保健医療科学

2023

Vol.72 No.1 p.62－75＜ Original ＞
Conflicts among public health nurses managers in Japan:
The reality of conflicts and influencing factors
OKUDA Hiroko 1), YOKOYAMA Tetsuji 1), TAKEDA Fumi 2), SONE Tomofumi 1)
1)
2)

National Institute of Public Health
Graduate School of Comprehensive Human Sciences, University of Tsukuba

Abstract
Objectives: The purpose of this study was to determine the actual situation of conflicts as perceived bypublic health nurses (PHN’s) managers working in Japanese local governments, it’s effect on the performance of their managerial duties, and the factors that contribute to these conflicts.
Methods: We conducted a mail survey using a self-administered questionnaire on 384 PHN’s managers in
14 prefectures selected by stratified random sampling. The questionnaire items covered the basic characteristics of respondents, conflict awareness, and conflict-handling style of PHN’s managers. The analysis
included descriptive statistics and a test of the difference in average scores A stepwise multiple regression
analysis was conducted using the basic characteristics of respondents, conflict-handling styles as explanatory variables, and conflict awareness frequency as dependent variables. The study data were analyzed using
IBM SPSS Ver. 25 statistical analysis software with a two-tailed significance level of <5%.
Results: Of 242 (63.0%) responses to the questionnaire received 223 (61.5%) were valid. A total of 51
respondents (21.6%) were aware of the high frequency of conflicts, while the mean proportion of all work
occupied by the conflict-handling fraction was 24.3%. The most common style of dealing with conflicts was“understanding each other’s ideas; integrating “ at 69 (29.2%), followed by “avoiding arguments; avoiding “
at 63 (26.7%), and “respecting each other’s goals; integrating” at 48 (20.3%). Multiple regression analysis
was used to examine the factors influencing the frequency of perceived conflict. The results showed a positive association with the percentage of work “managerial work fraction,” and a negative association with “thenumber of subordinate occupations,” ““integrating” of coping styles,” “superiors’ occupation,” and “population size”.
Conclusion: Approximately 20% of PHN’s managers frequently perceived conflicts in their job performance and 1/4 of their workload comprised dealing with them. The “integrating” style is considered amethod that leads to a solution that is fully satisfactory to both parties in a cooperative manner.
It was suggested that the choice of a desirable coping style by PHN’s managers may help in the performance of their duties.
keywords: public health nurses (PHN’s), manager, workplace conflict, handling style(accepted for publication, October 11, 2022)

I. Introduction
In recent years, Japan has seen remarkable demographic
changes due to advances in medical care and a rapidly aging
population with declining birthrates. As a result, community
health issues are becoming more serious, including changes

in the structure of disease and an increase in the number ofpeople receiving care at home. In addition, health risk management events that are extremely likely to have an immediate and serious impact on the lives and health of local residents, such as serious disasters and outbreaks of infectious
diseases, are also becoming more frequent. These changes

Corresponding Author: OKUDA Hiroko
2-3-6 Minami, Wako, Saitama 351-0197, Japan.
Tel: +81-48-458-6111
Fax: +81-48-468-7983
E-mail: okuda.h.aa@niph.go.jp

62

J. Natl. Inst. Public Health, 72 (1) : 2023

Conflicts among public health nurses managers in Japan: The reality of conflicts and influencing factors
in community issues continue to increase the demand forcommunity-based medical, health, and welfare services [1].
In Japan, PHN’s working for local governments are at
the forefront of efforts to solve these community healthissues. The regions to which these PHN’s working for local
governments are assigned are broadly classified into prefectures and municipalities. PHN’s working in municipalities,
as employees close to local residents, are mainly engaged inwork related to direct resident services, such as maternal,
child, adult, elderly, and nursing care. On the other hand,
PHN’s working in prefectures are responsible for healthissues that require a high level of expertise, such as intractable diseases, mental health, and infectious diseases, aswell as technical assistance to municipalities. As describedabove, the primary duties of PHN’s vary depending on
the department to which they belong. However, the legal
systems on which PHN’s assigned to any of these organizations base their activities have changed rapidly as community conditions have changed. As a result, PHN’s are now
being assigned to various local government departments
including public health, welfare, and education; and are required to leverage their professional expertise as membersof a multidisciplinary organization. With this change, PHN’shave more opportunities to collaborate with a variety ofprofessionals. Furthermore, in just seven years, from 2009
to 2015, the number of PHN’s appointed to managerial positions (“PHN’s managers”), where they are expected to playa key role in advancing public policy, has nearly doubled [2].
Meanwhile, Japan’s government faced tightening budgets
to fund its fiscal and administrative operations due to theeffects of a declining and aging population, a decrease in thenumber of reproductive-age adults, and adverse economic
conditions.[3]. This has meant that employees working
for local governments, including PHN’s, are expected toachieve consistent results by streamlining their work within the organization. In particular, the PHN’s manager is
expected to fulfill two distinct roles: nurse and administrator. As a result, PHN’s managers frequently face tasks that
require negotiation, not only to manage their subordinates,
but also to reach consensus with various stakeholders inside and outside the organization [4].
Such negotiations due to disagreements between self andothers are called “conflicts.” and are said to be inevitablein any society. In general, it is said that the negative impact
of job-related conflicts in social organizations is significant,with 24-60% of a manager’s time and energy being spent
on dealing with conflicts [5]. However, when managers areable to deal with conflicts effectively, the performance ofthe organization improves; therefore, the leader is said tobe the key person [6].
Previous studies referring to conflict in the nursing pro-fession have recognized that it is a commonly encountered
event for nurses who aim to provide high-quality care [7].
It has also been suggested that one of the factors contributing to the serious shortage of nurses in Europe and theUnited States is workplace conflicts [8,9]. Furthermore, it
has been pointed out that there is a need to improve theskills of nurse managers to constructively manage inevitable conflicts among nurses [10,11]. As mentioned above, inother countries, there have been few studies focusing on
conflicts among nurses working in hospitals that share anunderstanding of the existence of conflicts derived from job
performance, which is considered common knowledge in
general society, and the importance of the role of managers
in dealing with these conflicts.
In contrast, in Japan, the only research on conflicts
targeting the nursing profession exists in the previously
described study [12], which targeted head nurses, and isbeing conducted mainly in the fields of social psychology
and health psychology [13-15]. Furthermore, there is noresearch on conflicts faced by PHN’s, either domestically orinternationally.
Against this background, we thought it would be meaningful to clarify the actual situation of conflicts among
PHN’s managers, since conflicts are an unavoidable eventin society, and the response of management is particularly
important. Therefore, the authors conducted an interview
survey [16] with eight PHN’s managers as a preliminary
study. The results revealed the existence of various conflicts during the performance of their duties and the realityof their struggles to cope with them. However, the authors
felt that a survey of a larger number of PHN’s managers
was necessary to clarify the actual situation of PHNs’
perceptions of and coping with conflicts in managerial positions.

