Factors influencing constructive conflict management style of nursing interns: a structural equation modeling approach based on the self-determination theory

Nurse-patient conflict negatively impacts nursing staff’s physical and mental health, reduces job satisfaction, contributes to job burnout, and increases turnover [1‐3]. Furthermore, ineffectively managed conflicts have the potential to escalate into workplace violence. It creates a harmful loop that intensifies tensions between nurses and patients, disrupts healthcare facilities’ regular operations, minimizes patient satisfaction, and endangers patient safety [4]. Nursing interns refer to nursing students who transition from completing 2–3 years of theoretical courses in school to formal graduation. They study with clinical nursing teachers in the hospital [5]. Nursing interns are more likely to experience nurse-patient conflict because of obstacles such as lack of clinical experience, inadequate coping skills, and unclear roles [6]. Hallett and colleagues [7] found that over 50% of nursing interns have encountered episodes of hostility or violence in the medical setting, and the most frequent perpetrators were patients. Consequently, it is imperative to cultivate nursing interns’ nurse-patient conflict management abilities. The literature review indicated that constructive conflict management is of significant importance when it comes to effective nurse-patient conflict resolution [8].

Conflict management styles refer to different behavior patterns adopted by the parties to the dispute during conflict situations, including four types: collaborating, obliging, dominating, and avoiding [9, 10]. The constructive conflict management style seeks to optimize conflict resolution and attain a positive outcome that benefits all parties involved, commonly referred to as a win–win or all-win situation [11]. Collaborating means that conflicting parties seek mutually beneficial solutions through negotiation, which can improve interpersonal relationships as well as nurse and patient satisfaction [12]. Thus, it is considered the best constructive conflict management style in the medical setting [13]. Most nursing students prefer a positive conflict resolution style [14]. Nevertheless, several studies have demonstrated that it is difficult for nursing students to truly and effectively implement constructive conflict resolution styles when dealing with nurse-patient conflict [15]. This issue could be attributed to the absence of structured conflict management instruction in nursing schools, leading to a limited understanding among nursing students about the constructive conflict management style and its practical implementation in clinic scenarios [16]. This is also a major factor in the frequent conflicts and incidents of workplace violence that nursing students around the world have experienced in their clinical practice in recent years [17, 18]. Labrague and colleagues [8] further emphasized the importance of investigating the predictors that shape nursing interns’ use of a constructive conflict management style.

Self-determination theory is a motivational framework that examines the factors influencing individual behaviors, emphasizing the importance of three fundamental psychological needs: relatedness, autonomy, and competence. These needs drive motivation and shape behavior, and their synergistic effect encourages individuals to adopt positive behavioral patterns [19, 20]. Constructive conflict management style refers to the way individuals respond to conflict, and is largely influenced by their internal motivation to achieve favorable outcomes. This aligns with self-determination theory, as a motivated individual is more likely to engage in constructive behaviors to manage conflict. Given that self-determination theory offers a comprehensive framework for understanding the motivational drivers behind positive behaviors, it serves as the guiding theory for this study to methodically explore and validate potential pathways that can promote constructive conflict management style among nursing interns.

Relatedness is defined as establishing connections with others, feeling cared for and nurtured, and having a sense of belonging [21]. In nursing internships, career-related social support, which includes emotional, informational, and advice support, is a crucial category of relatedness [22]. Good social support fosters a strong sense of relatedness with others, guiding a proactive behavior pattern [23]. Therefore, career-related social support can be seen as a relatedness element in a constructive conflict management style. Researchers found that enough social support could promote effective conflict management [24]. However, the influence mechanisms remain unclear.

Autonomy is the perception that one’s behavior is self-directed rather than controlled or coerced by external forces [21]. As part of individual autonomy in conflict management, emotional intelligence refers to the individual’s ability to recognize, understand, assess, and handle their emotions and feelings [25]. Research has shown that it is affected by social support and plays a role in cognitive reappraisal strategies during emotional regulation processes [26]. This helps nursing students autonomously engage in positive emotional regulation and make valid behavioral pattern choices. Moreover, studies have demonstrated that emotional intelligence, which is a fundamental aspect of nurses’ personality traits, might impact the implementation of a constructive conflict management style [27]. Goleman’s theory of emotional intelligence asserts that emotional intelligence encompasses self-awareness, self-management (including self-regulation and motivation), social awareness, and social skills [28]. These four factors promote early conflict detection, effective emotional regulation during conflicts, empathy for others’ emotions and perspectives, and the application of appropriate conflict resolution styles.

