International Journal of Health Care Quality Assurance

Conflict and conflict management in Iranian hospitals

Ali Mohammad Mosadeghrad, Arezoo Mojbafan,
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Ali Mohammad Mosadeghrad, Arezoo Mojbafan, "Conflict and conflict management in Iranian hospitals", International
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 Conflict and conflict management in Iranian hospitals

Author 1: Ali Mohammad Mosadeghrad, PhD in Health Policy and Management, Associate
Professor, Health Management and Economics Department, School of Public Health,
Health Information Management Research Centre, Tehran University of Medical
Sciences, Tehran, Iran, Telephone: 02142933006, Email: Mosadeghrad@tums.ac.ir
Author 2: Arezoo Mojbafan, MSc in Healthcare Management, Health Management and
Economics Department, School of Public Health, Tehran University of Medical Sciences,
Tehran, Iran, Telephone: 00989123852546, E-mail: arezoomojbafan@yahoo.com

Corresponding author: Arezoo Mojbafan

Corresponding author’s e-mail: arezoomojbafan@yahoo.com
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Structured Abstract:
Purpose: Organizational conflict is disagreement between people working together.
Disagreement can be caused by differences in their personalities, values, feelings, needs, goals
and interests in a way that one tries to prohibit the other from achieving his or her goals.
Hospitals are complex and complicated organizations and are susceptible to conflict. This study
aimed to identify conflict intensity experienced by hospital managers and their conflict
management styles in hospitals affiliated to Tehran University of Medical Sciences (TUMS).
Design/Methodology/Approach: This quantitative and cross-sectional study was conducted in
2015. A self-administered questionnaire was used to collect data from top, middle and front-line
managers. Consequently, 563 managers from 14 hospitals responded to the questionnaires. Data
was analysed using SPSS software version 19.
Findings: Hospital managers reported a moderate conflict level (2.73/5). Heavy workload,
scarce resources, bureaucracy, and differences in managers’ personalities, knowledge,
capabilities and skills were the main reasons contributing to conflict. Organizational issues
caused more conflict than personal factors. Top managers experienced more conflict than middle
and front-line managers. Conflict was higher in specialized compared to general hospitals. Less
conflict was observed in administrative and support than in diagnostic and therapeutic
departments. Conflict was significantly associated with hospital size, workforce size and
managerial hierarchy, education, and turnover intention. Hospital managers used collaborating
style most frequently for managing conflict. There were significant relationships between
collaborating style and manager age, hierarchy and job tenure. Managers who attended conflict
management courses reported less personal conflict.
Practical implications: Hospital managers should mainly use collaborating, compromising and
accommodating conflict management styles to interact better with different stakeholders.
Training managers in conflict management helps them to use appropriate conflict resolution
strategies.
Originality/value: This is the first study conducted in Iranian hospitals that examines conflict
type and level and to explore senior, middle and front line managers’ dominant conflict
resolution strategies.

Keywords: Conflict, Conflict causes, Conflict management, Managers, Hospitals.

Article Classification: Original research

1
 Received – Sep 4th, 2017
Revised – June 28th, 2018; July 5th
Accepted – July 16th, 2018

Introduction
Conflict is the ‘internal or external discord that results from differences in ideas, values or
feelings between two or more people’ (Marquis and Huston, 2009, p.333), in a way that one tries
to prohibit the other from achieving his or her goals. Conflict occurs in organizations whenever
managers and employees are interacting and there is a misunderstanding, disagreement and
competition between them owing to the differences in their beliefs, values, goals, feelings,
attitudes, ideas, needs, interests and resources. Thus, conflict occurs in individuals, between
individuals, between groups and between organizations.
Personal and organizational factors cause conflict in organizations. Personal factors such
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employee personality, values, attitudes, beliefs, knowledge, abilities, and skills can contribute to
conflict (Zakari et al., 2010; Mosadeghrad, 2015). Organizational factors, including heavy
workload, time pressure, resource scarcity, unclear job descriptions and responsibilities, role
ambiguity, job uncertainty, poor communication, occupational stress, ambiguous rules and
policies, managerial expectations, and organizational changes are also the main reasons for
organizational conflict (Graham, 2009; Pavlakis et al., 2011; Mosadeghrad, 2014a).
Robbins (1978) argues that there are three views about conflict: traditional (1930-1940),
behavioral (1940-1970), and interactionist (after 1970). The traditional view suggests that
conflict is harmful with negative consequences such as violence and destruction, and therefore,
must be avoided or suppressed at any cost. The behavioral or human relations view argues that
conflict is natural and inevitable in organizations, may have either positive or negative results,
and thus, should be properly and carefully managed. Finally, the interactionist view proposes that
conflict is good and necessary for organizational growth and productivity, and hence, should be
embraced and advocated.
People working together possess different characteristics, traits, beliefs, values, habits,
needs, and expectations. Hence, organizational conflict is natural and inevitable. Conflict can be
functional or dysfunctional. Too much conflict increases frustration, anxiety, depression and
stress among employees, promotes apathy, suspicion, distrust, disintegration, disharmony,
disorder, and hostility, and reduces their morale, motivation, and productivity (Caykoylu et al.,
2011; Kunaviktikul et al., 2000; Mosadeghrad 2013a). Communication problems,
misunderstandings, role disputes, and low satisfaction and commitment are signs that too much
conflict is occurring among employees, which have detrimental effects on both employees and
organizations (Mosadeghrad 2014b). Too little conflict is also detrimental to organizational
productivity as there is little chance for change and improvement. An optimal conflict level
brings employees closer together, develops a strong team spirit, creates a healthy competition
environment, enhances employee motivation to work better and harder, stimulates innovative
thinking, generates creativity, and creates a challenging and problem-solving atmosphere, which
develops employee capabilities and allows underlying problems to be addressed and solved
(Henry, 2009; Mosadeghrad, 2015).
Hospitals are complex, complicated and bureaucratic social organizations and are
vulnerable to conflict, owing to work nature, diverse interactions, and stressful working
environments. Employees with different educational status in different disciplines are working
together in a hospital. Hence, conflict is natural and inevitable in hospitals. One Cyprus study

