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 Table of Contents  
Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 13-22

Negotiation as a management strategy for conflict resolution and its effect on enhancing collaboration between nurses and physicians

Department of Nursing Administration, Faculty of Nursing, Assiut University, Assiut, Egypt

Date of Submission20-Jul-2020
Date of Decision03-Aug-2020
Date of Acceptance20-Aug-2020
Date of Web Publication18-Nov-2020

Correspondence Address:
Eman K.H Ebrahim
Department of Nursing Administration, Faculty of Nursing, Assiut University, Assiut 71526
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ENJ.ENJ_22_20

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Aim The aim was to investigate negotiations as a management strategy for conflict resolution and its effect on enhancing collaboration between nurses and physicians.
Background Conflict is the main cause of poor collaboration between nurses and physicians, and negotiation is the best way to resolve conflicts between health care professionals.
Participants and methods A mixed-method (quantitative method and qualitative method) design was used in this study. The study was conducted on 222 participants (154 nurses, 56 doctors, and 12 nursing managers) from two Ministry of Health hospitals using four tools: a personal data sheet, Jefferson’s scale of attitude toward nurse–physician collaboration, negotiation style to a conflict resolution questionnaire, and semistructured interviews.
Results There was a strong positive correlation between negotiation and collaboration in both nurses and physicians (0.496** and 0.506** respectively), besides the support of qualitative data to this result. Regarding collaboration, the nurse mean scores were higher [48.45 (80.7%)] than physician mean scores, whereas in negotiation, physician mean scores were higher [99.86 (80.5%)] than nurse mean scores.
Conclusion The qualitative data in this study supported quantitative data. Negotiation helps enhance collaborations between nurses and physicians. Nursing managers must stress that the negotiation to be effective need training and administrative support for the beginners. Regarding the implications for nursing management, managers in managerial positions should conduct training sessions for nurses and young doctors on negotiation skills and techniques and their benefits for collaboration between health care professionals and for healthy work settings.

Keywords: collaboration, conflict, negotiation, nurses, physicians

How to cite this article:
Ebrahim EK. Negotiation as a management strategy for conflict resolution and its effect on enhancing collaboration between nurses and physicians. Egypt Nurs J 2020;17:13-22

How to cite this URL:
Ebrahim EK. Negotiation as a management strategy for conflict resolution and its effect on enhancing collaboration between nurses and physicians. Egypt Nurs J [serial online] 2020 [cited 2020 Dec 3];17:13-22. Available from: http://www.enj.eg.net/text.asp?2020/17/1/13/300781

  Introduction Top

Negotiation is a method for resolving administrative conflicts in a health care organization. Conflicts between health care nurses and physicians are not restricted in teams and may lead to suboptimal patient care (Cullati et al., 2019). Negotiation is based on skills that enable negotiators to succeed in their roles, so they must learn these skills and practices that lead to solving the various complexities and difficulties that arise in an organization along with awareness of negotiation techniques and knowledge of different concepts of negotiation (Schroeder, 2014; Zarei et al., 2016).

Negotiation was defined according to Webster’s glossary as to meeting and discussing with one another to reach an agreements (El-Hanafy, 2018). The management role for nurses arises from basic preparation (skills), knowledge, and experience of the management practices. Tools of management like negotiation of conflict are used to organize the managerial tasks logically and to support professional decision making (Eduardo et al., 2016).

It is significant to administrators in health care settings to recognize different negotiation styles; therefore, they can interact properly through diverse conditions of conflict in the organization. Nowadays, in the health care institute, the roles of nursing managers, especially first liners, differ, which are primarily focused on monotonous work and duty toward patients and nurses (Hossny and Abdelhafiz, 2019).

Negotiation passes in three stages/phases: preparation (gathering all possible information related to the negotiating parties and the causes of the problem), the procedure/action (the involvement of all parties in the discussion of the dispute under negotiation), and closure (ending the negotiation process by agreement or disagreement). Five principles must exist in conflict negotiations: the negotiation parties’ worries, involved concerns, the parties’ relationship, communication through process of negotiation, and the result attained (Helpern, 1993).

