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DOI: 10.1177/0898264306286196 2006; 18; 385 J Aging Health

Julian Montoro-Rodriguez and Jeff A. Small Long-Term Care

The Role of Conflict Resolution Styles on Nursing Staff Morale, Burnout, and Job Satisfaction in

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10.1177/0898264306286196JOURNAL OF AGING AND HEALTH / June 2006Montoro-Rodriguez, Small / CONFLICT STYLES AND NURSING

The Role of Conflict Resolution Styles onNursing Staff Morale, Burnout, and Job

Satisfaction in Long-Term Care

JULIAN MONTORO-RODRIGUEZKent State University

JEFF A. SMALLUniversity of British Columbia

This study focuses on the ability of nursing staff to interact with residents in a way thataffects positively on the nurses’ well-being and occupational satisfaction. It investi-gates the role of coping skills related to staff-resident interactions, in particular, theuse of conflict resolution styles and their influence on the level of morale, burnout andjob satisfaction of nursing professionals. A self-administered questionnaire was usedto collect information from 161 direct care nursing staff. The authors used a multipleregression procedure to examine the influence of predictors on nursing staff out-comes. Multivariate analyses indicated that nurses’ psychological morale, occupa-tional stress, and job satisfaction are influenced by conflict resolution styles, aftercontrolling by individual characteristics, work demands, and work resources factors.The findings highlight the importance of considering personal coping abilities to fos-ter positive staff-resident interactions and to increase nurses’ morale and jobsatisfaction.

Keywords: nursing staff; conflict resolution styles; occupational stress; job satis-faction; long-term care

Numerous studies have examined the influence of individual andorganizational factors on nursing home satisfaction and the provisionof care to older adults from the perspective of residents and familymembers (Kruzich, 2000); however, very little research has focusedon nursing staff outcomes such as morale, burnout, stress, and job sat-isfaction. The level of stress and job satisfaction of nursing profes-

385

JOURNAL OF AGING AND HEALTH, Vol. 18 No. 3, June 2006 385-406DOI: 10.1177/0898264306286196© 2006 Sage Publications



sionals along with other relevant factors, such as staffing issues andstaff turnover, are assumed to have an impact on the quality of care andthe well-being of the residents (Cohen-Mansfield & Noelker, 2000).Given the increasing demographic pressure for more institutional careand a higher quality of care, it is important to examine the main corre-lates of nursing staff outcomes including individual and work-relatedcharacteristics. Furthermore, the projected crises or shortage of nurs-ing professionals, in particular nurse aides and assistants in the fore-seeable future (Mee & Robinson, 2003), adds to the urgency of con-ducting such research. The present study focuses on the ability ofnursing staff to interact with residents in a way that positively affectsthe nurse’s well-being and occupational satisfaction. The goal of thestudy is to examine the relationships between individual characteris-tics, work demands, work resources, and conflict resolution strategieson the one hand and nursing staff outcomes such as psychologicalmorale, burnout, and job satisfaction on the other.

Researchers have proposed different occupational stress modelsfor professionals providing formal and informal care for dependentadults (Pearlin, Mullan, Simple, & Skaff, 1990; Demerouti, Bakker,Nachreimer, & Schaufeli, 2000; Wilder, Teresi, & Bennett, 1983). In astudy of stress among nursing staff, Cohen-Mansfield (1995) pro-posed a nurses’ occupational stress process model that centers onexplaining the person-job fit, attending to individual and work-relatedneeds, stressors, and resources. The model postulated that occupa-tional stress has an impact on both the individual’s well-being and hisor her ability to perform at the work site. More recently, Ramirez,Teresi, Holmes, and Fairchild (1998) advanced an occupational stressmodel for nursing staff that incorporates previous stress models andresearch. Their model posited that work-related outcomes (job satis-faction, burnout) are influenced by work-related demands and stress-ors (size of assignment, frequency of rotation, work load, heavy care,the working environment, and racial and ethnic tension stressors),work resources (nurse aides’ training, supervision, and support) andindividual resources (nurse aides’ years of experience). As predicted,their analysis indicated that different work demands and workresource factors were related to staff outcomes such as job satisfactionand burnout.

