International Journal of Nursing Practice 2001; 7: 406–413

INTRODUCTIONNursing in hospitals involves negotiating complex inter-personal relationships and working in a social and politi-cal context within economic constraints while balancing a multiplicity of tasks and roles. Nurses are busy practi-tioners who need to have a broad range of clinical knowledge and skills, and they are accountable to manypeople.1–3 Authors agree on the chaotic nature of nursingpractice and the constraints nurses face everyday in deliv-ering quality care.4–8

This project aimed to facilitate reflective practiceprocesses in experienced RNs in order to raise critical

awareness of practice problems they face everyday,work systematically through problem-solving processes touncover constraints against effective nursing care andimprove the quality of care given by nurses in light of theidentified constraints and possibilities. The significance ofthe project was in improving nursing care and in educat-ing nurses in processes they can use for a multiplicity ofclinical problems that emerge in their practice well afterthe completion of this project. In this project, nurseschose to identify and begin to transform dysfunctionalnurse–nurse relationships.

Literature reviewThe literature review included the origins of actionresearch and reflection in nursing, and the thematicconcern raised by the group of dysfunctional nurse–nurse

✠ R E S E A R C H P A P E R ✠

Identifying and transforming dysfunctionalnurse–nurse relationships through reflective

practice and action research

Professor Bev Taylor RN, RMProfessor of Nursing, Southern Cross University, Lismore, NSW, Australia

Accepted for publication January 2001

Taylor B. International Journal of Nursing Practice 2001; 7: 406–413Identifying and transforming dysfunctional nurse–nurse relationships through reflective practice

and action research

This project facilitated reflective practice processes in experienced Registered Nurses (RNs) in order to raise criticalawareness of practice problems, work systematically through problem-solving processes to uncover constraints, andimprove the quality of care given by nurses in light of the identified constraints and possibilities. Twelve experiencedfemale RNs working in a large Australian rural hospital shared their experiences of nursing during three action researchcycles. A thematic concern of dysfunctional nurse–nurse relationships was identified, as evidenced by bullying and hori-zontal violence. The negotiated action plan was put into place and participants reported varying degrees of success inattempting to improve nurse–nurse relationships.Key words: action research, bullying, dysfunctional nurse–nurse relationships, horizontal violence, reflective

practice.

Correspondence: Bev Taylor, Professor of Nursing, Southern Cross Uni-versity, School of Nursing and Health Care Practices, Lismore, NewSouth Wales 2480, Australia. Email: btaylor1@scu.edu.au

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relationships, a full description of which appears in thereport by Taylor.9

Action research and reflection innursing

Hart and Bond identify seven criteria in action researchthat distinguish it from other methodologies.

Action research is educative, deals with individuals as co-researchers

of social groups, problem-focused, context-specific and future-

oriented, involves a change intervention, aims at improvement and

involvement, involves a cyclic process in which research, action and

evaluation are interlinked and is founded on a research relationship

in which those involved are participants in the change process.10

It may also be useful to think of action research as a con-tinuum along which types of action research range fromLewinian to participatory and cooperative research, inwhich the barriers between researcher and participantsare removed.11,12

Action research in nursing has been varied and itincludes studies aimed at changing working conditions fornurses, helping them reclaim their authority, organizingthemselves to be more effective in their practice and toclarify their roles and their status. It has facilitated self-directed learning and provides a means of dealing withproblem-solving, planning and evaluating.10,13–15 Actionresearch does not only aim to change and improve prac-tice, but it also has the ability to empower participants byallowing them to acknowledge who they are as people andhaving a sense of self-determination.16

Blumberg argued that practitioners need ‘to changehow they think about their work’ in that they need to valuethemselves as practitioners and the knowledge and skillsof their day to day practice.17 Research has shown thatreflective practice offers nurses a strong sense of personaland professional worth, although caution has been empha-sized about the high degree of personal investmentrequired by nurses for successful practice outcomes.3,18–21

Argyris and Schon and Argyris, Putnam and Smith havesuggested that practitioners such as nurses often practiceat less than effective levels because they follow routine.22

Further, their actual practice does not necessarily coincidewith their ‘better knowledge’ or espoused theories aboutgood practice. In fact, as Kim suggests, they may not even be aware of this divergence.23 Action research thatincludes reflective practice is a way of determining whynurses’ perceptions of their practice diverges from idealpractice.

