Conflict management and perceived team cohesion of nurses in university hospitals

WANG Xiaoling

(Department of Burns and Plastic Surgery,The First Affiliated Hospital of Dali University,Dali,Yunnan,671000)

ABSTRACT: Objective Team cohesion is an essential component in a multidisciplinary team and can inspire the team to perform creative and complex works. This descriptive correlational study aimed to determine the styles of conflict management,levels of team cohesion,and the relationship between each style of conflict management and perceived team cohesion among nurses at affiliated hospitals of Dali University. Methods The sample consisted of 336 nurses from two university hospitals in Yunnan province,selected using the proportionate sampling method. Research instruments included demographic data form,Dutch Test for Conflict Handling (DUTCH) and Group Cohesion Scale. The Cronbach’s alpha coefficient for the five subscales of DUTCH were the following: forcing (0.83),yielding (0.81),avoiding (0.88),problem-solving (0.85),and compromising (0.84). The Cronbach’s alpha coefficient of Group Cohesion Scale was 0.83. Data were analyzed using descriptive statistics and Spearman’s rank-order correlations. Results The results of this study revealed that nurses were most likely to use avoiding conflict management style to deal with conflict situations,followed in rank order by problem-solving,compromising,forcing and yielding conflict management style. Nurses perceived team cohesion at a moderate level 4.43,SD = 2.01). Additionally,conflict management associated with team cohesion. Conclusion The study findings revealed that avoiding was the conflict management style most frequently utilized by nurses,and nurses perceived team cohesion was at a moderate level. It is required to identify various strategies to improve team cohesion in multidisciplinary teams and develop a support system for nurses.

KEY WORDS: conflict management; team cohesion; university hospitals; nursing management

Backgroundandsignificanceofresearchproblem

The development of a team environment has become increasingly important in healthcare delivery systems. Multidisciplinary team approaches utilize the skills and experiences of individuals from different disciplines in order to accomplish the best and the most cost-effective outcomes for patients and clients[1]. It has been recognized that two most important members of the multidisciplinary team are nurses and physicians,and they work together as a team to improve team effectiveness and achieve optimal patient outcomes[2]. Nevertheless,poor team communication,unresolved conflicts and lack of coordination among healthcare providers have been shown to impact the effectiveness of care,resulting in unnecessary hospital stays and costs,increased readmissions and mortality rates[3]. Effective teamwork in the health care is therefore extremely important.

Team cohesion is a vital component of effective teamwork. It is defined as all the forces that influence members to stay in a particular group and group attractiveness[4]. Good and Nelson proposed two subscales to measure team cohesion: perceived cohesiveness and group attractiveness. Team cohesion plays a crucial role in teams and many benefits have been demonstrated. Patient care teams with greater cohesiveness are associated with better quality of care and higher patient satisfaction[5]. Team cohesion was considered as a significant predictor of nurses’ turnover intention,and job satisfaction[6-7]. In addition,nurses who work in cohesive teams are more likely to have a sense of belonging and commitment to the team,mutual trust,and respect for each other. Furthermore,team cohesion is a requisite for effective team performance,team autonomy,effective collaboration,and problem solution[5].

One challenge to team cohesion is conflict,which is one of the factors that makes the environment either a positive or a negative one for professional nurses[8]. Conflicts in the workplace are normal and inevitable,and can lead to lowered morale,decreased productivity and poor team performance[9]. In addition,conflict can make interacting with team members a negative experience and reduce cohesion. Nurses who learn to manage conflict effectively can increase their cooperation within their work groups. Conversely,ineffective conflict management generates even more conflict. Conflict management refers to the behavioral reaction to other through the combination of self-concern and other-concern[10]. Pruitt and Rubin,based on two motives,concern for self and concern for others,proposed five styles of conflict management including problem-solving,forcing,yielding,avoiding,and compromising. Although,much research has been done related to conflict management among nurses in various settings,different preferences of conflict management were demonstrated within different cultural settings.