386 JOURNAL OF AGING AND HEALTH / June 2006



Cohen-Mansfield and Noelker (2000) conducted a thoroughreview of the literature and proposed a tentative comprehensive theo-retical model for understanding the sources and outcomes of job satis-faction and stress among staff in long-term care. Correlates of job sat-isfaction and stress refer to four factors: the facility’s organizationalfeatures (salary and benefits, lack of recognition, supplies, care plan-ning participation), aspects of the unit-level organization (work load,staff relationships, unit supervision, management style, job-relatedinjuries), family and resident care and relationships (dementia andbehavioral problems, incontinence, resident death, respect and socialrelationships between staff, residents, and families), and the personallife of staff members (gender, minority status, socioeconomic level,family status, self-esteem, health, and coping skills). This model alsoaddresses the impact of nursing satisfaction and stress on resident careand staff injuries, turnover, absenteeism, and mental health. The evi-dence suggests a negative impact on these outcomes, which in turnhave a detrimental effect on the sources or predictors of staff satisfac-tion and stress. The cyclical or recursive nature of this model makes itnecessary to identify conditions under which nurses’ occupationalsatisfaction, stress, and burnout can be reduced. Cohen-Mansfield andNoelker concluded that staff dissatisfaction and stress pose a signifi-cant problem leading to negative results for turnover, burnout, and lowmorale that in turn have a negative impact on the quality of care. Tomaintain and increase morale and satisfaction among nursing staffthey suggested focusing on staffing issues and staff support andtraining and fostering positive bonds or interactions between staff andresidents.

The present study investigates the role of coping skills related tostaff-resident interactions—in particular, the use of different styles ofconflict resolution and their influence on the level of morale, burnoutand job satisfaction of nursing professionals. In long-term care set-tings there is considerable potential for conflict, abuse, and abrasivebehavior between staff and residents (Foner, 1994; Pillemer & Hudson,1993; Pillemer & Moore, 1989). In view of the limited ability of resi-dents with cognitive impairment to handle interpersonal conflict, theinitiative and responsibility of maintaining positive staff-residentinteractions falls primarily on the nursing home staff. Pray (1993)

Montoro-Rodriguez, Small / CONFLICT STYLES AND NURSING 387



suggests that a model for effective staff-resident interaction requiresnursing staff who possess adequate knowledge of residents with cog-nitive impairment as well as training on how to effectively interactwith residents and their families. The abilities that nurses bring to theinteractive process include communicative behaviors, both verbaland nonverbal, that provide a means for handling conflict (Putnam &Wilson, 1982). These nursing staffs’ individual skills are manifestedin their ability to overcome disagreements or differences of opinionthat occur in interdependent relationships. Conversely, inappropriatemanagement of conflict because of a lack of communicative skillcould have deleterious effects on the quality of nursing home care(Sillars & Weisberg, 1987).

Studies on nursing home work stress have identified a variety ofstrategies to explain stress-coping processes (Healy & McKay, 2000;Lazarus & Folkman, 1984; Williamson & Schultz, 1993). These cop-ing strategies include attempts at managing or altering problemsthrough engaging in solution-oriented activities as well as managingemotions and attitudes, such as denial and avoidance. These copingstrategies or styles are posited as individual traits, suggesting thatnursing staff have specific predispositions about how to resolve per-sonal and work-related conflicts with residents. Previous studies ofcoping strategies used by nursing staff have indicated a significantassociation between coping styles and nurses’ stress and satisfaction.For example, Boumans and Landeweerd (1992), using a sample of500 nurses, found that active problem solving was positively related tojob satisfaction and negatively related to health. Likewise, Healy andMcKay (2000) found that the use of avoidance coping and the percep-tion of work overload were significant predictors of increased mooddisturbance among 129 qualified nurses. Tyler and Cushway (1995)found that use of avoidance coping predicted nurses’ mental distress.In addition, several studies (Ceslowitz, 1989; Chiriboga & Bailey,1986; Kimmel, 1981) have examined the relationship between burn-out and coping strategies, and their initial findings indicate that coop-erative coping may prevent burnout and that avoidance coping mayincrease emotional exhaustion. In another study among community-based nurses (Jansen, Kerkstra, Abu-Saad, & Van Der Zee, 1996),feelings of burnout were lower among nurses showing a preference




for cooperation and among those using an active approach to copingor handling problems. However, because these studies use differentmeasures, it is difficult to draw conclusions regarding the impact ofconflict resolution styles on nursing outcomes.

