talking about the same nurse. This is virtually impossible because they live in different
parts to the country. Both participants described similar characteristics and personality
traits: lack of communication skills; distant with colleagues and patients; unable to
relate to patient safety concerns raised by their manager; very articulate but unable to
apply knowledge to practice; poor social skills; lack of care and compassion excelled at
interview (recruitment process).
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could be the potential leaders of the future, because they are different with an ability to see things from another perception:
“Because I think you know, there are people that display odd behaviours. Very clearly. But there are also people that are a bit different, that perhaps are going to be the leaders in the
future …because they are a bit different” - Participant 15.
It is apparent that a very small percentage of nurses struggle to fit into the profession. The participants referred to the “odd” nurse as someone who appeared to lack social and human skills, a lack of compassion, communication skills, and a caring instinct towards their patients and colleagues. It is evident that employers take into consideration a nurses characteristics and values as part of the decision making process to refer an early career nurse to the NMC.
5.7 Discussion of Research Findings for Characteristics and Values Wanted and
Unwanted in Nurses with the Literature
This chapter is grounded in the data and represents the voice of the participants, with verbatim quotes and memos, but it is important to reflect on the perceived unconscious biases disclosed by the participants when describing the characteristics and values wanted and unwanted in nurses (Persaud, 2019). It could be argued we all have unconscious biases, which are learned stereotypes that are automatic, unintentional, deeply engrained within our beliefs, universal, and have the ability to affect our behaviour. The researcher acknowledges it has exposed the participant’s views of nurse leaders who could be considered to be ethically responsible for creating diverse and inclusive spaces for early career nurses. It is crucial leaders openly acknowledge and address the negative influence of bias and prejudice when managing an early career nurse whose fitness to practise is in question, which may stem from the culture within the organisation. This process begins with an in-depth examination of one's own biases and continues through actions at the individual and organisational levels (Persaud, 2019), which is aligned to one of the recommendations of this study.
Persaud (2019) promotes that nurse leaders are well positioned to address and mitigate the negative influence of bias within organisations. This is reflected by one of the participant who strongly advocated “there are people that are a bit different, that perhaps are going to be the leaders in the future …because they are a bit different” (Participant 15). Other participants described certain early career nurse’s behaviour and characteristics as “odd” and “difficult”, “scary” and a “personality disorder”. From a critical perspective the participants who appear to hold unconscious beliefs and biases are displayed by categorising the nurse’s behaviour and conduct as an unwanted characteristic or value. In this case this could be perceived as constraining the early career nurse’s opportunity to be innovative and creative, which could
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be an essential quality for leaders of the future who ‘think outside the box’ to react to the rapidly changing healthcare needs and policy.
This constructivist grounded research is not about power, status, prestige, manipulation, the rule of experts, fear, insecurity, but is based on a strong, well-founded argument. It is up to the reader to decide if the participants provide a reasonable and authentic argument which can be perceived as appropriate for this research. Alvesson and Skoldberg (2018; 189) describe the importance of considering if participants views carry “equal weight”. This can be dependent on a number of factors, including knowledge and experience, wisdom and the basis of their authority, their closeness to clinical practice and understanding of the reality and challenges faced by early career nurses. In this study the participant’s inclusion criteria required experience of making a referral to the NMC, therefore ascertaining the scope, relevance and reliability of statements made by experts in the field and it could be argued reasonable weight can be ascribed to them.
