Elsevier Editorial System(tm) for Collegian Manuscript Draft Manuscript Number: COLL-D-11-00034R1 Title: Collegial relationship breakdown: a qualitative exploration of nurses in acute care settings Article Type: Original Clinical & Educational Research Keywords: Collegiality, communication, staff relationships, team hierarchy, teamwork. Corresponding Author: Dr Leanne Cowin, Corresponding Author's Institution: University of Western Sydney First Author: leanne s cowin, PhD Order of Authors: leanne s cowin, PhD; Sandy C Eagar, B. Appl. Sc. (Adv Nsg), MSc. Hons Abstract: Abstract Poor collegial relations can cause communication breakdown, staff attrition and difficulties attracting new nursing staff. Underestimating the potential power of nursing team relationships means that opportunities to create better working environments and increase the quality of nursing care can be missed. Previous research on improving collegiality indicates that professionalism and work satisfaction increases and that staff attrition decreases. This study explores challenges, strengths and strategies used in nursing team communication in order to build collegial relationships. A qualitative approach was employed to gather nurses experiences and discussion of communication within their nursing teams and a constant comparison method was utilised for data analysis. A convenience sampling technique was employed to access both Registered Nurses and Enrolled Nurses to partake in six focus groups. Thirty mostly female nurses (ratio of 5:1) participated in the study. Inclusion criteria consisted of being a nurse currently working in acute care settings and the exclusion criteria included nursing staff currently working in closed specialty units (i.e. intensive care units). Results revealed three main themes; 1) externalisation and internalisation of nursing team communication breakdown, 2) the importance of collegiality for retention of nurses, and 3) loss of respect, and civility across the healthcare workplace. A clear division between hierarchies of nurses was apparent in how nursing team communication was delivered and managed. Open, respectful and collegial communication is essential in today's dynamic and complex health environments. The nurses in this study highlighted how important nursing communication can be to work motivation and how leadership fosters teamwork.
Cover Letter, including Author Details
Journal Collegian
Title Collegial relationship breakdown: a qualitative exploration of nurses in acute care settings
Authors Corresponding Author
Leanne S. Cowin RN PhD Senior Lecturer School of Nursing and Midwifery University of Western Sydney Locked Bag 1797 Penrith South DC NSW, Australia 2795 Phone: 02 4620 3762 Fax: 02 4620 3161
[email protected]
Word count = 4026
Sandy C. Eagar RN, A&E Cert, B Appl Sc (Adv Nsg), MSc Hons, Nurse Manager SSWAHS Area Nurse Education Unit Centre for Education & Workforce Development PO Box 149 Campbelltown NSW, Australia, 4560 Phone: 02 4634 3872 Fax: 02 4634 3850
[email protected]
2 Acknowledgements The authors thank Angela Firtko and Linda Gregory for their data collection skills and give their thanks to all of the nurses who kindly gave of their time and collegial support in the focus groups.
*Detailed Response to Reviewers
The Editor-in-Chief Collegian, Saturday, April 21, 2012
Dear Professor Daly, Please find submitted our revised manuscript entitled „Collegial relationship breakdown: a qualitative exploration of nurses in acute care settings‟ (ID COLL-D-11-00034). I hope we have attended to all requested revisions in an acceptable manner. I would be delighted if you would consider this paper further now for possible publication. Thank you very much for your consideration and as the corresponding author I hope to hear from the journal staff in the near future. Yours Sincerely Leanne Cowin Corresponding Author
List of changes Changes are highlighted (Yellow) within the manuscript Reviewer #1: A couple of minor edits to attend to. Pg.2 para.2 line.2, should be either the retention or retaining. Authors‟ response: changed to retaining Pg.3 para.2 line.3, should be collegial behaviour (singular) to ensure agreement with the following sentences. Authors‟ response: changed to singular Pg.3 para.3, the last sentence is clumsy and needs rewriting. Authors‟ response: sentence rewritten: The findings from the development of their assessment tool were that items on “respect, support, valuing opinion, exchange of ideas, open communication and effective conflict resolution” produced psychometrically sound outcomes for inclusion in the measure (Duddle & Boughton, 2008, p. 906). Pg.3 para.4 line.3, nurse retention and nurse recruitment. Authors‟ response: sentence trimmed as suggested Pg.4 para.1 line.1, retention rates. Authors‟ response: the retention rates added Pg.4 para.1 line.2, seems incomplete, are students being recruited and retained to undergraduate programs or graduate year programs? Authors‟ response: word added to sentence. Pg.4 para.2, I was able to identify the authors, need to be more careful in future. Authors‟ response: references removed Pg.8 para.2 line.3, leads some nurses to feel great dissatisfaction... Authors‟ response: leads changed to led Reviewer #2: As collegiality is the focus of the paper there needs to be a clearly stated definition of the term early in the work. It seems what is really meant is communication and its breakdown, which then impacts on collegialtiy. If the focus is communication then this needs to be stated so the reader knows exactly what is meant by the various terms. Authors‟ response: sentence in the introduction rewritten so as to highlight communication and its breakdown first. Communication breakdowns causing poor collegial relationships