Dysfunctional nurse–nurse relationshipsUnfortunately, the reality is that nurses’ working envi-ronments are often fraught with workplace violence in the form of horizontal violence, also known as bullying or mobbing. For the present study, workplace violencewas more narrowly defined in terms of dysfunctionalnurse–nurse relationships.

Workplace bullying is extensive but tends to go unre-ported. She suggests that it is often based on personal envywith the bully revealing an unpredicatable ‘Jekyll andHyde character’. Furthermore, bullying in organizationstends to filter from the top down and is often seen as anacceptable way of managing and getting promoted. Smithsuggested that more qualitative studies are needed toinvestigate the effects of bullying and possible ways of preventing recurrences.24

Literature about bullying in the workplace derivesmainly from non-health arena publications. Australian literature about workplace violence in the health contextis largely anecdotal with the exception of the work byauthors such as Glass, Serghis and Farrell that report on a study by the South Australian Working Women’sService.25–31 However, recently, organizations such asnurses’ unions, the Online Nurse Advocate and theQueensland Women’s Service have released statementsand accounts about bullying in the health sector on theInternet, and the problem of horizontal violence innursing is becoming more familiar.

The reasons for the prevalence of horizontal violencein nursing have been investigated from various perspec-tives. Spring and Stern comment that nurses enter theirprofession after having been educated to be caregivers.33

This means that they take on the role of carer and advo-cate for their patients whose needs always have priority.As a result, nurses’ humanity and their needs are often notacknowledged. In addition, nurses, who are traditionallyfemale, have undergone socialization into the female roleor otherwise grown up in situations where they learnedto be caregivers.32,33 Nurses are outer-focused as a resultof their daily exposure to human illness and tragedy.According to Spring and Stern, this leads to a desensitiza-tion about the effects that these daily experiences have onthem. Largely women, nurses remain an oppressed pro-fessional group. A sense of powerlessness and helplessnessoften turns into oppressed personal behaviour that isturned against colleagues. In reality, such behaviour isadaptive in that it consists of displaced attempts at gainingpower in helpless situations. Finally, nursing has a long tra-

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dition of hierarchical power-structure in which the youngand less experienced are the targets of victimization.Nurses themselves maintain the status quo through denial,minimization and ritualization, and thereby overlook theeffects of horizontal abuse. Not only are there personalconsequences of abuse but also for the profession as awhole.

In summary, action research that encompasses reflec-tive practice is generally considered a useful tool in thedevelopment of nursing knowledge for reducing thetheory–practice gap, increasing nurses’ professionaliza-tion and enabling their empowerment on several levels.Different nursing scholars emphasize different aspects ofreflective practice and action research depending on theirareas of interest and their academic perspectives. Whatmost would have in common is the aim for nurse eman-cipation and excellent patient care. The problem of workplace violence is multifaceted and not easily solved.Various possible avenues for addressing the problem havebeen suggested and nurse empowerment and emancipa-tion through various means appear to be fundamentalsteps toward creating a more positive work environmentfor nurses and, hence, improved patient care.

METHODGiven the collaborative nature of the project, a qualitativeapproach was chosen, informed by reflective practitionerconcepts and the technical, practical and emancipatoryintentions of action research.34 Full ethical clearanceprocesses through Southern Cross University and theNorthern Rivers Area Health Service preceded the com-mencement of the project. It was intended that theresearch would be for a 12-month period from January toDecember 1999. However, difficulties in recruiting par-ticipants necessitated a change of setting; therefore, theproject began in August and finished in late December1999. Convenience sampling was used to target inten-tionally those research participants who were interestedin reflecting on their practice in order to improve it.Twelve experienced female RNs working in a large localrural hospital with an age range of 25–50 years agreed toparticipate on a 1 h per week basis for 16 weeks.