The present study sought specifically to extend previous researchon nursing staff coping styles by measuring a range of conflict resolu-tion styles that might be used by nurses and nurse assistants wheninteracting with residents. Based on the previous empirical studies onconflict resolution styles as coping mechanisms to enhance nursingoccupational well-being and satisfaction, we anticipated that the useof different styles of conflict resolution would be associated withnursing staff well-being and occupational stress outcomes. The aim ofthis study was to examine the relationships between individual char-acteristics, work demands, work resources, and conflict resolutionstrategies on the one hand and nursing staff outcomes such as psycho-logical morale, burnout, and job satisfaction on the other. The theoret-ical model that guided our hypotheses and analysis includes the mainfactors postulated by the stress model reviewed by Ramirez et al.(1998) and Cohen-Mansfield and Noelker (2000). We also incorpo-rated conflict resolution styles as a psychosocial factor having a directimpact on nursing staff morale, occupational stress, and satisfaction.We contend that a better understanding of the relationship betweenconflict resolution styles and staff outcomes will enable us to identifyconditions under which staff and resident outcomes can be improved.

Method

SAMPLE AND METHOD

To assess the theoretical model and examine the role of conflict res-olution styles used by nursing staff in their interactions with residents,data were collected from nursing facilities using a convenience sam-ple. The final sample included 161 nursing staff professionals work-ing and providing direct care to residents at five nursing facilities inthe greater Cleveland area, Ohio (N = 117) and two facilities in Van-couver, British Columbia (N = 44) during the fall of 2002. Nursingstaff from different shifts in the facilities were invited to complete a




self-administered survey and to mail in the questionnaire on complet-ing their responses. The questionnaire included items from the fol-lowing domains: (a) individual characteristics (age, gender, minoritystatus, educational level, job description, time working in the facility,and personal views about nursing home residents), (b) work demands(average number of assigned residents per shift, the level of care-intensive residents per shift, frequency of shift rotation, frequency ofchange of residents per shift, and the observed past conflict amongstaff and residents), (c) work resources (frequency of care planningteam meetings, the average number of staff in-service training hours,and the level of the facility resources for staff), (d) staff conflict reso-lution styles (cooperative, confrontational, avoidance), and (e) nurs-ing staff outcomes including morale, burnout, and job satisfaction.Data entry and analysis were carried out using SPSS. The percentageof missing data was less than 5% in a few variables and only for onevariable, asking staff how many hours of in-service training theyreceived, missing data were higher (14.9% or 24 cases). After carefulexamination of the data, a factor analysis procedure was used toreduce the number of items and determine the final number of factorsand their dimensions. A principal-axis factoring (PAF) extraction anddirect oblimin rotation was performed including items from all theattitudinal variables and constraining the expected number of factorsas hypothesized by previous research. Overall, results indicated arecognizable factor structure representing the main concepts (see laterdiscussion for a more detailed description for each factor and itsdimensions).

DEPENDENT VARIABLES

Staff morale. Nursing staff morale was measured with a shortenedversion of the Psychiatric Epidemiology Research Instrument devel-oped by Bruce Dohrenwend and colleagues (Dohrenwend, Shrout,Ergi, & Mendelshon, 1980). This scale has been used with samples ofhealth care professionals (Grau, Colombotos, & Gorman, 1992).They describe demoralization as a condition that is likely to be associ-ated with a variety of problems such as physical illness, stressful lifeevents, and psychiatric disorders among others. After factor analyses




that included all the items from the different attitudinal constructs,only five items were used to create a composite index of staff morale:the items asking nursing professionals about their levels of loneliness,restlessness, confusion or difficulties in thinking, concentrating orkeeping their mind on their task, and nervousness. The five demoral-ization items use a 5-point scale, with 1 indicating always and 5 never.The higher scores indicate higher levels of staff morale. The internalconsistency (Cronbach’s alpha) for the present sample was .82.

