Abstract
Background:
Conflict is a continuous challenge in hospitals. Due to the nature of the treatment team, identifying conflicts in hospitals is one of the managers’ primary and essential tasks.Objectives:
The current study examined the level and causes of conflicts between hospital employees and managers.Methods:
The current descriptive-analytical study was conducted in 2018 - 2019 on a random sample of 320 hospital staff and managers. Data were collected by self-administered questionnaires. Descriptive statistics, t test, and ANOVA were used in SPSS version 15 for data analysis.Results:
The mean conflict scores showed that perceived conflict between staff and managers was the highest for nursing staff (4.17 ± 0.94), which was statistically significant. In contrast, paraclinical staff reported the least conflict with managers (2.94 ± 0.88). Nursing staff noted that the most critical cause of conflicts between employees and managers was “the unfair distribution of human resources”. In contrast, from managers’ perspective, “non-compliance with process/standards/regulations of the hospital” was the most important source of conflict. There were meaningful associations between marital status, job experience, and age, and conflict levels (P < 0.05).Conclusions:
Various reasons can cause conflicts in different parts of the hospital. The findings provide a clear vision for managers about the causes of conflicts, which must be addressed successfully.Keywords
1. Background
Human resources are the critical elements of any organization. Interactions between employees and managers determine the fate of organizations in a way that constructive and purposeful relationships between them lead to the organization’s success, and counterproductive relations result in negative consequences (1). Tepper believes that the relationship between managers and employees is a source of conflict (2). Conflict is the process of perceiving or feeling any incompatibility within or between individuals, groups, or organizations that leads to contradicting behavior, covert or overt, from both sides (3). According to a study by Choi, the most distressing conflict for individuals is the conflict between employees and managers; however, the conflict between individuals at different levels of a hierarchy is different from a conflict between two colleagues in terms of concept and consequences (4). Jehn and Mannix divide the conflict into two distinct types: Task conflict and relationship conflict. Through deep discussions about procedures, distribution of organizational resources, and decisions, task conflict can increase the quality of the decision, which, in turn, enhances the effectiveness of the organization, while relationship conflict, which is caused by rude attitudes, pessimistic comments, and deliberate ignoring of issues, only hinders organizational effectiveness (5). Relationship conflict can turn employees into uncooperative and counterproductive members of the organization. Managers are a potential source of such conflicts; meanwhile, by adapting employee-sensitive management styles, managers can increase organizational citizenship behavior and decrease workplace deviance behavior (4). According to a field study, 21% of managers’ time is spent addressing conflicts (6).
Hospitals as social institutions are one of the essential elements of the health system dealing with conflicts every day (7). The nature of hospitals and the urgency of services provided make them prone to conflicts (8). There is no doubt that these conflicts adversely affect the performance of hospitals, create conditions for losing efficient human resources, or cause conflicts and tensions, which, if profound and severe, can compromise patients’ treatment and the health status of the staff; therefore, they may become problematic (3, 9). In the long-term, conflict affects the effectiveness of hospitals and takes the time of managers and staff. Therefore, it will play a decisive role in the success or failure of the hospital (9). Studies have shown that conflict is challenging in hospitals affiliated with Ardabil University of Medical Sciences (10-12). Due to the nature of the treatment team, identifying conflicts in these hospitals is one of the managers’ primary and essential tasks.
2. Objectives
The current study examined the level and causes of conflicts between employees and managers of hospitals affiliated with Ardabil University of Medical Sciences. The results can be used as a practical guide for managers to increase the effectiveness of addressing conflicts.
3. Methods
The current descriptive-analytical study was conducted in 2018 - 2019 in hospitals affiliated with Ardabil University of Medical Sciences. Hence, the study population was all employees (physicians, nurses, paraclinical staff, and administrative staff) and managers (clinical and administrative) working in these hospitals.
A questionnaire was developed using the literature review and semi-structured interviews with 35 hospital managers and employees to collect the data. It contained two parts, one for demographic information and another for factors causing or intensifying the conflict between staff and managers rated on a five-point scale (1 indicating very low to 5 indicating very high). The study received approval from the Tehran University of Medical Sciences Ethics Committee. Besides, the consent of the study participants was obtained.
According to the total number of staff in each category, 320 staff and managers were randomly selected to fill out the questionnaire. It is worth noting that the participants were free to withdraw and had enough time to fill out the questionnaire. The content validity ratio and content validity index were used to evaluate the content validity quantitatively. The test-retest method and spearman’s correlation were used at an interval of 14 days to determine the reliability of the questionnaire (72% for staff and 76% for managers). Descriptive statistics, t test, and ANOVA were used in SPSS software version 15 for data analysis.