II. Aim
The purpose of this study was to determine the actual
situation of conflicts as perceived by PHN’s managers
working in Japanese local governments, it’s effect on theperformance of their managerial duties, and the factors that
contribute to these conflicts.

III. Method
1. Population and sampling
The job requirements of PHN’s differ according to thetype of government and characteristics of the region they
inhabit.
As such, the job requirements of PHN’s managers andthe nature of PHN’s manager conflict awareness are also

J. Natl. Inst. Public Health, 72 (1) : 2023

63

OKUDA Hiroko, YOKOYAMA Tetsuji, TAKEDA Fumi, SONE Tomofumi
47 prefectures
A block

７prefectures

B block

７prefectures

C block

D block

９prefectures

E block

７prefectures

９prefectures

F block

８prefectures

selected by stratified random sampling

16 prefectures
A block

２prefectures

B block

３prefectures

C block

D block

３prefectures

E block

２prefectures

３prefectures

２prefectures

withdrawal

14 prefectures
A block

B block

C block

D block

F block

３prefectures(n=384)E block

F block

２prefectures

３prefectures

２prefectures

２prefectures

２prefectures

３prefectures

Prefecture*

14

31

15

25

13

18

Municipality *

33

71

34

57

31

42

*No. of PHN’s managers

No. of Responses (n=242)
withdrawal

missing responses
male respondent

n=5
n=1

Analysis Subjects (n=236)

Figure 1 The sample selection flow chart

presumably influenced by regional characteristics and thetype of organization to which they are assigned.
Furthermore, the placement of PHNs in management
positions working in local governments in Japan varies
depending on the type of local government administrationand the region. To ensure the distribution of this questionnaire to PHN’s managers, it was necessary to identify theaffiliation of the target population. Therefore, in conducting
this survey, the following procedure was used to select the
subjects. There are 47 prefectures in Japan throughout thecountry. First, after dividing these into six regional blocks,
16 prefectures were selected by stratified random sampling.
Next, the purpose of the study was explained to the central
government officials in charge of each of the selected prefectures, and they were asked whether or not they would
be willing to share information on the assignment of PHN’s
managers under their government. Finally, consent was
obtained from the central government officials in charge of
14 prefectures, and local government health nurses underthese prefectures were selected for the survey. (Fig. 1)
2. Survey method
The survey was conducted between December 2018 andFebruary 2019 using a self-administered mail-in questionnaire.
3. Survey details(1) Demographic and background characteristics
Personal characteristics (e.g., age, basic education level,64

job position, years of PHN’s or managerial experience, advisor, subordinates, etc.), organizational characteristics (e.g.,
government facilities, assigned department, population size,etc.)(2) Extent of conflict awarenessThe survey asked about the frequency with which PHN’s
managers experience conflicts with others in their daily
managerial work that require a response. The survey responses were developed based on the opinions of PHN’s
managers who had cooperated in a previous survey[15].
They were asked to select one of the following options:“Almost daily,” “Several conflicts per week,” “One conflict
per week,” “Several conflicts per month,” “One conflict
per month,” or “Other,” based on what they felt was mostappropriate during the performance of their current duties.
(3) Extent of conflict handlingIn the survey question on conflict handling, PHN’s managers were asked to subjectively describe the amount oftime dedicated to conflict handling as a mean proportion (%)
of all routine work (100%) (“conflict handling fraction”).
(4) Selection of conflict handling style
The survey question asking PHN’s managers to selecttheir conflict- handling style utilized the “Handling Interpersonal Conflict Inventory” (HICI) scale [17],which wasdeveloped based on the two-dimensional model of five conflict-handling styles described by Rahim and Bonoma[18].This model serves as a scale for handling differences inopinion into five styles differentiated on two basic dimensions: concern for self, indicating the degree to which a

J. Natl. Inst. Public Health, 72 (1) : 2023

Conflicts among public health nurses managers in Japan: The reality of conflicts and influencing factors
person attempts to satisfy his/her own concern; and concern for others, indicating the degree to which a person attempts to satisfy others’ concerns. The “integrating” styleindicates a high concern for self and others, the “avoiding”
style indicates a low concern for self and others, the “forcing” style indicates a high concern for self and low concern
for others, the “yielding” style indicates a low concern for
self and high concern for others, and the “compromising”
style indicates an intermediate concern for self and others.
(Fig. 2) This scale has been adopted by many researchers,
and its efficacy as a measure of conflict handling has beenvalidated [19].
At the time of the present study, no scale existed formeasuring the handling of conflict, specifically in populations such as working adults, managers, and nurses; andthe HICI scale was the only instrument developed in Japanthat was capable of grasping the two-dimensional, five-stylemodel, which is why it was selected for use in this study.
In consideration of the study’s objective, the subject term“friend” used to describe the “yielding” style in Question 4of the survey was modified to “other party.” Furthermore,a preliminary survey was conducted with the cooperationof several PHN’s managers and the following descriptions
were modified based on the results. Specifically, the “integrating” style description “reaching a decision of benefit
to both parties,” was changed to “proposing a solution of
benefit to both parties” and “supporting each other’s objectives” was changed to “respecting each other’s intentions.”
The “compromising” style description “asserting that eachparty put their opinions aside” was changed to “attempting
to find a compromise to avoid an impasse.”
The handling of conflicts typically differs depending on
the parties involved and their circumstances. The survey
questions on conflict awareness were therefore worded toelicit a response on “the action and perspective that you
generally tend to adopt.” As in previous studies applying
the HICI scale, responses to scale questions were wordedHigh

