Introduction

Communication, a critical leadership function on a clinical unit, involves more than the spoken word. The participants convey far more through nuance, gesture, direct gaze, and posture in transmitting their interest toward the speaker and the exchange of information. Few studies have focused on a nurse-to-nurse communication pattern; most nursing communication research has centered on nurse-client interactions in a variety of settings rather than the actual observed verbal and nonverbal behaviors of nurses, particularly their leader-follower shift-report communication.

The majority of a nurse leader’s time is spent communicating with other nursing personnel. In any information exchange, communication encompasses content and relationships; thus, staff interaction is key to nursing outcomes, satisfaction levels, and retention. Each individual influences others, and is influenced by others.^1,2 Within an exchange, “both persons reward each other [with] mutual praise.”^3p163

This article describes supporting behaviors, one aspect of an exploratory study of the interactions of registered nurse (RN) leaders and followers during shift report in a hospital setting. The purpose of the article is to describe the observed supporting behaviors of RNs as they listen and respond to each other during their usual shift report. Supporting behaviors were selected as a significant reporting entity for the initial analysis of the video recorded reports in keeping with the American Nurses Association’s Cabinet on Nursing Research’s goals for the new century.⁴

Framework
In Hersey and Blanchard’s Situational Leadership (SL), leader behavior varies according to the followers and the situation.⁵ A leader engages in task or one-way communication by being directive. Supportive or relationship behavior is demonstrated when a leader engages in two-way communication, thereby becoming a facilitator in difficult or unfamiliar situations and fulfilling affiliation needs. These leader-follower behaviors can be observed within shift report.

A leader’s ability to influence followers often lies not in the leader’s actual behaviors, but rather in the appropriateness of those behaviors to the setting. Follower behaviors also influence the leader by triggering particular responses, thereby affecting the leader’s leadership style. A follower’s ability and willingness impacts the situational task.

A common language, mutuality, occurs when both the leader and follower listen and send messages.³ In such an interchange, leaders and followers help “each other (not just the manager) make changes in their behavior”^5p311 and therefore have a significant impact on nursing care.⁶

Leader-Follower Roles
In selected settings, a leader-follower relationship exists between the RN charge nurse (leader) on the off-going shift and the oncoming staff of RNs, who are in the role of followers. Each individual brings values, experiences, and skills that influence the interactions, including the need to “maintain a sense of personal worth and importance.”^7p109 Leaders and followers are “often the same people playing different parts at different times.”^8p146

Leaders and followers need to “express goodwill,”^1p242 that is, a mutual respect, support, and concern for each other within shift report.^1,3 “People who respect one another generally try to understand one another.”^1p242 Consequently, when negative information is presented within such a mutually supportive climate, there is “less need for anger, defensiveness, or withdrawal.”^3p163

Although the literature repeatedly refers to environments that incorporate a supportive communication, the actual behaviors in such environments are unclear. In an 8-year study, Gibb described supportive interactions as messages that describe behavior, focus on the issue, and display warmth and equality.⁹ Valuing others as worthy of concern allows both individuals “some control over the shared quest or the investigation of the ideas,” whereby supporting behavior promotes supporting behavior. ^9p148

However, self-reports or personal interpretations of these supportive behaviors traditionally have been used as the measuring tool.¹⁰ Albrecht and Adelman defined support as two persons verbally and nonverbally influencing each other in order to ease doubt and anxiety about the self, the situation, and their relationship. The process results in an “increased sense of personal control over an otherwise unpredictable and confusing situation.”^10p38 This process is tempered by how well acquainted members of the dyads are.

In work scenarios, Albrecht and Halsey found that nurses identified managers who listened and reassured them as demonstrating support.¹¹ Peterson and colleagues reported that supportive managers were able to “reframe and redefine situations,”^12p38 even during admonition or counseling, thus enhancing the follower’s self-worth and decreasing his or her anxiety.

