Co-worker relationships and their impact on nurses in Irish public healthcare settings

Relationships have an impact on every aspect of a person's life—their health and wellbeing, their ability to live independently, their capacity to engage with family and friends, participate in society and to enjoy life to its full potential (Handley et al, 2015). Relationships also permeate all settings of a person's life—home, school, workplace and community (Hanafin, 2018). In respect to relationships in the workplace, much of the focus has been on the challenges that arise, and in nursing, there is a growing literature relating to both bullying (Bambi et al, 2019; Caristo and Clements, 2019) and workplace incivility (Arslan Yürümezoglu and Kocaman, 2019).

Although the focus has been on negative aspects of relationships, there is also an increasing recognition of the importance of positive workplace relationships and their impact on employee wellbeing and productivity (O'Higgins-Norman and Kiernan, 2015). A positive, high-quality work relationship has been defined as a recurring connection between two people at work that is mutually beneficial (Ragins and Dutton, 2007:). Colbert et al (2016) reported that workplace relationships service a broad range of functions, including task assistance, career advancement and emotional support. In addition, these authors highlight the impact of positive workplace relationships in terms of personal growth, friendship and the opportunity to give to others. Caillier (2017) noted that peer relationships are important within organisations because co-workers provide their colleagues with emotional support, assist in career development, and share institutional and job-related knowledge required to carry out tasks.

While all relationships are important in the workplace, peer relationships, described as those that take place between co-workers with no formal authority over one another (Sias et al, 2002), have been identified as particularly important. These types of relationships represent the vast majority of workplace relationships and are crucial in establishing behaviour norms, thus holding a particularly powerful position in serving as positive or negative role models within organisations (Sias, 2005). Positive peer relationships are also positive for organisations. Findings from a study of almost 70 000 employees carried out by Basford and Offermann (2012) across 677 locations of a large US service-sector organisation, highlighted the impact of co-worker relations on motivation in the workplace. These authors found that the impact of positive co-worker relationships was significantly correlated to motivation for both higher- and lower-level employees and negative relationships with co-workers were demotivating irrespective of status within the organisation. The relationship between co-worker relationships on intention to remain in their current employment, however, was found to impact more on those in higher status, although, the authors note, this effect was small.

Box 1.Key elements of the study process

• Scoping review of literature focused on instrumentation
• Definition of research questions
• Questionnaire development
• Identification of a sampling frame for each stakeholder group
• Pilot studies
• Main quantitative data collections
• Analysis of quantitative data
• Individual and focus group interviews
• Analysis of qualitative data
• Report on findings

A number of organisational approaches to supporting positive social relationships in the workplace have been proposed. These include encouraging informal interactions that can foster the development of positive links between individuals and minimising the number of negative interactions by mediating and resolving differences early. This creates a culture of open communication that fosters trust and relationship building. Approaches also include revising workflow and communication patterns to reduce interactions between individuals with negative ties to each other (Eurofund, 2010).

Despite the importance of workplace relationships, little empirical evidence exists on how nurses view their co-worker relationships in the Irish context and the findings from this study set out to address this knowledge gap.

Aim

The aim of this study was to examine and describe co-worker relationships among nurses working in public healthcare settings in Ireland.

Methods

The study was based on a secondary analysis of quantitative data collected on behalf of the Public Service Pay Commission (PSPC) looking at predictors of intention to leave using a two-stage cascading sample design (Research Matters, 2019). The original study carried out by the authors of this article adopted a mixed methods sequential explanatory design including both quantitative (online surveys) and qualitative (structured interviews) approaches. This approach ensures nationally representative samples of nurses for the surveys, with interviews providing a deeper and richer understanding of the key issues. Key elements of the overall study are listed in Box 1.

This article presents the findings of one aspect of the quantitative data only, which focused on workplace relationships with co-workers. The overall methodology is reported on in detail in the main report of the findings from this research (Research Matters, 2019) and the authors of this article were involved in every stage of the study.

Questionnaire development

A questionnaire for use in the present study was developed through:

• A scoping review of peer-reviewed and grey literature and instrumentation
• Contact with developers of previously validated scales/indexes
• Advice from researchers with expertise in the area (including PSPC's advisers on this study)
• Interviews already conducted with human resource personnel and nurse managers
• Pre-testing (n=4) and piloting (n=107) with nurses.

The questionnaire was divided into four sections:

• Section 1: About your job
• Section 2: About your workplace
• Section 3: Job intentions
• Section 4: About you.

