Accepted: 12 February 2018

DOI: 10.1111/jonm.12631

ORIGINAL ARTICLE

Conflict management among health professionals in hospitals

of Cyprus

Maria Pitsillidou RN, PhD Candidate, Registered Nurse1 | Antonis Farmakas RN,

PhD, Psychotherapist (CBT)2 | Maria Noula RN, PhD, Associate Professor of Nursing
Program2 | Zoe Roupa RN, PhD, Professor Coordinator of Nursing Program2

1
Evangelistria Medical Center, Nicosia,
Cyprus
2
University of Nicosia, Nicosia, Cyprus
Correspondence
Maria Pitsillidou, Evangelistria Medical
Center, Nicosia, Cyprus.
Email: maria_pitsillidou@outlook.com
Aim: To record the types of conflict management that health professionals in Cyprus
hospitals encounter in their daily work and to explore the conflicts, their parameters
and causes, and the role ambiguity faced by the hospital employees.
Material and Methods: This is a descriptive study in which data were collected with
an anonymous self-­referral questionnaire. The study population consisted of 300
health professionals from six different hospitals in Cyprus. Data are presented with
averages and standard deviations.
Results: The health professionals identified the following causes of conflicts in the
workplace in descending order: heavy workload, low pay, and varying instructions
from different leaders. To deal with the conflict, 73.2% of the participants reported
using avoidance, 54.2% engaged in negotiation for mutual benefit, and 40.5% cited
compromise as a method.
Conclusions: Identifying the way in which conflicts are managed contributes to the
smooth functioning of organisations, and it improves the effectiveness of the ser-
vices provided.
Implications for Nursing Management: It is generally known that the high levels of
conflict in hospitals are associated with increased mistakes and low employee satis-
faction and performance levels. Managers deal with conflict-­management issues
within organisations on a daily basis. It is therefore essential to comprehend the rea-
sons behind conflicts and provide suitable training for the development of communi-
cation skills and conflict-­management strategies.

KEYWORDS
conflict, conflict management, health professionals, hospitals

1 |  BAC KG RO U N D of conflict within a company or organisation has become a point of

Conflicts exist in every organisation where people interact and work
together (Rovithis et al., 2017; Saitis, 2002). According to the the-
ory of human relations, the existence of conflict in groups is con-
sidered a natural consequence of human interaction. The concept
interest for many researchers (Giannikas, 2014; Rovithis et al., 2017).
Some conflicts arise when the organisation’s requirements conflict
with the opinions, attitudes, values, and beliefs of the individual
(Brewer & Clippard, 2002; Erdenk & Altuntas, 2017). According to
Jones (2007), role conflict exists when different people or different

