Practice Keywords: Whistleblowing/Behaviour/ Wellbeing Discussion ● This article has been double-blind peer reviewed Bullying can have extensive effects on nurses at work but action can be taken to dealing with this destructive behaviour Bullying in nursing and ways of dealing with it

In this article... 5 key Research into points Types of bullying Bullying in the How to prevent and combat bullying in the workplace 1workplace is a worldwide phenomenon Author Ludwig F Lowenstein is director, and organisational factors It is not only Southern England Psychological Services, (Johnson, 2009). Johnston et al (2010) 2senior staff Allington Manor, Hampshire pointed out that the issue of workplace who bully; often Abstract Lowenstein LF (2013) Bullying in violence and bullying is something of nurses bully each nursing and ways of dealing with it. which all organisations must be aware as it other Nursing Times; 109: 11, 22-25. affects staff and, in the case of nurses, it Bullying can As with many other , nursing can also affect patients. 3often affect has its share of bullies who discredit the Negative workplace behaviour such as nurses’ ability to , while other nurses work with bullying is a worldwide problem (Lindy provide high- dedicated efficiency and good will. and Schaefer, 2010). A Portuguese study by quality care Bullying has an impact on the workplace Sa and Fleming (2008) described nurses Organisational environment and nurses in general; it can being bullied in the workplace: “[The] indi- 4characteristics cause low morale and in some cases can vidual is persistently treated in an abusive are critical make nurses seek elsewhere manner over a period of time, with a antecedents of or even leave the profession. feeling of not being able to counter-attack bullying This article considers recent research or defend him/herself against the .” Policies to deal into bullying in the workplace, including its Workplace bullying has attracted 5with the prevalence within the profession, causes increased attention over the last 10-20 possibility of and identification, as well as different years due to greater awareness of the con- bullying in the types of bullying and its impact on victims. sequences for the victims, in this case workplace and It also highlights research into combating, nurses, as well as those they seek to help – “zero tolerance” of preventing and dealing with the problem. the patients. The issue was highlighted this behaviour are recently by the report into the Mid Staf- needed orkplace bullying is a sig- fordshire public inquiry (Francis, 2013). nificant issue confronting the nursing profession, Prevalence of bullying in nursing Wwith victims described as There have been relatively few studies that being part of an oppressed group. There consider the incidence of workplace bul- have been cases where managers have bul- lying in the nursing profession. lied staff or failed to provide support for A study of clinical nurses in Taiwan by possible victims (Jackson et al, 2002). Pai and Lee (2011) reported a high number However, it is not just senior staff who of incidents involving workplace bullying. carry out the bullying; often nurses have Nurses were invited to complete a work- reported that both the bullies and victims place violence questionnaire, which was are the nurses themselves (Hutchinson et designed to assess the frequency and types al, 2006a). of or bullying, Needless to say, workplace bullying including physical or , bul- occurs in numerous other occupations and lying or and sexual . is a complex phenomenon that can only be A total of 521 nurses completed the ques- understood through looking at social, tionnaire; 102 (19.6%) had been subject to Staff may feel unable to defend themselves