In total, the questionnaire for nurses comprised 46 questions. Co-worker relationships were measured through the co-worker element of the Workplace Affective Commitment Multidimensional Questionnaire short form, which contains three items (Perreira et al, 2018). These were:

• I am happy to work with my co-workers
• My co-workers make me feel like going to work
• I would describe my co-workers as great people to work with.

Data collection

Every director of nursing on the Health Service Executive (HSE) Office of the Nursing and Midwifery Services Director (ONMSD) database of directors was contacted by the ONMSD to:

• Inform them about the study
• Request their assistance in circulating a separate invitation email to all the nurses working in their organisation (including part-time and student intern employees)
• Send a text message to nurses that included a link to the survey, which could be completed on a smart phone, as well as on a computer or laptop if an email address was not available
• Publicise the link to the survey within the organisation including, if available, placing the link on the intranet to which only staff had access.

Three reminder emails were sent to all directors of nursing over the 3-week data-collection period by the ONMSD.

Response rate

The target population for this study was based on HSE counts from November 2017, of 42 041 nurses (whole time equivalent (WTE) of 36 616) who were working in the public sector. This is the target population. Of these, 59.6% work in acute services, 39.9% work in community services, and 0.5% work in other sectors (health and wellbeing, corporate and health businesses).

In total, 3769 nurses responded to the survey and completed at least 50% of the questionnaire, giving a response rate of 8.8%. The actual response rate may be higher due to the two-stage sampling approach, and also the number of nurses on leave while the survey was taking place—estimated at 23% (HSE, 2016)— which means that it is likely that not all nurses in the population of 42 041 nurses received an invitation to participate.

Data analysis

Quantitative data were exported from the internet survey provider (SurveyMonkey®) into SPSS v24.0). The data were weighted to provide nationally representative estimates on the basis of the characteristics used to compute the sampling weights. The weight was computed as the population proportion divided by the proportion in the sample, which corrected for differences in response rates on the basis of sector, grade and full/part-time status and results in analyses that may be generalised to the population on the basis of these characteristics. Of the 3769 respondents in the final datafile, 18 (0.48%) were missing sector/grade/full-time status. In these cases, a weight of 1 was computed. Using these data, population fractions on the basis of sector (acute, community, other), grade (director, manager, specialist, etc) and full-time/part-time status were calculated to produce 16 strata or groups. Where the total number of cases in the original cells was <200, cells were collapsed. For example, in the acute sector, both full-time and part-time nurse managers were combined, as there is a very low number of part-time nurse managers in this sector.

Following usual/best practice in data processing, all items were checked for missing data. Rates that exceeded 5% have been noted in the relevant Tables and Figure. All data were weighted using the relevant sampling weight. Prior to computation of the sampling weights, records were deleted from the nurses' datafile if questionnaire completion rates were below 50% (925 of the original 4752 records). Following this, 58 duplicate records were deleted, leaving 3769 records.

Questionnaire scales were constructed using the same methodology as in the Civil Service Employee Engagement Survey report (Department of Public Expenditure and Reform, 2017;73-74). That is, the responses to the individual items comprising each scale were combined to form a scale score expressed as a percentage. In some cases, items on the scale had to be reverse coded. For the majority of the scales used in this study, higher scores indicate a more positive outcome.

Data analysis included frequency tables of organisational and demographic characteristics of respondents:

• Questionnaire scales: frequency tables of the Likert items organised according to the questionnaire scales to which the items belong
• Scale means: scale means were calculated for each of the questionnaire scales (expressed as percentages), overall and compared by subgroups. For nurses, the subgroups were: age group; country of initial qualification; geographic region); grade; full/part-time status; sector; and job intention (stay/leave). Comparisons of scale means for these subgroups were made on the basis of t-tests (if two groups) or one-way ANOVAs (if more than two groups). Post-hoc comparisons of means for >2 groups were made on the basis of Bonferroni-adjusted significance levels
• Single items: frequency tables of single work-related characteristics of respondents (eg frequency of working overtime)
• Scale reliabilities: Cronbach's alpha were calculated for each scale and in respect of the co-worker scale for this measure was 0.899
• Scale intercorrelations: Pearson correlations between scale measures, including significance levels, were also calculated.

Ethical issues

Ethical approval for this study was sought from, and granted by, the Trinity College Dublin School of Nursing and Midwifery Research Ethics Committee. Ethical issues were considered and addressed throughout the process, particularly in areas of confidentiality, anonymity and data protection. In terms of confidentiality, only the minimum amount of personal data required was sought and personal data were not used for any purpose other than that specified at the time of the collection. All data were anonymised, and all research outputs were checked carefully to ensure that no individual would be identifiable. In addition, all appropriate steps were taken to ensure that data were held in a secure way. This included the removal of direct identifiers, the use of pseudonyms, and the use of technical means to break the link between data and identifiable individuals. Both system and physical security safeguards were put in place to ensure that the data were protected.