Staff burnout. Burnout has been defined as a specific kind of occu-pational stress reaction among human service professionals as a resultof the demanding and emotionally charged relationships betweennursing staff and residents. Burnout is defined as encompassing feel-ings of emotional exhaustion (draining of emotional resources),depersonalization (negative attitudes toward residents), and reducedpersonal accomplishment and tendency to evaluate one’s work withresidents negatively (feelings of insufficiency). The Maslach BurnoutInventory was used to measure burnout (Maslach, Jackson, & Leiter,1996). Factor analysis replicated the earlier-mentioned dimensions:(a) burnout as emotional exhaustion was represented with six items:feeling emotionally drained, used up at the end of the workday, don’twant to face another day on the job, feeling hardened emotionally,feeling burned out from work, and working involves too much stress(Cronbach’s alpha was .86); (b) burnout as depersonalization wasassessed with three items: becoming more callous toward residents,working in the facility makes you feel like residents are less thanhuman, and treating residents as impersonal objects (Cronbach’salpha was .66); and (c) burnout as positive accomplishment was mea-sured with four items: deal with work calmly, residents understandyou, deal with residents’ problems efficiently, and feel that youaccomplish worthwhile things in your job (Cronbach’s alpha was.66). In all three dimensions, the items used a 5-point scale where thevalue of 1 indicates not at all true and 5 very true, with higher valuesindicating higher levels of burnout, depersonalization, and positivejob experience or accomplishment (items were reverse coded for thisdimension).




Staff job satisfaction. Staff job satisfaction was measured withitems used in a study by Cantor and Chichin (1990). Professionalswere asked to what extent each item described their feelings about jobbenefits, their sense of accomplishment, and their personal satisfac-tion. Factor analysis identified two dimensions: (a) job satisfactionmeasured with five items: staff feelings about being able to see theresults of their work, having chances to make friends, feeling a senseof accomplishment, getting to do a variety of things on the job, andfinding their job interesting (each one used a 5-point scale where thevalue of 1 indicates not at all true and 5 very true, with higher valuesreflecting higher levels of job satisfaction; Cronbach’s alpha was .84);and (b) job benefits composed of four items: fringe benefits, security,pay, and chances for promotion (these items were measured with a 5-point scale where the value of 1 indicates not at all true and 5 verytrue, with higher values indicating higher levels of job benefits;Cronbach’s alpha was .78).

INDEPENDENT VARIABLES

Individual characteristics. The following sociodemographic infor-mation was used in the analysis: (a) age, recorded as number of yearsof each nurse, (b) gender of the respondent (0 = female, 1 = male), (c)minority status (0 = White; 1 = minority), (d) educational attainment(1 = less than 8th to 6 = college graduate), (e) occupational category(0 = nurse; 1 = aide), and (f) length of employment at the facility(number of months). In addition, nursing staff were asked about theirpersonal ideas and views about people placed in nursing homes usingthe Staff Attitude Toward Residents scale (Teresi, Holmes, Ramirez,& Kong, 1998). The scale includes five items, measured on a 5-pointcontinuum from strongly agree (1) to strongly disagree (5). Items askabout the degree of agreement on their perception of residents as notwanted by their families, having trouble getting along with others,being more likely to have been bad parents, coming from families withweak family ties, and being disliked by their families. Higher scoresindicate more negative views about people in nursing homes. Thelevel of internal consistency for this sample was .89.




Work demands. The nursing staff workload was measured with twovariables: (a) number of residents assigned on an average shift and (b)number of difficult-to-care-for assigned residents, including thosewho are confused (dementia), have disruptive behaviors (scream,scratch, smear feces), are difficult to care for because they are sick(need turning or positioning, bed sores), and are incontinent of blad-der and bowel. Other work demand variables included the frequencyof shift rotation measured on a continuum of never (0), rarely (1),sometimes (2), and often (3) and the frequency of change in assignedresidents, measured on a continuum of never (0), daily (1), weekly (2),monthly (3), and every 3 months (4). Additionally, using the ConflictTactics Scale (Straus, 1979), nursing staff were asked about theobserved physical and psychological abuse in the facility during thepast year. The adapted items (Pillemer & Moore, 1989) included fourphysical abuse observations (use of excessive restraints; pushing,shoving, or pinching a resident; throwing something at a resident; andslapping or hitting a resident) and three psychological abuse observa-tions indicating events such as isolating, insulting or swearing, andyelling or raising one’s voice at a resident in anger. The lack of vari-ability with the physical abuse items made it impractical to create anindex of that type of conflict. However, an index was created to repre-sent the psychological level of conflict or abuse scale. Each item useda 5-point continuum from strongly disagree to strongly agree(Cronbach’s alpha was .77). Higher scores reflect higher levels of abu-sive observations or conflict between staff and residents.