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 revealed that about 60% of hospital staff experienced conflict one to five times per week. Almost
37% spent 90 minutes in a working shift on conflict resolution. Organizational factors and poor
communication were the main reasons for conflict (Pavlakis, et al., 2011). In another study,
physicians and nurses in Greek pediatric hospitals mostly experienced conflict. Doctors reported
more conflict than nurses (Kontogianni, et al., 2012).
Employees experiencing too much conflict become more emotional and may lose their
focus on tasks and duties and become less productive. Dysfunctional or destructive conflict can
demoralize staff, decrease motivation and satisfaction, increase absenteeism and turnover, reduce
collaboration and it is detrimental to patients (Brinkert, 2010; Graham, 2009; Mosadeghrad
2014c). Hence, conflict must be managed effectively, otherwise, it causes further problems and
reduces organizational productivity. Healthcare managers must be able to identify conflict and its
sources, so, they can use appropriate conflict resolution strategies to combat or stimulate conflict.
Conflict management is ‘the process of recognizing the conflict, determining its type and
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intensity, evaluating its effects, determining and implementing appropriate intervention strategies
and measuring their results’ (Cinar and Kaban, 2012, p.199). Conflict management aims to
maintain conflict level to the point that causes a dynamic, live, and creative organization
encouraging people to be innovative and productive (Mosadeghrad, 2015). Managers should
encourage functional or constructive conflict and combat destructive conflict.
Thomas and Kilmann (1974), considering two dimensions, (i.e., assertiveness, and
cooperativeness) developed a model with four conflict solving strategies: collaborating,
accommodating, compromising, competing and avoiding. Competing (assertive and
uncooperative) is a win-lose strategy where an individual pursues his or her own concerns at the
other person’s potential expense. Accommodating (unassertive and cooperative), opposite to
competing, is a lose-win strategy, where, one party neglects his or her own interests to satisfy the
other party’s concerns. Avoiding (unassertive and uncooperative) is a lose-lose strategy where
both parties do not address conflict and prefer to leave it unresolved. Collaborating (assertive and
cooperative), opposite to avoiding, is a win-win strategy where each individual collaborates and
strives to find a solution that fully satisfies both parties’ concerns. It is usually the best style for
managing organizational conflicts. Finally, individuals using the compromising (moderate in
both assertiveness and cooperativeness) strategy aim to find an acceptable solution that satisfies
both parties’ concerns partially (Thomas and Kilmann, 1974).

Figure 1 here

Conflict management skills help managers to develop a trust atmosphere among staff in the
organization, so that employees can easily express their opinions. Ineffective conflict
management negatively affects an organization through generating more conflict. Therefore,
hospital managers should identify conflict type, intensity and its effects and accordingly apply
appropriate strategies to handle conflict smoothly and positively. Otherwise, conflict hinders
employees’ and organizational productivity.

Methodology
Purpose and objectives
We aimed to examine the conflict type and intensity and explore conflict management strategies
used by managers in hospitals affiliated to Tehran University of Medical Sciences (TUMS).

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 Design and setting
This descriptive and cross-sectional study was conducted in 2015. Tehran University of Medical
Sciences has 16 hospitals (i.e., five general and 11 specialized hospitals). Senior managers in two
hospitals did not allow us access, so the study was conducted in 14 hospitals.

Sampling
The study sample included all senior, middle and front-line managers working in therapeutic,
diagnostic, administrative and support departments and units.