22 Nursing Times 19.03.13 / Vol 109 No 11 / www.nursingtimes.net physical violence, 268 (51.4%) had experi- organisational conditions and unsympa- Types of bullying enced verbal abuse, 155 (29.8%) had been thetic leadership styles (Strandmark and Racism and bullying of immigrant nurses, victims of bullying/mobbing and 67 Hallberg, 2007). as documented by Allan et al (2009), sug- (12.9%) reported having experienced Others have noted one of the causes of gests racism is entrenched in the nurses’ . It was noted that bullying to be discrimination towards workplace due to an . This working night shifts appeared to increase overseas-trained nurses recruited to work can result in psychological distress and be the likelihood of sexual harassment. in the UK, suggesting that racism can costly to the organisation due to low An American study by Vessey et al sometimes become entrenched in the morale of the nurses being bullied (Cleary (2009) of nurses found that bullying was nursing workplace (Allan et al, 2009). et al, 2010). reported by a wide range of staff. Bullying Hogh et al (2011) found that non-western Gunnarsdottir et al (2006) carried out a occurred most frequently in medical sur- immigrant health workers had a signifi- comparative study of the bullying of gical care (23%), critical care (18%), emer- cantly higher risk of being bullied at work, female nurses, primary school teachers gency areas (12%), operating room/post particularly during their first year of and flight attendants. Repeated sexual har- anaesthesia care unit (9%) and obstetric employment and during their assment at work was more common care (7%). Perpetrators included senior trainee period. among flight attendants, with 31% of nurses (24%), charge nurses (17%), nurse The reasons behind bullying can also respondents from this group reporting managers (14%) and physicians (8%). be political, where it serves the self- they had experienced sexual harassment at Sa and Fleming (2008) found that one in interest of the perpetrators and is fre- work, compared with 4% of nurse respond- six nurses (13%) reported being bullied in quently due to a need for power and com- ents. the past six months. for promotion (Katrinli et al, Hutchinson et al (2006b) noted that 2010). A Canadian study by Laschinger et those who perpetrate bullying behaviour Identifying the signs of bullying al (2010) found bullying of new graduate were often found in informal organisa- behaviour nurses by more experienced older nurses tional alliances, which gave them opportu- Victims of bullying tend to feel intimi- to be common. nity to assert some control over teams and dated and often experience dissatisfac- A recent study by Huntington et al to enforce rules through indoctrina- tion as well as physiological and psycho- (2011) linked bullying to increasing pres- tion, often destroying the self- logical effects (Cleary et al, 2010). sures of work and organisational factors of those targeted and forcing them either Workplace bullying often takes the form of including a lack of support from manage- to comply to survive or to resign their posi- “ and ”, which can ment. It also found that workplace bul- tion. This form of bullying can also take lead to responses from victims (Fel- lying can be embedded within informal the form of nurses being asked to do tasks blinger, 2008). organisational networks. below their level of competence and An Australian study by Hutchinson et Hutchinson (2009) highlighted that having areas of responsibility removed or al (2006a) found “predatory alliances” ena- bullying is not always identified for what it replaced with more trivial or unpleasant bled bullying in the work setting to be is because it is associated with a whole tasks, something which frequently hap- hidden. In a later study, they found that organisation. Organisational characteris- pens alongside unmanageable those carrying out the bullying tactics tics influence both the likelihood of bul- levels (Sa and Fleming, 2008). were often rewarded by being promoted lying occurring as well as whether this Bullying can often take the form of (Hutchinson et al, 2009). Lewis (2006) also behaviour is challenged (Hutchinson et al, cyber-bullying rather than face-to-face. highlighted that managers could be tar- 2010a). Nurses frequently find it difficult This behaviour should be detected, treated gets of bullying themselves by the people to complain about the effects of bullying. and steps taken to prevent it happening above them. Whistleblowing can sometimes be viewed within organisations (Smoyak, 2011). A Chinese research project studied bul- as a revenge procedure (Jackson et al, lying through the use of questionnaires 2010), so organisations can be unaware The impact of bullying such as the Chinese Masloch Burnout that the bullying is even happening (John- Bullying has both a physiological and psy- Inventory, the Negative Acts Question- ston et al, 2010). chological effect on victims as well as a naire and the Overall and General Health Questionnaire (Li and Zhang, 2010). These inventories were also FRANCIS ON… used to ascertain whether the question- BULLYING naire accurately measured the bullying that occurred in the nursing population in ● In a Joint Negotiation and Consultation and bullying manner towards her staff a US study (Simons et al, 2011). The study Committee meeting on 12 February and junior doctors, for instance in assessed the concurrent validity of the 2009, reference was made to 30% of making derogatory comments; Negative Acts Questionnaire – Revised (22 staff [at Mid-Staffordshire trust] having ● Dr Turner – a specialist registrar on the items) and findings supported the use of a experienced or witnessed bullying by a A&E department – reported witnessing one-dimensional, four-item questionnaire member of management. a of bullying and harassment of to measure perceived bullying in nursing ● After reporting her concerns about staff, particularly the nursing staff, to the populations. senior A&E staff, staff nurse Helene extent of witnessing nurses emerging Donnelly reported she was threatened by from bed management meetings in Causes and victims of bullying colleagues of the nurses she had raised tears in fear of losing their . One of the suggested reasons for bullying concerns about. She alleged that the ● Concerns raised regarding bullying at is longstanding power struggles arising senior sister behaved in an inappropriate the trust were often not followed up. from conflict of values often caused by Alamy

www.nursingtimes.net / Vol 109 No 11 / Nursing Times 19.03.13 23 Nursing Practice Discussion Workplace bullying

