Explaining of Nurses’ Perception of Professional Relationship in the Coronary Care Unit (CCU)

Introduction: Considering that patients in the special units have critical conditions and require the best possible specialized care, having appropriate professional relationship in these units is of great importance. Taking care of patients under critical conditions requires occupational safety and sense of satisfaction in the nurses. Indeed, nursing managers should provide an appropriate organizational environment with emphasis on establishing an effective relationship.
Aim and objective: Explaining nurses’ perception of professional relationship in the coronary care unit.
Materials and methods: The present study was a qualitative study conducted through conventional content analysis method. The participants were 37 nurses working in the coronary care unit who were selected purposively. Data were gathered through 25 in-depth interviews and 3 focus groups
Results: After analyzing the data, the main theme of “ineffective relationship between the senior managers, head nurses, and the personnel of the coronary care unit” and two subthemes of “ineffective relationship between the head nurse and the personnel and “ineffective organizational environment” were extracted.
Conclusions: The results of the present study provided an image of real experiences of participating nurses about the relationships that exist between different levels of nursing profession. so, by establishing a professional relationship in the coronary care unit, specialized cares would be performed. The main theme obtained in the study, “ineffective relationship between the managers, head nurses, and personnel of the coronary care unit” suggested different aspects of the outcomes of ineffective relationship between nurses, head nurses, and nursing managers. Therefore, it is necessary that professional relationships be improved at different levels of nursing and emphasized seriously.


