Abstract
BACKGROUND:
Providing the high-quality services in hospitals depends on to minimize conflict between all members within a health team. This study aimed to identify the causes of conflicts experienced by clinical and administrative staff in hospitals.
METHODS:
A cross-sectional study was carried out in 2018. The sample included 320 clinical and administrative staff from six hospitals affiliated to Ardabil University of Medical Sciences that were selected using two-step clustering sampling method. Data collection was accomplished by self-administered questionnaires. Descriptive statistics, t-test, and ANOVA were used for data analysis.
RESULTS:
Total conflict score revealed that clinical staff had higher levels of perceived conflict than administrative staff. In terms of organizational position, the study results showed a significant difference in the reported conflict between nurse groups and other groups (physicians and paramedical, administrative, financial, and logistic staff). The most important causes of conflict in the viewpoint of clinical staff were organizational and job characteristics (3.54 ± 1.28), poor management (3.51 ± 1.12), and inefficient communication system (3.42 ± 1.33). For administrative staff, on the other hand, poor management (3.18 ± 1.33), inefficient communication system (3.17 ± 1.36), and attitudes and perceptions (3.06 ± 1.41) were shown to be paramount factors.
CONCLUSION:
Clinical and administrative staff of hospitals are like parts of a train track. The irrational relationship between them will result in distortion and lower quality of services. Therefore, effective strategies to decrease staffs’ experience of conflict need to be developed. This might create a healthier and more productive work environment which positively affects the care quality.
Keywords: Administrative staff, clinical staff, conflict causes, conflict management, hospital
Introduction
Hospitals play a vital role in meeting the objectives of health systems and this feature has distinguished them from other health-related organizations.[1] Because of the past few decades changes in social context, providing health-care services has become more dependent on the collaboration of different health professionals such as physicians, nurses, and paramedical and administrative staffs and has evolved from a physician-centric approach to a teamwork approach.[2,3] Thus, current health team comprises members of different ages, gender, incomes, ethnicity, educational levels, lifestyles, targets, disciplines, and professionals.[4] Although team members may have different backgrounds, it comes as no surprise that provid ing high-quality health care requires harmony and collaboration. Otherwise, such differences may lead to conflict.[5]“Conflict is a dynamic process that occurs between interdependent parties as they experience negative emotional reactions to perceived disagreements and interference with the attainment of their goals.”[6] As Brinkert noted, it is fundamentally a communication process which can potentially arise when individuals are engaged in communications with one another. Therefore, never does the conflict happen in the lack of communication.[7] Hospitals, like other organizations, are persistently confronted with conflict.[8] Differences between goal(s) and role(s), common source utilization, dependency, varying values and perceptions, non-application of efficient performance evaluation and effective rewarding system, disorders in organizational responsibilities, non-application of efficient team work, heterogeneity in educational levels[9] in addition economic and social inequalities and gender diversity can be classified as predisposing factors for various forms of conflicts.[4] Conflicts undoubtedly can have serious consequences for organizations and they can also give rise to situations in which organization loses a large percentage of its efficient staff. These situations lead to poor performance and high tensions, severe forms of which can negatively influence patients’ treatment and staff morale.[4,8] Hospitals’ role in delivery health care and patients’ satisfaction intensify the consequences of conflicts. Besides, inefficiency of communication system reduces the possibility of achieving goals. In addition to hospital, the society will also affect by these conflicts.[10] Researches show that 21% of manager's times spend on managing the conflict.[11] On the other side, research on effects of conflicts on staff shows that resource scarcity is the leading cause of conflict.[12] Not surprisingly, conflict within health-care team is a well-known issue which poses an obstacle for provision of high-quality care. Therefore, to fulfill hospitals’ mission, interaction between team members must be directed to reduce conflicts.[13] Different studies have investigated the issue of conflict in Iranian hospitals, but none of them explore the reasons and types of conflicts between administrative and clinical groups. Because the low knowledge of these types of conflicts can result in managerial and leadership challenges, further investigation can offer operational solutions to address conflicts between staff. Therefore, the current study, for the first time, aims to identify reasons of conflict between administrative and clinical groups in Iranian hospitals and to propose solutions to address them.