Competence encompasses learned skills or abilities, as well as the subjective sense of proficiency that arises from possessing those capacities [21]. The ability to communicate with angry patients refers to nursing interns’ ability to identify patients’ anger early, find out the reasons for anger, and resolve anger through effective communication skills [29]. This is the cornerstone of resolving nurse-patient conflicts, since patient anger is the direct cause of the conflict [30]. Therefore, the ability of nursing interns to communicate with angry patients may influence their adoption of a constructive conflict management style. Furthermore, empirical evidence demonstrates that social support and emotional intelligence have a significant impact on communication abilities [31, 32]. Strong social support and high emotional intelligence greatly enhance an individual’s communication abilities by promoting the integration of knowledge, attitudes, and skills in communication.

Prior studies have focused exclusively on the connection between individual-level factors and nursing interns’ use of the constructive conflict management style. When grounded in a theoretical framework, examining the predictors of constructive conflict management style remains insufficient. The relationship between career-related social support, emotional intelligence, communication ability with angry patients, and constructive conflict management style is intricate. Therefore, this study, guided by the principles of self-determination theory, aims to investigate and validate the intricate relationships among these four variables. The goal is to lay the groundwork for future interventions targeting constructive conflict management styles for nursing interns. This is with the objective of enhancing their capacity to effectively manage nurse-patient conflicts. Ultimately, this could lead to increased satisfaction among both nurses and patients, contributing to greater stability within the nursing workforce. We proposed the following hypotheses (see Fig. 1): (H1) Career-related social support, emotional intelligence, and communication ability with angry patients are all linked to a constructive conflict management style. (H2) Emotional intelligence and communication ability with angry patients each independently mediate the connection between career-related social support and constructive conflict management styles. (H3) Emotional intelligence and communication ability with angry patients act as a chain mediator between career-related social support and constructive conflict management style.

The self-determination theory suggests that the presence of relatedness, autonomy, and competence serve as key factors that motivate individuals to adopt favorable behavioral patterns [19]. Using self-determination theory, this study examined the complex relationship between career-related social support, emotional intelligence, communication ability with angry patients, and the use of a constructive conflict management style among nursing interns. The objective is to establish a basis for future interventions targeting constructive conflict resolution style, as it represents the most effective coping behavior pattern for nursing students to manage conflicts. This research’s primary discovery is that career-related social support has a direct impact on constructive conflict management style. Furthermore, this support indirectly influences the style by mediating emotional intelligence and communication ability with furious patients. These findings are consistent with hypotheses based on self-determination theory.

The study’s initial findings indicated a notable and favorable connection between career-related social support and the use of a constructive conflict management style among nursing interns. This aligns with prior studies [39, 40]. Nursing interns who receive a higher level of social support connected to their profession during their internships are more likely to improve their nursing abilities [41], thereby increasing their self-efficacy [42]. In addition, ample social support fosters the development of trust and comprehension, resulting in enhanced interpersonal connections [23]. Enhancing self-assurance and interpersonal connections empowers nursing interns to readily and effectively employ constructive conflict resolution styles in conflict scenarios [43, 44], fostering a more harmonious nurse-patient relationship.

Additionally, the study found that nursing interns’ career-related social support indirectly affected constructive conflict management style due to the multiple mediated effects of emotional intelligence and communication ability with angry patients. Firstly, social support could significantly influence emotional intelligence, which was consistent with previous research [26, 45]. Good social support can provide emotional comfort and assistance to nursing interns. This can help to alleviate stress and maintain emotional stability, thereby promoting their cognitive, expressive, and regulatory abilities in relation to emotions [46]. Furthermore, social support can also offer cognitive and behavioral feedback and advice [47], helping nursing interns better understand and manage their emotions, thus enhancing emotional intelligence. Secondly, the mediating model demonstrated a positive correlation between emotional intelligence and communication ability with wrathful patients among nursing interns. This aligns with the findings of prior research on universal communication proficiency [32]. Emotional intelligence is defined as an individual’s ability to perceive their own and others’ emotions and use this information to regulate their own thoughts and actions. Nursing interns possessing high emotional intelligence perceive and comprehend patients’ anger with heightened sensitivity. They harness positive emotions and employing efficient communication techniques to alleviate patients’ anger [48]. Finally, nursing interns’ communication ability with angry patients has a positive impact on their constructive conflict management style. Nes et al. [49] emphasized that the use of facilitative communication can significantly reduce conflicts. By engaging in prompt and efficient communication with irate patients, nursing interns can more accurately pinpoint the underlying reasons for nurse-patient discord and collaborate with patients to explore potential resolutions [29], ultimately attaining a constructive conflict management style.