INTRODUCTION
Coronary care unit was developed in 1960 to prevent the death of patients following myocardial infarction which has reduced 15 to 20% of the deaths. However, since then, CCU has changed from the unit to care for the irregularities after myocardial infarction to treating patients with balloon pump, temporary pace, and chronic cardiovascular diseases as well as providing care after performing angioplasty to remove the arterial sheath (1).
Nurses are faced with various challenges in providing specialized care for the patients (2). During the recent years, moral distresses, obligations, and occupational responsibilities of the nurses at difficult situations in the specialized care unit have been studied with the results indicating that nurses of the specialized care units require support at difficult situations (3). Establishing professional and specialized relationship is one of the essential aspects of providing care in the CCU which requires a collaborative approach and should be respected by all the members of the unit (4). In this regard, Wujtewics et al. (2015) stated that most of the conflicts in CCUs would usually be observed between nursing groups and physicians which are related to dissatisfaction with the received information, inappropriate communicational methods, and inappropriate treatment methods for the patients (5).
On the other hand, establishing professional relationship is considered as one of the competences of nursing managers (6). Furthermore, studies have suggested that professional relationship between nursing managers and nurses is associated with their job satisfaction (7,8). In this regard in the national online survey for the nurses, they reported receiving respect from their superiors as weak, where 1/5 to ¼ of them reported experiencing violence as well as verbal and physical abuse and half of the participants at least once intended to leave their job (9).
Considering that over the last decade, improving the quality and safety has become one of the priorities of hospitals all around the world, professional relationship between the members of the care team is one of the important and reliable indices for patient care (10), and it potentially would affect patient's safety (11). The study of Rabøl et al (2011) showed that the reason for more than half of the incidences is rooted in inappropriate verbal communication between the personnel (12). Also, the evidence and studies have suggested that promoting relationships and cooperation in CCUs would improve the quality of care, safety, and positive outcomes in the patients (10).
Unprofessional relationships in the CCU have led to various challenges including role conflict and lack of team work, lack of cooperation between nurses (13), willingness to change their working unit (14), unwillingness to perform team work, dissatisfaction (15), occupational burnout, and decreased safety of the patient (16).
What matters in CCUs is establishing professional and specialized relationship. Indeed, relationship is the heart of high-quality care. Considering that patients are under critical conditions in the CCU and require immediate specialized cares, it must be realized that taking care of the patients in critical conditions requires occupational safety and satisfaction of the personnel. The role of the nursing managers is to provide a healthy work atmosphere and create a team collaboration environment through coordinating the team members with emphasis on establishing a professional and specialized relationship. Furthermore, by establishing a professional and specialized relationship with the patients and their families, the nurses could improve the quality of care and reduce the rate of re-hospitalization of the patients, while also decreasing the patients' anxiety.
Recently, CCUs have changed into combined units; these units house CCU and cardiology, CCU and daily procedures unit, and other derivatives of the CCUs. Important factors including advancements in the medical treatments such as angioplasty, defibrillator insertion, and new valve interventions for the elderly as well as shortened duration of patients' hospitalization have contributed to these changes. All of these matters have created new stressors for the nursing personnel of CCUs who should provide specialized cares (17). So, to provide specialized care for critically ill patients, the nurses of the CCU would face various challenges at the workplace. One of the current challenges in the Iranian hospitals is shortage of nursing staff for providing care for the cardiovascular patients. According to the standards, the ratio of nurses to patients in CCUs of England is at least one nurse for every two patients; in America it is 1.29 nurses for every 3.8 patients (18). However, in the CCUs of Iran, the unit's nurse is in charge of 3-4 cardiovascular patients; in some cases, despite the presence of an intubated patient or a patient with critical condition, no changes have been made in the number of the nursing personnel of the working shift.
On the other hand, providing a safe environment would cause mental and physical comfort for the nurses and would facilitate communication skills and create the basis for professional and specialized relationships (19). The study of Vermeir et al (2018) revealed a significant association between relationships and nurses' job satisfaction plus less willingness to transfer and occupation burnout (20). So, healthy work environments would enable the nurses to reinforce the desirable outcomes of the patients and improve professional achievement. In these environments, positive relationships would be formed and the needs and cooperation of all the members would be respected. So, the situation of the nurses' workplace has the maximal impact on the quality and quantity of the relationships (21). In Iran, due to the heavy workload and shortage in nursing staff, the nursing managers of CCUs would not pay enough attention to providing a healthy workplace and increasing nurses' motivation, and there have been even reports about neglecting the nurses.
Pross (2010) in their study stated that creating a healthy workplace requires strong nursing leadership at organizational levels especially in the fields of care and levels of units (22). Therefore, it is expected from the nursing managers to provide a positive workplace for the nurses and fulfill their job satisfaction and to achieve professional improvement. They should empower the personnel and consequently, increase their commitment for improving the quality of care provided for the patients (23).
The basis for an effective relationship between the manger and the staff is trust; however, recently, a report suggested that nurses had different feelings toward the nature of trust or felt lack of trust in the relationships. This would lead to weak relationships and potential failure in effective team relationships (24).
Note that effective relationships could prevent the conflicts in interpersonal relationships, centralization of the decisionmaking processes, and distortion of the information flow (25). Indeed, mutual cooperation based on trust and respect is a must.
If the managers would interact with the personnel and improve their valuable feelings and support the team to achieve success, their personnel would help each other in providing care and a positive attitude would be created toward the organization, eventually making them more productive (26).
The relationship between the members of the health team has an essential role; a study showed that when the relationship between the team members is weak, it would threaten the patient's care and could cause irreparable complications (27). In other words, effective relationship and team work could improve the patient's care and safety, while weak relationship would cause negative outcomes and discontinued cares (28).
Studies have suggested that unprofessional relationship at all hierarchical levels of nursing, both horizontally and vertically, has extended from the nurses who are directly in charge of taking care of the patients to the nursing managers who supervise the nursing personnel and manage the nursing units (29,30). Also, nurse-to-nurse aggressive behavior could be observed at all professional levels (31).
Unfortunately, weak relationship and team work have been observed as evidence in CCUs indicating inconsistency in collaboration with each other (13).
Considering these points, evaluation of the challenges ahead of professional relationship in the care team is necessary. The controversies that exist in CCUs are a complicated issue, since the involvements would mostly occur in the CCU and they are inevitable which could cause positive changes, innovations, and advancements. However, the existing conflicts in the specialized units have negative effects on the patients, the integrity of the team, which could lead to occupational burnout. So, the skills of establishing effective relationships and conflict management are necessary for the nurses CCUs (16). Considering the functional role of the nurses in these units, professional relationships have a significant position in providing nursing cares for patients. Further, effective relationships not only could decrease preventable outcomes, but could also improve the satisfaction of the nurses and physicians (32).
Note that studies have suggested that professional interactions of nursing managers could affect the sense of wellbeing of the nurses and providing a safe caring environment (15).
Evan (2010) also showed that it is necessary for nurses to extend their supportive relationships with their colleagues to create a sense of safety and belonging (33).
Over the recent years, studies have been conducted .on moral distress, obligations, and responsibilities of the nurses in CCUs; the results have revealed that nurses would need support because of working in difficult conditions (3).
Some studies have investigated the nurses' perception of the barriers to establishing professional relationships and have suggested factors such as shortage in the nursing personnel, heavy workload, inadequate time for establishing relationships, low self-esteem of the nurses and nurses' poor economic conditions, difficult nursing responsibilities, and lack of welfare facilities (19,34). Hence, nurses should be able to recognize the signs and symptoms as well as outcomes associated with behaviors. Nursing managers should also support the personnel who have been the victim of mistreatment and find solutions for preventing these types of misbehaviors (35). So, considering the importance of relationships in the CCU, the researcher has tried to conduct a study on nurses' perception of the relationships in CCUs. The findings would be helpful in improving human relationships specifically in the healthcare context.

