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Bullying among nursing staff: Relationship with psychological/behavioral responses of nurses and medical errors Whitney Wright Naresh Khatri Aim: The aim of this article is to examine the relationship between three types of bullying (person-related, work-related, and physically intimidating) with two types of outcomes (psychological/behavioral responses of nurses and medical errors). In addition, it investigates if the three types of bullying behaviors vary with age or gender of nurses and if the extent of bullying varies across different facilities in an institution. Background: Nurses play an integral role in achieving safe and effective health care. To ensure nurses are functioning at their optimal level, health care organizations need to reduce negative components that impact nurses’ job performance and their mental and physical health. Mitigating bullying from the workplace may be necessary to create and maintain a high-performing, caring, and safe hospital culture. Methods: Using an internal e-mail system, an e-mail requesting the participants to complete the questionnaire on Survey Monkey was sent to a sample of 1,078 nurses employed across three facilities at a university hospital system in the Midwest. Two hundred forty-one completed questionnaires were received with a response rate of 23%. Bullying was measured utilizing the Negative Acts Questionnaire-Revised (NAQ-R). Outcomes (psychological/behavioral responses of nurses and medical errors) were measured using Rosenstein and O’Daniel’s (2008) modified scales. Results: Person-related bullying showed significant positive relationships with psychological/behavioral responses and medical errors. Work-related bullying showed a significant positive relationship with psychological/behavioral responses, but not with medical errors. Physically intimidating bullying did not show a significant relationship to either outcome. Whereas person-related bullying was found to be negatively associated with age of nurses, physically intimidating bullying was positively associated with age. Male nurses experienced higher work-related bullying than female nurses. Conclusion: Findings from this study suggest that bullying behaviors exist and affect psychological/behavioral responses of nurses such as stress and anxiety and medical errors. Health care organizations should identify bullying behaviors and implement bullying prevention strategies to reduce those behaviors and the adverse effects that they may have on psychological/behavioral responses of nurses and medical errors.
Key words: bullying, medical errors, nursing
Whitney Wright, MHA, is Business Manager, Therapy Services, University of Missouri Hospital & Clinics, Columbia. Naresh Khatri, PhD, is Associate Professor, Department of Health Management and Informatics, University of Missouri, Columbia. E-mail: [email protected]. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/HMR.0000000000000015 Health Care Manage Rev, 2015, 40(2), 139Y147 Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
B
ullying is a term commonly associated with children’s playgrounds and high school hallways. However, the prevalence of bullying in the workplace is increasing and the impact of this behavior is severe, specifically in the health care industry (Cleary, Hunt, & Horsfall, 2010; Hutchinson, Wilkes, Jackson, & Vickers, 2010; OlenderRusso, 2009). Multiple studies have determined that many health care workplaces possess negative environments that foster disrespectful attitudes, inappropriate behaviors, and bullying (Cleary et al., 2010). These behaviors are found to create financial costs such as turnover, physical costs in the form of symptoms experienced by the bullying victim, and psychological and behavioral costs such as stress and anxiety
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that can impact job performance (Center, 2011; Felblinger, 2009; Laschinger, Grau, Finegan, & Wilk, 2010; Lindy & Schaefer, 2010; MacIntosh, Wuest, Gray, & Cronkhite, 2010; Vessey, Demarco, Gaffney, & Budin, 2009; Yildirim, 2009). Nursing professionals make up the largest group of health care providers in the United States. According to the U.S. Department of Labor, there were 2,737,400 registered nurses and 752,300 licensed practical/vocational nurses in 2010. Throughout nurses’ careers, studies suggest that 80% of them experience bullying (Hutchinson et al., 2010). Nurses play an integral role in achieving safe and effective health care. To ensure nurses are functioning at their optimal level, health care organizations need to reduce negative components that impact nurses’ job satisfaction and their mental and physical health. Reducing bullying from the workplace may be necessary to create and maintain a high-performing, caring, and safe hospital culture (Piper, 2006). Bullying is generally defined as a situation in which a person perceives himself/herself as the target of negative actions, persistently over time, by one or several others (Rodwell & Demir, 2012). It often presents as repetitive acts of verbal aggression and criticism but may take more subtle forms, such as placing someone under increased scrutiny or talking behind another’s back (Szutenbach, 2013). Bullying may include mistreatment, incivility, disruptive behavior, disrespectful attitudes, or inappropriate behaviors. For example, Read and Laschinger (2013) used the term workplace mistreatment consisting of incivility and bullying in work place. Incivility is low-intensity rude or disrespectful behaviors with an ambiguous intent to harm others. In contrast, bullying is an intentional and intense form of workplace mistreatment that targets particular individuals and not others. Workplace bullying tends to be sophisticated and involve psychological cruelty. Another concept that is related and can be treated as part of bullying is disruptive behavior, which is defined as any inappropriate behavior, confrontation, or conflict, ranging from verbal, physical, or sexual harassment (Rosenstein & O’Daniel, 2008). Unlike, physician disruptive behavior, which is usually more overt and direct, nurse disruptive behavior is more passiveYaggressive in nature and is directed at the peers (Rosenstein & O’Daniel, 2008). Bullying does not include normal instruction, constructive feedback, safe workplace practices, or differing opinions (Cleary et al., 2010). As discussed by Cleary et al., bullying acts may be overt or covert and consist of a variety of behaviors. Some of the common bullying behaviors reported include being allocated an unmanageable workload, being ignored or excluded, having rumors spread about an individual, being ordered to carry out work below one’s competence level, having one’s professional opinion ignored, having information relevant to one’s work withheld, being given impossible target or deadlines, and being humiliated or ridiculed about one’s work Additional behaviors may include overchecking, silent treatment, belittling, excessive criticism, scapegoating, or
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sabotaging (Felblinger, 2009; LaVan & Martin, 2008; Olender-Russo, 2009: Vessey et al., 2009; Yildirim, 2009). A study completed by Yildirim found that 56% of the respondents had experienced a coworker belittling or demeaning them in the presence of others. Einarsen, Hoel, and Notelaers (2009) identified three categories of bullying: work-related, person-related, and physical intimidation. Work-related bullying may include behaviors such as being given unreasonable deadlines, assigning tasks below a person’s competency level, or withholding information that affects performance. Person-related bullying may consist of behaviors such as being ignored or excluded, spreading gossips and rumors, or hints and signals from others to quit one’s job. Physically intimidating behaviors may include invasion of personal space, shoving and blocking the way, threat of violence, physical abuse, or actual abuse.