negative impact on organisations and could indicate a person is being bullied, patient care (Broome and Williams-Evans, such as anxiety and or 2011). Nurses who work in a culture of bul- expressing a wish to leave the profession lying are likely to experience job dissatis- (Quine, 2001). Nurses who feel they are bul- faction, spend more time on leave, have lied should be encouraged to speak to col- decreased productivity and lower morale leagues and their superiors in the organi- (Cleary et al, 2010). This threatens nurses’ sation rather than relying on friends and wellbeing (Cleary et al, 2010; Felblinger, family; if these concerns are not dealt with 2008) and frequently results in them being sensitively, the victims may end up leaving unable to provide high-quality care (Hunt- the profession (Vessey et al, 2009). ington et al, 2011). Sheridan-Leos (2008) referred to bul- Recommendations lying in nursing as “lateral violence” or “an Allegations of bullying should always be act of aggression that is perpetrated by one investigated and the organisation itself nurse against another”. He felt that lateral should take responsibility. To assist in violence caused a downward spiral that making this a , policies must be in was costly to individual nurses, causing place to deal with investigations into bul- job dissatisfaction and psychological dis- lying and “zero tolerance” of such behav- tress. iour when it has been proven to exist. This finding is backed up by Hutch- Whistleblowing should be encouraged inson et al (2006b), who found that bul- rather than discouraged and victims of lying destroyed the self-confidence and bullying must have opportunity to voice self-image of those targeted and forced their feelings to their superiors. This could them eventually to resign their position or be made easier with the use of suggestion/ to reluctantly accept what was happening complaint boxes. around them. In a later study, Hutchinson Bullying can affect nurses’ ability to care Nurses at all levels should be aware they et al (2010b) found that bullying of nurses are expected to use empathy with their col- leads to erosion of professional compe- a harmonious approach and work collabo- leagues as part of an anti-bullying policy tence as well as increased sickness absence ratively to prevent any form of intimida- that everyone must be familiar with. The and employee attrition (Hutchinson et al, tion or bullying (Cleary et al, 2009). workplace should be seen as a place not 2010b; Johnson, 2009). Li and Zhang (2010) It has been noted that nurses with a per- only of physical safety but one without the also found that workplace bullying led to sonal system of resilience are better able to emotional stress caused by bullying; every burnout, job dissatisfaction and health counteract bullying behaviour (Jackson et member of the team should be treated with risks. It was shown to reduce self-confi- al, 2007). To make them more resilient, courtesy and respect. dence and decreasing work productivity excessive and a lack of Anyone making a complaint should feel by a Canadian study (Mackintosh et al, autonomy should be prevented. confident their concerns will be escalated 2010a). A later study by the same authors Whistleblowing is often seen as a nega- as necessary and that solutions will be had similar results and also highlighted tive act fuelled mainly by revenge and sedi- found. This means identifying and con- mental health consequences (Mackintosh tion; however, nurses should have the fronting the culprits of bullying and, after et al, 2010b). opportunity to raise concerns about a fair hearing, disciplining them, or even The obvious detrimental effects bul- patients’ care or organisational wrong- dismissing them if this is warranted. Vic- lying has on nurses make it essential that doing without fear of accusations (Jackson tims and perpetrators should both be early intervention takes place and that et al, 2010). It is important to consider con- offered counselling. staff recognise what is happening and pre- fronting the causes of bullying as well as Finally, Johnson (2009) recommended vent further bullying (Schoonbeek and the actual acts (Mackintosh et al, 2010b). more nurse-specific research in to how Henderson, 2011). The worst outcomes of Those in higher ranks in the nursing nurses are treated, including bullying bullying are victims being subjected to profession should be aware of signs that behaviour in the workplace, to generate a annoyance, exclusion, belittlement and greater understanding and allow for solu- isolation, deprived of resources, and pre- tions to be found. NT vented from claiming their rights BOX 1. GOT A PROBLEM (Yildirim, 2009). WITH BULLYING? References Allan HT et al (2009) Overseas nurses’ experiences of discrimination: a case of racist Combating bullying of nurses in For UK nurses who feel threatened, bullying? Journal of ; 17: the workplace bullied, or otherwise treated unfairly, the 898-906. Broome BS, Williams-Evans (2011) Bullying in a A number of steps can be taken to support Department of Health offers a grievance caring profession: reasons, results, and a healthy workplace and thereby prevent procedure, which includes a recommendations. Journal of Psychosocial Nursing bullying. The literature suggests several whistleblowing service and is available and Mental Health Services; 49: 30-35. 24 hours a day. The number to contact Cleary M et al (2010) Identifying and addressing ways to tackle bullying within nursing bullying in nursing. Issues in Mental Health Nursing; including providing , devel- is 01215 069133. 31: 331-335. oping codes of acceptable conduct and Some lawyers specialise in unfair or Cleary M (2009) Dealing with bullying in the introducing a zero tolerance policy wrong behaviour by any member of workplace: toward zero tolerance. Journal of Psychosocial Nursing and Mental Health Services; (Broome and Williams-Evans, 2011). staff at any level. 47: 34-41.