Instruments
A survey questionnaire was used for data collection. The questionnaire was based on a literature
review on prior research (Berryman‐Fink and Brunner, 1987; Valentine, 2001; Morrison, 2008),
and had three sections that asked managers about their demographic details, conflict type and
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intensity, and conflict management styles. The first section dealt with the personal demographic
characteristics, including gender, age, marital status, educational level, work place, working and
managerial tenure, etc. In the second section, we measured conflict type and intensity (cause and
level) using 22 personal and organizational conflict factors, which are rated on a 6-point Likert
type scale from not at all (representing 0) to very high (representing 5). Thus, conflict intensity
was varied between 0 and 5. Average scores less than 1, between 1 and 1.99, between 2 and 2.99,
between 3 and 3.99 and more than 4 considered as very low, low, moderate, high, and very high
conflict respectively. Finally, the third section, using 30 questions, assessed conflict management
styles using Thomas and Kilmann’s (1974) model. Each conflict management style had six
questions and a 5-point Likert type scale from very low (representing 1) to very high
(representing 5). Thus, possible score varied between 1 and 5. The style with the highest score
was the manager’s dominant conflict management style.
The questionnaire’s face and content validity were established through the literature
review, supplemented with a pilot survey among several hospital managers and academics,
knowledgeable about hospital conflict management. Experts’ suggestions were incorporated in
the instrument and reviewed again by them. Questionnaire internal consistency (reliability) was
tested using Cronbach's alpha coefficient. A Chronbach's α 0.7 and above is considered high
reliability (Cronbach, 1951). The Alpha coefficient was 0.94 for conflict intensity and 0.99 for
conflict management style indicating high internal consistency.

Data analysis
Data was analyzed using descriptive and analytical statistics via SPSS software (version, 19).
Missing values were checked prior to statistical analysis. Frequency, percentage, mean, and
standard deviation were the main descriptive statistics. Pearson and Spearman correlation
coefficients, Student’s t-test, ANOVA and regression analysis were the main inferential
statistics. Statistical significance level was set at 0.05.

Ethical considerations
The TUMS Research Ethics Committee reviewed and approved our study. The main ethical
issues involved in this study were voluntary participation, informed consent, anonymity,
confidentiality and respondents’ right to refuse to participate. Permission to gather data was
obtained from hospital presidents.

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 Result
Data was collected from 563 managers (74% response rate). Their demographic information is
presented in Table I. Respondents were mostly females (67.3 %), married (82.1%), in 41-50 age
groups (44 %), and holding a Bachelor’s degree (72.1%). Managers’ mean age was 41 years.
Their mean job tenure was 17 years and an 8 year mean managerial tenure. Only 7% received
education and training on conflict management. About 15.3, 57 and 27.7% had traditional,
behavioral, and interactionist views on conflict management, respectively.

Table I here

As Table II shows, hospital managers reported a moderate conflict level (2.73/5). Organizational
factors (2.75) caused more conflict than personal factors (2.71). Heavy workload (3.37), scarce
resources (3.18) and inappropriate organizational policies (2.92) caused the most; and sharing
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resources (2.53), organization size (2.23), and organization hierarchy (2.15) caused the least
organizational conflicts. Personality differences (3.04), knowledge (3), and skills (2.95) caused
the most; and demographic variables (2.35) and conflicting values and beliefs (2.33) caused the
least personal conflicts. There was a significant statistical correlation between conflict and
organizational factors (r = 0.917, p = 0.001) and personal factors (r = 0.892, p = 0.001).
Regression analysis showed that organizational factors were responsible for 84% of the variance
for overall conflict.

Table II and III here

Top managers experienced more conflict than middle and front-line managers (Table III).
Conflict was higher in specialized compared to general hospitals. However, the difference was
not statistically significant (p=0.851). Less conflict was observed in administrative and support
than diagnostic and therapeutic departments. Conflict was high in the cardiology ward (4.09),
hospital manager’s office (3.88), transplant ward (3.59), CEO office (3.31), paediatric ward
(3.30), operating room (3.25), finance and accounting (3) and nursing administrator office (2.95).
Less conflict was observed in IT (2.32), clinical laboratory (2.35), CCU (2.43), Pharmacy (2.44),
social worker office (2.45), hospital stores (2.47) and ICU (2.50). There was a statistically
significant relationship between conflict intensity and management hierarchy (r = 0.090, p =
0.032), education (r = 0.123, p = 0.003), hospital size (r = 0.090, p = 0.033), employee number (r
= 0.084, p = 0.046) and turnover intention (r = 0.139, p = 0.001). Single female managers with
higher education reported more conflict. Young managers and those with more than 30 years
working tenure reported more conflict (Table IV). There was a negative association between
attending conflict management courses and personal conflict (r= -0 .092, p = 0.029); i.e.,
managers who attended conflict management educational courses reported less personal conflict.

Table IV, V and VI here

Collaboration was managers’ dominant style for handling conflict. Compromising,

accommodating, avoiding and competing were the next most used styles for conflict handling
(Table V). Collaborating style was mostly used by senior managers, while, compromising and
accommodating styles were used mainly by middle managers and avoiding style was used
mostly by front line managers (Table VI). Female managers mainly used avoiding style