Concern for Others

Yielding(Accommodating)●Integrating（Collaborating）●

Forcing(Competing)
●
High

low
Concern for Self

4. Date Analysis
Descriptive statistics were calculated for the respondents’ background characteristics, conflict awareness frequency, conflict handling fraction, and modified HICI.
For the modified HICI, means and standard deviations(SD) were calculated for each subscale, and Cronbach’s alpha was calculated for correlations between the factors andthe overall HICI scale.
The conflict awareness frequency and conflict handlingfraction were referred to as the data variability, mean, andmedian, respectivery, after calculating descriptive statistics.
Based on the results, the frequency of conflict awarenessfrequency was assigned as “high group” for respondents
who recognize conflicts “more than twice per week” and“low group” for those who recognize conflicts less frequently. Respondents who answered “20% or more” wereassigned to the “high group” and those who answered “lessthan 20%” were assigned to the “low group” for the conflicthandling fraction. The association between these factors
and HICI selection was evaluated using the Mann-Whitney
U test.
The associations of PHN’s managers with individual andassigned department factors were evaluated using the chisquared test or Fisher’s exact test.
The analysis of factors related to perceived frequency
of conflicts among PHN’s managers was conducted using
the stepwise method of multiple regression analysis. In theanalysis, basic attributes and conflict handling styles wereused as explanatory variables, while the perceived frequency of conflicts was used as the explained variable.
Survey data were analyzed using the statistical analysis
software IBM SPSS Ver. 25 at a two-sided significance level<5%.

IV. Ethical considerations

Compromising●
Avoiding●

using a four-point Likert scale consisting of “Always:-3,”“Often:-2,” “Sometimes:-1,” and “Never:-0.”
Some studies have described the five categories of conflict styles of conflict as Collaborating instead of Integrating,Competing instead of Forcing, and Accommodating insteadof Yielding [20]. In this study, however, we adopted Kato’s
scale [17] representation.

The cooperation request explained to the participants inwriting the study’s aim, the protection of anonymity, andthe free will of individuals cooperating in the research. This
study was approved by the ethical committee of the National Institute of Public Health, Japan (NIPH-IBRA#12220)

Figure 2 Conflict management style
2 dimensional,5-style model [18]J. Natl. Inst. Public Health, 72 (1) : 2023

65

OKUDA Hiroko, YOKOYAMA Tetsuji, TAKEDA Fumi, SONE Tomofumi

V. Results
1. Demographic (Table 1)
The survey questionnaire form was distributed to 384
PHN’s managers.
A total of 242 questionnaire forms were collected (63%recovery rate), of which 236 forms contained valid respons-es (61.5% valid response rate). Mean years of PHN’s experience and managerial experience was 31.4 ± 4.5 years and
4.3 ± 3.1 years, respectively, and mean proportion of work
consisting of managerial tasks (“managerial work fraction”)
was 70.8 ± 25.4%. In the course of their work, a total of 51
PHN’s managers (21.6%) had experienced a high conflictawareness frequency of “at least several times per week”

Table 1 Summary of descriptive statistics of demographic and background characteristics; comparison by municipality type (n=236)
Government facility (n=236)
Characteristic

Prefecture (n=73)

municipality (n=163)

Mean±SD55.1±3.6

Mean±SD56.9±2.4

Years of PHN experience

31.4±4.533.6±3.330.4±4.6

Years of managerial experience

4.3±3.1

4.0±2.6

4.5±3.3

Years in current position

2.9±2.3

3.2±2.4

2.8±2.2

Managerial work fraction

70.8±25.472.4±20.9

70.0±27.2

No. of previous positions

1.1±0.4

1.0±0

1.1±0.4

No. of close advisors

2.3±1.0

2.2±1.0

2.3±1.0

No. of subordinates

13.4±16.0

10.7±11.4

14.7±17.6

No. of subordinate occupations

3.0±1.2

3.2±1.4

2.9±1.2

No. of non-permanent staff

6.4±10.4

1.9±1.4

8.5±11.9

Age (yr)24.3±18.4

Conflict handling fractionn (%)

54.3±3.724.5±18.0
n (%)

24.2±18.7
n (%)

Training school/vocational college

210(89.0)

66 (90.4)

144 (88.3)

Junior college/Non-degree course

19 (8.1)

5 (6.8)14 (8.6)

Undergraduate

6 (2.5)

1 (1.4)5 (3.1)

Postgraduate

1 (0.4)

1 (1.4)0 (0.0)187 (79.2)

53 (72.6)

134 (82.2)

Junior college/Non-degree course

21 (8.9)6 (8.2)15 (9.2)

Undergraduate

15 (6.4)

5 (6.8)10 (6.1)

Postgraduate

13 (5.5)

9 (12.3)

4 (2.5)Subsection manager

34 (14.4)

8 (11.0)26 (16.0)

Assistant section manager

44 (18.6)

10 (13.7)

34 (20.9)

Section manager

144 (61.0)

53 (72.6)

91 (55.8)

12 (5.1)

1 (1.4)

11 (6.8)No

107 (45.3)

17 (23.3)

90 (55.2)

Yes

128 (54.2)

56 (76.7)

72 (44.2)

Secondary) Model occupation PHN

94 (73.4)

43 (58.9)

51 (31.3)

Administrative

26 (20.3)

9 (12.3)

17 (10.4)

Physician<200,000 ppl

6 (4.7)171 (72.5)

4 (5.5)27 (37.0)

2 (1.2)144 (88.3)≥200,000 ppl

65 (27.5)

46 (63.0)

19 (11.7)

Physician39 (16.5)

35 (47.9)

4 (2.5)Administrative

164 (69.5)

31 (42.5)

133 (81.6)

PHN

16 (6.8)

3 (4.1)13 (8.0)

Other

16 (6.8)

4 (5.5)

12 (7.4)

Low-frequency (≤once/week)

185 (78.4)

55 (75.3)

130 (79.8)

High-frequency (≥twice/week)

51 (21.6)

18 (24.7)

33 (20.2)

Basic education level

Highest qualification

Job position

Training school/vocational college

Department or bureau manager
Role model

Population size
Superior’s occupation

Conflict frequency
Cross-tabulation: Chi-squared test†) Fisher’s exact test

Intergroup means comparison; Mann-Whitney U test***<0.001, **<0.01, *<0.05
Mean±SD: Mean ± Standard deviation; PHN: public health nursing.
Proportions for each characteristic (%) were calculated without imputation ofmissing values.

66

Mean±SD

J. Natl. Inst. Public Health, 72 (1) : 2023

Conflicts among public health nurses managers in Japan: The reality of conflicts and influencing factors(high group). Mean amount of time dedicated to conflicthandling as a proportion (%) of all work (“conflict handlingfraction”) was 24.3 ± 18.4%.

dents, “Attempting to win one’s position (forcing)” in 148(62.7%) respondents, and “Attempting to push throughone’s opinion” in 121 (51.3%) respondents.

