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A Dissertation Entitled New Graduate Nurses Perception of the Workplace

A Dissertation Entitled New Graduate Nurses Perception of the Workplace

A Dissertation

entitled

New Graduate Nurses Perception of the :

Have they Experienced Hostility?

by

Darla A. Vogelpohl

Submitted to the Graduate Faculty as partial fulfillment of the requirements for

The Doctor of Degree in Foundations of : Educational Psychology

______Mary Ellen Edwards, PhD., Committee Chair

______Lisa Kovach, PhD., Committee Chair

______Patricia Devlin, PhD., Committee Member

______Susan Rice, PhD., Committee Member

______Christopher Bork, PhD., Committee Member

______Dr. Patricia R. Komuniecki, Dean of Graduate Studies

The of Toledo

May 2011

Copyright 2011, Darla A. Vogelpohl

This document is copyrighted material. Under copyright law, no parts of this document may be reproduced without the expressed permission of the author.

An Abstract of

New Graduate Nurses Perception of the Workplace: Have They Experienced Hostility?

by

Darla A. Vogelpohl

Submitted to the Graduate Faculty in partial fulfillment of the requirements for the Doctor of Philosophy in Foundations of Education: Educational Psychology

The University of Toledo May 2011

Understanding the new ’s recognition of hostility in the workplace may give insight into how to handle encounters with this workplace problem. Preventing new graduate nurses from leaving the in the first three years after graduation is an important issue as there is a growing nursing of qualified licensed RNs. Through nursing education, the new nurse graduate needs to be prepared to recognize and handle the negative behaviors that may exist in workplace

This study investigated the bullying experience of 135 newly graduated RNs, using the Negative Acts Questionnaire-Revised, developed by Norwegian researchers. The participants reported that 20.5% of them had been bullied in the workplace and 46.7% had observed bullying in the workplace. Sixty percent of the new nurse graduate participants reported the main person causing the problem in the workplace were peers, physicians, and the patient’s . Bullying affected the performance for 31.6% and

29.5% had considered leaving the nursing profession. Less than one-fourth of the participants reported that bullying was a covered topic in their nursing curriculum in . Policies to deal with bullying in the workplace were supported by 96% of the participants. Internal and external behavioral reactions to bullying were analyzed.

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This study is dedicated to new graduate nurses that are beginning their as a newly licensed . Recognizing problems in the workplace and being able to manage and prevent them are important for achieving harmony in the workplace.

Retaining nurses in the with high professional standards is achieved through respect for one another.

iv

Acknowledgements

There are many to acknowledge who helped me on this journey. My husband, Chris, was continually very supportive and believed that I could accomplish this degree. My children, Curt, Dana, and Karyn were also very encouraging during this endeavor. I appreciate my Committee Chairs, Dr. Mary Ellen Edwards and Dr. Lisa Kovach who provided guidance, support, and thorough reviews of this paper. Other Committee

Members, Dr. Patricia Devlin and Dr. Susan Rice, provided much support and enthusiasm for completing the of this degree. My Committee Member, Dr.

Christopher Bork, provided expert direction in analyzing the statistical data. I also appreciate the faculty at The University of Toledo College of Nursing for their encouragement for finishing the dissertation. I truly appreciate the work of the Bergen

Bullying Research Group for their research in the area of and for the use of their tool, the NAQ-R, for this dissertation.

.

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Table of Contents

Abstract iii

Acknowledgements v

Table of Contents vi

List of Tables x

List of Abbreviations xi

I. Introduction 1

A. Background 4

B. Statement of the Problem 11

C. Purpose of the Study 13

D. Research Question and Hypothesis 15

E. Operational Definitions 17

a. Bullying 17

b. Workplace Bullying 18

c. Horizontal Hostility 18

d. Horizontal / Lateral Violence 19

e. Work – Related Bullying 19

f. Person – Related Bullying 19

g. Physically Intimidating Bullying 20

F. Delimitation 20

G. Limitiation 21

II. Review of Literature 22

A. Introduction 22

vi

B. Historical Background 22

C. Workplace Bullying Defined 29

D. Consequences of Bullying 33

E. Horizontal / Lateral Violence and Nursing 37

F. Oppression Theory and Nursing 40

G. Causes of Oppression and the New Nurse Graduate 44

H. Bullying and the New Nurse Graduate 47

I. Prevention of Bullying Through 49

J. Nursing and Bullying – 51

K. Responsibility 53

L. Summary 55

III. 57

A. Introduction 57

B. Research Design 57

C. Sample Population 58

D. Research Questions and Statistical Hypothesis 59

E. Survey Instrument 63

F. Procedure 63

G. Data Analysis Procedure 70

H. Protection of 71

I. Summary 72

IV. Data Analysis and Results 73

A. Demographic Description of Participants 73

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B. Analysis of Research Questions and Hypothesis 76

C. NAQ – R Survey Questions and New Nurse Graduate Responses 76

a. Work – Related Bullying 76

b. Person – Related Bullying 81

c. Physically Intimidating Bullying 88

D. Have You Been Bullied at Work? 90

E. Internal and External Behavioral Reactions to Bullying 92

F. Bullying Affects on 94

G. Who is the Bully in the Workplace? 96

H. Educational Efforts to Manage Bullying 97

I. Workplace Efforts to Educate Employees and Manage Bullying 99

J. Hypothesis Testing 102

K. Research Question One 103

L. Research Question Two A 107

M. Research Question Two B 109

N. Research Question Three 121

O. Research Question Four 125

P. Statistical Analysis Using Chi Square 128

Q. Summary of Data Analysis and Findings 132

V. Summary, Conclusion and Recommendations 140

A. Conflict Theory 141

B. Accepted Hypothesis and Rejected Hypothesis 143

a. Research Question One 143

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b. Research Question Two A. 1. 145

c. Research Question Two A. 2. 145

d. Research Question Three A. 147

e. Research Question Four A. 148

f. Research Question Four B. 149

C. Discussion 149

D. Implications 151

E. Limitations 152

F. Recommendations for Future Studies 153

G. Implications and Limitations 153

References 161

Appendices

A. Negative Acts Questionnaire - Revised 156

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List of Tables

Table 1. Factor loading and sub-factors of NAQ-R...... 66

Table 2. Frequency of race of nurse respondents...... 74

Table 3. Nurse practice settings of nurse respondents...... 74

Table 4. Nursing role of nurse respondents...... 75

Table 5. Educational background of nurse respondents...... 75

Table 6. Percentage of respondents who reported internal and external behavioral

reactions to bullying...... 93

Table 7. Percentage of nurse frequencies of “who is the bully in the

workplace?”...... 97

Table 8. Einarsen and new graduate nurse results “work-related

bullying”...... 103

Table 9. Einarsen and new graduate nurse results “person-related

bullying”...... 105

Table 10. Einarsen and new graduate nurse results “physically-intimidating

bullying”...... 107

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List of Abbreviations

ANA…...... American Nurses Association CP……...... Conditional Probability ED……...... Emergency Department ER……...... Emergency Room Ho: ...... Null Hypothesis HMO……...... Health Maintenance Organization IRB……...... Internal Review Board JCAHO…...... Joint Commission on Accreditation of Healthcare LCC……...... Latent Class Cluster MD…...... Medical Doctor MSN……...... Master Science in Nursing N……...... Nurse NAQ……...... Negative Acts Questionnaire NAQ – R…...... Negative Acts Questionnaire – Revised ONA……...... Ohio Nurses Association PWC HRI...... PricewaterhouseCoopers’ Health Research Institute RN………...... Registered Nurse RNC…...... Royal College of Nursing SPSS……...... Statistical Package for the Social Sciences UK…...... United Kingdom US…......

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Chapter One

Introduction

This chapter provides the background, statement of the problem, purpose of the study research questions and hypothesis, the definition of terms, and the limitations and delimitations of the study.

This study expands understanding of the new graduate nurse’s incidence and perception of workplace bullying in the US. The study determines if the new graduate registered nurse (RN) feels educationally prepared to recognize and manage bullies in the workplace, and if they have left a nursing position or their career in nursing due to bullying. Since the 1990s studies on workplace bullying have been done in various work settings mainly in Scandinavian countries, the UK, , and New Zealand. There are a few studies on workplace bullying in the US. One study assesses the prevalence, perception, and impact of bullying on the US worker (Lutgen-Sandvik, Tracy & Alberts,

2007). A few other studies involve the nurse’s perception of workplace bullying, the affects of the work environment, and their intent to leave the profession (Bowles &

Candela, 2005; Simons, 2006; and Johnson & Rea, 2009).

Workplace bullying is an ongoing display of interpersonal aggressive mistreatment from peers, subordinates, and managers in the workplace. And, there are catastrophic results for both the organization and the target of bullying of this current and prevalent workplace dilemma (Einarsen, Hoel, Zapf & Cooper, 2003; Rayner & Kreashly, 2005).

Workplace bullying has been described as a persistent, enduring form of at work that involves negative actions and interactions at work (Lutgen-Sandvik, et al. 2007).

1

Workplace bullying is a form of hostile, aggressive, interpersonal interactions and anti- social behaviors in the work environment of a bully toward a victim(s) (Salin, 2003).

The Oppression Theory provides understanding as to why bullying is occurring for newly graduated nurses in the workplace. An imbalance of power causes conflict between the dominant (e.g. experienced nurses) and subordinate group (e.g. newly graduated nurses). As one group has more power there is a conflict, power struggle, and the values of the subordinate group are oppressed (Friere, 1971). New graduate nurses are in a position to be oppressed as they do not know the tacit rules of the organization and are learning their new role within as registered nurses. The new graduate nurses become the targets of the more experienced nurses, the physicians, patients, patient’s and other health care workers.

Bullying behavior in the workplace has been defined with different terms in studies nationally and internationally. Terms such as the following are used:

(Leymann, 1990), workplace (Farrell, 1997), horizontal violence (McKenna,

Smith, Poole & Coverdale, 2003), (Brodsky, 1976), (Cortina,

Magley, Williams, & Langhout, 2001), bullying (Lewis, 2001), and (Cox,

1987). New graduate registered nurses (RN) in their first two years of practice in an organization need to be educationally prepared for hostility that may occur within the work environment.

Workplace bullying is a destructive relationship that is occurring for many nurses, especially new graduate nurses (Bartholowmew, 2006). Sixty percent of RNs in the US are leaving their first position within six months due to horizontal violence. Nursing is

2 primarily a female profession, and 90-97% of nurses report verbal abuse from physicians, which has historically been a male profession.

Simons (2008) did the first study in the US using the Negative Acts Questionnaire-

Revised (NAQ-R) (Einarsen & Hoel, 2001) on workplace bullying experienced by newly licensed RNs within six months of their most recent after becoming an RN.

Simons study was in the state of , and using the NAQ-R measured if RNs intended to leave the organization as a result of being bullied. Thirty-one percent of the participants in Simon’s study did relate their experience of being bullied in the workplace using the operational definition of at least two bullying behaviors on a weekly or daily basis occurring during the past six months. Bullying was higher in this study than other international studies previously done, using this operational definition of bullying.

Nurses (RNs) are increasingly in high demand in health care organizations to care for acutely ill patients, yet a significant numbers of RNs leave the profession within a few years of graduating. Perhaps a , more specifically bullying in

the workplace, may contribute to RNs leaving the profession. The questions this study explored are: 1. Have the new graduate RNs been exposed to negative behaviors in the workforce? 2. Do they feel educationally prepared to handle the confrontations or conflict from a bullying employee? 3. Have they left a former job or their profession of nursing as a result of negative behaviors directed at them in the workplace?

Understanding the new graduate nurses’ recognition of hostility in the work-place may give insight into how to handle encounters with this workplace problem. Preventing new graduate nurses from leaving the nursing profession in the first two years after graduation is an important issue as there is a growing of qualified

3 licensed RNs. Through nursing education, the new nurse graduate needs to be prepared to recognize and handle the negative behaviors that may exist in workplace bullying.

Conflict management is sparsely covered in many nursing programs. McKenna et al.

(2003) recommend after research on registered nurses in their first year of practice that basic nursing programs should include conflict management in a nurse’s educational experience. Prevention of horizontal violence or bullying of new graduate nurses in the workplace can be attained if the new graduate nurse is prepared to identify and manage bullying behaviors in the workplace. Kelly and Ahern (2008) explain that nursing curricula should prepare the graduate nurse for oppressive practices that can occur in the workplace, which will help the new graduate nurse prevent and respond to aggression or silence toward them in the workplace.

Background

Workplace bullying is a growing social problem involving disruptive behaviors.

Einarsen (1999), a professor of Work and Organizational Psychology and Director of the

Bergen Bullying Research Group at the University of Norway, has extensively studied workplace bullying since the early 1990s. Books and articles nationally and internationally defining the bullying phenomenon are to his credit. One early study

(Einarsen and Stogstad, 1996) reported the incidence of workplace bullying by using 14 different “quality of working life” surveys involving 7,986 Norwegian employees.

Employees in this research study were from many organizations and included , hotel and restaurant workers, industrial workers, university employees, clerks, electricians, psychologists, and health care employees. Findings of this study involving

4 many different were that 8.6% of the employees reported bullying at work within the previous six months.

A few years later after the Norwegian study on workplace bullying, (Einarsen &

Stogstad, 1996) the Negative Act Questionnaire (NAQ) was developed (Einarsen &

Raknes 1991, 1997; Mikkeson & Einarsen, 2001) to detect workplace bullying.

Workplace bullying was researched mainly in Scandinavian countries using the NAQ.

Within the next few years the Negative Acts Questionnaire-Revised (NAQ-R) was developed as an English version (Einarsen & Hoel, 2001) and was condensed to 22 items.

The NAQ-R was revised later to increase the validity, factor structure, and psychometric (Einarsen, Hoel, & Notelaers, 2009). The NAQ-R identifies three specific types of bullying: (a) work- related bullying, (b) person-related bullying, and (c) physically intimidating bullying. The NAQ-R is used today by many researchers internationally in many different types of work organizations to identify specific types of bullying in the workplace. The Bergen Bullying Research Group is directing research internationally on workplace bullying using the NAQ-R which has a copyright (Einarsen,

Raknes, Matthiesen, & Hellesoy, 1994).

More research is needed to determine if workplace bullying is causing nurses to leave their profession. The NAQ-R (Einarsen et al., 2009) is one tool that could help us determine if bullying is a problem and if it is related to the shortage of nurses. Workplace bullying has been researched in the nursing profession using the NAQ-R in only a few health care organizations in the US (Simons, 2008; Johnson & Rea, 2009). This research is important as the nursing profession has the largest number of health care employees in health organizations throughout the world. Because nursing is in the midst of a nursing

5 shortage, nursing cannot afford to lose nurses to the devastating problem of being bullied in the workplace.

Why are nurses leaving nursing and how does this affect the nursing profession?

Research indicates that job dissatisfaction is one of the major for the high nursing rate, which is estimated to consume 3.4% to 5.8% of a hospital’s budget

(Waldman, Kelly, Arora, & Smith, 2004). Nurses’ leaving the profession is very costly to health organizations and the consumers of health care. Others have found that the new nurse graduate’s intent to leave an organization is related to job dissatisfaction due to bullying in the workplace (Simons, 2008). New graduate nurses leaving the workplace or profession contribute to the existing nursing shortage.

As the nursing shortage is growing in the United States, newly licensed nurse graduates are in great demand. In an earlier report Auerbach, Buerhaus, and Staiger

(2000) stated that by the year 2015, 114,000 for registered nurses will be unfilled. In their studies of the two previous decades, the percentage of RNs in the workforce under

30 years of age decreased from 29.6% in 1980 to 10.3% in 1996.

PricewaterhouseCoopers’ (PWC) Health Research Institute (HRI) (2007) report an increasing number of nurses, which includes many newly graduated nurses under 30 years of age, plan to leave their jobs as a result of disillusionment with the nursing profession. Research interviews were conducted on 40 executives and leaders who represented nursing , hospitals, academic institutions, and . Also, 240 hospital executives throughout the US were surveyed for this research study. Nursing turnover in hospitals during the first two years after is reported to be at the

6 highest rate ever and nursing turnover was reported by hospital executives as costing each hospital up to $300,000 annually. In addition, a hospital with a poor nursing retention rate could spend an average of $3.6 million more than a hospital with a good nursing retention rate (PWC HRI, 2007).

Some statistics help to define the shortage that nursing is incurring. The U.S. Bureau of Labor Statistics (2007) has projected that more than one million replacement nurses will be needed to accommodate health care needs in the United States by 2016.

Government analysts also project plans to increase nursing job positions by 587,000 (a

23.5% increase) by 2016. Bartholomew (2006) explains that even though the nursing profession has the greatest nursing in the history of nursing, the number of RNs is at the lowest rate in 20 years.

Nursing has also identified other problems within the profession that are compounding the nursing shortage. One contributing problem the nursing profession is encountering is the increasing age of the RN. The average age of an RN was cited 10 years ago as 45 years of age (Buerhaus, et al., 2000). It is projected (Buerhaus, Potter, Staiger, French, &

Auerbach, 2008) that by the year 2012, nurses aged 50 years or older will be the majority of the nursing workforce.

Other statistical projections according to initial data released from the 2008 National

Sample Survey of Registered Nurses, (released by the Health Resources and Services

Administration, March, 2010), helps to disclose the problems. The Sample Survey, released every four years, reported there are presently 3.1 million RNs in the US, which is a 5% increase over the 2004 statistics. The average age of the RN population increased to 47 years of age, and nearly 45% of RNs were 50 years or older. Of these, the nursing

7 employment setting was: (a) 62.2% hospitals, (b) 10.8% outpatient clinics, (c) 7.3% community health, (d) 6.4% home health care, (e) 5.3% extended care, (f) 3.8% academia, and (g) 3.9% other ( insurance and utilization review).

The National Sample Survey of Registered Nurses data for 2008 also reports that the share of RNs less than 40 years of age did grow to 29.5% of the nursing workforce and is up from 26.6 % of the workforce reported in 2004. In March 2008 all nurses in the survey were asked about their future plans to remain in their nursing career. No plans to leave the nursing profession were reported by 54.5%, but 29.8% reported they had recently left a nursing position or planned to leave in the next three years. The following problems are identified by this study: 1.The average age of the RN is increasing. 2. Registered nurses less than 40 years of age are still less than one third of the nursing workforce. 3. Almost a third of the nurses in the survey had already left or planned to leave nursing within the next three years. We should ask the question “Could it be nurses are dissatisfied and leaving the profession?” It is important for researchers to analyze this as an ethical problem in nursing as it is very laborious and expensive for the nursing employee and the health care organizations.

Another contributing problem adding to the shortage in nursing is that 40% of qualified student applicants are turned away because of the lack of faculty to teach the nursing curriculum. According to The American Association of of Nursing, the average age of faculty who teach nursing is 50-57 years of age and this organization states that the problem is becoming intensified. Many younger nursing who are pursuing advanced degrees are not choosing academia. The long term result is that there are not enough replacement faculties for nursing schools and the faculty’s age is

8 increasing. Researchers further note that many masters and doctoral prepared nurses are choosing to pursue work in private practice rather than in the academic setting. Academia has notoriously been a lower paying career choice, which contributes to the lack of advanced degree nurses choosing academics after pursing higher education. This contributes to the nursing shortage, as many nurses achieving higher education do not pursue faculty positions. Presently there is not enough faculty to educate an increased number of nursing students at a faster pace. Many students are denied entry to due to the lack of faculty, and remain on a waiting list for years.

A hostile working environment in the nursing profession is compounding the shortage problem and is a threat to quality patient care-giving. The seriousness of disruptive nursing behavior is summed up by The Joint Commission on Accreditation of Healthcare

Organizations, (JCAHO), (2008) that released Sentinel Alert 40, requiring healthcare facilities to ensure healthcare organizations design an organizational approach to make employees aware of bullying and disruptive behaviors. Harmful behaviors between staff that are rude and hostile are threatening to the provision of quality patient care and prompted the JCAHO to address them in accreditations of health organizations.

In one study, Silence Kills (Maxfield, Grenny, McMillan, Patterson, & Switzler, 2005) disrespectful and abusive behavior between physicians, nurses, and staff has been noted by 20% of health professionals to cause actual harm to patients. This nationwide study given by Vitalsmarts and the American Association of Critical Care Nurses (Maxfield et al., 2005) recommended seven crucial conversations that health professionals need to have to prevent errors in the workplace. Among mistakes cited by employees in health organizations of this nationwide research study were: (a) broken rules, (b) mistakes, (c)

9 lack of support, (d) incompetence, (e) poor teamwork, (f) disrespect, and (g) . This study recommends that employees who have these crucial conversations are less likely to have errors, improve the quality of patient care, reduce the turnover in nursing, and be more productive as a health care organization.

Some statistics cited in the Silence Kills study determined that 1 in 20 patients in hospitals will be given the wrong dose of medication, 3.5 million will get infections because of the lack of hand-washing (Wenzel & Edmond, 2001) and 195,000 die as a result of mistakes made while they were hospitalized (Health Grades Quality Study,

2004). These statistics point to the fact that conflicts need to be successfully resolved in the workplace and bullying cannot be tolerated as patient care is endangered.

Bartholomew’s (2006) research as a nurse manager/counselor in Swedish Hospital in

Seattle, noted that some nurses were quite hostile towards one another in the workplace. This author (Bartholowmew) states that disruption in the workplace after students achieve the professional licensed RN status is contributing to the nursing shortage as many leave their jobs. Statistics of the JCAHO (2008) survey found that 50% of nurses have been a victim of bullying and/or disruptive behavior in the workplace, and

90 % in the survey stated they have witnessed others being the brunt of abuse within their organization.

Farrell (1999), a nursing researcher on aggression, summarizes the results of hostility in the workplace. Farrell states dealing with nurse to nurse aggression is the most distressing type of aggression to deal with on an interpersonal level in the health organization. A conflict in the workplace robs the nurse of energy, and distracts and

10 prevents the nurse from providing adequate patient care. The consequences of aggression affect the nurse on three levels: Personally, professionally and organizationally.

There are recently devised policies in place to address bullying in the healthcare organization workplace. The JCAHO (2008) released Sentinel Alert 40 which required healthcare facilities to ensure that healthcare organizations design an organizational approach to make employees aware of bullying and disruptive behaviors.

Recommendations from professional organizations call for participation of leaders and managers in skill-based focused on unprofessional employee behavior and conflict resolution. There is an important issue for the health care organizations to develop a zero tolerance for bullying within the workplace. Employees need to respect one another in the workplace.

Statement of the Problem

This study attempts to determine if the new graduate registered nurse does understand the issues and aspects in the work environment that can affect job performance, has experienced bullying, and has felt prepared educationally, formally or informally in the workplace to handle conflicts within the workplace. Graduating licensed nurses who change jobs within the first two years after graduation or leave the profession permanently present a serious nursing shortage problem as explained previously. The following statistics and research studies also highlight the global nature of the problem. A safe and healthy workplace is the right of every employee.

The health effects on an individual being bullied are continually documented to be personally destructive. Kivimaki, Elovainio and Vathera’s (2000) findings in a Finnish study of 5000 health workers found that those who were bullied had 26% more verified

11 sickness absences than those not bullied. Another Swedish study (Halberg & Strandmark,

2006) found that employees who are bullied report the following symptoms: (a) anxiety,

(b) pain, (c) fear, (d) low self esteem, (e) , (f) demoralization, (g) stress and (h) feeling vulnerable. These authors found that bullying traumatizes a victim and causes a lifelong internal scar.

One of the first studies on the prevalence of workplace involved a survey questionnaire to 1100 of England’s community health nurses (Quine, 2001).

Results from her study indicated that 44% of nurses reported experiencing one or more types of bullying within the past 12 months, and 50% had seen others in the workplace environment being bullied by others. They reported less and higher levels of anxiety and depression, and less levels of trust within the health organization. Also, nurses in this study were more often subjected to bullying than any other health care staff.

McKenna et al. (2003) surveyed 551 RNs experiences within their first year of practice in New Zealand. These authors found the new nurse lacks the skills to deal with hostility and that half of the workplace hostility that occurred was never reported by the new nursing graduate. These authors also stated that most nurses will be bullied at some time during their nursing profession as exposure begins during the student nurse’s undergraduate education, and the exposure risk increases in the workplace after licensure.

One research study indicates the newly licensed nurse is choosing to leave the nursing profession because of problems in the work environment. The survey study involved 352

RNs who graduated from a basic nursing program within the past five years in Nevada,

U.S. (Bowles & Candela, 2005). These authors determined the new nurse’s perception of

12 their work environment and reported that 30% of new nurses left their job within the first year, and 57% left by the second year, as a result of a negative work environment.