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954       PITSILLIDOU et al.
groups of people with whom the worker interacts have conflicting
expectations.
In a multivariate environment such as a hospital, the need for
interdisciplinary collaboration increases the degree of interac-
tion between the workers, which is necessary to achieve clinical
and administrative goals (Al-­Hamdan, Nussera, & Masa’deh, 2016;
McKibben, 2017; Papadopoulou, 2014). Vague description of busi-
ness functions and confusion of roles have been identified as two
of the main causes of conflict (Bonner & Walker, 2004; Haraway &
Haraway, 2005). The confusion and lack of clarity about the roles
and responsibilities is a common phenomenon for health profession-
als (HPs) because the health care workplace is unpredictable, com-
plex, and includes job ambiguity (Haraway & Haraway, 2005).
Identifying and dealing with conflict is a challenge for the man-
agement and it is therefore considered a valuable skill in managers
(Al-­Hamdan et al., 2016; Nayeri & Negarandeh, 2009; Papadopoulou,
2015). It has been shown that the late detection of conflicts impedes
their solution and leaders play a major role in the timely detection
of conflicts (Villi, Galani, & Bogiatzoglou, 2010). Tidd and Friedman
(2002) emphasized the importance of identifying specific behaviours
that can help employees cope with role conflict.
1.1 | Factors leading to conflict
In the health sector, countless factors, including past events, could
lead to conflicts, without necessarily being the actual cause. Studies
suggest that conflicts are the result of people’s interactions with
their working environment (Roussou & Pavlakis, 2011). Research
supports the view that conflicts are a result of people’s interactions
with two or more individuals who may have different beliefs, val-
ues, goals, ideologies, and perceptions, or when the expectations of
one person are affected by someone else’s actions (Graham, 2009;
Stathopoulos, 2006). Each individual has different perceptions, val-
ues, a different education, different abilities, experiences, and per-
sonal features, and often all of these may conflict with some of the
job-­role requirements, leading to disputes with other health care
professionals (Gerardi, 2004).
Cooperation is one of the most important factors in the effi-
cient functioning of an organisation (Fountouki, Gatzelis, Pantas, &
Theofanidis, 2009). However, the need for multidisciplinary cooperation
in a hospital also increases the level of interaction between health care
professionals and the level of interdependence among departments. It
is therefore natural that, with an increase in such interactions, the prob-
ability of occurrence of conflicts increases (Papadopoulou, 2014).
The size or the complex hierarchical structure of an organisation
with several departments, and thus, departmental heads, may be
a source of tensions (Stathopoulos, 2006). Health care profession-
als receive orders from many managers, and as a result, they feel
pressurized and experience a lack of independence in their work
(Roussou & Pavlakis, 2011). In such a situation, conflicting goals are a
common occurrence. When a person or a group has conflicting goals
and they feel that their benefits are threatened, communication dif-
ficulties arise (Bourantas, 2002).
Schmidt and Svarstad (2002) supported the notion that efficient
communication in health care settings improves clinical results, in-
creases the degree of patient satisfaction, and contributes to the re-
duction of expenditure of human and material resources. Inefficient
communication might be a result of different perceptions, education
levels, spoken language, and bad work conditions. Research reveals
that majority of health care conflicts arise from “interpersonal or pro-
fessional communication difficulties” (Shin, 2009). In addition, em-
ployees in large and complicated organisations or companies tend to
experience more conflicts (Villi et al., 2010). In large organisations such
as hospitals, conflicts tend to occur daily owing to the need for coop-
eration in providing health care services (Roussou & Pavlakis, 2011).
Role overload has been reported as a substantial and frequent
work stressor that has harmful consequences for employees’ be-
haviour and the overall organisation performance. Role overload oc-
curs when employees perform many different roles simultaneously
and they feel that they are required to meet many more duties than
their capabilities and available time allow (Bourantas, 2002). Vanishree
(2014) reported that work overload and role ambiguity cause work
stress among employees, resulting in poor concentration, work perfor-
mance, and decision making.
Role confusion and ambiguity could result from undecided duty
allocations and the absence of a role description with regard to what
the company expects from each worker. These can affect the func-
tioning of HPs and can create stress that leads to conflicts among
employees (Haraway & Haraway, 2005).
1.2 | Conflict management
Despite the negative consequences and the unpleasant condi-
tions caused by conflicts (Kreitner & Kinicki, 2010), they can be
partly constructive (Haraway & Haraway, 2005; McKibben, 2017).
Research supports the notion that, when managed correctly, con-
flicts can be used to derive positive results (Haraway & Haraway,