Negotiation depends on the competence of the negotiator; there is an anomaly in the organization when the negotiator or manager does not have this competence. Managers use negotiation because of its benefits. Negotiation is the best effective approach to conflict control (Rahimi and Aghababaei, 2012), to help build an agreement (Flogger and Bush, 2014), and to maintain the relationship between the parties (Frankel et al., 2017). Moreover, conflict resolution is very important, and negotiation skills can successfully apply to conflict unlike many other problems (Lewicki and Hiam, 2007). A huge group of more experienced nurses and nursing managers has stated that conflict with physicians is often the dominant professional conflict over other different occupations in the workplace (Lahana et al., 2017), and nurses and doctors often have difficulty creating healthy cooperative patterns because of different perceptions of professional practices in the clinical environment (Blue, 2019). Nurses and doctors are trained separately but are required to collaborate daily on patient treatment plans. Education of nurses focuses on care, whereas the primary practice for doctors is treatment.

Collaboration between the nursing and medical staff depends mainly on communication, and it is known that negotiation is a means of communication between individuals to reach a solution (Zarei et al., 2016), so negotiation and exchange of ideas are the appropriate ways to reach an agreement and understanding between them. Conflict negotiation is a mutual and voluntary contact in both the process and outcome (Schroeder, 2014).

As is well known, conflicts have negative effects on the quality of care provided. Aghamohammadi et al. (2019) stated that poor cooperation between the nurse and the physician may delay the performance of nurses associated with patient care, and also at the university hospital, disputes between health care professionals can affect patient care (Blue, 2019), which leads to increased medical errors and bad results (Cypress, 2011). On the contrary, unsatisfactory relationship between the nurse and the doctor partly contributes to the nurses’ shortage and enforces them to leave their profession (Elsous et al., 2017).

Based on the literature review and as it is recognized that collaboration between nurses and physicians is a global problem worldwide and the conflict between them is the main cause of this problem, recommendations for previous studies on this point also refer to conducting interventional studies to improve cooperation between the nurse and the doctor. The researcher tried to conduct this study within a series of studies to respond to these recommendations. Accordingly, the researcher started from this point to adopt the idea of negotiation as the most efficient and effective method for controlling the conflict, and it will have an effect on enhancing collaboration between nurses and physicians.

Study questions

  1. Do nurses and physicians use negotiation to resolve conflict?
  2. What is the relationship between negotiation and collaboration?
  3. What is the effect of negotiation on collaboration between nurses and physicians?

  Aims Top

The following are the aims of the study:
  1. To investigate negotiation as a management strategy for conflict resolution.
  2. its effect on enhancing collaboration between nurses and physicians.

  Participants and methods Top


This study used an exploratory mixed-method design.

Quantitative research method includes Jefferson scale of collaboration between nurses and physicians (JSCNP), and negotiation questionnaire.

Qualitative research method includes interviews with close-ended and open-ended questions.

Study setting

The study had been conducted at the Ministry of Health Hospitals, including Assiut General Hospital (El-Shamlla), with a bed capacity of 228 beds (total 244 nurse and 106 physicians), and El- Eman General Hospital, with a bed capacity of 410 beds (370 nurse and 128 physicians).

Study participants

The total number of participants in this study was 222, including 154 nurses, 56 physicians, and 12 nursing managers working in predefined study places, using a convenient sampling method to employ study participants.


Four instruments were used in this study, namely, a personal data sheet, Jefferson scale of attitude toward nurse–physician collaboration (JSANPC), negotiation style of conflict resolution questionnaire (NSCRQ), and semistructured interviews (SSIs).

The first one included personal data sheet, comprising age, sex, level of education, marital status, and years of experience.

The second one was the JSANPC. This scale was established at Jefferson University by Hojat and Herman (1985), in the English language and was reviewed by Hojat et al. (1999). The scale is translated into Arabic by researcher and then retranslated to ensure right translation. It consists of 15 questions under four subscales, namely, shared education and teamwork (seven statements), caring vs curing (three statements), nurses’ autonomy (three statements), and physicians’ authority (two statements), used for measuring attitudes toward the collaborative relationship between nurse and physician. Shared education and teamwork dimension score indicates a greater orientation toward interdisciplinary education and interprofessional collaboration.

