Barton, Sandra A. MS, RN-BC; Alamri, Majed S. MS, RN; Cella, Denise MS, RN; Cherry, Katherine L. MS, RN, CCRN; Curll, Karen MS, RN; Hallman, Britney D. MS, RN; Mckeon, Rachel MS, RN; Meyers, Deborah L. MS, RN; Williams, Alyssa A. MS, RN; Zuraikat, Nashat PhD, RN
When you hear the word clique, you might automatically think of childhood. Consider the popular children's game musical chairs, where there's a seat for everyone, except one. The theme is exclusion. And cliques are all about exclusion.
Clique behavior continues through high school, into adulthood, and is increasingly evident within healthcare settings. Uncertainty in the current financial climate with job cuts, reorganization, and economic instability triggers anxieties, fear, and frustration. People regress in the face of uncertainty and change. They may revert to developmental behavioral patterns exhibited in childhood and teenage years.
Definition and recognition
A clique is defined as "a narrow exclusive circle or group of persons; especially: one held together by common interests, views, or purposes."1 Clique membership is usually exclusive and based on social qualifications. Factors supporting cliques include social standing, similar interests and goals, job title, and friendships. To maintain the clique power structure, bullying, harassment, or exclusion takes place. Nonclique members feel like outsiders. Cliques in the workplace can lead to a lack of trust, insecurity about job, lack of respect and appreciation, and the feeling of being left out. Most managers strive for teamwork in their departments. Managers must recognize whether their staff is working as a team or as a clique.
Nurse managers are well aware of financial costs related to staff recruitment and retention, so it behooves them to be able to identify clique behavior. A recent study reported experiences of student nurses just before graduation and 1 month following.2 The study revealed that immediately before graduation, the students had an optimistic outlook about embarking on their new career. After 1 month, the students reported an abrupt awareness of cliques in which they were excluded and given little to no support or assistance with new nursing tasks.2,3
Societal norms, psychological underpinnings
Society, as a whole, widely accepts clique behavior. Reality shows, such as Survivor, encourage cliques as a means to winning. Donald Trump's infamous line, "You're Fired," humiliates the outcast. The cold delivery of what one did wrong on Runway Model and American Idol is more assaultive than assistive. Why does human nature desire to witness human denigration?
One author observes a "link between perceptions of unfair treatment and workplace violence and bullying in particular. Frustration and stress are factors that further trigger aggression."4 Another expert notes that bullying behaviors are witnessed by student or novice nurses who then internalize these behaviors as the norm; "to gain a sense of belonging to the profession, the new nurses continue to bully others."5
So, what causes cliques to develop? Workplace conditions can often trigger bullying and harassment.6 These triggers can include high stress levels, inadequate training, organizational change and uncertainty, pressure from management staff, and unrealistic targets.6
The literature affirms that cliques destroy unit morale and lead to higher nurse turnover. Cliques also decrease patient-care quality. Cliques destroy an optimal work environment. The unit quickly turns into an us and them situation.3 Common repetitive behaviors toward nonmembers include criticism, spitefulness, blaming, and exclusion.7 These harmful actions are often directed toward new graduates or reassigned nurses.7
Within work environments, healthy groups can form through a common connection without damaging morale.3 Examples include new employees who've bonded during the orientation process or veteran staff members who've worked many years together. Although these are recognizable groups within the unit, they work together and share knowledge to reach the goals of the unit without excluding coworkers.3
A bully, often with superior social skills, is good at scheming and building a supportive cohesive group.6 He or she is usually an informal leader. Nurses often seek out cliques when looking for approval. However, cliques can become a means of protection where bullies may conceal themselves. Bullies gain support within the group by using the organizational structure and social bonds, thus increasing their power.
Why do some individuals bully or try to put others down? The primary reason is to ensure their acceptance and inclusion. They inflict upon others that which they fear for themselves. Somewhere in their past lies a history of trauma and they're destined to repeat the hurtful behaviors with others.
