‘Toxic Nursing’: How to handle the “in crowd” on the unit


Male nurse prepped for surgery

Polka Dot | ThinkStock

In the Spring 2014 issue of Scrubs (get your copy here!), we gave you an in-depth look at incivility in the hospital with “Toxic Nursing.”

Now we’re sharing more on this subject with an in-depth look at friendships on the job.

Every day at the visiting nurse association, Terri and Jess meet for lunch between patients. When other nurses are available at lunch time, Terri and Jess don’t include them. Sandy, a new nurse, helps pick up some cases from Terri’s territory during a busy period. She asks Terri if they can meet for lunch and discuss the patients she will be taking over. “Oh, sorry, I’m meeting Jess for lunch,” Terri answers.

Sandy doesn’t think much of the decline until a few months later when she again has need of Terri’s input on a patient. She asks about meeting over the lunch hour, and Terri again refuses. “You guys always go to lunch at the same time. How come I’m not invited?” Sandy asks.

“Jess and I have been friends forever, and we work really well together,” Terri tells her. “You wouldn’t understand anything we’re talking about if you joined us.” Sandy is hurt and confused but drops the idea of ever having lunch with Terri.

Expert Commentary

There are two issues in this scenario: Sandy needs information from Terri regarding patients, and Jess and Terri’s luncheon meetings exclude other staff. If the lunch meetings occur outside of work time, there is not much the manager can do about this. Employees are allowed to decide how they spend their off-duty time. There is no requirement that employees must be friends with each other outside of work, but they must be cordial at work. However, to facilitate friendships among all the staff, management might arrange some social events during work time, like a potluck, a pizza lunch, or an ice-cream social. To address the first issue, management needs to create formal mechanisms for staff to collaborate during work time. When nurses take over patients that another nurse has cared for, or if there is overlap in assignments, nurses must give report or have care conferences with each other. These meetings could be done in person, via phone, or via an electronic venue such as Skype.
–Susan Johnson

From a personal perspective, Sandy feels left out. But from a professional perspective, she needs information from Terri about a patient, and Terri needs to come up with an alternative way to provide it. It’s on Terri to figure out how to address the need.

Do Terri and Jess have the kind of friendship where they can’t include another person occasionally? They aren’t being asked to share everything, but just one lunch. There may be some issues there in getting along with other colleagues in general. Sandy would at least understand the patient care things they are talking about, so it’s an insult to suggest she wouldn’t understand. Terri has put her down both personally and professionally.

It’s good for all nurses to be sensitive to the fact that everyone wants to be included. If you extend yourself for this one person, you’ll be glad you did if you need him or her to extend herself for you in the future. By including him or her, you open a door to an opportunity for this person to help you at some point.
–Kathy Curci


Do some of your employees tend to spend off-work time, such as their lunch hour, with each other, to the exclusion of others? Do you think this is a bad thing? After all—they’re just friends, right?

How might you—the nurse manager—handle a situation such as this one on your unit?

How does a nurse manager encourage a balance between professionalism and friendships among his or her staff?


Although nurses are adults, there can be a remarkable amount of high-school behavior on a unit. This might take the form of a campaign, in which a group of nurses gangs up on a coworker. Or it might be in the form of a drama queen, who deliberately stirs up trouble. Two-faced workers, who act pleasantly when in the company of management but terribly the rest of the time, are also a problem. Finally, the existence of cliques can have a negative effect on retention, not to mention lead to adverse symptoms among those left out.

Nurse managers must try to combat this behavior by encouraging staff to report it and ensuring those who do will not face retribution. Responding to this type of behavior can be really challenging, because it can feel murkey, unclear, or grey. Sometimes we might feel like something is wrong but can’t quite put our finger on what. Often in these types of situations, careful and quiet reflection can lead to a better understanding of the problem. Nurse managers have to do their very best to make it clear that we are no longer in high school (thank goodness!), and that this type of behavior will not be tolerated. Specific strategies might include a unit-based council of role models or a zero-tolerance policy.


Research has shown that drama and cliques continue into the workplace, much as they did in high school. Challenge your staff members to take the opportunity to get to know their co-workers in a “Create a New Connection Day” where each nurse spends a few minutes talking with another nurse they don’t know very well. You may even assign nurses to pairs where they must discuss an issue at work or just exchange a fun fact.

If possible, offer a motivator (such as a voucher for coffee or tea) to encourage these conversations.

Optional: If the opportunity presents itself, ask folks what fun thing they learned about their colleague.

Adapted with permission from Toxic Nursing by Cheryl Dellasega, PhD, RN, CRNP, and Rebecca L. Volpe, PhD. Published 2013 by The Honor Society of Nursing: Sigma Theta Tau International.

This is part nine of nine; don’t miss parts one, two, three, four, five, six, seven and eight!

Scrubs Contributor
We welcome your ideas and submissions to Scrubs Magazine! Here's how to submit your own story or story idea to our editors.

    The history of National Nurses Week

    Previous article

    Two new studies highlight nurses’ role in increasing patient comfort

    Next article

    You may also like

    More in Scrubs