Abstract

Conflict is an inevitable phenomenon in any environment where people interact. Although individuals, groups, and organizations work to accomplish their goals, there is always a continuous interaction between them during this process conflicts, disagreements, and inconsistencies between the parties can rise. Aim: The main aim of the current study was to compare types and levels of conflict experienced by nurses in National Medical Institute at Damanhur (Egypt) and Taif Governmental Hospitals (Saudi Arabia). Subject and methods: A comparative cross-sectional research design was utilized in the present study. Random sample (450) nurses from both Egyptian and Saudi hospitals composed the study sample. Nursing Conflict Scale was used to assess the types and levels of conflict experienced by nurses in the hospital settings. Results: Interpersonal conflict and intragroup conflict were the most common types of conflict experienced by Egyptian nurses. On the other hand, the greatest popular types of conflict experienced by Saudi nurses were intragroup conflict and competitive conflict. Conclusion: Egyptian nurses experienced moderate to high level of conflict, while, Saudi nurses experienced moderate to low level of conflict. Additionally, Egyptian nurses experienced a higher level of conflict than Saudi nurses. Recommendations: Nurse managers should develop effective conflict management strategies to decrease conflict between nurses and to create a more healthier and productive work environment which definitely affect the quality of nursing care provided.

1. Introduction

Conflict in healthcare, as in every working environment, is an inevitable challenge in the working relationships of nurses and other members of the healthcare team or other employees of the organization, which is also believed to be of a complicated character ^{1, 2}. It is unavoidable when individuals work together on a team or project. In a hospital setting, there are a large number of separate professions that need to work together to attain the collective goal of patient health, safety, and well-being ³. Unresolved conflict among healthcare professionals can have bad influence on patient care, therefore it is necessary to resolve it before it could impact the quality of care provided ⁴.

Nurses play different functions such as care provider, instructor, and manager. These functions lead to different kinds of interactions among nurses and other health care team members, which considerably increase the possibility for conflict to arise in hospital settings among nurses ⁵. Nurses are predictable to work with colleagues and patients who come from differing cultures and backgrounds and they are, consequently, required to form collaborative relationships with each other ⁶. As a result of persons having different values, conflict may possibly result in negative effects on employment relationships ⁷. The positive effect of conflict is found to improve team work through sharing of viewpoints and increased discussions which, in turn, improves decision making and, subsequently, performance ⁸.

In hospitals, individual professionals come from different cultural, religious backgrounds and have different values and beliefs making conflict unavoidable when working as a team hence, the method of conflict management tends to affect quality care either negatively or positively ⁹. Conflict is the consequences of experienced or perceived variations in common goals, values, ideas, attitudes, beliefs, emotional state, or actions ¹⁰. It is a dynamic method that can be positive or negative, healthy or dysfunctional, within work environment. Sometimes it can be creative. In some cases, it is essential to create conflict to bring justice in situation. It provides an opportunity to new system to shape better future. Thus, resolving conflict in an effective manner promotes good quality patient care. Unresolved conflicts may have several negative effects on patient outcomes ¹¹.

Conflict is a social process which consists of many episodes of different intensity and manifestation. It happens because wants, wishes, goals and ways of their satisfaction are not consistent, and the actions of one side impede the other in attaining its aims ⁴. Conflicts arise for many reasons: it can originate because of competition among professionals and variations in economic and professional values. Scarce resources, reform, poorly defined roles and expectations, the ability to work as a team, interpersonal communication skills, and expectations about level of performance in various nurses' roles are all sources of conflict in health care organizations ⁵.

Conflict may be constructive or destructive. Constructive conflict with favorable resolution may foster relationships, supply independence for decision making, and authorize others to use creative solutions for problem-solving. When used in a positive manner, conflict may assist all sides that are involved in growth and change. If emotions were controlled prior to entering into a negotiation, conflict resolution is accomplished best. To solve the conflict in a more realistic manner, must use the processes of positive confrontation, problem-solving, and negotiation. Unresolved conflict presents barriers to individual, team, and organization would lose its productivity ¹².