Work resources. Three variables were used to represent workdemands: (a) frequency of care planning team meetings asked nursingstaff how often they have team meetings with a supervisor and otherstaff for care planning (frequency was measured on a 5-point contin-uum from never (0) to every 3 months (4), (b) nursing staff trainingwas measured by asking how many hours of in-service training theyreceived to assist them in working with residents who are confusedand who have behavioral and physical problems, and (c) facility sup-plies was measured with two items describing the level of satisfactionof nursing staff with the availability of needed supplies and the ade-quacy of the staff facilities (e.g., dining room). These items used a 5-




point continuum from strongly disagree (1) to strongly agree (5). Cor-relation between the items was .60 (Cronbach’s alpha was .75).

Conflict resolution styles. Conflict resolution styles are patternedresponses or clusters of behavior that people use in resolving conflict(Hocker & Wilmot, 1995). These conflict resolution styles can beviewed as a set of preferences for communication, and each oneinvolves a different strategy toward resolving conflict. Putnam andWilson (1982) developed the Organizational Communication Con-flict Instrument to assess the different styles of conflict resolution.Using a short version of the conflict resolution style instrument (Orga-nizational Communication Conflict Instrument), we measured nurs-ing staff preferences for three conflict resolution styles: (a) the con-frontational style, which is characterized by aggressive anduncooperative behavior; (b) the cooperative or solution-orientedstyle, which is characterized by cooperation and concern for the rela-tionship; and (c) the avoidance style, which is characterized bynonconfrontational behavior or the use of indirect strategies for han-dling conflict. Factor analysis replicated the tridimensional originalstructure: (a) confrontational or controlling style, including six itemsdescribing how staff handled conflict—in particular, if staff tended tobe steadfast in their views, assert opinions forcefully, argue insistentlyfor their stance, stand firm in their views during conflict, take a toughstand refusing to retreat, and dominate arguments until the other per-son meets them halfway (Cronbach’s alpha was .80); (b) cooperativeor solution oriented, including five items describing how staff tend togo 50-50 to reach a settlement, meet the opposition at a midpoint of dif-ferences, suggest working together to create solutions, look for middle-of-the-road solutions, and give in a little if the other person meetsthem halfway (Cronbach’s alpha was .75); and (c) avoidance ornonconfrontational, including five items describing how staff reducedisagreements by minimizing their significance, not voicing theirviews to avoid disagreements, smoothing over disagreements by act-ing as if they were unimportant, making differences less serious, andeasing conflict by claiming differences are trivial (Cronbach’s alphawas .72). All items used a 5-point scale in a continuum from never (1)to always (5). Higher scores indicated higher levels of preference for aparticular style.




Results

The nursing home staff in the study comprised primarily of women,with an average age of 40, who had worked for the past 2 years in theircurrent facilities. The sample included 88 White (55%), 45 AfricanAmerican (28%), and 19 Asian American (12%) nurses. About half ofWhite nurses were college graduates (44%), one third of AfricanAmerican nurses completed high school, and more than two thirds ofAsian Americans were also college graduate nurses. With regards towork demands and available resources, subjects had an average shiftof 22 residents, a weekly change in assigned residents, and minimalshift rotation. They also reported attending care or planning teammeetings about every other week and had received about 6 hours of in-service training in the past 6 months. The majority of nursing profes-sionals in the sample were working in skilled-nursing facilities andonly a few of them in assisted living. In particular, more than twothirds of nursing staff in the American and Canadian sample workedin a nursing facility (76% vs. 81%, respectively). Preliminary analysisindicated that the type of facility was not a significant predictor in themodel and therefore, we did not include the type of facility as acovariate in the regression models. In relation to conflict resolutionstyles, participants on average indicated a score of 17.9 (range 5 to 25)for a preference of a cooperative style, 14.8 (range 6 to 25) for a con-frontational style, and 12.2 (range 5 to 22) for an avoidance style. Theaverage levels of self-declared nursing staff outcomes were 43.1(range 18 to 62) for psychological morale, 20.4 (range 8 to 25) for jobsatisfaction, 14.7 (range 6 to 28) for burnout, 16.6 (range 12 to 20) forjob accomplishment, 11.9 (range 4 to 20) for job benefits, and 4.2(range 2 to 11) for job depersonalization. Differences between theOhio and the Vancouver sample were small, but a few of them reachedstatistical significance (p < .05). In particular, professionals in Van-couver reported a higher educational levels, working for a longer time,more frequent changes in assigned residents per shift, a higher level ofin-home training, and a higher level of satisfaction with availabilityand adequacy of facility supplies. In addition, feelings of depersonal-ization, cooperativeness, and avoidance styles were higher amongnursing staff in Vancouver. We added a dummy variable indicating thesample group as a covariate for all the six regression models tested;