The importance of the leader-follower role in staff relationships within the shift report is significant in work performance. Pincus reported that head nurse-staff nurse communication was the most important influence in effectively carrying out hospital responsibilities, citing the “communication climate, and personal feedback.”^13p23 In studies of employee-supervisor dyads and performance, Peck found that a “relationship style of leadership was associated with units that performed well.”^14pv Patz and colleagues identified skill in human management as the top priority for middle managers. ¹⁵

Mutual respect and approval of the other seem to be lacking in shift report, the most intense period of information exchange.^16,17 In Wolf’s 12-month study of a hospital unit, the implicit function of the shift encompassed more than just forwarding information. Rather, the report served as a forum where “negative criticism prevailed, not praise for work well done.”^17p277 Although shift report is analogous to physician-staff teaching rounds, the “atmosphere for, and opportunity to engage in collegial sharing is not built into the system of the nurses’ intershift reports.”^16piv

The effect of peer relationships on staff collegiality and, ultimately, quality of patient care, has been proposed previously.^6,18 Interactions can accentuate or diminish the status differential between participants.¹⁹ Peterson and colleagues concluded that identifying behavioral interactions “that enhance the supportive process was a crucial step toward improving the quality of relationships in the hospital setting.”^12p38

Methods

Design
This study, using a single-case design with repeated measures, was designed to examine the communication behaviors of RN leaders and followers during shift report in a medical-surgical intensive care unit of an urban hospital in the Southeast. The shift report was selected because it is a forum for communicating priorities for care, includes situations that generate the behaviors of interest, and provides scheduled observational opportunities.

Sample and setting
The sample consisted of the voluntary participation of four charge RNs (leaders) and 13 staff RNs (followers) from the evening 12-hour shift on a medical-surgical intensive care unit in an urban hospital in a southeastern state. The unit was selected because reporting was conducted by verbal intershift reports. The follower sample varied on different days because of the inpatient census. A total of 24 minutes (2 minutes from each of the 12 shift reports) was analyzed.

Each report was observed in its natural setting, a conference room, via a small digital video camera recorder that was placed on a tripod at the end of the rectangular table. The RN leader sat at the opposite end of the table and the RN followers occupied the chairs along the sides. The investigator, who was independent of the hospital, began the recording, and then left the room. The same camera angle and natural lighting were used in each taping.

The four leaders were women, three Caucasian and one African-American, all employed full time. Their average age was 39; they averaged 12 years working in the current facility, and over 13 years in nursing. Two held 2-year degrees, and two held 4-year degrees.

The followers included eight women and five men; seven of the women were Caucasian and one was African-American; four of the men were Caucasian and one was African-American. The typical follower was 37 years of age, BSN prepared, employed in the hospital for over four years and in nursing for eight years. Their employment in the hospital ranged from fewer than three months to 14 years.

The four RN leaders varied in participation in the reports (range = 1–5); the 13 RN followers participated in 1 to 7 reports. Only work schedules constrained the staff participation. The length of the reports ranged from 8:30 to 25:50 minutes, with a mean of 15:51 minutes.

Instruments
The researcher-developed Target Behavior Instrument (TBI), based on the Interaction Influence Analysis (IIA) by Hersey and Keilty,²⁰ consists of three behavioral categories and 10 observable behaviors, as given below.

I.          Effective leader behaviors

            1.         Directing

            2.         Asking closed questions

            3.        Asking open questions

            4.         Exhibiting supporting behavior

II.         Effective follower behaviors

            1.         Listening attentively

            2.         Accepting

            3.         Responding rationally

III.       Ineffective follower behaviors

            1.         Nonattentive listening

            2.         Rejecting

            3.         Responding irrationally

Either the leader or the follower may communicate the target behaviors.

The IIA²⁰ was first used in a pilot study in a metropolitan nursing home.²¹ Based on the outcomes of the study, the tool was refined to establish greater exclusivity to the categories, thereby creating the TBI. The TBI was patterned after Gelfand and Hartmann’s model for observing children²² in order to elaborate, cite examples, and specify questionable circumstances for scoring. For example, the supporting behavior targeted for this study was originally defined as “providing socio-emotional support.”^20p1 By using elaboration, supporting behavior was to be scored when praise, concern, reassurance, or “understanding, or positive regard for the other” was expressed.^23p508 An example cited for scoring was identified as complimenting the other on completing or attempting a task. One of the questionable circumstances was “that was OK”; this was not scored as supporting. The descriptive terms were drawn from the pilot study for relevance to the setting, and the completed TBI met the study’s objectives and behaviors of interest in that setting, as per Hawkins.²⁴