In everyday life, conflict is often identified with a confrontation, disregard, loss or violence. It is considered as a negative, stressful and unpleasant incidence, which people tend to avoid because it causes negative emotions such as anger, hate, rage or fear. The negative consequences of conflict are dissatisfaction and weakening of relationships, work efficacy and communication ⁴. Moreover, it can lead to a number of negative outcomes, including; reduced performance and effectiveness, lower levels of productivity, health problems, absenteeism, high rate of turnover, alcohol and drug abuse and destructive behavior, which will result in industrial action, poor Labour relations and diminishing levels of quality patient care ^{6, 7}.

There are numerous types of conflict nurses may experience in the hospital setting. Intrapersonal conflict which occurs within one individual, it happens when one is facing with two or more incompatible demands. Interpersonal conflict which occurs between two or more individuals, whose values, goals and beliefs are incompatible. Intragroup type which arises within one group, it may be due to lack of support, new problem which necessitate changes within group member roles and relationships, imposed values and role inside the group. On the other hand, intergroup type arises between groups with differencing goals ^{9, 11}. Competitive conflict which happens when two or more groups attempt to reach a common goal, and finally disruptive conflict which results from trying to reduce or defeat the opponent. The last type of conflict is common between nurses and physicians and has been reported by both professions ⁵.

Nurse managers work in an environment that conflict repeatedly occurs and hard to loosen. They are responsible for inspiring a safe and healthy environment for the health care team and the patients ¹³. According to Kaitelidou, et al., ¹⁴, about 20% of nurse managers time consumed in managing conflict. In the nursing profession, the conflict must be handled with confidence and arouse the best results and nurse managers need to use her communication skills and interpersonal skills during interaction with the nurses to identify the main problem that leads to conflict and identify the most appropriate methods of handling conflict in the hospital ¹². Conflict management towards constructive action it is by far the best approach, but conflict management styles are complex and although some may use one style more than others, that is usually dependent on the particular situation and the participants ¹.

Conflicts in the healthcare environment tend to be far more complicated because they often involve ongoing, complex interactions that are based in emotion. As in hospital one would interact with various human resources with diversity, including physicians, nurses, managers and personnel from same or other departments ¹⁵. However, sometime nurses are working under difficult and stressful situation which can lead to negative interpersonal relationship with other co-workers, and they are so busy in their work to reflect upon and to resolve it. As a result, patient care will be compromised and organization would lose its productivity. Healthcare professionals, who understand each other’s roles and can work effectively together, have been shown to provide higher quality care ¹⁶.

This study will not only benefit these hospitals but other similar hospitals as well. It is also important to both decision makers to put into their perspective these data during policy making and to the nurses themselves to insight them with their problems to take care. However, currently, in Egypt few studies were done in the area of types of conflict. Hence this study was conducted to compare types and levels of conflict among nurses between Damanhur (Egypt) and Taif (Saudi Arabia).

The main aim of the current study was to compare types and levels of conflict among nurses in National Medical Institute at Damanhur (Egypt) and Taif Governmental Hospitals (Saudi Arabia).

1. What are the types and levels of conflict at the Egyptian hospital among studies nurses?

2. What are the types and levels of conflict at the Saudi hospitals among studies nurses?

3. Is there a differences between Egyptian and Saudi hospitals regarding types and levels of conflict?

4. Is there a correlation between socio-demographic characteristics of the studied sample and experienced types and levels of conflict among nurses?

2. Subjects and Methods

A comparative cross - sectional research design was utilized in the current study.

The present study was performed in two main settings:

Ÿ The first setting is National Medical Institute at Damanhur, Egypt which is affiliated to Ministry of Health and Population (MOHP).

Ÿ The second setting are Taif Governmental Hospitals, Saudi Arabia which are (King Faisal Specialized Hospital {KFSH} & King Abdul-Aziz Specialized Hospital {KASH}, at Taif city which are affiliated to Ministry of Health.

Random sample (450) nurses composed the study sample, (200) nurses from National Medical Institute at Damanhur, Egypt and (250) nurses from both (King Faisal Specialized Hospital {KFSH} & King Abdul-Aziz Specialized Hospital {KASH}, Saudi Arabia, who were working in the following areas (Intensive Care Units (ICU), Pediatric Intensive Care Units (PICU), Hemodialysis units and Emergency units).

Nurse managers and staff nurses who have at least one year of experience and working at the study settings, and as well as agreed to participate in this study were included.