In addition to multiple mediations, this study also showed that emotional intelligence and communication ability with angry patients of nursing interns each played a single mediating role between career-related social support and constructive conflict management style. This is consistent with previous research [50, 51]. First, nursing interns with high emotional intelligence can better regulate their emotions due to their strong self-awareness and societal awareness, and at the same time, they can find the most effective way to solve conflicts by combining all parties’ forces [52]. Second, the social support theory posits that the provision of emotional, informational, and material assistance by others can significantly augment an individual’s talents [53]. When dealing with irate patients, nursing interns’ communication abilities focus on understanding and handling anger, demonstrating a distinct professional skill. Nursing interns need specific social assistance to build their skills, including emotional support relevant to the nursing profession, professional informational guidance, and focused mentorship [22].

Although emotional intelligence and communication ability have significant multiple and single mediating effects between career-related social support and constructive conflict management style, these effects are much smaller than the direct effect. This contradicts previous research that regarded communication ability as the cornerstone of effective conflict resolution [54]. This may be because communication ability is only one component of constructive conflict management [55]. Hospital, as a complex system, its internal environment influences nursing intern conflict management [56]. Career-related social support is specific and multi-dimensional, encompassing emotional, opportunity, information, and advice support pertaining to the nursing profession [57]. These forms of support can be directly and rapidly transmitted to interns in the medical environment. For example, in the team collaboration atmosphere of a hospital, the guidance and suggestions given by teaching instructors and the positive encouragement provided by peers both become direct resources for interns to deal with nurse-patient conflicts, thus shaping their conflict management styles more directly [58]. In contrast, emotional intelligence improvement requires interns to develop gradually through long-term learning and practice, and its impact on conflict management styles is a relatively indirect and slow process [59].

Our findings have wide-ranging implications for nursing educators and administrators worldwide. Nursing educators should create a structured intervention program aimed at enhancing nursing interns’ constructive conflict management style. First, the most pertinent point is that nursing educators and administrators should emphasize the establishment and maintenance of a career support system, for example, by creating a secure and fulfilling work setting [37]. Nursing administrators could also cultivate a strong sense of belonging among interns, as it is imperative to treat them as valued members of the nursing team and implement measures to mitigate bullying by registered nurses [60, 61]. Furthermore, educators should utilize specific training strategies such as role-playing, virtual reality scenario simulations, peer mentoring, and case studies to boost nursing interns’ emotional intelligence and communication skills with wrathful patients [62]. In brief, it is imperative for nursing educators and managers to integrate the development of social support, emotional intelligence, and communication skills into global nursing education standards. This can be promoted through cross-cultural nursing education collaboration projects and international seminars. These initiatives will help facilitate nursing staff’s constructive conflict management worldwide, leading to professional growth.

This study’s main strength was utilizing self-determination theory to identify and validate the elements that influence nursing interns’ adoption of a constructive conflict management style. The conflict between nurses and patients presents a significant challenge for nursing interns. This style is considered the best form of addressing and managing nurse-patient conflict. Our study also has several limitations. First, the data collected in this study relied on self-reported measurements, which may introduce reporting bias, such as social expectation bias, especially in emotional intelligence and communication skills assessments. Second, causation explanation needs to be proven through additional longitudinal research because of the cross-sectional design. Third, although statistically significant demographic characteristics were included as control variables in the structural equation model, confounding factors such as organizational culture and the relationship between nursing interns and supervisors were not considered enough in this study. In subsequent investigations, we will refine potential confounding factors to further improve the rigor of the study. Fourth, the sample for this study is nursing interns from the same hospital. To increase the universality of the study results, we will conduct a multi-center study in the future, including nursing interns from different regions and hospitals of different grades, so as to expand the diversity and representativeness of the sample.​ Simultaneously, we will perform cross-cultural comparative studies, selecting nursing interns from diverse cultural backgrounds, such as mainland China, Hong Kong, and Macao Special Administrative Regions. This will provide a more valuable theoretical basis and practical guidance for global nursing education and practice.

This study, based on self-determination theory, fills a research gap on the factors that influence a constructive conflict management style. The results suggested that career-related social support had a relatively significant direct impact on constructive conflict management style. Between these variables, emotional intelligence and communication ability with angry patients played chain-mediation and single-mediation roles.