2. Selection of conflict handling style (Table 2)
Among the 20 questions on the modified HICI scale, thequestions for which “Always” was the most common response were “Understanding each other’s ideas to achieve
the best outcome (integrating)” in 69 (29.2%) respondents,“Refraining from arguing as much as possible (Avoiding)”
in 63 (26.7%) respondents, and “Respecting each other’s
intentions (Integrating)” in 48 (20.3%) respondents.
On the other hand, the questions for which more thanhalf of the respondents selected “Never” were “Doing as
the other party wishes (yielding)” in 160 (67.8%) respon-

3. Results of descriptive statistics on selection of conflict-handling style (Table 3)
The scale used in this study was a modified version of
the HICI scale, with some of its expressions. The factor
structure of the scale was similar to the results of a scale
developer’s study [19], and we confirmed that there was noeffect of modifying some linguistic expressions of the scale.
Next, we calculated the mean, SD, internal consistency, andinter-factor correlations for each of the five style subscales,
as in existing studies.
As a result, inter-factor correlations were of r=0.10 toTable 2 Results and simple summary of modified HICI scale responses (n=236)
Q

Style

1

Compromising

2

Yielding

3

Compromising

4
5

Never

QuestionnSometimes

%

n

%

Often

n

Attempting to find common ground of each opinion

10

4.2

117

49.6

Acquiescing to the other party’s demands

62

26.3

144

Attempting to find a compromise to avoid an impasse

6

2.5

76

Yielding

Accommodating the other party’s intentions

29

12.3

Forcing

Trialing various methods to push through one’s opinion

43

18.2

6

Integrating

Reaching a decision to benefit both parties

2

0.8

7

Integrating

Attempting to find a mutually-satisfactory conclusion

8

Avoiding

Attempting to avoid a difference of opinions

9

Integrating

10
11
12

Compromising

Attempting to find points of mutual compromise

5

13

Forcing

Seeking an outcome beneficial to one’s self

95

14

Forcing

Attempting to win one’s position

148

15

Compromising

6

16

Avoiding

Attempting to avoid a clash of opinions with the other party

28

11.9

17

Yielding

Doing as the other party wishes

160

67.8

18

Yielding

Recognizing the other party’s opinion

3

1.3

66

19

Avoiding

Attempting to avoid confrontation

Always

%

n

%

94

39.8

15

6.4

61.0

29

12.3

1

0.4

32.2

127

53.8

27

11.4

134

56.8

71

30.1

2

0.8

116

49.2

67

28.4

10

4.2

45

19.1

148

62.7

41

17.4
17.4

4

1.7

52

22.0

139

58.9

41

114

48.3

92

39.0

25

10.6

5

2.1

Respecting each other’s intentions

3

1.3

38

16.1

147

62.3

48

20.3

Integrating

Understanding each other’s ideas to achieve the best outcome

0

0.0

32

13.6

135

57.2

69

29.2

Avoiding

Refraining from arguing as much as possible

9

3.8

52

22.0

112

47.5

63

26.7

2.1

53

22.5

134

56.8

44

18.6

40.3

114

48.3

24

10.2

3

1.3

62.7

78

33.1

8

3.4

2

0.8

2.5

67

28.4

133

56.4

30

12.7

82

34.7

93

39.4

33

14.0

68

28.8

6

2.5

2

8.0

28.0

139

58.9

28

11.9

Attempting to agree on compromized common ground

Attempting to push through one’s opinion
Forcing
Underline: HICI scale modifications
20

8

3.4

42

17.8

141

59.7

45

19.1

121

51.3

107

45.3

5

2.1

3

1.3

Table 3 Modified HICI scale descriptive statistics; inter-factor correlations
Integrating
Integrating

Forcing

Yielding

Avoiding

Compromising

1.00

Forcing

0.15*

1.00

Yielding

0.22**

0.10

1.00

Avoiding

0.26**

0.10

0.50**

1.00

Compromising

0.54**

0.22**

0.39**

0.33**

1.00

Mean

SD

Alpha

8.06

2.06

0.59

2.87

1.93

0.69

4.24

1.61

0.59

6.14

2.23

0.60

6.94

1.90

0.58

HICI scale; four questions per subscale, four-point Likert scale from 0 to 3 (total score out of 12)
Mean=Average score; SD=Standard deviation; Alpha=coefficient**<0.01, *<0.05

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OKUDA Hiroko, YOKOYAMA Tetsuji, TAKEDA Fumi, SONE Tomofumi
r=0.54 and the alpha coefficient of each subscale was between 0.58 and 0.69, while Cronbach’s alpha coefficient for
the entire scale was 0.70.
In a previous study by the developer of this scale, it waspointed out that there were problems with the discriminant
validity of the “integrating” style and “compromising”
styles, and the “avoiding” and “yielding” styles.
In the results of this study, the overall supervisory coefficients for the “integrating” and “compromising” styles, andthe “avoiding” and “yielding” styles were r = 0.54 and 0.50,
respectively; which were similar the highest correlation
coefficient between conflict-handling.
The aggregate results for each scale in this survey
showed that the conflict-handling with the most responses was “integrating” style, followed by “compromising,”“avoiding,” “yielding,” and then “forcing.”

teristics of PHN’s managers and their selection of conflicthandling style, no significant differences were seen for anyof the “integrating” or “avoiding” questions.
The “forcing” style of handling conflict was selectedby a significantly higher proportion of respondents in thehigh-frequency conflict awareness group than those in the
low-frequency conflict awareness group (p<0.01).
The relationship between the background characteristicsof PHN’s managers and their choice of the “compromising”
style of conflict coping was examined. The results showed
that, as with the “forced” style of conflict coping, respondents in the high conflict awareness group were significantly more likely to choose this style than respondents in the
low conflict awareness group (p<0.05).
Among the organizational factors, a significantly higher
proportion of PHN’s managers working in government witha population of ≥200,000 people selected the “compromising” style than those working in the government with apopulation of <200,000 people (p<0.05).
Upon examining the relationship between the background

4. Investigation of factors related to selection of conflict handling style (Table 4)
In terms of the relationship between background charac-

Table 4 Relation between respondent background characteristics & selection of conflict handling style (n=236)
SubtotalItemnIntegrating

%

Mean

SD

Forcingp -value

Mean

SD

Compromising
p -valueMeanSD

p -value

Yielding
Mean

SD

Avoiding
p -valueMeanSD

p -value

Demographic & background characteristics
Age (yr)
Years of PHN experience
Years of managerial experience
Managerial work fraction
Basic education level
Highest qualification
Previous work history
Job position
Role model
Model occupation
Close advisor
Conflict frequency

Conflict handling fraction

≤55

111

47.0

8.08

2.04

≥56

125

53.0

8.04

2.10

≤30

82

34.7

8.05

1.80

≥31

154

65.3

8.06

2.20

<5

114

48.3

7.99

2.05

≥5

122

51.7

8.12

2.09

<80%

81

34.3

7.90

1.92

80% or above

155

65.7

8.14

2.14

Training school/junior college

235

99.6

8.04

2.05

Undergraduate/Postgraduate

1

0.4

12.00

.