may be one of the pivotal reasons why retaining nursing staff is increasingly difficult (Forni et al. 2009; Leiter et al. 2010; Proto & Dzurec, 2009). The "Results and Discussion" section needs to be divided into two seperate sections. It is important for readers to be presented with a logical structure and well-argued report of the research and this is assisted by having the results presented under the themes (which are clearly appropriate) and then the discussion answers the 'so what' question: that is what is the relevance and implications for both previous research and for the profession as a whole. Authors‟ response: results and discussion was divided into separate sections and one sentence was added to the discussion to assist in linking results and discussion. The ethics section needs the addition of the names of the committees giving approval. Authors‟ response: see editor‟s comment The limitations section is appropriately addressed although a comment could be added to specifically note that generalisations cannot be drawn from a study such as this. Authors‟ response: sentence restructured to include issue: While these findings cannot be generalised, it is initial scoping type studies such as this small project that can help to focus the spotlight on what are the important issues in retaining and maintaining good collegial working relationships.
*Manuscript, excluding Author Details
Abstract Poor collegial relations can cause communication breakdown, staff attrition and difficulties attracting new nursing staff. Underestimating the potential power of nursing team relationships means that opportunities to create better working environments and increase the quality of nursing care can be missed. Previous research on improving collegiality indicates that professionalism and work satisfaction increases and that staff attrition decreases. This study explores challenges, strengths and strategies used in nursing team communication in order to build collegial relationships. A qualitative approach was employed to gather nurses experiences and discussion of communication within their nursing teams and a constant comparison method was utilised for data analysis. A convenience sampling technique was employed to access both Registered Nurses and Enrolled Nurses to partake in six focus groups. Thirty mostly female nurses (ratio of 5:1) participated in the study. Inclusion criteria consisted of being a nurse currently working in acute care settings and the exclusion criteria included nursing staff currently working in closed specialty units (i.e. intensive care units). Results revealed three main themes; 1) externalisation and internalisation of nursing team communication breakdown, 2) the importance of collegiality for retention of nurses, and 3) loss of respect, and civility across the healthcare workplace. A clear division between hierarchies of nurses was apparent in how nursing team communication was delivered and managed. Open, respectful and collegial communication is essential in today‟s dynamic and complex health environments. The nurses in this study highlighted how important nursing communication can be to work motivation and how leadership fosters teamwork.
Key Words Collegiality, communication, staff relationships, team hierarchy, teamwork,
2 Introduction
The importance of nurses working together as a team through collegial or harmonious relationships may seem less vital when attempting to manage the ongoing critical shortage of nursing staff and resources. However, the quality and quantity of communication between nurses working in a team has enormous implications for the outcomes of patient care and safety as well as the recruitment and retention of the nursing workforce (Goldblatt, et al., 2008).
Communication breakdowns causing poor collegial relationships may be one of the pivotal reasons why retaining nursing staff is increasingly difficult (Forni et al. 2009; Leiter et al. 2010; Proto & Dzurec, 2009). In the rush to fulfil roster vacancies, it can be easy to underestimate the potential power of nursing team relationships and in doing so miss opportunities to create better working environments and increase the quality of nursing care. As Forni et al., (2009; 36) point out “employees who are engaged in their workplace and committed to their organizations give companies crucial competitive advantages, including greater productivity, lower employee turnover, and improved quality of care.” This paper explores acute care nurses ideas on the causes of communication breakdown in nursing teams including collegiality and workplace retention.
