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Conflict and professionalism: perceptions among nurses in Saudi Arabiainr_764 297..304

N.M. Zakari1 PhD, RN, N.I. Al Khamis2 MSN, RN & H.Y. Hamadi3 BCS 1 Assistant Professor, 2 Lecturer, Nursing Administration and Education Department, College of Nursing, King Saud University, Riyadh, Saudi Arabia, 3 Master Student in Health System Management, College of Health Human Services, George Mason University, Fairfax, Virginia, USA

ZAKARI N.M., AL KHAMIS N.I. & HAMADI H.Y. (2010) Conflict and professionalism: perceptions among

nurses in Saudi Arabia. International Nursing Review 57, 297–304

Aim: To examine the relationship between nurses’ perceptions of conflict and professionalism.

Background: In Saudi Arabia, health-care sectors are constantly undergoing major changes because of social,

consumer-related, governmental, technological and economic pressures. These changes will influence the

nature of health-care organizations, such as hospitals’ work environment. The ability of nurses to practise in

a professional manner may be influenced by their work environment and conflict level.

Methods: A cross-sectional design was conducted in this study. A simple random selection of three

health-care sectors in Saudi Arabia was performed and 346 nurse managers, as well as bedside nurses

participated to provide information about conflict levels and professionalism. The Perceived Conflict Scale

was used to assess the level of conflict, and the Valiga Concept of Nursing Scale was used to assess the

professionalism perception among nurses.

Results: The intragroup/other department type of conflict had a statistically significant correlation with the

perception of professionalism. In addition, the findings point to a low perception among the participating

nurses regarding their professionalism.

Conclusion: A number of factors might explain the low level of perception of professionalism. These relate to

the workplace itself, as well as to the personal background of the nurses, which includes the personal interest

in the nursing profession, as well as the family’s, society’s and the consumers’ views of the profession. Given

the findings of this study, nurse managers are encouraged to create a work environment that supports

professionalism and minimizes conflict.

Keywords: Academia, Conflict, Government, Health-care Sectors, Hospitals, Nurse Managers, Nurses,

Professionalism, Saudi Arabia

Introduction In Saudi Arabia, health-care sectors are constantly undergoing major changes because of social, consumer-related, governmen- tal, technological and economic pressures. These changes will influence the nature of health-care organizations, such as hospi-

tals. By nature, hospital environments are complex, combining many different professional groups within an intricate adminis- trative structure. Saudi Arabian hospitals in particular are extremely complex, as they rely on a nursing workforce is com- posed primarily of international expatriates. These complexities often lead to conflict.

Background Conflict is an integral part of the fabric of a post-modern society that is litigious, competitive, complex and alienating. Hospital

Correspondence address: Nazik Zakari, Nursing Administration and Education Department, College of Nursing, King Saud University, P.O. Box 50535 Riyadh 11533, Saudi Arabia; Tel: +966505423947; Fax: +96614682812; E-mail: [email protected].

Original Article

environments are exposed to many types of conflict com- pounded by increasing demands on an ever-limited staffing supply, a decrease in available resources and a period of profound changes (Gardner 1992; Kelly 2006). These complexities and ten- sions in hospital settings will undoubtedly continue, and even escalate, providing a fertile ground for conflict among health- care professionals (Saulo & Wegener 2000).

The forms of conflict are highly diverse and occur in four categories: (1) intrapersonal, which arises within the individual from two competing demands, (2) interpersonal, which occurs between two or more individuals arising from miscommunica- tion or a difference in values, (3) intergroup/support, which occurs between two or more groups that are supportive in work when differences in competition for resources, power or status arise, and (4) intergroup/other departments, which occurs between two or more groups for resources or services, and where the conflict may be competitive or disruptive or may centre around control (Yoder-Wise 2007). Intergroup conflict is common in an organization. Such conflict is generated from system differentiation, task interdependence, scarce resources, jurisdictional ambiguity and separation of knowledge from authority (Xu & Davidhizar 2004).