A communication expert established content validity by concurring that the target behaviors in the TBI represented the categories to be measured. Validity was strengthened by the mutually exclusive categories.²⁵

The TBI was then used to analyze a 2-week study of videotaped evening shift reports on one unit in an urban long-term care facility.²¹ The investigator and an expert in long-term care viewed the tapes together in real time in a test-retest procedure to establish 100% interrater reliability.

In both studies, the long-term care and the hospital,  the 3^rd and 4^th minute of each recording were selected for the analysis, thereby allowing a 2-minute warm-up period. The TBI was used to systematically identify and score the behavioral interactions. According to Wilmot, a dyadic relationship exists “as long as the two people, even in the presence of others, are engaging in face-to-face communication.”²⁶ The investigator and the communication expert viewed the videotapes together in real-time. To further refine supporting behaviors, nodding of the head at least two or more times by an individual was added to the subcategory of questionable circumstances for scoring purposes because it demonstrated reassurance, understanding, and concern in the hospital setting. Interrater reliability was 100% when the behaviors were analyzed in a 2-day period.

Procedure
Sixteen shift reports were video recorded in 19 days. This fulfilled the requirement for the use of repeated, frequent measures, which is a method of searching for variability in behavior.²⁷ Staff observation took place during the unit’s normal verbal intershift report. Prior to taping, the investigator viewed four reports as a nonparticipant observer. The first two video recordings then served as a baseline for the interactions. Two shift reports were later eliminated: one because multiple leaders gave report and the other because a non-participatory RN entered the room and interrupted report during the predetermined analysis period.

Videotaping is a valuable tool for reviewing clinical performance²⁸ and allows an analysis of person-to-person interactions.²⁹ The research adhered to the hospital’s Institutional Review Board protocol to protect the rights of the human subjects. Each participant gave written informed consent. The researcher emphasized to participants that the recordings were to reflect a naturally occurring report to minimize participant reactivity to the camera.

Results

No supporting behaviors were observed in the 162 charge nurse leader interactions. Only 11 supporting behaviors (6.8%), all nonverbal head nods, were identified in the 162 interactions by the followers.  No verbal statements of praise, support, reassurance, or concern were observed in any of the interactions. Table 1 displays the shift reports for each leader and the frequencies of supporting behaviors.

Table 1. Frequencies of Leader Shift Reports and Supporting Behaviors of Leaders (n = 4) and Followers (n = 13)
Leader No.	No. of reports	Leader supporting behaviors	Follower supporting behaviors
1	1	0	2
2	2	0	1
3	5	0	5
4	4	0	3
Totals	12	0	11

 

The seven staff nurses with supporting interactions consisted of four women and three men, median age 31. Three women were Caucasian, 1 was African-American; two males were Caucasian and one was African-American. Two held associate degrees; five held baccalaureate degrees. Their median length of employment in the facility was four years, and in nursing, five years.

The staff nurses, among whom no supportive interactions were observed, consisted of four women and two men, all Caucasian, median age 38.5 years. Two held associate degrees, two held baccalaureate degrees, and two held masters’ degrees. Their median length of employment in this hospital was 3.25 years, and eight years in nursing.

Supporting behaviors in the RN followers were identified in only six of the 12 (50%) shift reports, as shown in Table 2. Seven of the RN followers in these reports were women; four were men. One follower was an African-American. Men present at the reports numbered from 0 to 3. The supporting behaviors exhibited by both men and women were all nonverbal head nods.

 

Table 2. Shift Reports (N = 6) with Follower Supporting Behaviors (n = 11) with the Leaders (n = 4)
Report No.	Leader No.	Follower supporting behaviors
2	3	2
3	1	2
7	3	3
8	4	2
9	4	1
10	2	1

 

A visual inspection, one of the characteristics of single-case designs, was used to evaluate the environmental climate, thereby ensuring that only marked effects would be notable.³⁰ The environmental climate varied within the reports. For example, in Report 3, where supporting interactions were observed, all participants were women. The high energy level of all the participants was clearly apparent. A different leader, in another report, however, showed little energy or interest in the proceedings, even demonstrating indifference to the followers. In two reports, the leader was distracted by a critical telephone call regarding a patient; in another, an emotional exchange ensued regarding patient care.