The number of participants was appropriate for a quali-tative project because of the potential of the research togenerate rich data sufficient to bring about changes inwork practices.The number of participants was also con-gruent with the assumptions of qualitative research, whichemphasize the context-dependent quality of process,

experience and language. Therefore, this project did notseek high numbers to generalize results or use them forpredictive purposes. Also, in collaborative research of thisnature, the process becomes as important as the potentialoutcomes because the focus is on what people learn asthey experience the research itself.35

The nurses met weekly for 1 h to discuss clinical problems raised in journal writing and discussion. Theresearcher acted as a group facilitator and as a guide in theresearch processes by keeping meeting notes, writing upminutes, preparing agendas and contributing as appro-priate. Introductory sessions allowed group members tobecome familiar with some reflective practitioners andaction research literature, and with the activities outlinedin the project materials.9 Processes to enable effectivereflection included coaching and practice in writing andspeaking descriptively, confidentially and in facilitativegroup meetings. Confidence was bolstered in undertakingreflection in practice (during practice) and reflection onpractice (after practice) through individual and collectivestorytelling, keeping a journal, critical analysis and discussion.

The methods of action research involved a four-stageproblem-solving approach of collectively planning, acting,observing and reflecting. This phase led to another cycleof action in which the plan was revised, and further acting,observing and reflecting was undertaken systematically to work towards solutions to problems.The planning andacting phases included keeping a journal as a method ofgathering and analysing data. The non-confidential parts of journals were shared with peers in the weekly groupmeeting. Participant observation occurred during practicein clinical areas. Notes and/or journal entries were madeafter the nursing activities, given the immediacy of clini-cal situations.

The data analysis method included an analysis of journalexperiences by individual and group critical reflection,and problem-solving strategies. Group discussion alsoidentified the specific nature and determinants of theproblems, the most appropriate methods to investigateproblems further and the most practical and useful planof action. Descriptions of participant observation wereanalysed individually using a reflective analysis methodand collectively by group discussion. In each actionresearch cycle, the findings were pooled and discussed andthe appropriate action was planned and taken.34 Succes-sive observation of the effects followed before furtherreflection led to further action and analysis.

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RESULTS AND DISCUSSIONIn this project, there were three discernible actionresearch cycles. The first cycle (weeks 1–3) involved thedevelopment of group processes, becoming familiar withthe research aims and action research and reflectiveprocesses. The second cycle (weeks 4–7) involved usingreflective processes to locate individual and collectivepractice issues. Difficulties with nurse–nurse relationshipswere identified as important, specifically dysfunctionalbehaviours such as bullying and horizontal violence. Thethird cycle (weeks 8–16) involved working together onthis common practice issue to generate and act, and reflecton an action plan. The activities within the three actionresearch cycles were documented in the group’s minutesand confirmed weekly as faithful accounts by the groupmembers to represent the analysis and interpretationprocesses of individuals and the collective.9

First cycle (weeks 1–3)In the first meeting, packages containing a meetingagenda, a summary of action research, a summary ofreflective practice, an exercise book to be used as a journaland two articles to read on action research and reflectivepractice, respectively, were given to participants. Partici-pants and researchers were introduced using a ‘round thetable’ approach, and participants told the group wherethey work and why they decided to join the group. Thegroup moved through the agenda at a relatively relaxedpace as the following week could be used to get throughthe introductory ideas. The use of keeping and sharing ajournal, being involved in discussion and being involved inaction research cycles was explained.

Rules and dynamics were discussed in order to pre-serve individual’s privacy and confidentiality.This led to adiscussion of the areas that were important to the group.Researchers described the kind of group dynamics thatthey hoped would be fostered so that trust, openness andconfidentiality could be established and maintained.Theseincluded applying the general rules of professional confi-dentiality as practised already in work settings to thegroup, a respect for others’ feelings, informing the groupif an area being shared was confidential as sensitivities may vary, listening carefully, acknowledging the personspeaking if only with attention and a nod of the head,refraining from criticism and unnecessary advice, andwithholding the desire ‘to fix things’ except in cases wherethat was the explicit intention.