Conflict within a supervisory relationship can range from mild tension to very extreme forms. It can originate from differ- ences in personality, style, expectations, knowledge, experience or world view. In some cases, conflict can be constructive, that is when it improves the quality of decisions, stimulates creativity, encourages interest and curiosity among group members, pro- vides the medium through which problems can be aired and tensions released, and fosters self-evaluation. Interpersonal con- flict can serve as the impetus for needed change and can accel- erate innovation (Hagel & Brown 2005).

Conflict within the nursing profession, however, has tradi- tionally generated negative feelings. It has been seen to drain energy, reduce focus and cause discomfort and hostility (Wilson 2004). Nurses experience conflict in many forms. Piko (2006) indicated that the main form of conflict that nurses are vulnerable to is role conflict. Role conflict among nurses can include the following: role overload, in which they are required to perform the work of other health-care professionals; role ambiguity, in which their duties expand without a job descrip- tion change; or role stress, in which a non-nursing supervisor has different ideas about the nurse’s job (Forte 1997). As with any health manager, nursing managers spend an average of 20% of their time dealing with conflict. Nurses are known more for their use of avoidance, as opposed to open acknowl- edgment, of the factors contributing to the issues causing the conflict (Cavanagh 1988). For nurses, conflict management skills are rated as important as, or even more important than,

planning, communication, motivation and decision-making skills (McElhaney 1996).

Professionalism is the extent to which an individual identifies with a profession and adheres to its standards. In nursing, a profession comprises of a system of roles that is socially defined. Professions hold contracts to provide services for the public good, and in return, the professionals gain higher prestige and autonomy in their work (Adams & Miller 2001).

Professionalism in nursing is represented by leaders of various nursing organizations. For nurses, professionalism is primarily depicted and encouraged by nurse administrators and middle managers in the agencies in which they are employed (Spooner & Patton 2007). Therefore, nurse executives and middle managers can create work atmospheres free of conflict in which staff nurses perceive opportunities to increase their professionalism and improve professional practice (Adams 1991). To perform these functions, managers need to understand the nature of conflict and the concept of professionalism. This is essential to demonstrate and model the behaviours that denote profession- alism and, consequently, encourage similar behaviours among staff (Sand 2003). The most common criteria needed for the nursing professionalism are knowledge, service and autonomy. Nursing knowledge is the strong base of specialized education from which a professional practises. Professional service is providing society with essential activities. Professional autonomy is having authority over and accountability for one’s decisions and activities (Manojlovich & Ketefian 2002). Nursing requires both a high level of expertise and a sophisticated decision- making process, which are characteristics of strong leadership. Strong nursing leadership is required to assist in the profession- alization of nursing, and to act in a professional manner when dealing with conflict situations (Delgado 2002).

As the professional code of ethics guides nursing practice, a good working environment guides and encourages nurses to work in a professional manner to reduce the impact of conflict. The organizational and workforce structure of many hospitals is in conflict with the practice of professional nursing, such as in an academic teaching hospital. Nayeri & Negarandeh (2009) dem- onstrated that slow management processes, several and redun- dant medical orders, unskilled medical interns, lack of personnel and failure to recruit qualified health personnel in academic teaching hospital contribute to the rising level of conflict.

The ability of nurses to practise in a professional manner may be influenced by the organizational culture and conflict levels of their work environment (Wynd 2003).

Significance of the study A serious nursing shortage is creating a crisis in health care. Many experienced nurses are leaving the field, and young people

298 N. M. Zakari et al.

are not selecting nursing as a potential career. One reason is the conflict that nurses encounter in their work. Considerable researches on conflict and its impact on nursing outcomes have been conducted worldwide, but no such study has been per- formed in hospitals in Saudi Arabia. Moreover, there is very little research on the relationship between conflict and nurses’ perceptions of their professionalism. Thus, a reassessment of professionalism in nursing is indicated. Therefore, this study was an attempt to identify the relationship between conflict and professionalism.

Purpose This study was designed to explore the nature of the relationship between conflict and nurses’ perceptions of their professional- ism. The study addressed the following research questions: 1 What is the level of conflict among nurses working in different health-care sectors? 2 What is the level of perception of professionalism among nurses working in different health-care sectors? and 3 What is the relationship between the level of conflict and the perception of professionalism among these nurses?

Methods

Research design

This study was carried out using an analytic cross-sectional design.