MATERIALS AND METHODS
In the present study, for understanding the perception of nurses and head nurses of the relationships in CCUs, qualitative content analysis with conventional approach was used, as the nature-oriented paradigm and qualitative method would observe the reality based on the background and would accept the multiplicity of the reality and various structures of a phenomenon. Thus, it is more beneficial for studying the fields that have remained understudied.

Sampling of the Participants
Head nurses, supervisors, and nurses who had the experience of working in CCUs were Invited to participate in this study. The sampling was conducted using purposive method. The inclusion criteria were having an experience of inappropriate interpersonal interactions and willingness to express the experiences in a way that could provide a reliable image of the studied phenomenon.
A total of 37 individuals participated in the study; before conducting the study, informed consent was obtained from them all, and the goals and the method of data collection were explained for them.

Data Collection
For gathering qualitative data, in-depth interviews and focus groups were used. Interviews were started with open questions about expressing the experiences of the methods of establishing relationships and interactions between the personnel and nursing managers. Then, they were asked to talk more deeply about the problems and issues related to the relationships by asking exploratory and deep questions such as 'please explain more, what does this mean and why'. The place and time for the interviews were the office of the nursing manager or the nurses' lounge for 30-40 minutes as selected upon the request of the participants. In the end, 25 interviews and 3 focused group discussions with 12 supervisors and 4 nursing personnel were conducted, recorded and typed "wordby-word."

Data Analysis
For data analysis, conventional content analysis was used in accordance with the steps suggested by Lundman and Graneheim. Content analysis is appropriate for analyzing the multifunctional, important and sensitive phenomena of nursing (36). Through qualitative content analysis for interpreting the content of the text data by systematic classification, the apparent and hidden themes of the text would be extracted.
According to this method, the following steps were taken respectively: after performing each interview, the recorded interviews were written and then typed verbatim. The entire text was read over and over to achieve a general understanding of its content. The meaning units were then extracted. Then, the units were coded and similar codes were merged. After this step, the primary similar codes were placed in more comprehensive categories and the main themes of the categories were determined at an abstract level. Indeed, attempts were made to achieve the greatest homogeneity in along with the maximum heterogeneity between the categories. The data obtained from each interview were the guide for the next interview; so, sampling was continued until data saturation, where from the 23 rd interview afterwards, no new data or code were achieved. To be confident, 2 more interviews were conducted whereby no new data and codes were achieved.

Trustworthiness of Findings
To confirm the accuracy and reliability of the qualitative data, scientific accuracy criteria of credibility, dependability, transferability and confirmability were used (37).
Credibility was approved by long-term involvement of the researcher with the study's subject and controlling the data as well as revision of the data by the participants; after coding each interview, the researcher returned the interview back to the participant to assure the accuracy of the codes and interpretations. Also, the codes that would not indicate the viewpoint of the participants would be modified. On the other hand, to achieve integration, various methods for data collection including interviews and focus groups were used and to respect the appropriateness of the samples, sampling was conducted with the highest diversity from the head nurses, supervisors, and nursing personnel of the unit with different working experiences at different sessions.
To achieve the confirmability, data were evaluated and approved by two experts who were familiar with qualitative research such that the consistency between the main categories would be achieved.
In the present study, to achieve transferability, the researcher tried to clearly, accurately, and purposively explain the process of the study and the measures taken, so that it would be possible for others to follow the course of the study, and in turn decide on the results of the study for themselves.

Ethical Considerations
Firstly, the required permission was obtained from the ethics committee of Tarbiat Modares University (IR.TMU.REC.1396.596). All the ethical considerations including informed consent, anonymity, confidentiality, and the right to withdraw from the study were respected.
Before starting the interviews, the goals of the study and anonymity of the information were explained for the participants.

