Introduction
Conflict is a lack of agreement between two or more groups associated with a conscious effort to prevent opposing parties from achieving their goals. The occurrence of conflict in an organization is inevitable. Many individual and organizational factors lead to workplace conflicts [1, 2]. Individual factors of workplace conflicts result from differences in people’s characters, values, attitudes, tastes, information, abilities, skills, and experiences. In contrast, organizational factors are limited or shared resources, ambiguity in roles and tasks, poor communication, differences in organizational goals, organizational culture, and regulations [3, 4]. Workplace conflicts occur when a person faces multiple and contradictory job requirements or expectations and has to make difficult decisions to resolve these conflicts. Work conflicts may arise due to differences between job tasks, personal and professional needs and expectations, time, energy, resources, or job values and principles [3-6]. There are two types of conflict in general: Constructive and destructive. 
Constructive conflict motivates people to work harder, collaborate, and seek new solutions [7, 8, 9]. The impact of conflicts depends on their intensity, duration, and management. Conflicts can sometimes be considered challenges or opportunities useful for professional development and growth [10, 11]. Conflicts may increase stress and reduce job satisfaction and efficiency [12, 13]. Dealing with negative or destructive conflicts is very important, and appropriate strategies should be used in different situations.
Nursing is based on relationships and collaboration with patients and other healthcare team members. In this profession, interpersonal conflicts may arise when two or more medical staff see a situation from different points of view [3, 14]. Although conflict is usually considered a negative issue, its resolve can be fruitful for nurses, their colleagues, or patients [3, 4, 6]. A conflict that is controlled by nurses can lead to their personal or organizational growth [5]. However, suppose the conflict is not well maintained. In that case, it can decrease the quality of care and cause aggressive behaviors such as bullying or horizontal violence, which affects the therapeutic relationship between the patient and the nurse [3, 4]. Therefore, nurses should be aware of the reasons for conflict escalation and be ready to prevent or manage it in their workplace. The nurses who manage conflict effectively have respect for their patients, colleagues, and jobs [15, 16]. Studies have shown that people use different strategies, such as control, non-confrontation, and solution-oriented strategies, to resolve workplace conflicts [17, 18]. Conflict management is an effective and efficient practice that improves the quality of patient safety and the morale of the staff and limits their work stress in patient care. Nurses and nursing managers should have the necessary skills to resolve conflicts at work [15, 18]. To prevent conflict among nurses and provide strategies for its management, we should first be aware of the prevalence of conflicts and the coping strategies nurses’ use. The present study aims to determine the extent of workplace conflict among nurses working in teaching hospitals in Qom City, Iran, and their coping strategies.

Materials and Methods
This descriptive-analytical study used a cross-sectional design conducted from June 2019 to February 2020. The study population comprises all nurses in four teaching hospitals affiliated with Qom University of Medical Sciences. Of whom, 373 eligible nurses were selected using a simple random sampling method. The sample size was determined by considering the type I error of 5%, the accuracy of 0.05, and the workplace conflict prevalence of 58.4% in nurses based on Alhani’s study [19]. The inclusion criteria were being a nurse (with any nursing university degree), lacking a history of psychiatric disorders (based on self-report), and being willing to participate in the study. Those with incomplete questionnaires were excluded from the study.
Data collection tools were a demographic form, DuBrin workplace conflict questionnaire (WCQ), and Putnam and Wilson’s organizational communication conflict instrument (OCCI). The WCQ has 20 items answered by completely disagree (0 points) or completely agree (1 point). A score ≤3 indicates a low level of conflict; a score of 4-14 indicates a moderate level of conflict, and a score ≥15 shows a high level of conflict [20]. WCQ has been used in other studies in Iran [4, 21]. To determine its reliability, its Cronbach α was calculated as 0.83. The OCCI has 30 items that measure three conflict styles: Non-confrontation (12 items), solution-oriented (11 items), and control (7 items) [22]. The items are rated on a 7-point Likert scale: “Always,” “very often,” “often,” “sometimes,” “seldom,” “very seldom,” and “never.” In this study, the content validity of OCCI was examined by 10 faculty members of Qom University of Medical Sciences, and their comments were applied. The internal consistency of the Persian OCCI was calculated at 0.84 using the Cronbach α coefficient, and its test re-test reliability was estimated at 0.85.
The questionnaires were completed by self-report method. The questionnaires were distributed among the nurses at different work shift hours. They were given explanations about the study objectives and tools and were assured of the confidentiality of their information. Descriptive statistics such as Mean±SD, and frequency were used to describe the obtained data. The chi-square test, Fisher’s exact test, and one-way analysis of variance (ANOVA) were used to analyze data. Multivariate linear regression (enter method) was used to find the predictors of workplace conflict. Data analysis was done using SPSS software, version 20. The significance level was set at 0.05.

Results
Most participants were female (63.8%) and married (67%), holding a bachelor’s degree (88.3%) with temporary/permanent employment (74.5%). Their mean age was 34.78±5.96 years, and their mean work experience was 9.20±6.11 years. Their WCQ mean score was 10.04±3.93, indicating a moderate level of conflict in nurses. In the high-level conflict group, the highest percentage was related to females (86%) and single (55.8%) nurses with a bachelor’s degree (90.7%), temporary/permanent employment (69.8%), working in a coronary care unit (CCU) or intensive care unit (ICU) (53.5%) and these differences were statistically significant (P<0.05). Although the difference among workplace conflict levels was not statistically significant based on shift work, results showed that 100% of nurses with high-level conflict had rotating shift work (Table 1).


