Aims and intended learning outcomes

The aim of this article is to assist nurse managers to understand and investigate problematic behaviour towards colleagues within the nursing team. After reading this article and completing the time out activities you should be able to:

In nursing, despite high professional standards, there is what Dellasega (2020) described as ‘toxic nursing’, with behaviours such as incivility, bullying and organisational cynicism. NHS England (2023a) recognised that, in highly pressurised work environments, incivility, disrespect, bullying and harassment can become commonplace, with detrimental effects on teamwork, staff well-being and ultimately patient care. The problematic behaviour on the part of nurses towards colleagues within the team discussed in this article is defined as that which undermines teamwork and conflicts with national standards and local policies. In the absence of relevant research in this area of managerial work, the article draws on the author’s experience as a consultant working with managers in the healthcare sector.

Background

The nursing profession is under extensive pressure. Nurses have recently experienced the coronavirus disease 2019 pandemic, which severely tested collaboration between and within nursing teams (Smallwood et al 2022). Different professions within healthcare are making competing claims for pay increases, which puts service unity at risk (Campbell et al 2023). The number of written complaints to the NHS made by patients, or on their behalf, has risen (NHS Digital 2022) at a time when the debate continues on how to engage patients in their care (Price 2022). In that context, it is particularly challenging for nurse managers to build the esprit de corps – that is, the sense of unity and common interests and responsibilities – that is essential to sustain well-functioning nursing teams.

Nurses interact with more or less conscious reference to personal and professional beliefs, values and attitudes that underpin their reasoning and help them navigate different care situations (Chiffi 2020, Price 2021). The way nurses communicate with their colleagues can be described as a behaviour through which they express what they hold to be true and what they value. Communication is not always just a technical matter, a question of choosing the right words, tool or style, but can betray an underlying issue of discordant beliefs, values and attitudes. In that sense, nurses’ beliefs, values and attitudes can significantly affect, either positively or negatively, their colleagues and team (Fitzpatrick 2021). When nurse managers face the difficult task of balancing increasing service demand against limited resources, team motivation is key; to understand what motivates the team, nurse managers need to understand the beliefs, values and attitudes of team members.

There is little discussion in the literature on how nurses’ beliefs, values and attitudes affect the nursing team. There is research on negative attitudes on the part of nurses towards certain patient groups, for example drug users (Mahmoud et al 2021), on nurses’ experiences of negative attitudes on the part of patients and families (Boateng and Brown 2022) and on the stress experienced by nurses when service demand forces them to compromise on care ideals (Chambers and Ryder 2018). However, the author has found no research on how nurses’ beliefs, values and attitudes can affect the work they do together.

Beliefs, values and attitudes

Nurses work with more or less conscious reference to personal and professional beliefs and values. Sometimes there is disagreement within the team on beliefs and values, or the beliefs and values of individual team members are not well understood, leading to staff working to different ends.

Beliefs can be described as what a person accepts as true even in the absence of sufficient evidence (Connors and Halligan 2015). For example, people tend to believe that if a person smiles, they are friendly – but that belief can be challenged by arguing that a smile may indicate duplicity rather than friendliness. Beliefs are learned and reinforced over time. While beliefs are classically associated with faith, they are also accumulated with reference to oneself and the world (Connors and Halligan 2015). Values are beliefs about what is important and meaningful in life, indicating how one should live (Peterson 2023). During their personal development, people adopt values that are closely associated with their identity. Attitudes describe the disposition of the person in situations which require them to take a stance. A person’s attitudes need to reflect their beliefs and values while allowing for sensitivity towards others (Price 2021). Because beliefs, values and attitudes are deeply personal, it can feel like a direct attack on the person when they are challenged.

Having developed personal beliefs, values and attitudes as part of growing up within a particular culture (Rutjens and Brandt 2019), nurses bring these with them to work. Nurse education programmes attempt to instil and nurture beliefs, values and attitudes that are consistent with the professional standards of practice and behaviours set by the profession’s regulatory body – in the UK the Nursing and Midwifery Council (2018). In each healthcare organisation, these national standards are translated into local policies. Their profession requires nurses to scrutinise their beliefs, values and attitudes and change those that contradict professional standards and policies.