Hutchinson, Jackson, Vickers, and Wilkes (2006) study of 26 nurses taken from a larger national sample of nurses in Australia, who were identified as personally bullied and then interviewed. The authors state their research has important implications, as bullying jeopardizes patient care due to poor working relationships among staff. As there is decreased morale in the workplace, the overall result of nurses bullying other nurses is a . The result of the research included three important points: 1. Staff turnover was higher in the workplace. 2. Staff turnover was due to horizontal violence. 3.

Nurses were choosing to leave the profession.

If bullying is tolerated in the workplace, the following problems encountered by nurses have been identified in the literature: (a) increased illness, (b) increased absences,

(c) low self esteem, (d) depression, (e) less job satisfaction, (f) low job morale, (g) jeopardizing patient care, (h) lacking skills to deal with hostility, (i) leaving jobs, and (j) leaving the profession of nursing. Tolerating the bully in the workplace is damaging to nurses and the nursing profession.

Purpose of the Study

The I am interested in bullying is a result of my experiences as a nursing educator where I have seen bullying within the nursing profession. My original interest in bullying began from a different perspective of studying schoolyard bullying in children and working as a Clinical Nurse Specialist in a clinic. This led me to recognize that are also involved in bullying relationships in the workplace and

13 bullying occurs within the profession of nursing. (I question if there is something we as nurses can do about bullying)?

The overall purpose of this study is to investigate the bullying experience of the newly graduated RN. The experience of work-related bullying, person- related bullying, and physically intimidating bullying are three factors identified as a negative work experience

(Einarsen et al. 2009) using the NAQ-R survey tool. Newly graduated RNs, like other workers, experience negative behaviors in the workplace and experience workplace bullying. The purpose of this study is to find if the newly graduated RN experiences these three types of bullying and determine what affects bullying has on the newly graduated RN.

There is a critical shortage of nurses in health organizations, and the nursing profession cannot afford to lose any licensed RN, and especially the newly licensed RN.

After finishing two to four years of intense and expensive schooling, some RNs are choosing to leave their job or the profession. One questions why nurses, who are in very high in demand, are leaving the profession. As the nursing shortage increases, the numbers of qualified RNs are also leaving some health organizations. It appears that bullying is a contributing factor to a significant number of trained RNs to leave their profession as they cannot tolerate a hostile workplace.

This research study will examine the frequency of negative behaviors or bullying in the workplace for the newly graduated RN. The purpose is to find if new nurse graduates in Northwest Ohio experience three types of negative work environments identified by

Einarsen et al. (2009): (a) work-related bullying, (b) person-related bullying, and (c) physically intimidating bullying. Data will be collected using these researchers NAQ-R

14 survey tool and will answer the following questions: 1. Do the three types of bullying affect the newly graduated nurses differently from those in previous workplace research studies? 2. Does the newly graduated RN recognize the negative behaviors that occur in the workplace as bullying behaviors or normal work behaviors?

The new graduate nurses’ reactions to a negative workplace is important as it affects their future career choices. If the newly graduated RN feels the negative behaviors in the workplace are work- related bullying, person- related bullying, or physically intimidating bullying they may choose to change jobs, leave the profession, or pursue another degree to escape a hostile work environment. Career decisions and opportunities may be relinquished or abandoned as a result of workplace bullying.

Nursing education needs to prepare the newly graduated RN to manage conflicts in the workplace successfully. If the pre-licensed RN education or post graduate RN workplace orientation includes on aggressive work behaviors and assertiveness training, nursing graduates will be better prepared to cope with negative workplace behaviors. Education as a student nurse on bullying behaviors in the workplace will specifically help the new graduate RN to identify the negative workplace behaviors as bullying. If the negative behaviors are recognized, they are more skillfully managed.

Research Questions and Hypothesis

The following research questions were developed to examine the new graduate nurse perceptions of workplace bullying. Descriptions of the workplace include the three types of bullying: (a) work-related bullying, (b) person-related bullying and (c) physically

15 intimidating bullying. Table 1 categorizes the items, factors loadings, and correlations among the sub-factors of the NAQ-R (Einarsen et al., 2009).

1. Do a significant number of new nurse graduates report negative behaviors and different types of bullying in the workplace (work-related bullying, person-related bullying or physically intimidating behavior)?

1. 1 Hypothesis: There are a significant number of new nurse graduates who

report work-related bullying in the workplace.

1. 2. Hypothesis: There are a significant number of new nurse graduates who

report person-related bullying in the workplace.

1. 3. Hypothesis: There are a significant number of new nurse graduates who

report physically intimidating bullying in the workplace.

2. A. Who does the new nurse graduate identify as causing the problem in the workplace?

2. B. Do new nurse graduates identify that workplace bullying has affects on them personally (internal/external behaviors)?

2. B. 1. New nurse graduates identify internal behaviors that affect them as a

result of workplace bullying.

2. B. 2. New nurse graduates identify external behaviors that affect them as a

result of workplace bullying.

3. A. Do new nurse graduates believe that experiences of workplace bullying have an impact on their job performance?

3. A.1. Hypothesis: New nurse graduates identify that workplace

bullying has an impact on their present job performance.

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3. A. 2. Hypothesis: New nurse graduates identify that workplace

bullying has an impact on their changing jobs in the past two years.

3. A. 3. Hypothesis: New nurse graduates identify that workplace bullying has

an impact on decision to change jobs.

3. A. 4. Hypothesis: New nurse graduates identify that workplace bullying has

an impact on their decision to leave the nursing profession.

4. A. Do new nurse graduates identify formal nursing education as providing knowledge about bullying?

4. B. Do new nurse graduates identify informal workplace efforts to deal with bullying in the workplace?

Using the Negative Acts Questionnaire-Revised (NAQ-R) the above research questions / hypothesis are studied. Workplace bullying behaviors are described in the

NAQ-R survey for new nurse graduates in this study (See Appendix A).

Operational Definitions

The literature on aggression in the workplace displays many titles: Bullying, workplace bullying, horizontal violence, horizontal hostility, lateral violence, verbal abuse, mobbing, , , and .

There is no universal term of workplace bullying which makes it more difficult to describe and analyze behaviors in the workplace that constitute bullying. The following are a summary of some of the definitions used in the literature that will be used to describe hostile workplace behaviors:

Bullying: A person must do humiliating tasks and feels inferior to another person in a relationship. Tactics used by the aggressor include offending behaviors, harassment,

17 and/or , Bullying describes repeated incidents (e.g. once a week), and for a certain amount of time (e.g. for six months). A single occurrence is not bullying as an occurrence with two opposing strong persons having a single conflict does not constitute bullying (Zapf & Gross, 2001). Bullying is the persistent act of demeaning and downgrading another person through cruel words and negative actions that undermine another’s self and self-esteem (Adams, 1997).

Workplace bullying: Negative behaviors that are persistent (e.g. 6 months minimum) and occur at work. A few cases may be physical or sexual, but most cases of workplace bullying are psychological acts that are negative. Issues may involve work issues (e.g. withholding information needed to do a job) or non-work issues (e.g. humiliating and insulting acts) and the victim has difficulty defending him/herself

(Einarsen, Raknes, Matthiesen, 1994; Leymann, 1996). Workplace bullying is not a general conflict with another person, but one where a person feels forced into an inferior position in the relationship (Einarsen et al., 1994). The perpetrator has no intention to stop the bullying tactics directed toward the victim in workplace bullying (Hubert, Furda

& Steensma, 2001).

Horizontal hostility: A risk to health or safety as a result of continual behavior patterns that devalue, demean, or control a peer (or group). It can be overt behaviors such as name-calling, bickering, backstabbing, , , , shouting, blaming, put-downs, raising one’s eyebrows, gossiping. It can also be covert behaviors that are exhibited such as giving another an unfair assignment, making faces about another, sighing, rolling one’s eyes, using sarcasm, whining, sighing, refusing to work with another, isolating, excluding, fabricating, and sabotaging (Farrell, 2005).

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Horizontal / lateral violence: Coworkers on the same hierarchical level of an employee in an organization the employee’s efforts to do his job (Dunn, 2003).

In nursing there is nurse-on- nurse aggression and intergroup conflict, psychological violence (hurtful behaviors) rather than physical violence. Lateral violence is also described under the term horizontal violence, bullying and, in nursing, is referred to as

“eating our young” (Stanley, Dulaney, & Martin, 2007). In the nursing literature Griffin

(2004) describes 10 negative behaviors of lateral violence: (a) non-verbal gestures, (b) verbal attacks, (c) undermining another, (d) with-holding information, (e) sabotaging another, (f) infighting, (g) another, (h) backstabbing, (i) disrespect for another’s privacy, and (j) breaking another’s confidence.

Work-related bullying: Factors in the workplace include: (a) withholding information which affects job performance, (b) offered work below your competence level, (c) ignoring your opinions. (d) given tasks with irrational deadlines (e) over monitoring of work, (f) pressure to not claim what you are entitled to as an employee

(vacation or sick time), (g) having an excessive (Einarsen et al. 2009).

Person-related bullying: Factors in the workplace: (a) Being ridiculed or humiliated about your work, (b) responsibility removed and given menial tasks, (c) rumors and gossip spread about you, (d) being ignored and excluded, (e) having insulting or offensive statements made about your attitudes and beliefs about work and your private life, (f) hints that you should quit your job, (g) constant reminders of your mistakes, (h) practical jokes made by people that are adversaries, (i) having claims made against you,

(j) being teased excessively (Einarsen et. al, 2009).

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Physically intimidating bullying: Factors in the workplace: (a) yelled at or being the recipient of intense anger, (b) being threatened or being the recipient of ,

(c) someone intimidates you by blocking your space, shoving, or finger-pointing

(Einarsen et. al, 2009).

For the purpose of this study, horizontal violence/lateral violence will be considered by this author to be within the overall definition of bullying, and describes aggression of one person(s) toward another person(s). The terms defining studies on bullying may use these terms which constitute a form of bullying and reveal hostility and aggression of employees in the health care organization workplace.

Delimitations

This study is limited to those newly graduate nurses RN licensed in the state of Ohio within the past three years. The rationale for selecting three years post RN licensure is research (PricewaterhouseCooper’ Health Research Institute, 2007) stating the nursing turnover rate is the greatest in hospitals during the first two years after licensure. The email list for the survey is compiled from five different nursing schools within Northwest

Ohio. Included are The University of Toledo College of Nursing Alumni, Mercy College of Nursing Alumni, Owens College of Nursing Alumni, Lourdes College of Nursing

Alumni, and Northwest State College of Nursing Alumni. There will be a purposive expert sampling of this specific population as they have experience and expertise in the area of nursing. Privacy will be protected through an anonymous, confidential email return at the Institutional Research Department at The University of Toledo. One person, a research assistant, will compile the survey results and send the data to me to be analyzed with a University of Toledo Statistician using SPSS and Excel software.

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One de-limitation to the study is that it is a sample from only one state, Ohio, in the

Midwest of the United States. The perceptions of nurses in this Midwestern region may not be the general perceptions of nurses in other parts of the nation or internationally.

As the study is a survey report, which defines bullying using the Negative Acts

Questionnaire – Revised (NAQ-R), this is a delimitation to the study. There will be some who choose to not participate due to a lack of interest in the topic of workplace bullying, which may affect the validity. One other delimitation to this study is that some RNs will not access their college alumni email after licensure, so may miss the opportunity to participate in the survey.

Limitations

Due to nursing being primarily a female profession, the results may generalize female reactions to bullying and conflict. As most RNs work in hospitals, especially as the first job after finishing their schooling, more hospital RNs are expected to be responding to the survey than from other practice settings in nursing. Age is also a limitation in this study as most of the RNs attending nursing school are less than 30 years of age.

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Chapter Two

Review of the Literature

Introduction

This review of the literature embodies the following 11 major sections: Historical background, workplace bullying defined, consequences of bullying, horizontal/lateral violence and nursing, oppression theory and nursing, causes of oppression and the new nursing graduate, bullying and the new nursing graduate, nursing and bullying-role conflict, prevention of bullying through higher education, health organization responsibility, and the summary. The review of the literature provides the reader with studies that support the historical aspect of workplace bullying and the perspective of the new nurse graduate towards bullying in the health care organization workplace.

Historical Background

One of the earliest assessments of workplace harassment, The Harrassed Worker, was published, by a psychiatrist who interviewed 1,000 workers filing for compensation in

California and Nevada (Brodsky, 1976). In the 1980s research began on workplace bullying in after Olweus (2003) presented information on Swedish schoolchildren and schoolyard bullying. In the research on children, three criteria were presented as aggressive behaviors by children and include: The harm is intentional, there is an imbalance of power between the bully and the target victim, and it occurs repeatedly over a time-span (Olweus, 1999). Also, three main types of bullying were defined: (a) direct physical, (b) indirect, and (c) verbal aggression. The research on workplace bullying is more extensive than schoolyard bullying and involves the different disciplines

22 of psychology, , and sociology when analyzing the behaviors of the bully and victim in the workplace.

Leymann (1990), a Swedish psychologist, did one of the first research studies on workplace bullying in Europe and is considered to be the pioneer researcher on this topic.

Leymann (1990) and Leymann (1996) chose the word mobbing, rather than the British and Australian term bullying, because of the connotation that bullying is related to physical aggression and threat. Mobbing is described in the work site when a person feels put into an inferior position as they are harassed, bullied, offended, socially excluded, or doing offensive work (Zapf, 1999).

Within a few years of Leymann’s initial research, scholars from Norway (Einarsen, et al., 1994) and Finland (Bjorkqvist, Osterman, & Hjelt-Back, 1994) did extensive research on mobbing and harassment in the workplace. The above scholars state that although some international research is labeled as mobbing and other research is labeled as bullying, both terms refer to the same or similar situations in the international literature.

Workplace harassment is defined as a certain type of aggression that victimizes another person (Bjorkqvist et al., 1994). These authors state aggression can be short-lived or over a long time period and less intense, as in the situation of bullying. And, either type of aggression may be a catastrophe for the victim.

Research on workplace bullying is muddled as there are many different names describing a myriad of negative behaviors in the workplace. Depending on the discipline of psychology, business, or the social sciences, and the employee population studied blue collar, white collar, males, or females. The negative behaviors have many descriptions.

Harassment, for one, has usually been sexual or racial in origin (and has legal

23 connotations in the US), so workplace bullying is a newer harassment category identified by researchers. Other terms are used to describe negative workplace behaviors such as mobbing, verbal abuse, aggression, and physical and . The actual negative behaviors have been broken down into many distinct behaviors such as ignoring, terrorizing, gossiping about, and are either covert or overt actions.

Workplace aggression is defined as violence in the workplace expressed by an extreme act of aggression which is mainly in the form of verbal, indirect and passive communication, rather than physical in nature. Organizational changes such as downsizing and increased workforce have contributed to the incidence of aggression in the workplace (Baron & Neuman, 1998). Einarsen, et al. (1994) report from their research that employees rarely report physical bullying in the workplace, but do report many other intimidating behaviors that occur in the workplace.

Bullying is noted as a growing problem in society and involves maltreatment of one person, the victim, by another person or persons, the bully (Einarsen and Hoel, 2001).

Einarsen (1999) is one of the major researchers in the area of workplace bullying. His group, the Bergen Bullying Research Group at the University of Norway, has been studying bullying for years and developed survey instruments to collect data. Einarsen and Hoel (2001) explain that workplace bullying is a situation where a person feels mistreated, as they are persistently exposed to interpersonal aggression over a long period of time. Also, dealing with interpersonal aggression can have a devastating effect on the person and the organization in which they work.

Workplace harassment in the United States revolved mainly around sexual and racial harassment cases in the workplace in the 1960s. The Title VII

24 provided legal grounds to stop harassment issues and prevent discriminatory practices of employers to their employees. Workplace bullying is a recently identified form of harassment that is being studied more intensely in the US during the past decade.

There are very few medical and nursing harassment cases identified in the 1990s.

Some medically related bullying and harassment studies in the United States included

Cox’s (1991) research on the nurse’s experience of verbal abuse, mainly by physicians.

Verbal abuse is defined as professional or personal communication from one person to another that is perceived to be harsh and condemning and the target of the communication feels very distressed (Buback, 2004). Cox, a nursing professor in Texas, did a survey of nurses in the workplace after one of her best students threatened to leave nursing after being continually verbally abused by physicians. It was found in Cox’s study on nurses that physicians caused increased stress in the work environment and was a major source of conflict for nurses. Of the 1168 surveys returned, the results indicated there were 24.3% of staff nurses and 25.2% of nurse managers who left their positions. In this study verbal abuse by nursing and physicians were the major sources of verbal abuse. The nurses in the study reported at least five episodes of verbal abuse per month, and expected during a one year time period to be verbally abused at least once per week. Most of the respondents that were verbally abused felt angry, powerless and left their nursing position, as attempts to change the verbal abuse were futile.

Also, Sheehan, Sheehan, White, Leibowitz, and Baldwin (1990) did a study on medical students’ experiences of abuse as a student. Medical students reported in the

Sheehan et al. study that one-third would have dropped out of medical school if they knew before entering the profession they would be subjected to verbal abuse and

25 misconduct in their schooling. One-fourth of the students reported they would not have chosen the medical career and three-fourths of the medical students felt they were worse off than their peers who chose other .

Keashly and Jagatic (2003) suggest that within the US, hostile work behaviors have been identified in many disciplines with various names to define bullying. The international bullying research is more concise as there are fewer terms used to define the bullying phenomena. For the purpose of this research study on the new graduate nurse’s perception of hostility in the workplace, aggressive workplace behavior with varying names will be referred to as bullying behaviors.

Prior to studies on bullying of nurses, an earlier study on bullying of teachers in the

United Kingdom points to the financial and emotional loss to an organization. Travers and Cooper (1993) found 30-55% of all workplace stress is caused by bullying and 40 million working days a year were lost due to bullying. To prevent health care organizational losses similar to the educational losses described, Quine (2001) recommends that employers develop anti-bullying policies, formal and informal grievance policies, and provide employees with a positive work environment by providing support to employees who are bullied. Quine cites these measures as the most effective method of protecting an individual’s health and in the workplace. And, the additional benefits gained for an organization are there is less employee time lost to and lower turnover rates. Also, benefit analyses demonstrate that increasing financial support to analyze and manage the bullying phenomenon is a sound business decision.

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One recent online survey study in business management involving 469 participants found that 35-50 % of workers in the United States experience bullying by being humiliated or enduring harmful behavior at least weekly during a 6-12 month time period. Also, at least 30 % of the workers experienced two types of negative behavior often (Lutgen-Sandvik, et al., 2007). This study defined workplace bullying as having many names including horizontal violence, workplace aggression, mobbing, and lateral violence. The results of this research on workers experiencing bullying in the US included: (a) bullying involved negative acts against another person or persons, (b) there was a perceived power imbalance by the perpetrator and the victim, and (c) the end result was a hostile work environment.

Lutgen-Sandvik et al. (2007) also noted in their research on US employees that when comparing negativity levels reported by US employees to Scandinavian countries in previous studies, the US employees reported 20-50 % more negativity. They concluded from this finding that the US sample of employees perceived their workplace as more negative and/or they were more likely to interpret employee actions as negative. One in ten (9.4 %) of US workers identified the negative behaviors they were experiencing in the workplace as bullying. Lutgen-Sandvik et al. determined that bullying behaviors are ingrained in the US workplace culture.

Management theorist, Holstede (1993) provides the framework for this difference in negativity experiences of workers. In the US companies encourage , production, the importance of a manager over workers, and a competitive environment among workers, which minimizes collaboration in the workplace. For these reasons,

Lutgen-Sandvik et al. (2007) believe US culture supports bullying in the workplace. The

27 prevalence of bullying in this research study was found to be greater in the US than in studies previously done in Scandinavian countries and the UK.

Workplace violence has gained recognition as an increasing problem in the nursing profession. Individual state professional organizations are demanding health care organizations to develop policies to impede violence in the workplace against employees.

Locally, within the state of Ohio, more recent recommended organizational strategies to protect against were introduced by the Ohio Nurse’s Association

(ONA). This was published as the Position Statement on Workplace Violence Practice

Statement NP 83 (Brunt, Hoopingarner, Nanna, Nicholson, Smith, & Valentino, 2007), and includes the following recommendations for health organizations: 1. Organizations should have a review for past and present claims. 2. Each nursing position needs to be assessed for the risk of violence. 3. Focus groups need to be formed for nurses to discuss attitudes toward violence in the workplace. 4. Preventive tactics need to be in place including orientation, mandatory updates about risks, conflict resolution, and helpful confrontations. 5. Reporting policies should be readily available. 6. Nurses should be encouraged to report all violence in the workplace. 7. Any person in the organization should be accountable for their actions and if necessary nurses should pursue legal avenues. 8. Reports of violence should be followed up immediately by managers, and consequences in place for the perpetrator. 9. Following a bullying incident there should be counseling and evaluations. 10. If employees experience conflict in their , they need a supportive employer. 11. Waiting time in the emergency department should be minimal, and 12. Employee assistance programs are available for those who are a

28 victim of workplace violence. If these steps are enforced in the workplace bullying events would decrease as perpetrators would be accountable for their actions.

Also, the Position Statement on Workplace Violence: The ONA’s Nursing Practice

Statement NP 83 (Brunt, et al., 2007) recommends education as a key component to protect against workplace violence. Some of the strategies include: 1. Nurses should be educated on how to assess the workplace for violence. 2. Each employee should have violence prevention information in orientation and mandatory updates. 3. Nurses should be educated about how to identify and manage agitation. 4. Regular documented training sessions on violence are to take place within organizations. If nurses are educated on how to recognize negative acts or bullying in the workplace, they would be in a better position to prevent bullying events by being dissuasive to perpetrators.

In Northwest Ohio there have been recent proactive strategies within some of the local hospitals for providing information to employees and managers regarding workplace violence. These informational sessions on workplace violence are a positive influence and an encouraging outcome of the ONA Nursing Practice statement NP 83 (Brunt, et al.,

2007). The University of Toledo Medical Center in Northwest Ohio brought in Kathleen

Bartholowmew, the author of Ending Nurse to Nurse Hostility: Why Nurses Eat Their

Young and Each Other, during the month of June, 2010. Workplace violence issues and policies were discussed with hospital employees and managers.

Workplace Bullying Defined

Most of the instrumental research on workplace bullying has been done on other populations than nurses. Studies by research and organizational psychologists on a variety of occupations indicate that workplace bullying (the continuous exposure to

29 interpersonal aggression from co-workers) has a negative effect on individuals and the organization (Einarsen & Mikkelsen, 2003; Hoel, Einarsen, & Cooper, 2003). These authors project rates of absenteeism and leaving a job are higher if the individual feels bullied.

Victims of bullying may underreport bullying as a result of feelings of and shame. Rayner, Hoel, and Cooper (2002) determine that victims self-reporting the prevalence of bullying may underreport because of the connotation of being weak or childish. Einarsen, et al. (2003) summarized the feelings of the victim of bullying. These authors explained that the victim often feels isolated, demoralized, and unable to prevent the bullying or defend themself from the bully that is doing the terrorizing.

Randall (2001), who has been involved with studies on bullying in the workplace, explains the symptoms and feelings described by the victims of workplace bullying. The victims of workplace bullying in his studies appeared very cautious at work, and had a sense of dread and doom as they are in fear as to when and where the next attack from the bully will occur. Randall states fear and shame are two of the feelings victims have privately as they felt victimized and unable to protect themselves.

The Workplace Bullying Institute (2010) projects the victims of workplace bullying can be very costly to a health care organization. Lawsuits are pursued by some employees to seek justice against the aggressor or organization and the litigation and settlements cost up to $1.4 million. They project a Fortune 500 could spend up to $24,000,000 annually between staff turnover and lost . Bullying is costly both financially in the workplace for the health organization besides being destructive from the human relationship point of view.

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Bullying behaviors in the workplace studied by one European (Salin,

2003) are summarized when described as the following: A hostile work environment where one person feels there is a power imbalance as multiple repeated negative actions are directed at one person(s), the victim of the bullying. Lutgin-Sandvik et al. (2007), US economists, used the standardized measure of workplace bullying, the Negative Acts

Questionaire (NAQ), developed by Einarsen & Hoel (2001) to describe workplace bullying. In their study sample of US workers Lutgen-Sandvik et al. found a form of interpersonal aggression and the behavior of the bully to be anti-social and hostile. These authors description of workplace bullying displays the culture of workplace bullying as a form of abuse that is persistent and enduring for the victim.

A description of workplace bullying (Rayner & Hoel, 1997) proposes five bullying categories. The first is the threat to one’s personal status and the person is belittled, publicly humiliated professionally, or accused of not putting effort into his/her work. The second is the threat to one’s personal standing, which includes others in the workplace gossiping about an employee, calling him names, and insulting and him. The third is isolation, which includes withholding information the employee needs, isolating the employee socially and physically, and preventing the employee from pursuing training to better his career. The fourth is overworking the employee and occurs when the employer gives the employee impossible deadlines, pressures the employee to produce work, and plans disruptions for the employee. The last bullying category these authors define is destabilization which includes the of work recognition, giving senseless work tasks, demoting the employee, shifting or withdrawing the employee’s responsibilities, repeatedly criticizing an employee’s work, and setting the employee up for failure.