5.7.1 “Dishonest” Nurse
Honesty underpins a nurse’s integrity and professionalism when caring for people and their loved ones when they are vulnerable (Banks and Gallagher, 2008). The Nursing and Midwifery Council Code (2018) states that a nurse must uphold the reputation of the profession and act with honesty and integrity at all times. However, the complex role of the nurse involves delivering safe, effective clinical care for the health, welfare, maintenance, and protection of their patients, within an inter-professional health-care environment. The context of this work tends to be in an ever-changing set of social, cultural, ethical and political boundaries. Dishonesty in nurses may be both a state of mind and a course of action. The NMC (2018) state, when making a decision on a dishonesty charge, panel members of the Fitness to Practise Committee must decide whether or not the conduct took place, and if so, what was the nurse or midwife’s state of mind at the time, aligned with case law, such as Uddin v General Medical Council [2012] EWHC 2669 (Admin). British law assumes that people from all walks of life can easily recognise dishonesty when they see it, illustrated in the case of Ivey v Genting Casinos (UK) Ltd [2017] UKSC 67 para 53; further Ivey (para 48) restates that judges do not and must not attempt to define dishonesty, citing R v Feely [1973] QB 530. A course of action might be theft or it may be a state of mind, in which a nurse deliberately lies or cheats for their own personal reasons. A deliberate act of dishonesty may be influenced by a drug dependency, this may be fundamentally linked to their personality traits. However, the NMC (2018) advocate Panel Members consider if there is an innocent explanation for the registrant’s conduct, for example was it an innocent or carless mistake?
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Dishonesty, cheating and lying, are seen as a lack of integrity (Caruana et al, 2000). In English law there are two definitions of dishonesty. The Theft Act of 1968 defines dishonesty as a course of action. The second view is that dishonesty is a state of mind. This emerged from R v Ghosh (1982) 75 CR App. R. 154 in which the Court of Appeal held that dishonesty is an element of means, clearly referring to a state of mind. The Court of Appeal decided a test must be applied which "looks into the mind" of the person concerned and establishes what he was thinking (Allen 2005). The test asks the question: "Were the person's actions honest according to the standards of reasonable and honest people?" The decision of whether a particular action or set of actions were dishonest remained separate from the issue of moral justification. Trust has been indicated as a nursing ethical value and is defined by traits of honesty in words and practice (Shahraira, 2013). Nurses should gain patients’, their families’, and society's trust through understanding patients’ situation and status (Rassin, 2008; Pang et al, 2009; Rchaidia, 2009). To act honestly is a moral value. A person’s personality may influence how they react to certain situations. The Temperament and Character Inventory (TCI) is an inventory for personality traits devised by Cloninger et al (1994). TCI operates with seven dimensions of personality traits: four temperaments: these are Novelty Seeking; Harm Avoidance; Reward Dependence; Persistence, plus three characters: Self-Directedness; Cooperativeness; and Self-Transcendence. Cloninger et al (1993) argue that autonomy, moral values, and aspects of maturity and self-actualization are captured by self-directedness, cooperativeness, and self-transcendence respectively.
It appears that the “dishonest” nurse’s characteristics and values match the temperament traits of Novelty Seeking descriptors. Cloninger and his colleague Dragan Svrakic (2004) found that temperament alone did not capture the full range of personality. Cloninger (1994) identifies a second domain of personality variables, using character traits to measure a person's humanistic and transpersonal style. Participant 1 described, following an internal investigation the “dishonest” nurse’s conduct was orderly and detached. This appears to link with people who have low scores for the Novelty Seeking temperament, who have defined personality traits of indifferent, reflective, frugal and detached, orderly and regimented (Cloninger et al, 2012). Participant 1 recalled a case of an early career nurse who systematically stole medication for her personal use while being filmed by CCTV:
“We caught her on CCTV, and it was clinical, to see her take the tablets, she went into the clinical room, she took them out of the TTO packet she disposed of the packet and put them
in her pocket” - Participant 1.
Cloninger’s TCI model (2012) is unique in assessing components of personality related to the body, thoughts, and psyche. The emotional drives of the body are assessed as Temperament.
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The self-regulatory functions of thought are assessed by the character traits of Self- Directedness and Cooperativeness. The spiritual aspects of character are assessed by the dimension of Self-Transcendence. The TCI model is particularly effective in order to understand the development of a person’s capacity to work, love, and understand the meaning of life, as well as to understand the basic emotions they feel that may complicate mature development (Cloninger, 2012).