Two questionnaires were utilized to assess the variables in this study from nurses' points of view:

1. Assessment Sheet: This sheet was prepared by the investigators to collect the socio-demographic data of the study sample (such as; age, gender, qualification, occupation, total years of experiences, country, hospital, nationality and marital status).

2. Nursing Conflict Scale (NCS): was used to estimate the types and levels of conflict experienced by nurses in the hospital settings. NCS was first and foremost developed and examined in Ain Shams University Hospital, Cairo, Egypt by El-shimy et al., ¹⁷. The total instrument reliability is (0.86). It includes thirty six items uses five point Likert scales from (1-5): 1 = never, 2 = rarely, 3 = sometimes, 4 = often and 5 = always with a total score of (180). NCS is classified into six categories of conflicts: Disruptive conflict (5 items), interpersonal conflict (7 items), intrapersonal conflict (6 items), intergroup conflict (6 items), intragroup conflict (6 items), and competitive conflict (6 items). The scoring system of the tool was calculated as: Low conflict level ranges from (1 to 72), moderate conflict level ranges from (73 to 108) and high conflict level ranges from 109 to 180.

The data collection stage of the study was executed in three months from 1/9/2018 to 30/11/2018. Before distributing the questionnaire, clear instructions were given to each participant. The questionnaire sheets were distributed and collected on the same day or next day, according to the workload on the nurses.

Before any attempt to collect data, an official approval to conduct the study was obtained from medical and nursing directors of all hospitals included in the study. This was done by sending letters containing the aim of the study to each hospital director. Each participant was notified about the purpose of the study, the right to refuse to participate in the study. Anonymity and confidentiality of the information gathered was ensured.

A pilot study was performed on 20 nurses not involved in the study sample to test the practicability and applicability of the tool, detect any difficulties, estimate the time needed to fill in the questionnaire. Based on the results of the pilot study, the necessary modification and explanation of some questions were done. Validity and reliability of the study tool was tested using Cronbach’s coefficient alpha (0.86).

Data were checked out, coded, entered, analyzed and tabulated using Statistical Package of Social Sciences (SPSS) version 23. Both descriptive statistics (frequency, percentage, mean and standard deviation) and inferential statistics (Pearson correlation test, chi-square test, independent t test were used according to type of variables. P value less than 0.05 was considered significant.

3. Results

Table 1: illustrated socio-demographic characteristics of participant nurses, as noticed from the table, the mean age of participant nurses were (29.7±4.5 and 33.6±8.8 respectively) in both Saudi and Egyptian hospitals, while, the mean experience were ( 8.2 ±4.2 and 12.7 ±7.6 respectively) in both Saudi and Egyptian hospitals. The majority of participant nurses were staff nurses (77.2% and 81% respectively) in both Saudi and Egyptian hospitals. Regarding, education, about three fourth (75.2%) of studied nurses in Saudi Arabia had Bachelor degree, whereas, more than one quarter (27%) of participant nurses in Egypt had Bachelor degree. (92%) of participant nurses were female in Egyptian hospital, while (89.6%) of Saudi nurses were female.

Comparison between types and levels of conflict at both Saudi and Egyptian hospitals were demonstrated in Table 2. Regarding, disruptive conflict the highest percentage (48%) of participant nurses in Saudi hospitals had low level of disruptive conflict and the lowest percentage (9.2%) had high level of it. On the other hand, in Egypt more than one half (53%) of participant nurses experienced moderate level of disruptive conflict and the lowest percentage (4.5%) had low level of it and the differences between the two countries were statistically high significance, P=0.000. Concerning, interpersonal conflict, less than one half (46.8%) of participant nurses in Saudi hospitals experienced low level of interpersonal conflict. Likewise, (46.5%) of Egyptian nurses experienced moderate level of interpersonal conflict. There were a statistically high significant differences between both countries, P=0.000. It is clear that there were a statistically significant differences between all types and levels of conflict in both Egyptian and Saudi hospitals.

