Exploring Workplace Bullying in Nursing

PROFESSIONAL PRACTICE

Emerald Etienne, MSN, BSN, RNC-OB

Bullying in the nursing workplace has been identified as a factor that affects place bullying negatively affects nurses and their work, bullying con- patient outcomes and increases occupational stress and staff turnover. The tinues to be a global problem (John- purpose of this project was to assess registered nurses’ perceived exposure son & Rea, 2009; McKenna, Smith, to workplace bullying. A convenience sample of a Pacific Northwest state Poole, & Coverdale, 2003; Sa & professional nurses’ association membership was solicited for this descriptive Fleming, 2008; Simons, 2008). Due study using the Negative Acts Questionnaire-Revised (NAQ-R). Forty-eight to the worldwide nursing shortage (American Association of Colleges percent of respondents admitted to being bullied in the workplace during the of Nursing, 2012), factors that con- previous 6 months, with respondents choosing “being ignored or excluded” as tribute to nurse turnover and attrition the most common negative experience in the workplace. The results of this must be eradicated (Simons, Stark, & study suggest that workplace bullying remains a problem for which reduction DeMarco, 2011). It is imperative that strategies must be devised as a means of retaining nurses and preventing workplace bullying be investigated to adverse outcomes. One strategy shown to be effective in curbing bullying is identify the scope of the problem and possible solutions. The Joint Com- assertiveness and aggression training for nurses. [Workplace Health Saf mission (2008) has identified work- 2014;62(1):6-11.] place bullying as a sentinel event that should be reported because it “un- ullying of nurses has been in the course of employment, which dermines a culture of safety” (p. 1). identified as affecting pa- could reasonably be regarded as un- Implicit in this statement is the need tient outcomes, occupational dermining the individual’s right to to educate nurses about strategies for B dignity at work. (p. 5) stress, and staff turnover. The Task creating a safe environment where Force on the Prevention of Work- nurses want to work. place Bullying (2001) has defined Simons (2008) wrote that bully- bullying as: ing is a problem that must be explored LITERATURE REVIEW for the retention of an adequate work- Workplace bullies are individu- Repeated inappropriate behavior, force; both Quine (1999) and Simons als in diverse roles, including manag- direct or indirect, whether verbal, (2008) found a correlation between ers, administrators, clinical instruc- physical or otherwise, conducted by bullying and nurses’ intention to leave tors, charge nurses, and staff nurses. one or more persons against another or others, at the place of work and/or the employing organization. Nurse-to-nurse hostility, also known Creating an environment where as lateral or horizontal bullying, re- nurses feel safe increases productiv- fers to aggression among peers or co- ABOUT THE AUTHOR ity (Felblinger, 2008). Randle (2011) workers on the same organizational Ms. Etienne is a Registered Nurse and Mas- ter of Nursing Education Graduate, University stated that “work should not hurt” (p. level (Johnson & Rea, 2009). of Alaska-Anchorage, Anchorage, Alaska. 391); therefore, a zero tolerance of In Johnson and Rea’s (2009) re- Submitted: August 5, 2013; Accepted: Octo- workplace bullying should be adopt- search on workplace bullying, 27.3% ber 8, 2013; Posted online: January 7, 2014 The author has disclosed no potential con- ed and interventions should be imple- of the 249 emergency room nurses flicts of interest, financial or otherwise. mented to change workplace cultures surveyed admitted to being bullied Correspondence: Emerald Etienne, MSN, BSN, RNC-OB, 3025 183rd Place SE, Bothell, of aggression and dissention. More- at work. Fifty percent of those who WA 98012. E-mail: [email protected] over, despite decades of research reported being bullied identified doi:10.3928/21650799-20131220-02 (Einarsen & Skogstad, 1996; Quine, managers or directors as the bullies; 1999, 2001) documenting that work- 25% named charge nurses as the bul-