Theoretical Background The health care industry has become a focal point of research for workplace bullying with a significant focus on the nursing profession. MacIntosh et al. (2010) noted that workplace bullying is 16 times more likely to occur in the health care industry versus other sectors. Bullying incidents occur laterally between nurses, vertically between nurses and their superiors, or from physicians to nurses. There are varying degrees of bullying. Some cases are extreme and potentially lead to acts of violence. Center (2011) stated that the Joint Commission’s Sentinel Event Database includes 256 reports of assault, rape, and homicide since 1995 with 43% of those reports occurring in the past 3 years. The frequency of bullying in the workplace is alarming and even more so because bullying incidences are usually underreported (LaVan & Martin, 2008; Vessey et al., 2009). Reasons for underreporting include culture of acceptance, lack of trust in management, or fear of retaliation for being the ‘‘whistleblower.’’ A study by Vessey et al. identified sharing bullying experiences with family, friends, or other colleagues as a coping mechanism that further contributes to underreporting. The research literature suggests a number of presumed causes of bullying in nursing, three of which are cited more often. First, the longstanding paternalism in health care might have led to the oppression of nurses (Szutenbach, 2013). Oppression, by way of unfair, unjust, or cruel governance, deprives individuals and groups of their rights. Oppressed groups feel powerless in the face of their oppressors and turn their frustrations inward and toward other group members, especially those who they perceive to be less powerful (Read & Laschinger, 2013; Rodwell & Demir, 2012). A second plausible cause of bullying has to do with how and what nurses are taught. There is evidence that bullying is a learned behavior, and nurses are encultured to bully one another (Szutenbach, 2013; Vessey et al., 2009). When bullying goes unchecked by nurse managers,
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other staff members consider such activity as appropriate because these behaviors have become culturally normalized (Vessey et al., 2009). A third plausible explanation for bullying behavior in nursing is the existence of numerous rigid rules and procedures and authoritarian management practices (Brees, Mackey, & Martinko, 2013). There are financial, physical, and psychological costs associated with bullying. Pearson and Porath (2009) estimate that incivility or ‘‘mundane’’ slights and disrespect cause stress that costs U.S. companies $300 billion a year, which is avoidable. The average cost per victim can range from $30,000 to $100,000 (Lindy & Schaefer, 2010). Financial, physical, and psychological costs are experienced by the bullying victim, the patients they are responsible for, their coworkers, and the organization. Costs to the organization are in the form of job dissatisfaction; absenteeism; turnover; poor morale; low productivity; staffing shortages; and loss of expertise, loyalty, and commitment to the organization. If nursing staff is dissatisfied with their jobs, they are at higher risk of calling in frequently, changing departments, or resigning.
Research Objectives The purpose of this study was to add to the refinement of our current understanding of bullying behavior in health care settings. Specifically, we focused on bullying behavior among nurses only and investigated the relationships of three types of bullying behaviors, work-related, person-related, and physically intimidating, with nurses’ psychological/behavioral responses and medical errors. Research on the relationship of bullying with medical errors is limited, and thus, the findings of this study can fill this void in existing research. In addition, we examined if bullying varies with gender and age or across locations/facilities in the same institution.
The Hypothesized Model Einarsen et al. (2009) developed the Negative Acts Questionnaire-Revised (NAQ-R) in which they identified
three categories of bullying behaviors: work-related, personrelated, and physical intimidation. Rosenstein and O’Daniel (2008), on the other hand, in their study of disruptive physician behavior, a type of bullying behavior, developed two important job performance categories for health care settings: psychological/behavioral responses of health care workers and incidence of medical errors/adverse events. This study employed Einarsen et al.’s three types of bullying and Rosenstein and O’Daniel’s two types of job performance as a framework for this study. The model in Figure 1 presents the hypothesized relationships of bullying behaviors to job performance outcomes. All three types of bullying, work-related, personrelated, and physical intimidation, are hypothesized to be directly related to psychological/behavioral responses of nurses and medical errors. Bullying at work is considered a potent stressor that can negatively impact the physical and psychological well-being of the target. For example, Vessey et al. (2009) noted bullying to be associated with psychological and physical stress, underperformance, professional disengagement, and diminished quality of care. Similarly, Laschinger et al. (2010) observed that the nurses who reported being bullied were more likely to have anxiety and depression. Rodwell and Demir (2012) suggest that the exposure to workplace bullying results in increased psychosomatic symptoms, depression, anxiety, and cardiovascular risk. Rosenstein and O’Daniel (2008) reported that disruptive behaviors, a type of bullying behavior, can have a substantial impact on patient care. Furthermore, the authors noted that, although disruptive behaviors by either physicians or nurses occurred in a relatively small percentage of the physician and nursing staff, they could have a profound effect on patient safety and quality of care. Bullying behavior could affect staff morale, patient and family perceptions, and hospital reputation. The study by Rosenstein and O’Daniel provided the initial evidence linking bullying with adverse effects on patient care, which this study aims to build upon and extend by incorporating a more comprehensive set of bullying behaviors.
Figure 1
The theoretical model linking bullying with medical errors and psychological/behavioral responses
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In addition, we examined if three types of bullying varied with age and gender or across locations/facilities of the same institution. Perception of bullying may vary for male and female nurses. Because nursing is dominated by women, men may experience higher level of bullying (Deltsidou, 2009). Similarly, young nurses may face greater bullying than old nurses (Vessey et al., 2009; Yildirim, 2009). A rite of passage, where new graduates are tested and pranked by senior nurses, is a form of hazing but is often viewed as a cultural norm (Center, 2011; Cleary et al., 2010; Johnson, 2011; Laschinger et al., 2010; Rosenstein & O’Daniel, 2008; Vessey et al., 2009). Higher prevalence of bullying behaviors may exist at the primary hospital than at the orthopedic or women’s and children’s hospitals because it is a trauma center and has multiple ICUs, multiple service lines, and multiple surgical units (Rosenstein & O’Daniel, 2008; Vessey et al., 2009).