Case (2011) reports that a doctor in the early stages of their career who has an allegation of dishonesty, their actions can be mitigated against if they have several glowing testimonials. Participant 1 reflected on a case of dishonesty involving a newly qualified nurse who had worked for the healthcare organisation as a healthcare assistant, a student nurse, and a staff nurse. The registered nurse was caught stealing medication for her own use, following a significant family bereavement. During the disciplinary hearing the nurse showed no remorse, insight or acknowledgement that her conduct was in breach of professional standards and legislation. This conduct and behaviour could be perceived to mirror the Novelty Seeking temperament (impulsive, quick-tempered vs. rigid, slow-tempered), in particular, the low score descriptor of frugal and detached behaviour. The nurse’s misconduct could have been triggered by a life changing event. Interestingly, Zald et al (2008: 14372) highlights that “novelty seeking personality traits are a major risk factor for the development of drug abuse and other unsafe behaviours.” Studying personality may help researchers better understand and treat these problems (Rettner, 2014).
“There was no acknowledgement that actually what she was doing was dishonest” - Participant 1.
It is apparent the conduct and behaviour of the “dishonest” nurse could map against the character traits of a low score in Cooperativeness. Conrad et al (2014) describes that individuals who are low in cooperativeness are critical, unhelpful, and opportunistic with the tendency to be inconsiderate of other people's rights or feelings. Interestingly, participant 14 reflected on a serious case of a nurse who stole from a relative. The nurse eventually admitted the theft after the money was found in her possession. This is a dishonest act and a significant breach of professional standards. The participant who worked in the Human Resources Department clearly felt the nurse saw an “opportunistic moment” to steal the money. The participant described this person as “dishonest” and a “difficult nurse” with a history of inconsiderate and unhelpful behaviour and conduct towards colleagues in the workplace, often displaying a lack of regard for others. Eley et al (2015: 569) states that a nurse with “low CO is indicative of someone who tends to be self-absorbed, less tolerant, and more opportunistic, looks out for themselves.”
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“I just think she saw an opportunity. There was absolutely no reason for her to steal. She lived at home with parents, she there was absolutely no … justification for what she did. As I
say if she was destitute, she was a single parent on a … on a restricted income… But there wasn’t anything that she offered that was reasonable mitigation for what she did at all” -
Participant 14.
Paal and Bereczkei (2007) found a strong negative correlation between low cooperativeness and a person's tendency to deceive and manipulate other people for their personal gain. Participant 16 recalled a case of a nurse who presented fraudulent documentation to deceive and manipulate the organisation to gain employment, the newly qualified registrant was referred to the NHS counter fraud services:
“It wasn’t a spur-of-the-moment, there wasn’t anything like that to mitigate it. It was deliberately planned in full knowledge that it was actually a criminal act” - Participant 16.
It is apparent that the participants have described significant cases which have questioned the nurse’s rationale for their conduct with a reaction of “I can’t believe she did that” (participant 4). Ultimately, the participants explained their experiences but often reflected on a “zero tolerance” to dishonesty.
5.7.2 “Scary” Nurse
The participants have described cases of the early career nurse who are “scary” to work with because they tend to significantly lack insight into their knowledge, skills and competence deficiencies, “whose fitness to practise was perceived and proved to be unsafe.” These characteristics appear to map against the qualities of inert and ineffective identified in Cloninger et al’s (1994) model, illustrated in table 20.
“So insight is life and death” - Participant 13.
“Your lack of insight, is really very scary” - Participant 2.
It is apparent that the participants have experienced the “scary” nurse demonstrating the characteristics of self-striving and not recognising their behaviour or conduct had an effect on patients or others. In this case, employers often perceived the nurse to be at a real risk of repeating this behaviour of conduct, resulting in dismissal for gross misconduct and lack of competence and a referral to the NMC.