Table 3: displayed comparison between levels of conflict in both Saudi and Egyptian hospitals, as observed from the table, one third (33.2%) of participant nurses had low level of conflict in Saudi hospitals, whereas (21.5%) of them had low level of conflict in Egyptian hospital. The differences between both countries were statistically significant, P=0.006. Moreover, (56.4% and 41.5% respectively) of participant nurses had moderate level of conflict in both Saudi and Egyptian hospitals and there were a statistically significant differences between both countries, P=0.001. In addition, only (10.4%) of participant nurses had high level of conflict in Saudi hospitals. In addition, more than one third (37%) of participant nurses had a higher level of conflict in Egyptian hospital and the difference between them were statistically significant.

Table 4: demonstrated comparison between types of conflict experienced by participant nurses in both Saudi and Egyptian hospitals. The highest mean score of experienced conflict among Egyptian nurses were interpersonal conflict followed by intragroup conflict (13.8 ±3.1 13.3±1.7 respectively). On the other hand, the highest mean score of experienced conflict among Saudi nurses were intragroup conflict followed by competitive conflict as evident by (12.9± 2.5, 12.8±3.0 respectively), while the lowest mean score was disruptive conflict (8.7±2.6). Moreover, there were a highly statistically significant differences among all types of conflict between both Saudi and Egyptian hospitals, P=0.000.

Relation between socio-demographic characteristics and total conflict score among both Saudi and Egyptian hospitals are illustrated in Table 5. Nearly less than three quarters (71.3%) of Saudi nurses aged from 20-30 experienced conflict, while (60.5%) of Egyptian nurses in the same age group experienced conflict. Three quarters (74.9%) of Saudi nurses who had less than 10 years of experiences had conflict, likewise, (60.8%) of Egyptian nurses with the same years of experiences had conflict. Regarding, marital status (63.5%) of Saudi nurses experienced conflict, and about two thirds (65.6%) of Egyptian nurses experienced conflict. Concerning occupation, (88.6%) of staff nurses experienced conflict among Saudi nurses and (85.4%) of staff nurses had conflict among Egyptian nurses.

Figure 1: depicted comparison of the total conflict experienced by nurses in the Saudi and Egyptian hospitals, the total level of conflict experienced by nurses in Saudi hospitals were (68.6%). Likewise, the total level of conflict experienced by nurses in Egyptian hospital were (76.9%). As observed from the table, Egyptian nurses had a higher level of conflict than Saudi nurses.

4. Discussion

Conflict in nursing profession is natural and inevitable and arises as a daily challenge in healthcare organizations. Therefore, conflict management is extremely important for organizational effectiveness and efficiency and nursing staff must effectively manage conflict in order to provide an environment that stimulates personal growth and ensures quality of patient care ¹¹. Nurses as first-line healthcare providers experience conflicts at sufficiently great rates, on a regular base and most reports identify that interpersonal and intragroup conflict are the most common sources ^{1, 18}. Nurses' conflict has multiple harmful consequences on patients, healthcare organizations and also nurses themselves ¹⁹.

The current study's findings revealed that the highest mean score of conflict experienced by Egyptian nurses were interpersonal and intragroup conflict. In the same line, study conducted by El-Hosany ²⁰ reported that the majority (73.5%) of the surveyed nurses had interpersonal conflicts and may arise from the persistent and challenging interaction between nurses and other staff members with different perspectives that lead to conflict. In addition, this finding was in agreement with Arafat et al., ¹² who found that more than three quarters (78.0 %) of nurses had interpersonal conflict. This is may be due to the nurses face simultaneous work environment that known by heavy workload requirements with greatest emphasis on quality patient care ²¹. Also, the study was confirmed by Zakari et al., ²² who reported that (82.1%) of the included nurses had interpersonal conflict.

Additionally, a study aimed to determine type and frequency of interpersonal conflict, an explanation of the most distressing event experienced, consequences of the behavior; and training to manage such events among nurses in their first year of practice in New Zealand. The results reflected that numerous nurses in their first year of practice experienced interpersonal conflict; which lead to a greater rate of absenteeism and affected their intent to leave the profession, nurses also stated that they did not obtain any training to handle such events ²³.

Furthermore, study conducted by Cavar and Petrak ⁴ reported that the most often causes of conflict are interpersonal relationships, since nursing always encompasses teamwork, which is exceptionally demanding; every member has their role and responsibility, which opens up a possibility for potential escalation of conflict between them. Similarly, study conducted by Jerng et al., ²⁴ revealed that the employee of the hospital utilized the Incident Reporting System (IRS) to actively report the Workplace Interpersonal Conflicts (WICs) although the IRS was originally designed for the reporting of safety events.