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Categorizing these negative acts of bullying provides distinct actions and behaviors a perpetrator inflicts on a victim.

Four main defining characteristics of horizontal violence or workplace bullying are described (Einarsen et al., 2003; Rayner et al., 2002; Rayner & Keashley, 2005; Lutgen-

Sandvik et al. 2007): (a) intensity, (b) repetition, (c) duration, and (d) power disparity.

Intensity describes the number of aggressive acts directed toward a specific person.

Repetition is defined as a pattern of behavior that occurs daily or weekly. The duration includes the behavior that occurs over an extended period of time, usually six months or more. The power disparity is an imbalance of power between the perpetrator and the target of the bullying, where the target feels incapable of stopping the bullying. These characteristics help define the bullying event.

Rau-Foster (2004) defines one other form of negative workplace behavior as incivility or rude and disrespectful behavior that lacks regard of another and is the beginning of the bullying culture. But, workplace bullying is more intense and involves more aggressive behaviors. It has grown from the original definition of physical violence toward another to more covert behaviors such as backbiting, blaming, degrading, and excluding others for the intense purpose of doing harm (Hoel, Giga & Davidson, 2007;

Hutchinson, Vickers, Jackson & Wilkes 2006; & Randle, 2003).

Workplace bullying is also distinct from other definitions such as incivility or disruptive behaviors, as the behaviors of the bully toward the victim are not random acts, are intentional, and occur over an extended period of time. Workplace incivility is defined as disrespectful deviant work behaviors of a person to harm another which violates workplace rules (Andersson & Pearson, 1999). And, uncivil behaviors are

32 generally discourteous and rude, and demonstrate the lack of mutual respect in the workplace.

The conflict is difficult to resolve as there is often a power disparity between the bully and victim. The bullying on the surface appears non-aggressive, which makes it difficult for a victim to speak out about the aggression (Lurgen-Sandvik et. al., 2007; Leymann,

1996, Zapf-Gross 2001).

Consequences of Bullying

Constant acts of bullying can lead to serious harm to the victim (Hutchinson, Vickers et al. 2006). Adams (1997) describes bullying as undermining of another’s self confidence and self esteem as the person is devalued, demeaned, and downgraded through vicious and cruel words or acts. Longo and Sherman (2007) explain that members oppressed by horizontal violence exhibit low self esteem, powerlessness, problems sleeping, disconnection from other staff, and extended sick leaves from the organization they work.

The outcome for individuals experiencing horizontal violence or bullying over an extended period of time can lead the victim of bullying to permanent psychological and occupational damage (Crawford, 2001; Leymann & Gustafsson, 1996) and result in devastation for an individual (Adams & Crawford, 1992). Bullying research has found victims can experience damage in cognitive functioning, self-esteem, emotional health, and physical health (Brodsky, 1976; Einarsen & Mikkelsen, 2003; Keashley & Harvey,

2005). Some victims are devastated to the point they cannot work unless they are rehabilitated (Leymann & Gustafsson, 1996; Scott & Stradling, 2001).

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A supporting survey study (Quine, 2001) on workplace bullying of 396 community health nurses in the National Health Service Trust in England analyzed the prevalence of bullying. The goal of the study was to determine if there was an association between bullying and the occupational outcome of the nurse employee, and if the workplace supported and moderated the effects of bullying for the victim of bullying. Results of the study included 44% of the community health nurses report of being bullied in some form in the past 12 months compared to 35% of other staff. Also, 50% of the community health nurses had witnessed others being bullied at their workplace. The bullied community health nurses had a lower level of job satisfaction, more anxiety and depression, and were more critical of the organizational environment of trust. The community health nurses also reported that the nurses supported at the workplace were protected from the destructive effects of bullying.

Medical problems were also found in victims of bullying in some studies. Research by Kivimaki, Ferrie, Brunner, Head, Shipley, and Vahtera, et al. (2005) found work related injustices that were experienced by victims of bullying were also associated with the medical problems of hypertension, increased risk of coronary heart disease, and prolonged stress. In an earlier study by the authors, the average body mass was one unit higher for the victims of bullying than other employees at the workplace, which was ultimately found to increase the risk for heart disease (Kivimaki, Virtanen, Vartia,

Elovainio, Vahtera, & Keltikangas-Jarvinen, 2003).

Psycho-social problems were also experienced by victims of bullying. Vartia (2001) reported that co-workers of the bullies in the workplace lived in fear of being the next target, had high stress levels, and related their intent to leave the workplace. Bullying in

34 the workplace was also found to negatively affect family life and interpersonal relationships (Jennifer, Cowie, & Anaiadou, 2003; Tracy, Lutgen-Sandvik, & Alberts,

2006).

Other research found there is a greater risk of developing psycho-emotional problems such as post-traumatic stress disorder (Leymann & Gustafsson, 1996), alcohol abuse

(Richman, Rospenda, Flaherty, & Freels, 2001), prolonged duress stress disorder (Scott

& Stradling, 2001) and suicide (Leymann, 1990) for victims of bullying. McKenna et al.

(2003) state that bullying can come in many varieties in the workplace, but that psychological harassment is the most common form a victim must deal with. These same researchers also state that psychological harassment causes a person to develop hostility.

Psychological harassment is very different from physical aggression as the effects may haunt the victim for years. These authors suggest psychological harassment is more damaging to deal with for the victim.

The prevalence of bullying and the relationship between burnout and the mental health of Portuguese nurses was the focus of one research study ( Sa & Fleming, 2008).The results of this study identified that of 107 nurse participants, one out of six (13%) had experienced bullying within the past six months. The most common type of bullying behavior that was experienced by the nurse participants was doing tasks below their competence, having responsibility removed, being given more insignificant unpleasant tasks, and being given unmanageable levels of workload. These authors found the nurses were more exhausted and had lowered levels of mental health than their non-bullied peers in the workplace.

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Bullying categories also include belittling another, professional , and failure to recognize and appreciate another’s work (Rayner et al., 2002). A victim of the bullying has poor psychological health and is dissatisfied with his existing workplace.

The Royal College of Nursing (RNC) (2002) in England found that one in six nurses were bullied by a colleague in the past year, but only 6% reported the incidents, as they chose to remain silent. The RCN (2002) also reported that one-third of the nurses who took an extended had plans to leave the profession, compared to 16% who were never bullied. One in three of the bullied victims intended to permanently leave the nursing profession.

A recent survey study on 3,465 emergency room nurses reported physical violence against the nurses as a major problem in the workplace. In fact, a study by Gacki-Smith,

Juarez, Boyett, Homeyer, Robinson, & MacLean (2009) portrays the emergency department (ED) as a dangerous area of nursing to work.

Some of the most common types of physical violence experienced by more than 50% of respondents were “spit on,” “hit,” “pushed/shoved,” “scratched,” and “kicked.” In terms of verbal abuse, 70% or more of respondents experienced being “yelled/cursed at,”

“intimidated,” and “harassed with sexual language/innuendo.” Sixty-seven percent rated their position of safety as 5 or below on a 10 point scale (1, not at all safe to 10, extremely safe). One third had considered leaving their ED or because of ED violence. (pp. 342-343)About 25% of the participants in this study reported more than 20 incidences of physical violence and 200 incidences of verbal abuse during a three year time period before submitting this survey.

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Gacki-Smith et al. (2009) state that there were many barriers for emergency room

(ER) nurses in this study in reporting violence in the workplace. These barriers included avoiding having negative service evaluations, vague emergency room policies, fear of retaliation and the lack of support from managers, administrators, staff, and physicians, the feeling that reporting violence provoked others to see the employee as weak or incompetent, and the attitude that violence comes with the job when employed in the emergency room. The violence presented in this workplace research is displaying a work environment where many patients are hostile due to their illness or condition that led them to seek ER care. For example, some patients arriving in the ER are in critical shape and become violent as a result of drugs, alcohol, and are car/gun accident victims.

The consequences presented in this study of being bullied as an ER nurse are a great occupational risk and would cause many nurses to leave or reconsider their ER nursing career.

Witnesses to bullying also suffer consequences as a result of witnessing bullying in the workplace. One study (Lutgen-Sandvik et al., 2007) on workplace bullying of US workers using the Negative Act Questionnaire (NAQ) (Einarsen & Hoel, 2001), a 22 item questionnaire, found that employees who were non-bullied witnesses of bullying experienced increased stress, decreased job dissatisfaction, and decreased work production. The consequence of bullying affects the entire work organization, and is not limited to an interpersonal issue between the bully and the victim.

Horizontal/Lateral Violence and Nursing

Horizontal hostility is also a term used to describe bullying that occurs between two persons on the same power level (e.g. nurse to nurse). Horizontal hostility is a pattern of

37 behavior that controls, diminishes, or devalues a peer or a group, which creates an unsafe environment and is a health risk for the victim (Farrell, (2005).

Farrell (2005) stated that horizontal hostility can be either verbal or physical, but in the nursing profession verbal aggression is the primary form of hostility. The mistreatment makes the person feel personally and professionally attacked, devalued, and humiliated. Farrell defines the overt and covert bullying behaviors. Overt bully behaviors, which have the greatest affect, include such behaviors as name-calling, bickering, finding fault, intimidating, gossiping, putting down, shouting, and raising one’s eyebrows. Covert bully behaviors include unfair assignments, sarcasm, ignoring, making faces or eye rolling, refusing to help, whining, sighing, refusing to work with another, sabotaging, isolating, excluding, or fabricating.

Horizontal violence between nurses is defined as aggressive acts where one nurse perpetrates another nurse (Longo & Sherman, 2007). These authors explain that horizontal violence involves verbal or emotional abuse and can be overt or covert behaviors. The most common horizontal violence behaviors demonstrated include talking behind another’s back, belittling or criticizing another person in front of a group, blocking the other nurse from recognition or a promotion, and isolating another from group activities. If the acts of horizontal violence are repeated, they become defined as bullying. Further, they found that horizontal violence has been linked to oppression as the person does not feel respected and develops a low self esteem. Supporting this idea,

DeMarco and Roberts (2003) state that oppression leads to a lack of autonomy, a low self-esteem, and powerlessness.

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Lewis (2006) defines features of bullying acts in his research on nurse bullying as a planned, intentional activity to discredit another person. The bullying acts are often not obvious to others, continues over a period of time, and there is no witness. Lewis states the bullying acts include: (a) undermining of another’s work, (b) disadvantaging the target, (c) physical abuse (rare), (d) verbal abuse, (e) isolating the person, (f) interfering in work practices, (g) criticizing continually, (h) being sarcastic, (i) the demeaning of another, (j) destroying another’s confidence, (k) making false complaints about another person, and (l) setting another person up for failure. Lewis states that nurses frequently do not recognize bullying early on until it occurs repeatedly. The target of the bullying is often informed by another nurse and helped to understand that a bullying event has occurred. This brings the bullying event into the open at the workplace. Lewis suggests the target should keep a record of the pattern and frequency of the events. Bullying events in Lewis’s research vary from six months to seven years in length. The target of the abuse may have been abused for years and may require a long period of recovery from the abuse. In Lewis’s research, the bully within the workplace was found to be a “serial bullier” 90% of the time. And, it was often found that many events to different employees could be traced to a specific person who was the bully.

In nursing practice, Bartholowmew (2006) in her review of much of the literature on lateral violence has summarized the 10 most frequent forms of lateral violence. These forms of violence are ordered from the most to the least in occurrence as follows: (a) nonverbal innuendo, raising eyebrows and making faces; (b) verbal confrontations, covert or overt, snide remarks, lack of openness, being abrupt in responding; (c) undermining, turning away or not being available; (d) withholding information; (e) sabotage,

39 deliberately setting up a negative condition; (f) infighting, bickering with peers; (g) scape-goating, making one person responsible for a negative situation; (h) backstabbing, making complaints about one person but not going to the person; (i) failing to respect another’s privacy; and (j) breaking another’s confidences.

One research study determines the new nurse graduate who is bullied may make career choices as a result of being bullied. Simon’s (2008) study on 511 new nurse graduates in the state of Massachusetts in the United States found that a bully can drive the new nurse graduate away from the health organization and cause him/her to seek a new profession. Simon states that the bully causes the victim in this study to have feelings of humiliation as a result of being ridiculed, ignored, excluded, yelled at, criticized, encouraged to find a new job, and extra monitoring of their work. Thirty-one percent of the participants in this study were found to meet the standards for being bullied when using the 22 item survey of the English version of the Negative Act Questionnaire-

Revised (Einarsen, Hoel, 2001).

Oppression Theory and Nursing

Oppression theory (Fanon, 1963; Roberts, 1983) is one way of exploring how a dominate group’s behavior interacts with a subordinate group’s behavior. The dominant group places their value system as the superior system and demands the subordinate group’s value system and culture be repressed. As a result, the subordinate group takes on characteristics of an oppressed group as they internalize the view of the oppressor and then mimic patterns of behavior of the oppressor. This oppressive situation in nursing causes distorted thinking, feelings of decreased autonomy, being powerless, having a low self esteem, having feelings of self-hatred and the nurse doubts there is any alternative

40 way to function (Roberts, 1983). Roberts also states that rigid, coercive behavior is a trait of the leader in oppressed groups and the oppressed group adapts the leader’s behavior.

This leads to rigid, non-flexible thinking by the oppressed group.

Nursing is a profession with a system in subordination, of which the resulting outcome is oppression (Bartholowmew, 2006) and horizontal hostility in the workplace is the ultimate result of the suppressed anger. Bartholowmew gives one reason for the increase of horizontal hostility in nursing, which she attributes to the restructuring of healthcare in the 1990s. Nursing lost its representation in the health care of many organizations, as businessmen became the managers. Nursing is one of the most predominant healthcare groups that exhibit bullying and we can see the effects of horizontal violence. Horizontal violence means nurse to nurse violence, but that there is also a dominance hierarchy within the nurses themselves within an organization. This is what is more psychologically damaging as a new graduate, the subordinate, expects her peers, other nurses, to be supportive and not to be the bullies. Consequently, the new graduate nurse thinks there is something wrong with him/her as they are bullied in the workplace as they perform their role as a new graduate nurse within the health care organization.

The bullying is thought to be the outcome of an oppressed group that displays much hostility toward one another (Dunn, 2003). The oppressed group has characteristics of low self-esteem, self-hatred, passive-aggression, and infighting among group members.

Dunn explains an oppressed group normally has anger and aggressive behavior toward the oppressor. But the oppressed individual fears retaliation so does not express either emotion; anger or aggression. Instead, the oppressed group displaces their anger and

41 exhibits aggression and self-destructive behavior within the oppressed group in the form of infighting and self-criticism.

Roberts’ (1983) study on oppression in the nursing profession determined that we must analyze the strategies of an oppressed group, if we want to change nursing and develop successful leaders in the future. Behaviors labeled oppressive by nurses in Robert’s research study demonstrated decreased self-esteem, powerlessness, and self hatred. These psycho-social characteristics in an individual are breeding grounds for feelings of oppression.

Friere (1971) underscores the importance of the imbalance of power that causes conflict between a dominant and a subordinate group. If there are two groups, and one has more power, there may develop a conflict as a result of a power struggle, and the values of the subordinate group are oppressed. A key point is that a new nurse graduate is in a position to be oppressed as they do not recognize the tacit rules of the new workplace. The experienced staff, managers, and physicians may target the new nurse employee, as the work culture has many organizational, hierarchical, and staff role rules about which the new graduate is unaware. This places the new inexperienced nurse graduate into a subordinate position in the organization.

One nursing study (Hutchinson, Jackson, et al., 2006) demonstrates the catastrophic results of an oppressive workplace wherein bullies used covert behaviors to control their nursing peers. The Australian study interviewed 26 nurses on bullying in the workplace and found that workplace bullies had informal organizational alliances between them, which allowed the bullies to use emotional abuse and psychological violence to control the work into using the bullies’ definition of the workplace rules. The nursing work

42 teams were controlled by bullies through their interpretation of roles, tasks, and status of the nursing hierarchy. The bullies used surveillance, , and control of the targets to change the targets’ thought processes of themselves. The bullies enforced their rules by a ritual indoctrination, and were capable of destroying the self confidence and of the target. The bullies could force the target into or accepting the bullies’ interpretation of the work rules if the target desired to continue working within the organization. The bullies formed alliances which encouraged tolerance of abusive behavior and a loyalty among the bullies which ensured the bullying behavior was hidden from others. Of the 26 nurses interviewed in the Hutchinson, Jackson et al., (2006) study, one-third moved to other positions, even though it was noted that none of the participants had previous employment performance issues within the organization.

The experiences of the bullied nurses included being ignored, denied, or diminished by the administrators of the organization, and they were labeled as stressed or weak nurses. On the other hand, the bullies’ were labeled those of excellent nurses

(Hutchinson, Jackson et al., 2006).

Some recommendations were made after the study by these authors. For one, the administrators of health organizations need to review power relations within the nursing organization, as bullying may be concealed and systematically planned. And, policies and procedures within health organizations on anti-bullying and harassment may not uncover the covert methods of the bullying team as those who speak against it are silenced. This study is a good example of how the bullying events remained undetected within an organization and that many of the nurses were oppressed.

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Nursing is not different today in spite of the many different programs it offers. Kelly and Ahern (2008) state it is disturbing that baccalaureate nursing education, which stresses autonomy and , is not producing a nurse different from the 19th century. Nurses and health care organizations are still enforcing a hierarchy in the workplace. Oppression in nursing is a growing problem as experienced nurses are treating the new nurse graduate as they were treated when they entered the profession years ago. This situation supports the Friere theory (1971) and describes horizontal violence or bullying behaviors. As nurses become involved with violence in an oppressed group they attack one another as they vent frustration and anger with the oppressed system.

Causes of Oppression and the New Nurse Graduate

A bullying manager is one cause of oppression in the workplace. Namie (2000) surveyed 200 employees through the American Workplace Bullying and Trauma Institute and found that 80% of the bullying was attributed to the employee’s manager. On the survey when an employee tried to seek help, they reported they often became the target of their bullying manager. were often not helpful to the victim of the bullying, as the employees reported little support was provided for the victim of bullying.

The negative relationship of the nurse manager to the nursing employee is one cause of oppression in nursing. Lewis (2006) explains in a study on that nurse managers were very negative when dealing with bullying events. And, organizational policies on harassment and grievances failed to effectively manage the bullying event. Many times the manager was part of the bullying problem for the nursing employee targeted. Lewis recommends that organizations do a total review of their

44 policies and procedures managing bullying, and especially evaluate anti-bullying procedures. Lewis concludes from his research that bullying is a learned behavior within the workplace, and not a psychological deficit of the bully or the target of the bullying.

Negotiations between the bully and target are recommended (Lewis, 2006). Benefits of the bullying negotiations include avoiding the following situations for the bully and the target: Trouble, illness, litigation, damage to one’s reputation, poor working practice, resentful staff, and being labeled as a troublemaker. Lewis contends that the bully’s manipulative actions should be the focus of the negotiation process.

The hierarchy of the health care organization is also a problem that contributes to oppression in nursing. Farrell (1997) states that the nursing profession has been historically managed by a patriarchal system that includes physicians, administrators, and nurse managers working within the hierarchy of the organization. McKenna’s et al.

(2003) study of 551 new graduate nurses in New Zealand supports Farrell’s idea, that the health care organization hierarchy is a problem. Most of the horizontal violence or bullying described by the new graduates in McKenna et al. (2003) study involved a person the new graduate was accountable to including a charge nurse, nurse co- coordinator, , unit manager, duty leader, acting charge nurse, and senior nurse.

Half of the distressing events that occurred were also not reported as the new graduate nurses in this study feared retaliation. The new graduate nurse reported feeling cynical that the problem would be solved. The horizontal violence involved a senior nurse that was also responsible for the bullying.

Nurses are also in a position to be oppressed related to the lack of autonomy, dependence on the physician for medical orders, and because the nursing gender is

45 primarily a female profession. Nurses feel oppression due to a lack of autonomy because nurses are under the medical supervision of physicians. Nursing has historically been a female profession, and some physicians regard nurses as their handmaidens. The physician, a primarily male profession, provides nurses with patient orders and assumes dominance in the health organization hierarchy (Dargon, 1999). Many nurses are not aware of actions by physicians that stress their dominant role and place the nurse in a subordinate role. Bartholowmew (2004) stated that an action of physician dominance includes curt conversations, not learning the nurse’s name, and avoiding eye contact with a nurse. Many nurses have accepted these actions as normal behavior, and do not realize the position they are being put in, which causes feelings of hostility and oppression.

The nursing profession that is rooted in subordination causes some nurses to react with feelings of anger from the oppression and to display horizontal hostility or bullying behaviors towards one another (Bartholomew, 2006). Nurses were found to aggressively attack one another mostly verbally and occasionally physically as a result of being frustrated and oppressed when having little autonomy within the health care organization.

One study presented the expectations of final year nursing students regarding the workplace environment (Kelly & Ahern, 2008). Work expectations before employment were compared with their actual experience in the workplace in their first six months of employment after they were licensed nurses. These authors concluded from their interviews of the 13 Australian baccalaureate students interviewed in nursing school, and at one month and six months after employment, that nursing curricula should prepare new graduates for stressors and oppressive environments. The new graduates need to be prepared to be proactive and to prevent, and respond to, workplace issues such as

46 aggression and silence. Also, nursing courses should socialize students before their graduation to identify oppressive practices and provide the knowledge on how to eradicate oppressive practices in the workplace environment. Health organizations need to educate and manage hostility issues within the workplace to prevent the attrition of new graduates from the profession. Staff and nurse managers need to realize their socialization influence on the new nurse graduate.

By learning oppression theory and conflict management in the nursing curriculum, and during the workplace orientation, the new graduate nurse will be better prepared to handle a negative workplace environment including bullying behaviors and conflicts that arise within the workplace.

Bullying and the New Nurse Graduate

Namie and Namie (2000) state that the populations at risk in nursing for horizontal violence are the weakest members, including the new nurse graduate, a transfer nurse, or a newly hired nurse. Bullies were defined by these authors as scanning the environment to attack the weakest prey, which is compared to a common situation occurring in the animal kingdom. Bartholowmew (2006) stated that as the weakest link, the new graduate nurse is powerless, and is “broken” into the workplace by the experienced nurses who use the oppression theory. The new nurse graduates were expected to become part of the existing dominant culture that exists within the health organization workplace. The fear of change was expressed by the experienced nurses through horizontal hostility as the new graduate nurse is acculturated into the workplace.

A New Zealand study (McKenna et al., 2003) surveyed 551 new graduate nurses to determine if horizontal violence or bullying was occurring from nursing colleagues in the

47 workplace during the first year of practice. Mckenna et al. (2003) described horizontal violence or bullying as psychological harassment, verbal abuse, threats, intimidation, humiliation, increased criticism, excluding, denying professional opportunities in the workplace, discouragement, disinterest, and the withholding of information. Of the 551 new graduate nurses who completed the survey the major findings regarding horizontal violence were: 1. A new graduate nurse felt undervalued. 2. issues were the most distressing events. 3. There was an alarming 58% who had considered leaving nursing. 4. There was evidence of under-reporting of the incidents by the management. 5. There was no discussion after an incident. 6. Undergraduate education and orientation training at the health organization were not adequate.

Batholowmew (2006) recommends that new nurses need connection through meaningful relationships, which will protect them when voicing their concerns and building their self-esteem as a new nurse. New nurse graduates need to verbalize concerns as their voices are their power in the workplace and help them build confidence in their new role as a licensed RN. Verbal feedback for the new nurse is important in their new role, so they can understand an oppressive environment, and discuss the implications of its existence. McKenna et al., (2003) state that stress and conflict in the new job are the stressful issues new nurse graduates encounter in their first year of employment as RNs.

Also, they sight the as the first line of protection, and the nurse administrators and staff are the second in line of protection in preventing hostility in the workplace.

Workplace hostility is defined as an offensive problem with offensive behaviors that have occurred for years in the nursing profession (Stanley et al., 2007). These authors

48 describe lateral violence, horizontal violence, or bullying as the names for a problem where “nurses eat their young.” You may ask yourself, why is this negative hostile behavior occurring? One reason is there are many tacit rules that are procedural, intuitive, unspoken, or unwritten in the organization that take time to learn (Sternberg & Horvath,

1999). The experienced nurses who are successful in their work know the tacit rules of the organization and may not pass this knowledge on to the new graduate nurse. Many new graduate nurses become subjected to following rules they do not know which exist within the workplace. “Nurses eating their young” is not a new problem and has existed for many years in the nursing profession. It is a phrase that has become part of the nursing culture when new nurses are learning the nursing role. This abusive behavior needs to cease if we want the nursing profession to experience growth. New graduate nurses need the support of their co-workers to remain in the nursing profession.