4. Results
Of 320 questionnaires, 281 were analyzed after eliminating the incomplete ones, indicating a response rate of 88%. Among them, 76.5% were clinical staff, and 23.5% were administrative staff. Most of the participants (61.5%) were women, and 39.1% were aged 31 - 40 years. Besides, 67.3% were married, and 42% had work experience of 11 to 20 years. Moreover, 77% had a bachelor’s degree, and 58.4% were formally employed. Finally, 10.7% of the participants had managerial positions.
The mean conflict scores showed that perceived conflict between staff and managers was the highest for nursing staff (4.17 ± 0.94), which was statistically significant (Table 1). In contrast, paraclinical staff reported the least conflict with managers (2.94 ± 0.88).
Mean Conflict Score by Managers, Clinical, Paraclinical, and Administrative Staff a
| Occupational Group | Mean ± SD | P-Value | |
|---|---|---|---|
| Staff | Managers | ||
| Physicians | 3.31 ± 0.79 | - | 0.037 |
| Nurses | 4.17 ± 0.94 | - | |
| Paraclinical staff | 2.94 ± 0.88 | - | |
| Administrative staff | 3.12 ± 1.49 | - | |
| Managers | - | 3.47 ± 1.68 | |
As shown in Table 2, among various factors causing conflict, three factors with the highest impact on conflicts between employees and managers in each field of work were selected and described. Nursing staff pointed out that the most crucial cause of conflicts between employees and managers is “the unfair distribution of human resources,” while physicians and paraclinical staff mentioned “not paying attention to opinions, and lack of opportunity to participate in decisions” as the most significant causes of conflicts. Administrative staff believed that “inadequate managers’ awareness about the work processes” is the most critical cause of conflicts. In contrast, from managers’ perspective, “non-compliance with process/standards/regulations of the hospital” was the most important source of conflict.
Most Important Causes of Conflict Between Staff and Managers
| Occupational Group | Conflict with | Mean ± SD | Most Important Causes of Conflict | Mean ± SD |
|---|---|---|---|---|
| Nurses | Managers | 4.17 ± 0.94 | Unfair distribution of human resources | 4.84 ± 1.23 |
| Unconventional income differences between the staff | 4.74 ± 1.17 | |||
| Not paying attention to opinions and lack of opportunity to participate in decisions | 4.72 ± 0.83 | |||
| Physicians | Managers | 3.31 ± 0.79 | Not paying attention to opinions and lack of opportunity to participate in decisions | 4.41 ± 0.88 |
| While necessary resources are not available, managers expect perfection | 4.22 ± 0.75 | |||
| Prolongation of processes | 4.01 ± 1.12 | |||
| Paraclinical staff | Managers | 2.94 ± 0.88 | Not paying attention to opinions and lack of opportunity to participate in decisions | 3.87 ± 1.30 |
| While necessary instruments and resources are not available, managers expect perfection | 3.79 ± 1.03 | |||
| Late salary payment | 3.44 ± 1.34 | |||
| Administrative staff | Managers | 3.12 ± 1.49 | Inadequate awareness of managers about the processes | 3.75 ± 1.34 |
| Lack of unity of command | 3.52 ± 1.31 | |||
| Not paying attention to opinions and not providing the opportunity to participate in decisions | 3.48 ± 1.28 | |||
| Managers | Staff | 3.47 ± 1.68 | Ignoring procedures/standards/regulations of the hospital | 3.97 ± 0.83 |
| Providing incomplete information, either inadvertently or intentionally | 3.93 ± 0.99 | |||
| Lack of responsibility | 3.81 ± 0.60 |
According to our findings, there was a statistically significant relationship between the level of conflict and the work experience of individuals (P = 0.03). People with 11 - 20 years of work experience reported the highest conflict rate. In terms of age group, the most perceived conflict was related to the age group of 31 - 40 years (P < 0.001). Marital status was another variable that affected the perception of conflict so that married people experienced more conflict than single people (P = 0.01). However, gender (P = 0.45), education (P = 0.80), and type of employment (P = 0.07) did not have a significant relationship with the level of conflict (Table 3).