Training school/junior college

223

94.5

8.01

2.04

Undergraduate/Postgraduate

13

5.5

8.85

2.41

Yes

63

26.7

8.16

2.29

No

173

73.3

8.16

2.29

<Section chief

78

33.1

8.02

1.98

≥Section chief

158

66.9

8.07

2.09

Yes

128

54.2

8.27

1.89

No

107

45.3

7.81

1.89

PHN

94

39.8

8.26

2.19

Other occupation

142

60.2

7.93

2.01

Yes

205

86.9

8.08

2.10

No

30

12.7

7.83

1.86

Low group: ≤once/week

185

78.4

7.98

2.06

High group: ≥twice/week

51

21.6

8.33

2.09

Low group: <20%

133

56.4

7.96

2.08

High group: ≥20%

99

41.9

8.17

2.03

0.624
0.952
0.625
0.396
0.056
0.158
0.656
0.913
0.091
0.236
0.537
0.285
0.445

2.82

1.87

2.91

1.98

2.80

1.79

2.90

2.00

2.78

1.95

2.95

1.91

2.62

1.59

3.00

2.07

2.86

1.93

5.00

.

2.83

1.86

3.46

2.90

2.84

1.73

2.88

2.00

2.62

1.75

2.99

2.00

3.03

1.92

2.65

1.93

0.715
0.712
0.499
0.117
0.269
0.255
0.896
0.157
0.135

7.03

1.93

6.86

1.88

6.78

1.74

7.02

7.98

6.97

1.88

6.90

1.93

6.86

1.88

6.97

1.91

6.93

1.90

9.00

.

6.95

1.90

6.77

1.96

6.94

2.09

6.94

1.83

7.09

1.97

6.86

1.87

7.13

1.84

6.70

1.95

3.31

1.91 0.004**

7.17

1.84

2.58

1.89

6.78

1.93

2.92

1.93

2.53

1.91

0.304

6.95

1.92

6.77

1.72

2.58

1.87 0.002**

6.75

1.78

3.40

1.93

7.28

2.07

6.76

1.94

7.22

1.82

2.79

1.88

3.04

1.98

0.326

0.491
0.359
0.772
0.674
0.277
0.745
1.000
0.385
0.089
0.124
0.628
0.042*
0.066

4.39

1.67

4.11

1.55

4.33

1.70

4.19

1.56

4.40

1.72

4.09

1.49

4.27

1.64

4.23

1.60

4.23

1.61

6.00

.

4.25

1.62

4.15

1.41

4.38

1.63

4.19

1.60

0.190
0.542
0.137
0.836
0.275
0.840
0.423

6.24

2.33

6.04

2.14

6.24

2.26

6.08

2.22

6.29

2.39

5.99

2.06

6.00

2.31

6.21

2.19

6.12

2.23

9.00

.

6.17

2.20

5.62

2.69

6.44

2.01

6.02

2.30

4.56

1.69 0.030*

6.21

2.05

4.08

1.55

6.10

2.32

4.45

1.61 0.031*

6.36

2.14

3.99

1.59

5.89

2.32

4.32

1.57

4.19

1.64

4.29

1.59

3.90

1.77

4.16

1.58

4.40

1.66

4.18

1.61

4.33

1.57

0.543
0.219

0.486
0.587
0.306
0.501
0.198
0.388
0.200
0.737
0.107

6.13

2.53

6.14

2.21

0.984

6.17

2.18

0.446

6.08

2.29

0.594

6.24

2.12

2.56
0.274
0.470

6.15

2.13

6.19

2.34

0.888

Organizational factors
Government facility
Population size
Superior’s occupation
No. of subordinates
Total no. of subordinate occupations
No. of non-permanent staff

Prefecture

73

30.9

8.34

2.17

municipality

163

69.1

7.93

2.01

<200,000 ppl

171

72.5

7.96

2.07

≥200,000 ppl

65

27.5

8.32

2.05

PHN

16

6.8

8.19

1.80

Other occupation

220

93.2

8.05

2.09

≤10

122

51.7

8.02

2.00

≥11

114

48.3

8.11

2.14

<3

168

71.2

8.08

2.05

≥3

64

27.1

8.06

2.14

≤3

108

45.8

8.12

2.01

≥4

102

43.2

8.09

2.03

0.159
0.227
0.798
0.742
0.946
0.908

2.99

2.04

2.82

1.88

2.72

1.90

3.26

1.95

3.25

2.08

2.84

1.92

2.67

1.90

3.08

1.94

2.68

1.84

3.34

2.10

2.66

1.84

3.27

2.01

0.531
0.053
0.414
0.105
0.019*
0.021*

7.45

1.86 0.005**

4.23

1.53

6.71

1.88

4.25

1.65

4.26

1.64

4.20

1.54

3.50

1.37

4.30

1.62

4.24

1.71

4.25

1.51

6.67

1.93

7.40

1.76

7.31

2.18

6.91

1.88

6.92

1.90

6.96

1.91

6.85

1.92

7.17

1.87

7.09

1.83

6.79

1.86

Mann-Whitney U test

Mean=Average value; SD=Standard deviation; PHN: public health nursing.
***<0.001,**<0.01,＊<0.05

Proportions for each characteristic (%) were calculated without imputation of missing values.