Methods
The current descriptive analytical study was conducted in hospitals affiliated to Ardabil University of Medical Sciences (AUMS). Both clinical staff (i.e., physicians, nurses, and paramedical staff) and administrative staff (i.e., administrative, financial, and logistic staff) were included. Two questionnaires were prepared by the authors to collect information. In order to attain such questionnaires, related studies were reviewed, 35 semi-structured interviews with hospital staff. They consisted of two parts: (a) demographic information and (b) causes of conflict between administrative and clinical groups, with a Likert scale which 5 indicates very high and 1 very low.
This research was approved by the Ethical Committee of the Tehran University of Medical Sciences. Two-step clustering sampling method was used. Initially, some of the hospitals affiliated to the AUMS were randomly selected, and regarding the staff of each hospital and occupational groups, a number of participants were selected. To collect information, all 320 participants were first informed about the research and they were asked to fill out and sign informed consent.
Content validity ratio (CVR) and content validity index (CVI) were used for checking the validity of the questionnaires (for clinical staff questionnaire CVR = 75.4, CVI = 87.31 and for administrative staff questionnaire CVR = 75.53, CVI = 85.48). In addition, the reliability was tested by test–retest method. Spearman correlation coefficient for clinical and administrative staff was 75% and 84%, respectively. Descriptive statistics, t-test, and ANOVA were used. Data were analyzed by SPSS version 15.
Results
Two hundred and eighty-one questionnaires (out of 320) were completed, with 88% response rate. About 76.5% of participants were clinical staff and 61.5% of participants were women. Most of the participants (39.1%) were 31–40 years old and married (67.3%), 42% of whom had between 11 and 20 years of experience. Seventy-seven percent of employees had bachelorette degree and were permanent employees. Almost 10.7% of participants were also found to be manager. Total conflict score revealed that clinical staff had higher levels of perceived conflict than administrative staff [Table 1].
Table 1.
Average conflict score of clinical and administrative staff
| Occupational group | Mean±SD | P |
|---|---|---|
| Clinical staff | 3.37±0.98 | <0.001 |
| Administrative staff | 2.98±0.76 |
SD=Standard Deviation
In terms of organizational position, results of statistical tests showed a significant difference in reported conflict between nurse groups and other groups (i.e., physicians and paramedical, administrative, financial, and logistic staff (P < 0.05)). Married staff had higher levels of conflict than single employees (P = 0.013).
Also there was a meaningful association between job experience and conflict levels. As those with 11–20 years of job experience had higher levels of perceived conflict than those with < 10 years (P < 0.001) and >20 years (P = 0.006) of experience. On the other hand, 31–40-years-old participants had higher levels of reported conflicts than 21–30 (P < 0.001) and >40 (P = 0.006) years old ones. However, gender (P = 0.45), education (P = 0.8), and type of employment (P = 0.07) showed no remarkable correlation with reported conflict [Table 2].
Table 2.
Average conflict score of demographic variables
| Demographic variable | Occupational Group | M±SD | P |
|---|---|---|---|
| Organizational position | Physician | 3.02±0.93 | 0.042 |
| Nurse | 3.87±0.87 | ||
| Paramedical | 3.26±0.81 | ||
| Administrative | 2.79±0.81 | ||
| Financial | 2.93±0.90 | ||
| logistic | 3.24±0.95 | ||
| Marriage status | Single | 2.97±0.81 | 0.013 |
| Married | 3.40±0.96 | ||
| Job experience | <10 | 2.95±0.89 | 0.030 |
| 20-11 | 3.48±0.81 | ||
| 20> | 3.06±0.67 | ||
| Age groups | 30-21 | 2.81±1.21 | <0.001 |
| 40-31 | 3.63±1.20 | ||
| 40> | 3.09±1.21 | ||
| Gender | Male | 3.08±1.18 | 0.45 |
| Female | 3.25±1.06 | ||
| Education | Diploma | 3.08±1.18 | 0.808 |
| Bachelorette | 3.33±0.98 | ||
| Master | 3.04±0.89 | ||
| PhD and higher | 3.26±1.24 | ||
| Type of employment | Under service | 3.02±1.10 | 0.070 |
| Contractual | 2.98±1.33 | ||
| Conditional agreement | 3.41±1.15 | ||
| Permanent | 3.23±1.10 |
SD=Standard Deviation
The most important causes of conflict in view point of clinical staff were organizational and job characteristics (3.54 ± 1.28), poor management (3.51 ± 1.12), and inefficient communication system (3.42 ± 1.33).