5
 compared to their male colleagues. Single managers used more competing style, while married
managers used more collaborating, compromising and avoiding styles. Managers with a PhD,
more than 50 years old and with more than 30 years’ work tenure used more collaborating style
(Table VII). There was a statistically significant relationship between management hierarchy and
using collaborating style (r = -0.087, p = 0.038). Senior managers used more collaborating style
than middle and front-line managers. Gender was statistically related to competing style (r =
0.093, p = 0.027). Male managers used more competing style compared to female managers.
There was a statistically significant correlation between managers’ age and using collaborating (r
= 0.101, p = 0.016) and accommodating (r = 0.087, p = 0.039) styles. Older mangers used more
collaborating and accommodating styles in conflict handling. There were also associations
between managers’ working tenure and collaborating (r = 0.099, p = 0.019) and accommodating
(r = 0.096, p = 0.023) styles. Managers with a longer working tenure used more collaborating
and accommodating conflict management styles. There were associations between managers’
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managerial tenure and collaborating (r = 0.098, p = 0.021), competing (r = 0.103, p = 0.015) and
accommodating (r = 0.108, p = 0.011) styles.
There was an association between conflict management style and work place (r = 0.103, p
= 0.014). Administrative and logistic managers used a more competing style than their
colleagues in diagnostic and therapeutic departments. Managers in specialized hospitals used
more collaborating, accommodating and compromising styles than managers in general
hospitals. Attending conflict management courses was positively related to using collaborating
style (r = 0.138, p = 0.001), and was negatively related to using competing style (r = -0.113, p =
0.007). Managers with traditional view to conflict used more competing style.

Table VII and VIII here

There were significant statistical correlations between organizational factors and competing style
(p = 0.077, r = 0.006) and also between personal factors and collaborating style (p = 0.135, r =
0.001), accommodating (p = 0.079 r = 0.005), and compromising (p = 0.079, r = 0.006). Also,
there was an association between total conflict and collaborating style (p = 0.103, r = 0.015).

Discussion
We aimed to examine conflict type and level in TUMS hospitals and identify hospital managers’
conflict resolution strategies. The findings revealed that TUMS managers perceived a moderate
conflict level, which is necessary for organizational growth (Mosadeghrad, 2015). While too
little conflict reduces employees’ motivation, creativity, and productivity and as a result,
organizational productivity may diminish, too much conflict causes chaos in the organization,
and employees deviate from organizational goals (Çınar and Kaban, 2012; Rahim, 2010).
Organizational factors caused more conflict for hospital managers than personal factors
in this study. Organizational factors such as heavy workload, limited resources, vague and
conflicting organizational rules and policies, and organizational changes caused more conflict for
managers. Similar studies also addressed heavy workloads, resource scarcity, bureaucracy, and
poor communication as important organizational factors that create conflict (Kontogianni, et al.,
2012; Pavlakis, et al., 2011; Tengilimoglu and Kisa, 2005).
Knowledge, skills and personalities differences were the most common personal factors
leading to conflict in this study. Personal and cultural differences increase miscommunication
and misunderstanding, which in turn may result in conflict. Baron (1989) found that people with

6
 personality type A (ambitious, outgoing, proactive, rigidly organized, highly sensitive, impatient,
anxious, nervous, exited and high-achieving) experience more conflict than those with
personality type B (calm, quiet and reflective) (Friedman and Rosenman, 1959). Differences in
employee education may halt transferring information between employees; act as a barrier in
effective communication and cause conflict (Tengilimoglu and Kisa, 2005). Thus, hospital
managers should pay attention to employee personality types and educational background in
recruiting and selecting staff for hospital departments.
Our study showed that conflict increases as hospital beds and employees increased.
Therefore, managers, especially in large hospitals, should know the conflict type and level
among employees and apply the right strategies to control it. Senior managers reported higher
conflict than middle and front-line managers. Hospital CEO, hospital internal managers and
nurse administrators reported high conflict. Many responsibilities and employees, patients,
relatives and authorities’ expectations created too much conflict for them. Therefore, they should
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be trained in conflict management strategies to deal with conflict easily. Organizational factors
caused more conflict for senior managers, while, personal factors created more conflict for junior
managers.
Conflict was higher in diagnostic and therapeutic departments than administrative and
logistic departments. Clinicians, especially nurses, owing to their job nature, are communicating
constantly with patients, relatives and other service providers. Therefore, they are vulnerable to
conflict (Baddar, et al., 2016). Conflict was high in cardiology, transplant, and pediatric wards
and the operating theatre. Patient type and service nature provided in these wards are responsible
for creating more conflict in these wards. Thus, senior managers should be meticulous in
choosing managers for these wards. They should consider experienced and knowledgeable
managers with good personality traits. Staff shortage and heavy workload increase stress and
cause conflict, which in turn, reduce staff concentration and increase clinical errors. Managers in
these wards should be trained in conflict management strategies. Conflict in those departments
and units where patients do not attend (e.g., stores, IT, etc.) or have less interaction with patients
(e.g., CCU, ICU, pharmacy and clinical laboratory) was low. Educating patients and their
relatives on conflict and conflict management makes patients' expectations reasonable and
rational and reduces conflict. Employees should be educated and trained to enhance their
emotional intelligence (the capacity to be aware, control, and express one's emotions, and to
handle interpersonal relationships judiciously and empathetically) (Goleman, 2005) and conflict
management skills to communicate better with patients and their relatives.
We found a positive significant correlation between conflict and manager turnover and
quit intention, which is consistent with similar studies (Mosadeghrad 2013b; Piko, 2006; Tunc
and Kutanis, 2009). Thus, hospital managers should reduce destructive conflict through proper
planning, policy making, organizing and leadership. Communication has a crucial role in
conflict. Hospital managers should create open and clear communication channels in the
organization; so, employees can easily communicate and share information.
The most commonly used conflict management style was collaborating followed by
compromising, accommodating, and avoiding styles. Competing approach was the least used
conflict management style. Hospital work and the customer type need an environment in which
managers and employees create a friendly and trustful atmosphere and try to solve problems
through effective communication and negotiation. These results support previous studies
(Friedman, 2000; Pavlakis, et al., 2011; Vivar, 2006). Nevertheless, managers in different
countries may use different conflict resolution strategies. Cultural and situational factors affect