Caring vs curing indicates a more positive view of the nurse’s contribution to the psychosocial and educational aspect of patient care. The high scores of the nurses’ self-dimension indicate compatibility and nurse participation in patient care decision making and policy. The high marks of the authority of the doctors indicate that the dominant role of the doctor in patient care is completely rejected. It was based on a four-point scale, where ‘strongly agree’ obtained a score of 4 and ‘strongly disagree’ obtained a score of 1, from a total score of 15 to 60, with higher values indicating a more positive position toward the cooperative relations between the nurse and the doctor. Α Cronbach’s Jefferson scale ranged from 0.70 to 0.93.

The third one was the NSCRQ: adopted by Ahmad (2016). It consists of three phases: preparation phase (11 items), action phase (16 items), and closure phase (four items) based on a four-point scale from 4 (strongly agree) to 1 (strongly disagree), with a range of 31–124; the higher the scores the higher negotiation between health care professional. The tool reveals high reliability and Cronbach’s α coefficients of 0.82–0.90.

The fourth one was the SSIs, which was used to supplement and add depth to quantitative approach. Close-ended and open-ended questions (agenda for the interview guide) were used, for instance, in your judgment, did you practice a negotiation process in your unit? If yes, give an example, did the negotiation process success and give required outcomes? Did you follow specific negotiation techniques? What is the effect of negotiation on collaboration between nurses and physicians? And so on, until the researcher has been satisfied with the amount of questions and no more questions were found to ask related to this topic.


Quantitative method

A pilot study was conducted on 10% of the sample to ensure clarity, understanding of the content, and time estimate for the study tools. The actual time for collecting data was approximately three months starting from January 1, 2018 and ending in March 2018. The researcher met with all the nurses and doctors to explain the purpose of the study, made sure that they provided informed consent, and clarified that withdrawal from the study at any time is available. Data were collected using the first three study questionnaires from all the nurses and doctors mentioned previously in the study topic.

Qualitative method

A SSI for 12 nursing managers was conducted. All the participants are women, with a mean age of 47.36±6.66 years and a mean work experience of 23.10±5.57 years. Among all of them, two individuals had PhDs, four individuals had master degrees, and six individuals had a bachelor degree in nursing. Approximately 60-min interviews were conducted at times agreed upon previously with the participants. Each individual interview was recorded, and the interview entitled ‘negotiation practices for conflict resolution and its effect on collaboration between nurses and physicians’.

Statistical analysis

Statistical analysis was performed for responses to JSANPC and NSCRQ using the statistical software package SPSS 20.0 (Ver. 20, SPSS, Chicago, IL, USA). Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables. Continuous variables were expressed as mean±SD. For comparison of categorical variables, the co-efficient test and Pearson correlation analysis were used for assessment of the interrelationships among quantitative variables P greater than 0.05 was considered not significant, and P less than 0.05 was considered significant.

The SSIs data were analyzed through a traditional (conventional) content analysis approach using the Graneheim and Lundman (2004) method. In this method, the entire interview is considered an analysis unit. The unit of analysis refers to the notes that must be analyzed and coded. The recorded interviews were transcribed accurately after the researcher listened to the interviews several times. Paragraphs, phrases, and words are considered meaning units. A meaning unit refers to a set of words and phrases that are related to each other in terms of content. They are classified according to their content and context. Written texts have been revised several times to highlight words containing key concepts or units of meaning, and extract initial symbols. The codes were then revised several times in a continuous process from code extraction to labeling. Similar symbols were combined, categorized, and named, and subcategories were obtained. Finally, the extracted subcategories were compared and combined to form the major categories or themes.

Assessment stability and accuracy of data

Guba and Lincoln’s criteria were used to make sure the stability and accuracy of data. The believability of the data was assessed using the Triangulation method: member-checking, prolonged engagement techniques, and external checking process (external researcher).

Ethical considerations

The eligible participants were selected after obtaining the approval of the Faculty of Nursing Ethics Committee (it is a routine approval) with essential agreements. Before data collection and conducting the interviews, explanations were provided to participants about their privacy, concealment of their data, the aims of the study, study methods, and their right at any time to leave the research.