RESULTS
A total of 37 participants were enrolled in the present study consisting of 1 matron, 8 supervisors, 9 head nurses, and 18 nurses aging from 30 to 49 years old with a working experience of 2 to 21 years.
After data analysis, 16 primary codes were extracted and based on their similarities and differences, reduction was performed at 4 stages. Eventually, from the data analysis, the main theme of "ineffective relationship between the senior managers and the nursing personnel of the CCU" was developed. Two themes of "ineffective relationship between the head nurse and the personnel" and "ineffective organizational environment" were developed in line with the main theme ( Table 1).

Theme No. 1: Ineffective Relationship between the Head Nurse and the Personnel
The theme of ineffective relationship between the head nurse and the personnel accommodated the subthemes of "unprofessional relationship between the nurses and the head nurse", "non-sympathetic behavior of the head nurse toward the personnel" and "inappropriate interaction between the head nurse and the personnel". They are explained in detail in the following part.
1-Unprofessional relationship between the personnel and the head nurse: head nurses felt disappointed for the disrespectful behavior of the personnel toward them such as ignoring their entrance into the unit at the beginning of the shift, aggressive behavior toward the head nurse, and taking the head nurse responsible for completely implementing their requests for the working shifts. In most of their experiences, they stated being ignored by the personnel, turning their faces away from them, and not greeting them when entering the unit. Some of their statements are as follows.
"Personnel do not pay the required respect to the head nurses. When the head nurse enters the unit, some of the personnel do not care that the person in charge has come. Sometimes, they would be disrespectful just because one of their requested plans has not been fulfilled; for example, they do not greet them or turn their heads away. If they want to change a program, they would not ask it themselves, but instead, they would ask one of the personnel to make their request." (Head nurse, 42 years old, 18 years of working experience, 5 years of management experience).
Also, another head nurse mentioned lack of cooperation of the personnel for planning the working schedule.
"Personnel are asking for off days in the request notebook but they are not willing to work both the morning and the evening shifts; they want to have vacation but they also want to have fewer working shifts. When I explain that to them, due Regarding the aggressive behavior of the personnel, another head nurse stated: "when I entered the ward, one of the personnel shouted at me rudely and loudly and said that all the critical patients should be handled by her and I cannot take care of this patient." (Head nurse, 40 years old, 15 years of working experience, 5 years of management experience).
2-Non-sympathetic relationship between the head nurse and the personnel: Personnel of CCUs were dissatisfied with the unfriendly atmosphere of the ward and believed that it was caused by the aggressive and repressive behaviors of the head nurse. They mentioned issues such as not paying attention to the personality of the personnel, unfriendly behavior of the head nurse and sometimes, the passive behavior of the head nurse. Participant No. 5 stated that: "The personnel are afraid of the head nurse because of his/her strictness, he/she is too serious. The unit environment is too heavy. Because of the strict behavior of the head nurse and his/her low forgiveness, the personnel try to criticize each other all the time and since there is no friendliness in the workplace, they would not forgive each other's errors… Our head nurse does not have a good behavior, if he/she gets upset of something, he/she would show a severe reaction immediately. He/she has a strict behavior." (Nurse, 36 years old, 12 years of working experience).
"When you go home after the night shift and want to rest, the head nurse would call and says that one of the tools is missing. In fact, he/she could have blamed me another time, while it is my working shift." (Nurse, 29 years old, 6 years of working experience).
3-Inappropriate interaction between the head nurse and the personnel: Supervisors mentioned the behavior of the head nurses toward the personnel in their experiences and in this regard stated that head nurses would not consider the ethical issues when interacting with the personnel, would discriminate between the personnel, would not be decisive when dealing with the personnel, and their judgment would not be based on reason and logic. One of the supervisors stated: "One of the problems of the head nurses is that they would discriminate between the personnel and when they are told that their behavior is unfair, they would say this staff is cooperating with me. But this is wrong, and the mistakes of the personnel should be pointed." (Supervisor, 40 years old, 16 years of working experience, 8 years of management experience).
Concerning the method of head nurse's interaction with the personnel, another supervisor said: "In some of the wards, the head nurse has established an unprofessional relationship with the personnel and this has caused various problems but no efforts have been made to correct these problems. Examples are division of the personnel and issues related to caring for the patients. Since the head nurse has a very close relationship with the personnel in the ward, he/she cannot decisively remind them of their job and this is a serious problem." (Supervisor, 49 years old, 24 years of working experience, 15 years of management experience).