2005; McKibben, 2017; Tang & Chang, 2010).
Conflict management is defined as a systematic process aiming
at the discovery of satisfying solutions for the members involved in
the conflict (Al-­Hamdan, Shukri, & Anthony, 2011). At the same time,
its ultimate purpose is to decrease non-­functioning conflicts that re-
duce the group’s efficiency, and in turn, to use effective or construc-
tive conflicts to create positive results (Lee, 2008).
Depending on the circumstance and the time when the conflict
takes place, different methods can be used to address or manage it
(Herzog, 2000; Papadopoulou, 2015). According to the Thomas–
Kilmann Conflict Mode Instrument (TKI) (Thomas & Kilmann, 2010),
the following techniques are commonly used for resolving conflicts:
1. Avoidance. The parties avoid addressing the problem and be-
lieve that, if they ignore it, it will solve itself. When avoiding
a conflict, an individual does not immediately pursue his or
her own concerns or those of the other person.
2. Accommodating. The strategic goal here is to maintain good rela-
tions, which is only met by one party as the other does not try to
PITSILLIDOU et al.
achieve his or her own objectives. This method is also chosen
when one party is stronger than the other. It is not assertive and
may take the form of selflessness or philanthropy, but it does not
favour cooperation.
3. Compromise. In a compromise, the involved parties try to find a
common solution that is not optimal but it mitigates the needs and
requirements of both sides. It is a kind of negotiation based on a
relationship of give and take, and it is not considered a suitable
method for solving complex problems.
4. Competition. This is an assertive, uncooperative, and power-ori-
ented mode. In this method, one party attempts to achieve its
objectives by trampling over the other party, without any concern
for him/her.
5. Collaboration. The two sides try to cooperate with each other to
find a solution that fully meets the needs of both parties. Due to this
cooperation, the two sides overlook their mutual conflicts, unite
their knowledge and their ideas, and fight for a common purpose.
2 | A I M S
The aim of the present study was to examine the conflict-­management
methods experienced by employees in hospitals in Cyprus. The causes
of conflicts were also explored to develop a scientific explanation for
the failures and problems faced by workers in hospitals.
2.1 | Research questions
1. Is the extent of role conflict experienced by workers related
with their work experience?
2. Are work overload and salary important factors for the experi-
ence of conflict?
3 | M ATE R I A L S A N D M E TH O DS
This survey was conducted in hospitals in Cyprus (in the city of
Nicosia), which had 2,535 HPs (doctors, nurses with university or
TA B L E   1   Population of study
Name of hospital
Nicosia General Hospital
Archbishop Makarios
Hospital
Evangelistria Medical
Center
Bank of Cyprus Oncology
Centre
Arodafnousa
Aretaeio
Total
|
      955
technical education, health visitors, physiotherapists, nurses assis-
tants, midwives, chemical laboratory technologists, radiotherapists,
and medical physicists).
An anonymous self-­
report questionnaire was distributed and
collected from January 2016 until the end of February 2016. The
questionnaire comprised two parts. The first pertained to the de-
mographic information of the participants. The second consisted of
questions concerning the role ambiguity and role conflict they expe-
rienced, and their management.
The Conflict Health Professionals questionnaire used in the in-
vestigations by Kontogianni et al. (2011), and Pavlakis et al. (2011)
was employed, with permission, in the present study. The original
questionnaire was created by Tegnilimoglu and Kisa (2005), and was
translated from English to Greek and back-­translated from Greek
to English. The reliability of the questionnaire, as indicated by the
Cronbach’s α, was .75 (Kontogianni et al., 2011; Pavlakis et al., 2011;
Tengilimoglu & Kisa, 2005).
The survey’s population was 400 HPs, who were selected with
proportional stratified sampling. See Table 1 for details. From this
population, 310 HPs – representing 77.5% – accepted the invitation
to participate and questionnaires were distributed to them. From the
total distribution of questionnaires, 300 were collected, with the re-
sponse rate being 96.7%.
Distribution and collection took place anonymously. The ques-
tionnaire was accompanied by a letter stating the details of the
researcher, the purpose of the study, and the participants’ right to
confidentiality and voluntary participation.
To ensure the reliability and validity of the questionnaire, a pilot
study was conducted with 30 participants, to determine the time
required for completion, the clarity of the questions, and the need
for possible amendments.
3.1 | The pilot study
We conducted a pilot study with 30 participants to test the reli-
ability and validity of the questionnaire. The questionnaire’s va-
lidity was evaluated by experienced researchers who assessed
the ease of completing the questionnaire and the clarity of the
questions. The questionnaire was completed by 15 nurses and 15
Total number of health
professionals – total population Targeted population
1,432 225
648 102
79 13
166 26
28 5
182 29
2,535 400
 |
956       PITSILLIDOU et al.