Methods Settings and Sample Approximately 1,078 registered nurses and licensed practical nurses employed at a university hospital system in Midwest were targeted as potential study participants. The university hospital system is composed of three facilities located within the same community, a main hospital with trauma center, a women’s and children’s hospital, and an orthopedic hospital. The purpose of the study was reviewed with the Director of Nursing for support and consent to proceed. The research study was also reviewed and approved by the University of Missouri Institutional Review Board before data collection. The survey was conducted using an internal e-mail system. An email was sent to the respondents explaining the purpose of the study and inviting them to participate. Completion of the survey indicated their consent to participate in the study. In addition, participants were informed that the data being collected were voluntary and would be confidential and responses would not be identified individually. The email included a link to the online survey located on the Survey Monkey Web site. The survey included four demographic questions, 22 questions related to specific bullying behaviors, and 14 questions related to psychological/behavioral responses and medical errors. Incomplete surveys were discarded. Of the 248 surveys returned, 241 were complete and used in data analysis. The response rate was 23%.
Measures A demographic information form was created to collect data regarding participant’s age, gender, years of experience, and the facility where the employee worked. The investigator
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utilized the NAQ-R to define the frequency of bullying and bullying characteristics. The NAQ-R is a reliable, valid, and a short questionnaire that can be used in a range of occupations and has been adapted to the Anglo-American culture (Einarsen et al., 2009; Laschinger et al., 2010). The NAQ-R consists of 22 questions that focus on the varying aspects of bullying behaviors. Three categories emerge among these questions: work-related bullying, person-related bullying, and physically intimidating bullying. Questions are written in behavioral expressions and do not reference ‘‘harassment’’ or ‘‘bullying.’’ The questionnaire has a Cronbach’s ! of .92 (Einarsen et al., 2009; Laschinger et al., 2010). Bullying behaviors were examined using the 22 questions from the NAQ-R to measure exposure over the course of work within the university facilities. Response alternatives included: never, now and then, monthly, weekly, and daily. The investigators also utilized a survey created by Rosenstein and O’Daniel (2008) that assessed job performance. This survey was modified to meet the investigation goals and assimilate with the structure of the NAQ-R. Response alternatives were changed from ‘‘never, rarely, sometimes, frequent, and constant’’ to ‘‘never, now and then, monthly, weekly, and daily.’’ The original survey consisted of 12 questions. Two questions were added addressing ‘‘physical symptoms’’ and ‘‘absenteeism’’ to make a total of 14 questions. Another modification included replacing the question regarding ‘‘adverse events’’ with a question about ‘‘medical errors’’ as the investigators felt the original question was too broad. The survey concluded with an additional free-text option to allow respondents to voice any comments regarding the survey content or share personal experiences, thoughts, or concerns.
Reliability and Validity of Measures Factor analysis was performed to test if the scales measuring three types of bullying in the NAQ-R instrument were distinct from each other. The results of factor analysis are provided in Table 1, which shows that three clear factors emerge. Person-related bullying had 12 items (Cronbach’s ! = .95), work-related bullying had five items (Cronbach’s ! = .84), and physically intimidating bullying had two items (Cronbach’s ! = .66). A composite score for each scale was computed by adding the scores on items loading on the scale divided by the number of items. Similarly, factor analysis was employed to see if the two outcome variables are distinct from each other. The results are presented in Table 2. There are two clear factors. The factor on psychological/behavioral responses consisted of nine items (Cronbach’s ! = .94), and the factor on medical errors consisted of five items (Cronbach’s ! = .91). The composite variables were developed by adding the scores for the items loading on the factor divided by the number of items loading on the factor.
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psychological and behavioral responses was higher than the mean score of 1.79 for medical errors.
Results After examining the participating nurses’ demographic characteristics, it was determined that 1% of participants were less than 20 years old, 44% were between 21 and 39 years old, 50% were between 40 and 59 years old, and 5% were over 60 years old. There were 17% of nurses with less than 2 years of experience, 29% between 3 and 10 years, 16% between 11and 20 years, 22% between 21 and 30 years, and 16% with over 31 years of experience. Most nurses were women (91%). A significant number of nurse participants were employed at the main hospital (67%), followed by women’s and children’s hospital (27%), and orthopedic hospital (2%), with 4% of the participants not responding to this question. The descriptive statistics and zero-order correlations between the study variables are presented in Table 3. The mean scores for work-related and person-related bullying suggest that the extent of person-related bullying (mean = 2.28) was higher than work-related bullying (mean = 1.78). The extent of physically intimidating bullying was the lowest (mean = 1.26). Furthermore, the mean score of 2.14 for
Testing of the Hypothesized Model On the basis of a combination of multiple regressions and path analyses, the best-fitting path model was developed, which is presented in Figure 2. Physically intimidating bullying behavior was found rather uncommon and also did not show any significant relationship with either medical errors or psychological/behavioral responses. Thus, it was excluded from the model. When work-related and person-related bullying were regressed on medical errors, they showed significant standardized beta weights of .260 and .370, respectively (both coefficients significant at p G .001). However, when work-related and person-related bullying were regressed along with psychological and behavioral responses on medical errors, the standardized beta weight for work-related bullying was reduced to j.06, which is insignificant, and the standardized beta weight for person-related bullying declined from .370 to .251 (both significant at p G .001). This analysis suggests that the effect
Table 1
Factor analyses of bullying behaviors of the NAQ-R instrument Item
Factor 1 Factor 2 Factor 3 Mean score
Person-related bullying 1. Spreading of gossip and rumors about you .83 2. Being ignored or excluded .73 3. Having insulting or offensive remarks made about your personality or .83 attitudes or your private life 4. Hints of signals from others that you should quit your job .80 5. Repeated reminders of your errors or mistakes .82 6. Being ignored or facing a hostile reaction when you approach .73 7. Persistent criticism of your errors or mistakes .84 8. Practical jokes carried out by people you don’t get along with .65 9. Having allegations made against you .70 10. Being the subject of excessive teasing and sarcasm .63 11. Excessive monitoring of your work .65 12. Being ridiculed or humiliated in connection with your work .70 Work-related bullying 13. Being ordered to do work below your level of competence .17 14. Having your opinions ignored .47 15. Being given tasks with unreasonable deadlines .29 16. Being exposed to an unmanageable workload .12 17. Having key areas of responsibility removed or replaced with more .45 trivial or unpleasant task Physically intimidated bullying 18. Intimidating behaviors such as finger-pointing, invasion of .31 personal space, shoving, blocking your way 19. Threats of violence or physical abuse or actual abuse .17 Percent variance explained 38.65 Note. NAQ-R = Negative Acts Questionnaire-Revised.