68

J. Natl. Inst. Public Health, 72 (1) : 2023

0.020*
0.413
0.878
0.253
0.243

4.20

1.55

7.36

1.75

4.31

1.63

4.22

1.62

0.956
0.808
0.056
0.970
0.507
0.659

6.14

2.12

6.13

2.28

6.14

2.22

6.12

2.26

6.13

2.53

6.14

2.21

6.07

2.39

6.21

2.05

6.17

2.17

6.00

2.30

6.10

2.11

6.18

2.31

0.995
0.958
0.984
0.619
0.594
0.807

Conflicts among public health nurses managers in Japan: The reality of conflicts and influencing factors
characteristics of PHN’s managers and their selection of
the “yielding” style of handling conflict, a significantly higher proportion of those occupying a lower position selected
this style than those with a section manager or higher job
position (p<0.05).

cy and conflict processing time as a percentage of total work(“conflict handling fraction”), we referred to data variability,
mean, and median values.
On the basis of these results, we assigned respondents
whose conflict awareness frequency was once a week orless and those whose conflict handling ratio was 20% orless to the “low group.” Those whose conflict awarenessfrequency was twice a week or more and those with a conflict handling ratio of 20% or more were assigned to the“high group.”

5. Investigation of factors affecting conflict awarenessfrequency and conflict handling fraction(1) Single correlation results (Table 5)
To identify factors related to conflict awareness frequen-

Table 5 Relation between respondent background characteristics & conflict awareness frequency and conflicthandling fraction (n=236)
Conflict awareness frequency

Item

Low group(n=185)High group(n=51)

n

n

n

%

%

%

p -value

≤55

111

47.0

91

49.2

≥56

125

53.0

94

50.8

20

39.2

0.206

31

60.8

≤30

82

34.7

66

≥31

154

65.3

119

35.7

16

31.4

64.3

35

68.6

Conflict handling fraction
Low group(n=133)High group(n=99)nn%%

p -value

Individual PHN factors
Age (yr)
Years of PHN experience
Years of managerial experience
Managerial work fraction
Basic education level
Highest qualification
Previous work history
Job position
Role model
Model occupation
Close advisor

<5

114

48.3

91

49.2

23

45.1

≥5

122

51.7

94

50.8

28

54.9

0.568
0.605
0.867

63

47.4

44

44.4

70

52.6

55

55.6

49

36.8

30

30.3

84

63.2

69

69.7

71

53.4

41

41.4

62

46.6

58

58.6

<80%

81

34.3

64

34.6

17

33.3

53

39.8

26

26.3

80% or above

155

65.7

121

65.4

34

66.7

80

60.2

73

73.7

Training school/junior college

235

99.6

185 100.0

50

98.0 0.216 1)
2.0

133 100.0

98

99.0

0

0.0

1

1.0

124

93.2

95

96.0

9

6.8

4

4.0

Undergraduate/Postgraduate

1

0.4

0

0.0

1

Training school/junior college

223

94.5

176

95.1

47

Undergraduate/Postgraduate

13

5.5

9

4.9

4

92.2 0.486 1)
7.8

Yes

63

26.7

47

25.4

16

31.4

No

173

73.3

138

74.6

35

68.6

<Section chief

78

33.1

63

34.1

15

29.4

≥Section chief

158

66.9

122

65.9

36

70.6

Yes

128

54.2

99

53.5

29

56.9

No

107

45.3

85

45.9

22

43.1

0.394
0.533
0.698
0.586

44

33.1

19

19.2

89

66.9

80

80.8

51

38.3

26

26.3

82

61.7

73

73.7

68

51.1

58

58.6

64

48.1

41

41.4

PHN

94

39.8

72

38.9

22

43.1

51

38.3

41

41.4

Other occupation

142

60.2

113

61.1

29

56.9

82

61.7

58

58.6

Yes

205

86.9

165

89.2

40

78.4 0.033*

120

90.2

81

81.8

No

30

12.7

19

10.3

11

21.6

12

9.0

18

18.2

0.691
0.329
0.084
0.036*
0.427 †)
0.565 †)
0.025*
0.067
0.350
0.685
0.042*

Organizational factors
Government facility
Population size
Superior’s occupation
No. of subordinates
No. of subordinate occupations
No. of non-permanent staff

Prefecture

73

30.9

55

29.7

18

35.3

37

27.8

36

36.4

municipality

163

69.1

130

70.3

33

64.7

0.447

96

72.2

63

63.6

<200,000 ppl

171

72.5

141

76.2

30

58.8 0.014*

106

79.7

61

61.6

≥200,000 ppl

65

27.5

44

23.8

21

41.2

27

20.3

38

38.4

PHN

16

6.8

8

4.3

4

7.8

220

93.2

173

93.5

47

92.2

≤10

122

51.7

103

55.7

19

37.3 0.020*

79

59.4

40

40.4 0.004**

≥11

114

48.3

82

44.3

32

62.7

54

40.6

59

59.6

<3

168

71.2

137

74.1

31

60.8

64

27.1

45

24.3

19

37.3

≤3

108

45.8

85

45.9

23

45.1

≥4

102

43.2

76

41.1

26

51.0

0.063
0.473

7

5.3

9

9.1

126

94.7

90

90.9

0.021*

Other occupation

≥3

0.733

0.199

96

72.2

69

69.7

36

27.1

27

27.3

57

42.9

49

49.5

56

42.1

44

44.4

0.325

0.882
0.781

*p<0.05, **p<0.01
Chi-squared test†) Fisher’s exact test

Proportions for each characteristic (%) were calculated without imputation of missing values.

J. Natl. Inst. Public Health, 72 (1) : 2023

69

OKUDA Hiroko, YOKOYAMA Tetsuji, TAKEDA Fumi, SONE Tomofumi

VI. Discussion

We then examined the relationship between each of thesegroups and the PHN’s personal and organizational factors.
The results showed that conflict awareness frequency
differed significantly according to the background characteristics of whether or not the PHN’s managers had a close
advisor (Y/N) (p<0.05), the organizational factors of population size (p<0.05), and number of subordinates (p<0.05).
Furthermore, in addition to the above three variables(presence of a close advisor (Y/N) (p<0.05), organizational
factors of population size (p<0.05), and number of subordinates (p<0.01)), the background characteristics of thepercentage of managers and respondents’ job experience (Y/N) significantly affected the conflict handling ratio. (p<0.05)(2) Results of multiple regression analysis (Table 6)
To investigate the factors affecting the frequency ofperceived conflicts among PHN’s managers, a multiple regression analysis using the stepwise method was conductedwith the dependent variable as the frequency of perceived
conflicts and the explanatory variables as background characteristics and conflict-handling styles.
In consideration of multicollinearity through correlation
analysis among the explanatory variables, four items were
removed from this study: years of experience as a healthworker, years of experience in the current position, numberof subordinates, and percentage of conflicts handled.
As shown in Table 6, the results of the multiple regression analysis showed a positive association with managerial
work fraction. On the other hand, there was a negative association with “number of subordinate occupations,” “integrating” of conflict-handling styles,” “superior’s occupation(dummy variables: PHN’s =0, others=1,” and “population
size (dummy variables: <200,000 ppl=0, ≥200,000 ppl=1)”(adjusted R2=0.397, p<0.001).