Mean Conflict Scores by Demographic Variables a
| Demographic Variable | Mean ± SD | P-Value |
|---|---|---|
| Marital status | 0.013 | |
| Single | 2.97 ± 0.81 | |
| Married | 3.40 ± 0.96 | |
| Job experience | 0.030 | |
| < 10 | 2.95 ± 0.89 | |
| 11 - 20 | 3.48 ± 0.81 | |
| > 20 | 3.06 ± 0.67 | |
| Age groups | < 0.001 | |
| 21 - 30 | 2.81 ± 1.21 | |
| 31 - 40 | 3.63 ± 1.20 | |
| > 40 | 3.09 ± 1.21 | |
| Gender | 0.45 | |
| Male | 3.08 ± 1.18 | |
| Female | 3.25 ± 1.06 | |
| Education | 0.808 | |
| Diploma | 3.08 ± 1.18 | |
| Bachelorette | 3.33 ± 0.98 | |
| Master | 3.04 ± 0.89 | |
| Ph.D. or higher | 3.26 ± 1.24 | |
| Type of employment | 0.070 | |
| Under service | 3.02 ± 1.10 | |
| Contractual | 2.98 ± 1.33 | |
| Conditional agreement | 3.41 ± 1.15 | |
| Permanent | 3.23 ± 1.10 |
5. Discussion
The conflict between managers and employees is common in all organizations, but it is hidden in most cases. Employees do not express their feelings or attitudes about conflicts with their direct managers and/or supervisors explicitly and prefer to express their concerns and negative feelings to colleagues, friends, or even family members or revenge indirectly, cleverly, and imperceptibly. In such situations, managers must prevent and address such behaviors with tact and sharpness. The role of managers is of crucial importance, mainly when behaviors are directly related to management and leadership style, behavior, and quality of the manager’s relationship with employees (1). Studies of the causes of conflicts have shown that whenever the causes of conflicts are ignored and, therefore, a good managerial style is not applied, not only is the conflict not addressed, but also the situation is intensified (12-14).
The current study investigated the sources of conflict between managers and employees and found that the nursing staff had the highest perceived conflict with managers. Studies by Jerng et al. (15) and Panahi Tosanloo et al. (10) investigated the conflicts in healthcare settings and found that nursing staff had the highest level of reported conflict. In contrast, based on a study conducted by Elfering et al. that investigated conflicts between employees and supervisors/managers, technical and administrative staff had the lowest level of conflict. The nursing staff and physicians were in the middle (16). Since nurses are the front-line staff of hospitals (17), the necessity of saving lives causes high anxiety. It increases the feeling of insecurity and perceived risk in them, which, in turn, enhances the likelihood of conflicts (18).
Among the causes of conflicts, “unfair distribution of human resources” was the most critical factor in the conflicts between nursing staff and managers. Notably, most of them felt like a victim of injustice, and their colleagues were not as affected as they were. It is clear that the shortage of human resources, particularly nursing staff, exacerbates the condition. In Iran, a study by Ganji Zadeh et al. showed that 98% of nursing staff pointed out “lack of enough human resources and inadequacy of salary” as the most influential factor in creating conflicts (19). Shortage of a nursing workforce is a factor that harms the performance and management decisions made to improve the productivity of this group of employees, which creates a conflict (20). That is in line with the findings of studies by Payami Bousari et al. (21), Esmaeelzadeh et al. (22), and Dehghan Nayeri and Negarandeh (23). Regarding the imbalance between the workload and payments of the nursing staff, Fili and Pooya mentioned the fair distribution of work shifts and attention to nurses’ requests when scheduling work shifts as factors improving organizational justice and reducing organizational conflicts and work-family conflicts (24).
In the current study, “differences in paid salary” was another critical factor causing conflict between nursing staff and managers. According to the equity theory, everyone who joins the organization brings the capabilities, abilities, skills, and in some cases, credibility to the organization and expects to be pretty compensated for by the organization (25). In this regard, the non-fulfillment of nurses’ demands for revising tariffs of nursing services can prepare the ground for conflicts between nursing staff and managers. “Not paying attention to opinions and lack of opportunity to participate in decisions” is a factor mentioned by all four groups as a fundamental cause of conflict with managers. Employees expect to participate in decision-making processes that eventually may apply their final results. Employees’ participation in decisions increases the probability of success. In contrast, not involving employees in making decisions may result in conflicting and sometimes destructive behaviors, which lead to failure. Nasiripour et al. reported that participation in the decision-making process via problem-solving groups or committees reduces the sources of conflict (26). Elfering et al. investigated the impacts of mediating factor of job resources on conflicts between staff and supervisors/officials in Switzerland hospitals and reported that the level of conflict was negatively associated with participation in decision-making processes (16). Therefore, as Akel and Elazeem (27) and Tengilimoglu and Kisa (28) recommended, providing opportunities for dialogue and exchange of views by managers to help employees resolve conflicts and engage them in decision-making processes is among the best strategies. Çınar and Kaban also emphasized employee feedback to achieve visionary leadership and manage conflicts (29).