Setting and sample

A simple random selection of three different health-care sectors in Saudi Arabia was performed from government, military and academic health sectors, and 346 nurse managers in first-line and mid-level positions, as well as bedside nurses participated to provide information about conflict level and professionalism. Statistically, the sample size was calculated to determine any expected level of conflict or professionalism of �35%, with a 15% standard error and a 95% level of confidence, using spss 13.0 statistical software package (Statistical Package for the Social Sciences, SPSS Inc. Chicago, IL, USA). The required sample size estimated by power analysis was 317 subjects. The actual sample size was increased to 420 to compensate for an anticipated dropout or non-response rate of 25%.

Instruments

Data were collected via a questionnaire containing the following two instruments: • The Perceived Conflict Scale, which was designed to measure the level of conflict. It consists of 16 items on a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree). The items

are classified into four subscales (intrapersonal, interpersonal, intergroup/support, and intergroup/other departments). Scores of 1, 2, 3, 4, or 5 were given to the responses of ‘strongly disagree,’ ‘disagree,’ ‘uncertain,’ ‘agree’ and ‘strongly agree,’ respectively. The scores of the items were summed, and the total score was divided by the number of items giving a mean score for perceived con- flict. These scores were converted into a percent score, and the means and standard deviations (SD) were computed. The con- flict was considered high if the percent score was �60%, and low if <60% (Huber 1996). The Cronbach’s alpha coefficient in this study was 0.67, which indicates good reliability. • The Valiga Concept of Nursing Scale was used to assess nurses’ professionalism. It includes 25 items to measure the ideas held by the nurse about nursing as a profession, the role of the nurse, and the relationship of the nurse to the client, the physician, and other health team colleagues. The responses are on a 5-point Likert-type scale (strongly agree to strongly disagree). The negative state- ments are scored negatively. Therefore, the total minimum score was -50 and the maximum score was +50 (Valiga 1996). The Cronbach’s alpha coefficient for this study was 0.79, which indi- cates a high degree of reliability. An additional section was added, which included eight questions for the demographic characteris- tics, such as nursing qualification and years of experience.

Procedures

Prior to data collection, an institutional review board at each of the three health-care sectors granted approval for the study. Before the study was conducted, the research team met with the directors of the research centres in the selected hospitals and explained the study procedures. Questionnaires were handed out to supervisors in the selected hospitals who then gave them to nursing professionals on the wards. A letter to each participant accompanied the questionnaire explaining the objective of the research. All questionnaires were self-administered; paper-and- pencil instruments were distributed, completed and collected on the hospital wards. Throughout the study, protection of human rights was assured and adherence to ethical principles was secured. Thus, the researcher ensured that each individual’s autonomy was supported. Participation was voluntary, and there was no penalty for withdrawal from or termination of the study. In addition, the research methodologies were non-invasive, and there were minimal or no anticipated risks to participants. A written consent form was obtained from all participants. Total confidentiality of information was also ascertained.

Statistical analysis

Data entry and analysis were done using the spss 13.0 statistical software package. Pearson correlation analysis was used for assessment of the inter-relationships among quantitative vari-

Conflict and professionalism 299

ables. The Cronbach’s alpha coefficient was calculated to assess the reliability of the developed tools through internal consis- tency. To identify the independent predictors of the score of professionalism, multiple stepwise backward linear regression analysis was used, and analysis of variance for the full regression models were performed. Statistical significance was considered at a P-value < 0.05.

Results Of 420 questionnaire forms distributed, 346 were completed, returned and validated, with a response rate of 82.4%. The responding sample consisted mainly of staff nurses (86.4%), with higher percentages from internal medicine departments (43.9%). The results indicated that around 43% nurses were participated from governmental hospitals while 28% and 29% nurses participated from military and academic hospital, respec- tively. The sample age ranged between 20 and 60 years, with a mean � SD of 37.0 � 8.7 years. The majority of participants were females (92.8%), married (74.6%) and had a bachelor’s degree in nursing (63.6%). The experience in nursing ranged between 1 and 40 years, with a mean � SD of 11.4 � 7.4 years. Slightly more than one-third of the sample (37.3%) had a high perception of nursing professionalism. The mean � SD percent score was 53.8 � 16.7. With respect to the types of conflict, the finding indicates that the interpersonal type was the most common (82.1%), whereas the intrapersonal type was the least common (38.4%).