Similarly, situational events impacted four of the other shift reports in which no supporting behaviors were observed. In Report 11, the leader had little energy, in Report 12, the leader was listless, and in Reports 6 and 14, the leaders exhibited total disinterest. Two high-stress situations combined with lack of energy were observed in Reports 6 and 14 with the same leader. Both situations involved the leader’s improper comments regarding two patients. In Report 6, the leader also showed such disinterest that the followers became apathetic, and each demonstrated only listening behavior. In Report 12, when the leader displayed little energy, the leader also made a statement of disapproval regarding a patient’s behavior, but the followers remained passive and accepting, as observed in a prior study in a nursing home setting.²¹

In contrast, Report 3 had an overall appearance of collegiality. The leader and the three followers were in the same 10-year age cohort (median age 41.5 years), with longer employment in this hospital (median 5 years), and in years worked in nursing (median 17 years) than either of the groups of followers with or without supporting behaviors. Their educational levels included an associate degree (leader), two baccalaureate degrees (followers), and one master’s degree (follower). All were women; one was African-American.

In comparing the followers who demonstrated supportive behaviors with those who did not in the remainder of the shift reports, the staff nurse followers who presented supportiveness were younger, yet were employed longer in the hospital. This may be a function of individuals’ fitting in with their cohort with similar backgrounds and their attraction to each other, and therefore, demonstrating similar behaviors. ³¹These same followers were also employed in nursing for fewer years suggesting that unsatisfactory relationships in other positions or settings may have affected the staff that did not display support.

Although the leaders had varying energy levels, both types of reports produced supporting interactions. Similarly, educational levels and ethnicity varied in the groupings. The influence of internal and external environmental factors supported the contention that significant positive or negative events occur during report and influence the participants.^17,32

In the reports in which the three leaders displayed indifference, the individual who was the actual charge nurse leader may have been perceived to be “less experienced.”^31p255 This “status incongruence” can be a disruptive factor and interfere with group cohesion.^31p255

Supportiveness by the followers did not engender supportive behavior even in the more experienced and educated leaders. The absence of these reciprocal behaviors may indicate a process of “system-disintegration,” as found in dysfunctional families, rather than the “system-integration” of functional families.^33p223 In Alexander’s study, functional families reciprocated each other’s supportive communications, whereas dysfunctional families did not.

Although the four RN leaders had extensive experience in the current facility, in hospitals, and in nursing, they did not exhibit supporting behaviors in the videotaping. The lack of positive, supporting interactions by the leaders and the few by the followers may be attributed to insufficient knowledge of the effect of verbal and nonverbal communication. In settings other than nursing, researchers have reported an absence of support within dyads. In a simulated business setting, Sims and Manz³⁴ reported that subjects emphasized task-oriented, as opposed to support-oriented, leader behaviors.

The observation of limited use of supporting behaviors is consistent with Wolf’s findings that the shift report is a place where criticism is more evident than praise.¹⁷ A possible explanation is that the atmosphere of the report has become ritualized with no defining philosophy established for leader-follower interactions.

Because shift report is essentially a directive conference controlled by the leader, it is expected that task information will be the primary communication behavior. The findings suggest, however, that when the interaction style expected in shift report is not clearly defined and previous history prevails, supportive behaviors will not be displayed. Further, in any conference, it is the responsibility of the participants to participate and not just to be there physically.³⁵ If supporting interactions become a part of the usual dyad and group routine, however, it is likely to engender similar interactions in the other activities within the unit.

