A Study of Interpersonal Conflict Among Operating Room Nurses

Abstract

Background: 

Team collaboration is an important factor that affects the performance of the operating room (OR). Therefore, the ability of OR nurses to adapt to and manage interpersonal conflict incidents properly is very important.

Purpose: 

The aims of this study were to investigate the interpersonal conflict management capabilities of OR nursing staffs and to find the relationships among the demographics of OR nurses and the following: work-related variables, interpersonal conflict management style, and target of interpersonal conflict.

Methods: 

This study investigated 201 OR nurses who had worked for more than 6 months at the target hospitals, which were located in the three counties of Changhua, Yunlin, and Chiayi. The questionnaire that was used to collect data included three components: a demographic and work-related variables survey, interpersonal conflict management factor analysis scale, and interpersonal conflict parties and frequency scale. Data were analyzed using independent t test, analysis of variance, Scheffe’s test, and Pearson’s correlation coefficient.

Results: 

The main findings were as follows: (a) Integration and arbitration were the major interpersonal conflict management strategies adopted by the participants; (b) medical doctor, OR nurses, and anesthetists were the primary targets of conflict for the participants; (c) the factors of educational background, job position, experience in other departments, seniority, attending courses in conflict management, and level of hospital significantly affected the strategies that participants used to manage interpersonal conflict; and (d) license level, experience in other departments, seniority, and inclination toward serving in the OR were each found to relate significantly to the target of interpersonal conflict and the frequency of interpersonal conflict incidents.

Conclusions/Implications for Practice: 

The main implications of this study are as follows: (a) The environment for communication in the OR should be made more friendly to encourage junior OR nurses to adopt constructive interpersonal conflict management strategies; (b) prior experience in other departments should be one of the most important factors of consideration when recruiting new nurses for the OR; and (c) hospitals should provide more interpersonal conflict management training courses to support the capability of OR nursing staffs in terms of adopting cooperativeness strategies and coping effectively with all types of interpersonal conflicts.

Introduction

Interpersonal conflict is an inevitable part of medical practice (^{Blackall, Simms, & Green, 2009}). Medical professionals often must make critical decisions with deficient or equivocal information under strict time limitations. Internal power struggles, including those between nurses and medical doctors, are common between administrative chiefs and medical personnel (^{Reich, Wagner-Westbrook, & Kressel, 2007}). Nurses are at the center of interpersonal conflict in the modern healthcare system (^{Su, Chang, Hsu, & Chu, 2007}). The operating room (OR) is one of the most high-risk and high-stress departments in hospitals. Features that lead nurses to experience interpersonal conflict risk in the OR include working quickly, working irregular shift schedules, and working with other professionals in a team setting (including OR chiefs, surgeons, anesthetists, and other OR staff nurses). Because team collaboration is an essential factor affecting the performance of the OR (^{Ma, 1998}), the ability of OR nurses to manage interpersonal conflict is very important.

Many studies in the field of conflict management have indicated that conflict is an inevitable aspect of organizations (^{Callanan, Benzing, & Perri, 2006}; ^{Cavanagh, 1991}). Conflict is common in organizations because the characteristics, values, objectives, and needs of groups and individuals do not always coincide (^{Armstrong, 2008}). ^{Hunsaker and Alessandra (2008)} indicated that most conflicts are triggered by personal differences, structural design, or communication problems. Factors that may contribute to personal differences include cultural background, education, experience, and training (^{Payton, 2014}). Increases in organizational task interdependencies, team-based structures, diversity, and uncertainty in terms of working conditions have all been shown to increase the risk of interpersonal conflict within organizations (^{Amason, 1996}; ^{Cheng, 2003}).

The traditional attitude toward conflict is that it is harmful to the organization. Conflict has been portrayed as a malfunction in organizational control systems or a failure in the chain of direction (^{Pondy, 1992}). ^{Gladstein (1984)} and ^{Wall and Nolan (1986)} identified that conflict correlates inversely with productivity and work satisfaction. Failing to manage conflict correctly may decrease staff morale, increase turnover, and raise the risk of litigation (^{Losa Iglesias & Becerro de Bengoa Vallejo, 2012}) as well as undermine the work of even the best nurse or manager (^{Payton, 2014}). In the medical system, unresolved conflict may decrease staff productivity and teamwork and potentially decrease the quality of patient care (^{Hocking, 2006}).