1. Characteristics related to selection of conflict-handling style
Although this study is limited in its ability to make simple comparisons because there are no studies on conflicts
targeting PHN’s, we would like to focus on previous studies
from other countries on nursing managers because of theircommonality as both managers and nurses.
The results of this study revealed that Japanese PHN’s
managers most frequently selected the “integrating” styleas their conflict management style, followed by “compromising,” “avoiding,” “yielding,” and “forcing“ . Amongthese five styles, “integrating” is said to be the style expected to create the most desirable interrelationships [21].
In a study aimed at examining the conflict management
styles of nursing managers working in Jordanian hospitals[22], the “integrating” style was chosen most often and the“forcing” style least often, supporting the results of thisstudy. In addition, a study of nurse managers working in
hospitals in other countries [23,24]also found that the “integrating” style was most commonly selected. Furthermore,this study reported that managers with diplomatic andconscientious personality traits selected the “integrating”
style, while emotionally inconsistent managers selected the“avoiding” style. While both studies are similar in that the“integrating” style was the most frequently selected, theorder of responses for the other conflict management skills
is not entirely consistent.
On the other hand, in a survey of nursing managers
working in Portuguese hospitals [25], the “forcing” style(original: force strategies) was the most common, while the“integrating” style (original: cooperative strategies) wasparadoxically limited to once a month. Furthermore, 60%of the nursing managers in the survey indicated that they

Table 6 Association with conflict perception (Multiple-linear Regression: stepwise method)
non-standardization（B）(constant)collinearity

95％CI for B

partial regression coefficient
Independent Variables

β

8.483

p-valuelower limit

upper limit<0.001

5.782

11.184

tolerance level

VIF

Number of subordinate occupations-0.463-0.4690.001***-0.725-0.201

0.909

1.100

Conflict handling style: integrating
Superior’s occupation-0.206-0.4080.003**-0.336-0.075

0.956

1.046

（0＝PHN，1=others）-2.820-0.3730.007**-4.818-0.823

0.915

1.093

Managerial work fraction

0.015

0.308

0.023*

0.002

0.027

0.919

1,088

-0.745-0.3010.025＊‐1.390‐0.100

0.94

1.064

Population size

（0＝<200,000 ppl ，1=≥200,000 ppl ）２2

coefficient of determination R (ajusted R )F(5，34)0.475 (0.397)

６.140＊＊＊

dependent variables: conflict awareness frequency
Deleted Variables:age, yearsof managerial experience,no. of previous positions, No. of close advisors, No. of non-permanent staff,basic education level, goverment facility,
model, supervisor job title, municipality type, job position,, conflict handling style forcing,compromising,yielding and avoidance＊<0.05.

70**<0.01. ***<0.001

J. Natl. Inst. Public Health, 72 (1) : 2023

Conflicts among public health nurses managers in Japan: The reality of conflicts and influencing factors
have to deal with conflicts on a daily basis. Therefore, while
recognizing the importance of dialogue, they tend to act
compulsively in their daily work.
In the case of Japanese PHN’s managers, the survey results revealed that those who were more frequently awareof conflicts were significantly more likely to choose the“forcing” style (P<0.01). This result can be interpreted
as suggesting that managerial nurses who are frequently
aware of conflicts have difficulty dealing with them according to the conflict style they consider desirable. Rahim [6]found that the “forcing” style (original; dominating) is more
likely to be used when the issues involved in the conflictare minor or important to you, but is inappropriate when aquick decision is not required, he argues. It has been suggested that improved skills in effectively dealing with conflicts may lead to a reduction in perceived frequency.
On the other hand, the relationship between conflict-handling style and job position also revealed that section managers and below were more likely to choose the “yielding”
style than section managers and above. This result is
consistent with a previous study of nurses working in a
Mississippi hospital [8], suggesting that the power balanceassociated with position and years of experience may also
influence the choice of conflict-handling style.
In this study, for PHN’s managers, only women wereanalyzed, but prior research has shown that men tend tochoose the “forcing” (original; competing) type more than
women [26].
As of March 2020, the male-to-female ratio of publichealth nurses in Japan was only about 3% of all public healthnurses [27]. Although the number of male PHN has been
increasing every year in recent years, it will be some time
before a certain number of PHN’s in management positions
are appointed; it will be necessary to include gender differences in future studies. It is believed that nursing managers
will be able to support themselves and others by appropriately handling conflicts [28]. In the future, there is a need tofurther examine the relationship between personality traits,working conditions, various other factors, and conflict-handling styles.
2. Perceptions of conflicts and influencing factors in
PHN’s managers
Approximately 20% of PHN’s managers were aware ofconflicts occurring at least twice per week in the course of
performing their duties. And they spent approximately 25%of their work time to resolve the conflicts they recognized.
In addition, the results of the examination of factors affecting the perception of conflicts showed that “number of job
titles of subordinates,” “”integration” of conflict-handlingstyles,” “position of supervisor “ and “population size”