however, only staff benefits was significant, and the main effectsremained the same. Therefore, we believe that participants in bothsamples belong to the same population. The existence of thesedifferences across sites may be beneficial in our analysis in thatvariability of the sample contributes to the ability to detect maineffects of the variables in the model.

To test the proposed theoretical model and examine the maineffects of each domain of variables—in particular, the influence of theconflict resolution styles on nursing staff morale, burnout, and jobsatisfaction—a series of six multiple regression analyses was con-ducted. Table 1 displays the standardized beta coefficients and themodel explained variance for each outcome. Each set of variables wasentered in the same order, individual characteristics first then workdemands, work resources, and finally conflict styles. Results indi-cated significant moderate levels of prediction, with the adjusted r2

ranging from .14 to .23. Overall, conflict resolution styles made a sig-nificant contribution to nursing staff morale, burnout, and jobsatisfaction.

Psychological morale among nursing staff was primarily influ-enced by two staff-resident conflict resolution styles: the confronta-tional (beta = –.23) and the avoidance (beta = –.19), indicating thatnursing professionals with lower levels of morale have a preferencefor these two styles of conflict resolution. On the other hand, staffmorale was positively associated with the case load of care-intenseresidents (beta = .23) and negatively associated with the frequency ofshift rotation (beta = –.15), the observed conflict between staff andresidents (beta = –.15), and the availability and adequacy of facilitysupplies for nursing staff (beta = –.16). No individual characteristicsemerged as significant predictors of staff morale.

Each of the three dimensions of nursing staff burnout showed asimilar pattern of significant effects. Burnout as emotional exhaustionamong nursing staff was primarily influenced by variables from thedomains of work demands, work resources, and psychosocial factors.Staff burnout was positively associated with the average number ofresidents (beta = .20), the level of observed conflict in the facility(beta = .18), and the use of a confrontational style (beta = .19). Staffwho reported less satisfaction with availability and adequacy of facil-ity supplies also indicated higher levels of burnout (beta = –.20). The




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data also show an inverse relationship between staff burnout, feelingsof depersonalization, and satisfaction with availability and adequacyof supplies for nursing professionals (beta = –.17) as well as a prefer-ence for the cooperative style (beta = –.17). On the contrary, a positiveassociation was observed between feelings of depersonalization andthe preference for the other two conflict resolution styles, indicatingthat those with higher preference for avoidance (beta = .18) and con-frontational (beta = .17) styles also expressed more feelings of jobdepersonalization. Finally, staff who experienced their job as a senseof accomplishment pointed to work demand variables as main predic-tors, including a positive association with higher care-intensive loads(beta = .22) and a negative relation with the average number of resi-dents assigned per shift (beta = –.25), the frequency of shift rotation(beta = –.16), and the level of observed conflict (beta = –.25). Otherfactors affecting the feeling of job accomplishment were satisfactionwith availability and adequacy of facility supplies (beta = .25) and theuse of a cooperative conflict resolution style (beta = .16), indicatingthat a higher feeling of job accomplishment was associated with agreater preference for the cooperative style.

The two dimensions of job satisfaction among nursing home staffexhibited somewhat different predictors. Job satisfaction is influ-enced primarily by the satisfaction with availability and adequacy ofsupplies in the facility (beta = .27) and the frequency of care planningteam meetings (beta = .22). On the other hand, staff benefits wereassociated with the satisfaction with availability and adequacy offacility supplies (beta = .35) and the use of a cooperative conflict reso-lution style (beta = .15). In addition, there was a significant differencein the perception of staff benefits when minority status is considered,indicating that minority staff are more likely to perceive lower jobbenefits than White nursing professionals (beta = –.20).

Finally, in addition to the main effects, we examined the indirecteffects of the variables in the model. Indirect effects were expectedfrom variables in each domain in the model—that is, individual char-acteristics, work demands, and work resources on nursing staff out-comes through the psychosocial intervening factors or conflict resolu-tion styles. Only a few significant effects were detected and theirmagnitude was rather small.