Background Nursing team structures continually evolve (Kenny & Duckett 2004; Leiter, et al. 2010) and may vary greatly from one country to the next (Proto & Dzurec, 2009). Irrespective of the many variations within teams there continues to be hierarchies structured on knowledge and power within the nursing profession. These divisions, most commonly derived through education, qualification and license, may present potential avenues for internal
3 communication breakdown (Chaboyera et al., 2008). Communication required for the delivery of nursing care is dependent on the relationships developed within a nursing and health care team. For example, relating well together is understood as being „collegial‟ or intercollaborating (Bonalumi, 2005). Not only is collegiality a workplace issue from one individual to another, but it is also an important aspect within the ranking or hierarchy of the nursing team (Duddle & Boughton 2008; Dearnley 2005; Goldblatt et al. 2008).
Evaluations of effective nursing team communication are an important clinical management tool for successful nursing workplaces. Effective communication, according to Hearnden (2008: 50), “involves being able to produce contextually appropriate language and understand the nuances of a given situation”. Nursing teams operating within the workplace comprise the context of the situation and in particular, the nature of those persons within the context contributes to defining the success of communication (Hearnden, 2008). There is a perceived shortage of nursing literature currently available to comprehensively address changing and evolving communication issues such as the need for collegiality within the context of the nursing team although studies by Duddle and Boughton (2008) and Apker et al. (2006) highlight ongoing research in nursing team communication.
Duddle and Boughton (2008) explored the nursing workplace searching out any relation between a conflicted workplace, job dissatisfaction and nursing attrition. The authors include collegiality as one of their three key concepts for a good nursing work environment (2008). Collegial behaviour as a factor within the nursing workplace assessment tool constructed by Duddle and Boughton is defined as “positive relationships among colleagues”, where communication promotes collaboration, enjoyment and respect (2008, p. 903). The authors found that items on “respect, support, valuing opinion, exchange of ideas, open
4 communication and effective conflict resolution” produced psychometrically sound outcomes and were included in the new assessment tool (Duddle & Boughton, 2008, p. 906).
In the findings of a qualitative study of communication and nursing teams Apker et al. (2006: 184) report that „enhanced nursing practices‟ are the outcome of „socially supportive‟ nursing teams where communication demonstrated professionalism. O‟Connell et al. (2006) recognised the importance that good working relationships and good communication has on the health care team and indeed occupy “about 25% of their time” (Chaboyer et al. 2008: 1275).
Creating and maintaining collegial relationships with other nursing staff on the team is also important for developing a sense of belonging (Levett‑Jones et al. 2008). Feeling as though one belongs within a team is vital to nursing retention and nursing recruitment (Duchscher, 2009) A decreased sense of belonging and consequent communication breakdown causes a lack of collegiality, according to Freeney and Tiernan (2009), heavily impacting on the retention rates of experienced and junior nursing staff. In their study of student placements Levett-Jones et al. (2008) also discovered that, among other personal issues, collegiality, belongingness and a sense of security gained through nursing team communication was critical for even students‟ recruitment and retention.
Aim of the study The aim of this study is to explore the challenges, strengths and strategies used in nursing team communication in order to build nursing team relationships by providing new perspectives on the topic of collegiality. The result reported is one part of a larger preliminary study exploring the evolving issue of nursing team communication in healthcare
5 environments. Three major themes were determined from an analysis of the focus group data with the concept of communication breakdown – collegiality reported here. The second and third major concepts – scope of practice conflict, and communication issues within nursing handover, are reported elsewhere.
Method Study Design This exploratory study employed a qualitative method to gather data from nurses. While no specific category of qualitative method was utilised (Ball et al. 2011; Beanland, et al. 1999), the constant comparison method (grounded theory) for analysing data was used (Birks & Mills, 2011).
Six focus groups were conducted in medical and surgical wards at three different hospitals in a major metropolitan city (1 focus group for Enrolled Nurses and 1 for Registered Nurses in each hospital). The focus groups were conducted in a conveniently located meeting room at each hospital site and were timed to coincide with the change of shift between morning and afternoon. This approach assisted in maximising the number of potential participants as additional staff were on the ward to ensure continuation of nursing care. Advertising of the project and the date and time of the focus groups included ward posters, „word of mouth‟ and inclusion in nursing management meetings.