The point that reflective disclosures should only bemade at a level with which individuals were comfortablewas reiterated. If any group member experienced pro-found catharsis or was in need of emotional support, itwould be offered by the group members immediately andappropriately (given they were RNs and registered mid-wives (RMs)), and if further help was required, names ofcounsellors were available. Also, journals were to be theprivate domain of individual participants (with the excep-tion of meeting process notes). When participants readfrom their journals, it would only be those excerpts theychose to share with the group.

In the second and third meetings, we continued todiscuss and practice group processes. The agenda topic of how we could manage power influence differences in the group and these areas were discussed. Strategiesincluded making sure everyone had a voice, encouragingresearchers who were not speaking while being sensitiveto their need to be quiet at times, and accepting speakersin non-judgemental ways. It was recognized that powercomes from different amounts of knowledge, and foreveryone to feel equal and empowered, we needed torespect each other’s knowledge.

An action research summary sheet that was handed outpreviously was used to explain data collection (planning,acting, observing) and data analysis (reflecting) ideas in action research. A summary sheet on reflection was read out describing the reasons why it was useful toreflect on childhood experiences and ‘rules of living’.Each researcher either read out or were encouraged to write out their own childhood memories and reflec-tions. Some discussion followed about what the task wasabout, why it was important and hints for how to reflectspontaneously.

Many researchers shared their experiences ‘from theheart’ and generously offered their insights into them-selves as people and practitioners. The group discussedsome of the ideas raised and supported one another as sensitive and precious disclosures were made. Mostresearchers indicated that they found the reflectivewriting task useful and enjoyable. One researcher sharedthat she has difficulty speaking her ideas, but found writingthem so easy that she had written many pages in her journal and that she really enjoyed the experience.Researchers were guided through a summary sheet for writing a practice reflection and it was reiterated that the group would have at least 4 weeks to share practice stories and to decide on a thematic concern

410 B.Taylor

to work on together using action research and reflection.

Second cyle (weeks 4–7)In the second cycle, the group located individual and col-lective practice issues within participants’ stories. Eachstoryteller was guided through the reflective process oflocating the bases of their actions, and of looking at all ofthe determinants and constraints of the situation. Tworesearchers shared from their journal and responded tothe group questions, comments and other contributions.The first story had an underlying theme of advocacy, ofwanting to speak up in situations where it is difficultbecause of doctor–nurse relations and professional expec-tations about roles. The story also sparked discussionabout horizontal violence in nursing and how ‘nothingchanges’ in some respects when it comes to some nega-tive aspects of professional relationships.The second storycontained a theme of professional victimization and thegroup discussed many issues relating to this story, includ-ing a sense of betrayal by peers, fear of powerful hierar-chical figures, problems about clinical incompetence inpeers, doctor–nurse relations, nurse–nurse relations, theneed of fearful obedience and the message to not com-plain. For many of the stories, researchers acknowledgedsimilar circumstances and responses.

When locating and collating issues in practice reflec-tions, researchers talked about the issues they had notedin their journals and the meeting discussions. Theseincluded many issues that grouped into two main areas,professional relationships and professional identity. Pro-fessional relationships included the doctor–nurse,patient–nurse and nurse–nurse relationships.Within theserelationships, there were issues of gender, hierarchy,communication, peer pressure in decision-making, power,advocacy and recognition as professionals. Professionalidentity included issues such as guilt, regret,‘feeling I havenot performed’,‘not really knowing my work peers’, lackof confidence and self-esteem, blaming the past instead oflearning from it, feeling responsible, needing to be invin-cible and perfect, having pride in work, needing to achieveand accountability.The two categories were discussed andit was realized that they were related in that if the profes-sional identity issues were remedied, professional rela-tionships would most probably benefit also. The groupdecided to focus on professional relationships and to seeif some of the other issues from professional identity arealso addressed along the way.

Third cycle (weeks 8–16)The third cycle involved working together on a commonpractice issue to generate, act and reflect upon an actionplan. The group decided that they wanted to remain asone large group rather than divide into two smallergroups. At this point, appreciation was expressed for theprocess thus far and researchers acknowledged how muchthey had derived from the trusting and open dynamics the group had evolved over the time that they had beenmeeting.