Impact on nurse retention
The effects of nursing cliques on retention vary from individual experiences to larger, more negative effects on the organization as a whole. Nurses have described physical symptoms such as weight loss or gain, hypertension, cardiac palpitations, and irritable bowel syndrome.8 These personal experiences lead to overall job dissatisfaction and psychological stress, including mental illness, depression, and anxiety.8 In turn, absenteeism and use of leave time occurs. This is costly for the organization. Termination of employment is even more costly. Stress is increased for those who remain. Now, a vacancy must be filled, oriented, and trained. In the meantime, staff is shorted or is working excessive hours.
Ultimately, these stressors may result in nurses leaving their jobs and leaving the profession entirely. For nurse managers, success is often measured by staff turnover rates, absenteeism, low overtime, and budgetary adherence. Continued poor scores in these areas can result in career derailment for managers.
Millions of dollars each year are spent on employee benefits, retention, and recruitment.9 The economic cost for nurse turnover is reported to be as great as $64,000 per nurse.8 At this price, it's obvious why organizations loathe high turnover rates. Nurse turnover not only costs the facility money, but it also places patients at risk.8 Risks include complications from errors, accidents, or poor work performance.8 Remaining nurses may suffer a loss of trust, leading to reluctance to ask for help. Nursing expertise, another important element, may be lost as experienced nurses leave the profession.
Impact on patient care
In actual practice, if a nurse doesn't feel part of the group, he or she may be reluctant to ask questions of others. Patient care is adversely affected if the nurse does something wrong because he or she was afraid to ask. Substandard care performed by clique insiders may go unquestioned. Worse yet, nonmembers may adopt these same unsafe practices to gain acceptance. In the end, patient care suffers.
Numerous articles have been written identifying behaviors associated with the detrimental effects of cliques. Suggested solutions include education and development of policies to prevent such behavior. However, little information is available regarding the effectiveness of these solutions. Managers focus on developing a quick fix, but fail to evaluate the effectiveness of that fix.
Many organizations have established a professional code of conduct. All staff members, including managers, review and sign the code of conduct upon hire, indicating knowledge and acceptance of the guidelines. Unfortunately, though, the document is placed in the employee file and often forgotten. Without a continuing champion and a concerted focus on the issue at hand, the clique issue quickly becomes lost, until another event of incivility occurs.
Nurse managers may believe the problem is addressed and solved after a few workshops on bullying. But perceptions of bullying are individualized. For example, repeated reminders by a manager to complete a competency may be construed as bullying by an employee. A disciplinary action for unacceptable behaviors may also be viewed as bullying. Perception is everything!
Some organizations have developed policies incorporating zero tolerance to address inappropriate behavior.3 Zero tolerance can mean grim repercussions for the identified perpetrator. Disciplinary actions, even termination of employment, may occur. But, now there are new bullies. Managers who want to resolve the problem, are cast as fixers and blamers. Exclusion of the highest order has occurred. The "good guys" have become the "bad guys" and the problem is merely perpetuated.
Such policies don't solve the problem and don't encourage open communication, nor do they support blame-free environments. Education, communication, conflict resolution, and team building activities are a more positive approach toward developing and retaining valued human capital.
Confronting clique formation or clique behavior often meets strenuous denial. Confrontation sends the behavior underground. Players are careful to not exhibit obvious behavior. They deny to managers the existence of clique-like behavior.
People, in general, seek comfort and support within groups. Few people embrace solitude and independence. And within stressful settings such as healthcare, cliques are born. For the individual outside the clique, a steady diet of rejection, humiliation, and avoidance eats away at self-esteem and competence. Depression, physical illness, and incompetence stem from loneliness and feeling unwanted. Rejection becomes a prophecy, and the rejected must decide whether to stay or leave.