In the workplace, nurses come across the beliefs, values and attitudes of others within their team. Ideally, as team members explore together how to conceive and deliver care, each one learns to accommodate their colleagues’ beliefs, values and attitudes and reconcile these with their own. However, there may be a conflict between individual nurses’ beliefs, values and attitudes and those mandated by the organisation and/or held by the rest of the team.

Challenges of investigating potential problematic behaviour

Dellasega (2020) described several types of behaviour towards colleagues within the team that, if sustained, can become problematic:

Dellasega (2020) made it clear that such behaviours must be identified and investigated promptly. That is the responsibility of nurse managers, who will need to investigate the matter, identify whether there is an issue, determine what the issue is and decide what course of action is required. A potential problematic behaviour may have arisen because of a disconnection between the beliefs, values and attitudes of an individual nurse and those of the team, with the nurse manager having to arbitrate.

Nurse managers need to tread carefully, since investigating potential problematic behaviour towards colleagues poses several challenges. The workplace is an environment where it can be difficult to talk about beliefs, values and attitudes. Edmondson (2012) and Edmondson et al (2016) explained that work environments may contain differing levels of accountability (what staff are requested to do) and psychological safety (staff’s perceived ability to share their thoughts, speak up about issues or ask for help). A work environment where levels of accountability are high, but staff feel psychologically safe, is a learning environment. A work environment where levels of accountability are high but staff do not feel psychologically safe is an anxiogenic environment (one that causes anxiety) (Edmondson et al 2016). In an anxiogenic work environment, staff will be less willing to raise concerns and nurse managers will find it harder to investigate problematic behaviour towards colleagues.

Investigating potential problematic behaviour towards colleagues risks disrupting communication and jeopardising psychological safety within the team. The different parties involved can quickly feel threatened or judged; for example, the staff member who has raised concerns may feel that the rest of the team considers them disloyal; or the staff member suspected of displaying problematic behaviour towards colleagues may feel their personal identity is being attacked. Nurse managers need to move with great care, insisting on high standards of accountability while protecting individual nurses’ right to feel respected and safe.

Nurses may not always be aware of their own beliefs, values and attitudes. They may become aware of a belief, value or attitude through a new care encounter. They may be genuinely surprised to discover that they hold beliefs, values and attitudes that may have led them to adopt a behaviour towards colleagues that others deem problematic. Nurse managers should therefore avoid assuming that nurses who display behaviour that others regard as problematic simply have a ‘bad attitude’.

The fictional case study of Elspeth and Jude further explores what problematic behaviour towards colleagues within the nursing team might look like (Case study 1).

Understanding the team’s values

Potential problematic behaviour by one member of the team towards their colleagues is sometimes an expression of opposition to the beliefs, values and attitudes of the team as a whole. In the case study, Elspeth’s colleagues may agree with her that the previous team manager’s prescriptive practice is how the team should work, but they may also value loyalty towards Jude and therefore regard Elspeth’s criticism as deceitful and uncompassionate. To take another example, in a team that values fast problem solving, concerns may be raised about a colleague who wishes to pause and take time to evaluate the situation; in that situation, what some team members may describe as an ‘attitude problem’ is actually a mismatch between different team members’ values.

It is therefore important that nurse managers understand the team’s values and identify potential areas of tension, ideally before any potential problematic behaviour towards colleagues arises and needs investigation. If nurse managers already possess a good understanding of the team’s values, they will be better equipped to understand the basis of complaints about an individual member and put the potential problematic behaviour into context. One way of understanding the team’s values is to collectively assess and discuss values using an adapted version of Whyte’s (2007) ‘team wheel’.