Prevention of Bullying Through Higher Education

Preventing bullying of a new graduate nurse should be a primary concern of higher education for two of the following obvious reasons. The nursing student spends an extraordinary amount of time and money and the nursing faculty spends much time in helping the student pursue the nursing degree. Primary prevention of bullying begins with nursing education regarding bullying. McKenna et al.'s (2003) study of horizontal violence in the new graduate’s first year of practice found the majority of the 551 new nurse graduates responding indicated there was no undergraduate or postgraduate training to deal with bullying staff in the workplace. McKenna et al. states nursing schools need to prepare nursing students to deal with bullying.

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Stanley et al. (2007) suggests that faculty, preceptors, and nurse educators should teach student nurses and new graduates specific behavioral techniques to use if they are victims of lateral violence. These authors suggest workshops on lateral violence should be offered in workplace settings for all nurses and not just student nurses and new graduates.

One Australian study on the new graduates’ role stress and role ambiguity suggests that students should be prepared by nursing educators and administrators in health care organizations to face issues of stress as they transition from student graduates to registered nurses (Chang & Hancock, 2003). These authors state that students can be prepared educationally to handle the “ ” of their new roles and to develop coping strategies to deal with stress. Chang and Hancock cite one aspect of role stress for the new graduate is conflict that must be managed in the workplace. And, if there is a negative work environment many new graduates do not have the work experience or educational foundation to deal with conflicts in the workplace.

The role of the educator is an important factor. When the educator is working with undergraduate nurses, violence prevention should be stressed and begins with training as a student (McKenna, Poole, Smith, & Coverdale, 2004). These authors contend that undergraduate nursing programs need to teach undergraduate nurses and licensed nurses in their first year in the workplace the following: (a) aggression theory, (b) how to report violence, (c) how to analyze for the risk of violence occurring, (d) how to de-escalate violence through using communication skills, (e) how to away from violence to remain safe, (f) coping mechanisms, and (g) calming and restraint techniques for some specialty areas if personal safety is compromised by aggressive employees or patients.

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Nurses should be educationally prepared to deal with the negative interactions that will occur in the work environment. Griffin (2004) states that research demonstrates if new nurses are educated about horizontal hostility or bullying it allows them to ask questions and continue to learn. Learning is compromised when the work environment is a closed system where questions are not allowed (Sternberg and Horvath, 1999).

Education suppresses oppression as a person gains understanding of the ramifications of an oppressive environment. Friere (1990) states freedom from oppression is attained through education that provides the oppressed individual with insight of the cycle, connection to others, support, and an increased self-esteem. Because of the uneven power struggle there is the motivating force for the occurrence of hostility. Roberts (1983) encourages nurses to enlighten themselves about the cycle of oppression. Knowledge of oppression raises the nurse’s self-esteem and creates feelings of .

Nursing and Bullying - Role Conflict

Historically nursing is portrayed as being one’s calling, where the nurse is the angel of mercy, and nurses are not portrayed as angry (Reverby, 1987). Unrealistic expectations of the nursing role are a historical problem in nursing. Reverby states nurses have the following attitudes and expectations in their role as a nurse: 1. One expects to be a consistent caretaker. 2. One diminishes the needs of the self. 3. One works long to care for others. 4. One is non-complaining about the workload. 5. One is a subordinate within the health care organization 6. One speaks only if spoken to first by another in the workplace. Many nurses enter the profession with these noble feelings and expectations.

A nurse’s expectation of her role was later defined as a caretaker for patients and to be caring, professional, and a subordinate member of an organization (Chambliss, 1996).

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But, this is a dichotomy if the nurse is involved in a bullying workplace as the nurse values being caring and professional, but does not exhibit caring and concern for their nursing peers in a hostile work environment. The conflict professionally involves the value of caring for others versus acting non-professional and non-caring to one’s peers within the health organization.

Bartholowmew (2006) explains that the reason that nurses are mean to one another is that caring is not valued by the dominant group. The hierarchy that exists diminishes caring in the power struggle between the dominant and oppressed nurse. The individual’s self esteem is lowered which causes the oppressed nurse to feel morally dissatisfied, unhappy, and hostile. Bartholowmew states that surprise attacks by the dominant nurse puts the target nurse on guard, as they never know when hostility will strike. Farrell

(2005) explains that abuse runs in vicious cycles and leads to a nurse’s increased feelings of hostility. The abuse is not stopped unless corrective action is put in place and there is zero tolerance for bullying.

The American Nurses Association’s (ANA) (2003) Code of Ethics stresses the importance of a nurse being respectful to colleagues and patients. Hughes (2008) states the nurse provides patient care in a team approach and must have positive relationships to provide optimal patient care. The patient’s safety is compromised when there is disruptive behavior among the nursing staff. The Standards of Professional Performance

(ANA, 2003) is a list of definitions of collegiality and includes: 1.The nurse interacts and contributes to the of peers. 2. The nurse collaborates with the patient and family. 3. The nurse provides leadership in the practice setting when caring

52 for a patient. High quality ethical and moral standards of professional performance are difficult to achieve when a new nurse graduate is distracted in a bullying workplace.

We need to understand the perceptions of the new nurse graduate as they transition to the new role as a registered nurse. We also need to educationally prepare the student nurse to evaluate the work climate and respond appropriately in negative interactions.

Through undergraduate education, the new nurse graduate can be prepared to recognize a negative workplace environment and be prepared to manage conflict.

Health Organization Responsibility

Health care organizations have the responsibility to be knowledgeable about the occurrence of hostility in the workplace. Bartholowmew’s (2006) recent research on the hostile work environment for nurses in healthcare recommends managers in health care organizations need to be educated about bullying and hostility so they feel empowered to manage staff. Staff will mimic the leadership style of the manager and also develop a sense of empowerment. Assertiveness training for all staff would improve communication which is necessary to identify hostile staff behaviors. Bartholowmew encourages nursing leaders to evaluate the organizational climate by evaluating interpersonal relationships in the workplace, and following up with staff problems. Also, decreasing hostility by developing a zero-tolerance policy for hostile behaviors would promote accurate honest information from staff members. Education about policies is needed for all staff. A reporting system is suggested for the health care organization and investigation should occur; especially if there is a high rate of staff turnover, absenteeism, and staff complaints. Individual states in the US are encouraged to tackle bullying

53 through their state boards of nursing and introduce legislation to address horizontal violence or bullying behaviors.

One study on workplace bullying (Johnson and Rea, 2009) found that most of the nursing respondents of the Washington State Emergency Nurses Association identified their nursing managers, directors, or charge nurses as being the bully. Of the 249 nurse respondents in this study, 27.3% identified they had been bullied in the last six months when responding to the Negative Acts Questionnaire-Revised (NAQ-R) 22 item survey

(Einarsen, et al., 2001). Many of these respondents also noted their intent to leave their job. Johnson and Rea state that it is becoming a critical situation as it involves nursing retention. These authors recommend that nurse leaders need to determine why there is bullying and suppress it within the organization. Some of their recommendations for nursing leaders are the need for education about bullying tactics, and then for the leaders to examine their own behaviors. Also, leaders need to develop a healthy work environment by encouraging respect among one another and having open communication about conflicts that present. And, it is recommended that research on organizational and management styles is important to determine if certain leadership styles promote workplace bullying.

Longo and Sherman (2007) charge nurse managers and recruiters to recognize horizontal violence or bullying and create a workplace environment that promotes professional empowerment. Longo and Sherman state that nurse victims experience powerlessness and eventually experience the following health problems as a result of horizontal violence: (a) insomnia, (b) low self-esteem, (c) low work morale, (d)

54 disconnection from others, (e) depression, and (e) use more sick leave than the nurse not involved in horizontal violence.

Horizontal violence or bullying cause many problems for a health organization as the patient’s care and a health organization’s financial status are affected by a large turnover rate in nursing (Griffin, 2004). In Griffin’s study in the United States, the annual turnover rate for the staff RN was 33% to 37%. The range becomes larger for the newly graduated RN and ranges from 55% to 61% for new graduate RNs. It was found in this author’s research that as many as 60% of newly graduated RNs leave their first job within the first six months due to lateral violence. Griffin used cognitive rehearsal techniques for

26 new graduate RNs as a method to teach them how to protect themselves from horizontal violence. By educating RNs about practical ways to handle conflict in the workplace, the RN felt better prepared to recognize and handle conflicts in the workplace without becoming emotional. Education regarding horizontal violence or bullying needs to be taken seriously by health organization administers to retain our nurses within the workforce.

Summary

This study of the new graduate nurse’s perception of hostility in the workplace was designed to determine if a nurse’s age, gender, or first three years of service as a registered nurse had affected their perception of bullying in the workplace. What we do know is that the new nurse graduate is very vulnerable to hostility in the workplace and may be unprepared to handle negative conflicts in the workplace. As a result, many have chosen to leave their job or their nursing profession.

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Through gaining knowledge about the phenomena of bullying in the workplace and conflict management, the nursing employee and employer are better prepared to prevent and manage bullying. The Oppression Theory has helped us as nurses realize how the profession of nursing is a hierarchal system that can promote oppression within the health organizations where we are employed. The nurse’s primary role as a caring patient caregiver creates an interpersonal conflict when bullying behaviors exist in the workplace. This is a time for change as health care organizations are accountable for preventing and managing bullying in the workplace. Individuals who have participated in bullying a victim are being held accountable as policies and laws are presently developing in many organizations, states, and on the national level to deal with this issue.

As employees become more educated in identifying the existence of bullying and knowing how to deal with conflict in the workplace, it is hopeful that incidences of this sufferable dilemma will be decreased.

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Chapter Three

Methodology

Introduction

The purpose of this descriptive research study is to provide expanded knowledge about the newly licensed RNs’ perception of bullying in the workplace during the first two years post licensure, and determine if they feel educationally prepared to handle conflict in the workplace. This chapter provides the methodology of the research study investigation. The methodology involves the following: Research design, sample population, hypothesis, research questions and statistical hypothesis, survey instrument, procedure, data analysis procedure, protection of human rights, and summary.

Research Design

This research design is a quantitative study utilizing survey research to describe the attitudes, opinions, behaviors, and characteristics of a sample population. RNs licensed within the past two years in the state of Ohio are the sample population, and the research involves whether they perceive bullying to be a problem in the workplace. Two years has been selected as the cutoff for this survey as the PricewaterhouseCoopers’ Health

Research Institute (2007) has identified that the nursing turnover rate is highest during the first two years post-licensure. The perceptions of the RN population are important as there are research studies indicating some RNs are leaving nursing during a widespread shortage in nursing, and bullying is noted to be the underlying problem. The information is useful as it supports nursing education and health care organizations in the development of educational programs to assist the newly licensed RN deal with conflicts

57 in the workplace and be educationally prepared to handle any bullying behaviors that new nurse graduates might encounter in the workplace.

This descriptive research study surveyed the newly licensed RNs’ perception of bullying occurrence in the workplace. This simple purposive survey is a one time collection of data that measures the newly licensed RNs’ perception of bullying in the workplace. The main characteristics of this descriptive survey include: The newly licensed RN population is sampled, the information is collected through the electronic survey, and a survey instrument is used to measure the variables. The goal is to obtain a high response rate from the sample population of newly licensed RNs within the past three years.

Sample Population

A survey research design study was implemented to determine the perceptions of the new graduate nurse RN regarding bullying in the workplace. New graduate nurses registered as RNs within the past three years from the following Nursing Alumni

Associations in Northwest Ohio are the targeted population: The University of Toledo,

Lourdes College, Mercy College, Owens College, and Northwest State. The RNs may be residents anywhere in the United States or abroad, as their alumni mailing list will be used to track them.

The five Northwest Ohio, Nursing Alumni Associations were surveyed with an electronic questionnaire on the Web. The Nursing Alumni Associations from each of the colleges agreed to compile an electronic email list of newly graduated RNs within the past three years. Purposive sampling of new graduate RNs in Northwest Ohio was used with the anticipation of 400 responses. This study described the respondent’s

58 demographic characteristics to determine if they match the demographic characteristics known about the RN population within this study. Power analysis using SPSS software indicated a sample size of 384 would show statistical results (Backstrom & Hursh-Cesar,

1981). The single random sample size is for several degrees of precision with a confidence level of 95% (alpha 0.5) and the total tolerated reduction error of no more than plus or minus 5%. This is interpreted as 95 samples in 100 at confidence level and the margin of error at 5% or less. These results are statistically significant with confidence at 0.5% of a minimum sample of 384 participants (Backstrum & Hursh-Cesar,

1981).

Only new nurse graduates registered within the past three years of gaining their RN license were the focus of this study. The electronic survey of the questionnaire was submitted online to registered RN graduates and included submission to potentially 3,000

RN graduate licensed participants within the past three years.

Research questions to be examined from the study of the new graduate nurse perception of workplace bullying were gathered by an electronic survey questionnaire.

The response to the questions included the Likert scale, some forced choice (yes/no) answers, and one open-ended question.

Research Questions and Statistical Hypothesis

The following research questions were developed to examine the new graduate nurse perceptions of workplace bullying. Descriptions of the workplace include the three types of bullying: Work-related bullying, person related bullying and physically intimidating bullying. These types of workplace bullying are based on the work of Einarsen et al.,

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2009) which is discussed in detail below. Table I categorizes the items, factors loadings, and correlations among the sub-factors of the NAQ-R (Einarsen, et al., 2009).

1. Do a significant number of new nurse graduates report negative behaviors and different types of bullying in the workplace (work- related bullying, person-related bullying or physically intimidating bullying)?

1. 1. Null Hypothesis (Ho): There are no statistically significant difference

between the frequency of new nurse graduates who report work related

bullying in the workplace and the population norm reported by Einarsen et al.

1. 2. Ho: There are no statistically significant difference between the

frequency of new nurse graduates who report person related bullying in the

workplace and the population norm reported by Einarsen et al.

1. 3. Ho: There are no statistically significant difference between the

frequency of new nurse graduates who report physically intimidating bullying

in the workplace and the population norm reported by Einarsen et al.

2. A. Who does the new nurse graduate identify as causing the problem in the workplace?

While this research question does not have a hypothesis that can be statistically tested, descriptive information on who is most likely responsible for workplace bullying is presented.

2. B. Do new nurse graduates identify that workplace bullying has effects on them personally (internal/external behaviors)?

2. B. 1. Ho: There are no statistically significant differences in the frequency

of new nurse graduates identifying internal behaviors that affect them as a

result of workplace bullying.

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2. B. 1. a. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling powerlessness.

2. B. 1. b. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling increased stress.

2. B. 1. c. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling low self esteem

2. B. 1. d. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling decreased job satisfaction.

2. B. 1. e. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling sad.

2. B. 1. f. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling anxious. . 2. B. 1. g. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling increased fatigue.

2. B. 1. h. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling disconnected.

2. B. 2. Ho: There are no statistically significant differences in the frequency of new nurse graduates identifying external behaviors that affect them as a result of workplace bullying.

2. B. 2. a. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling irritated with others.

2. B. 2. b. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of expressing a short temper. .

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2. B. 2. c. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling a decrease in patience.

2. B. 2. d. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of feeling decreased job

production.

2. B. 2. e. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of gaining weight.

2. B. 2. f. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of losing weight. . 2. B. 2. g. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of having sleeplessness.

2. B. 2. h. Ho: There are no statistically significant differences in the

frequency of the likelihood of the effect of having increased sick days.

3. A. Do new nurse graduates believe that experiences of workplace bullying have an impact on their job performance?

3. A. 1. Ho: There are no statistically significant differences in the frequency

of new nurse graduates reporting that workplace bullying has an impact on

their present job performance.

3. A. 2. Ho: There are no statistically significant differences in the frequency

of new nurse graduates reporting that workplace bullying has an impact on

their changing jobs in the past two years.

3. A. 3. Ho: There are no statistically significant differences in the frequency

of new nurse graduates reporting that workplace bullying has an

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impact on their decision to change jobs.

3. A. 4. There are no statistically significant differences in the frequency of

new nurse graduates reporting that workplace bullying has an

impact on their decision to leave the nursing profession.

4. A. Do new nurse graduates identify formal nursing education as providing knowledge about bullying?

4. B. Do new nurse graduates identify informal workplace efforts to deal with bullying in the workplace?

Using the Negative Acts Questionnaire - Revised (NAQ-R) the above research questions / hypothesis were studied.

Survey Instrument

The survey instrument, the Negative Acts Questionnaire-Revised (NAQ-R) (Einarsen et al., 2009) was used to measure bullying behavior in the workplace and consists of 22 questions. The written permission of the authors of this survey instrument was granted for this dissertation research study. The NAQ-R is found in Appendix A. The NAQ-R is the

English revised version of the Negative Acts Questionnaire (NAQ). The threshold to measure bullying is achieved if participants choose a 4 or above rating on the NAQ-R, 22 question survey identifying bullying as being important.

The original NAQ (Einarsen & Raknes, 1991, 1997; Mikkelsen & Einarsen, 2001) was designed and used in Norway to measure the perceived exposure of workers to bullying in the workplace. The NAQ had 29 items for participant response and had an internal stability of .87 to .93, measured by Cronbach’s alpha. The original NAQ construct validity was established by its correlation with the following: Job satisfaction,

63 range of r = 0.24 to r = 0.44; psychological health and well-being range of r = -0.31 to r = 0.52; and psychosomatic complaints, r = 0.32. The original NAQ had some shortcomings (Einarsen & Raknes, 1997; Matthiesen & Einarsen, 2001) as it was thought to have a cultural since it mainly was confined to research in Scandinavian countries

The NAQ original was modified to a 22 question version (NAQ-R) making it a shorter, more reliable scale (Hoel, Cooper & Faragher, 2001; Hoel, Cooper & Faragher,

2004). An additional benefit of the 22 question NAQ-R is that it is more adaptive to the

Anglo-American culture (Einarsen & Hoel, 2001; Nielson et al., 2008). Later, a modified

22 question version of the NAQ-R was proposed as a shorter, more reliable and valid scale. And, the 22 question NAQ-R is noted to be more adaptive to the Anglo-American culture (Einarsen & Hoel, 2001; Nielson et al., 2008).

The questions are written in behavioral terms and identify direct and indirect bullying.

Bullying is categorized as the following: Work related bullying, person related bullying, and physical intimidation of an employee in the workplace. The 22 questions of the

NAQ-R are more objective than the NAQ and rely on the employee to self report rather than self label behaviors in the workplace as bullying. Since the questionnaire does not use the words “bullying” or ” harassment,” it was determined to cause less cognitive and emotional energy for the employee to answer questions without referencing them as bullying behavior (Arvey & Cavanaugh, 1995; Einarsen & Hoel, 2001; Nielson et al.,

2008).

In a sample of 5,288 British Employees from 70 public and private organizations, the reliability and factor solution using Cronbach’s alpha was .90, indicating an excellent internal consistency (Einarsen, Hoel, and Notelaters, 2009; Einarsen et al., 2009, Hoel et

64 al., 2001)) These authors determined that a three dimensional structure model had the best fit statistically, dividing the items into work related bullying consisting of seven items, person related bullying consisting of 12 items, and physically-intimidating bullying consisting of 3 items. The factor loading structure is in Table 1 and all factor loadings exceed .70 without cross loadings or error correlations. Einarsen et al. (2009) notes the correlations of the dimensions are very high: .96 between person-related and work bullying; .89 between work-related and physically intimidating bullying; and .83 between person-related and physically intimidating bullying. Due to the high correlations between the factors these authors have determined there are specific bullying behaviors that co-occur (See Table 1).

The first factor structure “work related bullying” presents seven items of bullying behavior one is exposed including having opinions ignored, having information withheld, being given tasks with irrational deadlines, excessive monitoring of work, pressure to not claim work benefits, having an unacceptable workload, and demoted in your present job.

The second factor “person related bullying” structure has 12 items and describes one’s exposure to behaviors such as being humiliated, given less responsibility in job and trivial-unpleasant tasks, being gossiped about, being ignored-excluded, being insulted, hints made to quit job, reminders of your mistakes, being ignored or facing hostility, persistent criticism, practical jokes, allegations made against you, and being the subject of excessive teasing. The third factor “physically intimidating bullying” consisted of three items and described being shouted at, having your personal space invaded, and being threatened with physical abuse.

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Table 1 Einarsen, Hoel, & Notelaers (2009) pp.32-33.

The NAQ-R (Einarsen et al., 2009) instrument also reports norms for the degree of bullying reported by the population studied for each question. These population norms are reported as percentages of the population of over 5,000 employees who completed the

22 item questionnaire. The 22 questions on the NAQ-R asked employees to respond to

66 whether they had been bullied in the last six months. Respondents selected the five following categories: “Never,” “Now and then,” “Monthly,” “Weekly,” and “Daily” when answering the 22 questions on the NAQ-R.

The latent class cluster (LCC) (Magidison & Vermunt, 2001-2004) using Latent

GOLD (Vermunt & Magidson, 2003) was used to analyze respondent results of the

NAQ-R. The LCC helped to validate the NAQ-R by identifying and differentiating between the different groups of respondents that were exposed to bullying in the workplace and their level of victimization from bullying and harassment (Notelaers,

Einarsen, DeWitte, & Vermunt, 2006). The LCC identified groups of respondents that shared a definite probability of being bullied, and defined the nature and frequency of their bullying events (Einarsen et al. 2009; Notelaers et al., 2006).

The seven clusters identified from the profile output were the following: “No bullying,” “some work criticism,” “occasional negative encounters,” “occasional bullying,” “work related bullying,” “severe bullying,” and “physical intimidation”

(Vermunt & Magidson, 2003). The seven clusters were combined (Einarsen et al., 2009) and the resulting average conditional probability (CP) for respondents included five time related response periods. These were “Never,” “Now and then,” “Once a month,”

“Weekly,” and “Daily” to the 22 questions regarding negative workplace acts on the

NAQ-R.

The first cluster, the “No bullying cluster,” had 28% of the respondents that reported they never encountered negative acts in the last six months at their workplace. These respondents were determined by the high (CP) to answer “never” in receiving any type of negative act that was asked by the NAQ-R questionnaire.

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The second cluster found respondents had a high (CP) to answer “never,” but were exposed to work related negative acts “Now and then.” This cluster was named “some work related criticism,” but it was decided that this cluster was not bullying. Twenty-five percent of the respondents were from this cluster.

In the third cluster the probability of some “person related acts” were reported by respondents as in the second cluster, but not the negative acts such as social isolation or physical intimidation. Fifteen percent of the respondents reported some negative encounters, but it was found they were probably not bullied (Einarsen et al., 2009).

The fourth cluster was characterized by the CP that respondents had reported that workplace negative acts occurred for them “Now and then.” The difference for this cluster was that exposure to physical intimidation or social isolation occurs twice to four times of the previous cluster. This cluster was named “Occasional bullying” as 13% of respondents reported regular exposure to workplace bullying.

The fifth cluster was titled “Work related bullying” as the CP of being bullied on a monthly or especially a weekly basis was high. Ten percent of respondents reported this to occur in the workplace.

The highest average CP, the sixth cluster, was “Severe bullying,” as respondents were exposed to bullying on a weekly basis. This occurred for 5% of the respondents, and the

CP doubled for work related acts. The CP was ten times greater for “person related and

/or physically intimidating” acts in the workplace.

In the last and seventh cluster respondents reported a high average CP of “Never” being exposed to specific negative acts. But it was found that the report of weekly / daily occurrences of bullying were higher than the three previous clusters: “Severe bullying,”

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“Occasional bullying,” or “Work related bullying.” Respondents in the seventh cluster which is labeled “physical intimidation” were 3% of the NAQ-R survey study respondents.

Procedure

Informed occurred as the participants in this electronic survey study chose to participate in the study by submitting the survey by email. The participants received the

NAQ-R 22 item survey questionnaire, including educational, job and career retention, and demographic questions for completion. The bullying definition was given to the participants after they responded to the 22 items and the participants then indicated if they considered themselves to be bullied (Einarsen & Hoel, 2009).

Using the NAQ-R in this survey research study was intended to determine if the newly licensed RN recognizes bullying as a problem in the workplace. Additional questions on the survey determined if: (a) the participants felt educationally prepared to handle workplace bullying, (b) they experienced internal and external behaviors and (c) they planned to leave their present position or career in nursing as a result of workplace bullying.