First, place no blame
No one wants to be the outsider. Many times poor behavior is overlooked or excused. Every person must be accountable for his or her own behavior. They must stand up for those who haven't discovered their voice. Managers have a responsibility to investigate previous approaches toward clique behavior and assess whether these approaches had any positive impact. If not, leaders must brainstorm new avenues.
Bullying behaviors have been and continue to be extensively studied in psychological specialties. These behaviors are part of the human state and are frequent responses to threatening situations. Learning about these behavioral responses and how to manage them is a critical component of workplace civility. Psychology of workplace behavior can help us better understand all the components contributing to a bullying situation. Managers must do what they think is right without becoming bullies themselves. In this scenario, the defined perpetrator is merely a player, one component of a systems problem.
In viewing a system as dysfunctional, managers can take away the blame aspect. They can work to promote a supportive learning environment. In a supportive environment, people can be more comfortable looking at the role each plays in making up the whole system. In a no-blame situation, psychological injuries are less damaging because there's no personal intent. Individuals can feel free to express feelings and thoughts. This management approach can result in growth and healing. Consider offering an education workshop about the concept, consequences, and management of this issue as a first step to more comprehensive management.4
Consider the following ideal organizational antidote to bullying:
"The organization selects all levels of employees, including senior positions, for integrity. The organization has processes that measure and reward respectful behavior. Processes for formal and informal complaint resolution are in place and widely disseminated to employees. In the fully responsive organization, the actual incidence of bullying and mobbing is low and dealt with immediately in a supportive manner to all parties involved".4
Teamwork must be promoted and developed. The team includes the bully, the clique-former, the outsider, the informal leader, the novice, the expert, and everyone in the group. In a team, each is aware of the other's differences, strengths, weaknesses, and talents and knows how to use these differences. Although there's considerable emphasis on the idea of teamwork, there's little actual training of the subject. Few nurses have formal education in group dynamics or group process. Yet these are the areas at issue.
Managers can promote team values best through constant, open communication within a blame-free environment. Celebrating differences and embracing unity can lead to a supportive work environment. Diversity enhances a group and adds a richness of talents and abilities to a team.
Points to ponder
Cliques are a form of bullying. They impact retention, working environment, and patient care. It's essential that nurse managers recognize clique formation and help staff members feel included and valued. They must enforce policies and create a blame-free environment with open communication and teamwork.
Conflict resolution, rather than disciplinary action, can be more effective in creating a culture of teamwork and inclusion. Many facilities have policies related to bullying behavior; however, the policies are written, enforced temporarily, forgotten, and never evaluated. Perhaps a reassessment is in order. Managers can use evidence-based knowledge to evaluate effectiveness of those policies. Ongoing education for all staff regarding bullying behaviors and conflict resolution should be helpful.
Emphasize and celebrate diversity among people. All team members have a variety of strengths. Education regarding teamwork should be provided as well. Recognition of how the characteristics and differences of individuals can contribute to a team can be learned. Team building exercises and opportunities can be employed on a daily basis.
Although it's difficult to change human nature, managers can utilize the principles discussed to manage clique behavior and facilitate a positive change in the work environment. Recognition, education, communication, celebration, focus, and management are key positive responses to bullying and cliques.
Is there a clique in the house?
* Information isn't relayed.
* Equipment needed to perform duties isn't made available.
* Immediate supervisors assign favorable duties and permit longer rest periods to favored employees.
* Career advancement may be based on popularity rather than job performance.
* Disciplinary measures differ for staff members.
Sources: Clavreul G. Cliques, and why this is not a good thing. Working Nurs. 2006;March:14–18.Randle J, Stevenson K, Grayling I. Reducing workplace bullying in healthcare organizations. Nurs Stand. 2007;21(22):49–56. View Full Text | PubMed | CrossRef Sheridan-Leos N. Understanding lateral violence in nursing. Clin J Oncol Nurs. 2008;12(3):399–403.
© 2011 by Lippincott Williams & Wilkins, Inc.