In order to ensure informed consent, a detailed information sheet was provided that included contact details of the research team, should respondents have any questions.

Results

Characteristics of respondents

Table 1 presents information on the percentages of nurses across different grades who provided this information (n=3754).

A number of demographic characteristics were also considered and the percentages included in the sample according to these are presented in Table 2.

• More than two fifths (42.9%) of respondents worked in acute settings and just over one in ten worked in community settings (Table 2)
• More than one-third of respondents were aged 41-50 years while just over 40% were aged under 40 years
• About one third of respondents (32.4%) held a primary degree and almost half (46.5%) held a postgraduate qualification
• Almost one in five respondents reported obtaining their basic nursing/midwifery qualification in another EU country, while almost one in ten reported obtaining it in another non-EU country. The majority (72.6%) had obtained their degree in the Republic of Ireland, with 18.3% in another EU country and 9.1% in a non-EU country.

Overall levels of satisfaction with co-workers

The overall findings from this analysis suggest moderate-to-high levels of satisfaction with co-worker relationships. Across the three scale items agreement ranged from 74% (I would describe my co-workers as great people to work with), to 75% (my co-workers make me feel like going to work) and 82% (I am happy to work with my co-workers) (Figure 1). More than one in ten nurses (11.1%) indicated that they would not describe their co-workers as great people to with work with.

Significant findings across demographic characteristics

To compare the findings across demographic characteristics a scale mean was derived by combining responses to individual items on the scale to form a scale score expressed as a percentage. Adopting this approach, the overall scale mean was 77% and statistically significant differences across characteristics are as follows:

• Nurses who gained their basic nursing qualification in a non-EU country reported significantly lower index scores for co-worker satisfaction (72%) than those who gained theirs in Ireland (77%) or another EU country (77%)
• Perceptions of co-workers did not vary markedly across nursing grades, although scores on this index were significantly higher among public health nurses (84%) and significantly lower among student interns (64%), relative to staff nurses (76%)
• Respondents' perceptions of their co-workers were similar across Dublin (78%), the rest of Leinster, Cavan and Monaghan (78%) and Munster (76%) and were slightly but significantly lower in Connaught (74%), relative to Dublin
• Perceptions of co-workers scores did not vary significantly by full/part-time status, age or sector (acute, community or other).

Correlations between co-worker relationships and workplace issues

A correlation analysis of the relationship between co-worker relationships and a number of workplace issues was considered and the strength of the relationship identified. A positive correlation indicates the extent to which those variables increase or decrease in parallel; a negative correlation indicates the extent to which one variable increases as the other decreases. For example, item 1 in Table 3 ‘workplace engagement’ is positively correlated with co-worker relationships, meaning that the higher the level of satisfaction with the relationships, the higher the level of engagement reported. The findings show that co-worker relationships are significantly, although weakly, positively correlated with a number of attitudinal workplace issues. These are workplace engagement (0.233), job satisfaction (0.225), organisational commitment (0.221) and perceptions of managers (0.259).

Findings in respect of intention to leave

Respondents intending to leave in the next 2 years reported significantly lower scores on this index (74%) than those intending to stay (79%).

Discussion

The findings presented in this study suggest there are moderate-to-high levels of satisfaction with co-worker relationships among nurses working in public healthcare settings in Ireland. Across a range of demographic and geographic variables, the lowest scale mean for satisfaction with co-workers was identified in respect of those who gained their basic nursing qualification in a non-EU country (72%). This finding was statistically significant when compared with those who gained their basic qualification either in Ireland or within the EU (77%). This finding is important because dependence on nurses from other jurisdictions is a common characteristic of the Irish health services (Wismar et al, 2011). According to Humphries et al (2012) between the years 2000 and 2010, 35% of new recruits into the Irish health system were non-EU migrant nurses—a higher proportion than similar-type countries such as the UK, New Zealand or Australia. This dependence is borne out by recent nurse registration data in Ireland, which shows that more than one third (38%) of the 3803 first-time registered nurses and midwives in 2018 completed their training in a non-EU country (Nursing and Midwifery Board of Ireland, 2018). Other authors have also identified challenges for nurses who have trained outside their country of origin. Roth et al (2021), for example, identified a range of difficulties such as feeling like outsiders within the nursing team, having to cope with loneliness and social isolation, being lost, and feeling resentful and frustrated when peers were unhelpful.