lies. Similarly, 21% of the 286 nurses ior (i.e., nurses who lack the power as the bullying frequency increased surveyed in a Turkish study admitted to respond effectively to managers so did the likelihood of nurses leav- exposure to workplace bullying and or hospital administrators turn their ing the organization. Rosenstein and reported that 39% of the bullying hostility toward each other). O’Daniel (2005) surveyed 1,509 behaviors were perpetrated by ad- In exploring nurses’ experiences health care workers about bullying ministrators (Yildirim, 2009). Berry, confronting workplace bullies, Gaff- and found that 17% of the workers Gillespie, Gates, and Schafer (2012) ney, DeMarco, Hofmeyer, Vessey, reported that disruptive workplace used an Internet-based descriptive and Budin (2012) noted that inad- behaviors adversely affected workers cross-sectional design to survey 197 equate nursing support in the work- and the organization. Moreover, one novice nurses from Ohio, Kentucky, place and a culture of silence pro- in four respondents acknowledged a and Indiana; 72.6% of those nurses tected perpetrators. Porto and Lauve link between disruptive behavior and reported experiencing at least one (2006) also alluded to a history of patient mortality. workplace bullying event in the pre- indifference to and tolerance of bul- In a descriptive study, Simons vious month. Sixty-three percent lying in health care workplaces. Ka- and Mawn (2010) examined bul- of those who experienced bullying trinli, Atabay, Gunay, and Cangarli lying in the workplace among 184 identified the perpetrators as more (2010) explored the perceptions of a newly licensed registered nurses in experienced nursing colleagues. group of 232 Turkish nurses regard- the United States. They identified Their findings were comparable to ing individual and organizational rea- four main themes, including structural those of Clarke, Kane, Rajacich, and sons for horizontal bullying. Among bullying (“perceived unfair and puni- Lafreniere (2012), who surveyed 674 the perceived reasons for bullying tive actions taken by supervisors,” p. baccalaureate nursing students and were negative performance apprais- 307), nurses eating their young (abu- found that the two main sources of als, decisions about organizational sive treatment of new nurses), being bullying in the clinical setting were structure (e.g., a perpetrator bullies out of the clique (feeling alienated clinical instructors (30.25%) and to secure a new position in the orga- due to ethnicity or educational level), staff nurses (25.49%). nization), and equipment allocation. and leaving the job (leaving the job or It has long been said that “nurses In other words, for career ad- profession due to bullying). Those re- eat their young” (Bartholomew, 2006), vancement or a better performance sults are similar to the findings of Fel- and if left unhindered these negative review, nurses may bully others to blinger (2008), who examined nurses’ acts can further escalate the nursing negatively affect others’ performance shame responses related to incivility shortage. Novice nurses are the face and enhance their own performance. and bullying in the workplace; those of the future; experiencing workplace Possible motivations for bullying in- responses included anger and a ten- bullying when entering the nursing cluded perpetrators’ need for power dency of nurses to blame themselves workforce sets a negative precedent. and their own psychological and per- for the behavior of others, resulting sonal life problems. in occupational stress that can ad- REASONS BULLYING OCCURS versely affect nurses and negatively AND PERSISTS IN THE EFFECTS OF BULLYING affect patient outcomes. Nurses who WORKPLACE Hutton and Gates (2008) sur- are stressed or “burned out” are not Einarsen, Hoel, and Notelaer veyed 184 direct care workers, 81% able to practice competently, increas- (2009) categorized bullying into per- of whom were registered nurses. ing the risk of clinical errors. Some sonal bullying, work-related bully- The study results suggested that the nurses experienced symptoms of post- ing, and physically intimidating acts. source of bullying had a greater im- traumatic disorders after being bullied Personal bullying is gossiping about pact than the frequency of bullying. at work (Felblinger, 2008). an individual and work-related bul- For example, although bullying from lying includes criticizing an individ- supervisors and patients was less fre- METHODS ual’s work. Physically intimidating quent than from physicians and other A descriptive survey design was acts may involve physical violence direct care workers, bullying from used to generate information regarding or the risk of violence. Both staff supervisors and patients had a greater the extent to which nurses in a Pacific shortages and occupational stress impact on productivity. Thus, it is vi- Northwest state perceived that they create an environment conducive to tal to identify the sources of bullying were experiencing workplace bullying. bullying (Simons & Mawn, 2010). in an effort to develop effective and Approximately 10,000 registered nurs- Some researchers have hypothesized appropriate interventions to curtail es from that state’s professional nurses’ that because nurses are an oppressed bullying behaviors and the effect on association were invited to participate, group (i.e., being controlled by ex- workers. via the association’s online newsletter, ternal forces) they bully each other Simons (2008) examined work- in an online survey about workplace and exhibit behaviors similar to other place bullying and its relationship to bullying. Participation was voluntary oppressed groups (Roberts, 1983). nurses’ intention to leave the organi- and all information collected was strict- Horizontal bullying can be viewed zation. Of the 511 respondents, 31% ly confidential. Informed consent was as a form of oppressed group behav- reported being bullied at work and required at the beginning of the survey