“The difficulty being, you’re dealing with somebody who doesn’t recognise they’ve got a problem” - Participant 13.
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The participants described nurses whose qualities reflected traits of blaming others and who completely denied the allegations. Participant 16 discussed the case of an early career nurse who had been caught sleeping on night duty by two senior nurses. This is discussed in the chapter A Chain of Expectations. This conduct and behaviour could be linked to Eley et al’s study (2015: 569), who describes nurses with “Low Self-Directness shows someone who tends to be blaming and is less reliable people and less able to define, set and pursue internal goals.”
“There were witnesses but she just totally denied it” - Participant 16.
The participants explained that some nurse’s natural response is to deny the allegations when they are fighting for their registration, ultimately reflecting on their values and beliefs and revealing their true character traits.
“I think people accused of something and they know they’re going to lose their career. And their livelihood if they’re found to have committed those acts so therefore, they almost are
compelled to deny”- Participant 16.
Notwithstanding the case of an early career nurse who refused to admit the error and in fact blamed the patient described by participant 10:
“It is when somebody says, nothing to do with me that was the patient’s fault” - Participant 10.
Overall, it is apparent that if a nurse with a low scorer for the Self-Directness dimension and character profile could impact on their reaction when a question is raised about their fitness to practise. The participants felt their inability to demonstrate insight into their deficiencies and take responsibilities for their actions was a risk. Further research is needed to explore how this behaviour and attitude can be tackled to give the nursing team the confidence to manage and report this type of behaviour and conduct.
5.7.3 “Friendly” Nurse
It is apparent that the participants who described the “friendly” nurse match the higher scorer for Self-Directness, whose qualities reflect traits such as socially tolerant, empathic, helpful, compassionate, constructive, ethical and principled. This has been illustrated in the table 20 Character traits (adapted from Cloninger et al, 1994). The participants describe cases of the early career nurse being involved in a one off incident that resulted in patient harm yet due to severity of the error, the organisation had no choice but to refer the nurse to the NMC. This is discussed in the chapter Alarm Bells. The participants explored the characteristics of the friendly nurse as hard-working and respected.
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“Individuals who are hardworking, highly thought of, by their team members and senior clinicians, and they just make a terrible mistake” - Participant 9.
“An excellent nurse and they’ve just had a one off problem” - Participant 4.
The participants referred to the “friendly” nurse as ethical, applying principles and upholding standards to provide good care for their patients.
“Great person, great registrant, gave good care, was well-liked, well-respected, always turned up on work on time” - Participant 4.
“A lot of integrity and they’ve got a lot of, really bright and you know really ambitious and they are really patient focused” - Participant 9.
Overall, it is apparent that the compassionate and empathic, highly ethical nurse can be involved in a one off incident that has serious consequences for their patients and their professional registration. A nurse with the characteristic of self-directness may react positively to this situation when involved in a one off incident, thereby assuring the employer the risk of repetition is lower.
5.7.4 “Difficult” Nurse
Eley’s (2012) research concluded that nurses in their study strongly represented the character trait of a high score of Cooperativeness. A character trait reflects personal goals and values, which are subject to socio-cultural learning; therefore, each trait quantifies the extent to which an individual displays certain related qualities (Eley et al, 2012). Previous studies have revealed the stability of personality factors across time and the factors which may influence the character traits of students in the caring profession, such as relationships, work satisfaction, role strain and coping (Bradham et al, 1990; Deary et al, 2003; Baldacchino and Galea 2012). It is apparent that the participants who described the “difficult nurse” match the low score for Cooperativeness, whose qualities reflect traits such as socially intolerant, critical, unhelpful, revengeful and destructive, opportunistic. This has been illustrated in the Table 20 Character traits (adapted from Cloninger et al, 1994). Participants recalled the experience of managing an early career nurse whose personality was “difficult” and closely linked to the critical and unhelpful descriptors of Cloninger’s model.
“They might be abrupt or difficult” - Participant 4.