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.17 .28 .11
.16 .17 .29
2.06 2.21 1.91
.13 .27 .30 .29 .21 .20 .31 .34 .42
.13 .01 .24 .06 .19 .28 .39 .11 .25
1.50 1.71 1.97 1.66 1.31 1.58 1.47 2.16 1.87
.73 .60 .77 .80 .65
.25 .26 .01 .09 .16
2.29 2.76 2.07 2.65 1.63
.29
.73
1.37
j.05 18.41
.85 10.39
1.16
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Table 2
Factor analyses of outcome variables Item
1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14.
Factor 1
Psychological and behavioral responses How often have you experienced personal stress as a result of bullying behaviors? .90 How often have you experienced physical symptoms (nausea, gastrointestinal .81 upset, headaches) as a result of bullying behaviors? How often have you experienced frustration as a result of bullying behaviors? .86 How often have you experienced absenteeism as a result of bullying behaviors? .52 How often have you experienced loss of ability to concentrate as a result of .82 bullying behaviors? How often have you experienced reduced team collaboration as a result of .81 bullying behaviors? How often have you experienced reduced information transfer as a result of .78 bullying behaviors? How often have you experienced reduced communication as a result of .85 bullying behaviors? How often do you think there is a link between bullying behavior and the .65 following clinical outcome at your hospital: poor staff morale? Medical errors How often do you think there is a link between bullying behavior and the .25 following clinical outcome at your hospital: medication errors? How often do you think there is a link between bullying behavior and the .22 following clinical outcome at your hospital: medical errors? How often do you think there is a link between bullying behavior and the .28 following clinical outcome at your hospital: impaired patient safety? How often do you think there is a link between bullying behavior and the .43 following clinical outcome at your hospital: impaired quality? How often do you think there is a link between bullying behavior and the .20 following clinical outcome at your hospital: patient mortality? Variance explained 42.66
of work-related bullying on medical errors is mediated fully by psychological and behavioral responses and the effect of person-related bullying is partially mediated by psychological and behavioral responses. In summary, work-related bullying showed a highly significant positive relationship with psychological/behavioral responses but did not have any direct relationship with medical errors. Person-related bullying, on the other hand, showed significant positive relationships with both psychological/behavioral responses and medical errors. Additional analyses were performed to examine if bullying behavior differed between facilities and according to age and gender. Analysis of variance was performed to test the effects of gender and facilities, and simple regression analysis was performed to test the effect of age on bullying. The analysis suggested no significant differences of bullying between facilities, but significant differences in bullying behavior were observed for age and gender. Person-related bullying was negatively associated with age (t = j3.120, p G .001), and physically intimidating behavior was positively associated with age (t = 1.948, p G .05). Male nurses experienced significantly higher work-related bullying than female nurses
Factor 2
Mean score
.21 .21
2.25 1.84
.25 .21 .24
2.43 1.27 1.89
.30
2.29
.29
2.01
.26
2.27
.37
3.05
.80
1.66
.88
1.80
.86
1.93
.75
2.11
.74
1.43
27.98
(F = 3.393, p G .067), but there were no significant differences in person-related and physical bullying.
Discussion The results show that person-related and work-related bullying have a significant relationship with psychological/ behavioral responses and medical errors. The person-related bullying could be viewed as an informal bullying composing of behaviors such as gossip, practical jokes, or being excluded. The person-related behaviors could come from peer groups or cliques and may be fostered by organizational culture. Study participants commented in the open-ended question that bullying behaviors were more behind the scenes, showed lack of teamwork/cooperation, a ‘‘figure it out yourself’’ attitude, snarky comments, and a lot of negative gossips. Work-related bullying could be viewed as formal bullying including behaviors such as assignment of unmanageable workloads and deadlines. These are more likely to be driven from superiors and are supported by the structure of the organization. Multiple study participants commented that bullying behaviors derived from supervisors or management.
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Table 3
Means, standard deviations, and correlations of study variables
1. 2. 3. 4. 5.
Variable name
Mean
SD
1
2
3
4
5
Work-related bullying Person-related bullying Physical bullying Psychological and behavioral responses Medical errors
1.78 2.28 1.26 2.14 1.79
0.87 0.95 0.58 0.94 0.78
.84 .66* .52* .82* .51*
.95 .38* .68* .54*
.66 .46* .27*
.94 .61*
.91
Note. N = 241. The scales range from 1 = never to 5 = daily. Cronbach’s ! is provided in the italics along the diagonal. *p G .01.
A study participant commented that more and more tasks are added with zero recognition given and faults are pointed out by management whereas the good outcomes are ignored. Work-related bullying did not show a direct relationship with medical errors but showed an indirect relationship through psychological/behavioral responses. This could be explained utilizing the participant’s example; more and more tasks are given with no recognition. This may not directly impair the quality of care delivered, but lack of recognition could affect morale, which in turn affects quality of care. Study participants did not perceive physically intimidating bullying behaviors as related to psychological/behavioral responses or medical errors. As participants’ age increased, the amount of bullying reported decreased. This could be explained by normalization of person-related bullying as participants become accustomed to those behaviors, bullying behaviors become encultured, or alternatively actual bullying behaviors decline (Hutchinson et al., 2010). In terms of individual items constituting the three types of bullying behaviors, the prevalent person-related bullying behaviors included ‘‘being ignored or excluded’’ and ‘‘excessive monitoring of your work’’ (see Table 1). The prevalent
work-related bullying behaviors were ‘‘having your opinions ignored’’ and ‘‘being exposed to an unmanageable workload’’ (see Table 1), and the prevalent psychological/behavioral responses included ‘‘poor staff morale’’ and ‘‘feelings of frustration’’ (see Table 2). These results confirm that bullying behaviors are related to morale, job satisfaction, and diminished quality of care and are consistent with previous studies (Cleary et al., 2010; Felblinger, 2009; OlenderRusso, 2009; Vessey et al., 2009; Yildirim, 2009)
Relationship of Bullying With Gender, Age, and Facility Work-related bullying did not change with age/experience. This could be explained by staffing shortages resulting in high workloads, which potentially impact ability to meet deadlines, or being assigned work below competency levels. Person-related bullying is perceived higher with younger/ less experienced nurses and decreases as age/experience increases. This finding is consistent with the previous research. In this study, men experienced more work-related bullying. This can be explained because women dominate the nursing
Figure 2
The best-fitting empirical model showing relationships between bullying behaviors and psychological/behavioral responses and medical errors
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profession and men are the minority (Deltsidou, 2009). For example, Salin and Hoel (2013) observe that women tend to utilize social manipulation, social relationships, and social reputation as forms of bullying. Those behaviors align with peer-to-peer, person-related bullying. There was no significant difference in bullying behaviors or outcomes among the three locations studied. This can be explained because the three locations are within the same community and employees often float from one facility to the other. The locations are all part of a large organization with the same mission, vision, values, and leadership.