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Table 1 Example of Bullying Behaviors on the Negative Acts Questionnaire-Revised Factor Item Wording Work-related bullying Someone withholding information that affects your performance Being ordered to do work below your level of competence Having your opinions ignored Personal bullying Spreading gossip and rumors about you Being ignored or excluded Hints or signals from others that you should quit your job Physical intimidation bullying Being shouted at or being the target of spontaneous anger Intimidating behaviors such as finger-pointing, invasion of personal space, shoving, blocking your way Threats of violence or physical abuse or actual abuse and respondents could not proceed with tive acts within the previous 6 months, views ignored’; 35% and 28% of re- the survey unless they consented. No specifying the frequency of occurrence spondents, respectively, reported they identifying information was collected as never, now and then, monthly, week- experienced bullying weekly or daily. and respondents could only access the ly, or daily. Respondents who reported Table 3 presents the frequency with survey once from an Internet provider experiencing two or more negative acts which respondents said they experi- address. This project was approved by on a weekly or daily basis were classi- enced various negative acts. the University of Alaska-Anchorage In- fied as experiencing workplace bully- stitutional Review Board. ing. Respondents were then given the DISCUSSION The link for the survey was sent definition of bullying and asked to state It is alarming that 4% of respon- out on March 28, 2013, and again in the (yes or no) whether they had been bul- dents classified themselves as experi- May 10, 2013, newsletter. The survey lied at work. encing bullying on a daily basis and was made available through Qualtrics 12% on a weekly basis. It is even (Provo, UT), an online anonymous sur- RESULTS more disconcerting that 16% of re- vey tool available to all students at the A total of 95 completed surveys spondents reported being exposed to author’s home school. Data were ana- were submitted online, approxi- threats of violence or physical abuse lyzed using the Statistical Package for mately a 1% response rate. The re- or actual abuse monthly or now and the Social Sciences version 20 (SPSS, spondents were predominately white then. Although the response rate was Inc., Chicago, IL). Descriptive statistics (88%) and female (94%), with an low, the results were consistent with were used to describe the sample char- average of 20 years of nursing ex- other studies on workplace bullying acteristics. perience. Forty-nine percent (49%) in nursing (Johnson & Rea, 2009; Si- Data were generated through par- had a bachelor’s degree and 17% had mons, 2008). Nulty (2008) stated that ticipants’ completion of the Negative earned master’s degrees; the majority the response rates for online surveys Acts Questionnaire-Revised (NAQ-R), (76%) of respondents worked in hos- are lower than paper-based surveys. an internationally accepted research pitals as staff nurses (65%) (Table 2). This low response rate is of concern to tool used to explore various acts of bul- Forty-eight percent of partici- the researcher; it is possible that only lying. The tool has a Cronbach alpha pants stated they had been bullied respondents who found the topic rele- value of .90. Developed by Einarsen in the workplace. The final item on vant responded. However, considering et al. (2009) to measure exposure to the questionnaire was a definition of the seriousness of this topic, even one workplace bullying, and used with workplace bullying and respondents nurse being bullied is one too many the permission of the developers, the were asked to use that definition to and interventions are needed. NAQ-R includes 22 negative acts or indicate whether they had been bul- The negative acts chosen most behaviors that can be categorized as lied. Twenty-four percent of respon- often by respondents were ‘being ig- exemplifying personal bullying, work- dents stated they were bullied at work nored or excluded’ and ‘having opin- related bullying, and physical intimida- only rarely, 20% said now and then, ions and views ignored’; both acts tion; examples of items in each bully- 12% said several times a week, and were identified by 35% and 28% of ing category are presented in Table 1. 4% said on a daily basis. The negative respondents, respectively, as happen- Respondents were asked to indi- acts that were chosen most frequently ing on a weekly or daily basis. This cate how often they had experienced by respondents were ‘being ignored finding should be of interest to man- those 22 behaviorally defined nega- or excluded’ and ‘having opinions and agers and educators who formulate