7
 managers’ conflict management strategies; e.g., Elsayed-EkJiouly and Buda (1996) concluded
that Arab Middle Eastern managers use more integrating and avoiding conflict resolution styles,
while US executives use more obliging, dominating, and compromising styles. Kunaviktikul and
colleagues (2000) in a study in four Thai hospitals found that managers commonly used
accommodating style to manage conflict.
In our study, senior managers mostly used the collaborating style while middle and
operational managers used compromising and avoiding styles. We reveal that older and senior
managers prefer mostly to use collaborating and accommodating styles. Previous studies also
confirmed collaborating style in older ages (Baddar, et al., 2016). Older and senior managers are
more acquainted with their work environment and colleagues and prefer to satisfy their
coworkers and avoid conflict. Married managers were highest on the collaborating, avoiding and
compromising styles compared to single managers. Their role in the family as a father or mother
teaches them to be more caring and consider other parties’ interests. Managers in administrative
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and support departments used more competing style than their colleagues in diagnostic and
therapeutic departments.
Most hospital managers (57%) accepted conflict and believed that it is inevitable
(behavioral view). Only a fourth believed that conflict should be even stimulated to improve
organizational performance (interactionist view). The remaining managers had a traditional view
to conflict and mainly used competing style to handle conflict in the hospital. Interactionist
managers mostly used collaborating and competing styles. Hospital managers should be provided
with education and training on conflict management and be encouraged to use appropriate styles
for keeping it in an optimal level for organizational growth.
Education and training have crucial roles helping managers choose an appropriate
conflict resolution strategy. Our findings showed that only 7% attended conflict management
training courses. Hospital managers, therefore, may be lacking knowledge and skills for effective
conflict resolution. Managers familiar with conflict management mostly used the cooperative
style and reported lower personal conflict. Thus, hospital senior managers should provide more
education and training on conflict management for junior managers and employees. Education
and training help employees to understand conflict and those factors causing conflict in an
organization, and to use appropriate strategies for managing conflict (Haraway, 2005). As junior
managers and employees are not trained in conflict management, top managers have to spend
more time on conflict resolution. Managers and employees should receive education and training
on emotional awareness, effective communication, stress control, and time management. These
courses help them to understand themselves and others, communicate effectively and manage
conflict properly.
Managers should promote shared decision making, clearly communicate organizational
goals to employees in writing and make sure they understood them. Hospital managers should
act fairly, keep communication channels open and create a culture that employees respect, and
tolerate conflicting perspectives. Managers should also develop official conflict management and
grievance policies and procedures. The conflict management process should be clearly defined
and communicated to employees; they should know what to do when conflict is arising and how
to deal with conflicting situations. Vague and unclear policies and procedures, especially when
employees are not trained in conflict management comes with negative consequences.
Employees should know how to report conflict to managers without fearing punishment
(whistleblowing).

8
 Conclusion and recommendations
Conflict is natural, inherent and inevitable in hospitals. Managers in TUMS hospitals reported
moderate organizational conflict. An optimum conflict level is necessary and beneficial for
individual growth and organizational productivity. Heavy workload, limited resources, unclear
policies, organizational changes, poor communication and differences in employees’ abilities,
skills and personalities were the main conflict factors in TUMS hospitals. Hospital managers
mainly used the collaborating style. Relevant education and training programs should be
organized to raise managers’ awareness in conflict management and help them keep conflict at a
constructive level by using the right conflict management styles and strategies. Despite its
contributions, this study’s results should be interpreted with caution. This study was limited to
TUMS affiliated hospitals. Further studies are needed to fully explore conflict and conflict
management solutions in healthcare organizations. Future research, using a multinational
comparative approach, can explore national and organizational culture roles in conflict type,
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intensity and management strategies.