According to the opinions of the physicians and paraclinical staff, “managers’ expectation of achieving perfection without providing necessary instruments and resources” was among the crucial causes of conflict. Achieving organizational goals is not feasible without having access to necessary equipment, tools, or processes. No one can be held accountable for activities that they cannot do, mainly because necessary tools should be available. Elfering et al. reported that the degree of conflict with supervisors was strongly correlated with providing job resources and understanding social support by supervisors (16).
In the current study, physicians believed that the “prolongation of process” causes conflict. Ardalan and Beheshti Rad also investigated the association between organizational conflicts and the performance of private hospitals and found that the incidence of conflicts was positively and significantly associated with bureaucratic culture (30). A study examining the conflict among senior, middle, and operational managers of hospitals affiliated with Tehran University of Medical Sciences by Mosadeghrad et al. also emphasized this issue (31).
Since the processes of career advancement and administrative appointments are different from those of clinical sectors, the most important cause of conflict mentioned by the administrative staff was “inadequate awareness of managers about the processes,” mainly because some managers do not have enough experience. While for clinical staff, particularly nurses, career advancement is largely predefined and similar for everyone.
On the other hand, managers believed that “non-compliance with processes/standards of work/regulations” is the most critical cause of conflicts. Managers expect employees to comply with the rules and regulations of the organization. As reported by Leineweber et al., investigating the work-family conflict among nursing staff, when staff do not comply with regulations and ignore the recommended procedures to achieve the goals, the likelihood of conflicts increases (32). In the current study, “providing incomplete information, either inadvertently or intentionally” and “lack of responsibility” were also identified as factors causing conflict. According to the study by Fili and Pooya, the organizational commitment had the most effect on information justice (i.e., employees’ perception of the amount and quality of received information) (24). Ambiguous strategies and instructions, lack of understanding opinions and feelings, incomplete information, lack of proper understanding of performance, and staff emotions are among the most critical symptoms of ineffective interpersonal and in-hospital communications (33). Sometimes conflicts arise because of not providing appropriate, sufficient, or in-time information, either inadvertently or intentionally. A study conducted in Cyprus Government Hospitals indicated that about 60% of the staff experienced a conflict one to five times a week. Organizational variables and weak communications were the most important causes (34). Leineweber reported that problems in interpreting and explaining the conversations, exchanging inaccurate information, and disruption in the communication channels are barriers to effective communication. Besides, this study reported that when people and groups’ regulations, methods, and behaviors are not clear enough, the likelihood of conflicts increases—the consequent chaos results in reducing organization performance or losing highly efficient personnel (32). Khadivi et al., in a study entitled “prediction of organizational conflict in public hospitals of Tabriz city based on nurses’ professional ethics”, reported a significant association between dimensions of professional ethics and organizational conflicts. There was a negative association between the degree of conflict and dimensions of trust, fairness, knowledge and empowerment, conscientiousness, respecting colleagues, quality of care, and commitment to respect the nursing field (35). According to our findings, among demographic characteristics, marital status, age, and work experience had a statistically significant relationship with the conflict level. According to the present study, people in the middle decade of their career experienced the highest level of conflict. Çınar (29) also mentioned this issue in a study. Cohen (36) calls this “power-seeking and adaptation to one’s position” and believes that employees’ most adaptability and flexibility occurs in the early work period. However, as their position in the organization stabilizes, their ambitions for power increase, and they become inflexible. This issue can lead to more conflicts. On the other hand, getting used to the situation or learning conflict management methods during the work period can be the reason for reducing conflicts reported by employees.
5.1. Conclusions
Regarding the nature of healthcare services, identifying conflicts in hospitals is one of the most important tasks of managers. The current study investigated the causes and levels of conflicts between staff with various positions and hospital managers. According to the current study, various reasons cause conflict in different parts of the organization. Therefore, the findings provide a clear vision for managers about the causes of conflicts, which must be addressed successfully. Based on the results, balanced redistribution of existing human resources, appropriate implementation of plans such as classification and ranking of jobs, performance-based payments, use of participatory management, re-engineering of processes, holding regular meetings to review challenges, and proper implementation of employee socialization process help manage organizational conflicts.
Acknowledgements
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