Within the study, 15 questions were added to the survey to find out about the new graduate nurse’s background and experiences of bullying. The additional questions to the

NAQ-R were to answer questions that are gaps in the literature as to why RNs are leaving nursing during their first two after becoming licensed. Questions included obtaining information on formal and informal educational preparation, the workplace effort to deal with bullying, if there were certain internal or external behaviors that the participant had as a reaction to bullying, and if a nurse has left or intended to leave a present job or their

69 nursing career as a result of being bullied. Questions specifically inquired: 1.Was bullying formal education included in the new graduates’ nursing program and if not should it be included? 2. Was bullying education presented by their present workplace and if not should it be included? 3. Was the new registered nurse provided a mentor at their present workplace? 4. Does the newly licensed registered nurse feels prepared to handle bullying behaviors in the workplace? 5. Is the workplace organization supportive of victims of bullying? 6. Who does the newly licensed nurse determine to be the bully?

7. Has the newly licensed graduate RN left a job position? 8. Has the newly graduated

RN contemplated leaving their present job position or career in nursing? 9. If bullying was experienced, have you experienced any internal or external behaviors? 10. Does the newly graduated nurse feel that Joint Commission on Accreditation of Hospital

Organizations (JCAHO) is important? Demographic information consisting of nine questions about the participants was also included. Demographic information included the age, sex, race/ethnicity, highest educational degree obtained number of months as an

RN, length of time in present position, how long since graduated, current practice setting, and present position in nursing.

Data Analysis Procedure

A quantitative data analysis in this study addressed the survey questions that included descriptions and relationship results. Statistical Package for the Social Sciences (SPSS)

17.0 for Windows (2009) was used to analyze the data. Statistical tests were used to determine the perceptions of the new graduate nurse’s experience of workplace bullying.

Tables, using Excel, reported the frequencies and percentages from characteristic demographic data of the electronic survey questionnaire.

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Chi square, a nonparametric test that determines frequencies, was used to analyze the data. The chi square distribution analyzed nominal data and compared the observed frequencies of occurrence with the theoretical or expected frequencies. Chi-square compared the directly observed frequencies with those frequencies based on a hypothesis.

By calculating the chi square the observed value of the frequency was compared to the critical value and the null hypothesis is rejected or accepted. Chi square deals with the non-relationship between categories, and is called the test of independence. Chi square also deals with the connection between variables and is used to establish a relationship among factors. If a connection is identified, there can be predictions made, risk factors identified, and causes related through the data collected (Polit, 1996).

A one sample t test was used to compare sample means to population means, which were determined from the literature (previous studies).

Protection of Human Rights

This research study was submitted to the Institutional Review Board (IRB) at the

University of Toledo for review after the proposal defense. After the proposal defense and Institutional Review Board approval, the questionnaire was sent electronically to new graduate alumni nurses with a registered license within the past three years. Five

Northwest, Ohio College of Nursing Alumni Associations were participants that submitted their email lists. A one week period of time for respondents to return the questionnaire was planned. One repeat electronic mailing one week later after the initial e-mail was planned to get the maximum return rate.

The Volvici software was used at the Institutional Research Center at the University of

Toledo. The survey data was sent to the participants, and the Volvici software was used

71 to gather and store the data for at least three years. Only one person in the Institutional

Research Center had access to the emails and information submitted by participants. A random selection process and privacy and confidentiality were incorporated within the data collection process of the study. The results were compiled fall semester, 2010.

Summary

Understanding the new graduate registered nurse’s perception and recognition of workplace bullying may give insight of how to handle this workplace problem.

Preventing new graduate nurses from leaving the nursing profession in the first three years after graduation is important. Through nursing education, the new nurse graduate needs to be prepared to recognize and handle the negative workplace behaviors that are defined as workplace bullying.

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Chapter Four

Data Analysis and Results

This chapter contained the following sections: Demographic Description of

Participants, Hypothesis Testing, Analysis of Research Questions and Hypotheses, and an overall Summary of the Data Analysis Findings. The data were automatically coded and entered into a data file. The Statistical Package for the Social Sciences (SPSS) version

17.0 was used to perform statistical analysis.

Demographic Description of Participants

The respondents in this survey were nurses licensed between 2007- 2010 who were sent a survey through their alumni email. The five Northwest Ohio Nursing Alumni

Associations included: University of Toledo College of Nursing, Lourdes College of

Nursing, Mercy College of Nursing, Owens College of Nursing, and Northwest State

College of Nursing. A total of 135 participants completed the survey. In terms of gender there were 120 females (90.2%), 13 males (9.8%), and 2 (1.5%) who chose not to answer the questions. The respondent’s age range was from 22 to 59 years, with a mean age of

29.45 years, the median age of 26 years, and a standard deviation +/- 8.469 years. The respondents were licensed as a registered nurse for a mean of 20.16 months, a median of

16 months, and the SD +/- 11.786 months, with a range of 0-49 months. The respondent’s length of time working in the current position was a mean of 4.09 months, a median of 2 months, the SD of +/-6.427 months, and with a range of 0 to 27 months. The length of time since being initially licensed for the respondents had the mean of 19.56 months, the median of 16 months, SD of +/-11.508 months, and a range of 0- 48 months. A summary of those 135 new RN graduates who responded to the survey is given in Tables 2-5 and

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include Table 2 - race, Table 3 - practice setting, Table 4 - nursing role, and Table 5-

educational background.

Table 2

Frequency of Race of Nurse Respondent Race Frequency Frequency Percent White, non-Hispanic 125 92.6 Black or African American 7 5.2 Hispanic 2 1.5 Asian or Pacific Islander 1 .7 Total 135 100.0 Table 2 notes the race of respondents of the survey and White non-Hispanic was overwhelmingly the most 92.6%, followed by Black or African American at 5.2%.

Table 3

Nurse Practice Settings of Nurse Respondents Type of Nurse Practice Settings Frequency Percent Ambulatory Care (MD , clinic, HMO) 2 1.5 Community/ / Home care 2 1.5 Hospital (specify type of unit below) 112 83.0 Nursing Home or extended care 11 8.1 Nursing Education 2 1.5 I am not currently working as a nurse 2 1.5 Other 4 3.0 Total 135 100.0 Table 3 summarizes nurses submitting the survey worked in the following practice settings. The vast majority of the respondents, 83% worked in the hospital, followed by 8.1% that worked in nursing homes or extended care.

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Table 4

Nursing Role of Nurse Respondents Type of Nursing Role Frequency Valid Percent Staff nurse 106 80.3 Charge nurse 10 7.6 Nurse Manager 1 .8 Supervisor 3 2.3 Instructor/faculty 2 1.5 Clinical Nurse Specialist 1 .8 8 6.1 Office Nurse 1 .8 Total 132 100.0 Missing System 3 Total 135 Table 4 describes the type of nursing role the new RN is involved in their daily activities in the workplace. The respondents were mainly staff nurses, 80.3%, followed by Charge nurses, 7.6%, and Nurse Practitioners, 6.1%.

Table 5

Educational Background of Nurse Respondents Type of Educational Background Frequency Percent Associate Degree 27 20.0 Bachelor’s degree in Nursing 82 60.7 Bachelor’s degree in another area 6 4.4 Master’s degree in nursing 12 8.9 Direct-entry Master’s degree in nursing 5 3.7 Master’s degree in another field 1 .7 Other 2 1.5 Total 135 100.0 Table 5 displays the educational background of the respondents as mainly the Bachelor’s degree in nursing, 60.7%, followed by Associate degree nurses, 20%, and the Master’s degree in nursing, 8.9%.

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Analysis of Research Questions and Hypothesis

The Einarsen et al., (2009) studies surveyed a large number of people (n=5288) regarding workplace bullying. Their results were used as criteria to compare bullying in the sample of 135 new nurse graduates. The definition of bullying for the purpose of this study focused mainly on daily and weekly bullying using the NAQ-R questionnaire

(Einarsen & Hoel, 2001; Einarsen & Hoel, 2009). Although any bullying is serious, if a victim is bullied on a daily or weekly basis, this is very serious. The next 22 questions present the results of the 135 new nurse participants and their perception of bullying and hostility in the workplace using the NAQ-R.

NAQ-R Survey Questions and New Nurse Graduate Responses

Twenty-three questions were separated into seven questions regarding ”work related bullying,” 13 questions related to “person related bullying,” and three questions related to

“physically intimidating bullying.” After answering the 22 questions, respondents answered the twenty-third question about whether they had been bullied.

Work related bullying. As defined by Einarsen and Hoel, (2001), the first grouping of questions of the survey that new RN participants responded were related to work related bullying. These include the specific questions 1, 3, 14, 16, 18, 19, and 21. The survey instrument is presented in Appendix A. Einarsen, Hoel, & Notelaers (2009) report that the average conditional probability of work related bullying on a weekly basis is 10% of those who report bullying.

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Question 1

1. Someone withholding information which affects your performance Frequency Percent Valid Never 62 45.9 Now and then 53 39.3 Monthly 12 8.9 Weekly 3 2.2

Daily 5 3.7 Total 135 100.0

Question 1. 45.9% of respondents determined that they never had someone in the workplace withhold information that affected their performance. Another 39.3% noted it occurred now and then. 14.8% claimed it occurred more often, on a monthly/weekly/ daily basis. Withholding of information occurred for eight (5.9%) nurses on a weekly or daily basis.

Question 3

3. Being ordered to work below your competence Valid

Frequency Percent Valid Never 48 35.8 Now and then 63 47.0 Monthly 9 6.7 Weekly 6 4.5 Daily 8 6.0 Total 134 100.0 Missing System 1 Total 135

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Question 3. Although 48 (35.8%) reported never being required to work below their competence, those that were ordered to work below their competence on a weekly and daily basis were 14 (10.5%) of the new nurse respondents. Being over 10% for daily/weekly is alarming. One nurse opted to not respond to this question.

14. Having your opinions and views ignored Frequency Valid Percent

Valid Never 51 38.1 Now and then 59 44.0 Monthly 13 9.7 Weekly 6 4.5 Daily 5 3.7 Total 134 100.0 Missing System 1 Total 135

Question 14. Having your opinions ignored as never was reported by 51 (38.1%) of the new nurse respondents, but 24 respondents (19%) reported this as occurring monthly, weekly, and daily to them. Weekly and daily ignoring occurred for 10.5% of the new nurses, which is a large percentage. One nurse opted to not respond to this question.

Question 16

16. Being given tasks with unreasonable or impossible targets or deadlines Frequency Percent Valid Never 80 59.3 Now and then 38 28.1 Monthly 6 4.4 Weekly 7 5.2 Daily 4 3.0 Total 135 100.0

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Question 16. Most new nurse respondents in the study 80 (59.3%) reported they were never given unreasonable tasks or target dates, and another 28% noted this to occur now and then. There were 11 (8.2%) respondents that reported unreasonable tasks and target dates occurred weekly/daily for them.

Question 18.

18. Excessive monitoring of your work Frequency Valid Percent Valid Never 74 56.1 Now and then 42 31.8 Monthly 6 4.5 Weekly 6 4.5 Daily 4 3.0 Total 132 100.0

Missing System 3 Total 135

Question 18. Having excessive monitoring of your work was mostly not a problem for respondents as 116 (87.9%) reported it never or only now and then occurred. On a monthly/weekly/daily basis 16 respondents (12%) reported this has occurred to them. A total of 7% of the nurse respondents reported this to occur on a weekly/daily basis.

Three respondents were missing.

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Question 19.

19. Pressure not to claim something which by right you are entitled to (e.g. sick leave, holiday entitlement, travel expenses) Frequency Percent Valid Never 93 68.9 Now and then 26 19.3 Monthly 6 4.4 Weekly 5 3.7 Daily 5 3.7 Total 135 100.0

Question 19. Having pressure to not claim what the responding nurses were entitled to such as sick leave, holiday entitlement or travel expenses, was never reported by 93

(68.9%) of the respondents. It is interesting that ten (7.4%) of the respondent nurses reported this to occur on weekly/daily basis, and to six nurses (4.4%) on a monthly basis.

Question 21.

21. Being exposed to an unmanageable workload Frequency Valid Percent Valid Never 49 36.6 Now and then 46 34.3

Monthly 16 11.9 Weekly 14 10.4

Daily 9 6.7 Total 134 100.0 Missing System 1 Total 135

Question 21. Twenty-three (17.1%) of the nurse respondents reported being exposed to an unmanageable workload on a weekly/daily basis. This is the highest negative behavior percentile for the twenty-two survey questions for 134 nurse respondents. An additional 80

16 (11.9%) nurse respondents reported an unmanageable work load on a monthly basis.

This never occurred for 49 (36.6%), and only occurred now and then for 46 (34.3%) of the respondents. One nurse did not respond to question 21.

Person related bullying. New RN respondents defined their perception of workplace bullying as person related bullying which includes the following questions:

2,4,5,6,7,10,11,12,13,15,17,20. The survey instrument is presented in Appendix A.

Einarsen, et al., (2009) report that the average conditional probability of this type of bullying occurring, which they rate as severe bullying, is 5% of those answering the above person related bullying questions.

Question 2.

2. Being humiliated or ridiculed in connection with your work Frequency Percent Valid Never 70 51.9 Now and then 50 37.0 Monthly 11 8.1 Weekly 3 2.2 Daily 1 .7 Total 135 100.0

Question 2. Being humiliated or ridiculed in connection with their work was a very low occurrence daily/weekly for four nurses (2.9%). Overwhelmingly it never or only now and then occurred for 120 (88.9%) nurse respondents. It is interesting that 11 (8.1%) reported humiliation as occurring monthly which is twice the number that reported this occurring on a weekly/daily basis.

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Question 4.

4. Having key areas of responsibility removed or replaced with more trivial or unpleasant tasks Frequency Percent Valid Never 77 57.0 Now and then 41 30.4 Monthly 7 5.2 Weekly 6 4.4 Daily 4 3.0 Total 135 100.0

Question 4. Key areas of responsibility removed or replaced with more trivial tasks has never been a problem for 77 (57%) of the nurse respondents, and only now and then for

41 (30.4%) totaling 118 (87.4%) of the respondents. Those reporting it weekly and daily were ten (7.4%) of the respondents.

Question 5.

5. Spreading of gossip or rumors about you Frequency Percent Valid Never 62 45.9 Now and then 52 38.5 Monthly 10 7.4 Weekly 5 3.7 Daily 6 4.4 Total 135 100.0

Question 5. Most of the respondents did not have a problem with the spreading of gossip and rumors as it never occurred for 62 (45.9%) and only now and then for 52 (38.5%).

For 11 (8.1%) nurse respondents, gossip occurred in the workplace weekly/daily and

82 another 10 (7.4%) monthly. The respondents reported the spreading of gossip on a monthly basis by 10 (7.4%).

Question 6

6. Being ignored, excluded, or being isolated from others Frequency Valid Percent Valid Never 60 45.1 Now and then 45 33.8 Monthly 13 9.8 Weekly 10 7.5 Daily 5 3.8

Total 133 100.0 Missing System 2 Total 135

Question 6. Many nurse respondents (105 or 79%) reported they had never been ignored, excluded, or isolated from others in the workplace. Fifteen (11.3%) nurse respondents reported this occurred on a weekly/daily basis. This is sizeable as it was over 10% of the respondents. Another 10 (7.5%) had this occurrence monthly. Two nurses did not respond to this survey question.

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Question 7

7. Having insulting or offensive remarks made about your person (i.e. habits and background), your attitudes on your private life Frequency Percent Valid Never 81 60.0 Now and then 35 25.9 Monthly 11 8.1 Weekly 5 3.7 Daily 3 2.2 Total 135 100.0

Question 7. Most of the nurse respondents 116 (86%) have never or only now and then dealt with insulting and offensive remarks in the workplace, about their person (habits and background) or their attitudes or private life. For eight (5.9%) nurses this occurred on a weekly/daily basis, and interestingly another 11 (8.1%) nurses reported it occurred on a monthly basis. The monthly occurrence was again greater than daily or weekly combined.

Question 10

10. Hints or signals from others that you should quit your job Frequency Percent Valid Never 112 83.0 Now and then 18 13.3 Monthly 5 3.7 Total 135 100.0

Question 10. There were no nurse respondents that were given hints or signals to quit their job weekly or daily, and a surprising low number of nurse respondents (five or

3.7%) claimed this happened to them on a monthly basis. Of the 135 responses, 130 nurses reported this as never or now and then. One-hundred and twelve (83%) reported never and 18 (13.3%) reported this occurrence as now and then.

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Question 11

11. Repeated reminders of your errors or mistakes Frequency Valid Percent Valid Never 81 60.4 Now and then 36 26.9 Monthly 14 10.4 Weekly 1 .7 Daily 2 1.5 Total 134 100.0 Missing System 1

Total 135

Question 11. Repeated reminders of errors and mistakes never occurred for 81 (60.4%) nurse respondents and only now and then for 36 (26.9%) respondents. It is interesting that for 14 (10.4%) of the respondents this occurred on a monthly basis and that very few respondents noted this occurred on a weekly, one (.7%), or a daily two, (1.5%) basis.

Question 12

12. Being ignored or facing a hostile reaction when you approach Frequency Percent Valid Never 88 65.2 Now and then 30 22.2 Monthly 7 5.2 Weekly 7 5.2 Daily 3 2.2 Total 135 100.0

Question 12. Having others ignore you or facing hostile reactions when you approach others in the workplace did not occur for 88 (65.2%) of the respondents, and only now and then for 30 (22.2%). This rarely occurred daily as three (2.2%) of the respondents

85 reported this occurrence. The daily/weekly occurrence was for ten (7.4%) of the respondents. Having others ignore or facing hostility was reported monthly by seven

(5.2%) of the nurse respondents.

Question 13.

13. Persistent criticism of your work and effort Frequency Valid Percent Valid Never 89 66.4 Now and then 39 29.1 Monthly 4 3.0 Weekly 1 .7 Daily 1 .7 Total 134 100.0 Missing System 1 Total 135

Question 13. Very few of the nurse respondents reported there was persistent criticism of their work and effort in the workplace, as occurrences weekly and daily were reported by two (1.4%) nurse respondents. Eighty-nine (66.4%) were never criticized, and it occurred now and then for another 39 (29.1%) of the nurse respondents. One nurse did not respond to this question.

Question 15.

15. Practical jokes carried out by people you don’t get along with Frequency Percent Valid Never 118 87.4 Now and then 13 9.6 Monthly 3 2.2 Weekly 1 .7 Total 135 100.0

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Question 15. Practical jokes done by others you do not get along with occurred never for

118 (87.4%) of the nurse respondents, and now and then for 13 (9.6%). It was not reported as occurring daily and occurred weekly/monthly for four (2.9%) of the nurse respondents.

Question 17.

17. Having allegations made against you Frequency Percent Valid Never 106 78.5 Now and then 21 15.6 Monthly 6 4.4 Weekly 1 .7 Daily 1 .7 Total 135 100.0

Question 17. Allegations made against the nurse respondents by others in the workplace were reported as very low on a weekly/daily basis by two (1.4%) nurse respondents.

Surprisingly, this occurrence was more often monthly as reported by six (4.4%) of the respondents. No allegations were reported by the majority of the 106 (78.5%) nurse respondents.

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Question 20.

20. Being the subject of excessive teasing and sarcasm Frequency Valid Percent Valid Never 113 84.3 Now and then 15 11.2 Monthly 5 3.7 Weekly 1 .7 Total 134 100.0 Missing System 1 Total 135

Question 20. Being the subject of excessive teasing and sarcasm occurred never for the majority of the nurse 113 respondents or (84.3%). It is interesting that the nurse respondents did not report this as a daily occurrence, and only six (4.4%) reported this occurring weekly/monthly. One nurse did not report on this question.

Physically intimidating bullying. Physically intimidating bullying behaviors were perceived by the following new RN graduate nurses using the NAQ-R survey and included the questions on the survey 8, 9, and 22. The survey instrument is presented in

Appendix A. Einarsen et al. (2009) state the average conditional probability of respondents rating physically intimidating behavior is 3%.

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Question 8

8. Being shouted at or being the target of spontaneous anger (or rage) Frequency Percent Valid Never 83 61.5 Now and then 40 29.6 Monthly 4 3.0 Weekly 7 5.2 Daily 1 .7 Total 135 100.0

Question 8. Nurse respondents that reported being shouted at or the target of someone’s rage included those who were never bullied (83 or 61.5%), and another 40 (29.6%) that were bullied only now and then, which was 91.1% of the sample. Eight (5.9%) of the nurse respondents reported this negative behavior occurred weekly/daily and four (3%) of the nurse respondents did experience being shouted at monthly by others in the workplace.

Question 9.

9. Intimidating behavior such as finger-pointing, invasion of personal space, shoving, blocking/barring the way Frequency Percent Valid Never 113 83.7 Now and then 8 5.9 Monthly 9 6.7 Weekly 4 3.0 Daily 1 .7 Total 135 100.0

Question 9. Intimidating physical behaviors such as finger-pointing, invasion of personal space, shoving, and blocking/barring the way was never experienced by 113

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(83.7%) of new nurse respondents. This occurred more on a monthly basis for nine

(6.7%) nurse respondents or weekly/daily for four (3.7%) of the nurse respondents.

Question 22.

22. Threats of violence or physical abuse or actual abuse Frequency Percent Valid Never 125 92.6 Now and then 5 3.7 Monthly 3 2.2 Weekly 1 .7 Daily 1 .7 Total 135 100.0

Question 22. Threats of physical violence occurred very rarely as 125 (92.6%) of the nurse respondents reported this to never have happened to them in the workplace. Only two (1.4%) respondents reported this to have happened on a daily or weekly basis. Nurse respondents reported the monthly occurrence was three (2.2%), which is interesting, as it again is more than the weekly/daily percentage. Any threat of physical violence or abuse is considered serious, and it is very disturbing that seven percent have experienced this.

Have You Been Bullied at Work?

After RN participants answered twenty-two questions on workplace negative acts they were given the definition of bullying. Participants determined if they had been bullied after reading the definition of bullying when responding to question 23. This question was part of the original NAQ questionnaire (Einarsen, Raknes, Matthiesen, & og

Hellesoy, 1994).

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Question 23.

Have you been bullied at work? We define bullying as a situation where one or several individuals over a period of time perceive themselves to be on the receiving end of negative actions from one or several persons, in a situation where the target of bullying has difficulty in defending him or herself against these actions. We will not refer to a one time incident as bullying. Frequency Valid Percent Valid No 105 79.5 Yes, but only rarely 17 12.9 Yes, now and then 4 3.0 Yes, several times per 6 4.5 week Total 132 100.0 Missing System 3 Total 135 100.0

Question 23. Nurse respondents that reported they had been bullied at work included 132 nurses respondents, and three responses were missing. This question was asked to respondents after they had completed the 22 questions of the NAQ-R survey. They were not given the definition of bullying until question 23. Of the 132 nurse respondents, 105

(79.5%) reported they were never bullied. There was a total of 20.5% of nurse respondents who did report they had been bullied in the workplace. Those who reported bullying were 17 (12.9%) nurses who reported bullying occurred rarely, four (3%) nurses who reported bullying had occurred now and then or occasionally, and six (4.5%) nurse respondents who reported bullying occurred frequently in the workplace several times per week.

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Question 24.

24. Please answer the following questions concerning bulling in the nursing profession. Have you seen others being subjected to bullying in your workplace during the last six months? Frequency Percent Valid Yes 63 46.7 No 72 53.3 Total 135 100.0

Question 24. Of the 135 nurse respondents 63 (46.7%) reported they had seen others being bullied in their workplace within the last six months and 72 (53.3%) had not seen this occur in the workplace in the last six months.

Internal and External Behavioral Reactions to Bullying

RN respondents were asked to respond to their experience of internal and external behavioral reactions to bullying.

Question 25.

25. If you have experienced bullying in the workplace, do any of the behaviors below

apply to you? Check all the behaviors that apply.

Nurse respondents were given eight internal behaviors and eight external behaviors to respond to if they had experienced bullying in the workplace. For the purpose of this study, the percentages over 10% are considered to be very serious for internal or external behavioral reactions in the victim that are aroused due to bullying. Table 6 is a summary of the data of the percent of respondents that reported “yes” to feeling the specific eight internal and eight external behavioral reactions to bullying.

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Table 6

Percent of Respondents Reporting Internal and External Behavioral Reactions to Bullying

Percent of Respondents Reporting “Yes”

Internal Behavioral Reactions

Powerlessness (10.4)

Increased Stress (21.5)

Disconnected (8.9)

Low self esteem (11.9)

Decreased job satisfaction (20.7)

Sadness (11.9)

Anxious (19.3)

Increased fatigue (15.6)

External Behavioral Reactions

Irritated with others (20)

Short temper (8.9)

Decreased patience (19.3)

Decreased job production (7.4)

Increased weight (9.6)

Decreased weight (2.2)

Decreased sleep (12.6)

Increased sick days (3.7)

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In summary, the Internal Behaviors frequency that occurred for more than 10% of the new nurse respondent population that had experienced bullying in the workplace were a low self esteem, sadness, fatigue, and powerlessness. The Internal Behaviors that were about 20% or over were decreased job satisfaction, being anxious and increased stress.