As noted earlier, Colbert et al (2016) highlighted the importance of positive workplace relationships for both functional (eg task assistance, career advancement) and personal satisfaction and growth. In this study, correlations were identified between co-worker relationships and four attitudinal areas (perceptions of manager, workplace engagement, job satisfaction and organisational commitment). Although these correlations were weak, they do, nevertheless, point to areas for further exploration in terms of co-worker relationships.

When reporting on factors identified in the European-wide Registered Nurse Forecasting study (RN4CAST@IT) as having an impact on Italian nurses' intention to leave, Sasso et al (2019) identified a number of push and pull factors. Push factors included the leadership style of the nurse manager and the trust nurses have in their leaders, which the authors noted was identified as being of paramount importance for nurses' wellbeing. The findings from the present study showed that respondents who had more positive perceptions of their managers were also more positive about their relationships with co-workers, suggesting a better overall relational environment.

The findings from the present study also highlighted a correlation between higher levels of satisfaction with co-worker relationships and higher levels of organisational commitment and engagement. Organisational commitment has been defined as ‘a psychological state that binds the individual to the organisation’ (Allen and Meyer, 1990). High levels of organisational commitment have been shown to have direct positive benefits in the healthcare context, including workers providing extra help to both patients and co-workers; being considerate; volunteering for special activities; and being proactive when emergencies arise at the hospital (Mafini and Dlodlo, 2014).

Sheehan et al (2019) reported that the retention of nurses is impacted by their expectations of their work environment, including co-operative relationships and good communication with colleagues. This is also highlighted by Marufu et al (2021) who, in a systematic review, identified nine domains that influenced nursing staff turnover and found that, in addition to nursing leadership and management, issues such as the organisational environment, support at work and financial remuneration were all important. Similar relationships have been established between job satisfaction and intention to remain in the place of employment (Brook et al, 2019). High levels of job satisfaction are associated with intention to remain in an employment, while low levels are associated with intention to leave. A multi-country study on the retention of nurses found that 42% of nurses in Ireland were dissatisfied with their job in general and this was the second highest across all 12 countries included in the study (Aiken et al, 2013). The correlation between co-worker relationships and job satisfaction identified in this study are relevant to concerns about the retention of nurses in Ireland and can form part of a focused approach to creating a positive workplace environment.

Finally, the findings from this analysis showed that respondents intending to leave their job in the next two years reported significantly lower scores on this index (74%) than those intending to stay (79%). Although similar results were reported by Basford and Offermann (2012), this was only in respect of those in higher status jobs and, as noted earlier, the effect was small in both this study and in that by Basford and Offermann (2012). It is nevertheless an important finding, given the challenges of retaining nurses in the Irish public service.

Limitations

All research has some limitations. The overall response rates in this study were lower than desired at 8.8% of all nurses working in Ireland and while the data were weighted to provide nationally representative estimates, there is no way of empirically assessing the extent to which particularly enthusiastic or particularly disenfranchised individuals may have responded. This potential bias should be borne in mind when interpreting the results.

Conclusion

This article has considered co-worker relationships and has highlighted a number of findings that are worthy of further exploration. Statistically lower levels of satisfaction with co-worker relationships were identified among those who had gained their basic qualification in a non-EU country. This is an issue that needs to be addressed, particularly in the context of the substantial contribution being made to the Irish public health service by nurses from outside the EU. Respondents reporting higher levels of satisfaction with their co-workers are less likely to indicate that they intend to leave their job. This is reflected in the correlations identified between co-worker relationships and a number of attitudinal areas, including perceptions of manager, engagement, job satisfaction and organisational commitment. These correlations show that where co-worker relationships are positive, perceptions of these areas are also more positive. Although these correlations are weak, they are, nevertheless, important because of their relationship to the retention of nurses.

Key action points

As a result of this study, it is suggested that greater consideration should be given to:

• Ongoing monitoring and evaluation of co-worker relationships in healthcare settings
• Raising awareness about the importance of co-worker relationships in healthcare workplaces
• Identifying and putting supports in place for nurses who obtain their basic nursing/midwifery qualification outside the EU.

KEY POINTS

• This article presents findings on co-worker relationships identified in a survey of nurses (n=3769) working in public healthcare settings in Ireland
• The findings identified moderate to high levels of satisfaction with an average scale mean of 77%
• Nurses who achieved their basic nursing qualification in a non-EU country, student nurses, those working in the west of Ireland and those reporting an intention to leave reported lower levels of satisfaction
• More needs to be done to support co-worker relationships, particularly in respect of those nurses who qualified in a non-EU country

CPD reflective questions

• How satisfied are you with your co-worker relationships?
• Do they positively or negatively impact on your overall satisfaction with your work?
• If you are dissatisfied with your co-worker relationships is there anything you can do to improve the situation?