Moreover, study done by Mais ²⁵ revealed that the participants in her study reported staffing shortages and increased workload as a factor that contributed to stress and nurse-to-nurse conflict. Conflict between nurses arises during staff shortages by creating an increased workload and additional stress. In the same track, Sompa ²⁶ asserted that interpersonal conflict is an unavoidable outcome of human interaction. Some sources of interpersonal conflict are discrimination of activities, communication problems, unclear authority, differences in attitude, diversity of perception and unsuitable organization environment.

Meanwhile, the study's results demonstrated that the most common types of conflict experienced by Saudi nurses were intragroup and competitive conflict. These results can be explained as most of nurses in Saudi Arabia were contracted and compete against each other to guard their job. Also, the majority of them are afraid of losing their jobs at any time. Therefore, they do their best to protect their jobs which leads to the occurrence of conflict.

The major findings of the present study revealed that the majority of surveyed nurses experienced moderate level of conflict in both Egyptian and Saudi hospitals. These findings were in agreement with Kunaviktikul et al., ²⁷ who assessed in their study the level of conflict, the level of job satisfaction, and turnover intention among nurses. The study detected that staff nurses had a moderate degree of conflict. In a similar path, Higazee ⁵ determined the level of conflict perceived by hospital nurses. She identified that the majority of the studied nurses (72.7%) had moderate to high level of conflict.

Likewise, Zakari et al., ²² tested the correlation between nurses' perceptions of conflict and professionalism in three health care sectors in Saudi Arabia. The Perceived Conflict Scale was utilized to assess level of conflict, and the Valiga Concept of Nursing Scale was used to assess perception of professionalism among nurses. The study displayed a low perception of professionalism among nurses and intragroup type of conflict had a statistically significant association with their perception of professionalism. Meanwhile, study targeted to explore the relationships between scope of practice and communication among teams of nurses from Sydney metropolitan hospitals in New South Wales. Nurses asserted that unless they realize their roles and scope of practice intra-professional workplace conflict may arise. In addition, intra-professional conflict may negatively affect both nurses and patients ²⁸.

The current study's findings indicated that inexperienced nurses in both Egyptian and Saudi hospitals had greater conflict level. These results were supported by El-Hosany ²⁰, who mentioned that inexperienced nurse had higher interpersonal conflict and job dissatisfaction level. These findings were congruent with Mulki et al., ²⁹ who concluded that experience has a negative relationship with stress and conflict. These findings can be interpreted as experienced individuals are less vulnerable to the adverse effects of stress and conflict factors such as panic from making mistakes, anxiety of career pathway, work overload or job security. As a result, it can be suggested that promoting the emotional regulation could decrease the negative effects of job stress and interpersonal conflict.

Moreover, the study's findings concluded that conflicts were more among younger nurses than older nurses. These results were in the same line with Polat et al., ³⁰ who mentioned that as the age of nurses increases the work-family conflict total scale score (WFCTS) decreases. However, the regression analysis suggested that age is not predictive of work and family conflict. Lambert et al., ³¹ found a negative correlation between work family conflict and age.

In the same line, study done by Arafat et al., ¹² revealed that the nurses with interpersonal conflict were, younger age, married, less than five years of experience. This is may be due to work overload, emotional exhaustion, dealing with critical illness, death, lack of personal accomplishment poorly planned work shifts, deep supportive relationship, interpersonal/intergroup conflict, and role ambiguity. Also, these findings were congruent with Rengin ³² who found that job stress has been reported among younger ones rather than older ones and increasing among new graduate nurses.

Likewise, the study's findings indicted that the majority of married nurses experienced conflict more than unmarried nurses. These findings can be interpreted as married nurses had dual roles as mothers and employees, and also had babies which makes it difficult for them to reconcile their roles as mothers and their roles as employees. These results were supported by Polat et al., ³⁰ who declared that according to the social role theory of gender differences, women in our society are expected to fulfill their main roles in families and their roles in the workplace as secondary in order to have a career. Additionally, Aras and Karakiraz ³³ reported a difference in work-family conflict in terms of marital status, wedded people experienced more conflicts than single people.