educational interventions geared to- Table 2 ward specific areas where nurses feel they are most challenged. Characteristics of Respondents Characteristics No. of Respondents IMPLICATIONS FOR Gender OCCUPATIONAL HEALTH NURSING PRACTICE Female 89 (94%) The findings of this study have Male 6 (6%) particular implications for occupa- Ethnicity tional health nurses, who possess the knowledge and skills to imple- White 84 (88%) ment interventions to curb and Hispanic 3 (3%) eventually eradicate workplace bullying. They can educate their col- American Indian/Alaska Native 1 (1%) leagues and administrators on the Other 2 (2%) effects of workplace bullying and Prefer not to answer 5 (5%) strategies for maintaining a more supportive work environment. Oc- Highest education cupational health nurses could also Diploma 6 (6%) benefit from educational programs Associate degree 24 (25%) that address types of bullying behaviors and strategies for confront- Bachelor degree 47 (49%) ing these negative acts. Educational Master’s degree 16 (17%) interventions should include all Doctorate 2 (2%) team members to raise their aware- ness of this problem. Practice setting Stagg and Sheridan (2010) Hospital 72 (76%) systematically reviewed strategies known to be most effective in curb- Clinic 5 (5%) ing bullying behaviors in health care. Office 2 (2%) They found rehearsed responses to be School 1 (1%) an effective defense against negative acts; along with skills performance Other 15 (15%) (Griffin, 2004), rehearsed responses Position title were 100% effective after interven- Staff nurse 62 (65%) tion. Another strategy was the pro- vision of assertiveness and aggres- Charge nurse 9 (9%) sion training (Oostrom & Mierlo, Educator 6 (6%) 2008), which helped nurses handle Nurse practitioner 3 (3%) adverse working environments. They also stated that Latham, Hogan, and Supervisor 1 (1%) Ringl’s (2008) approach of partner- Other 13 (14%) ing registered nurse mentors with academic participants resolved con- flicts and provided support and effective communication that enhanced the work climate. This collaboration those targeting nurse leaders who in son, 2009) toward workplace bul- increased nurse and patient satisfac- turn can change the organizational lying and provide education and tion and decreased nurse attrition. climate. Therefore, as nurse leaders counseling to employees, victims, Bennett and Sawatzky (2013) and emerging nurse leaders, occupa- and perpetrators (Center for Ameri- also explored the concept of emotional health nurses can learn about can Nurses, 2008). Moreover, they tional intelligence (the “ability to ac- emotional intelligence, an effective should develop bullying prevention curately perceive, appraise, and ex- intervention in creating successful programs including strategies for press emotions,” p.147) as a strategy working environments (Bennett & recognizing and addressing bullying to assist nurse leaders in fostering a Sawatzky, 2013). behaviors. The author recognizes positive work environment. Johnson Organizations should imple- that education is not the panacea for and Rea (2009) stated that the most ment a zero tolerance policy ending workplace bullying, but it is effective anti-bullying strategies are (Cleary, Hunt, Walter, & Robert- a positive start in creating a culture

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Table 3 Frequency of Negative Acts Experienced by Respondents Now and Then Weekly or Negative Acts Never (%) or Monthly (%) Daily (%) Being ignored or excluded 28 (30) 33 (36) 32 (35) Having opinions and views ignored 26 (28) 42 (45) 26 (28) Being ignored or facing a hostile reaction when you approach 41 (44) 32 (34) 21 (22) Someone withholding information that affects your 32 (34) 43 (45) 20 (21) performance Being exposed to an unmanageable workload 17 (18) 57 (61) 20 (22) Being ordered to do work below your level of competence 48 (51) 27 (29) 19 (21) Spreading gossip or rumors about you 35 (37) 40 (43) 19 (20) Having insulting or offensive remarks made about your 46 (49) 30 (32) 17 (18) person (i.e., habits and background), your attitudes, or your private life Persistent criticism of your work 52 (55) 25 (27) 17 (18) Being humiliated or ridiculed in connection with your work 37 (39) 41 (44) 16 (17) Excessive monitoring of your work 52 (56) 26 (28) 15 (17) Having key areas of responsibility removed or replaced 49 (52) 33 (35) 12 (12) with more trivial tasks Having allegations made against you 55 (59) 30 (32) 9 (9) Being given tasks with unreasonable or impossible deadlines 54 (58) 31 (33) 8 (8) Pressure not to claim something that by right you are 56 (60) 30 (31) 8 (8) entitled to (e.g., sick leave, holiday entitlement, travel expenses) Being the subject of excessive teasing and sarcasm 60 (65) 25 (27) 8 (8) Being shouted at or being the target of spontaneous anger 42 (46) 43 (47) 7 (7) Hints or signals from others that you should quit your job 69 (73) 18 (19) 7 (7) Intimidating behavior such as finger-pointing, invasion of 59 (63) 29 (31) 6 (6) personal space, shoving, blocking/barring the way Repeated reminders of your errors or mistakes 47 (50) 42 (45) 5 (5) Practical jokes carried out by people you don’t get along with 80 (85) 11 (12) 3 (3) Threats of violence or physical abuse or actual abuse 78 (83) 15 (16) 1 (1) of safety that respects the dignity of workplace bullying. Collaboration CONCLUSION nurses. A collaborative effort is re- with all sectors, such as policy mak- This research project yielded quired to eradicate workplace bully- ers, hospitals, and physicians, should similar results to previous studies, ing by educating nurses about con- be used to ensure that all appropri- which suggests that workplace bul- flict resolution and empowerment. ate resources are available to address lying of nurses continues to occur. Recommendations for further workplace bullying. Researchers Workplace bullying should be ad- study include research on factors should also measure the impact of in- dressed through educational pro- contributing to workplace bullying terventions on this study sample and grams geared toward curbing and and innovative ideas for eliminating then generalize such interventions to ultimately eradicating bullying. Bul- bullying. Nurses should be advocates nurses in all settings. The develop- lying can be both subtle and overt for change by actively participat- ment of a standardized educational and nurses should be equipped with ing in policy making and legislative tool could prove invaluable in com- the necessary tools for early recog- changes geared toward eradicating bating workplace bullying. nition of these negative acts and the

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