Participants Between 4 and 7 Registered Nurses (RNs) and Enrolled Nurses (ENs) agreed to participate in each of the six focus group held in medical and surgical wards (total of 30 participants overall). Most participants were female (ratio of 5:1). The ages of participants ranged from 21
6 through to 50 years old. All focus groups demonstrated a mixture of nursing experience ranging from first year new graduate nurses and newly enrolled nurses through to participants with more than 20 years of experience. Participants were excluded if they worked in closed speciality units such as intensive care units, neonatal units and operating theatres because it was felt that communication within nursing teams in specialty units may be substantially different to general wards, thereby compromising the data collection.
Focus group questions Two researchers conducted each of the six focus groups. The first researcher aimed to guide the discussion with the help of a list of probing questions (semi structured approach, see Table 1). The second researcher ensured informed consent and collection of written consents, audiodigital taping, as well as the comfort, privacy and ambience of the data collection environment. Each of the six focus groups lasted for approximately 60 minutes. Participant checking (feedback on findings) was offered at each focus group however, no individual opted to be contacted for this purpose.
Trigger questions (Table 1) aimed to generate thoughts, ideas and discussion within the focus group and provide some direction for discussion towards nursing team communication strengths and challenges. Researchers were able to gently probe for responses to further explore subject material that had arisen as a result of discussion. This was particularly so when participants became excited, distressed or emotional.
[Insert Table 1 here]
7 Data analysis During each focus group participants were encouraged to remain anonymous and not identify other individuals. Group discussions were audio taped using a digital voice recorder. The files were later transcribed verbatim. All six members of the research team participated in the analysis, reduction and the creation of themes from the data using a constant comparison method (Glasser & Strauss1967; Polit & Beck 2006). Data analysis was undertaken by a review of the transcribed discussions whereby common themes are located in the text of the transcripts, explored and then compared to current and past nursing and other related literature. The aim of the constant comparison method is to divide data into categories and compare these categories with all of the data so that the researchers can identify commonalities as well as variations (McCreaddie & Payne, 2010). Constant comparison for the six transcripts was a time consuming approach to data analysis however, as Ball et al. (2011) point out, consistency and rigor are vital to the methodological orientation. Saturation of information (Burns & Grove 2009) was achieved within the six focus groups where no new information was identified.
Ethical considerations Individual participants were provided with a written summary of the research aims and objectives and were required to sign a consent form prior to joining a focus group session. Permission to conduct this study was obtained from the relevant health services authorities and university ethics committee. Results Three main themes were determined from an analysis of the focus group transcripts and are compared to current nursing literature. The themes are 1) externalisation and internalisation of nursing team communication breakdown, 2) the importance of collegiality for retention of
8 nurses, and 3) loss of respect, civility, and the run-on effects across the healthcare workplace. A discussion of potential management techniques for nursing team communication breakdown follows as it addresses these findings.
Externalisation and internalisation of nursing team communication breakdown In this study, the local division of nursing is distinctly related to the qualifications of the individual. For example, RNs possess a Bachelor of Nursing (a three year university based course) and ENs possess a certificate (a one year college based course). It was decided by the researchers that discussions were more likely to be frank, open and honest if the focus groups were split into RN or EN only groups. The drawback of this decision however, is that an “Us and Them” tension could potentially arise.