Whyte (2007) designed the team wheel to support coaches to assess the individual and collective perspectives of team members on important issues. The team wheel consists of eight spokes extending out from a central point, each relating to a core value rated from 0 at the centre of the wheel to 10 at the other end of the spoke. In Whyte’s (2007) original, the eight values are team identity, team vision, team role clarity, team effectiveness, team leadership, team social reflexivity, team stability and team conflict resolution, while the ratings range from ‘totally dissatisfied’ (0) to ‘totally satisfied’ (10).

The author of the present article suggests that nurse managers can conduct, with the members of their team, a collective exploration of the team’s values using an adapted version of Whyte’s (2007) team wheel. Because different teams have different missions and roles, the eight values used in such an exploration will ideally be chosen to reflect the local context. They will usually need to reflect corporate goals as well.

The exercise starts with each team member individually rating each value according to their perception of its importance for the team’s work. This reveals what individual team members value least and most. The next step, building on Whyte’s (2007) work, is that each team member rates to what extent they feel the team is achieving the highest standard for each value. This reveals the team’s ‘work in progress’ in terms of incorporating the values within its work. The wheels are then collected and discussed among the team, which identifies where aspirations and achievements match and where there are gaps.

Figure 1 provides an example of how Whyte’s (2007) team wheel could be presented to team members for a collective exploration of team values. An exercise like this requires tact, especially in an anxiogenic work environment, so in some cases it may be necessary to discuss values anonymously. The exercise does not determine what the team’s values should be or whether they are right or wrong, only what they are.

Figure 1.

Exploring team values using an adapted version of Whyte’s team wheel

Exploring potential problematic behaviour with staff

To investigate potential problematic behaviour towards colleagues, nurse managers need to engage in a sensitive and respectful exploratory process with the member of staff concerned. A rigid approach is not recommended but the author suggests implementing the following steps and principles:

Deciding what needs to happen next

If the nurse manager and the staff member agree that the behaviour in question was problematic, it is now time to discuss what the person would like to do about it and how the nurse manager can help – asking, for example, ‘What would you like to do next?’ and ‘What can I do to help you address the issue?’ A trusted senior colleague (but not the one who was asked for a second opinion) could be asked to undertake reflective partnering with the member of staff. The nurse manager, in their final report, may want to acknowledge the reflection undertaken and insights gained. Any persistent problematic behaviour or relapse in problematic behaviour will need to trigger critique and possible sanction in the form of further investigation, additional correction, escalation and/or formal reprimand (Filipova 2018).

If the nurse manager concludes that the criticism directed at the member of staff was entirely misplaced, the next steps will need to include feedback to the team member who raised concerns. If the nurse manager concludes that the behaviour was problematic but the member of staff does not accept that conclusion, if they show no willingness to reflect on their behaviour, if their behaviour seems particularly objectionable and/or if there is a pattern of, or repeated, problematic behaviour, the matter may need to be escalated to the next level of intervention in the ‘promoting professionalism’ pyramid (NHS England 2023b) (Figure 2).

Figure 2.

NHS England ‘promoting professionalism’ pyramid

As hinted at in the case study, an intervention at team level may also be required. It is possible that Elspeth’s behaviour towards Jude is indeed problematic, but it may also be indicative of wider issues affecting the team as a whole – for example, that Jude has not engaged with the team about the new ways of working she wants to introduce. One solution in that case would be to invite the whole team, including Elspeth and Jude, to discuss old and new ways of working and agree on how the team will work in future. A potential problematic attitude often needs to be considered in the light of team development and practice change.

Conclusion

Most nurses have high standards about how they interact with others in their team; nonetheless, there are instances of disrespect, incivility, bullying and harassment towards colleagues. Nurse managers need to understand and investigate potential problematic behaviour towards colleagues. This requires a sensitive and respectful exploratory process, starting with an objective assessment of the nurse’s behaviour, then moving to underlying beliefs, values and attitudes. This process is more challenging if the team works in an anxiogenic environment where psychological safety is lacking.

Nurse managers will be better equipped for the process if they already have a good understanding of the team’s values. Problematic behaviour towards colleagues may reveal wider issues that concern the team as a whole and need to be considered in the context of team development and practice change.