TA B L E   2   Demographic and work

N % N %
characteristics of the sample
Sex Do you hold an administra-
tive position?
Females 223 74.3 Yes 57 19.1
Males 77 25.7 No 243 80.9
Total 300 100.0 Total 300 100.0
Work experience If yes, specify:
0–2 55 18.4 Director 4 7.0
3–5 64 21.4 Deputy director 4 7.0
6–10 50 16.7 Head of sector 2 3.5
>10 130 43.5 Chief 39 68.4
Total 300 100.0 Deputy head 2 3.5
Level of education Other 6 10.5
Diploma/degree 205 68.2 Total 57 100.0
MSc 83 27.8
PhD 12 4.0
Total 300 100.0

physicians, and their comments and questions were recorded. No
substantial changes were required based on the comments of the
participants.
3.2 | Statistical analysis
The data were analysed using descriptive and inferential statistics
to create frequency tables for the variables under consideration.
Data were presented with averages and fixed (standard) deviations.
Comparisons between subgroups were performed using the χ2 test
for qualitative variables and the Mann–Whitney U test or Kruskal–
Wallis test for categorical variables with two or more samples, re-
spectively. These analyses were followed by a post hoc analysis
using the Holm’s test. The level of statistical significance was set at
p < .05. All analyses were conducted using SPSS 22.0.
with a percentage of 74.3; 60.2% of the participants had worked
for more than 6 years, and 27.8% had a master’s degree. In terms
of administrative positions, the majority of the 19.1% who had held
administrative positions had been departmental heads. Nurses
with university-­level certificates made up a majority of the sample
(57.2%).
4.2 | Conflict-­management methods
As is evident from Table 3, avoidance (73.2%), negotiating for
mutual benefit (54.2%) and compromise (40.5%) were the most
common methods of conflict management. These were followed
by assertiveness (13.7%), and the use of “arbitration” (21.4%). If
the HPs had to choose a person as a judge for resolving a con-
flict, they preferred a colleague or a supervisor (50.8% and 56.2%,
respectively).

3.3 | Limitations
The questionnaire was completed during the shift and, mainly, dur-
ing the break, under time pressure, which might have influenced
the responses of the HPs. Not all types of HPs agreed to partici-
pate. However, this outcome did not have a negative effect on the
present findings. The present results can still be considered reli-
able. Finally, the numbers of male and female participants were
not equal. For this reason we could not conduct a gender-­based
comparison.
4 |   R E S U LT S
4.1 | Demographic and work-­related characteristics
Table 2 represents the demographic and employment characteris-
tics of the present sample. Women were predominant in the sample,
4.3 | Relationship between job duration and conflict
Those with more than 10 years of experience did not tend to use
compromise and acceptance as conflict-­resolution methods (they
were more assertive) (p < .01). Those with 6–10 years of work
experience tended to negotiate more often to resolve conflicts
(Table 4).
4.4 | Suggestions for resolving conflicts in the
hospital setting
The establishment of communication and cooperation (17.7%), re-
spect for individuals’ rights and professional development (14.7%),
and clear allocation of responsibilities (13.4%) were the most com-
mon recommendations made by the participants for resolving con-
flicts in the hospital setting (Table 5).
PITSILLIDOU et al. |
      957

TA B L E   3   Nature of conflict experienced in management roles

What kind of behaviour occurs when you are in If you were to select another person as a judge to resolve
conflict? % the conflict, who would you choose? %

I usually argue until I win 13.7 Colleague 50.8

I usually compromise 40.5 Chief or senior officer 56.2
I try to avoid collision 73.2 Service manager (e.g., nursing, medicine) 17.1
I accept the desire of the opposite side by speaking to 26.4 Director/doctor 9.7
another person
I negotiate with the opposite side for mutual benefit. 54.2 A person from another profession 8.0
I speak to another person to act as a judge/mediator for 21.4 Anyone 9.0
conflict resolution

TA B L E   4   Nature of conflicts experienced by work experience and cultural group

Work experience

Years 0–2 3–5 6–10 >10 p

Conflicts with subordinates or those less educated than me 32.7% 26.5% 18.0% 38.2% .041
from the same professional category
I usually compromise 56.3% 51.5% 40.0% 28.2% .001
I accept the desire of the opposite side 25.4% 31.3% 42.0% 18.3% .012
I negotiate with the opposite side for mutual benefit 45.5% 40.6% 68.0% 58.8% .008
Colleague 54.5% 57.8% 66.0% 51.9% .037
Forceful 21.8% 28.0% 48.0% 35.1% .027
Peace 49.0% 60.0% 34.0% 25.2% .017

TA B L E   5   Suggestions for resolving

Suggestions for resolving conflict in the hospital setting %
conflict
Equitable distribution of resources 2.3
Communication and cooperation should be established in the organisation/hospital 17.7
The causes of conflict should be identified and both sides should be heard 11.0
Fair approach to reward and punishment 8.7
Conducting meetings (for conflict resolution) 5.0
No discrimination/the management must remain neutral 12.4
Clear allocation of responsibilities 13.4
Fewer political considerations at work 1.0
An autonomous professional management body should be established and should be in 8.7
control.
Respect for individuals’ rights and career development 14.7
Fair pay 5.0
Total 100