  Results Top

Quantitative data

[Table 1] presents the demographic data of nurses and doctors.
Table 1 Numbers and percentages of participants’ personal data

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More than half of the studied nurses (56.5%) were between 20 and 29 years old. Almost half of the doctors (48.2%) were between 30 and 39 years old. More than half (52.6%) of the studied nurses are male, and approximately three-quarters (73.2%) were male among doctors. Approximately a third (31.5%, 30.5%) of the nurses held a diploma of a nursing institute. However, more than two-thirds of the doctors (64%) obtained a master’s degree and (31%) obtained a doctorate degree. Most (85.7%) doctors and nurses (72.7%) had less than 10 years of experience.

[Table 2] demonstrates the mean values of negotiation phases for both nurses and physicians. Generally, physicians had high mean scores [99.86 (80.5%)] than nurses. It was revealed that physicians in all negotiation phases had increased values constantly than nurses. Also it is observed that most of them [13.11 (81.9%)] preferred after negotiation phase, whereas nurses preferred during negotiation phase [51.53 (80.5%)].
Table 2 Mean values of negotiation phases for both nurses and physicians

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[Table 3] illustrates the mean values of JSANPC subscales for both nurses and physicians. It is observed that nurses’ mean scores [48.45(80.7%)] were high than physicians in overall attitude of collaboration. Regarding subscales, nurses had high mean score in nurses’ autonomy [10.35 (86.3%)] and least one regarding physician’ authority [5.12 (64%)]. However, physicians had high mean score in shared education and teamwork and least one regarding physician’ authority [22.36 (79.8%) and 4.93 (61.6%), respectively].
Table 3 Mean values of subscales of JSANPC for both nurses and physicians

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[Table 4] reveals the correlation co-efficient between NSCRQ and JSANPC for both nurses and physicians. There was a strong significant positive correlation between negotiation score and overall attitude for both nurses and physicians (0.496** and 0.506**, respectively). It is observed that total negotiation has a high positive correlation (0.450**) with shared education and teamwork subscale for nurses, whereas for physicians, total negotiation had a high positive correlation (0.499**) with caring-vs-curing subscale. Furthermore, nurses’ perceived total negotiations had a significant negative correlation with physician’s authority (−0.176*).
Table 4 Correlation co-efficient between NSCRQ and JSANPC for both nurses and physicians

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Qualitative data

Based on the results of the interview, the following themes of ‘Conflict and running the negotiation process,’ ‘Factors contributing success of negotiation process,‘ and ‘Effect of negotiation on collaboration between conflicted parties’ were identified as the main factors affecting the negotiation of conflict to enhance collaboration between nurses and physicians ([Table 5]).
Table 5 Categories, subcategories, and codes extracted from the interview analysis

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Conflict and running the negotiation process

Most nursing managers’ interviews confirmed that most types of conflicts in health care settings occur between nurses and physicians/doctors. Nursing managers such as the head nurses and supervisors are the third party to solve the problems that arises between them and usually use negotiation. It is essential that nursing managers know how to negotiate effectively and be prepared well for that. The following factors are related to this theme.

Using and mastery of negotiation techniques

Mastery of negotiation techniques contributes mainly in success of negotiation process. Nurse manager/negotiator must be aware of negotiation skills and should be trained well to do this. Effective negotiation depends on the negotiator’s ability to separate people from the problem, to be objective, and to focus on the topic of negotiation, just attitude during a conflict situation, and avoiding judging who is right or who is wrong during the process of negotiation. Moreover, the negotiator must bear in mind the outcome to be achieved, so the participation of all parties in the process is essential as a requirement for obtaining a meaningful result.

One participant stated: ‘all negotiation efforts depends on the mastery of negotiator in the skills and techniques of negotiation’ participant 4.

Well preparation for negotiation

Nursing managers in order to constructively negotiate and create a win-win situation must know the procedures before, during, and after the negotiation. The conflict between nurses and doctors must be resolved effectively without leaving any residual traces, and this is what the manager needs to prepare well. An agenda for arranging ideas and ideas before negotiations begin. Moreover, the manner in which the negotiator manages the discussion and the art of using all the aforementioned skills and techniques is necessary for the success of this process. The negotiator must understand each party’s behavior and needs to deal with it accordingly, help others focus on the public interest rather than taking situations, use creativity during negotiation to reach acceptable points, should effectively treat defensive as well as passive individuals, and finally make the feuding parties feel perfect without harming anyone. In addition to ending the discussion by clarifying all points of view again and reaching agreement, any concern of anyone at this stage should be addressed.