However, more recently, some researchers have come to take a different view of conflict. These researchers note that conflict may have a positive effect on organizations when it is handled properly (^{Jameson, 1999}; ^{Rahim, 2002}). Furthermore, healthy conflict may keep an organization from becoming unnatural and bland by stimulating new ideas, insights, and approaches to solutions through the objective and rational exchange of ideas (^{Armstrong, 2008}). When its positive aspects are considered, conflict may be supported as maintaining a basic level of stimulation and inspection among organizational systems, helping maintain an organization’s capabilities for adaption and innovation, and serving as a basic source of feedback regarding interdependent relationships, the allotment of power and resources, and the problems that require administrator attention.

^{Thomas (1976)} classified the strategies for managing conflict into five modes: competing, compromising, avoiding, accommodating, and collaborating. ^{Lee (2002)} stated that people adopt different conflict management strategies when facing different conflict parties. ^{Ting-Toomey and Oetzel (2001)} indicated that arbitration is one of the more frequent conflict management strategies that are adopted in Asian cultures. Thomas indicated that collaboration is a popular conflict management strategy for all parties to a conflict. ^{Chou, Cheng, and Chen (2009)} indicated that domination is a reasonable conflict management strategy in emergency situations. ^{Moisoglou et al. (2014)} classified conflict management strategies into two behavioral dimensions: assertiveness (attempt to satisfy one’s own concerns) and cooperativeness (attempt to satisfy the other side’s concerns). According to these views, we define “competing” (assertive and uncooperative), “avoiding” (unassertive and uncooperative), and “accommodating” (unassertive and cooperative) as assertiveness conflict management strategies and “collaborating” (assertive and cooperative), “compromising” (moderate in both assertiveness and cooperativeness), and “arbitration” (moderate in both assertiveness and cooperativeness) as cooperativeness conflict management strategies.

The cooperativeness conflict management styles that nurses tend to adopt include collaborating and compromising, whereas the assertiveness conflict management styles that they tend to adopt include competing and avoiding (^{Tomey & Poletti, 1991}). Nurse leaders mainly adopt the compromising conflict management strategy, whereas basic level nurses mainly adopt the avoiding conflict management strategy (^{Barton, 1991}). Junior nurses tend to adopt avoiding and compromising conflict management strategies more frequently than senior nurses (^{Eason & Brown, 1999}). Conflict management is very important in the medical system. One study of a Greek public hospital showed that 65.6% of healthcare professionals had not attended any training on conflict management, whereas 34.4% expressed that they had obtained related conflict management theoretical knowledge during their graduate studies (^{Moisoglou et al., 2014}).

The OR is one of the units with the highest cost, highest profit, and highest conflict in the hospital. Many studies have stated that conflict management correlates with job performance, demographic data, and work-related variables. However, our review of the literature shows that no study has focused on the relationships among demographics and work-related variables, interpersonal conflict management strategies, and interpersonal conflict parties in the context of OR nurses.

Therefore, the purpose of this research was to investigate demographic and work-related variables, interpersonal conflict management strategies, and interpersonal conflict parties among OR nurses. Figure 1 shows the conceptual framework of this study.

Figure 1.: Demographic data and work-related variables may affect conflict management strategies and conflict frequency. Conflict management strategies and conflict frequency are interrelated.

Methods

Subjects

This study was approved by the institutional review board (No. 99-CCH-IRP-90). First, the researcher contacted the chiefs of the target hospitals in Changhua, Yunlin, and Chiayi Counties to explain the purposes and procedures of the study to recruit OR nurse volunteers to participate. Two hundred twenty-one OR nurses from one medical center, four regional hospitals (RHs), and four community hospitals agreed to participate. Two hundred one of the enrolled participants (95.26%) finished all of the questionnaires. All 201 subjects were OR nurses who had been employed as an OR nurse for at least 6 months.

Instruments

The questionnaire that was used included three parts: a demographic and work-related data survey, an interpersonal conflict management factor analysis scale, and an interpersonal conflict target and frequency scale. A review of the relevant literature was used as the basis for developing the questionnaire (^{Chen, Lin, Wang, & Hou, 2009}; ^{Rahim & Magner, 1995}; ^{Su et al., 2007}), which was evaluated and revised by five scholars and OR chiefs with relevant expertise.

Demographic and work-related data included age, gender, marital status, number of children, religious affiliation, educational level, practical license, position, professional career status (including experience in other hospitals, experience in other departments, years employed in the present hospital, and years employed in the OR), whether the job position was voluntary or appointed, whether the participants had attended courses for interpersonal conflict management or not, and the level of the hospital.