Different styles of dealing with conflict situations are associated with different levels of effective teamwork in the organization[11]. Many scholars have attempted to study the relationship between conflict management and team cohesion in various settings including healthcare settings[12]. However,several gaps exist in the study of conflict management and team cohesion. Firstly,different preferences of conflict management were demonstrated according to different cultural setting. Furthermore,there is no research into conflict management among nurses in Dali,Yunnan Province. Secondly,whist there are many studies regarding team cohesion in Western countries,the results may not explain the nature of team cohesion in a Chinese context. Thirdly,not only did these researches illustrate inconsistent findings in the relationship between conflict management and team cohesion,but only three of a range of possible conflict management styles with team cohesion were examined. Hence,including all five conflict management styles might result in a more comprehensive understanding of how conflict management styles interact with team cohesion. Lastly,most recent researches have been conducted regarding the relationship between these two variables among non-health personnel. No study extends the research area to the healthcare multidisciplinary team in China. Therefore,developing a better understanding of the influence of conflict management on team cohesion in a Chinese context is indispensable. Nurse administrators could apply the results of this study as baseline information to foster value-positive work environments and respectful working relationships.

This descriptive correlational research aimed to explore the styles of conflict management and the level of team cohesion,as well as to determine the relationship between conflict management and perceived team cohesion among nurses in affiliated hospitals of Dali University in Yunnan,China.

ConceptualFramework

The conceptual framework of conflict management based on Dual Concern Theory[10],which included five styles: forcing,yielding,avoiding,problem-solving,and compromising. Team cohesion based on Good and Nelson’s cohesion model,which included two dimensions: perceived cohesiveness and group attractiveness. Effective conflict management such as problem-solving and compromising might influence team cohesion by neutralizing any negative impact that conflict had on team cohesion. Ineffective conflict management such as forcing,yielding,and avoiding may negatively associate with team cohesion.

Methodology

Populationandsample

The samples were 336 subjects with 1089 nurses who had worked at least one year in two university hospitals of Dali University inYunnan,China.

Instruments

The instruments used in this study consisted of three parts,the Demographic Data Form,the Chinese version of the Dutch Test for Conflict Handling (DUTCH) and the Chinese version of Good and Nelson's (1973) Group Cohesion Scale. ①The Demographic Data Form was used to gather basic demographic information of each subject. It was developed by the researcher with open-ended and closed-ended questions including gender,age,marital status,educational level,professional title,working department,working duration,working shift,and employment status. ②Conflict management styles were measured by the Chinese version of DUTCH. It was originally developed by Van de Vliert[13]and was translated by Luo[14]. This instrument consists of 20 items with 4 items for each of 5 subscales including forcing,yielding,avoiding,problem-solving,and compromising. Responses were rated using a 5-point Likert scale ranging from 1 (not at all) to 5 (very much). Comparing the mean score of five subscales,a higher score represents a great tendency to use that particular conflict style. The Cronbach’s alpha coefficient for the five subscales of DUTCH,forcing,yielding,avoiding,problem-solving,and compromising were 0.83,0.81,0.88,0.85,and 0.84,respectively. ③The Chinese version of Group Cohesion Scale was developed by Good and Nelson and was translated by Hsieh[15]. This instrument contained 6 items which were divided into two dimensions: perceived cohesiveness (4 items) and group attractiveness (2 items). Each item required responses on a Likert-type scale ranging from 1 to 7. An overall team cohesion score was obtained by summing and averaging of the items,with the score ranging between 1 and 7. The average score was classified into three levels: low level (1.00- 3.00),moderate level (3.01- 5.00) and high level (5.01- 7.00). The reliability of Good and Nelson's Group Cohesion Scale in this study was .83,and the Cronbach’s alpha coefficient of the subscales of perceived cohesiveness and group attractiveness were 0.90 and 0.86.

Protectionofhumansubjects

The researcher gave the research consent form to the subjects. The subjects were free to refuse participation or to withdraw from the study at any time without losing any benefits and without affecting performance evaluations. Confidentiality and anonymity of individual responses were guaranteed by a statement which included in the cover letter information that provided to each of the subjects.

Datacollection

After receiving the approval from the Ethics Committee,permissions for data collection obtained from the administrative authorities at the affiliated hospitals of Dali University in China. The study design and data collection plan assured privacy,confidentiality,informed consent. Nurses who rostered to inpatient and outpatient departments,and had worked more than one year in affiliated hospitals of Dali University were invited to participate in this study between February to April 2017. The researcher and coordinator distributed the research package to the participants. The participants were asked to return the questionnaires in sealed envelopes within two weeks to the locked box which placed in the nursing department. The researcher distributed 355 questionnaires to the subjects,344 were returned and checked for completeness. Among them,336 (96.65%) were completed and used for data analysis.