4.5 | Organisational factors in relation to conflict
As shown in Table 6, 66.2% of the participants believed that their
workload was greater than that of other professional groups, and
52.5% believed that their salaries were not satisfactory and that
they were not commensurate with their workload. Participants also
suggested that receiving commands from more than one person in
charge affected them negatively (56.6%).
5 | D I S CU S S I O N
The results of the present study show that the majority of the HPs
(59%) encountered conflicts at their workplace, with the main par-
ties involved being doctors and nurses.
The most common method for managing conflict in a clinical set-
ting was avoidance (73.2%), followed by negotiating for mutual ben-
efit (54.2%), and compromise (40.5%). Avoidance may have emerged
 |
958       PITSILLIDOU et al.
TA B L E   6   Organizational factors that cause conflicts
None (%)
Do you believe that your workload is greater than that 7.7
of other professional groups?
Do you think your salary is sufficient to motivate you 35.1
considering your workload?
Do you accept commands from more than one person 9.7
in charge? Does it affect your productivity negatively?
χ2, Bonferroni post hoc correction.
as the most commonly used conflict-­resolution method due to the
large number of nurses in the present sample. Nurses tend to work
under pressure and fear because they do not have the advantage of
power or autonomy (Papathanassoglou et al., 2005). Avoidance may
therefore be considered as an easy workaround.
Various surveys have found compromise and avoidance to be the
two dominant conflict-­resolution methods (Hendel, Fish, & Galon,
2005; Sportsman & Hamilton, 2007; Valentine, 2001). These conflict-­
management methods were also identified in the present survey, with
a difference in the order of preference, as avoidance was the first, and
compromise was the third most commonly cited method. In a survey
of HPs in Cyprus, it was identified that avoidance and collaboration
were the preferred ways of resolving conflicts (Pavlakis et al., 2011).
Similar results were shown in the study by Kontogianni et al. (2011),
where avoidance was identified as the most common strategy used by
HPs, while acceptance was the least used strategy.
In regards to the choice of an “arbitrator” to cope with the conflict,
the participants in the present study seemed to prefer a colleague or
supervisor (50.8% and 56.2%, respectively). This finding corresponds
with the results of Kontogianni (2007), which found that HPs usually
preferred to choose a colleague rather than a senior as a judge to re-
solve conflicts, while their immediate superior was a common choice.
The above decision may be due to the direct collaboration between
colleagues and the sense of trust felt toward departmental heads.
The present study also revealed that the conflict-­management
method tended to vary based on employment characteristics.
Nurses with more than 6 years of experience had a lower tendency
to compromise and appeared more assertive in resolving conflicts
(p < .001). This finding contradicts that of the study by Borou et al.
(2013), which found that nurses with more than 10 years of expe-
rience chose to compromise to resolve conflicts more often than
those with less than 10 years’ experience. Meanwhile, this means
they are not passive in conflict resolution, and they preferred to deal
with their conflicts in a mutually beneficial way (p < .05) and by being
assertive (p < .01) (Borou et al., 2013).
Participants’ knowledge of the hospitals’ specific conditions and
their previous experience may enable most employees with longer work
experience to negotiate more easily than less experienced employees.
However, owing to the fear of dismissal and the limited resources (e.g.
administrative foundations, financial rewards) within the hospital, less
experienced employees may not have much room to bring about a
change, and therefore they may tend to choose to compromise (56.3%).
Low (%) Moderate (%) High (%) Very high (%)
6.4 19.7 31.4 34.8
17.4 33.8 10.7 3.0
12.7 21.1 30.8 25.8
The present study found that high workload (66.2%), low wages
(52.5%), and receiving orders from different leaders (56.6%) were im-
portant organisational factors affecting conflict management. These
findings may be a result of the recent economic crisis experienced
in Europe (Kalogeropoulou & Papathanasopoulou, 2013), which
has led to wage cuts, layoffs, and an increase in workload for HPs
owing to the lack of manpower. In a survey conducted by Pavlakis,
Theodorou, and Kaitelidou (2008), it was found that more than half
of the nurses experienced higher workload than physicians. This
finding may be explained by the fact that physicians are often paid
highly in relation to other groups for their services, and they have
more power and autonomy in relation to decision making (Gampel,
2006). In relation to the negative impact of receiving orders from
several supervisors, Kontogianni (2007) also revealed that this was a
major cause of conflicts among HPs.