Discussion

The multivariate analyses indicated that nursing staff outcomes areinfluenced by staff conflict resolution styles, after controlling by indi-vidual characteristics, work demands, and work resource factors. Theresults showed a similar pattern of predictors across models of nursingstaff outcomes in the analyses. The main hypothesis that staff conflictresolution styles would contribute to nurses’ psychological morale,occupational stress, and job satisfaction was supported. The analysesalso suggest that the theoretical model is a parsimonious one becausethe levels of variance explained were moderately high, with factorsfrom each domain making a significant contribution to the levels ofpsychological morale, burnout, and job satisfaction.

There have been few studies focusing on psychological moraleamong nursing professionals in institutional care settings and evenless among nurses and nurse aides working in nursing homes (Cronin& Becherer, 1999; Grau et al., 1992; Gregoratos, 1995; Seago &Faucett, 1997). The data generated from this sample regarding thelevel of morale of nursing staff indicated that demoralization is pri-marily influenced by styles of conflict resolution. Staff with a prefer-ence for confrontational and avoidance styles reported lower levels ofpsychological morale. These two conflict resolution styles were thestrongest predictors of morale among nursing staff. It is of interest tonote that individual characteristics did not contribute to predictmorale among nursing staff. These results provide an initial under-standing of those conditions that have a positive and detrimentalimpact on the level of psychological morale among nursing staff.Increased morale relates specifically to work demands, resources, andconflict resolution abilities. Unlike personal characteristics, workdemands, resources, and conflict resolution skills have the potential tobe modified to enhance nursing staff morale and other outcomes. Ifpolicy makers and nursing administrators can identify work-relatedaspects and coping mechanisms preferred by nursing professionals,we would have a better understanding of how to implement specificinterventions to assist them in having a more positive job experiencethat ultimately would affect their level of morale, turnover, and well-being.




A puzzling finding from this study relates to the observed positiveassociation between the nursing staff participants’ levels of psycho-logical morale and their caring for residents with higher caredemands. This association is somewhat contrary to previous research,where either a negative or a nonsignificant association between staffoutcomes and caring for high-care demand residents has beenreported (Astrom, Nilsson, Norberg, Sandman, & Winblad, 1991;Hallberg & Norberg, 1995; Ramirez et al., 1998). Logic would sug-gest a negative impact on morale and other staff outcomes for nursingstaff caring for residents with high care demands. For this study, otheraspects might have contributed to this unexpected positive associa-tion. For example, the sample represents a self-selected group of nurs-ing staff who volunteered to participate from a few nursing facilities.This self-selection could raise the question about the directionalitybetween these two variables because it could be argued that nursingstaff providing care for high-demand residents are highly motivated tobegin with and may hold a more positive attitude toward the provisionof care than other nursing staff. Likewise, the staff participating in thisstudy could be less interested in a confrontational and avoidance con-flict resolution style and prefer the cooperative style (in fact, the datashowed a trend toward a significant association between thecooperative style and morale).

The pattern of predictors for nursing staff psychological moralewas similar to those findings on nursing staff burnout and job satisfac-tion. The findings confirm and expand empirical evidence from previ-ous research on nursing staff occupational stress and satisfaction(Ramirez et al., 1998; Cohen-Mansfield & Noelker, 2000; Demeroutiet al., 2000). The analyses pointed to several factors as conditionsexacerbating the participants’ feelings of emotional exhaustion andjob depersonalization. Emotional exhaustion could be intensified byindividual characteristics such as having negative views about the res-idents (Sheridan, White, & Fairchild, 1992). Staff burnout was alsoinfluenced by work demand–related factors. Confirming previousresearch, participants pointed to work demand predictors, includingthe nursing staff work load, in which having a heavier assignment wassignificantly related to emotional exhaustion and negative job experi-ence (Ramirez et al., 1998; Chapell & Novack, 1992) as well as shiftrotation, which had a negative effect on nursing staff job satisfaction