Implications for Practice The findings of this study suggests that the overall level of bullying behaviors at the university hospital system is not severe; however, there is a prevalence of person-related and work-related bullying that directly and indirectly impact behavioral/psychological responses and medical errors. Personrelated bullying is more common with a mean score of 2.28, whereas work-related bullying had a mean score of 1.78. A mean score of 2.0 would suggest bullying behaviors occur now and then. As the score rises to 3.0, the frequency of bullying behaviors increases to monthly. Mean scores above 3.0 would indicate a serious problem with bullying as the behaviors occurs weekly or daily. These study findings reinforce the necessity to identify bullying behaviors and implement prevention strategies in the workplace. Organization leaders hold the primary role to address workplace bullying behaviors. As leaders, they must set the example of how employees should conduct themselves within the workplace and with their coworkers. Their behaviors trickle down and impact organizational culture. An organization’s culture may contribute to continued bullying behaviors. Leadership should evaluate the current culture’s tolerance of bullying behaviors. Center (2011) provided a set of assessment questions to aid leadership in creation of a culture that does not tolerate bullying. Questions include the following: How are incidents handled when they occur? Are they ignored, indirectly teaching staff they are acceptable? Are incidents acknowledged as an opportunity for improvement and growth, empowering staff to confront the issues as quality improvement? How can these issues be addressed in team meetings? How is the incident investigated? Are there assumptions of individual blame, or are breakdowns considered a system issue requiring a system investigation? How many incidents of bullying behavior are tolerated before action is taken to change behavior? Utilizing these or similar questions to assess current practices and culture will help leadership determine what prevention strategies they must take to counter bullying. Person-related bullying includes gossip, being ignored, criticism, practical jokes, or teasing. Prevention should be
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focused on the bullying instigator, target, and culture. Conflict resolution is required to address and resolve poor behaviors as stated by Johnson (2011). Encouraging all employees to practice emotional intelligence, crucial conversations, and collaboration through sensitivity training, education about staff relationships, and team communication programs is essential (Cleary et al., 2010; Piper, 2006; Rosenstein & O’Daniel, 2008). Behaviors are taught and often passed down from mentors and experienced coworkers. In the freetext comments of the survey, study participants mentioned feeling intimidated by preceptors during orientation and that senior nurses were hesitant to teach new nurses. To prevent bullying behaviors becoming accepted in the organizational culture, it is important to modify orientation and mentoring of new employees to ensure behaviors are not being passed down (Center, 2011). Early education such as open discussion of bullying behaviors during orientation and continuous coaching will allow young professionals to develop skills required to collaborate, communicate, and be accepting of differences. Early introduction to workplace bullying will also eliminate norms that have developed regarding ‘‘hazing’’ and ‘‘rites of passage’’ (Center, 2011; Laschinger et al., 2010; Olender-Russo, 2009; Vessey et al., 2009). Improper reporting mechanisms have been found to be a huge barrier to successful implementation of workplace bullying initiatives. Study participants’ comments revealed that there was a fear of being reprimanded for reporting bullying behaviors and that the current reporting system served as a form of tattling on coworkers versus being a useful tool for process improvement. Clear and trustworthy mechanisms must be in place for employees to report bullying behaviors such as a reporting ‘‘hot-line’’ (Rosenstein & O’Daniel, 2008; Vessey et al., 2009). The human resources department needs to own the investigation and grievance procedures. It is vital that those involved with the investigation have no connection or regular interaction with the individuals involved (Hutchinson et al., 2010). Work-related bullying includes being ordered to complete work below one’s competence level, being given unreasonable deadlines, having one’s opinions ignored, and being given unmanageable workloads. Work-related bullying may be the product of staffing shortages, workplace design, policies, or structure of the organization. Examining workplace design and policies is important to discover if they are the fertile ground for bullying. Characteristics that contribute to bullying are a rigid, vertical organization structure, informal alliances and hierarchies, imbalance of power, job insecurity, and organizational wide restructuring and downsizing (Cleary et al., 2010; Hutchinson et al., 2010; Johnson, 2011; LaVan & Martin, 2008; Olender-Russo, 2009). Controlling, power-driven and rigid cultures do not encourage communication, group work, or collaboration (Khatri, Brown, & Hicks, 2009). Hierarchical workplaces create power imbalances that fuel bullying and dehumanize employees (Khatri, Baveja, Boren, & Mammo, 2006). It is
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important for organizations whose goal is to prevent and eliminate bullying to restructure their workplace design.
Limitations Participation was an important limitation in this research. Of the 1,078 nurses employed at a university hospital system in Mid-Missouri, 248 returned the survey. Of the 248 responses, 241 were complete and usable, leaving 837 nurses not participating. The reasons for the low response rate may be that the survey was distributed via email through nursing managers and supervisors. Surveys may have not been forwarded to staff especially by managers having bullying tendencies, surveys may have not been forwarded in a timely manner, reminders may have not been forwarded, or nurses may have not had private access to complete the survey. Subject sensitivity is a limitation. Bullying behaviors are highly underreported because of fear and mistrust. Those feelings may inhibit an individual from completing a survey. Reviewing the free-text comments from survey results revealed that nurses felt other people such as physicians, leadership, and patients’ families often act as bullies. Level of bullying may be higher if the study included other sources such as physicians and families of patients. Some nurses also expressed their opinions about the importance of this topic and recommended expanding the research to include other professions.