Theme No 2: Ineffective Organizational Environment
The theme of ineffective organizational environment includes the subthemes of "inappropriate interaction between the senior managers and the head nurse" and "unsupportive behavior of the nursing manager for the head nurse".
1-Inappropriate interaction between the senior managers and the head nurse: Considering the characteristics of the CCU which has a stressful environment, it is necessary that the senior managers and the head nurse establish a productive and supportive relationship. However, the participants mentioned the ineffective interaction between the manager/senior manager and the head nurse, as well as the unprofessional relationship and inappropriate interaction between the senior managers, including matrons and supervisors, and the head nurse. Regarding the behaviors of the chief of the hospital and the administrators toward the head nurses, one of them said: "The manager and the chief have abandoned the system. They should be in contact with the wards and establish a relationship with them and should be friendly. The executive manager of the hospital who should visit the entire hospital routinely does not know the head nurse and is not in contact with the head nurses of the wards. The chief of the hospital should visit the wards and make direct connection with the head nurses." (Head nurses, 45 years old, 20 years of working experience, 9 years of management experience).
Also, concerning the inappropriate interactions of the supervisors with the head nurse, one of the participants said: "The supervisors have supreme executive power in the hospital and believe that the head nurse is their subaltern." (Head nurse, 46 years old, 20 years of working experience, 11 years of management experience).
In this regard, one of the nurses said: "The supervisors do not respect us. Once, one of the supervisors asked me about a procedure and I did not have the information, he/she angrily reprimanded me in front of the patient. I was really upset with his/her behavior. He/she destroyed patient's trust in me." (Nurse, 3 years of working experience).
2-Unsupportive behavior of the nursing manager for the head nurse: Most of the head nurses had experiences of unsupportive behaviors of the chief, manager, nursing manager and supervisors in the form of unreasonable interventions and their ignorance toward the problems and issues of the head nurses. One of the head nurses mentioned: "Another problem is that the head nurse does not have executive power and the nurses do not count on us at all. For example, if the head nurse rejects the nurse's request, the matron or the supervisor would intervene to accomplish the nurse's request and would order the head nurse to accept their request. Some of the personnel have learned that if the head nurse does not accept their request, they could go to the matron and the matron would order the head nurse to accept their request about the program or give others permission to leave." (Head nurse, 38 years old, 15 years of working experience, 8 years of management experience).
Considering the unsupportiveness of matrons, another head nurse said: "One of my problems is that I think the matrons would not support us. Feeling unsupported in front of the authorities of the other wards has made me lose my motivation." (Head nurse, 45 years old, 20 years of working experience, 9 years of management experience).
On the other hand, some of the supervisors also mentioned the unreasonable interventions of the nursing managers and supervisors. One of the participants stated:" In this hospital, the personnel are overvalued and the personnel have learned to continuously complain about the head nurse. Then, the supervisor or the matron would tell the head nurse to get along with the personnel. I believe that the supervisor is not fully aware of the ward's problems and the head nurse knows the ward better. This way, the head nurse would be forced to calmly speak to all the personnel so that they would not go to the nursing office for giving their complaints." (Supervisor, 44 years old, 20 years of working experience, 16 years of management experience).