The relationship between nurses’ perception of professional- ism and conflict is displayed in Table 1. Only the intragroup/ other department type of conflict had a statistically significant association with the perception of professionalism (P = 0.03). It is evident that a higher level of professionalism is associated with a higher level of such conflict. A similar relationship existed with intrapersonal conflict, although it had only borderline signifi- cance (P = 0.054).

Similarly, Table 2 points to statistically significant positive cor- relations between the scores of nurses’ perception of their pro- fessionalism and intrapersonal (R = 0.12) and intragroup/other department (R = 0.35) types of conflict. The Table also indicates that the four types of conflict were positively inter-correlated, with the strongest correlations between intrapersonal conflict and both types of intergroup conflicts.

Multivariate analysis was carried out to identify the indepen- dent predictors of the score of nursing professionalism. The best fitting model is presented in Table 3. It is evident that the only statistically significant independent predictors of this score were years of experience and the score of the intra group/other department type of conflict, with the former being a negative predictor. These were adjusted for the nurse’s age, gender, qualifications, job position, marital status, as well as hospital and department of work, and other types of conflict scores. However, as indicated from the value of the R-square, the model only explains 4% of the variation in the professionalism score.

Table 1 Relationship between nurses’ perceptions of professionalism and conflict

Perceptions of professionalism X2 P

High Low

No. % No. %

Interpersonal conflict: High (60%+) 111 86.0 173 79.7 Low (<60%) 18 14.0 44 20.3 2.20 0.14

Intrapersonal conflict: High (60%+) 58 45.0 75 34.6 Low (<60%) 71 55.0 142 65.4 3.70 0.05

Intergroup/support conflict: High (60%+) 84 65.1 133 61.3 Low (<60%) 45 34.9 84 38.7 0.51 0.48

Intergroup other department conflict: High (60%+) 71 55.0 93 42.9 Low (<60%) 58 45.0 124 57.1 4.82 0.03*

*P < 0.05.

300 N. M. Zakari et al.

Discussion Nurses have a certain social standing in society, the dimensions of which can be measured by various indicators pertaining to their socio-economic status and respectability. They occupy a particular hierarchical and vertical professional location in the division of health-care sectors. Moreover, nurses work in various health-care sectors in which they occupy particular functional roles and hierarchical positions. In order to understand the per- ceptions and experiences of nurses with their professionalism, we have to assume that nurses’ actions and perceptions are taken from particular positions with specific resources and constraints. These positions are located at three nested structural levels: society, the field of health care and the organization of the par- ticular clinic or hospital (Bourgeault et al. 2005).

The present study was designed to examine the relationship between conflict and nurses’ perceptions of their professio- nalism. The study findings point to low perception among the studied nurses of their professionalism. Only about one-third of the sample had a high perception of nursing. A number of factors might explain this low level of perception of profession- alism. These relate to the workplace itself, as well as the per- sonal background of the nurses, which includes the personal interest in the nursing profession, as well as the family’s, soci- ety’s and consumer’s views of the profession. The workplace factors have been addressed very early in the literature. It was claimed that employment of professionals in bureaucratic organizations has typically been thought to result in varying degrees of de-professionalization or the diminishing of pro- fessional autonomy (Armstrong & Armstrong 2002). This phenomenon has been extensively studied in the profession of nursing.

Nayeri & Negarandeh (2009) explored Iranian hospital nurses’ perception about conflict and identify conflict sources. The finding confirmed that both the hierarchy in the organization and the condition of nursing assignment have a negative impact on nursing professional practices by increasing fragmentation, stress and exhaustion.

Similar findings were indicated in French hospitals, which showed that increased bureaucracy and work intensity both led to an equivalent increase in frustration with the inability to provide care (Bourgeault et al. 2005).

