive conflict
management strategies. Nurse leaders and educators need to endorse and adapt a trans-cultural
framework of nursing practice to dilute the effect of individual background as a source of
conflict. Nurse leaders should acknowledge that a statement of professional nursing scope of
practice is a necessity to overcome role conflict. In addition, role identification with clear
equivalent benefits, rewards and promotional paths with alternative tracks can be strong means to
increase professionalism and commitment to the profession with years of experience. Nurse
administrators must also consider departmental designs that decrease bureaucracy and strengthen
nurses' positions. Nurse managers must implement strategies that provide professional support at
the point of care, as well as assignment models that provide reasonable work intensity.
Conclusion
The study indicates that higher level of professionalism is associated with higher level of conflict
especially of the inter personal and intragroup/departmental type. Individual cultural background
and organizational climate seem to be the most influential factors driving this result.
Understanding conflict management styles can increase nurses' positive conflict outcomes and
lead to improved relationships, increased job satisfaction and increased retention of nurses.
Further nursing education in conflict management for staff nurses and nurse managers is greatly
needed. Both nurses and nurse managers should be made more aware of the conflicts between
them and better trained to understand how they can be constructively resolved. Overall, the
professional identity of nurses remains strong, but it is important for policy makers to be aware
of the potential negative effects, in terms of conflict in the current state of the health-care sector.
Acknowledgement
This research was funded by King Saud University, College of Nursing Research Center.
Author contributions
Nazik Zakari planned and designed the study, carried out data analysis, and the interpretation of
data. Nada Al khamis and Hanadi Hamadi jointly collected the data, developed an outline for the
paper and wrote the initial draft. All members critically reviewed the manuscript and have
approved the final version submitted for publication.

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