The use of probing questions and sensitivity to this potentiality meant that the researchers were forewarned to guide focus group discussions away from this issue. In the processes of the constant comparison technique though, it became apparent that this approach had been unnecessary for the RN focus groups as the participants appeared keen to mostly acknowledge external sources of communication breakdowns. An example of how RNs in this study are comfortable to assume external causes is explored by the following participant; if you‟re comfortable as a team I suppose the danger is that it can become us against them, you know, them, being either doctors or patients or allied health or whatever. I think most people have a pretty healthy attitude towards teamwork. (LG RNs p.11)
For the EN groups however, it is clear by the large number of discussions this strategy was not successful in managing the “qualifications” divide, as there is an internalising of communication breakdown issues from these focus groups. Many EN participants accuse RNs
9 of being the causative or central agent in their discussions of communication breakdown as evidenced in the following story; I would have not expected a team leader to have spoken to me in that disrespectful manner and spoken to me rudely in front of three other RNs plus a doctor…I was very upset and teary. So I sorted myself out and she came across and put her arms around me and then said „oh I‟m sorry for yelling at you but you just don‟t take the initiative, you‟re just not coping.‟ I could have just gone home, that is how bad I felt but I would not because they were my patients and I was not going to walk out. So, since that issue, we haven‟t really spoken a lot, she doesn‟t approach me, she hasn‟t apologised because she doesn‟t believe she did anything wrong. (LG ENS p.6)
The importance of collegiality for retention of nurses Many participants gave examples of communication breakdown and discussed what they felt were the causative factors. It soon became clear from reviewing all transcripts that communication breakdown and a loss of collegiality has common threads throughout all nursing ranks and led some nurses to great dissatisfaction, sadness and grief in their job. According to White (2009, p. 109), collegiality is important because it is linked to our selfconfidence “collegial support is necessary to gain confidence in oneself”.
Participants spoke frequently of collegial communication issues including nursing leaders such as their Nursing Unit Managers (NUM) claiming that communication channels from NUMs are becoming increasingly problematic. This issue is supported by the Garling Report (2008; 1.124) even leading to a recommendation that the NUM should spend at least 70% of their workload in clinical duties forging better relationships with their nursing team. The N/MUM occupies a frontline management position and their skills and performance is
10 critically important to health service outcomes (Duffield et al 2007a; Duffield et al 2007b). The following excerpt highlights team leader communication issues - “in the last four years we‟ve had four NUMs and for every different NUM the ward runs differently, you are expected to behave different, you are expected to communicate on a different level, everything changes. Not always for the better”. (SE ENS p.7)
Courteous and professional communication is also understood as potentially localised phenomena by many participants who raise the notion that nursing is particularly compartmentalised and specialised these days. Communication within specialised teams may not spill over into other „non team members‟. This point is clearly explored by an RN who claims it is an entire team issue and that; “Communities, closed communities, intensive care, midwifery, any community, any unit that is totally closed, theatre, theatre, they all become very incestuous, cannibalistic, because they‟ve just got the same personalities going round and round and round, they‟re so close to each other, they don‟t have to talk to the patients” (LG RNs p.13).
Collegiality - having respectful and communal relations with fellow nurses, is clearly important to both RNs and ENs within this study however, the data from the focus groups reveals that collegiality may mean different things to these groups of nurses. EN focus groups gave many examples of collegiality being more often a „one way‟ affair where ENs were collegial with other ENs and ENs being collegial with RNs but they perceived that RNs did not return this respectful communal behaviour to ENs. This was discussed as a point of intense angst, sadness and irritation by the EN groups. Examples and highlights of this point include: “I still think there‟s that issue of RN versus EN, very much so, we do all the work and
11 they do all the other things and you don‟t feel you mix some times,” and “they don‟t want to team nurse with us and they don‟t understand team nursing, yeah. I find it very frustrating, yesterday was just awful”. (SE ENs p.5)
Despite the previous view, a more experienced EN summed up her ideas regarding collegiality between the EN and the RN as more often uncomplicated: Most of them [RNs] are good but you might get one or two that expect from you but won‟t give anything back, and that‟s where the breakdown is because I then don‟t want to approach her or him to ask for anything because I in turn don‟t want to help them”. (AF ENs p.7)
Respect and civility Escalating aggression, verbal abuse and threatening behaviours are no longer the domain of mental health care facilities for these participants and their workplaces. Managing potentially aggressive and violent situations within medical and surgical wards is understood by participants as a part of their workplace in the 21st century. For example, “they [visitors] are very hard to talk with up until we have to call for security, we do not want that to happen” (SE ENs p14).