Conclusion The use of the NAQ-R and survey created by Rosenstein and O’Daniel are reliable tools to identify the existence of bullying, what type of behavior is experienced most frequently, who is likely to experience these behaviors, and the relationship to job performance. Findings from this study suggest that bullying behaviors exist and affect psychological/behavioral responses, such as stress and anxiety, and medical errors. Implications from bullying behaviors can be costly in the form of low morale, frustration, reduced collaboration, poor communication, and impaired quality. Health care organizations should identify bullying behaviors in their culture and organization and implement bullying prevention strategies to reduce bullying behaviors and their effects. Additional research is recommended after prevention strategies are implemented to evaluate success. References Brees, J., Mackey, J., & Martinko, M. (2013). An attributional perspective of aggression in organizations. Journal of Managerial Psychology, 28(3), 252Y272. Center, D. (2011). Mandates for patient safety: Are they enough to create a culture of civility in health care? The Journal of Continuing Education in Nursing, 42(1), 16Y17. Cleary, M., Hunt, G., & Horsfall, J. (2010). Identifying and addressing bullying in nursing. Mental Health Nursing, 31, 331Y335.
Deltsidou, A. (2009). Undergraduate nursing students’ level of assertiveness in Greece: A questionnaire survey. Nurse Education in Practice, 9(5), 322Y330. Einarsen, S., Hoel, H., & Notelaers, G. (2009). Measuring exposure to bullying and harassment at work: Validity, factor structure and psychometric properties of the Negative Acts Questionnaire-Revised. Work & Stress, 23(1), 24Y44. Felblinger, D. (2009). Bullying, incivility and disruptive behaviors in the healthcare setting: Identification, impact, and intervention. Frontiers of Health Services Management, 25(4), 13Y23. Hutchinson, M., Wilkes, L., Jackson, D., & Vickers, M. (2010). Integrating individual, work group and organizational factors: Testing a multidimensional model of bullying in the nursing workplace. Nursing Management, 18, 173Y181. Johnson, S. (2011). An ecological model of workplace bullying: A guide for intervention and research. Nursing Forum, 46(2), 55Y63. Khatri, N., Baveja, A., Boren, S., & Mammo, A. (2006). Medical errors and quality of care: From control to commitment. California Management Review, 48(3), 115Y141. Khatri, N., Brown, G., & Hicks, L. (2009). Moving from a blame culture to a just culture in health care. Health Care Management Review, 34(4), 312Y322. Laschinger, H., Grau, A., Finegan, J., & Wilk, P. (2010). New graduate nurses’ experiences of bullying and burnout in hospital settings. Advanced Nursing, 66(12), 2732Y2742. LaVan, H., & Martin, W. (2008). Bullying in the U.S. workplace: Normative and process-oriented ethical approaches. Business Ethics, 83, 147Y165. Lindy, C., & Schaefer, F. (2010). Negative workplace behaviors: An ethical dilemma for nurse managers. Nursing Management, 18, 285Y292. MacIntosh, J., Wuest, J., Gray, M., & Cronkhite, M. (2010). Workplace bullying in health care affects the meaning of work. Qualitative Health Research, 20(8), 1128Y1141. Olender-Russo, L. (2009). Creating a culture of regard: An antidote for workplace bullying. Creative Nursing, 15(2), 75Y81. Pearson, C., & Porath, C. (2009). The cost of bad behavior: How incivility is damaging your business and what to do about it. New York, NY: The Penguin Group. Piper, L. E. (2006). A theoretical model to address organizational human conflict and disruptive behavior in health care organizations. The Health Care Manager, 25(4), 315Y320. Read, E., & Laschinger, H. K. (2013). Correlates of new graduate nurses’ experiences of workplace mistreatment. The Journal of Nursing Administration, 43(4), 221Y228. Rodwell, J., & Demir, D. (2012). Psychological consequences of bullying for hospital and aged care nurses. International Nursing Review, 59, 539Y546. Rosenstein, A., & O’Daniel, M. (2008). Managing disruptive physician behavior. Neurology, 70, 1564Y1570. Salin, D., & Hoel, H. (2013). Workplace bullying as a gendered phenomenon. Managerial Psychology, 28(3), 235Y323. Szutenbach, M. P. (2013). Bullying in nurses: Roots, rationales, and remedies. Journal of Christian Nursing, 30(1), 16Y23. Vessey, J., Demarco, R., Gaffney, D., & Budin, W. (2009). Bullying of staff registered nurses in the workplace: A preliminary study for developing personal and organizational strategies for the transformation of hostile to health workplace environments. Professional Nursing, 25(5), 229Y306. Yildirim, D. (2009). Bullying among nurses and its effects. International Council of Nurses, 56(4), 504Y511.
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Bullying among nursing staff: Relationship with psychological/behavioral responses of nurses and medical errors Whitney Wright Naresh Khatri Aim: The aim of this article is to examine the relationship between three types of bullying (person-related, work-related, and physically intimidating) with two types of outcomes (psychological/behavioral responses of nurses and medical errors). In addition, it investigates if the three types of bullying behaviors vary with age or gender of nurses and if the extent of bullying varies across different facilities in an institution. Background: Nurses play an integral role in achieving safe and effective health care. To ensure nurses are functioning at their optimal level, health care organizations need to reduce negative components that impact nurses’ job performance and their mental and physical health. Mitigating bullying from the workplace may be necessary to create and maintain a high-performing, caring, and safe hospital culture. Methods: Using an internal e-mail system, an e-mail requesting the participants to complete the questionnaire on Survey Monkey was sent to a sample of 1,078 nurses employed across three facilities at a university hospital system in the Midwest. Two hundred forty-one completed questionnaires were received with a response rate of 23%. Bullying was measured utilizing the Negative Acts Questionnaire-Revised (NAQ-R). Outcomes (psychological/behavioral responses of nurses and medical errors) were measured using Rosenstein and O’Daniel’s (2008) modified scales. Results: Person-related bullying showed significant positive relationships with psychological/behavioral responses and medical errors. Work-related bullying showed a significant positive relationship with psychological/behavioral responses, but not with medical errors. Physically intimidating bullying did not show a significant relationship to either outcome. Whereas person-related bullying was found to be negatively associated with age of nurses, physically intimidating bullying was positively associated with age. Male nurses experienced higher work-related bullying than female nurses. Conclusion: Findings from this study suggest that bullying behaviors exist and affect psychological/behavioral responses of nurses such as stress and anxiety and medical errors. Health care organizations should identify bullying behaviors and implement bullying prevention strategies to reduce those behaviors and the adverse effects that they may have on psychological/behavioral responses of nurses and medical errors.