For administrative staff, on the other hand, poor management (3.18 ± 1.33), inefficient communication system (3.17 ± 1.36), and attitudes and perceptions (3.06 ± 1.41) were shown to be paramount factors [Table 3].
Table 3.
Pillars of conflict causes between clinical and administrative staff
| Causes of Conflict | M±SD | |
|---|---|---|
| Clinical staff | Administrative staff | |
| Managerial weakness | 3.51±1.12 | 3.18±1.33 |
| Attitudes and perceptions | 3.28±1.75 | 3.06±1.41 |
| Ignoring professional ethics | 3.25±1.30 | 2.85±1.09 |
| Personal characteristics | 2.32±1.28 | 3.05±1.35 |
| Inefficient communication system | 3.42±1.33 | 3.17±1.36 |
| Organizational and job characteristics | 3.54±1.28 | 3.00±1.23 |
SD=Standard Deviation
As shown in Table 4, according to clinical staff, “delays in salary payment” was the most important conflict reason (3.84 ± 1.17).
Table 4.
The most important causes of conflict between clinical and administrative staff according to clinical staff view
| Causes of conflict | Mean±SD |
|---|---|
| Delays in salary payment | 3.84±1.17 |
| bureaucracy and prolongation of the processes | 3.78±0.83 |
| Ignoring opinions and lack of opportunity for staffs’ participation in decision-making | 3.74±1.08 |
| Unreasonable differences in salaries and other benefits | 3.56±0.99 |
| Perceived inequality in workload distribution | 3.49±0.60 |
| Ambiguity in hospital policies | 3.48±1.15 |
| Weakness of hospital communication system to inform regulations | 3.37±0.63 |
| Ignoring organizational hierarchy | 3.36±0.63 |
| Ignoring clinical priorities in organizational decision-makings | 3.33±0.12 |
| Lack of systemic perspective and prioritizing own responsibilities | 3.31±0.62 |
| Insufficient understanding of the working conditions of curative affairs and imposing opinions of nonclinical staff in process of making decision | 3.29±0.62 |
| Nonapplication of efficient performance evaluation and effective rewarding system | 3.27±1.12 |
SD=Standard Deviation
According to Table 5, ambiguity in hospital policies (3.55 ± 1.34) is the main conflict cause in viewpoint of administrative staff.
Table 5.
The most important causes of conflict between clinical and administrative staff according to administrative staff view
| Causes of conflict | Mean±SD |
|---|---|
| Ambiguity in hospital policies | 3.55±1.34 |
| Undervaluing roles and responsibilities of administrative, financial and logistic staff | 3.46±1.14 |
| Low awareness of clinical staff about hospital policies and managerial decisions | 3.32±1.17 |
| Bureaucracy and prolongation of the processes | 3.29±1.30 |
| Managers insufficient knowledge about the processes | 3.18±1.43 |
| Unreasonable differences in salaries and other benefits | 3.09±1.32 |
| Discrimination between staff, departments, and units | 3.09±1.22 |
| Unreasonable expectations to bypass laws and regulations | 3.06±1.19 |
| Insufficient awareness of clinical staff about work conditions of nonclinical staff | 3.00±1.45 |
| Ignoring organizational hierarchy | 2.87±1.30 |
| Perceived inequality in workload distribution | 2.83±1.23 |
SD=Standard Deviation
It should be noted that reasons of low scores are not mentioned in the tables.