Dataanalysis

To answer the research questions,the analysis plan drew on descriptive statistics and correlational statistics. The Statistical Package for the Social Science (SPSS) version 13.0 was used for data analysis. The demographic characteristics of nurses,styles of conflict management and level of team cohesion were analyzed by frequency,percentage,mean,and standard deviation (SD).The relationship between conflict management and team cohesion among nurses was analyzed by using Spearman’s rank order correlations since the data showed non-normal distribution.

Results

Demographicdataofthesubjects

The subjects consisted of 336 staff nurses from eight departments in two affiliated hospitals of Dali University. Nurses were primarily female (97.92%) with an average age of 30.69 years (SD= 6.58). More than three-quarters of the subjects were married (76.08%),and the majority was senior nurses (70.08%). A Bachelor’s degree was the most common level of education held by 52.33% of the subjects,whereas a Diploma’s degree held by 44.06%. More than half of the subjects (51.15%) had work experience of between 3-10 years with a mean tenure of 10.28 years (SD=7.18). Furthermore,a majority of the subjects (65.36%) worked on rotating shifts. Among the total nurses,40.01% worked in medical departments,and 25.60% worked in surgical departments. About 32.54% were permanent nurses,and 67.46% were temporary.

Conflictmanagement

Representatives of 336 nurses in the two tertiary general hospitals affiliated to Dali University,Yunnan province,China. As shown in Table 1,72.02% of nurses used only one style of conflict management. Among them,40.77% used avoiding to solve conflict situations,19.94% of nurses used problem-solving,5.06% used compromising,4.46% of nurses used forcing,and 1.79% of nurses used yielding. About 27.98% of subjects used more than one style of conflict management.

Table 2. Means,standard deviations,and the level of team cohesion of overall and sub-dimensions as perceived by subjects (n=336)

Table 1. Frequency and percentage of the subjects categorized by styles of conflict management (n=336)

Teamcohesion

Therelationshipbetweenconflictmanagementandteamcohesion

Data showed non-normal distribution,so Spearman’s rank-order correlation coefficient used in analyzing the relationship. In Table 3,the results of Spearman’s rank-order coefficient showed that there was a positive relationship between team cohesion and the score of problem-solving (r= 0.53,P<0.01),and the score of compromising (r=0.31,P<0.01). It also indicated that team cohesion was negatively related to the score of avoiding (r=-0.24,P<0.01),and the score of forcing (r=-0.21,P<0.01). However,there was no relationship between team cohesion and the score of yielding (r= -0.10,P<0.01).

Table 3. The relationship between score of conflict management and team cohesion of the subjects (n=336)

Discussions

ConflictManagement

The results of this study showed that avoiding was the conflict management style most frequently utilized by Chinese nurses (40.77%). The findings of this study could be explained by Chinese culture. Chinese people are collectivist with a strong emphasis on maintaining relationships. Collectivism leads them to be hesitant about engaging in aggressive interaction that may challenge the social face of others[16]. They are highly averse to interpersonal hostility and assertive ways of handling frustrations and problems. Furthermore,the demographic profile of nurses in this study may be another reasonable explanation for this result. In this study,the majority of the subjects (97.92%) were female. Women are more likely to take their partner’s interests into consideration,preferring more tactful strategies,whereas men prefer competitive,unyielding,and aggressive strategies[17]. Moreover,more than half of the subjects (55.65%) were aged between 22-30 years old,while 51.15% of the subjects had work experience between 3-10 years. Researchers have revealed that younger nurses with less work experience used the avoiding style more than those with more work experience[18]. Therefore,nurses adopt the avoiding style as a way to manage conflict while also attempting to maintain harmony and preserve relationships.

TeamCohesion

However,there are also some barriers to team working in health care,which impact nurses’ perception of team cohesion. In this study,more than half of the subjects are junior nurses who had work experience of between 3-10 years,and were aged between 22-30. Lucas M D,et al.[19]pointed out that nurses with less experience in nursing practice had less team cohesion. Moreover,the hospital organization environment could be another barrier where nurses often fail to show good organization support in their work. Hayhurst A,et al.[20]indicated that a lack of support in the work environment diminished nurses’ perception of group cohesion[20]. With the rigidity of hierarchical structures in Chinese health care settings,nurses are at lower status than other professionals in entire healthcare systems[21]. Nurses have inadequate opportunity for professional development,and rarely get enough support of human resources,funding and materials to perform their work. Additionally,due to the management structure of hospitals,nurses themselves have had little opportunity to participate and express their thinking in important decision-making. Furthermore,nurses stated a lack of support and a lack of positive feedback from superiors with few encouragements from nurse managers.