Regarding age and work experience, the difference among workplace conflict levels was statistically significant (P<0.05). Tukey post hoc test results revealed (Table 2) that the mean age of the nurses in the high-level conflict group (32.53±5.39 years) was lower than in the moderate-level conflict group (35.06±5.93 years).


In terms of conflict management strategies, the difference among workplace conflict levels was statistically significant only in solution-oriented and control strategies. The mean score of solution-orientated strategy in the group with a low level of conflict (39.53±2.21) was higher than in the group with a moderate level of conflict (36.65±4.46). This outcome indicates that nurses with low workplace conflict use the solution-oriented strategy to manage the conflict more than nurses with moderate workplace conflict. The mean score of the control strategy was higher in the high-level conflict group (24.90±3.75) and lower in the low-level conflict group (17.70±4.62).
The results of multivariate regression analysis showed (Table 3) that the variables of age (95% CI; β=0.26, 0.04 to 0.31, P=0.009), marital status ( 95% CI, β=-0.17, -0.65 to -2.35, P=0.001), type of employment (95% CI, -0.65 to -1.54; β=0.22, P=0.001), department of service (95% CI, -0.09 to -0.44; β=-0.09, P=0.04), work experience (95% CI, -0.07 to -0.35; β=-0.32, P=0.003), non-confrontation conflict resolution strategy (95% CI, -0.01 to -0.12; β=-0.12, P=0.01), and control conflict resolution strategy (95% CI, -0.27% to -0.43%; β=0.43, P=0.001) could significantly predict the percentage of workplace conflict in nurses (adjusted R2=0.32).



Discussion
The present study revealed high workplace conflict among nurses in Qom hospitals. Some studies show that nurses have a moderate level of conflict in their workplace [4, 23, 24]. Some studies report a higher level of conflict [25, 26]. The discrepancy may be due to differences in management systems and the quality of nursing care in the study settings. Environmental conditions, organizational support, the number of nursing staff, and available equipment can also influence this difference.
Most nurses with a high level of conflict were female and single, had bachelor’s degrees, were employed temporarily/permanently, and worked in CCU/ICU, in line with the results of some studies [27-29]. In Azizzadeh’s study, the highest conflict was related to open-heart ICU nurses and the lowest to CCU nurses [23]. Our results also showed that older nurses used the solution-oriented style to resolve conflict, while younger nurses used the non-confrontational style. These results are consistent with the results of other studies [15, 30, 31].
Coping styles are among the main methods for managing conflicts [32]. In our study, most nurses were reported to use the solution-oriented strategy, followed by non-confrontation and control strategies, to resolve conflicts. Other studies have also reported the preferred use of a solution-oriented strategy [27, 33]. A solution-oriented approach can help reduce conflicts in the workplace based on understanding, cooperating, and using problem-solving techniques. Akhlaghi’s findings also showed that none of the nurses used the control style to resolve workplace conflicts [34]. In Mardani’s study, nurses with direct supervisory beliefs used the conflict resolution style of control and non-confrontation [35], which was inconsistent with our results. This difference can be caused by the lack of examination of nurses’ supervisory beliefs in our study. According to Farasat’s study, nurses use control, non-confrontation, and then solution-oriented conflict solution styles, which can decline the quality of patient care [4]. In fact, instead of controlling and competing, nurses should investigate and solve the problem; otherwise, the conflict will become more intense and more challenging to resolve. Implementing conflict management programs for nurses can reduce workplace conflicts and improve patient care [34].
It should be noted that contextual factors play an essential role in determining coping strategies. The nature of the stressful situation, the individual’s personality, and the social context can all influence which particular coping strategy is used. The results of some studies have shown that adopting a specific coping strategy relates to factors such as gender [36-39], age [37, 40-42], marital status [40, 43], work experience [40, 44], shift work [45, 46], and workplace [37, 47]. Perhaps the reported contradictions can be related to the difference in occupational, situational, cultural, and social conditions, which indicates the need for further investigation in different cities and occupations, especially high-stress jobs.
In this study, workplace conflict was investigated in general and not specifically; hence, one of the current study’s limitations was the lack of attention to the type of workplace conflict. On the other hand, different tools to investigate workplace conflict management styles make it difficult to compare the results.
Nurses of hospitals in Qom experience a high level of conflict in their workplace. They mostly use the solution-orientated strategy followed by non-confrontation and control strategies to resolve their conflicts. Nurses should be trained about workplace conflicts and their management. Educational programs or workshops for job enrichment and workplace conflict management can help nurses create a balance in the work environment.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Qom University of Medical Sciences (Code: IR.MUQ.REC.1399.074). After explaining the study objectives, informed consent was obtained from the participants. They were assured of the confidentiality of their information and were free to leave the study at any time.

Funding
The study was funded by Qom University of Medical Sciences (Grant No.: 981088).

Authors' contributions
Study design: Mahsa Haji Mohammad Hoseini, Fatemeh Sharififard, Mohammad Parvaresh-Masoud and Roohollah Farhadloo; Data collection: Mohammad Reza Azadeh and Mahsa Haji Mohammadhoseini; Data analysis: Mostafa Vahedian; Data interpretation, and writing the initial draft: Mahsa Haji Mohammad Hoseini and Fatemeh Sharififard; Supervision: Mohammad Parvaresh-Masoud and Roohollah Farhadloo; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank all nurses for their participation and the Qom University of Medical Sciences for funding this project.



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