Another workplace-related factor that has been assessed in the literature is the feeling of professional support, which fosters a nurse’s perception of professionalism. This feeling could be lacking among some of the nurses in the present study who are expatriates and who have to deal with foreign seniors who may have different perceptions and attitudes regarding the nursing profession. In this regard, Healy & McKay (2000) and Attree (2001) have demonstrated that nurses in the ward were better able to accommodate patients’ demands on nursing time and energy when there was a high proportion of senior staff with knowledge, skill and experience in the specialty area. In addition, the stress experienced by the nursing staff was reduced. Other researchers supported the fact that both staffing levels and support from other staff were important factors in the percep- tion of workload and quality of patient care (Jones & Cheek 2003; Strachota et al. 2003). Additionally, nurses were found to experience a lack of control over factors that affect practice standards, which generate dissatisfaction, frustration and demoralization, and consequently, a decreased perception of professionalism (Attree 2005).

Furthermore, the lack of resources, time and manpower affect the caring aspect of nurses’ professional tasks, skills and

Table 2 Correlation matrix of nurses’ perception of professionalism and conflict scores

Scores 1 2 3 4 5

1. Perception of professionalism 1.00 2. Interpersonal conflict 0.02 1.00 3. Intrapersonal conflict 0.12* 0.12* 1.00 4. Intergroup/support conflict 0.06 0.12* 0.44** 1.00 5. Intergroup/other departments

conflict

0.15** 0.17** 0.41** 0.35** 1.00

*P < 0.01; **P < 0.05.

Table 3 Best fitting multiple linear regression model for the score of per- ception of professionalism

Unstandardized

coefficients

Standardized

coefficients

t-test P-value

Beta SE

Constant 53.4 45.47 9.777 <0.001* Years of experience -0.26 0.12 -0.11 2.075 0.039* Intergroup/other

departments

conflict

0.18 0.07 0.14 2.602 0.010*

*The experience in nursing ranged between 1 and 40 years, with a mean � SD of 11.4 � 7.4 years. R-square = 0.04. Model analysis of variance: F = 4.53, P = 0.01. Variables excluded by model (non-significant): age, sex, nursing qualifica- tion, marital status, job position, department, hospital, other conflict scores. SE, standard error.

Conflict and professionalism 301

knowledge. This would have a negative impact on their percep- tion of nursing professionalism.

Caring is the core of a nurse’s professional identity. The indi- vidual understanding of caring directs the choice of nursing as profession. Consequently, when this perception is not supported by the work environment conflict may arise (Kirpal 2004). This is important to the present study because of a workforce with diverse nationalities, education and social backgrounds, all of whom may have different perceptions of caring.

Concerning conflict, the present study findings indicated that the interpersonal type was the most common, while the intrap- ersonal type was the least common, and intergroup conflicts were in between. The findings are incongruent with a study in Egypt (Ahmed 2008), which found that intergroup conflict was the most common type, whereas interpersonal conflict was the least common, thus indicating that nurses have no problems in personal relationships, and that the conflict comes between groups, usually because of competition for the scarce resources needed to achieve the work. Moreover, the present study findings are not in agreement with another study conducted in Egypt which demonstrated that intrapersonal conflict was the highest type of conflict among nurses in Ain-Shams University and El-Demerdash hospitals (El-Berry 2003). The discrepancies among these studies might be explained by the nature of the setting. In the present study, the nursing workforce is multina- tional, while the resources are not comparably tight. Hence, unsurprisingly, interpersonal conflict is the highest among the four types. This effect of the factors connecting culture and organizational climate on the incidence of various types of con- flict has been previously reported (Clarke 2006).

The present study findings demonstrated a statistically signifi- cant negative correlation between the scores of perception of nursing professionalism and a nurse’s years of experience. This implies that more years of experience is associated with a decrease in the perception of a nurse’s professionalism. This phenomenon was discussed as a division into practical nurses of an older generation and young academic nurses. These distinc- tions are potential sources and means of internal conflict, par- ticularly in the conditions of cost-cutting and lacking resources (Edmunds & Turner 2005; Eraut 2004). As this phenomenon is common world wide, it is also obvious in Saudi Arabia with the expansion of academic nursing programmes in the last decade. Goodson & Norrie (2005) reported the subsequent diminished hierarchies between nurses, with the experienced nurses noting how it leads to diminished respect for older colleagues. In agree- ment with this, in Saudi Arabia, it is common to find a younger nurse with a bachelor’s degree in a managerial position, with more experienced, less educated older nurses as subordinates, a situation that may contribute to this phenomenon.