The External Behaviors that were about or over 10% for the new nurse graduate respondents were a short temper, increased weight gain, and decreased sleeping. The

External Behaviors that were about or over 20% for the nurse respondents were having decreased patience with others, and being irritated with others. New nurse graduates reported on how bullying affected their job performance in questions 26 through 29.

Bullying Affects on Job Performance

RN participants were asked to respond as to whether bullying had affected their job performance, if they had changed jobs, and whether they had considered leaving the nursing profession as a result of being bullied in the workplace.

Question 26.

26. If you have experienced bullying, do you think it has affected your job performance? Frequency Valid Percent Valid Yes 30 31.6 No 65 68.4 Total 95 100.0 Missing System 40 Total 135

Question 26. Forty (29.6%) of the 135 nurse respondents to this study did not respond to this question. But, of the 95 who did respond, 30 (31.6%) of the nurse respondents did claim that experiencing bullying in the workplace did affect their job performance. Sixty- five (68.4%) reported that it did not affect their job performance. 94

Question 27.

27. Have you changed jobs in the past two years? Frequency Valid Percent Valid Yes 45 35.4 No 82 64.6 Total 127 100.0 Missing System 8 Total 135

Question 27. Forty-five (35.4%) of the nurses who responded had changed jobs in the past two years. Eighty-two (64.6%) had not changed jobs in the last two years. Eight nurses of the 135 chose to not answer this question.

Question 28.

28. Did workplace bullying play a role in your decision to change jobs? Frequency Valid Percent Valid Yes 14 13.2 No 92 86.8 Total 106 100.0 Missing System 29 Total 135

Question 28. Although 29 (21.5%) chose to not answer this question, fourteen (13.2%) did report that workplace bullying did play a role in their decision to change jobs. Ninety- two (86.8%) of the nurses reported that workplace bullying did not play a role in their decision to change their job.

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Question 29.

29. Have negative workplace behaviors made you consider leaving the nursing profession? Frequency Valid Percent Valid Yes 36 29.5 No 86 70.5 Total 122 100.0 Missing System 13 Total 135

Question 29. Thirty-six (29.5%) nurse respondents reported that negative workplace behaviors made them consider leaving the nursing profession, and eighty-six (70.5%) of those answering this question reported this to not be the case. Thirteen (9.6%) chose to not answer question 29.

Who is the Bully in the Workplace?

The RN participant identified who the bullies are in the , who are identified in question 30.

Question 30.

Who is most likely to be the bully in the workplace? The bullying individual in the workplace was reported as a peer or fellow nurse, a patient, the patient’s family, a manager/ administration, a nurse supervisor, a physician, other health care workers, or others. Table 7 displays who the most likely, likely, or unlikely bully is in the workplace.

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Table 7

Percentage of Nurse Frequencies of “Who is the Bully in the Workplace”

New Nurse Reponses Most Likely Likely Unlikely N/A Peer or fellow nurse (32.8) (31.1) (13.4) (22.7)

Patient (9.2) (30.8) (37.5) (22.5)

Patient’s family (11.7) (47.5) (22.5) (18.3)

Manager/Administration (11.8) (24.4) (42) (21.8)

Nurse Supervisor (11.9) (27.1) (39) (22)

Physician (25.4) (34.4) (21.3) (18.9)

Other health care worker (3.5) (26.1) (43.5) (27)

Others (2.7) (3.6) (40.5) (53.2)

In summary, the most likely person to be the bully in the workplace on a daily or weekly basis was named by new nurse respondents in the survey as a nursing peer or fellow nurse, the patient’s family, or the physician. The nurse manager or manager/administrator was reported as being the likely or most likely bully by over one- third of the nurse respondents. Other health care workers were reported as the most likely or likely bully by about thirty percent of the nurse respondents.

Educational Efforts to Manage Bullying

Education about bullying may occur in the nursing curriculum or in the health care organization the nurse is employed. The next few questions determine whether nursing education has been perceived as adequate and if the new nurse graduate feels that education would be helpful in managing a bully in the workplace.

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Question 31.

31. Was workplace bullying included in any courses in your formal nursing education? Frequency Valid Percent Valid Yes 30 22.4 No 104 77.6 Total 134 100.0 Missing System 1 Total 135

Question 31. Thirty (22.4%) of nurse respondents reported that workplace bullying was included in courses in their formal nursing education. The overwhelming majority

(104 or 77.6%) of the nurse respondents reported this to not be included in their formal nursing education.

Question 32.

32. Do you think information on workplace bullying should be included in a nursing curriculum? Frequency Valid Percent Valid Yes 111 82.8 No 23 17.2 Total 134 100.0 Missing System 1 Total 135

Question 32. Of the 135 nurse respondents, only one nurse chose to not respond to question 32. Overwhelmingly, 111 (82.8%) of the nurses reported that information on workplace bullying should be included in the nursing curriculum. Only 23 (17.2%) reported that workplace bullying should not be included in the nursing curriculum.

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Workplace Efforts to Educate Employees and Manage Bullying

RN respondents were asked if bullying was addressed in staff education, if there are workplace policies, if they have a mentor, if their employer was supportive to victims, and if they felt it was important for JACHO to inform employees in the workplace about bullying and disruptive behaviors in the workplace.

Question 33

33. Is bullying addressed in staff education? Frequency Percent Valid Yes 49 36.3 No 86 63.7 Total 135 100.0

Question 33. Forty-nine (36.3%) of the nurse respondents to the survey reported that bullying was addressed in staff education in their workplace. The large majority, eighty- six (63.7%), reported that bullying is not addressed in their staff education at their workplace.

Question 34.

34. Do you think your workplace should have a policy in place to deal with bullying? Frequency Valid Percent Valid Yes 128 95.5 No 6 4.5 Total 134 100.0 Missing System 1 Total 135

Question 34. One-hundred twenty eight (95.5%) of the nurses reported that their workplace should have a policy in place to deal with bullying. Six (4.5%) of the nurses

99 did not report a policy on bullying in their workplace was needed. One chose to not answer this question.

Question 35.

35. Do you have a person assigned to you that you can discuss workplace issues with? Frequency Valid Percent Valid Yes 80 59.7 No 54 40.3 Total 134 100.0 Missing System 1 Total 135

Question 35. Eighty (59.7%), the majority of the nurse respondents, reported they did have a person in their workplace to discuss work issues with. Fifty-four (40.3%) reported they did not have someone in their workplace to discuss workplace issues. One chose to not answer this question of the 135 respondents.

Question 36.

36. Do you feel confident and prepared to handle a bully in your workplace? Frequency Valid Percent Valid Yes 84 62.7 No 50 37.3 Total 134 100.0 Missing System 1 Total 135

Question 36. Only one nurse chose to not answer this question. Eighty-four (62.4%) reported they were confident to handle a bully in their workplace. But, 50 (37.3%) reported they did not feel confident to handle a bully in their workplace.

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Question 37.

37. Is the management at your workplace supportive for those who are victims of bullying? Frequency Valid Percent Valid Yes 87 64.9 No 47 35.1 Total 134 100.0 Missing System 1 Total 135

Question 37. Having a supportive workplace management for those who are victims of bullying was reported by 87 (64.9%) of 134 of the respondents of the survey. Forty-seven

(35.1%), which is over one-third of the respondents reported that the management at their workplace was not supportive of victims of bullying.

Question 38.

38. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has called for healthcare workplaces to launch an organizational approach to inform employees of bullying and disruptive behaviors in the workplace. Do you feel this is important? Frequency Valid Percent Valid Yes 131 98.5 No 2 1.5 Total 133 100.0 Missing System 2 Total 135

Question 38. The largest number of nurse respondents (131 or 97%) reported that it is important that health care workplaces need to launch an organizational approach to inform employees of bullying and disruptive behaviors in the workplace as JCAHO has

101 called for. Only two (1.5%) of those surveyed reported this should not occur, and two did not respond to this question.

Hypothesis Testing

The research study determining the new nurse graduates perception of hostility or bullying in the workplace is a sampling distribution that is compared to Einarsen’s et al.,

(2009) landmark study. Using the laws of probability and the NAQ-R questionnaire the research hypotheses predicts whether there is a relationship between the variables that defines bullying behaviors in the workplace. The new nurse graduates in this study are compared to the Einarsen et al.’s findings of bullying behaviors in the workplace. An objective decision can be made analyzing with chi-square to determine whether the null hypothesis is accepted or rejected. That is, do the perceptions of hostility or bullying in the workplace for new nurse graduates in this study differ from the perceptions that the

Einarsen group report for other employees. The Einarsen study on workplace bullying involved twenty-two questions that employees were asked to respond. These questions were factored by Einarsen and colleagues and determined the probability of employees being bullied related to “work related bullying,” “person related bullying,” and

“physically intimidating bullying.” As was discussed in Chapter 3 the NAQ-R normative data found significant “work related bullying” reported by ten percent of the population completing the NAQ-R, “person related bullying” was found in thirteen percent of the population, and “physically intimidating bullying” was reported by three percent of the population. These population norms were the comparison group for this study of new nurse graduates.

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Research Question One

Do a significant number of new nurse graduates report negative behaviors and different types of bullying in the workplace (work- related bullying, person-related bullying or physically intimidating bullying)?

1.1. Ho: There will be no significant difference between the frequency of new

nurse graduates who report work-related bullying in the workplace and the

population norm.

The respondents in the new nurse graduate survey selected frequencies for daily and weekly “work related bullying” were compared with Einarsen’s et al. (2009) landmark study. The following are the summary of the percentages of respondents that claimed

“work related bullying” daily/weekly. These scores were compared with Einarsen’s et al. study to determine if bullying was significant or not significant using Chi-square. The summary of the new nurse respondent’s scores are listed in Table 8.

Table 8.

Einarsen and New Graduate Nurse Results

“Work Related Bullying”_

Einarsen New Grad Nurse

(Expected %) (Observed%) (x2) p

Questionnaire / behaviors

1. Withholding information (10) (5.9) 1.15 NS

3. Working below one’s competence (10) (10.5) 0.01 NS

14. Having opinions ignored (10) (8.2) 0.02 NS

16. Given tasks with impossible deadline (10) (8.2) 0.20 NS

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18. Being excessive monitored (10) (7.5) 0.39 NS

19. Being pressured to not claim entitlements (10) (7.4) 0.43 NS

21. Having an unmanageable workload (10) (17.1) 2.10 NS

“Work related bullying” was analyzed in the survey on new nurse graduates using

Chi square and the frequency scores for each of the questions. The seven questions

1,3,14, 16, 18, 19, and 21 were factored together in the original study (Einarsen et al.,

2009) to create the latent fifth cluster titled ”work related bullying.” The “work-related bullying” cluster five established the size of the cluster as 10% in Einarsen’s et al., 2009 study, and this population norm was used to compare the two groups. New nurse graduates reporting negative behaviors and “workplace bullying” were reported as non- significant, the degrees of freedom (1) using the Chi square analysis for each of the questions and result in failure to reject the null hypotheses. The questions included: 1.

Withholding information, 3. Work below competence, 14. Having opinions ignored, 16.

Tasks have an impossible deadline, 18. Being excessively monitored, 19. Pressure to not claim entitlements, and 21. Unmanageable workload.

1. 2. Ho: There will be no significant difference between the frequency of new

nurse graduates who report person-related bullying in the workplace and the

population norm.

The following twelve questions were factored together by Einarsen as “person related bullying” 2, 4, 5, 6, 7, 10, 11, 12, 13, 15, 17, and 20. The questions were responded on a daily and weekly basis except for question 11. and question 15. Question 11. (hints at leaving your job, which was reported to occur monthly) and question 15. (practical jokes

104 from adversaries, was reported monthly/weekly). The following data on Table 9 are the reported percentage results from the new nurse graduate respondents to the questions.

Table 9

Einarsen and New Graduate Nurse Results

“Person Related Bullying”_

Einarsen New Grad Nurse

(Expected %) (Observed%) (x2) ( p)

Questionnaire / Behaviors

2. Being humiliated and ridiculed (13) (2.9) 6.87 .0083 *

4. Responsibility removed/trivial tasks (13) (7.4) 1.71 NS

5. Spreading gossip about you (13) (8.1) 1.27 NS

6. Being ignored/secluded (13) (11.3) 0.14 NS

7. Insulting remarks (13) (5.9) 2.95 NS

10. Hints at quitting job (13) (3.7) 5.65 .0174 *

11. Being reminded of mistakes (13) (2.2) 5.30 .004 *

12. Being ignored or hostility (13) (7.4) 1.71 NS

13. Persistent criticism (13) (1.4) 10.07 .0015 *

15. Practical jokes by adversaries (13) (2.9) 6.97 .0083 *

17. Allegations against you (13) (1.4) 10.07 .0015*

20. Excessive teasing/sarcasm (13) (4.4) 4.66 .031 *

Some questions were found to be statistically significantly different when comparing the original Einarsen et al., (2009) population norm which had a cluster size of 13% to the survey of the new nurse graduates. Statistically significant differences were found of

105 the specific respondent’s responses to the questions and are as follows: 2. being humiliated and ridiculed, 10. hints to quit job, 11. being reminded of mistakes, 13. persistent criticism, 15. practical jokes from adversaries, 17. allegations against you, and

20. being excessively teased/sarcasm. As these questions were found to be statistically significant when analyzed using Chi square, the null hypothesis is rejected. Being statistically significant they were significantly less than the population norm.

Questions within the “person-related bullying” that were found to be non-significant were as follows: 4. responsibility removed and given trivial tasks, 5. spread gossip about you, 6. being ignored/secluded, 7. insulting remarks, and 12. being ignored or hostility.

As these questions were found to be statistically non-significant using the Chi square analysis, there is failure to reject the null hypothesis as it compares to the population norm.

1.3. Ho: There will be no significant difference between the frequency of new

nurse graduates who report physically intimidating bullying in the workplace

and the population norm.

New graduate nurse respondents reported about the three questions 8, 9, and 22 that indicated “physically intimidating bullying.” The following percentages were accumulated for a weekly/daily basis and are in Table 10.

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Table 10

Einarsen and New Graduate Nurse Results

“ Physically Intimidating Bullying”

Einarsen New Grad Nurse

(Expected %) (Observed%) (x2) (p)

Questionnaire / behaviors

8. Being shouted at (3) (5.9) .99 NS

9. Intimidating behavior (3) (3.7) .08 NS

22. Threats of violence (3) (1.4) .59 NS

Each of the three questions 8. being shouted at, 9. intimidating behavior, and 22. threats of violence were factored together to represent “physical intimidation” and were non-significant. “Physically intimidating bullying” had a cluster size of 3% in Einarsen’s original population norm which was compared to the new nurse graduate survey. Using the Chi square analysis and one degree of freedom, there is failure to reject the null hypothesis for these questions as there were no statistically significant differences to the population norm.

Research Question Two A.

Who does the new nurse graduate identify as causing the problem in the workplace?

The descriptive data of who the new nurse graduate feels is the bully in their workplace is summarized in Table 2. Comparing the most likely, likely, and unlikely, the percentages contribute to identifying who the bully is in the workplace. Combining the most likely and likely percentages helps one view the data in the order of who is the most likely bully.

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The peer or fellow nurse has the highest percentage of being the most likely or likely bully in the workplace (63.9%). The physician also has a very high percentage for being the most likely or likely (59.8%). The patient’s family has a high percentage for being the most likely or likely bully (59.2%). Somewhat lower are the patient as the most likely or likely bully (40%), the nurse supervisor as the most likely or likely bully (39%) and the manager/administrator as the most likely or likely bully (36.2%). The other health care workers in the workplace as identified most likely or the likely bully (29.6%), and others as the most likely or likely bully (6.3%).

The most unlikely bully identified in the workplace is as follows: Other health care worker (43.5%), manager/administrator (42%), others (40.5%), Nurse Supervisor (39%), patient (37.5%), patient’s family (22.5%), physician (21.3%), and peers or fellow nurses

(13.4%). From these new graduate nurse responses regarding the unlikely bully we can see the peer or fellow nurse, physician, and patient’s family are again the most likely culprits of bullying in the workplace.

The new nurse respondents that chose not applicable to who the most likely bully in the workplace were the highest percentage for others (53.2%) and other health care workers (27%). The other categories of workers were each at about (20%): Peer or fellow nurse, patient, patient’s family, manager/administration, nurse supervisor, and physician.

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Table 7

Percentage of Nurse Frequencies of “Who is the Bully in the Workplace?”

New Nurse Reponses Most Likely Likely Unlikely N/A Peer or fellow nurse (32.8) (31.1) (13.4) (22.7)

Patient (9.2) (30.8) (37.5) (22.5)

Patient’s family (11.7) (47.5) (22.5) (18.3)

Manager/Administration (11.8) (24.4) (42) (21.8)

Nurse Supervisor (11.9) (27.1) (39) (22)

Physician (25.4) (34.4) (21.3) (18.9)

Other health care worker (3.5) (26.1) (43.5) (27)

Others (2.7) (3.6) (40.5) (53.2)

In summary, the overall most likely bully in the workplace is the peer or fellow nurse

(32.8%) or the physician (25.4%). The likely bully identified was the patient’s family

(47.5%), the physician (34.4%), the peer or fellow nurse (31.1%), or the patient (30.8%).

The most unlikely bully was the other health care worker (43.5%), the manager/administrator (42%), others (40.5%), or nurse supervisor (39%).

Research Question Two B.

Do new nurse graduates identify that workplace bullying has affects on them personally

(internal/external behaviors)?

2. B. 1. Ho: There will be no statistically significant difference in the frequency

of new nurse graduates identifying internal behaviors that affect them as a

result of workplace bullying.

The 27 new nurse graduates who reported experiencing workplace bullying were compared to those not reporting bullying to examine how they might have been affected

109 by the bullying experience. Chi- squared was used to analyze the relationship of the frequency of new nurse graduates that reported the internal behaviors of powerlessness, increased stress, low self esteem, decreased job satisfaction, feeling sad, feeling anxious, increased fatigue, and feeling disconnected when bullied at work. External behaviors were also analyzed of those bullied at work and include irritated with others, expressing a short temper, decreased patience, decreased job production, gaining weight, losing weight, having sleeplessness, and having increased sick days.

Internal Behaviors: Powerlessness * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: No Count 102 16 118 Powerlessness Expected Count 93.9 24.1 118.0 Yes Count 3 11 14 Expected Count 11.1 2.9 14.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 32.510, df = 1, p<.001

The internal behavior of powerlessness as a result of new nurse graduate being bullied at work was analyzed using Chi-squared and the comparison resulted in the expected frequency (2.9) and the observed (11), of the total count (27). Those who did not report bullying and powerlessness were observed (102) at the expected frequency

(93.9) of the total (105). Using Fisher’s Exact Test (2-sided) there was a statistically significant relationship (p<.001).

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Internal Behaviors: Increased stress * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: No Count 98 6 104 Increased stress Expected Count 82.7 21.3 104.0 Yes Count 7 21 28 Expected Count 22.3 5.7 28.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 64.985, df = 1, p<.001

The internal behavior of increased stress as a result of new nurse graduates being bullied at work using Chi-squared analysis had the expected frequency (5.7) and the observed frequency (21) of the total (27) of new graduate nurses. The nurses who did not report increased stress and bullying at work were observed (98) and expected (82.7) of the total (105). The Fishers Exact Test, (2-sided test), analyzed the relationship to be statistically significant (p< .001).

Internal Behaviors: Disconnected * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: No Count 103 17 120 Disconnected Expected Count 95.5 24.5 120.0 Yes Count 2 10 12 Expected Count 9.5 2.5 12.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note x2 = 32.076, df = 1, p<.001

The internal behavior of new nurse graduates being disconnected as a result of being

111 bullied in the workplace used Chi-square to analyze the relationship. The observed frequency (10) was well over the expected frequency (2.5) of the total (27) that reported being bullied. The number of new nurse graduates that did not report bullying and feeling disconnected were observed frequency (103) and expected frequency (95.5) of the total

(105). Fishers Exact test was used (2-sided) and found the relationship statistically significant (p< .001).

Internal Behaviors: Low self esteem * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: Low No Count 103 14 117 self esteem Expected Count 93.1 23.9 117.0 Yes Count 2 13 15 Expected Count 11.9 3.1 15.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 45.598, df = 1, p<.001

The internal behavior of a low self esteem as a result of being bullied in the workplace reported by new nurse graduates was analyzed by Chi-square. The observed frequency

(13) was much higher than the expected frequency (3.1) of the total (27) who reported bullying. Those nurses that did not report a low self esteem or bullying were observed

(103) and expected frequency (93.1) of the total (105). Fishers Exact Test (2-sided) analyzed a significant relationship (p < .001).

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Internal Behaviors: Decreased job satisfaction * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: No Count 98 6 104 Decreased job Expected Count 82.7 21.3 104.0 satisfaction Yes Count 7 21 28 Expected Count 22.3 5.7 28.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 =64.985, df = 1, p<.001

The internal behavior of decreased job satisfaction when bullied in the workplace of the new nurse graduate used Chi-square. The observed frequency (21) was well over the expected frequency (5.7) of the total (27) who reported bullying. Those nurses that did not report bullying were observed (98) and expected (82.7) of the total (105). Fishers

Exact Test (2-sided) analyzed the relationship and it was statistically significant (p<

.001).

Internal Behaviors: Feel sad * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: Feel No Count 103 13 116 sad Expected Count 92.3 23.7 116.0 Yes Count 2 14 16 Expected Count 12.7 3.3 16.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 50.300, df = 1, p = < .001

Analyzing the internal behavior, feeling sad and being bullied at work, using Chi-

113 square there was an expected frequency (3.3), and the observed frequency (14) of the total (27). The nurses that did not report bullying was analyzed and the observed frequency (103) was over the expected frequency (92.3) of the total (105). Fishers Exact

Test (2-sided) analyzed the relationship to be statistically significant (p< .001).

Internal Behaviors: Feel anxious * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: Feel No Count 96 11 107 anxious Expected Count 85.1 21.9 107.0 Yes Count 9 16 25 Expected Count 19.9 5.1 25.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 35.943, df = 1, p< .001

Chi-square analyzed the relationship of those bullied at work feeling the internal behavior anxiousness for an observed frequency (16) compared to the expected frequency

(5.1) of the total (27). The nurses that did not have a problem with being bullied and feeling anxiousness were observed frequency (96) and expected frequency (85.1) of the total (105). The Fishers Exact Test (2-sided) analyzed the relationship as statistically significant (p< .001).

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Internal Behaviors: Increased fatigue * Bullied at work Crosstab Bullied at work

No Yes Total Internal Behaviors: No Count 99 12 111 Increased fatigue Expected Count 88.3 22.7 111.0 Yes Count 6 15 21 Expected Count 16.7 4.3 21.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 39.881, df = 1, p < .001

Chi-square analyzed the internal behavior having feelings of increased fatigue and being bullied in the workplace of the new nurse graduates for an observed frequency

(15) compared to the expected frequency (4.3) for the total (27). The nurses that did not report being bullied were an observed frequency (99) compared to the expected frequency (88.3) of the total (105). Fishers Exact Test (2-sided) analyzed the relationship and it was found to be statistically significant (p< .001).

3. B. 2. Ho: There will be no statistically significant difference in the frequency of

new nurse graduates identifying external behaviors that affect them as a

result of workplace bullying.

External behaviors were analyzed using Chi-square for the new nurse graduates feelings of being irritated with others, expressing a short temper, having decreased patience, a feeling of decreased job production, having gained weight, having lost weight, having sleeplessness, and having an increase of sick days when being bullied in the workplace. Fishers Exact test (2-sided is used to calculate the statistical significance of the relationships.

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External Behaviors: Irritated with others * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: No Count 95 10 105 Irritated with others Expected Count 83.5 21.5 105.0 Yes Count 10 17 27 Expected Count 21.5 5.5 27.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 37.696, df = 1, p< .001

The external behavior of being irritated with others when bullied in the workplace was an observed frequency (17) and the expected frequency (5.5) of the total (27). The nurses that reported no bullying in the workplace had the observed frequency (95) and the expected frequency (83.5) of the total (105). The Fishers Exact Test (2-sided) was statistically significant (p < .001).

External Behaviors: Short temper * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: No Count 102 18 120 Short temper Expected Count 95.5 24.5 120.0 Yes Count 3 9 12 Expected Count 9.5 2.5 12.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 24.137, df = 1, p < .001

The external behavior of expressing a short temper with others when bullied in the workplace was an observed frequency (9) and the expected frequency (2.5) of the total

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(27). The nurses that reported no bullying in the workplace had an observed frequency

(102), and an expected frequency (95.5) of the total (105). The Fishers Exact Test (2 sided) was statistically significant (p < .001).