DISCUSSION
The results of the present study found interrelated themes or concepts which revealed the real perception of the personnel and nursing managers about relationships in CCUs. Considering the main theme of the present study "ineffective relationships between senior managers, head nurses and personnel of the CCU", the results of the present study indicated that no professional relationship exists between the different levels of nursing in CCUs and this is one of the important factors that could cause ineffective organizational environment in the CCU, dissatisfaction of the managers and nursing personnel for continuing their work in this environment, lack of a friendly environment, and lack of the sense of trust and reliability among different levels of nursing. So, considering that relationships at the workplace are considered a necessity from the organizational point of view, and many of the social, personal, and organizational problems could be caused by unprofessional relationships, it is necessary for the managers to spend sufficient time for establishing professional relationship with their personnel. Researchers have revealed that open relationship between the managers and the personnel would increase their efficiency and indicates organizational support of the sense of well-being and personnel value (38). Meanwhile, establishing professional relationship is a method for improving the commitment and stimulating the personnel for achieving the goals of the organization.
One of the themes achieved in the study was ineffective relationship between the head nurse and the personnel which had the subthemes of unprofessional relationship between the head nurse and the personnel, non-sympathetic behavior of the head nurse and the personnel, and inappropriate interaction between the head nurse and the personnel.
Regarding the subtheme of unprofessional relationship between the personnel and the head nurse, head nurses had complaints about the disrespects imposed on them by the personnel. Probably, heavy workload, difficult working conditions of the CCU, shortage in personnel, and disregarding allocation of the right proportion of the patients to the personnel could be some of the reasons that have affected the behavior of the personnel. Further, due to their physical and mental exhaustion, the personnel might not have enough time for establishing professional relationships.
In this regard, the study of Norouinia et al. (2015) which evaluated the viewpoints of nurses in Iran showed that heavy workload, shortage in nursing personnel, and insufficient time were the main important suggested barriers by the nurses (19). Furthermore, it is believed that professional communicational skill is required for establishing efficient relationships and lack of such skills could have negative effects on the nurses as well as the performance of their team (26,28). In this regard, the participants of a study indicated the importance of team work in providing care for patients, effective cooperation with each other, and their role in occupational and moral satisfaction. They also stated that team work is effective on the relationship between the team members (39).
Non-sympathetic behavior of the head nurse with the personnel was another subtheme of this study, which is one of the unprofessional behaviors observed in CCUs. It seems that the non-sympathetic behavior of the head nurse with the personnel has affected nurses' behaviors and has impacted the sense of cooperation and empathy in the nurses. In this regard, the study by Weigl (2016) indicated that nurses who have a heavy workload and are not supported by their managers suffer from more mental exhaustion and depression in comparison to other nurses (40). On the other hand, the study of Podsakoff (2009) focused on the supportive approach of the head nurse and revealed that nurses who were supported by the head nurse were more active regarding team works, respectfulness, and other behaviors that would lead to organizational effectiveness and improvement of the team spirits (41).
Since there is a relationship between managers' communicational behaviors and nurses' willingness to work, it must be noted that organizational problems and ambiguities such as communicational gaps, are the first reason for causing conflicts. Thus, it is better that the job description and the roles be determined and the communicational methods of the workplace be improved.
Another subtheme in the present study was "inappropriate interaction of the head nurse with the personnel" which indicated the ineffective interaction between the head nurse and the nursing personnel. In this regard, in CCUs, cases of head nurse's disability in resolving the existing conflicts, lack of trust in the personnel, and discriminating between the personnel have been observed. These factors have led to inappropriate interaction with the personnel. In this regard, a qualitative study by Hartung and Miller (2013) to discover the viewpoints of the nursing managers suggested relationships as one of the leadership roles based on the subcultures. Also, the results of the study showed that the skill of developing positive interaction between the managers and the nurses and ensuring establishing an effective relationship have a significant role in creating a healthy workplace (42). The results of the mentioned study have not been in line with the present study, as the head nurses were not able to establish an appropriate relationship with the personnel, which has caused dissatisfaction in the personnel. Providing a safe and comfortable environment would cause a sense of physical and mental comfort in the nurses. It would also facilitate communicational skills and would lead to establishment of effective relationships (19).
Also, the study of Cullen and Gordon (2014) stated that nursing managers are effective leaders and their communication skills would affect the organizational behaviors of the nursing team (26). Similarly, Vermeir (2018) reported that 68% of the nurses were satisfied with the communicational manner of the managers. Also, the results of a study revealed a relationship between communicational satisfaction of the personnel and job satisfaction and willingness to leave the workplace (20). So, it is necessary that the head nurses be justified about their roles so that they could establish an appropriate relationship with the personnel.
Ineffective organizational environment was another theme of the study which consisted of the subthemes of "inappropriate interaction between senior managers and the head nurse" and "unsupportive behavior of the nursing manger toward the head nurse".
The results of the study revealed that inappropriate interaction between senior managers and the head nurse is involved in causing ineffective organizational environment. It seems that issues such as making the decisions by the supervisors for the head nurses without respecting their opinion, the nursing managers ignoring the head nurses' requests, the supervisors pointing out the mistakes of the head nurses in front of the personnel, and not seeking head nurses' opinions in the time of personnel's complaints could be effective in this regard. The study of Harris et al. (2011) also showed that the quality of the managers' relationship with their employees, as a conditional variable, could affect their professional relationships. Also, the results of a study revealed that some of the supervisors had offensive behavior toward their employees (43).
According to the results of the present study, unsupportive behavior of the nursing managers was one of the unprofessional behaviors. Specifically, behaviors such as not assigning power and authority to the head nurses, unreasonable intervention of the supervisors in planning personnel's schedules, the authorities suppressing the head nurse due to lack of support for the head nurse from the nursing manager have been observed. Considering that management of the CCU is considered as the most important nursing task, supportive structure for the head nurse in professional performance could lead to adaptive creativity, improvement of the nursing for the patients, and positive organizational outcomes (44,45). On the other hand, in the study by Lee et al (2008), it was reported that the head nurses of the wards should feel powered and valued in their job and should have the organization's support so that they could support the nurses (46).
Further, the study of Dasgupta et al. (2013) showed that the style of professional relationships would reinforce the support for the personnel. So, being supported by the supervisors has increased the satisfaction of the personnel regarding the method of establishing the relationship. It has also strengthened the emotional bond with the managers and increased their trust in the organization (47). Therefore, one of the important findings of the present has been clarifying the fact that working in hard conditions and the necessity of providing specialized care for patients with critical conditions, shortage in the nursing personnel, increased working shifts, insufficient amount of time for establishing professional relationships, lack of welfare facilities, unprofessional behaviors of the physicians and physicianoriented environment of the hospitals have caused tension and dissatisfaction between the personnel and nursing manager. All of these factors together have lowered the level of patience in the nurses of CCUs and have disrupted establishment of professional behaviors. So, it is necessary to find the main roots of the unprofessional behaviors to provide the ground for improving the performance of the nursing personnel and managers.
On the other hand, the results of the preset study suggested that lack of practical knowledge at different levels of nursing regarding communicational skills and lack of appropriate behavioral model in CCUs have caused unprofessional behaviors. Therefore, nursing personnel and managers should gain the necessary competencies regarding communication skills and their competency should be evaluated.
So, according to the results of the present study, it seems that there is an unprofessional relationship between the nursing personnel and managers. Therefore, considering that establishing professional relationships is a necessary principle for providing nursing care and as one of the most important causes of anxiety in the nursing profession is lack of a good working relationship with their colleagues, determining the barriers to establish effective relationships between the nurses could help develop more effective interventions and programs for resolving the barriers and facilitating the communications. Further, by executing communicational skills development programs, the level of communicational skills would be improved in the nurses (48)(49)(50)(51).