Key words: bullying, medical errors, nursing
Whitney Wright, MHA, is Business Manager, Therapy Services, University of Missouri Hospital & Clinics, Columbia. Naresh Khatri, PhD, is Associate Professor, Department of Health Management and Informatics, University of Missouri, Columbia. E-mail: [email protected]. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. DOI: 10.1097/HMR.0000000000000015 Health Care Manage Rev, 2015, 40(2), 139Y147 Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
B
ullying is a term commonly associated with children’s playgrounds and high school hallways. However, the prevalence of bullying in the workplace is increasing and the impact of this behavior is severe, specifically in the health care industry (Cleary, Hunt, & Horsfall, 2010; Hutchinson, Wilkes, Jackson, & Vickers, 2010; OlenderRusso, 2009). Multiple studies have determined that many health care workplaces possess negative environments that foster disrespectful attitudes, inappropriate behaviors, and bullying (Cleary et al., 2010). These behaviors are found to create financial costs such as turnover, physical costs in the form of symptoms experienced by the bullying victim, and psychological and behavioral costs such as stress and anxiety
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that can impact job performance (Center, 2011; Felblinger, 2009; Laschinger, Grau, Finegan, & Wilk, 2010; Lindy & Schaefer, 2010; MacIntosh, Wuest, Gray, & Cronkhite, 2010; Vessey, Demarco, Gaffney, & Budin, 2009; Yildirim, 2009). Nursing professionals make up the largest group of health care providers in the United States. According to the U.S. Department of Labor, there were 2,737,400 registered nurses and 752,300 licensed practical/vocational nurses in 2010. Throughout nurses’ careers, studies suggest that 80% of them experience bullying (Hutchinson et al., 2010). Nurses play an integral role in achieving safe and effective health care. To ensure nurses are functioning at their optimal level, health care organizations need to reduce negative components that impact nurses’ job satisfaction and their mental and physical health. Reducing bullying from the workplace may be necessary to create and maintain a high-performing, caring, and safe hospital culture (Piper, 2006). Bullying is generally defined as a situation in which a person perceives himself/herself as the target of negative actions, persistently over time, by one or several others (Rodwell & Demir, 2012). It often presents as repetitive acts of verbal aggression and criticism but may take more subtle forms, such as placing someone under increased scrutiny or talking behind another’s back (Szutenbach, 2013). Bullying may include mistreatment, incivility, disruptive behavior, disrespectful attitudes, or inappropriate behaviors. For example, Read and Laschinger (2013) used the term workplace mistreatment consisting of incivility and bullying in work place. Incivility is low-intensity rude or disrespectful behaviors with an ambiguous intent to harm others. In contrast, bullying is an intentional and intense form of workplace mistreatment that targets particular individuals and not others. Workplace bullying tends to be sophisticated and involve psychological cruelty. Another concept that is related and can be treated as part of bullying is disruptive behavior, which is defined as any inappropriate behavior, confrontation, or conflict, ranging from verbal, physical, or sexual harassment (Rosenstein & O’Daniel, 2008). Unlike, physician disruptive behavior, which is usually more overt and direct, nurse disruptive behavior is more passiveYaggressive in nature and is directed at the peers (Rosenstein & O’Daniel, 2008). Bullying does not include normal instruction, constructive feedback, safe workplace practices, or differing opinions (Cleary et al., 2010). As discussed by Cleary et al., bullying acts may be overt or covert and consist of a variety of behaviors. Some of the common bullying behaviors reported include being allocated an unmanageable workload, being ignored or excluded, having rumors spread about an individual, being ordered to carry out work below one’s competence level, having one’s professional opinion ignored, having information relevant to one’s work withheld, being given impossible target or deadlines, and being humiliated or ridiculed about one’s work Additional behaviors may include overchecking, silent treatment, belittling, excessive criticism, scapegoating, or
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sabotaging (Felblinger, 2009; LaVan & Martin, 2008; Olender-Russo, 2009: Vessey et al., 2009; Yildirim, 2009). A study completed by Yildirim found that 56% of the respondents had experienced a coworker belittling or demeaning them in the presence of others. Einarsen, Hoel, and Notelaers (2009) identified three categories of bullying: work-related, person-related, and physical intimidation. Work-related bullying may include behaviors such as being given unreasonable deadlines, assigning tasks below a person’s competency level, or withholding information that affects performance. Person-related bullying may consist of behaviors such as being ignored or excluded, spreading gossips and rumors, or hints and signals from others to quit one’s job. Physically intimidating behaviors may include invasion of personal space, shoving and blocking the way, threat of violence, physical abuse, or actual abuse.