External Behaviors: Decreased patience * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: No Count 99 7 106 Decreased patience Expected Count 84.3 21.7 106.0 Yes Count 6 20 26 Expected Count 20.7 5.3 26.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 63.453, df = 1, p < .001

The external behavior of decreased patience with others when bullied in the workplace was an observed frequency (20) , well over the expected frequency (5.3) of the total (27). The nurses that reported no bullying in the workplace had an observed frequency (99), and the expected frequency (84.3) of the total (105). The Fishers Exact

Test (2 sided) was statistically significant (p < .001).

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External Behaviors: Decreased job production * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: No Count 104 19 123 Decreased job production Expected Count 97.8 25.2 123.0 Yes Count 1 8 9 Expected Count 7.2 1.8 9.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 27.801, df = 1, p < .001

The external behavior of decreased job production when bullied in the workplace was an observed frequency (8) , well over the expected frequency (1.8) of the total (27). The nurses that reported no bullying in the workplace had an observed frequency (104), and the expected frequency (97.8) of the total (105). The Fishers Exact

Test (2 sided) was statistically significant (p < .001).

External Behaviors: Gained weight * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: No Count 99 20 119 Gained weight Expected Count 94.7 24.3 119.0 Yes Count 6 7 13 Expected Count 10.3 2.7 13.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 9.882, df = 1, p < .001

The external behavior of gained weight of new nurse graduates when bullied in the workplace was an observed frequency (7) , over the expected frequency (2.7) of the

118 total (27). The nurses that reported no bullying in the workplace had an observed frequency (99), and the expected frequency (94.7) of the total (105). The Fishers Exact

Test (2 sided) was statistically significant (p = .005).

External Behaviors: Lost weight * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: Lost No Count 104 25 129 weight Expected Count 102.6 26.4 129.0 Yes Count 1 2 3 Expected Count 2.4 .6 3.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 4.029, df = 1, p = .106

The external behavior of lost weight of new nurse graduates when bullied in the workplace was a low observed frequency (2) , over the expected frequency (.6) of the total (27). The nurses that reported no bullying in the workplace had an observed frequency (104), and the expected frequency (102.6) of the total (105). The Fishers Exact

Test (2 sided) was not statistically significant (p =.106).

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External Behaviors: Sleeplessness * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: No Count 99 17 116 Sleeplessness Expected Count 92.3 23.7 116.0 Yes Count 6 10 16 Expected Count 12.7 3.3 16.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 19.782, df = 1, p < .001

The external behavior of sleeplessness of new nurse graduates when bullied in the workplace was an observed frequency (10), of the expected frequency (3.3) of the total (27). The nurses that reported no bullying in the workplace had an observed frequency (99), and the expected frequency (92.3) of the total (105). The Fishers Exact

Test (2 sided) was statistically significant (p < .001).

External Behaviors: Increased sick days * Bullied at work Crosstab Bullied at work

No Yes Total External Behaviors: No Count 104 23 127 Increased sick days Expected Count 101.0 26.0 127.0 Yes Count 1 4 5 Expected Count 4.0 1.0 5.0 Total Count 105 27 132 Expected Count 105.0 27.0 132.0 Note: x2 = 11.325, df = 1, p =.006

The external behavior of having increased sick days of new nurse graduates when bullied in the workplace was an observed frequency (4), of the expected frequency (1.0)

120 of the total (27). The nurses that reported no bullying in the workplace had an observed frequency (104), and the expected frequency (101) of the total (105). The Fishers Exact

Test (2 sided) was statistically significant (p < .006).

Research Question Three

Do new nurse graduates believe that experiences of workplace bullying has an impact on their present job performance?

3. A. 1. Ho: There is no statistically significant difference in the frequency of

new nurse graduates identifying that workplace bullying has an impact on

their present job performance.

If you have experienced bullying, do you think it has affected your job performance? * Bullied at work Crosstab Bullied at work

No Yes Total If you have experienced Yes Count 10 19 29 bullying, do you think it Expected Count 20.5 8.5 29.0 has affected your job performance? No Count 55 8 63 Expected Count 44.5 18.5 63.0 Total Count 65 27 92 Expected Count 65.0 27.0 92.0 Note: x2 = 26.719, df = 1, p < .001

The new graduate nurses that experienced bullying in the workplace and their thoughts of bullying affecting their job performance were analyzed using Chi-square. The observed frequency (19) was more than the expected frequency (8.5) of the total (27).

Those nurses that had not experienced bullying were the observed frequency (55) of the expected frequency (44.5) of the total (65). Fishers Exact Test (2-sided) was statistically significant (p>.001).

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3. A. 2. Ho: There is no statistically significant difference in the frequency of

new nurse graduates reporting that workplace bullying has an impact on

their changing jobs within the past two year.

Have you changed jobs in the past two years? * Bullied at work Crosstab Bullied at work

No Yes Total Have you changed jobs Yes Count 32 12 44 in the past two years? Expected Count 34.4 9.6 44.0 No Count 65 15 80 Expected Count 62.6 17.4 80.0 Total Count 97 27 124 Expected Count 97.0 27.0 124.0 Note: x2 = 1.211, df = 1, p = .363

The new graduate nurses that were bullied in the workplace was analyzed as to whether they had changed jobs in the last two years analyzed using Chi-square. The observed frequency (12) was nearly as the expected frequency (9.6) of the total (27). Of those not having the bullied experience in the workplace the observed frequency (65) as close to the expected frequency (62.6). The Fisher Exact Test (2-sided) was not statistically significant p = .363).

3. A. 3. Ho: There is no statistically significant difference in the frequency of

new nurse graduates reporting that workplace bullying has an impact on

their decision to change jobs.

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Did workplace bullying play a role in your decision to change jobs? * Bullied at work Crosstab Bullied at work

No Yes Total Did workplace bullying Yes Count 3 11 14 play a role in your Expected Count 10.3 3.7 14.0 decision to change jobs? No Count 73 16 89 Expected Count 65.7 23.3 89.0 Total Count 76 27 103 Expected Count 76.0 27.0 103.0 Note: x2 = 22.963, df = 1, p < .001

The new nurse graduates that were bullied in the workplace and reported that bullying played a role in their decision to change jobs was analyzed using Chi-square. The observed frequency (11) was over the expected frequency (3.7) of the total (27). Of those nurses that did not experience bullying in the workplace the observed frequency was (73) of the expected frequency (65.7) of the total (76) respondents. The Fisher’s Exact Test was used to analyze the relationship and it was statistically significant (p < .001).

3. A. 4. Ho: There is no statistically significant difference in the frequency of new

nurse graduates reporting that workplace bullying has an impact on their

decision to leave the nursing profession.

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Have negative workplace behaviors made you consider leaving the nursing profession? Bullied at work Crosstab Bullied at work

No Yes Total Have negative workplace Yes Count 25 11 36 behaviors made you Expected Count 27.8 8.2 36.0 consider leaving the nursing profession? No Count 67 16 83 Expected Count 64.2 18.8 83.0 Total Count 92 27 119 Expected Count 92.0 27.0 119.0 Note: x2 = 1.821, df = 1, p = .233

Of those new nurse graduates that had endured negative behaviors in the workplace, and considered leaving the nursing profession, chi-square was used to analyze the relationship. The observed frequency (11) was close to the expected frequency (8.2) of the total (27). For the nurses that did not report being bullied in the workplace, the observed frequency (67) of the expected frequency (64.2) of the total (92). The Fisher’s

Exact Test (2-sided) analyzed the relationship and it was not statistically significant (p =

.233).

In summary, the null hypothesis was not statistically significant for the new graduate nurses report of being bullied in the workplace for 3.A. 2. Ho: changing jobs in the past two years and 3. A. 4. Ho: considering leaving the nursing profession as a result of negative workplace behaviors. The null hypothesis was statistically significant for 3. A.1. bullying has affected their job performance, and 3. A. 3. bullying did play a role in their decision to change jobs.

Education and training efforts also have an effect on the new nurse graduates perception of bullying in the workplace. Do new graduate nurses feel they have the

124 training in their nursing education to deal with bullying the workplace? Does the workplace treat bullying as a serious topic of staff education, and hold bullies responsible and support the victims? Hypothesis 4 provides some insight to these questions.

Research Question Four

4. A. Do new nurse graduates identify formal nursing education as providing

knowledge about bullying?

Frequencies reported. Questions 31, 32, 33, 34, 35, 37, and 36 were answered by RN respondents by answering yes or no as to whether they had bullying included in their nursing curriculum, and the importance of covering bullying in the nursing curriculum.

Also RN respondents reported as to whether there are policies on bullying, mentors for them to discuss work issues, and if they felt confident to handle a bully in the workplace.

Question 31.

31. Was workplace bullying included in any courses in your formal nursing education? Frequency Valid Percent Valid Yes 30 22.4 No 104 77.6 Total 134 100.0 Missing System 1 Total 135

Question 31. Thirty (22.4%) of nurse respondents reported that workplace bullying was included in courses in their formal nursing education. The overwhelming majority 104

(77.6%) of the nurse respondents reported this to not be included in their formal nursing education.

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Question 32

32. Do you think information on workplace bullying should be included in a nursing curriculum? Observed N Yes 111 No 23 Total 134

Question 32. Most of the new nurse graduates think information on workplace bullying should be included in the curriculum. Of the 134 new nurse graduates who reported on this question, 111 (82%) agreed it should be included. Twenty-three (18%) did not feel that it was important to include workplace bullying in their nursing education.

4. B. Do new nurse graduates identify informal workplace efforts to deal with

bullying in the workplace?

Question 33.

33. Is bullying addressed in staff education? Observed N Yes 49 No 86 Total 135

Question 33. All 135 new graduate nurses reported about staff education. Forty-nine

(36.5%) of the new graduate nurses reported that bullying was addressed in staff education and (63.5%) reported bullying was not addressed in staff education.

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Question 34. 34. Do you think your workplace should have a policy in place to deal with bullying? Observed

N Yes 128 No 6 Total 134

Question 34. One hundred twenty-eight (95.5%) of the one hundred thirty-four new nurse graduates reported that the workplace should have a policy in place to deal with workplace bullying.

Question 35.

35. Do you have a person assigned to you that you can discuss workplace issues with? Observed N Yes 80 No 54 Total 134

Question 35. Eighty (52.2%) of the one-hundred thirty-four new nurse graduates reported they did have a person in the workplace they could discuss workplace issues with. This is just over half of the respondents.

37. Is the management at your workplace supportive for those who are victims of bullying? Observed N Yes 87 No 47 Total 134

Question 37. Of the one hundred thirty-four new nurse graduates, eighty-seven (64.9%)

127 reported that the management of their workplace was supportive to victims of bullying in the workplace. This was almost two-thirds of the new nurse respondents.

Question 36.

36. Do you feel confident and prepared to handle a bully in your workplace?

Observed N Yes 84 No 50 Total 134

Question 36. Of the one hundred thirty four new graduate nurses, eighty-four (62%) reported that they felt confident to handle a bully in the workplace.

Statistical Analysis Using Chi Square

Using Chi square the following relationships were analyzed: New nurse graduates reported on whether they felt confident to handle a bully in the work place if they had the topic workplace bullying in their nursing courses; new nurse graduates reported on whether they felt confident to handle a bully in the workplace if management was supportive; and new nurse graduates reported on feeling confident in the workplace if they had a person assigned to them that they could discuss workplace issues.

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Was workplace bullying included in any courses in your formal nursing education? * Do you feel confident and prepared to handle a bully in your workplace?

Do you feel confident and prepared to handle a bully in your workplace? Yes No Total Was workplace bullying Yes Count 18 11 29 included in any courses Expected 18.3 10.7 29.0 in your formal nursing Count education? No Count 66 38 104 Expected 65.7 38.3 104.0 Count Total Count 84 49 133 Expected 84.0 49.0 133.0 Count Note: x2 = .019, df = 1, p = 1.000

When new nurse graduates were asked if workplace bullying was included in any of their formal nursing education and if they felt confident and prepared to handle a bully in the workplace, the observed frequency (18) was at the expected frequency (18.3) of the total (84) analyzed using Chi-square. Those nurses that stated that workplace bullying was not included in their nursing curriculum had the observed frequency (38), that is the same as the expected frequency (38.3) of the total (49). The Fisher’s Exact Test (2-sided) was used to analyze the relationship and it was not significantly significant (p=1.000) for those who feel confident and those that had formal nursing education courses. Having workplace bullying included in their coursework did not help the new nurse graduate feel confident to handle a bully in the workplace. 129

Is the management at your workplace supportive for those who are victims of bullying? * Do you feel confident and prepared to handle a bully in your workplace? Do you feel confident and prepared to handle a bully in

your workplace? Yes No Total Is the management at Yes Count 56 24 80 your workplace Expected Count 50.2 29.8 80.0 supportive for those who are victims of No Count 20 21 41 bullying? Expected Count 25.8 15.2 41.0 Total Count 76 45 121 Expected Count 76.0 45.0 121.0 Note: x2 = 5.225, df =1, p = .029

Using chi-square to analyze when new nurse graduates were asked if the management was supportive of victims of bullying and if they felt confident to handle a bully in the workplace, the observed frequency (56), was higher than the expected frequency (50.2).

The new graduates who do feel that management is supportive of victims are more confident in handling a bully in the workplace. The new nurse graduates that did not feel management was supportive to victims of bullying and determined they did not feel confident to handle a bully in the workplace, the observed frequency (21), was higher than the expected frequency (15.2) of the (121) that reported on this relationship. The

Fisher’s Exact Test (2-sided) was (.029) and was statistically significant. The new graduate nurses expressed they felt confidence in dealing with the bully if the workplace or the management was supportive of victims of bullying.

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Do you have a person assigned to you that you can discuss workplace issues with? * Do you feel confident and prepared to handle a bully in your workplace? Do you feel confident and prepared to handle a bully in

your workplace? Yes No Total Do you have a person Yes Count 46 24 70 assigned to you that you Expected Count 44.3 25.7 70.0 can discuss workplace issues with? No Count 30 20 50 Expected Count 31.7 18.3 50.0 Total Count 76 44 120 Expected Count 76.0 44.0 120.0 Note: x2 = .410, df = 1, p = .522

Using chi-square the new nurse graduate relationship was analyzed for having a person assigned in the workplace to discuss workplace issues, and their confidence to handle a bully in the workplace. The observed frequency (46) was similar to the expected frequency (44.3) for those new graduates that reported that they did have a person assigned to help them and they felt confident to handle a bully in the workplace. Those nurses that did not have a person assigned to them and did not feel confident were slightly greater for observed (20),than the expected (18.3) of the (120) new graduates that reported on this relationship. Pearson’s chi-square (2-sided) was (.410), and was not statistically significant (p = .522). Having a support person does not affect confidence in handling a bully.

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Question 38.

38. The Joint commission on Accreditation of Healthcare Organizations (JCAHO) has called for healthcare workplaces to launch an organizational approach to inform employees of bullying and disruptive behaviors in the workplace. Do you feel this is important? Observed N Yes 131 No 2 Total 133

Question 38. Of the 133 new nurse respondents that reported, one hundred and thirty-one

(97.7%) reported that they felt it was important for the workplace to launch an organizational approach to inform employees of bullying and disruptive behaviors that occur in the workplace.

Summary of Data Analysis Findings

The new graduate nurse respondents were overwhelmingly White, non-Hispanic

(92.6%), worked in the hospital setting (83%), were mostly staff nurses (80.3%), and the majority had the educational degree, Bachelor of Science in Nursing (60.7%), followed by the Associate degree (20%), and MSN (8.9%).

The 22 questions on the NAQ-R bullying survey were first analyzed for the frequency of new graduates that responded to the five categories “never,” “now and then,”

“monthly,” “weekly,” and “daily.” The percentages for each question were observed for

“weekly” and “daily” occurrences that indicated serious bullying was occurring for the new graduate nurse in the workplace. Any frequency of percentages at or over ten percent of the 135 new nurse respondents is considered to be serious and define the bullying experience in the workplace.

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“Work-related bullying” included questions 1,3,14,16,18,19, and 21. New graduate nurse respondents reported on “weekly” and “daily” events where they were ordered to work below their competence (10.5%). Also being exposed to an unmanageable workload (17.1%) was reported. Having an unmanageable workload was the highest negative behavior reported of the 22 question NAQ-R survey. There was no significant difference in the frequency of the new nurse graduate responses for the work related bullying questions compared to Einarsen’s et al., 2009 study used as the population norm.

“Person-related bullying“ included the NAQ-R questions 2,4,5,6,7,10,11,12,13,15,17, and 20. Some are statistically different than Einarsen’s population norms but the difference is that the new nurse grad reported less “person related bullying”. This might be related to the overwhelming percentage of women in nursing. When analyzing person related bullying using Chi-square there was a significant difference for questions 2, 10,

11, 13, 15, 17, and 20. These questions relate to the new graduate nurse being humiliated, ridiculed, hints at quitting their job, being reminded of mistakes, being persistently criticized, being the brunt of practical jokes by adversaries, having allegations made against them, and being excessively teased or receiving sarcasm. These specific questions were not identified by the new nurse graduates as they were in Einarsen’s et al., 2009 study. The other questions that are “person related bullying” were significant using Chi- square. New graduate nurses were much like the population norm for the following questions 4, 5, 6, 7, and 12. The new graduate nurses related they had responsibilities removed and were given trivial tasks, gossip was spread about them, they were ignored or secluded, insulting remarks were made about them, and they were ignored or there was hostility if they approached others in the workplace. Farrell (2005) identifies that nursing

133 behaviors are overt or covert. The behaviors the new graduates reported as being the same as the population norm were mostly the covert behaviors such as being given trivial tasks or being ignored.

The new graduates referenced that some bullying behaviors were more increased on a monthly basis and often occurring two to three times as often than on a weekly or daily basis. The monthly meetings.may be a situation where bullying is occurring, as

21.1% of new graduates reported they were ignored and secluded, 15.5% reported there was gossip spread about them, 14% reported insulting remarks were made about them, and 12.6% reported their responsibility was removed and they were given trivial tasks percentages. This report may be a hint for those in management or staff development.

Meetings should have a positive and open environment, and not the place for disciplining staff in front of others. Managers should handle negative job issues in a different forum and individually. But, by and large there seems to be somewhat less person related bullying for nurses, than in Einarsen’s landmark study, but this is a “caring and helping profession”.

“Physically intimidating bullying,” a very serious form of bullying, was reported on a

“weekly” or “daily” basis by 5.9% of new nurse respondents as being shouted at, or being the target of someone’s spontaneous anger (or rage). Another 3.7% of the respondents reported intimidating behavior such as finger pointing, invasion of their personal space, shoving, and blocking/barring the way. A threat of violence or physical abuse or actual abuse was reported by 1.4% of the new nurse graduates. It is interesting that on a

“monthly” basis, the intimidating behavior was reported by 10.4%. Any physical threats of violence should be taken very seriously by healthcare organizations and employees.

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The questions 8, 9, and 22 were all not statistically significant using Chi-square. The new graduate nurses experience in the workplace for being shouted at, intimidated, or being threatened with violence was similar to Einarsen’s et al., (2009) population norm.

After the new nurse graduate completed the NAQ-R 22 question survey, the definition of workplace bullying was given in question 23. A total of 20.5% of the nurse respondents reported they had been bullied in the workplace. This is a much greater percentage than Einarsen et al., 2009 British study on 5,288 employees where it was reported there were 10.6% of the employees that reported being bullied in the workplace.

This is disturbing as it is about twice the percentage of the population norm of the landmark study. Why is the overall bullying higher when the individual behaviors are lower? Focus groups with nurses in the health care organization may help uncover that something else is going on here that needs further exploration.

Other studies report victimization as even being greater than what was found in this research study. JCAHO, (2008), reported that 50% of the nurses in that study had been a victim of bullying. Quine, (2001) reported that 44% of the nurses in her survey had reported being bullied within the past 12 months.

The person most likely or likely to cause the bullying problem in the workplace was

1. The nursing peer or fellow nurse, 2. The physician, or 3. The patient’s family. The patient, nurse supervisor, and manager administrator were also rated moderately as the likely bully. Namie (2000) reported that 80% of the bullying in the workplace was attributed to the manager, which was not the case in this research study. Respect and civility, assertiveness and conflict management need to be professional topics introduced

135 to nursing students through their curriculum. Physicians would also benefit from attaining this educational information on bullying in their undergraduate education.

Also, a high percentage of graduate nurses reported the patient’s family as being the bully. This is a topic that nursing education should really stress and help prepare their nursing students for negative patient family interactions. Families are much stressed and probably take out their anxieties on the nurses. This is an important issue as families rely most on nurses for information and communication and nurses should be able to try and deflect some of this in order to maintain open lines of communication for the patient.

Using chi-square to analyze the relationships of the internal and external behaviors in those who had experienced bullying, all the behaviors were statistically significant, except for the one external behavior losing weight. This indicates that when the new graduate nurse was bullied, almost all the internal and external behaviors were present, except for losing weight. It is alarming that sleeplessness is also a problem for new graduate nurses. Being irritated, stressed, anxious, fatigued and having decreased patience are expected.

Longo and Sherman (2007) found that horizontal violence causes oppression that develops into powerlessness, a decreased self esteem, and sleep problem for the victims of bullying. Adams (1997) found that bullying undermines another’s self confidence and self esteem. DeMarco and Roberts (2003) also reported that oppression leads to the lack of autonomy, a decreased self esteem, and powerlessness. This research study supports their findings regarding internal and external behaviors that affect nurses that endure the bullying experience.

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New graduate nurses (46.7%) reported that they had seen others the subject of bullying during the last six months. This situation was reported by JCAHO, 2008, as 90% of nurses in their study having witnessed others being the brunt of abuse in their health care organization. Quine (2001) reported that 50% of the nurses in her study had seen others bullied in the workplace.

New graduate nurses were asked if bullying had affected their job performance. About one-third reported that bullying has affected their job performance. Using Chi-square the relationship of those who had experienced bullying and had their present job performance affected was found to be a statistically significant relationship. New graduate nurses did report that bullying did have an impact on their present job performance. This is a serious issue as patient care could be affected. Nurses deal with many critical life and death issues and cannot be distracted from doing their work by being bullied.

Using chi-square to analyze, the relationship of those bullied at work and whether workplace bullying played in their decision to change jobs was statistically significant.

Workplace bullying did play a role in the new nurse graduates decision to change jobs as there were three times more of the graduate nurses that confirmed this than were expected.

The new graduate nurses were asked if they had considered leaving nursing and

29.5% reported they had considered leaving nursing due to negative behaviors in the workplace. Over one-third of the new graduate nurses that had been bullied had changed jobs within the past two years. Using chi-square to analyze the relationship of negative workplace behaviors making the new graduate consider leaving the nursing profession

137 was not statistically significant. If the nurse was bullied at work, negative behaviors did make a difference and affected their decision to change jobs.

Nurses are changing jobs if they have been bullied. This is comparable to Simons

(2008) study on newly licensed nurses in Massachusetts where 31% of the respondents in the survey were leaving the health organization due to bullying. McKenna et al., (2003) reported that 58% of the 551 new baccalaureate nurses in their study had considered leaving nursing after being bullied. Bartholowmew (2006) reported that in her research

60% of nurses were leaving their position within six months. In the National Sample

Survey of Registered Nurses, (2008), it was reported that 29.8% of nurses reported they recently left a nursing position or planned to leave in the next three years.

New graduate nurses leaving their job as a result of being bullied in the workplace is an unneeded expense to the health care system and to the new graduate that has spent much time and money to pursue a career in nursing. Bullying is preventable.

In this research study 82.8% of new graduate nurses reported that workplace bullying should be included in the nursing curricula. But, only 22.4% of the nurse respondents reported the topic of bullying was covered in nursing coursework. McKenna et al., (2003) study of RNs after their first year of practice recommended that nursing education should include conflict management and students need to be prepared to handle bullying. Kelly

& Ahern (2008) relate that oppression is the reason nurses are not much different than in the 19th century even though the modern nursing curriculum stresses critical thinking and autonomy. Kelly and Ahern recommend that nurses should be prepared for stressors and oppressive environments in their nursing curriculum. This research supports the findings

138 in these previous research studies. Through education, conflicts can be managed effectively.

This study also looked at the workplace environment and asked if having a management supportive of victims, and having a person to talk to were common practices. It is important that one-third of the group did not report that management was supportive of bullying victims. The nursing profession, which is promoting zero tolerance for bullying, has much work to do to help employees related to reporting and managing bullying in the workplace. Having one-third of the new graduate nurses feel that management would not support them if there was a bullying problem is a big problem.

New nurse graduates (98.5%) in this research study did report overwhelmingly that healthcare organizations should launch an organizational approach to provide information to employees about bullying and disruptive behaviors as recommended by JCAHO. As bullying is a new form of harassment being identified in the workplace, employees often do not recognize the patterns of behavior that constitute bullying. Education during orientation and through staff development in services within the health care organization to all employees is crucial.