CONCLUSION
The results of the present study provided a clear image of the perceptions and experiences of the participating nurses about the relationships that exist between different levels of nursing profession. The main theme of the study was "ineffective relationship between senior managers, supervisors and head nurses" which contained the subthemes of "ineffective relationship between the head nurse and the personnel" and "ineffective organizational environment". Taking nurses' opinion into account and understanding their relationships from different aspects could offer valuable data for decreasing and resolving the existing problems. The outcomes of ineffective relationships in the unit have affected all the levels of nursing including nurses, nursing managers, other medical professions, and the patients. It has caused dissatisfaction, occupational burnout, non-sympathetic behaviors, lack of cooperation between the nurses, unsupportive behaviors, and lack of organizational commitment. So, improvement of professional relationships at different levels of nursing should be considered seriously.

STUDY LIMITATIONS
This study was limited to a group of specialized nurses in one specific place and it could not be generalized to other groups and other places. Other studies about the perception of nurses on relationships in other wards and with other medical professions are required. No specific limitation existed for conducting the present study.

RELEVANCE TO CLINICAL PRACTICE
The main theme achieved from the results of the present study, "ineffective relationship between senior managers, head nurses and nurses", indicated the existence of unprofessional relationship between different levels of nursing profession and the nurses. Indeed, due to their heavy workload and the effect of their critically ill patients on their physical and mental condition, they did not have a positive perception of establishing professional relationships in the CCU. So, considering that patients in CCU have a critical condition and require specialized care, establishing professional relationship between different levels of nursing profession and other medical professions has a key role in providing proper care for the patients and preventing medical errors and harms to the patients. It is necessary for the nurses to improve their communicational skills to improve the quality of the care provided for the patients; meanwhile, nursing managers, using communicational skills, could also have an important role in improving the professional relationships.