One participant, participant no 1, stated that ‘I can’t start negotiations before I better understand each individual’s problem and develop ideas on how to get into each one of the point that helps them reach agreements for both of them.’. Another, participant 3, stated that ‘When the negotiation process is done right, the conflicting parties smile and shake hands.’

Factors contributing toward the success of negotiation process

Many factors must be taken into consideration to achieve successful negotiation process and to be workable. The following factors were reflected as subcategories of this theme.

Amount of autonomy nurses have

Autonomy of head nurse, supervisors, and even staff nurses plays a significant role in effectiveness of negotiation process. Autonomy is the ability of nurses to apply their own skills, having confidence, and practice their rights.

One participant, participant 7, stated that ‘You cannot expect nurses who are sometimes secretaries, and are seen as second-class staff in hospitals, can take steps to strengthen the negotiation process, because they do not feel confident enough’.

Personality traits negotiator have

Based on the data, personality traits push the negotiation process to success; a charming personality is the key to an effective negotiation. You must try to be yourself. It is important to be sincere rather than just being serious (sincerity an important personality trait required in negotiation). One should be honest, smart, be patient, be flexible, and learn to compromise. Moreover, trust of the second party is better for negotiation. One participant, participant 9, stated ‘strong personality of nurse manager (negotiator) leads to successful outcome and relation backs to previously’.


A total of 10 of 12 participants confirmed that experience is required for negotiation. Experience is required through practice and learning from observing repeated situations in this regard and reference support from those with experience.

One participant stated that ‘at the beginning of my career when I am asked to solve a problem among others in my unit, I miss how to do this due to lack of experience.’ Another, participant 11, stated that ‘lack of experience is one of the reasons for the failure of the negotiation process,‘.

Communication is the key

Based on interview data, effective communication is directly proportional to effective negotiation; the better the communication (verbal and non-verbal) the better the negotiation. Moreover, open two-way communication, as well as the need for excellent communication skills for effective and healthy discussion of both nurses and doctors is required. The ability to persuade someone depends mainly on the ability to communicate, and to turn the idea into words that the other side clearly understands. Moreover, listening to the other’s point of view, and lack of defense is important.

Administrative support

It is important for managers to learn and train junior nurses in effective negotiation skills. Negotiation is not learned in nursing schools. Nurses need administrative support to negotiate their problems and confront other professionals, as well as to encourage cooperative behavior (Ministry of Health and Long-Term Care CA, 2012).Effect of negotiation process on relation between conflicted parties

According to the opinion of the participants, the effect of the negotiations appears early after the discussion is completed, whether positive or negative.

Positive effect

According to the views of the participants, the relationship between the conflicting parties is back natural after each one clarifies point of view. Nurses and physicians works together again and confidence between them are increased.

One participant, participant 8, stated that ‘I note that after the conflict ends, the nurse works with the same doctor to care for patients without any discomfort after the dispute ends.’

Negative effect

The negative effect usually occurs when the outcome of the negotiations is not satisfactory to one or both of the conflicting parties, such as dissatisfaction, increased absence, increased turnover, and decreased emotional commitment owing to the lack of factors that contribute to the success of the negotiation process that we discussed earlier. Moreover, major problems can occur beyond the reach of nursing managers (negotiators) such as patient injury, neglect, or misuse of expensive equipment.

One participant, participant 5, stated that ‘when the problem relates to the doctor’s authority, negotiation fails, and when it comes to negligence, the problem is significant according to what it is, and they usually need punishment’.

  Discussion Top

Based on the results of the quantitative and qualitative data in this study, negotiations are a successful conflict resolution strategy and very important for enhancing cooperation between nurses and physicians. Our study aims to explore negotiations as an administrative strategy for conflict resolution and their effect on strengthening cooperation between nurses and physicians.

In general, the quantitative data in this research ([Table 4]) revealed that there is a positive correlation, with a high statistical significance between total negotiation and overall attitudes between nurses and physicians. This means that cooperation between nurses and doctors increases with the negotiation process. Moreover, the results of our qualitative interviews support these data. According to interviews with nursing managers, negotiation has a positive effect on strengthening cooperation between the conflicting parties, and this helps to restore balanced cooperative relationship between nurses and doctors to meet patients’ needs through quality care, mutual respect and trust between nurse and physician. This positive effect mainly depends on many factors such as training and mastery of negotiation techniques, according to Mellman and Dauer, (2007), as serious training in negotiation skills increases the cooperation and partnership between the nurse and the doctor.