Discussion
Conflict within health team is a serious challenge for provision of health-care services all around the world.[14] The majority of Iranian studies have been focused on conflict management approaches to address conflict. According to these studies, whenever conflict causes were ignored and an appropriate approach was not followed, not only conflicts would not be addressed, but they also become more frequent.[15,16] Therefore, this study aimed to identify conflict causes among clinical and administrative staff. Findings showed that clinical staff, particularly nurses, reported higher levels of conflict than did administrative staff. Jerng et al. in a study focused on conflict between health staff found that nurses reported higher levels of conflict.[17] Hatam et al. reported that the level of work–family conflict among staff of clinical departments was higher than that of nonclinical departments, which apparently related to nature and characteristics of work conditions.[18] Clinical staffs, particularly nurses, are at the pioneers of service provision and could be affected by the situations of patients. Consequently, their work condition is stressful and makes them susceptible to conflict.[19]
According to the current study, age and job experience are other factors that have impact on the level of conflict, as during the first decade and last years of work, less conflict was shown to be reported. This finding is consistent with the study of Çınar and Kaban on conflict in hospitals in Turkey.[9] Cohen[20] has noted that this is probably due to compatibility with situation and domineering of individuals. Employees seem to be more compatible with situations at the 1st years of work, and as their job experience increases, they change their behaviors. As their job experience increases and becomes more stable, their tendency to domineering increases and more conflict would be observed. For the lower levels of conflict at the last decade of work, it can be noted that individuals are either involved in normalization process or learn conflict management techniques during the past years. Although other studies have noted gender as a variable that can affect conflict, findings of the current study failed to show such association.[4,9]
As discussed above, organization and job characteristics as well as inefficient management and communication system are the most important reasons of conflict between clinical and administrative staff. On the other hand, personal characteristics had the least importance. Mosadeghrad et al. in a study on conflict between high, middle, and operational managers in hospitals found that the impact of organizational characteristics was greater than personal characteristics. Workload, resource scarcity, inappropriate laws and regulations, and poor communications were other important variables consistently with the findings of the current study.[21]
The current study found in organizational and job characteristic dimension, “bureaucracy and prolongation of the processes,” and “ignoring organizational hierarchy” were reported as important factors. Organizational hierarchy and bureaucracy can have impacts on communication channels or struggles for power in the organizations, so that large and multi-departmental organizations which have severe hierarchies are less affected by problems of conflict.[22,23] Given that hospitals have a bureaucratic nature,[24] it appears that ignoring hierarchies can lead to conflict, owing to the importance of formal communications and focusing on hierarchical communications.
The findings also showed that poor management was an important influential factor for conflict, such that “unreasonable differences in salaries and other benefits” was the most important factor which resulted in conflict. Regarding the organizational equity theory, staffs compare their inputs and outputs with that of others, and if they feel inequality, resulted contradiction and discontent can lead to conflict.[25]“Lack of opportunity for staffs’ participation in decision-making” was another important factor, as Nasiripour et al. have noted that participation in these activities through team works or problem-solving committees can reduce conflict among these individuals.[24]Çınar and Kaban also emphasized the importance of using staff opinions to achieve visionary leadership and address conflict.[9]
“Ambiguity in hospital policies,” “weakness of hospital communication system to inform regulations,” and “low awareness of clinical staff about hospital policies and managerial decisions” are also mentioned to play role in arising conflict. A study in public hospitals of Cyprus revealed that nearly 60% of employees reported to have one to five conflict situations per week. Organizational factors and poor communications were among the most important factors of conflict in these hospitals.[26] Furthermore, ambiguous job descriptions, laws, and instructions have been mentioned as conflict creator factors.[10] Another study highlighted that problems in interpretation of verbal communications, vague information, and disturbance in communication channels create obstacles for efficient communication, and if regulations, methods, behavior of individuals, and groups are not transparent enough, probability of arising conflict and decreased performance or losing efficient staff will be high.[27] Thus, regulations, instructions, and administrative regulations must be as transparent as possible to minimize the probability of conflict.
Managers always expect that actions and behaviors should be in line with laws and regulations. Leineweber et al. in a study on work–family life conflict of nurses found that when behaviors are not in line with regulations and instructions are ignored, the probability of conflict would be high.[28] In the current study, this issue in personal characteristic dimension was more a conflict cause among administrative staff than clinical ones.
With regard to the fact that clinical staff are responsible to provide high-quality health services to patients, which makes them a critical part of the hospital, they expect administrative staff to follow their orders. While, according to the findings of the current study, they believe that they are neglected in decision-making process in the hospital. On the other hand, administrative staff, which indirectly support clinical affairs of the hospital, believe that clinical staff do not have a good understanding about their needs and are undervalued in hospital. It seems that, to have a comprehensive view and to decline current challenges between hospital staff, the management team should address these challenges first of all.
Like other studies, the current study also has limitations, including (1) natural limitations of questionnaires, (2) reluctance to respond to questions because responders may think such research would not be useful, and (3) inexperience participants may not spend enough time and care to answer questions.