were negatively correlated. European and U.S. nursing
managers devote approximately 20% of their work time todealing with conflicts [29]. Therefore, the conflict-handlingrate of Japanese PHN’s managers is higher than that ofWestern nurse managers.
In general, in hospitals, nurses comprise the majority ofthe organization. However, within municipal organizations,the most common occupations are administrative staff,
and PHNs are in the minority. In the results of the present
survey, approximately 70% of the supervisors of PHN’s
managers were administrative staff. In the results of a previous survey conducted by the authors, the most common
job title that perceived conflicts in PHN’s managers wasadministrative staff [16]. A study focusing on the dilemmaof staff PHNs in Japanese local governments showed differences, with administrative staff being more concerned withproject procedures and PHN’s more concerned with projectcontent [30]. This highlight the need to share the purposeand effectiveness of a project. Therefore, for PHN’s managers to effectively deal with conflicts with administrative
staff, it would be beneficial for them to intentionally develop
skills in dealing with conflicts that arise with administrative
staff through their daily work, beginning when they are staff
public health nurses.
On the other hand, the results of the analysis of factors
affecting the perception of conflict showed a negative correlation with the “number of subordinate positions” and“population size.” Generaly, the size of a municipality’s
population is proportional to the size of its organization.
Therefore, it was assumed that the larger the size of themunicipality in which the PHN’s managers work, the greater the opportunity to recognize conflicts with various third
parties inside and outside the organization, and the greater
the recognition of conflicts, the more proportional it would
be. However, the results obtained in this study were different. One possible reason for this may be that, in general,
amicable work environments tend to have fewer interpersonal conflicts and are better able to fulfill their roles [31].
In other words, it is possible that the work environmentand organizational climate, rather than simply the variety
of job types or the number of people in the organization,
may influenc the perception of conflicts. Alternatively, if theorganizational size of the managerial health professional’s
work environment is large, and if there are many types ofsubordinate positions under his/her supervision, the environment can be paraphrased as a human environment inwhich they can demonstrate the wealth of skills and knowledge necessary to carry out organizational goals.
Therefore, the presence of a diverse professional workforce was considered to indicate a beneficial environment
for management health professionals.

J. Natl. Inst. Public Health, 72 (1) : 2023

71

OKUDA Hiroko, YOKOYAMA Tetsuji, TAKEDA Fumi, SONE Tomofumi
Furthermore, as mentioned in the introduction, owing to
the recent increase in the complexity of community healthissues in Japan, the organizational structure centered on
public health centers is staffed by a diverse range of professions [32]. In a survey of public health nurses regarding
their recognition of the importance of health activities[33], more than 80% of public health nurses recognized theimportance of coordinating their organizations, and gained
experience in working with multiple professions throughdaily activities. It was assumed that this background ofcommunity health administration and the results of publichealth nurses’ activities to date had an impact on the levelof recognition of conflicts.

VII. Research limitations and future directions
Since most of the interpretation of the results of thisstudy is based on previous studies of nurses working in
hospitals in other countries, there may be limitations to thepresenting of characteristics of PHN’s managers working inJapanese municipalities. In addition, it has been noted thatstudies conducted in other countries have also observed
various contradictory results when demographic variables
are taken into account [34], and one should be cautious
about making simple comparisons with other cultures.
In addition, there have been no studies of conflicts targeting PHN, which may have led to differences in the understanding of the term “conflicts” among the collaborators of
this study. Furthermore, the individual responses regarding
the ratio of conflict awareness to conflict-handling styles
depended on subjective evaluations, which may have been
influenced by recall bias, which limits our ability to say thatthe results of this study are representative of the actual situation.
In the future, it is expected that the results of this study
will be used as a basis for the development of a scale thatreflects the actual situation of conflicts among PHN’s
managers, and for implementation research to clarify the
relationship between conflict-handling styles and their effects on management work. In addition, further exploration
through comparisons and development into a survey of theactual situation of conflicts among health workers overseas
is desirable.

VIII. Conclusion
About 20% of PHN’s managers frequently perceived conflicts in their job performance and 1/4 of their workload wasin dealing with them.
Of the five handling styles for conflicts, the choice of“integrating” style, which is considered a win-win for both72

parties involved in the differences, was the most common.
However, PHN’s managers, who frequently perceived
conflicts were negatively associated with the “integrating”
style choice. The results suggest that improving skills in
dealing with differences in views of diverse stakeholders,even before becoming managers, may help PHN’s managers, perform their managerial duties.

Acknowledgements
We thank the PHN’s managers for their cooperation inthis study.
This study was presented at the 8th Annual Japanese
Conference on Public Health Nursing (2020.01). This study
was based on a doctoral dissertation at the Graduate Schoolof Comprehensive Human Sciences, University of Tsukuba,with additions and modifications.

Conflicts of interest
No conflicts of interest.

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Conflicts among public health nurses managers in Japan: The reality of conflicts and influencing factors＜原著＞
管理職保健師のコンフリクトの実態―コンフリクトの現状と影響を及ぼす要因―
奥田博子 1），横山徹爾 1），武田文 2），曽根智史 1）
1）

国立保健医療科学院

2）

筑波大学大学院人間総合科学研究科

抄録
研究目的：本研究は，地域保健行政に従事する管理職保健師が，管理職としての職務遂行上に認知するコンフリクトの実態と，その要因を明らかにすることを目的とした．
研究方法：層化無作為抽出により選定した14都道府県下，384名の管理職保健師を対象に，自記式質問紙調査票を用いた郵送調査を実施した．主な調査内容は，基本属性，管理職の職務遂行上において認知するコンフリクトの実態，対処スタイルであった．分析方法は，記述統計，平均の差の検定，コン
フリクトの認知頻度を従属変数，回答者の基本属性，コンフリクトの対処スタイルを説明変数とした重回帰分析（ステップワイズ法）を行った．統計解析にはSPSS Ver.25を使用し，両側検定5％を有意水準とした．
結果：回答数（率）は242（63.0％），有効回答数（率）は223（61.5％）であった．コンフリクトの認知頻度が高いと回答した者は51（21.6％）であった．全業務量に比し，コンフリクトへの対処のために要する時間の割合は平均24.3％であった．コンフリクトの対処スタイルは「お互いの考えを理解す
る”統合”」が69（29.2％）と最も多く，次いで「議論を回避する”回避”」63（26.7％），「お互いの目的を尊重する”統合”」48（20.3％）であった．重回帰分析を用いて，コンフリクトの認知頻度に影響を与える要因を検討した．その結果，管理職の業務割合との間に正の関連，部下の職種の数，対処スタ
イルの“統合”，上司の職種，人口規模の間に負の関連が認められた．
結論：管理職保健師の約 2 割が職務遂行上のコンフリクトを頻繁に認知し，その対処のために全業務量の1/4の時間を費やしていた．コンフリクトの対処スタイルの”統合”は，双方が満足する解決策を導く望ましい方法とされている．管理職保健師が，望ましい対処スタイルを選択することが，職務遂行上の一助となる可能性が示唆された．
キーワード：保健師，管理職，職務コンフリクト，対処スタイル

J. Natl. Inst. Public Health, 72 (1) : 2023

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