Supportive behaviors provide a basis for not only collegiality but also professional ethics. Curtin and Flaherty called for nurses to “improve their relationships with one another” as an ethical commitment to the profession.^36p132 Further, educators need to teach nurses how to give and to receive “criticism, support, direction, and guidance.”^36p133 This nurse-to-nurse nurturing not only fosters collegiality but also helps the other to survive and to act professionally while doing so.³⁷ Expressing appreciation promotes belonging, a sense of team, a connecting to one another and, therefore, to one’s work unit.³⁸

According to situational leadership theory, both leaders and followers need to assess each other’s and the group’s ability and willingness to reinforce supportive behaviors because this developmental or maturity cycle differs, depending on the individuals. The group may be functioning at one level, but an individual may be at a different level. For example, neither the charge nurse leaders nor the staff nurse followers exhibited the supporting behaviors of verbal statements of praise or acknowledgment in the analyzed shift reports. In contrast, in a study of shift reports in a long-term care setting with an experienced Licensed Practical Nurse (LPN) and nurse aides (NAs) with varying levels of work experience, these verbal supporting behaviors were observed in the LPN.²¹

Supportiveness can only be applied when individuals perceive that their interactions will be rewarded by the unit and the organization and will contribute to their self esteem. Therefore, nurses need to inform each other of their perceptions and then respect those beliefs.

One unexpected finding was that the RN followers who demonstrated supporting behaviors were younger in age, but had longer current employment. A second unexpected finding was that the RNs with masters’ degrees, the highest education level among the study population, exhibited no supporting behaviors. Also of interest was that, in four of the six reports lacking the behavior of interest, the leaders’ vigor, energy, and interest were either subdued, low, or rated as nonexistent. The extreme variability of leader behavior from report to report was comparable to the variability seen in the LPN’s behavior.²¹ In both studies, the majority of the followers displayed less variability, that is, they exhibited more similar behavior patterns throughout the repeated measures. Followers may interpret the variable energy levels or the indifference of the leaders as an indication that the leaders consider the staff unimportant.

Limitations
Perhaps various personal issues, such as a second job, lack of sleep, or family concerns, affected the group climate and the staff’s ability to interact. The patients who were being discussed in the analyzed minutes may not have been the primary responsibility of those individuals, thereby prompting less interest. Cultural issues, which were not addressed in this study, could have affected the interactions. The use of turn-taking behaviors, regulators, and adaptors in the communication process also were not addressed.

Further limitations were the staff’s customary positioning and natural lighting. At times, the usual lighting and seating positions did not allow a total view of each individual, but interactions could be analyzed and scored because the TBI was developed with molar concepts; that is, large observable actions rather than small, precise muscle movements. The incorporation of the normal unit’s procedures in a natural setting, the exiting of the camera operator after starting the recorder, the baseline tapes, and the researcher being a nonparticipant observer prior to taping, minimized the Hawthorne effect.³⁹ Generalizability is limited although the sample size did allow the concentrated observation of a few individuals in a natural event and supports the study of the “uniqueness of the individual” in a practicing discipline that focuses on dyad and small group interactions.⁴⁰

Conclusions

Despite the limitations of the study, the following recommendations are proposed for recognizing, encouraging, and supporting other nurses in any clinical unit:

Although generalizability is limited, the analysis supports educating leader-followers to develop supportive behaviors. Future studies may serve as a bridge between the interrelationship of shift reports and leader-follower interactions with individual values and unit outcomes, staff recruitment to that unit, and retention. Turnover has more far-reaching results than just direct cost. The loss of a nurse or nurses interjects a feeling of negativity and/or a rejection of that unit while the use of any replacement staff, whether temporary or permanent, disturbs the communication patterns, hence, the work of the unit, and patient outcomes.

Managers can use situational leadership for ongoing education, including setting-specific interventions. The framework is appropriate for staff with wide-ranging maturity levels. The opportunity for staff to mutually grow can solidify bonding to the organization, thereby lessening their desire to change employers when individuals sense they are valued for more than the task.

This exploratory study provided an opportunity to learn from the results and to generate hypotheses such as finding the defining variable(s) in shift reports where supporting behaviors occurred versus those where they were absent. Future investigations that compare behaviors displayed in stable and unstable units, as demonstrated by staff longevity versus frequent staff turnover, may predict the effect of supporting interactions on the dyads, on the dynamics of the group, and on care outcomes.

References