(Barton, 1995; Coffey, Skipper, & Jung, 1988; Fitzpatrick, While, &Roberts, 1999). On the contrary, nurses assigned to more difficult-to-care-for residents declared having a significantly more positive expe-rience with their job. This finding is, again, somewhat contrary to pre-vious research, and as we suggested, the self-selection bias could be atwork. Also, the perception of conflict was related to emotionalexhaustion and negative job experience. As Pillemer and Moore(1989) have noted, staff with negative attitudes toward older adults aremore likely to behave inappropriately toward them, and those who areburned out, dissatisfied, and have significant staff-resident conflictare at greater risk of engaging in abusive behavior. Finally, our studyfound support for previous research regarding the influence of workresource factors, showing that staff burnout and lower job satisfactionincrease when nurses perceive an inadequate level of supplies in thefacility and their lower involvement in care planning (Cohen-Mansfield, 1989; Dunn, Rout, Carson, & Ritter, 1994; Noelker, 1993;Ramirez et al., 1998).

Predictors of the nursing staff’s job satisfaction were somewhat dif-ferent because none of the work demand variables were associatedwith either staff satisfaction or perceived job benefits. The only con-flict resolution style associated with satisfaction was the cooperativestyle. Nursing staff satisfaction was primarily associated with workresource factors, such as the perception of availability and adequacyof facility supplies and the practice of having frequent care planningmeetings. Perception of job benefits, on the other hand, was also influ-enced by the minority status of nursing staff because in comparison toWhites, minority staff expressed a higher level of dissatisfaction withjob benefits. As indicated by Ramirez et al. (1998), the ethnic incon-gruence between residents and staff in nursing homes needs to beaddressed. They found that minority nursing staff perceived a higherethnic or racial bias and that nursing aides’ethnicity was a significantpredictor of job satisfaction and burnout. These findings underscorethat different ethnic or racial groups have different experiences andthat we need to consider cultural diversity as a core factor whendeveloping training for nursing.

Conflict resolution styles were strong predictors of morale, burn-out, and job satisfaction for nursing staff participants. Conflict resolu-tion styles also emerged as having either a significantly negative or




positive influence. As anticipated, nursing staff expressing a higherpreference for a confrontational style reported higher levels of emo-tional exhaustion and feelings of job depersonalization. Conversely,the nursing staff’s positive feelings about their job and perception ofhigher job benefits were related primarily to a preference for a cooper-ative conflict resolution style. Conflict resolution styles made a stron-ger contribution when the feelings of job depersonalization amongnursing personnel were examined. All three styles of conflict resolu-tion were significant predictors, either to increased burnout associatedwith a confrontational and avoidance preference or to amelioratedburnout in association with a cooperative style. These findings con-firm previous research providing support for the role of coping mech-anisms on the outcomes of stress (Williamson & Schultz, 1993). Itwould appear that nursing staff would benefit by using specific adap-tive coping mechanisms or cooperative conflict resolution styles intheir everyday interactions with residents. The results from this studyare also consistent with previous evidence supporting the positiveassociation between nursing staff job satisfaction and the preferencefor a cooperative style of interaction with residents (Boumans &Landerweerd, 1992). The findings also endorse the observed benefi-cial effects of positive coping, namely, the cooperative style, on staffburnout (Ceslowitz, 1989; Chiriboga & Bailey, 1986; Jansen et al.,1996; Kimmel, 1981). The analyses further corroborate that the use ofnegative coping mechanisms, such as confrontational and avoidancestyles, is associated with negative nursing staff outcomes, such asburnout and occupational stress (Tyler & Cushway, 1995; Healy &McKay, 2000).

Caution in the interpretation of these results is emphasized givenseveral limitations in this study: (a) the cross-sectional nature of theanalyses prevents the inference of causality in the relationshipsbetween nursing staff outcomes and independent variables, in particu-lar the conflict resolution styles; (b) the nature of these attitudinalvariables makes it difficult to establish the proper causal model (forexample, an alternative acceptable model might propose a reverserelationship because it could be presumed that nursing staff outcomescould influence the set of preferences of conflict resolution styles);and (c) other important predictors of nursing staff outcomes (such asenvironmental aspects, the culture and climate of the facility, leader-




ship style of administrator, etc.) were not included in this study. Futureresearch needs to address these limitations using representative sam-ples and a longitudinal research design so that the role of conflict reso-lution styles in determining staff outcomes might be more clearlyunderstood. Our findings highlight the importance of considering per-sonal coping abilities of nursing staff to foster positive bonds andinteractions between staff and residents and to maintain and increasemorale and satisfaction among nursing staff.

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