The interpersonal conflict management strategy factor analysis scale was designed based on The Rahim Organizational Conflict Inventory-II (^{Rahim & Magner, 1995}) and our review of the literature. A pilot test of this scale was conducted on five professionals, including senior OR chiefs and others scholars with relevant specialties. The 26-item scale was scored using a Likert scale that ranged from 1 = extremely disagree to 5 = extremely agree. Factor analysis was used to determine the factor composition of this scale. On the basis of the Kaiser–Eigen value criterion, five factors were extracted from the 26 items. The alpha reliability coefficients of the five factors of the interpersonal conflict management strategy factor analysis scale were all between .72 and. 88. The five factors covered the aspects of avoiding and accommodating (nine items), integration (five items), domination (four items), compromising (five items), and arbitration (three items).

For the interpersonal conflict target and frequency scale, nine types of interpersonal conflict parties of OR nurses were surveyed, including OR medical doctors, OR chiefs, OR head nurses, OR nurses, anesthetists, other department nurses, medical personnel, administrative personnel, and patients and their families. Interpersonal conflict frequency was scored using a Likert scale that ranged from 1 = never to 5 = always.

Data Analysis

Data from finished questionnaires were analyzed using SPSS version 12.0. Descriptive statistics such as mean value and standard deviation were used to represent subject traits, frequency of interpersonal conflict management strategies adopted, and frequency of interpersonal conflict. The correlations between conflict management strategies, the targets of interpersonal conflict, and variable characteristics were analyzed using independent t test, analysis of variance, Scheffe’s test, and Pearson’s correlation.

Results

Demographic Data and Work-Related Variables

General characteristics and work-related variables for the 201 nurses are shown in Table 1. Most of the participants were female (95.5%). A slight majority was married (50.7%), claimed no religious affiliation (55.2%), and held a baccalaureate degree as their highest level of education (49.8%). Regarding the professional career status of participants, 44.8% had nursing experience in more than one hospital, 73.1% had nursing experience only in the OR, 57.2% had worked in their present hospital for more than 5 years, and 54.2% had OR nursing experience for more than 5 years. Only 10.0% had been assigned to the OR, and only 20.4% had participated in courses in conflict management. Furthermore, most (50.7%) currently worked in medical centers, with the remainder working in RHs (27.9%) and community hospitals (21.4%).

TABLE 1.: Demographic Data and the Work-Related Variables of Participants (N = 201)

Conflict Management Strategies

Table 2 shows the results of the analysis of variance and t test for interpersonal conflict management. Among the five factors of the interpersonal conflict management strategy factor analysis scale, integration was ranked as the most adopted strategy (mean = 3.77, SD = 0.53), followed by arbitration (mean = 3.56, SD = 0.62), compromising (mean = 3.45, SD = 0.54), avoiding and accommodating (mean = 3.18, SD = 0.60), and domination (mean = 2.62, SD = 0.74).

TABLE 2.: Analysis of Variance and t Test for Interpersonal Conflict Management Strategy (N = 201)

Table 2 shows that the number of years employed in the present hospital (F = 4.84, p = .00) and the number of years employed in the OR (F = 3.94, p = .00) both had a significant affection on the avoiding and accommodating strategy. Participants who had been employed in their present hospital or in the OR for less than 1 year were significantly more inclined to adopt the avoiding and accommodating strategy than their peers. Position (t = 2.33, p = .03), experience in other departments (t = 2.29, p = .02), and attending courses in conflict management (t = 2.64, p = .01) significantly affected the adoption of the integration strategy, with being a nurse leader, having experience in other departments, and prior participation in conflict management courses all positively affecting the decision to adopt the integration strategy. The level of hospital significantly affected the adoption of the domination strategy (F = 8.19, p = .00), with participants who were currently serving in a medical center more likely to adopt this strategy than their peers serving in RHs. Position significantly affected the decision to adopt the compromising strategy, with nurse leaders adopting this strategy more often than basic level nurses (t = 2.25, p = .03). Furthermore, variables including number of children (F = 3.71, p = .01), educational level (F = 2.77, p = .04), position (t = 2.49, p = .02), experience in other departments (t = 3.51, p = .00), and attending courses in conflict management (t = 2.37, p = .02) all significantly affected the decision to adopt the arbitration strategy. Nurses with more than two children, with a graduate school education, who were nurse leaders, who had experience in other departments, or who had attended courses in conflict management were more likely to adopt the arbitration strategy than their peers.