Another possible reason for this finding may due to the heterogeneous characteristics of the multidisciplinary team members in Chinese healthcare settings. The members of multidisciplinary teams,especially nurses and physicians,differ in their education,status,experience,attitude,and theoretical orientations to teamwork. The diverse characteristics of multidisciplinary team members may detract from members’ perceptions of each other’s commitment and reduce their sense of “togetherness,” thereby weakening cohesion. Clearly,the above reasons could result in lack of supportiveness among nurses in the university hospitals of Yunnan,leading to a moderate level of team cohesion.

Therelationshipbetweenconflictmanagementandteamcohesion

The result showed that there was a positive relationship between problem-solving style and team cohesion (r= 0.53,P<0.01). Problem-solving style was considered as a collaborative conflict management strategy[22]. The probable explanation may be that problem-solving conflict management is a win-win strategy,aiming to take co-operation and attempting to find a solution that optimizes outcomes of all parties involved[10]. People who adopt a problem-solving conflict management style attend to the issue openly,frankly,and neutrally by communicating with others[23],and facilitate friendship,effective interaction and communication. Furthermore,problem-solving in conflict situations increases individuals’ satisfaction,and a feeling of self-efficacy,develops trust,reduces likelihood of future conflict,and maintains a better interpersonal relationship,thus promoting team cohesion[24].

Regarding the correlation between compromising conflict management style and team cohesion,this study found that there was a positive association between compromising conflict management style and team cohesion (r=0.31,P<0.01). Compromising is seen as half-hearted problem solving with intermediate concern for self and intermediate concern for others[10]. It is associated with behaviors of seeking middle-ground and mutually acceptable solutions through give and take to solve the conflict. In conflict situations,a compromising style can encourage team members to work together to manage conflict between them[25],and parties try to solve the conflict cooperatively,and better understand each other. The more positive a member feels about his or her team,the more motivated the person is to promote in-group solidarity,cooperation,and support.

In terms of avoiding conflict management style,there was a negative relationship between avoiding conflict management style and team cohesion (r=-0.24,P<0.01). Avoiding is a lose-lose strategy that involves taking a passive stance and attempts to reduce and downplay the importance of the conflict issues,as well as attempts to suppress thinking about the issues[10]. An avoiding approach did not help solve conflicts,instead exasperating the dysfunctional effects of conflict on team cohesion[26]. In doing so,individuals may feel less attraction to the team,and it is not worth the effort being a member of this team. Accordingly,people who tend to avoid conflicts have lower team cohesion.

This study found that there was a negative relationship between team cohesion and forcing conflict management style (r=-0.21,P<0.01). A forcing conflict management style is a win-lose oriented strategy in a conflict episode. It involves using coercive behaviors to get others to conform to one’s position. Forcing comprises behavior of threats and bluffs,which frustrate communication,undermine trust and result in deadlocks or imposed solutions[10]. Researchers have shown that people who try to surpass one another do not utilize each other’s ideas and resources,that they hide information,and block each other’s efforts[27],which results in decreased team cohesion.

The result of this study reveals that there was no significant correlation between a yielding conflict management style and team cohesion (r= -0.10,P>0.05). The possibility for the result may be that there were only a few subjects in this study who used this style to manage conflict (n= 6). Thus,there is a possibility that team cohesion scores of this group are small variable,resulting in no relationship between yielding conflict management and team cohesion.

Conclusion

The study findings revealed that,avoiding was the conflict management style most frequently utilized by nurses,and nurses perceived team cohesion was at a moderate level. Additionally,there was a positive relationship between team cohesion and the score of problem-solving and the score of compromising. It also indicated that team cohesion was negatively related to the score of avoiding and the score of forcing. However,there was no relationship between team cohesion and the score of yielding. The findings of this study can provide valuable information for administrators who should be encouraged to identify various strategies to improve team cohesion in multidisciplinary teams and develop a support system for nurses. Moreover,nurse managers can promote the development of multidisciplinary team cohesion by encouraging nurses to use problem-solving and a compromising style to handle conflict situations within their team.

Recommendations

Based on the study findings,the researcher proposes the need to conduct future studies in health care institutions among nurses in other regions of China. The intervention to improving nurse team cohesion should implement in further research. Moreover,identify factors that influence team cohesion among nurses,such as team behaviors,leadership styles,and situational variables.