Conclusion
Clinical and administrative staff of hospitals are like parts of a train track that, undoubtedly, irrational relationship between them will result in distortion and lower quality of provided services. Hospital management team must do their best to preserve this relationship and make it more rational because they are both necessary for the success of organization. The current study found some important conflict causes between clinical and administrative staff. The findings can be used to make decision and develop strategies to address workplace conflict. The authors propose the following suggestions to address conflict in health-care settings:
Practical trainings about conflict management, effective communications, problem-solving, and so on should be included in intra-inter organizational training curriculums to strengthen staffs’ managerial and behavioral skills
Meetings to solve problems with presence of both clinical and administrative staff to increase understanding about working conditions, reaching common understandings, and identifying potential sources of conflict
Implementing plans such as job classification to create a comprehensive framework for all occupations in the hospital and increasing equality in compensations
Developing clear instructions and protocols to increase transparency and addressing ambiguities
Using participatory management with emphasize on decision-making through hospital committees, as mentioned in hospitals’ national accreditation standards of Iran
Commitment of high-level managers to observe hierarchies and appropriate and timely informing about hospitals’ policies and regulations through official communication channels
Restructuring processes that increase delays and delegating responsibilities that can be delegated to shorten administrative processes.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
The current study is a part of a Ph.D. Thesis in health-care management that is approved by the Research Deputy of Tehran University of Medical Science (IR.TUMS.SPH.REC.1396.4132). The authors are grateful to all the participants.
References
- 1.Whitehead DK, Weiss SA, Tappen RM. 4th ed. PA: F.A. Davis Company; 2007. Essentials of nursing leadership and management. [Google Scholar]
- 2.Guidroz AM, Wang M, Perez LM. Developing a model of source-specific interpersonal conflict in health care. Stress Health. 2012;28:69–79. doi: 10.1002/smi.1405. [DOI] [PubMed] [Google Scholar]
- 3.Hendel T, Fish M, Berger O. Nurse/physician conflict management mode choices: Implications for improved collaborative practice. Nurs Adm Q. 2007;31:244–53. doi: 10.1097/01.NAQ.0000278938.57115.75. [DOI] [PubMed] [Google Scholar]
- 4.Demir B, Kasapoǧlu A. Nurse physician relations: A qualitative case study in the emergency department of a hospital in Ankara, Turkey. European Journal of Turkish Studies Social Sciences on Contemporary Turkey. Complete List. 2008. [Last accessed on 2008 Mar 31]. pp. 1–18. Available from: http://journals.openedition.org/ejts/1783 .
- 5.Akel DT, Elazeem HA. Nurses and physicians point of view regarding causes of conflict between them and resolution strategies used. Clin Nurs Stud. 2015;3:112. [Google Scholar]
- 6.Barki H, Hartwick J. Conceptualizing the construct of interpersonal conflict. Int J Conflict Manage. 2004;15:216–44. [Google Scholar]
- 7.Brinkert R. A literature review of conflict communication causes, costs, benefits and interventions in nursing. J Nurs Manag. 2010;18:145–56. doi: 10.1111/j.1365-2834.2010.01061.x. [DOI] [PubMed] [Google Scholar]
- 8.Elfering A, Gerhardt C, Grebner S, Müller U. Exploring supervisor-related job resources as mediators between supervisor conflict and job attitudes in hospital employees. Saf Health Work. 2017;8:19–28. doi: 10.1016/j.shaw.2016.06.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Çınar F, Kaban A. Conflict management and visionary leadership: An application in hospital organizations. Procedia Soc Behav Sci. 2012;58:197–206. [Google Scholar]
- 10.Nasiripour AA, Riahi L, Afzal E. The relationship between communication system and organizational conflict at hazrate rassoul hospital Tehran. Sci J Manage Syst. 2009;20:55–64. [Google Scholar]