A breakdown in communication is reported by both levels of nurses from the public to a point where nurses are threatened as they go about their work. Several participants recalled how they felt fearful in going about their nursing practice, “I was told that I‟d be „picked off‟ in the car park at the end of my shift over things where we were trying to help somebody. It was meant seriously” (SE RNs p15). Another participant explained recent events;
12 “I had my life threatened more than once, probably half a dozen times….serious enough so that I would take an hour to drive home and I live twelve minutes away – just to make sure that nobody was actually following me” (SE ENs p.16)
Discussion This study utilised focus groups to illicit and explore nursing team communication issues for nurses working in acute care settings. The use of focus groups as the primary source of data collection was as an attempt to capture the “social dynamic and interactions between participants” (Redmond & Curtis, 2009: 57). The researchers acknowledge that focus groups are more concerned with meaning than measurement (Krueger & Casey, 2009) and are a useful research tool to explore phenomena.
The issue of externalisation and internalisation of nursing team communication breakdown was not one that the researchers had considered prior to the focus groups. Internalising can be a semi- subconscious action caused often by frustration, limitations, exclusion and marginalisation (Quick & Tetrick, 2011). It is not exclusively automatic, as it will require a measure of personal choice to re-direct values and ideals (Quick & Tetrick, 2011). Externalising is defined here as attributing communication problems to outside causes (Thomas, 2002) – outside of the nursing profession. While internalisation can be selfdestructive and continue a sense of oppression and powerlessness, externalisation locates these problems outside of nursing thereby supporting the nursing team.
Nursing literature highlights the issue of oppression, powerlessness and a lack of ownership as critical elements causing communication breakdown for ENs more so than RNs as they have less control over their workload (scope of practice) and workplace (Chaboyer et al.,
13 2008; Heartfield & Gibson, 2005; Gibson & Heartfield 2003). Further research here will be important to uncover and direct strategies and resources to develop more harmonious and balanced nursing team communication.
A loss of collegiality (breakdown in communication) may be more commonly associated with generational workforce factors according to Leiter et al. (2010). The authors found from their study that Generation X nurses experience greater workplace distress from decreased collegiality than their older colleagues. This signalled cynical responses followed by a cognitive withdrawal leading to workforce attrition (Leiter et al, 2010). Nurses in this study referred to younger and older nurses however, no specific comments supported generational workplace issues as a cause of less collegiality.
According to the participants of this study, healthcare workers external to nursing teams may cause current communication breakdown. For example, at least one example of a loss of respect, civility and courtesy is reported by all focus groups from sources such as patients, families, visitors, and doctors. Cassirer, Anderson, Hanson and Fraser (2000) argue that there can be high levels of abusive behaviour between clinicians. This weakens the willingness and ability to work together effectively, and in turn, is a cause of errors that prejudice patient safety. The most common abusers are administrators and doctors, and the most common victims are female nurses and allied health professionals (Cassirer, Anderson & Hanson 2002).
Sadly, rude and aggressive behaviours in the healthcare setting have been experienced by at least two thirds of nurses in the past six months (Flin, 2010). Measureable outcomes include a
14 loss of concentration and decreased cognitive functioning, both of which affect nursing care outcomes, patient safety, and impact directly on retention (Flin 2010; Leiter et al. 2010).
Managing nursing team communication issues As far back as 2001, NSW Health (Douglas et al, 2001) released domains of best practice for clinical nursing care and suggested that “ conversations between senior and junior staff should be based on an acceptance that benefits accrue on all sides, rather than being seen to be granting of a favour to the junior staff,”. Since that time, numerous programs have been trialled to increase staff teamwork and collegiality. In NSW, the Essentials of Care Program, „Take the Lead‟ and the „Above the Line‟ program have been introduced as examples of transformative change management. The „Essentials of Care‟ (EOC) program was implemented across NSW Health in February 2008 and all NSW Area Health Services are now at various stages of implementation. The application of EOC is enabling nurses (ENs and RNs) and midwives to focus on the development of clinical environments that enhance patient care, teamwork and individual work satisfaction (NSW Health, 2009,).
Crucial to the success of these programs is the ability of the nursing team to identify values and beliefs around their clinical practice and themselves, and how these values translate into their everyday work. The identification of team values provides a basis to challenge practice and workplace cultures. Indeed, the anecdotal success of the „Above the Line‟ program is attributed to the ability of junior nursing staff to challenge (or call) a senior nursing staff member on their behaviour (or language or attitude) without fear of retribution or admonishment.