Moreover, study done by Namdari et al., ³⁴ pointed out that most participants highlighted that family-work conflict places a major tension on them, decreases their concentration and preciseness at work, and by this means, negatively influences the quality of their care services. In the same line, with these findings, a previous study notified that family-work conflict is connected with various negative outcomes for nurses, such as physical and mental fatigue, emotional strain, poor professional performance, increased likelihood of nursing errors, and reduced ability for quality care provision ³⁵.

Similarly, another study on nurses at five hospitals in Taiwan also discovered that work-family conflict negatively influenced nurses’ professional practice. Thus, it can also result in great probability of nursing errors ³⁶. Another cross-sectional research on Chinese female nurses specified that family-work conflict reduced their professional efficacy ³⁷.

In the same track, conflict between family and work is a two-sided problem, which contains both family-work conflict and work-family conflict. The previous takes place when familial problems influence the quality of work life and result in reduced ability to perform occupational roles. The last happens when professional responsibilities decrease worker’s time, commitment, and energy, and by this means inhibit him/her from effectively accomplishing his/her familial roles ³⁸.

On the contrary, study conducted by El-Hosany ²⁰ indicated a significant negative relationship between interpersonal conflict scores and marital status (p < .01), where 61.2% of the nurses with interpersonal conflict were unmarried. This finding may be because they are younger and allocated more tasks than their older and senior colleagues. Furthermore, married nurses frequently take maternity leave that gives them a break and let them rest in their homes retrieval their power and recovering from the stressful events associated with the working climate.

In this regards, Okwaraji and En ³⁹ detected high burnout and psychological distress levels among unmarried nurses compared to married nurses. In the same track, study conducted by Cavar and Petrak ⁴ revealed that the participants think that sociodemographic differences very rarely become the source of conflict, and at the same time, they experience emphasis of such differences and polarization in their society. Also, the study's findings were contradicted with Polat et al., ³⁰ who mentioned that single nurses experienced Work Family Conflict (WFC) and WFCTS more than married nurses.

The current study's results revealed that Egyptian nurses had a higher level of conflict than Saudi nurses. These findings can be interpreted as nurses in Saudi Arabia had a higher socioeconomic status than nurses in Egypt. Also, nearly about two thirds of surveyed nurses in Saudi Arabia were non- Saudi and contracted which respect policies and procedures, adhere to law and respect culture differences more than nurses in Egypt.

Conflict may be more personally important as nurse colleagues’ action / inaction may inhibit the work group’s ability to function properly, impede attainment of individual work goals, or even potentially jeopardize one’s safety. As such, incompetence and irresponsibility are important behavioral aspects of nursing care ²¹.

Finally, Conflict has also been described as unavoidable, dynamic, constant, and an innate human attribute ^{40, 41}. It is the root cause for any mishap in patient care, these are medication error, improper communication, lack of respect, delay care, cultural and religious valves violation, which would have a direct impact on image of organization, as a result staff turnover and job dissatisfaction will be intensified. Therefore, it is vital for a nurse leader to identify the causes and sources of conflict, for which the leader should have specific skills to avoid it and improve the quality of patient care ¹⁵.

5. Conclusion

Conflict is unavoidable in nature. It is an important issue within health care organizations all over the world. Interpersonal conflict and intragroup conflict were the most common types of conflict experienced by Egyptian nurses. On the other hand, the greatest popular types of conflict experienced by Saudi nurses were intragroup conflict and competitive conflict. Moreover, Egyptian nurses experienced moderate to high level of conflict, while, Saudi nurses experienced moderate to low level of conflict. Additionally, Egyptian nurses had a higher level of conflict than Saudi nurses. Likewise, conflict are greater among younger age nurses, married, staff nurses and nurses with less than ten years of experience.

6. Recommendations

In the light of the study findings, the followings are recommended:

1. It preferable for hospital administrators to make efforts to collaborate organizational activities, creativity, and high performance to manage existing conflict successfully.

2. Nurse managers in the chosen hospitals need to utilize effective conflict management strategies to reduce conflict between nurses and to create a more healthier and productive work environment which definitely affect the quality of nursing care provided.

3. Nurse managers should develop proper strategies for nurses’ job enrichment, in-service and continuing education programs about stress management, time management, and different conflict management styles to improve quality patient care.

References