In summary, bullying is a problem for new graduate nurses. Through education, the bullying experience for many can be prevented. Health care management also has a responsibility to support those who are victims of bullies and provide bullies the education and necessary referrals that may be needed. Bullying is preventable!

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Chapter Five

Summary, Conclusion, and Recommendations

This chapter contains the following sections: Summary and Conclusions, Accepted

Hypothesis and Rejected Hypothesis, Discussion, Implications, and Recommendations for future studies.

Summary and Conclusions

New graduate nurses did report being bullied in the workplace (20.5%) or observed others in the workplace being bullied (46.7%). Nursing peers or fellow nurses, physicians, and the patient’s families were the main sources of bullying. New graduate nurses do have many internal and external behaviors that affect them as the result of bullying. New graduate nurses (31.6%) did report that bullying affected their job performance, and (29.5%) had considered leaving the profession of nursing. Asked if bullying was covered in nursing curriculum, less than one-fourth of the respondents reported that it was a covered topic. About 83% thought that bullying should be covered in their nursing education. Policies to deal with bullying were supported by 96% of the participants. Workplaces providing information to employees on bullying through staff education was reported by slightly over one-third of the participants. New graduate nurses reported that feelings of confidence to handle a bully in the workplace could be increased by a more supportive workplace management for providing support to the victims. A person assigned to mentor that the new nurse graduate can talk about workplace issues is important, and helped build the confidence of the nurse to handle a bully in the workplace. Confidence of the nurse to handle a bully in the workplace could be increased by education on bullying added to the nursing curriculum. So, what can be

140 done? Information on bullying and conflict management to handle those who bully is the best form of prevention and treatment for new graduate nurses. Conflict management and assertiveness should be incorporated into nursing school curricula. What does conflict management involve? Some information on conflict management helps nursing education and leadership make decisions about directions for the future.

Conflict Management Theory

Conflict is defined (Thomas, 1976) as a process that includes two different parties and one party is frustrated with the goals and behaviors of the other party, and perceives them as a threat. Thomas describes five different conflict managing styles: Accommodation, avoidance, collaboration, and compromising. First, accommodation is when an individual gives up his own needs for another, due to the of having a harmonious relationship, and their need of acceptance and approval of others. Second, avoidance nullifies the issue of the conflict as hopeless and futile, as the person has little concern for their own needs. The person does not take a strong stand on the issue and may not communicate or deny knowing about the issue. The third, collaboration, is when a person seeks effective problem-solving of all parties involved regarding the issue.

There is a concern for the needs of both parties and issues are encouraged to be openly discussed. The fourth, competition, occurs when a person pursues their own goals, and excludes the needs of others. There is open confrontation to gain power and influence in the relationship, and there is much frustration, anger, and arguments that occur as the conflict may diminish. And finally, compromising is the give and take behavior where a middle ground is found to solve the conflict.

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A few nursing studies on conflict management help us understand what has been effective in the environment of the health care organization. One study ( Marriner,1982) on 128 nurses found that nurses used collaboration and compromising as their most successful method of resolving conflicts, and that avoiding and competing were the most unsuccessful methods of resolving conflicts. Another early study, Woodti (1987) surveyed deans of colleges handling conflicts with faculty and found the most deans used conflict resolution in the following sequence: Compromising, collaborating, avoiding, accommodating, and competing. Cavanaugh’s (1991) study of staff nurses and managers found they both used avoidance most often, but nurse managers did use compromise sometimes. A later study, Marriner-Tomey and Poletti (1991) on 55 Italian nurses and how they managed conflict found they used collaboration and compromising more frequently in successful conflict management, and competing and avoidance in unsuccessful conflict resolutions.

Some strategies are recommended (Bartholowmew, 2006) that improves relationships and retention of new nurse graduates: Having the new nurse graduate fill out a feedback questionnaire on their preceptor after their orientation period may alert the nurse administrators to problems encountered. Making time for bonding of the new graduate nurse with the preceptor during their first two months is important. which is clinically supervised is also valuable to a new nurse graduate as it allows them to express their feelings and prevents anger. Educating the new graduate nurse about horizontal violence and how to stop it is valuable as it allows a cognitive rehearsal which empowers the new nurse graduate into handling conflict. Lastly it is recommended that specifically a new nurse graduate advancement program is implemented, besides the

142 orientation, which provides the new nurse graduate with a year-long mentor and special meetings that are arranged to discuss workplace issues.

One health care organization made changes to help transition the new graduate nurses into the organization. Bartholowmew (2006) states that Moses Cone Hospital in

Greensboro, NC developed a Graduate Advancement Program and raised the retention of new graduates from 69% to 97%. Through meaningful relationships with other nurses and administrators in the workplace, the administrators recognized and met the needs of the new nurse graduate and provided the support they needed.

Accepted Hypothesis and Rejected Hypothesis

Research question 1. Do a significant number of new nurse graduates report negative behaviors and different types of bullying in the workplace (work-related bullying, person-related bullying or physically intimidating behavior)?

New nurse graduates (20.5%) reported they had been bullied in the workplace. Also,

46.7% reported they had seen others as the subject of bullying in the workplace. The null hypothesis 1.1, (work-related bullying) 1.2 (person-related bullying) and 1.3 (physically intimidating bullying) explain using chi-square the reported bullying experiences of the new nurse graduates.

Hypothesis 1. 1. Ho: There will be no significant difference between the

frequency of new nurse graduates who report work-related bullying in the

workplace and the population norm.

The NAQ-R seven questions, 1,3,14,16,18,19, and 21 on “work-related bullying” were analyzed for relationship using Chi-square. These results are not significantly different from what Einarsen, et al., 2009 found. The new nurse graduates matched the population

143 norm in the Einarsen original study. The 1.1 null hypotheses was accepted. It is likely the probability of these results deviating from the null hypothesis only occurred by chance.

Hypothesis 1. 2. Ho: There will be no significant difference between the frequency

of new nurse graduates who report person-related bullying in the workplace and

the population norm.

The NAQ-R twelve questions 2,4,5,6,7,10,11,12,13,15,17, and 20 on “person-related bullying” were analyzed using Chi-square to analyze the relationship and the following were statistically significant: 2. Being humiliated and ridiculed, 10. Hints at quitting your job, 11.Being reminded of mistakes, 13.Persistent criticism, 15, Practical jokes,

17.Allegations against you, and 20.Being the subject of excessive teasing and sarcasm.

These results were statistically significant, and were very different as new nurse graduates reported these negative acts less than the comparison population mean,

Einarsen’s et al. 2009 study in Great Britain on 5,288 employees. The null hypothesis was rejected, and the probability was not likely to be the result of chance factors.

Statistically non significant results for some of the questions relating to person related bullying included: 4. Having key areas of responsibility removed or replaced with more trivial tasks or unpleasant tasks, 5.Spreading gossip and rumors about you, 6.

Being ignored, excluded, or being isolated from others, 7.Having insulting or offensive remarks made about your person (e.g., habits and background), your attitudes and your private life, and 12. Being ignored or facing a hostile reaction when you approach. These questions were not different from Einarsen’s et al. (2009) population norm, and the null hypothesis was accepted.

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Hypothesis 1. 3. Ho: There will be no significant difference between the

frequency of the new nurse graduates who report physically intimidating bullying

in the workplace and the population norm.

All three questions on physically intimidating bullying did not show statistically significant differences from what Einarsen et al., (2009) found in the British study on

5,288 employees. The null hypothesis was accepted.

Research question 2. A. 1. The new nurse graduates identify who is causing the problem in the workplace.

When combining the most likely and likely person category to be the bully in the workplace the following was reported by new nurse graduates; 1.The nursing peer or fellow nurse had the highest percent for bullying (63.9%). 2. The physician was reported

(59.8%). 3. The patient’s family was reported (59.2%). These relationships were who over half of the new graduate nurses identified as the most likely or likely bully in the workplace.

Nursing has much work to do in establishing zero bullying policies, and not allowing other nurses in the workplace to “eat their young.” Codes of civil behavior and respect should be established within the nursing profession that does not tolerate any bullying behaviors from nurses, physicians, patient’s families, or patients. It is surprising that the

Administrator/manager and nurse supervisor were lower than in some other reported studies. Johnson & Rea (2009) reported that 27.3% of nurses bullied in Washington State cited the nurse manager or charge nurse were the most identified bully in the workplace.

Research question 2. B. Do new nurse graduates identify that workplace bullying has affects on them personally (internal/external behaviors)?

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Hypothesis 2. B.1. Ho: There will be no statistically significant difference in the

frequency of new nurse graduates identifying internal behaviors that affect them

as a result of workplace bullying.

Internal behaviors that occurred for the new graduate nurse that were extremely high and they occurred for more than 20% of the graduates were increased stress (21.5%), decreased job satisfaction (20.7%), and having anxiousness (19.3%). Powerlessness, increased stress, being disconnected, having a low self esteem, decreased job satisfaction, feel sad, feel anxious, and increased fatigue were all much higher than expected by chance as they were found to be statistically significant. The results found these behaviors were much higher in those who reported being bullied than those who were not bullied.

Hypothesis 2 .B. 2. Ho: There will be no statistically significant difference in the

frequency of new nurse graduates identifying external behaviors that affect them

as a result of workplace bullying.

The external behaviors identified by the new nurse graduates using Chi-square to analyze the relationships included being irritated with others, expressing a short temper, having decreased patience, a feeling of decreased job production, having gained weight, having lost weight, having sleeplessness, and having an increased number of sick days.

The external behaviors were statistically significant, except for losing weight which was not statistically significant. The null hypothesis was rejected for losing weight as there was a significant difference, but the null hypothesis was accepted for the other seven external behaviors experienced by the new graduate nurse as a result of being bullied as there was no statistical difference. In summary, the nurses that experienced external

146 behaviors of bullying was observed much more than expected, except for losing weight.

As losing weight was not significant, the deviation from the null hypothesis was likely to have occurred by chance.

Research question 3. A. Do new nurse graduates believe that experiences of bullying have an impact on their job performance?

The new nurse graduates (31.6%) reported that if they were bullied their job performance had been effected. This was almost one-third of the respondents. The graduates also reported an alarming 35.4% had changed jobs in the past two years, well over one third of the new graduates. Only 13.2% reported that bullying was the reason they changed jobs, but negative behaviors in the workplace caused 29.5% of the nurse respondents to consider leaving the nursing profession. Some statistical analysis using chi-square of the following null hypothesis helps us understand these results.

Hypothesis 3. A. 1. Ho: There is no statistically significant difference in the

frequency of new nurse graduates identifying that workplace bullying has an

impact on their present job performance.

The relationship was found to be statistically significant, and the null hypothesis was rejected. The probability of new graduates identifying that workplace bullying has an impact on their present job performance was not likely to be the result of chance factors.

Hypothesis 3. A. 2. Ho: There is no statistically significant difference in the

frequency of new nurse graduates reporting that they have changed jobs in the

past two years when comparing those who report experiencing bullying and those

who have not reported being bullied.

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These new nurse graduates changed jobs often, and the median time in the present position was two months for respondents. About a third of all new nurse graduates had changed jobs in the past two years and there was no difference in changing jobs between the group that reported bullying and the group that did not. The null hypothesis was accepted.

Hypothesis 3. A. 3. Ho: There is no statistically significant difference in the

frequency new nurse graduates reporting that workplace bullying has an impact

on their decision to change jobs.

Using chi-square to analyze the relationship, it was determined that new nurse graduates bullied in the workplace were impacted and reported that workplace bullying was a factor in their decision to change jobs. The null hypothesis was rejected.

Hypothesis 3. A. 4. H o: There is no statistically significant difference in the

frequency of new nurse graduates reporting that workplace bullying has an

impact on their decision to leave the nursing profession.

This hypothesis was accepted. New nurse graduates bullied in the workplace

were not significantly different from those not reporting bullying in agreeing that negative workplace behaviors made them consider leaving the nursing profession. This statistic analyzed by chi-square projects that deviation from the null hypothesis may have occurred by chance. The graduates who were bullied may or may not have considered leaving the nursing profession due to bullying.

Research question 4. A. Do new nurse graduates identify formal nursing education as providing knowledge about bullying?

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Thirty (22.4%) of new graduate nurses reported that workplace bullying was included in their formal nursing education. One hundred-eleven (82.7%) of the new graduate nurses reported that they thought workplace bullying should be included in their formal nursing education.

Research question 4. B. Do new nurse graduates identify informal workplace efforts to deal with bullying in the workplace?

Forty-nine of the new nurse graduates (36.5%) reported that bullying should be included in staff education. One-hundred twenty-eight (95.5%) reported they thought there should be a policy in the workplace to deal with bullying. Eight (52.2%) of the new nurse graduates reported they had a person assigned to them in the workplace to discuss workplace issues with. Eighty-seven (64.9%) reported that the management in their workplace was supportive to victims of bullying. Eighty-four (62%) of new nurse graduates reported they felt confident to handle a bully in the workplace. Using chi- square to analyze if bullying is included in formal nursing education and boosted confidence in handling a bully in the workplace was not statistically significant. This statistical finding could have occurred by chance. Having workplace bullying in nursing coursework did not necessarily help the new graduate feel confident in handling a bully in the workplace.

Discussion

From the results, nurses were significantly more likely to experience being bullied than in Einarsen’s et al., 2009 study. The results of the survey may have been greater for being bullied in the study, because a few respondents chose to not answer some of the questions. Respondents chose to not answer the questions related to whether they

149 experience the internal or external behaviors, naming who the bully was in their workplace, and if bullying affected their job performance. Questions were worded so that some respondents may only have answered the question if they related they had experienced bullying in the workplace. Some chose to skip the question if they had not been bullied.

This instrument, the NAQ-R, (Einarsen et al., 2009) is a very thorough questionnaire that identifies bullying behaviors in the workplace. The NAQ-R primarily has been used in European countries on employees from many different disciplines. It is interesting to use this tool with the nursing profession as it is educational and defines the characteristics of bullying that may be occurring in the workplace.

The NAQ-R (Einarsen et al., 2009) is a good place to start with this population of nurses, who are mostly women. A researcher might want to do some fine tuning, and develop additional questions to determine relationships that exist in the healthcare workplace. One question is intriguing. Why individual types of negative behaviors are lower in this research study on new nurse graduates, but overall reports of bullying are higher than those reported by Einarsen’s et al. (2009) population? Focus groups within the workplace to talk with nurses may uncover why the reports of bullying are high and to see why nurses responded this way. New nurse graduates may suggest other negative behaviors that are in the workplace that were not asked about in this study. It would be interesting to know if there are other types of negative behaviors that are contributing to the new graduate nurse’s perception of being bullied in the workplace.

The NAQ-R (Einarsen et al., 2009) was a good tool to help nurses identify the bullying behaviors they may have experienced in the workplace. It is recommended that

150 many health care organizations should use this questionnaire to determine the level of bullying in their organization and in the process educate employees as to what behaviors constitute bullying. This questionnaire could be a teaching tool for all employees about the different behaviors encountered in the workplace that constitute bullying.

Implications

Nursing schools need to include conflict management, assertiveness, and information on the types and signs of bullying. New graduate nurses are not prepared for the culture shock of the workplace in spite of the multiple hours of coursework that are involved for them to finish their degree in nursing. Employees in the workplace also need information on bullying from employers and need to know steps to take that will eliminate bullying.

Managers and administrators in health care organizations need to take bullying seriously and establish an environment that is supportive to victims and promotes zero tolerance for bullying. Nursing cannot afford to lose our new graduate nurses or any nurse from the profession in these times of a nursing shortage. Educators and nurse managers especially need to take a stand as there is much that needs to be done to inform our nursing students and nurse employees of information about bullies. Nurse employees need to know: Who are the bullies? What do they look like? How do you handle them in the workplace? How can we as employees prevent bullying? Does my workplace support me in efforts to report bullying? The ultimate goal is to eliminate the power of the bully in the workplace, and create a balanced work environment where employees have a harmonious environment. This will prevent new graduate nurses from leaving their career of nursing.

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Limitations

Contacting participants for the survey was difficult, as their alumni email was the method used for the electronic email. Many participants from the five nursing schools,

University of Toledo, Lourdes, Owens, Mercy, and Northwest State did not check their email on a regular basis after leaving nursing school. For this reason it is anticipated that many newly graduated RNs did not receive the survey.

Another difficulty was that the University of Toledo graduates included Bowling

Green State University in their consortium. It was found after collecting data for over a month that one-third of the students that received their nursing education from the

University of Toledo, the Bowling Green State University graduates, were cut off from the UT email the day of their graduation. For this one-third of the UT class, a separate

IRB request was made to the Alumni Association at the Bowling Green State University.

The electronic email survey was then sent to this third of the three classes from 2007-

2010. Knowing that the emails were cut off for students the day of graduation would have saved time in the research process.

Another limitation found when analyzing the data of the new graduate nurses survey was that most studies that used the NAQ reported results using ordinal data. It was difficult using the seven clusters and nominal data that had been set by Einarsen, et al.,

(2009) as the tool validation for measurement. The NAQ-R was changed to a more statistical validation from the operational criteria used in previous years. The statistical latent class - cluster (LCC) (seven clusters related to work-related bullying, person- related bullying, and physically intimidating bullying) were the landmark study parameters that were used as the population norm from the Einarsen et al. study.

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Applying the data found in this research study to the LCC Einarsen et al. data was difficult.

One limitation is that this study had a small sample size. Five nursing schools in

Northwest Ohio in Midwestern United States were sent the electronic survey to complete, and included new nurse graduates from 2007-2010. One hundred thirty-five new nurse graduates responded to the survey of the 2079 that were sent to the five nursing schools in Northwest Ohio. One may not be able to generalize the findings to newly graduated nurses in other parts of the US or internationally.

Recommendations for Future Studies

This research study provides the foundation for the need for nursing educators to provide information on the bullying work environment. Future studies may analyze bullying after new nursing graduates have been provided information about the bullying work environment or as new employees have been given information in staff education and orientation about bullying. Future studies should be done on the seasoned nurse’s perception of bullying in the workplace. Physicians also need this information in their medical training and in staff development sessions within health care organizations, and studies could be done on their perception of bullying in the workplace. Bullying is a serious problem and may have serious consequences for the victim. We must as nurses promote the ANA Code of Ethics where patients as well as staff we are employed with are treated with respect and dignity.

Implications and Limitations

One difficulty when analyzing the data of the new graduate nurse’s survey was that most studies that used the NAQ-R survey reported ordinal data, rather than nominal data.

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This study did validate that bullying is occurring in the workplace for the new graduate nurse, and about 30% have considered leaving the profession. Over one-third attribute job changes are due to bullying in the past two years. Through education at nursing schools, health care organizations, and in general society, there needs to be polices developed for zero tolerance for bullies. If bullies are allowed to be unaccountable for their actions, the victim and society suffers. Much health organization time and money is wasted due to managing bullying situations in the workplace. Time, money, , and creativity of the new nurse graduate are also wasted in dealing with the bully in the workplace. Bullying must stop! Education is the key to making a difference for the new nurse graduate.

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Appendix A NEGATIVE ACTS QUESTIONNAIRE - REVISED

The following behaviours are often seen as examples of negative behaviour in the workplace. Over the last six months, how often have you been subjected to the following negative acts at work?

Please circle the number that best corresponds with your experience over the last six months: 1 2 3 4 5 Never Now and then Monthly Weekly Daily

1) Someone withholding information which affects your 1 2 3 4 5 performance 2) Being humiliated or ridiculed in connection with your work 1 2 3 4 5 3) Being ordered to do work below your level of competence 1 2 3 4 5 4) Having key areas of responsibility removed or replaced with 1 2 3 4 5 more trivial or unpleasant tasks 5) Spreading of gossip and rumors about you 1 2 3 4 5 6) Being ignored, excluded or being isolated from others 1 2 3 4 5 7) Having insulting or offensive remarks made about your 1 2 3 4 5 person (i.e. habits and background), your attitudes or your private life 8) Being shouted at or being the target of spontaneous anger (or 1 2 3 4 5 rage) 9) Intimidating behavior such as finger-pointing, invasion of 1 2 3 4 5 personal space, shoving, blocking/barring the way 10) Hints or signals from others that you should quit your job 1 2 3 4 5 11) Repeated reminders of your errors or mistakes 1 2 3 4 5 12) Being ignored or facing a hostile reaction when you approach 1 2 3 4 5 13) Persistent criticism of your work and effort 1 2 3 4 5 14) Having your opinions and views ignored 1 2 3 4 5 15) Practical jokes carried out by people you don’t get along with 1 2 3 4 5 16) Being given tasks with unreasonable or impossible targets or 1 2 3 4 5 deadlines 17) Having allegations made against you 1 2 3 4 5 18) Excessive monitoring of your work 1 2 3 4 5

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19) Pressure not to claim something which by right you are 1 2 3 4 5 entitled to (e.g. sick leave, holiday entitlement, travel expenses) 20) Being the subject of excessive teasing and sarcasm 1 2 3 4 5 21) Being exposed to an unmanageable workload 1 2 3 4 5 22) Threats of violence or physical abuse or actual abuse 1 2 3 4 5

23. Have you been bullied at work? We define bullying as a situation where one or several individuals persistently over a period of time perceive themselves to be on the receiving end of negative actions from one or several persons, in a situation where the target of bullying has difficulty in defending him or herself against these actions. We will not refer to a one-time incident as bullying.

Using the above definition, please state whether you have been bullied at work over the last six months? No  Yes, but only rarely  Yes, now and then  Yes, several times per week  Yes, almost daily 

NAQ – Negative Acts Questionnaire © Einarsen, Raknes, Matthiesen og Hellesøy, 1994; Hoel, 1999

Please answer the following questions concerning bullying in the nursing profession.

24. Have you seen others being subjected to bullying in your workplace during the last six months? Y N

25. If you have experienced bullying in the workplace, do any of the behaviors listed below apply to you? Check all that apply:

Internal Behaviors External Behaviors

Powerlessness o Irritated with others o Increased Stress o Short temper o Disconnected o Decreased patience o Low self esteem o Decreased job production o Decreased job satisfaction o Gained weight o Feel sad o Lost weight o

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Feel anxious o Sleeplessness o Increased fatigue o Increased sick days o

26. If you have experienced bullying, do you think it has affected your job performance?

Y N

27. Have you changed jobs in the past two years? Y N

28. Did workplace bullying play a role in your decision to change jobs? Y N

29. Have negative workplace behaviors made you consider leaving the nursing profession? Y N

30. If you have experienced workplace bullying or have seen others bullying, who is most likely to “be the bully”?

Most Likely Unlikely Not Applicable

a. Peer or fellow nurse o o o o b. Patient o o o o c. Patient’s family o o o o d. Manager/Administration o o o o e. Nurse Supervisor o o o o f. Physician o o o o g. Other health care worker o o o o h. Others o o o o

31. Was workplace bullying included in any courses in your formal nursing education?

Y N If yes, what courses? ______

32. Do you think information on workplace bullying should be included in nursing curriculum? Y N

33. Is bullying addressed in staff education in your workplace?

Y N

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34. Do you think your workplace should have a policy in place to deal with bullying?

Y N

35. Do you have a person assigned to you that you can discuss workplace issues with?

Y N

36. Do you feel confident and prepared to handle a bully in your workplace?

Y N

37. Is the management at your workplace supportive of those who are victims of bullying? Y N

38. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has called for healthcare workplaces to launch an organizational approach to inform employees of bullying and disruptive behaviors in the workplace. Do you feel this is important?

Y N

39. Your age today ______(years)

40. Gender Female Male

41. Race/ethnic

o White, non-Hispanic o Black or African o American o Hispanic o Native American or Native Alaskan o Asian or Pacific Islander o Other

42. Highest education degree:

o Diploma o Associate Degree o Bachelor’s degree in Nursing o Bachelor’s degree in another area

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o Master’s degree in nursing o Direct-entry Master’s degree in nursing o Master’s degree in another field o Other (please specify) ______

43. Number of months as a registered nurse ______(months)

44. Length of time working in current position ______(months)

45. How long has it been since you were initially licensed to practice as a nurse?

______(months)

46. Current practice setting:

o Ambulatory Care (MD office, clinic, HMO o Community/ Public Health/ Home care o Hospital (specify type of unit) ______o Nursing Home or extended care o Nursing Education o School o I am not currently working as a nurse o Other (please specify)______

47. Which role best describes your daily activities

o Staff nurse o Charge nurse o Nurse Manager o Supervisor o Instructor/faculty o Travel nurse o Clinical Nurse Specialist o Nurse Practitioner o Office Nurse o Other (please specify)______

If desired, please write additional comments on this form.

Thank you for completing this survey.

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