15 In all nursing teams the power and influence of the team leader remains a central feature. „Take the Lead‟ was introduced to nursing workplaces in 2007 in recognition of the crucial role of the Nursing Unit Manager. „Take the Lead‟ preliminary data analysis revealed that over 40 % of NSW Nursing Unit Managers (n= 264) identify a basic nursing entry level qualification as their highest level of education and that there was enormous variation in the job responsibilities across the state. Evidence also suggests that the higher the educational qualifications and professional status amongst nurses providing care, the better the patient outcomes (Aitken et al 2007). Therefore, the capacity and capability of those in the NUM role is crucial if they are to influence organisational culture, clinical and financial outcomes, retention and sustainability of the health care team.
The „Take the Lead‟ program reinforces that effective Nursing Unit Managers are role models for their staff, have a high degree of emotional intelligence and value equity and fairness. These values translate into day-to-day issues such as fair rostering practices, fair workload distribution and staff having equal access to education and professional development opportunities. Regular team meetings, open door policies and zero tolerance of workplace bullying and aggression will enhance nursing team communication and thereby increase workplace satisfaction. Staff retention rates may increase, and indeed, there can be a waiting list of staff wanting to join these successful teams.
Strengths and weaknesses A small qualitative study such as this, involving a small number of participants in a specific geographical location and at one point in time, is only able to provide an indication of some of the issues surrounding nursing team communication. While these findings cannot be generalised, it is initial scoping type studies such as this small project that can help to focus
16 the spotlight on what are the important issues in retaining and maintaining good collegial working relationships. The results can inform the creation and development of a specific measurement tool aimed at predicting successful nursing team communication in nurses‟ clinical practice. Conclusion Open and respectful communication is essential in today‟s dynamic and complex health environments. Patient safety is enhanced when the different team members can exchange information without fear of ridicule, contempt, or fear of their views being dismissed and ignored. The role of the Nursing Unit Manager may be crucial in setting the “tone” of their units, managing team relationships and clarifying above and below the line behaviours. Our focus groups of ENs demonstrated behaviours typical of oppressed groups that are not conducive to effective team outcomes. Respecting the scope of practice of team members, monitoring official and unofficial complaints about communication from patients, staff and external contractors and leading by example will be qualities that health facility senior management should actively seek and promote in their middle managers.
17
Reference list Apker, J., Propp, K. M., & Zabava Ford, W. S., (2005). Negotiating status and identity tensions in healthcare team interactions: an exploration of nurse role dialectics. Journal of Applied Communication Research, 33 (2), 93–115. Ball, E., McLoughlin, M. & Darvill, A. (2011). Plethora or paucity: A systematic search and bibliometric study of the application and design of qualitative methods in nursing research 2008–(2010), Nurse Education Today, doi:10.1016/j.nedt.(2010).12.002. Beanland, C., Schneider, Z. LoBiondo-Wood, G. & Haber, J., (1999). Nursing research: Methods, critical appraisal, and utilisation. Mosby Publishers Australia, South Melbourne. Birks, M. & Mills, J., (2011). Grounded theory: a practical guide. Sage, Los Angeles USA. Bonalumi, N., (2005). Collegiality: It‟s Priceless (Editorial). Journal of Emergency Nursing 32, 367. Burns, N. & Grove, S. K., (2009). The practice of nursing research: Appraisal, synthesis, and generation of evidence. (6th ed.). Saunders Elsevier, St Louis, Missouri. Cassirer, C., Anderson, D., Hanson, S., & Fraser, H., (2000). Abusive behavior is barrier to high-reliability health care systems, culture of patient safety. QRC Advisor 17(1), 1-6. Chaboyer, W., et al. (2008). Comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study. International Journal of Nursing Studies 45, 1274–1284. Dearnley, C. A., (2006). Knowing nursing and finding the professional voice: A study of enrolled nurses converting to first level registration. Nurse Education Today 26, 209–217. Douglas, N., Robinson, J., & Fahy, K., (2001). Inquiry into Obstetric and Gynaecological Services at King Edward Memorial Hospital 1990-2000. Health Department of Western Australia, Perth Australia. Duchscher J. E. B., (2009). Transition shock: the initial stage of role adaptation for newly graduated Registered Nurses. Journal of Advanced Nursing 65 (5), 1103-13. Duffield, C., Kearin, M., Johnston, J., & Leonard, C., (2007)a. The impact of hospital structure and restructuring on the nursing workforce. Australian Journal of Advanced Nursing 24(3), 42-46. Duffield, C.M., et al., (2007)b. Glueing it together: nurses, their work environment and patient safety, Centre for Health Services Management, UTS, Sydney, 1-243. Duddle, M. & Boughton, M., 2008. Development and psychometric testing of the nursing workplace relational environment scale (NWRES). Journal of Clinical Nursing 18, 902–909.