Moreover, negotiation requires administrative support that relies on education and training to provide the nurse and doctor with the skill and ability to arrange for greater safety and comfort when engaging in conflict situations in the workplace (Yoder-Wise, 2013), in addition to the personal characteristics of the negotiator, the experience one has, the level of independence, and the way in which the negotiator/manager deals with the conflict situation. Research evidence has demonstrated that positive and open cooperation and communication between the nurse and the doctor is absolutely necessary, which results in reduced medical errors, care expenses, increased quality of care, patient satisfaction, and professional satisfaction, as well as increased nurse retention (Nelson et al., 2008; Jerng et al., 2017). Moreover, expertise plays an important role among nursing managers to be successful negotiators to help in the conflict between nurses and doctors and to maintain a cooperative working relationship. [Table 4] also revealed that the negotiation is negatively linked to the doctor’s authority by the nurses. This means that when the subject of negotiation is related to the authority of the doctor, the practice of the negotiation process is reduced. This is in line with the results presented in this study in [Table 3], where the physician’ authority received the lowest scores from the nurses. This means that they do not fully reject the dominance of doctors in patient care, and this is what nurses have been in Egypt for a long time. According to Murata et al. (2014), physician have education, jurisdictional power, and superior role over patient care. This is what leads the negotiation process before it begins to aborted, because the results are known, and therefore this domination by the doctors does not help strengthen cooperation. According to Feggie-Bodole (2009), the doctor’s authority adds to the disappointment of the establishment of active cooperation between nurses and doctors.

The results of our study ([Table 2]) show that physicians have the highest mean scores in all stages of negotiation than nurses; physicians need to negotiation to end the conflict with nurses who need them in caring for patients and in teamwork ([Table 3]). However, nurses have the higher mean score regarding overall attitudes than physicians, which they felt that cooperation with the physician seemed to be a more important complementary role. Many previous studies confirm that nurses have demonstrated constructive attitudes toward cooperation between nurses and physicians (Jones and Fitzpatrick, 2009; Taylor, 2009; Hughes and Fitzpatrick, 2010; Cheng et al., 2016; Falana et al., 2016).

From the researcher’s point of view, the reason for the lack of a language for communication between them may be the reason. According to Elsous et al. (2017), the two most important people authorized toward the care for patients are nurses and physicians, but they often do not speak to each other correctly, and if that happens, often they do not exchange and cooperate effectively. Moreover, it is well known that nurses are mediators in various conflict situations and are equipped to deal with such conditions through discussions and negotiations (Baggs et al., 1999) cited (Leever et al., 2010).

According to Nelson et al. (2008) realize that the nurse’s experience enables her to express her meanings clearly and understandably and that they are more knowledgeable about their communication skills in general and their problem solving skills in particular, and they have more power. Shokri et al. (2013), stated that the lack of belief in the expert role of nurse in patient care is the most significant hindered factor in collaboration between physician and nurse. Moreover, increasing the professional independence of nurses plays a contributing role in this. According to the results of the study, these nurses have a high degree of autonomy.

  Conclusion Top

In this paper, qualitative data support quantitative data. A conflict between nurses and physicians usually occurs in health care institutions, and negotiation plays an important role in returning the working relationship back to normal. The data in this study reveal that physicians prefer negotiation, whereas nurses prefer cooperation. Managers, as a third party, stress that the negotiations to be success need many factors the negotiator must have in addition to training and administrative support for beginners from the side of nursing managers.

Implications for nursing management

Based on the previous results, the researcher asked managers in managerial positions to conduct professional development workshops for junior nurses and doctors on negotiation skills and techniques, and the benefits of negotiations for effective work flow in health care settings. Conflicts between health care professionals are offensive, so more attention to the importance of negotiation is required from the side of administrators. Moreover, negotiation leads to eradication of conflict, without any adverse effects among the conflicted parties, leading to better collaboration between nurses and physicians. At the end, the success of negotiation depends on negotiators, so it is very important to train them accordingly and spread the concept of negotiation among health care providers.[29]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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