Targets of Interpersonal Conflict

Table 3 shows that, among the nine different targets of interpersonal conflict, medical doctor in the OR was ranked as being the most common target of conflict for OR nurses (mean = 2.49, SD = 0.94), followed by OR nurses (mean = 2.28, SD = 0.82), anesthetists (mean = 1.94, SD = 0.85), nurses from other departments (mean = 2.04, SD = 0.80), OR chiefs (mean = 2.62, SD = 0.74), medical personnel (mean = 1.83, SD = 0.69), OR head nurses (mean = 1.89, SD = 0.88), administrative personnel (mean = 1.65, SD = 0.61), and patients and their families (mean = 1.56, SD = 0.65).

TABLE 3.: Analysis of Variance for Interpersonal Conflict Parties Among Operation Room Nurses (N = 201)

Being a registered nurse (RN; t = −2.29, p = .03), being a nurse leader (t = 2.50, p = .02), and being employed in the OR (F = 12.71, p = .00) for more than 1 year were associated with higher levels of conflict frequency with OR medical doctors. Participants who were RNs (t = −3.79, p = .00) had a higher frequency of conflict with OR basic level nurses, whereas participants who had been employed in the OR for more than 5 years (F = 7.11, p = .00) had a higher frequency of conflict with OR basic level nurses than their peers who had been employed in the OR for less than 1 year.

Participants who had been employed in the OR for more than 5 years had a higher frequency of conflict with anesthetists than their peers with less than 1 year of OR employment (F = 6.22, p = .00). Participants who had been employed in the OR for over 1 year (F = 9.51, p = .00) had a higher frequency of conflict with nurses from other departments.

Being a nurse leader (t = 2.13, p =.04), lack of experience at other hospitals (t = −2.92, p = .00), serving voluntarily in the OR (t = −2.10, p = .05), and being employed in the OR for more than 1 year (F = 13.79, p = .00) were each related with having a higher frequency of conflict with OR chiefs. Participants who had been employed in the OR for more than 20 years had a higher frequency of conflict with OR chiefs than those who had been employed in the OR for less than 5 years.

Being a nurse leader (t = 2.83, p = .00) and lack of experience at other hospitals (t = −2.62, p = .01) were associated with a higher frequency of conflict with medical personnel. Participants who were employed in the OR for more than 5 years (F = 9.75, p = .00) had a higher frequency of conflict with medical personnel than their peers who had been employed in the OR for less than 1 year.

Being a nurse leader (t = 2.32, p = .03) and lack of experience at other hospitals (t = −2.36, p = .02) were associated with a higher frequency of conflict with medical personnel. Participants who were employed in the OR (F = 8.91, p = .00) for more than 5 years had a higher frequency of conflict with OR head nurses than their peers those who were employed in the OR for less than 1 year.

Participants who had been employed in the OR for more than 10 years (F = 6.95, p = .00) had a higher frequency of conflict with OR head nurses than their peers who had been employed in the OR for less than 1 year.

Relationships Between Conflict Management Strategies and the Targets of Interpersonal Conflict

Table 4 shows that, among the five factors on the conflict management strategies scale, avoiding and accommodating, integration, compromising, and arbitration strategies were correlated inversely with all of the targets of conflict. Only the domination strategy correlated positively with all of the targets of conflict.

TABLE 4.: Pearson Correlation Between Conflict Management Strategies and Targets of Interpersonal Conflict Frequency Among Operation Room Nurses (N = 201)

After the Pearson’s correlation coefficient test, we found that, among the five factors of the conflict management strategies scale, the avoiding and accommodating strategy correlated inversely with the frequency of interpersonal conflict with OR medical doctors, OR chiefs, OR head nurses, OR nurses, anesthetists, other department nurses, and medical personnel; the integration strategy correlated inversely with the frequency of interpersonal conflict with OR medical doctors, OR nurses, anesthetists, other department nurses, medical personnel, administrative personnel, and patients and their families; the domination strategy correlated positively with the frequency of interpersonal conflict with other department nurses, medical personnel, and administrative personnel; the compromising strategy correlated inversely with the frequency of interpersonal conflict with OR nurses and anesthetists; and finally, the arbitration strategy correlated inversely with the frequency of interpersonal conflict with OR medical doctors, OR head nurses, OR nurses, anesthetists, other department nurses, medical personnel, administrative personnel, and patients and their families.

Discussion

The Conflict Management Strategies of Operating Room Nurses

Findings reveal that integration is the most frequently adopted strategy and that domination is the least frequently adopted strategy of OR nurses. These findings are similar to those of ^{Tomey and Poletti (1991)}. Moreover, arbitration was identified as the second most frequently adopted strategy, which echoes the findings of ^{Ting-Toomey and Oetzel (2001)}.