Alamy Leaders and managers must use Felblinger DM (2008) Incivility and bullying in the

24 Nursing Times 19.03.13 / Vol 109 No 11 / www.nursingtimes.net Nursing For more articles on nursing management, Times.net go to nursingtimes.net/management workplace and nurses’ shame responses. Journal indoctrination in work teams dominated by bullies. bullying on how women work. Western Journal of of Obstetric, Gynecologic & : Contemporary Nurse; 21: 228-238. Nursing Research; 32: 910-931. Clinical Scholarship for the Care of Women, Jackson D et al (2010) Trial and retribution: A Mackintosh J et al (2010b) Workplace bullying in Childbearing Families, & Newborns; 37: 234-242. qualitative study of whistle blowing and workplace health care affects the meaning of work. Francis R (2013) Report of the Mid Staffordshire relationships in nursing. Contemporary Nurse; 36: Qualitative Health Research; 20: 1128-1141. NHS Foundation Trust Public Inquiry. London: 34-44. Pai HC, Lee S (2011) Risk factors for workplace Stationery . tinyurl.com/HMSO-Francis2 Jackson D et al (2007) Personal resilience as a violence in clinical registered nurses in Taiwan. Gunnarsdottir HK et al (2006) strategy for surviving and thriving in the face of Journal of Clinical Nursing; 20: 1405-1412. harassment at work and self-assessed health of workplace adversity: a literature review. Journal of Quine L (2001) Workplace bullying in nurses. female flight attendants, nurses and teachers. Advanced Nursing; 60: 1-9. Journal of Health Psychology; 6: 73-84. Work: a Journal of Prevention, Assessment & Jackson D et al (2002) Who would want to be a Sa L, Fleming M (2008) Bullying, burnout and Rehabilitation; 27: 165-172. nurse? Violence in the workplace – a factor in mental health amongst Portuguese nurses. Issues Hogh A et al (2011) Are immigrants in the nursing and retention. Journal of Nursing in Mental Health Nursing; 29: 411-426. industry at increased risk of bullying at work? A Management; 10: 13-20. Schoonbeek S, Henderson A (2011) Shifting one-year follow-up study. Scandinavian Journal of Johnson SL (2009) International perspectives on workplace behavior to inspire learning: a journey Psychology; 52: 49-56. workplace bullying among nurses: a review. to building a learning culture. The Journal of Huntington A et al (2011) Is anybody listening? A International Nursing Review; 56: 34-40. in Nursing; 42: 43-48. qualitative study of nurses’ reflections on practice. Johnston M et al (2010) The bullying aspect of Sheridan-Leos N (2008) Understanding lateral Journal of Clinical Nursing; 20: 1413-1422. workplace violence in nursing. JONA’s Healthcare violence in nursing. Clinical Journal of Oncology Hutchinson M (2009) Restorative approaches to Law, Ethics, and Regulation; 12: 36-42. Nursing; 12: 399-403. workplace bullying: educating nurses towards Katrinli A et al (2010) Nurses’ perceptions of Simons SR et al (2011) A new, four-item instrument shared responsibility. Contemporary Nurse; 32: individual and organizational political reasons for to measure workplace bullying. Research in 147-155. horizontal peer bullying. Nursing Ethics; 17: Nursing & Health; 34: 132-140. Hutchinson M et al (2010a) Integrating individual, 614-627. Smoyak SA (2011) A rose is a rose is a rose: work group and organizational factors: testing a Laschinger HKS et al (2010) New graduate nurses bullying in all of its disguises. Journal of multidimensional model of bullying in the nursing experiences of bullying and burnout in hospital Psychosocial Nursing and Mental Health Services; workplace. Journal of Nursing Management; 18: settings. Journal of Advanced Nursing; 66: 49, 6-7. 173-181. 2732-2742. Strandmark KM, Hallberg LRM (2007) The origin Hutchinson M et al (2010b) A typology of bullying Lewis MA (2006) Nurse bullying: organizational of workplace bullying: experiences from the behaviours: the experiences of Australian nurses. considerations in the maintenance and perspective of bully victims in the public service Journal of Clinical Nursing; 19: 2319-2328. perpetration of health care bullying . sector. Journal of Nursing Management; 15: Hutchinson M et al (2009) The worse you behave, Journal of Nursing Management; 14: 52-58. 332-341. the more you seem to be rewarded: bullying in Li Y-X, Zhang L (2010) Relationship of workplace Vessey JA et al (2009) Bullying of staff registered nursing as organisational corruption. Employee bullying with job burnout, job satisfaction and nurses in the workplace: a preliminary study for Responsibilities and Rights Journal; 21: 213-229. health in nurses. Chinese Mental Health Journal; 24: developing personal and organizational strategies Hutchinson M et al (2006a) Workplace bullying in 625-628, 632. for the transformation of hostile to healthy nursing: towards a more critical organisational Lindy C, Schaefer F (2010) Negative workplace workplace environments. Journal of Professional perspective. Nursing Inquiry; 13: 118-126. behaviors: an ethical dilemma for nurse managers. Nursing; 25: 299-306. Hutchinson M et al (2006b) They stand you in a Journal of Nursing Management; 18: 285-292. Yildirim D (2009) Bullying among nurses and its corner; you are not to speak: nurses tell of abusive Mackintosh J et al (2010a) Effects of workplace effects.International Nursing Review; 56, 504-511.

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