Regarding role ambiguity, the present study revealed that re-
ceiving orders from several superiors and the non-­identification of
responsibilities hampered the execution of tasks, leading to conflicts
(13.4%). The lack of clear responsibilities confuses employees be-
cause they do not know what is involved in their role. This in turn
has been found to negatively affect the work efficiency of HPs, to
hamper their job satisfaction, and increase anxiety (Tunc & Kutanis,
2009). In this regard, Kontogianni (2007) stated that majority of the
participants reported that the statutory regulations did not clearly
define their tasks and did not help them perform their tasks effi-
ciently. The same was observed in the present study.
Apart from the clear division of responsibilities, the most com-
mon suggestion for resolving conflicts in hospitals was to strengthen
communication/cooperation (17.7%) and respect for individuals’
rights/development (14.7%). An individualistic business culture
between occupational groups may undermine effective communi-
cation. Casanova et al. (2007) identified that professional respect
is essential for successful communication. Each professional group
differs in relation to the way it works; however, negative behaviours
affect communication among these groups.
6 | CO N C LU S I O N S
The findings of the present study, in combination with the sugges-
tions of the HPs indicated that communication between physicians
and nurses is essential to manage conflicts such that no issues among
PITSILLIDOU et al.
them remain unresolved, which may pose a threat to the sustain-
ability of the health care system. Additionally, teamwork and mutual
respect lead to good working relationships.
The ambiguity experienced in regards to the responsibilities and
competences of the professionals in the health sector is responsible
for conflicts, especially in the Greek setting. There is thus a need
for the immediate establishment and implementation of clear and
objective professional duties that affect professional collaboration.
The health sector has been characterized as being “labour inten-
sive” because of the stress caused by the working conditions. The
culture of the organisation needs to change by emphasizing commu-
nication and cooperation. Further, the timely recognition of conflicts
and identification of solutions to resolve the same are necessary
for the proper functioning of the organisation, as these measures
guarantee its effectiveness. This is particularly crucial for health care
organisations.
Staff training and equivalent sensitivity towards this issue from
the management are also expected to contribute positively toward
the creation of a peaceful work environment in hospitals. Conflicts
are inevitable but, by effectively managing them, they can be used as
a springboard for dialogue. Such conflicts can also foster changes in
practices and situations by enhancing the optimal functioning of the
organisation. Conflict management is thus an important organisa-
tional activity, and HPs, especially managers, should be well trained
to recognize conflicts early and tackle them effectively.
7 | I M PLI C ATI O N S FO R N U R S I N G
M A N AG E M E NT
In order to deal with conflicts it is necessary to understand the rea-
sons for them and the methods to apply to resolve them. Employees,
and especially all of them, need appropriate training to develop their
communication skills and conflict-­management strategies because
conflicts in the work environment are stressful for employees, af-
fecting the quality of the care provided and professional satisfac-
tion. Cyprus is a country where conflicts among health care workers
are a fact. Consequently, learning how to deal with conflicts is crucial
so that they can participate efficiently and adopt a constructive at-
titude when dealing with conflicts to ensure the provision of secure
and effective nursing. The current study confirmed that conflicts
exist in the health care setting and that the use of “avoiding” is the
most common behaviour in response, which avoids resolving the real
problem that originally caused the conflict, according to the majority
of the participants. These findings indicate that there is a need to
strengthen the relationships between health care professionals to
improve working conditions in Cyprus hospitals to resolve existing
conflicts.
AC K N OW L E D G E M E N T S
The authors would like to thank the health professionals from
Nicosia’s hospitals for participating in the research study.
|
      959
E T H I C A L A P P R OVA L
This study was approved by the National Committee of Bioethics,
the Privacy Commissioner, and the Directorate of Nursing Services
of the Ministry of Health in Cyprus, and the directors of the selected
hospitals (approval number: ΕΕΒΚ ΕΠ 2015.01.86).
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How to cite this article: Pitsillidou M, Farmakas A, Noula M,
Roupa Z. Conflict management among health professionals in
hospitals of Cyprus. J Nurs Manag. 2018;26:953–960. https://
doi.org/10.1111/jonm.12631