Furthermore, we found that nurse leaders were more likely than their other nursing peers to use integration, compromising, and arbitration management strategies during incidents of interpersonal conflict, whereas OR nurses with experience in other departments were more likely to use integration and arbitration strategies. These findings echo those of ^{Su et al. (2007)}. It may be that OR nurse leaders and OR nurses with experience in other departments hold a more global view and have more experience in dealing with interpersonal conflict and thus prefer to handle conflicts in a relatively more cooperative manner than their peers. Therefore, having prior experience in other departments may be used as a priority consideration when recruiting new nurses for the OR.

Our analysis indicated that junior OR nurses had a higher frequency of using avoiding and accommodating strategies in interpersonal conflict than their senior OR peers. This finding is the same as the finding of ^{Eason and Brown (1999)}. Thus, it may be inferred that, compared with senior OR nurses, junior OR nurses are at a disadvantage in terms of job position, hospital resources, and work environment familiarization during interpersonal conflict. Therefore, the OR administrative department should pay more attention to workplace bullying and work to improve the OR communication environment to encourage junior OR nurses to adopt cooperative interpersonal conflict management strategies.

In addition, this study found that participants with prior training in conflict management were more likely to use integration and arbitration strategies in interpersonal conflicts. This may indicate that participation in this training provides participants with greater knowledge and skills for dealing with interpersonal conflicts. Therefore, we suggest that hospitals should sponsor more interpersonal conflict management training courses to help their OR nurses cope effectively with the various types of interpersonal conflicts.

Targets of Interpersonal Conflict

The findings of this study show that OR medical doctors were the most frequent target of interpersonal conflict for the participants, followed by OR nurses and anesthetists. This may be explained by interaction and dependence being the most important factors underlying interpersonal conflict in the workplace (^{Cheng, 2003}).

Although we found that participants with more than two children were more likely to experience conflict with OR nurses and administrative personnel, only 10 participants had more than two children. Thus, further research should be conducted to test the validity of this finding.

Our analysis found that participants who worked at medical centers were significantly more likely to use the domination strategy than their RH peers. This may be because of nurses working in medical center OR settings being confronted with more multiple, complex, emergency, and critical patient care situations than their lower-level hospital peers (^{Chen et al., 2009}; ^{Chou et al., 2009}).

Furthermore, we found that RNs experienced significantly more frequent conflicts with OR medical doctors and OR nurses than licensed vocational nurses. This may indicate that the type of nursing license affects the confidence and will of OR nurses during interpersonal conflict incidents.

Finally, we found the participants with prior experience in other hospitals to be less likely to engage in conflicts with OR chiefs, medical personnel, and OR head nurses than their peers with no prior experience in other hospitals. This may be explained by the probability that OR nurses with experience in other hospitals hold a more global perspective on administrative interaction and have more experience in dealing with interpersonal conflict than their peers.

Relationships Between Conflict Management Strategies and the Targets of Interpersonal Conflict

Avoiding and accommodating, integration, compromising, and arbitration strategies were found to have an inverse relationship with the frequency of interpersonal conflict with various targets. Although avoiding and accommodating also related inversely to the frequency of interpersonal conflict with various targets, this strategy cannot solve the interpersonal conflict problem. Rather, this strategy simply defers problem resolution and may even increase the damage that is ultimately caused by the interpersonal conflict.

In addition, the domination strategy was found to relate positively to the frequency of interpersonal conflict with various targets. This may be because of domination being one type of competition strategy, which is associated with an increase in interpersonal conflict frequency.

Conclusions

The first finding of this study is that integration is the most frequently used of the five conflict management strategies examined, followed by arbitration, compromising, avoiding and accommodating, and domination.

The second finding is that medical doctors in the OR were the most frequent target of conflict among the nine interpersonal conflict examined, followed by OR nurses, anesthetists, other department nurses, OR chiefs, medical personnel, OR head nurses, administrative personnel, and patients and their families.

The third finding is that the educational level, position, and professional career status of OR nurses as well as having attended courses in conflict management and the hospital level in which they work all relate to the interpersonal conflict management strategies that OR nurses adopt during incidents of interpersonal conflict.

The fourth finding is that practical license, experience at other hospitals, professional career status, and volunteering or being appointed to their OR position all relate to the frequency of conflict between OR nurses and their conflict targets.

The fifth finding is that task interdependence relates to the frequency of conflict between OR nurses and their conflict targets.

In considering the generalizability of these findings, it is important to consider that the participants were recruited only from ORs in Changhua, Yunlin, and Chiayi Counties in central Taiwan. Therefore, the conclusions of this study may not be applicable to OR nurses working in other areas.