References
Baddar, F., Salem, O.A. and Villagracia, H.N. (2016), ‘Conflict resolution strategies of nurses in
a selected government tertiary hospital in the Kingdom of Saudi Arabia’, Journal of
Nursing Education and Practice, Vol. 6 No.5, pp. 91-99.
Baron, R.A. (1989), ‘Personality and organizational conflict: Effects of the Type a behavior
pattern and self-monitoring’, Organizational Behavior and Human Decision Processes,
Vol.44 No. 2, pp.281-96.
Berryman-Fink, C. and Brunner, C.C.S. (1987), ‘The effects of sex of source and target on
interpersonal conflict management styles’, Southern Speech Communication Journal,
Vol.53 No.1, pp.38-48.
Brinkert, R. (2010), ‘A literature review of conflict communication causes costs, benefits and
interventions in nursing’, Journal of Nursing Management, Vol. 18 No.2, pp.145-56.
Caykoylu, S., Egri, C.P., Havlovic, S. and Bradley, C. (2011),’Key organizational commitment
antecedents for nurses, paramedical professionals and non‐clinical staff’, Journal of
Health Organization and Management, Vol. 25 No. 1, pp. 7-33.
Çınar, F. and Kaban, A. (2012), ‘Conflict management and visionary leadership: An application
in hospital organizations’, Procedia Social and Behavioral Sciences, Vol. 58, pp.197-206.
Cronbach, L.J. (1951), ‘Coefficient alpha and the internal structure of tests’, Psychometrika, Vol.
16 No. 3, pp. 297-334.
Elsayed-EkJiouly, S.M. and Buda, R. (1996), ‘Organizational conflict: a comparative analysis of
conflict styles across cultures’, International Journal of Conflict Management, Vol.7 No.
1, pp. 71-81.
Friedman, M. and Rosenman, R. (1959), ‘Association of specific overt behaviour pattern with
blood and cardiovascular findings; blood cholesterol level, blood clotting time, incidence
of arcus senilis, and clinical coronary artery disease’, Journal of the American Medical
Association. Vol. 169 No. 12, pp. 1286-1296.
Friedman, R.A., Tidd, S.T., Currall, S.C. and Tsai, J.C. (2000), ‘What goes around comes
around: The impact of personal conflict style on work conflict and stress’, International
Journal of Conflict Management, Vol. 11 No. 1, pp.32-55.
Goleman, D. (2005). Emotional intelligence, 10th ed., Bantam, New York.

9
 Graham, S. (2009), ‘The effects of different conflict management styles on job satisfaction in
rural healthcare settings’, Economics and Business Journal: Inquiries and Perspectives,
Vol.2 No.1, pp.71-85.
Haraway, D.L. and Haraway, W.M. (2005), ‘Analysis of the effect of conflict-management and
resolution training on employee stress at a healthcare organization’, Hospital Topics, Vol.
83 No.4, pp.11-7.
Henry, O. (2009), ‘Organizational conflict and its effects on organizational performance’,
Research Journal of Business Management, Vol. 2 No.1, pp.16-24.
Kontogianni, A., Kaitelidou, D., Pavlakis, A., Galanis, P., Mallidou, A., Kostagiolas, P.,
Liaropoulos, L., Siskou, O. and Theodorou, M. (2012), ‘Conflict management and job
satisfaction in paediatric hospitals in Greece’, Journal of Nursing Management, Vol.20 No.
4, pp.571-8.
Kunaviktikul, W. and Booth, R.Z. (2000), ‘Relationships among conflict, conflict management,
Downloaded by The University of Edinburgh At 13:40 25 March 2019 (PT)

job satisfaction, intent to stay, and turnover of professional nurses in Thailand’, Nursing
and Health Sciences, Vol. 2 No.1, pp.9-16.
Marquis, B.L. and Huston, C.J. (2009), Leadership roles and management functions in nursing:
Theory and application, 1st ed., Lippincott Williams and Wilkins, Philadelphia.
Morrison, J. (2008), ‘The relationship between emotional intelligence competencies and
preferred conflict‐handling styles’, Journal of Nursing Management, Vol.16 No. 8,
pp.974-83.
Mosadeghrad, A.M. (2013a), ‘Occupational stress and turnover intention: Implications for
nursing management. International Journal of Health Policy and Management, Vol. 1
No.2, pp. 179-186.
Mosadeghrad, A.M. (2013b), ‘Quality of working life: Antecedents to employee’s turnover
intentions’, International Journal of Health Policy and Management, Vol. 1 No. 1, pp. 49-
58.
Mosadeghrad, A.M. (2014a), ‘Why TQM does not work in Iranian healthcare organisations’,
International Journal of Health Care Quality Assurance, Vol. 27 No. 4, pp. 320-335.
Mosadeghrad, A.M. (2014b), ‘Occupational stress and its consequences: Implications for health
policy and management’, Leadership in Health Services Journal, Vol. 27 No. 3, pp. 224 -
239.
Mosadeghrad, A.M. (2014c), ‘Factors affecting medical service quality’, Iranian Journal of
Public Health, Vol. 43 No. 2, pp. 210-220.
Mosadeghrad, A.M. (2015), Essentials of healthcare organization and management. Tehran:
Dibagran Tehran. [In Persian]
Pavlakis, A., Kaitelidou, D., Theodorou, M., Galanis, P., Sourtzi, P. and Siskou, O. (2011),
‘Conflict management in public hospitals: the Cyprus case’, International Nursing Review,
Vol. 58 No. 2, pp.242-8.
Piko, B.F. (2006), ‘Burnout, role conflict, job satisfaction and psychosocial health among
Hungarian health care staff: a questionnaire survey’, International Journal of Nursing
Studies, Vol. 43 No. 3, pp.311-8.
Rahim, M.A. (2010), Managing conflict in organizations, 4th ed., Transaction Publishers., New
Brunswick, New Jersey.
Robbins, S.P. (1978), ‘Conflict management and conflict resolution are not synonymous terms’,
California Management Review, Vol. 21 No. 2, pp.67-75.