As nurse–nurse relationships were being discussed,analogies were raised for other researchers who relatedsimilar issues.The conversations were very direct and thestories were risky in terms of anonymity and confiden-tiality. At this point, one researcher asked how the groupcould be sure that they were doing research and notengaging in a ‘witch hunt’ for certain unfavoured individ-uals.The group realized that they needed to discuss issuesdirectly, clearly and with a very high degree of confiden-tiality in order to approach these issues effectively.

The statement was repeated that the group was focus-ing on nurse–nurse professional relationships as they werethe ones that this group could probably fix. At that point,a researcher produced a ‘Lamp’ article that related to theincidence of bullying in workplaces and its prominence innursing.36 While the group were grateful for the insightsprovided, they agreed that they needed to be careful toavoid assuming that all nurse–nurse relationships that donot work well are based on some form of bullying.

The planning phase continued as the group looked at‘filling in the gaps’ in the participant’s stories to find com-monalities and general principles about how to managenurse–nurse professional relationships. Each situation wasinvestigated about how it came about, and what could bedone about them. For example, in one story, the issueswere about devious behaviour, bullying by proxy, betrayaland being let down, and problems that occur when eventsare twisted out of context. Professional jealousy and theuse of power in a manipulative way might have been determinants in the situation, related to perpetuating theculture of horizontal violence.

The sheet that was prepared for analysis of the scenar-ios was looked at to find commonalities and principles ofaction, the group noted that the common issues and feel-ings were all of a negative, unfair, unprofessional and dis-empowering nature. The common determinants could belinked to the historical progression of nursing, culturalnorms in roles and relationships, and political and per-

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sonal aspects of interpersonal communication in nurse–nurse encounters in the hospital setting. For example,researchers identified the possibilities of low self-esteemin the person causing the problem, gender issues of under-mining and horizontal violence, bullying by proxy,attempts to carry out a ‘put down’, professional jealousyand the use of power in a manipulative way.

The list of common strategies from the previous meet-ings was varied and contained numerous suggestions, withthe addition of a review of job descriptions to ensure thatpersons had acted within the boundaries of work activi-ties and responsibilities. The next step was to look at thelist of strategies and prioritize them into a plan of action,which needed to be flexible to allow for unforeseen effectsand constraints in the situation, and allow the group to gobeyond present constraints to become empowered to actmore effectively in the situation.

The group discussed and subsequently eliminated thoseideas that were too non-specific, idealistic and unlikely tobe of practical use in the weeks remaining in the project.The strategies to ‘stay in’ the action plan included: (i)starting a culture of positive strokes and acknowledge-ment; (ii) deal with the nurse directly and immediatelyand through recourse to policies and procedures; (iii)provide strong leadership; (iv) look carefully at the deter-minants of situations and try to ‘turn them around’; (v)engage in conflict resolution; (vi) raise the possibility thatmaybe nurses are in need of recognition, acknowledge-ment and involvement in creating practice policies; (vii)encourage nurses to support each other; (viii) use evi-dence and documentation procedures; (ix) use the line ofcommand; (x) build skills to deal with situations directlyand/or ask for facilitation as soon as possible; and (xi) use‘people power’ and a ‘united front’ to senior staff in theline of command.

The group agreed that the list of strategies had manyideas within it that begged the question of ‘how?’. Forexample, how can we handle these issues directly, providestrong leadership and deal with conflict resolution? Thegroup discussed how it would be necessary to approachsituations directly with a tentative and gentle attitude,seeking to clarify the situations. Reflective listening wouldbe needed, and organization face-to-face meeting betweenkey peoples would be required, with strict attention toconfidentiality. Specific skills, such as statement of one’sown feelings and paraphrasing, were necessary. Knowingthe difference between aggression and assertiveness wasimportant so that direct approaches to conflict resolution

used the attitude and skills discussed in such a way that allparties felt that they were being heard in order to nego-tiate fair and reasonable solutions to nurse–nurse rela-tionship problems.