- 11.Radfar F, Hozoori M, Tavafian SS. Comparison of the attitudes of hospital staff and managers towards managers’ practice as regards conflict management in hospitals affiliated to Tehran University of Medical sciences, 2008-2009. J Sch Public Health Inst Public Health Res. 2011;9:59–66. [Google Scholar]
- 12.Hotepo O, Asokere A, Abdul-Azeez I, Ajemunigbohun S. Empirical study of the effect of conflict on organizational performance in Nigeria. Business and Economics journal. 2010;20:15–21. [Google Scholar]
- 13.Olajide T, Asuzu C, Obembe A. Doctor-nurse conflict in Nigeria hospitals: Causes and modes of expression. Br J Med Med Res. 2015;9:1–12. [Google Scholar]
- 14.Sportsman S, Hamilton P. Conflict management styles in the health professions. J Prof Nurs. 2007;23:157–66. doi: 10.1016/j.profnurs.2007.01.010. [DOI] [PubMed] [Google Scholar]
- 15.Nekuei Moghaddam M, Taghavi Rad A, Hakimipour S, Shafiei M, Goudarzi G. Evaluation of relation between styles of conflict management and creativity of staff in teaching hospitals of Kerman city in 2008. J Hosp. 2011;9:29–38. [Google Scholar]
- 16.Taghipour A, Dejban R, Khadem DZ, Naami A. Investigating relationship between communication skills and conflict resolution styles of managers with employee empowerment. Soc Psychol Res. 2011;1:17–43. [Google Scholar]
- 17.Jerng JS, Huang SF, Liang HW, Chen LC, Lin CK, Huang HF, et al. Workplace interpersonal conflicts among the healthcare workers: Retrospective exploration from the institutional incident reporting system of a university-affiliated medical center. PLoS One. 2017;12:e0171696. doi: 10.1371/journal.pone.0171696. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Hatam N, Keshtkaran V, Mohamadpour M, Ghorbanian A. Comparison of work – Family conflict between clinical and non clinical staffs of Shahid Faghihi hospital (public hospital) in Shiraz: 2010. Iran Occup Health J. 2013;10:52–60. [Google Scholar]
- 19.Baddar F, Salem OA, Villagracia HN. Conflict resolution strategies of nurses in a selected government tertiary hospital in the Kingdom of Saudi Arabia. J Nurs Educ Pract. 2016;6:91. [Google Scholar]
- 20.Cohen M. When it Comes to Negotiating Business Conflict, be Active; 2010. Retrieved January. 2000;5:2010. Retrieved January 2000;5:2010. [Google Scholar]
- 21.Mosadeghrad AM, Arab M, Mojbafan A. Study of conflict management styles in Tehran University affiliated hospitals. J Health Based Res. 2016;2:1–13. [Google Scholar]
- 22.Kaitelidou D, Kontogianni A, Galanis P, Siskou O, Mallidou A, Pavlakis A, et al. Conflict management and job satisfaction in paediatric hospitals in Greece. J Nurs Manag. 2012;20:571–8. doi: 10.1111/j.1365-2834.2011.01196.x. [DOI] [PubMed] [Google Scholar]
- 23.Inderst R, Müller HM, Wärneryd K. Distributional conflict in organizations. Eur Econ Rev. 2007;51:385–402. [Google Scholar]
- 24.Nasiripour A, Raeissi P, Nagaf Bagy R, Adabi A. The survey of structural factors in general hospitals of Yazd-Iran based on mechanic and organic approach 2012. Tolooebehdasht. 2013;12:194–204. [Google Scholar]
- 25.Chen SY, Wu WC, Chang CS, Lin CT, Kung JY, Weng HC, et al. Organizational justice, trust, and identification and their effects on organizational commitment in hospital nursing staff. BMC Health Serv Res. 2015;15:363. doi: 10.1186/s12913-015-1016-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Pavlakis A, Kaitelidou D, Theodorou M, Galanis P, Sourtzi P, Siskou O. Conflict management in public hospitals: The cyprus case. Int Nurs Rev. 2011;58:242–8. doi: 10.1111/j.1466-7657.2011.00880.x. [DOI] [PubMed] [Google Scholar]
- 27.Balay R. Conflict management strategies of administrators and teachers. Asian J Manage Cases. 2006;3:5–24. [Google Scholar]
- 28.Leineweber C, Chungkham HS, Westerlund H, Tishelman C, Lindqvist R. Hospital organizational factors influence work-family conflict in registered nurses: Multilevel modeling of a nation-wide cross-sectional survey in Sweden. Int J Nurs Stud. 2014;51:744–51. doi: 10.1016/j.ijnurstu.2013.09.010. [DOI] [PubMed] [Google Scholar]