10
 Tengilimoglu, D. and Kisa, A. (2005), ‘Conflict management in public university hospitals in
Turkey: a pilot study’, The Health Care Manager, Vol. 24 No.1, pp.55-60.
Thomas, K.W. and Kilmann R.H. (1974), the Thomas-Kilmann Conflict Mode Instrument,
Tuxedo, NY: XICOM, Inc.
Tunc, T. and Kutanis, R.O. (2009), ‘Role conflict, role ambiguity, and burnout in nurses and
physicians at a university hospital in Turkey’, Nursing and Health Sciences, Vol. 11 No. 4,
pp.410-6.
Valentine, P.E. (2001), ‘A gender perspective on conflict management strategies of nurses’,
Journal of Nursing Scholarship, Vol.33 No.1, pp.69-74.
Vivar, C.G. (2006), ‘putting conflict management into practice: a nursing case study’, Journal of
Nursing Management, Vol. 14 No. 3, pp. 201-6.
Zakari, N.M., Al Khamis, N.I. and Hamadi, H.Y. (2010), ‘Conflict and professionalism:
perceptions among nurses in Saudi Arabia’, International Nursing Review, Vol. 57 No.3,
Downloaded by The University of Edinburgh At 13:40 25 March 2019 (PT)

pp.297-304.

Figure 1: Conflict management styles (Thomas and Kilmann, 1974)

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 Table I: Subjects’ socio-demographic characteristics
Characters Frequency Percentage Characters Frequency Percentage
Female 379 67.3 Less than 5years 223 39.6
Male 184 32.7 5-10 years 181 32.2
Sex

Managerial experience
Single 96 17 11-15 years 94 16.7
Marital
status

Married 462 82.1 16-20 years 49 8.7

Divorced 5 0.9 21-25 years 7 1.2

Diploma 33 5.8 26-30 years 3 0.5

Education

Post diploma 12 2.1 More than 30years 2 0.4

B.Sc. 408 72.1 No answer 4 0.7
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M.Sc. or GP 96 17.5 Diagnostic 36 6.4

Ph.D. 14 2.5 Department.

Less than 30 years 48 8.5 Therapeutic 269 47.8

Age(yea

31-40 years 215 38.2 Administrative 133 23.6

rs)

41-50 years 248 44

More than 50years 52 9.3 Logistic 125 22.2
Less than 5 years 36 6.4
5-10 years 65 11.5
Work experience

11-15years 126 22.4

16-20 years 163 29
21-25 years 116 20.6
26-30 years 52 9.2
More than 30 years 5 0.9

Table II: Personal and organizational conflict among hospital managers

Conflict level Very Low Medium High Very Means Standard
low high Deviations
Conflict type No % No % No % No % No %
Organizational factors 19 3.4 101 17.9 220 39.1 191 33.9 32 5.7 2.75 0.87
Personal factors 24 4.3 109 19.4 228 40.5 170 30.2 32 5.6 2.71 0.92
Total conflict 13 2.3 94 16.7 260 46.2 168 29.8 28 5 2.73 0.81

Table III: Conflict at general and specialized hospitals and among various managers

Management level Managers Hospitals

Hospital type Senior Middle Front Line General Specialized
M SD M SD M SD M SD M SD
Conflict type
Organizational Factors 3.17 1.13 2.89 0.95 2.72 0.85 2.69 0.90 2.79 0.85
Personal Factors 2.97 0.77 2.83 0.97 2.68 0.91 2.66 0.90 2.74 0.93
Total Conflict 3.08 0.95 2.86 0.87 2.70 0.79 2.68 0.82 2.76 0.80

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 Table IV: Conflict level among hospital managers distributed by demographic characteristics

Conflict type Personal Organizational Total conflict

conflict conflict
Subjects characteristics M SD M SD M SD
Male 2.65 0.92 2.74 0.90 2.70 0.83
Sex

Female 2.73 0.92 2.76 0.85 2.75 0.80

Single 2.87 0.85 2.88 0.85 2.88 0.76

Marital
status

Married 2.67 0.93 2.72 0.87 2.70 0.81

Divorced 2.74 0.66 2.83 1.1 2.79 0.85

Diploma 2.53 0.91 2.48 0.84 2.49 0.80

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Education

Post diploma 2.49 0.89 2.85 0.51 2.68 0.64

B.Sc. 2.70 0.90 2.74 0.84 2.72 0.78
M.Sc. or GP 2.76 0.92 2.86 0.92 2.82 0.83
Ph.D. 2.93 1.30 2.86 1.38 2.89 1.32
Less than 30 years 2.92 0.87 2.97 0.83 2.87 0.77
Age (years)