The intention of the research from then was to usewhatever skills in the action plan deemed appropriate todirectly manage nurse–nurse professional relationshipproblems that arose in the weeks ahead. Observations of the effectiveness or otherwise of the strategies would be written in journals. Stories would be shared in meetings as to the success of the actions and adjustmentswould be made along the way to make them as effectiveas possible.

When the group began sharing the effectiveness of theaction plan, an opening comment was,‘It feels good to bepositive’. Two stories were shared relating to the use ofthe action plan. The first story was about a situation inwhich the researcher felt reactive, recognized her feelingsand turned it around so that it was no longer an issue forher. After group discussion, the researcher said that shemight speak with the nurse to clarify her position. She felt that she had begun to establish a culture of positivestrokes by her action in being self-reflective and non-reactive.

The second story involved a researcher’s use of manyof the strategies in the action plan that turned out to beof little use given further events over time, which exac-erbated nurse–nurse relationships. Researchers wereaware of the situation and provided other perspectives on the same situation. As the perspectives unfolded, itbecame apparent that the situation was very complex andthat it involved nurses’ equal willingness and ability tocommunicate openly and directly. It also showed that ittakes courage to communicate effectively and that thereare perils inherent in trying to be everything to everyone,and difficulties can ensue with an unclear and broad jobdescription.Thus, the first try of the action plan resultedin stories with different outcomes.

The group discussed how important it was to realizethere were no quick fixes and that the nurse–nurse rela-tionships were complex and required lots of work inacting, observing and reflecting in the goal of improvingthem.

As the group continued to explore the benefits of theaction plan for improving nurse–nurse relationships, oneresearcher said that she found herself communicatingdirectly more often. For example, if someone came up toher ‘for a whinge’, she checked whether or not she should

412 B.Taylor

regard the interaction as ‘just a whinge’ or something thatshould be taken further. The discussion then turned towhat to do when you do your best to communicatedirectly and with all the ideas in the action plan, and theother party is unwilling or unable to do likewise. Sug-gestions often resembled the action plan, for example, toprovide strong leadership about how to communicate,recognize the person’s lack of skills/willingness, usedirect one-to-one approaches and then resort to the lineof command if necessary.After many anecdotes, the groupcame to the conclusion that nurses from various back-grounds face multiple constraints in their practice andthey are often thwarted in giving ideal care and commu-nicating with each other. This being so, the group allneeded to recognize their parts in this and the contribu-tion of constraints, forgive themselves for their imper-fections and work towards identifying and remedying theconstraints.

The group reviewed the progress of the previous fewweeks, pointing out that the action plan had been usedwith some success with researchers being able to get thebasis of their interactions with other nurses. Also notedwas that they had been able to look at some of the eco-nomic, sociocultural and political reasons for problems innurse–nurse relationships.

During the informal last meeting that served as a groupfarewell and Christmas celebration, researchers agreedthat there was a need for ongoing connections so that thespirit engineered in the meetings could continue. This wasdeemed possible if researchers gathered for regular con-versations and support, and that they woud be coached tomaintain their own group processes for any problems theymight have.While they agreed that the processes had beenhelpful, they also acknowledged the need for the role ofan outside facilitator. Unfortunately, the group did notcontinue in a self-supporting fashion the following year,although positive feedback is still being received about theprocesses.

CONCLUSIONIn this project, researchers shared their experiences ofnursing during three discernible action research cycles. Athematic concern of dysfunctional nurse–nurse relation-ships was identified as evidenced in bullying and horizon-tal violence.The negotiated action plan was put into placeand researchers reported varying degrees of success inattempting to improve nurse–nurse relationships. As theliterature suggests, dysfunctional nurse–nurse relation-

ships have a complex pathology and they might be diffi-cult to eradicate.This project confirmed the necessity forreflective practice and continued collaborative researchprocesses in the workplace to bring about a culturalchange within nurses’ collectives and in the places inwhich they work that weigh against mutual respect andcooperation in nurse–nurse relationships.

ACKNOWLEDGEMENTSThis project was funded by a Small ARC grant of A$6000.Thank you to all the researchers in this project, you knowwho you are. Thank you also to Dr Liz Porritt for herexcellent research assistance.

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