18 Forni, S., Tijerina, L., Hunter, B. & Davenport, D., (2009). Engaging the nursing workforce: a hospital‟s approach to linking best practices with positive outcomes. Nurse Leader 7 (6), 369, 44. Freeney, Y. M. & Tiernan, J., (2009). Exploration of the facilitators of and barriers to work engagement in nursing. International Journal of Nursing Studies 46, 1557–1565. Garling P. Final report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. Sydney: NSW Government, 27 Nov 2008. (accessed June (2011)). http://www.lawlink.nsw.gov.au/lawlink/Special_Projects/ll_splprojects.nsf/pages/acsi_finalre port Goldblatt H., Granot M., Admi H. & Drach-Zahavy A., (2008). The experience of being a shift-leader in a hospital ward. Journal of Advanced Nursing 63(1), 45–53. Glasser, B. G., & Strauss, A., (1967). The discovery of grounded theory: Strategies for qualitative research. Aldine, Chicago. Hearnden, M., (2008). Coping with differences in culture and communication in health care. Nursing Standard 23 (11), 49-57. Krueger, R.A., & Casey, M. A., (2009). Focus groups: A practical guide for applied. (4th ed). Thousand Oaks CA: Sage Publications. Leiter M. P., Price S.L., & Spence Laschinger H.K., (2010). Generational differences in distress, attitudes and incivility among nurses. Journal of Nursing Management 18, 970–980. Levett‑Jones, T., Lathlean, J., Higgins, I., & McMillan, M., (2008). The duration of clinical placements: a key influence on nursing students‟ experience of belongingness. Australian Journal of Advanced Nursing 26(2), 8-16. McCreaddie, M., & Payne, S., (2010). Evolving grounded theory methodology: Towards a discursive approach. International Journal of Nursing Studies 47, 781–793. NSW Health Nursing and Midwifery Office, (2009). Essentials of Care Resource Guide for Facilitators. NSW Department of Health, Government Printers. O‟Connell, B., Duke, M., Bennett, P., Crawford, S., & Korfiatis, V., (2006). The trials and tribulations of team-nursing. Collegian 13 (3), 11-17. Polit, D. F., & Beck, C., (2006). Essentials of nursing research : methods, appraisal, and utilization. (6th ed.). Lippincott Williams & Wilkins, Philadelphia. Proto, M. B., & Dzurec, L.C., (2009). Strategies for successful management and oversight of nurse faculty workforce initiatives: Lessons from the field. Journal of Professional Nursing 25(2), 87–92. Quick, J. C. & Tetrick, L. E. (eds) (2011). Handbook of occupational health psychology. (2nd ed). American Psychological, Washington, DC.
19 Redmond, R., & Curtis, E., (2009). Focus Groups : Principles and process. Nurse Researcher 16 (3), 57-69. Thomas, L., (2002). „Poststructuralism and therapy – what‟s it all about?‟ International Journal of Narrative Therapy and Community Work 2, 85-89. White, K. A., (2009). Self-Confidence: A Concept Analysis, Nursing Forum 44(2), 103-114.
20 Table 1 Semi-structured focus groups trigger questions
1.
Tell me about the usual communication between the nurses in your workplace. Do you discuss the issues of communication with others?
2.
What, in your opinion, makes for good communication between all of the nurses in your workplace?
3.
Tell me about the challenges or obstacles that you have experienced?
4.
What strategies do you use for these challenges or obstacles and what practices do you have in place to overcome them?
5.
From your experience of working and communicating in a nursing team, what would you like to say to those who were considering a career in nursing?
6.
Would some of you like to share what may be one of your best experiences in working as a nursing team since you took up nursing?