31-40 years 2.60 0.85 2.69 0.83 2.65 0.76

41-50 years 2.74 0.95 2.78 0.89 2.76 0.84
More than 50 years 2.74 1.01 2.76 0.96 2.75 0.88
Less than 5 years 2.94 0.81 2.85 0.90 2.89 0.78
Work experience

5-10 years 2.78 0.87 2.79 0.87 2.78 0.82

11-15 years 2.61 0.90 2.62 0.81 2.61 0.75
16-20 years 2.65 0.91 2.85 0.85 2.76 0.79
21-25 years 2.78 0.96 2.67 0.96 2.72 0.89
26-30 years 2.69 0.98 2.77 0.81 2.74 0.78
More than 30 years 2.98 0.71 3.38 1.14 3.20 0.93

Table V: Conflict management styles used by TUMS managers

Conflict level Very low low Medium high Very high means Standard
No % No % No % No % No % Deviations
Conflict styles
Collaborating 2 0.4 30 5.3 185 32.8 282 50.1 64 11.4 3.57 0.60
Competing 51 9.1 142 25.2 251 44.6 108 19.1 11 2 2.82 0.75
Avoiding 13 2.3 95 16.9 295 52.4 137 24.3 23 4.1 3.09 0.63
Accommodating 16 2.8 81 14.4 291 51.7 154 27.4 21 3.7 3.11 0.62
Compromising 5 0.9 57 10.1 299 53.1 180 32 22 3.9 3.22 0.56

Table VI: TUMS senior, middle and front line managers’ conflict management styles

Management levels Senior Middle managers Front line

managers managers
Conflict styles M SD M SD M SD
Collaborating 4 0.40 3.63 0.70 3.55 0.59

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 Competing 2.96 0.62 2.85 0.69 2.82 0.76
Avoiding 2.59 0.26 3.07 0.66 3.11 0.63
Accommodating 3.20 0.60 3.20 0.56 3.09 0.63
Compromising 3.14 0.61 3.24 0.56 3.22 0.56

Table VII: Managers’ conflict management styles distributed by demographic characteristics

Conflict styles Collaborating Competing Avoiding Accommodating Compromising

M SD M SD M SD M SD M SD
Subjects characteristics
Male 3.61 0.62 2.92 0.70 3.08 0.60 3.11 0.63 3.23 0.58
Sex

Female 3.55 0.59 2.78 0.76 3.10 0.64 3.11 0.62 3.21 0.55

Single 3.53 0.57 2.92 0.61 2.98 0.67 3.03 0.57 3.16 0.58
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l status
Marita

Married 3.58 0.61 2.80 0.77 3.12 0.62 3.13 0.63 3.23 0.56
Divorced 3.26 0.43 3.03 0.62 2.96 0.57 3.13 0.63 2.90 0.91
Diploma 3.51 0.56 2.81 0.64 3.22 0.43 3.16 0.59 3.17 0.56
Education

Post diploma 3.68 0.39 3.37 0.58 3.63 0.54 3.44 0.85 3.43 0.60
B.Sc. 3.56 0.62 2.82 0.77 3.11 0.65 3.10 0.62 3.24 0.55
M.Sc. or GP 3.54 0.59 2.80 0.68 2.92 0.59 3.06 0.60 3.10 0.51
Ph.D. 4 0.59 2.64 0.71 3.03 0.43 3.20 0.68 3.26 0.88
Less than 30 years 3.51 0.64 2.91 0.70 2.91 0.59 3.04 0.64 3.30 0.53
Age(year

31-40 years 3.53 0.59 2.71 0.77 3.11 0.61 3.06 0.60 3.19 0.56
s)

41-50 years 3.57 0.60 2.88 0.72 3.12 0.67 3.14 0.62 3.22 0.56
More than 50years 3.78 0.63 2.99 0.78 3.08 0.54 3.22 0.68 3.28 0.62
Less than 5 years 3.52 0.66 2.91 0.73 3 0.55 3.09 0.56 3.17 0.50
Work Experience

5-10 years 3.56 0.52 2.82 0.64 2.92 0.62 3.01 0.56 3.26 0.57
11-15 years 3.50 0.63 2.70 0.79 3.14 0.64 3.05 0.61 3.18 0.55
16-20 years 3.56 0.63 2.81 0.76 3.08 0.62 3.10 0.63 3.22 0.56
21-25 years 3.56 0.56 2.87 0.74 3.21 0.67 3.23 0.65 3.22 0.55
26-30 Years 3.77 0.59 3.02 0.76 3.06 0.58 3.14 0.61 3.30 0.62
More than 30 years 4.36 0.43 2.86 0.24 2.86 0.54 3.53 0.82 3.43 0.68

Table VIII: Correlation between conflict type and conflict management style

Conflict types Organizational Personal Total

Conflict styles factors factors conflict
Collaborating 0.056 0.135** 0.103**
Competing 0.077* 0.020 0.056
Avoiding 0.059 0.056 0.063
Accommodating 0.031 0.079* 0.059
Compromising 0.030 0.079* 0.058

14