Presently in Saudi Arabia, there is no national nursing scope of practice and career ladder, which may explain this relationship between years of experience and perceived professionalism. Lack of scope of practice leads to highly diversified job descriptions and specifications for a similar position. This ultimately results in role conflict, which when prolonged may decrease perceived professionalism. The absence of a career ladder may be related to the sense of diminished perceived professionalism as the nurse stays in the profession. A nursing multinational workforce with diverse perceptions of the nursing profession and the local soci- etal perception of the nursing profession combined together could drive nurses in Saudi Arabia to lose their perceived profes- sional commitment. In addition, the perceived lack of control over resources and constraints associated with nursing positions within the organization hierarchy could also contribute to the explanation of this finding.

When the relationship between nurses’ perceptions of their professionalism and conflict was examined in the present study, the results indicated that only the intragroup/other department type of conflict had a statistically significant positive correlation with the perception of professionalism. The higher the level of professionalism, the greater was this conflict. This was further confirmed by multivariate analysis, which adjusted for the effect of other variables, such as age, experience, workplace and other types of conflict. The finding is incongruent with a study which revealed that intergroup conflict was higher in smaller units with a higher ratio of registered nurses to total staff, while it was not associated with satisfaction with pay or anticipated turnover (Cox 2003). Meanwhile, it has been argued that the high percep- tions of unit morale and interpersonal relationships buffered the effect of unit size and skill mix on inter group conflict. Thus, unit morale and interpersonal relationships might relate to nurses’ perceptions of their professionalism (Cox 2001; Severinsson 2003).

Limitations The present study has limitations which must be acknowledged. First, self-report questionnaires were used for data collection with research assumption of trustworthiness of the respondents. Second, for the majority of the nursing workforce, English is the second language. Perception concepts may have been difficult for nurses to interpret in concrete terms. Third, the tool was limited to address the cultural diversity among nurses.

Recommendations for further research Saudi Arabia will continue to experience diversity in its nursing workforce for the foreseeable future. Therefore, further qualita- tive research is recommended to focus on to what extent attitudes and values are a source of promoting nursing profes-

302 N. M. Zakari et al.

sionalism. Replication of this study should be carried out with nurses in different regions. More studies are needed to examine the impact of nursing scope of practice on conflict and professionalism.

Implications for nursing practice The study indicates that a higher level of professionalism is asso- ciated with a higher level of conflict. Organizational training and development models must encourage the proactive conflict management strategies. Nurse leaders and educators need to endorse and adapt a trans-cultural framework of nursing prac- tice to dilute the effect of individual background as a source of conflict. Nurse leaders should acknowledge that a statement of professional nursing scope of practice is a necessity to overcome role conflict. In addition, role identification with clear equivalent benefits, rewards and promotional paths with alternative tracks can be strong means to increase professionalism and commit- ment to the profession with years of experience. Nurse adminis- trators must also consider departmental designs that decrease bureaucracy and strengthen nurses’ positions. Nurse managers must implement strategies that provide professional support at the point of care, as well as assignment models that provide reasonable work intensity.

Conclusion The study indicates that higher level of professionalism is associated with higher level of conflict especially of the inter personal and intragroup/departmental type. Individual cultural background and organizational climate seem to be the most influential factors driving this result. Understanding conflict management styles can increase nurses’ positive conflict outcomes and lead to improved relationships, increased job sat- isfaction and increased retention of nurses. Further nursing edu- cation in conflict management for staff nurses and nurse managers is greatly needed. Both nurses and nurse managers should be made more aware of the conflicts between them and better trained to understand how they can be constructively resolved. Overall, the professional identity of nurses remains strong, but it is important for policy makers to be aware of the potential negative effects, in terms of conflict in the current state of the health-care sector.

Acknowledgement This research was funded by King Saud University, College of Nursing Research Center.

Author contributions Nazik Zakari planned and designed the study, carried out data analysis, and the interpretation of data. Nada Al khamis and

Hanadi Hamadi jointly collected the data, developed an outline for the paper and wrote the initial draft. All members critically reviewed the manuscript and have approved the final version submitted for publication.

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