Theoretical Background The health care industry has become a focal point of research for workplace bullying with a significant focus on the nursing profession. MacIntosh et al. (2010) noted that workplace bullying is 16 times more likely to occur in the health care industry versus other sectors. Bullying incidents occur laterally between nurses, vertically between nurses and their superiors, or from physicians to nurses. There are varying degrees of bullying. Some cases are extreme and potentially lead to acts of violence. Center (2011) stated that the Joint Commission’s Sentinel Event Database includes 256 reports of assault, rape, and homicide since 1995 with 43% of those reports occurring in the past 3 years. The frequency of bullying in the workplace is alarming and even more so because bullying incidences are usually underreported (LaVan & Martin, 2008; Vessey et al., 2009). Reasons for underreporting include culture of acceptance, lack of trust in management, or fear of retaliation for being the ‘‘whistleblower.’’ A study by Vessey et al. identified sharing bullying experiences with family, friends, or other colleagues as a coping mechanism that further contributes to underreporting. The research literature suggests a number of presumed causes of bullying in nursing, three of which are cited more often. First, the longstanding paternalism in health care might have led to the oppression of nurses (Szutenbach, 2013). Oppression, by way of unfair, unjust, or cruel governance, deprives individuals and groups of their rights. Oppressed groups feel powerless in the face of their oppressors and turn their frustrations inward and toward other group members, especially those who they perceive to be less powerful (Read & Laschinger, 2013; Rodwell & Demir, 2012). A second plausible cause of bullying has to do with how and what nurses are taught. There is evidence that bullying is a learned behavior, and nurses are encultured to bully one another (Szutenbach, 2013; Vessey et al., 2009). When bullying goes unchecked by nurse managers,
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other staff members consider such activity as appropriate because these behaviors have become culturally normalized (Vessey et al., 2009). A third plausible explanation for bullying behavior in nursing is the existence of numerous rigid rules and procedures and authoritarian management practices (Brees, Mackey, & Martinko, 2013). There are financial, physical, and psychological costs associated with bullying. Pearson and Porath (2009) estimate that incivility or ‘‘mundane’’ slights and disrespect cause stress that costs U.S. companies $300 billion a year, which is avoidable. The average cost per victim can range from $30,000 to $100,000 (Lindy & Schaefer, 2010). Financial, physical, and psychological costs are experienced by the bullying victim, the patients they are responsible for, their coworkers, and the organization. Costs to the organization are in the form of job dissatisfaction; absenteeism; turnover; poor morale; low productivity; staffing shortages; and loss of expertise, loyalty, and commitment to the organization. If nursing staff is dissatisfied with their jobs, they are at higher risk of calling in frequently, changing departments, or resigning.
Research Objectives The purpose of this study was to add to the refinement of our current understanding of bullying behavior in health care settings. Specifically, we focused on bullying behavior among nurses only and investigated the relationships of three types of bullying behaviors, work-related, person-related, and physically intimidating, with nurses’ psychological/behavioral responses and medical errors. Research on the relationship of bullying with medical errors is limited, and thus, the findings of this study can fill this void in existing research. In addition, we examined if bullying varies with gender and age or across locations/facilities in the same institution.
The Hypothesized Model Einarsen et al. (2009) developed the Negative Acts Questionnaire-Revised (NAQ-R) in which they identified
three categories of bullying behaviors: work-related, personrelated, and physical intimidation. Rosenstein and O’Daniel (2008), on the other hand, in their study of disruptive physician behavior, a type of bullying behavior, developed two important job performance categories for health care settings: psychological/behavioral responses of health care workers and incidence of medical errors/adverse events. This study employed Einarsen et al.’s three types of bullying and Rosenstein and O’Daniel’s two types of job performance as a framework for this study. The model in Figure 1 presents the hypothesized relationships of bullying behaviors to job performance outcomes. All three types of bullying, work-related, personrelated, and physical intimidation, are hypothesized to be directly related to psychological/behavioral responses of nurses and medical errors. Bullying at work is considered a potent stressor that can negatively impact the physical and psychological well-being of the target. For example, Vessey et al. (2009) noted bullying to be associated with psychological and physical stress, underperformance, professional disengagement, and diminished quality of care. Similarly, Laschinger et al. (2010) observed that the nurses who reported being bullied were more likely to have anxiety and depression. Rodwell and Demir (2012) suggest that the exposure to workplace bullying results in increased psychosomatic symptoms, depression, anxiety, and cardiovascular risk. Rosenstein and O’Daniel (2008) reported that disruptive behaviors, a type of bullying behavior, can have a substantial impact on patient care. Furthermore, the authors noted that, although disruptive behaviors by either physicians or nurses occurred in a relatively small percentage of the physician and nursing staff, they could have a profound effect on patient safety and quality of care. Bullying behavior could affect staff morale, patient and family perceptions, and hospital reputation. The study by Rosenstein and O’Daniel provided the initial evidence linking bullying with adverse effects on patient care, which this study aims to build upon and extend by incorporating a more comprehensive set of bullying behaviors.
Figure 1
The theoretical model linking bullying with medical errors and psychological/behavioral responses
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In addition, we examined if three types of bullying varied with age and gender or across locations/facilities of the same institution. Perception of bullying may vary for male and female nurses. Because nursing is dominated by women, men may experience higher level of bullying (Deltsidou, 2009). Similarly, young nurses may face greater bullying than old nurses (Vessey et al., 2009; Yildirim, 2009). A rite of passage, where new graduates are tested and pranked by senior nurses, is a form of hazing but is often viewed as a cultural norm (Center, 2011; Cleary et al., 2010; Johnson, 2011; Laschinger et al., 2010; Rosenstein & O’Daniel, 2008; Vessey et al., 2009). Higher prevalence of bullying behaviors may exist at the primary hospital than at the orthopedic or women’s and children’s hospitals because it is a trauma center and has multiple ICUs, multiple service lines, and multiple surgical units (Rosenstein & O’Daniel, 2008; Vessey et al., 2009).
Methods Settings and Sample Approximately 1,078 registered nurses and licensed practical nurses employed at a university hospital system in Midwest were targeted as potential study participants. The university hospital system is composed of three facilities located within the same community, a main hospital with trauma center, a women’s and children’s hospital, and an orthopedic hospital. The purpose of the study was reviewed with the Director of Nursing for support and consent to proceed. The research study was also reviewed and approved by the University of Missouri Institutional Review Board before data collection. The survey was conducted using an internal e-mail system. An email was sent to the respondents explaining the purpose of the study and inviting them to participate. Completion of the survey indicated their consent to participate in the study. In addition, participants were informed that the data being collected were voluntary and would be confidential and responses would not be identified individually. The email included a link to the online survey located on the Survey Monkey Web site. The survey included four demographic questions, 22 questions related to specific bullying behaviors, and 14 questions related to psychological/behavioral responses and medical errors. Incomplete surveys were discarded. Of the 248 surveys returned, 241 were complete and used in data analysis. The response rate was 23%.
Measures A demographic information form was created to collect data regarding participant’s age, gender, years of experience, and the facility where the employee worked. The investigator
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utilized the NAQ-R to define the frequency of bullying and bullying characteristics. The NAQ-R is a reliable, valid, and a short questionnaire that can be used in a range of occupations and has been adapted to the Anglo-American culture (Einarsen et al., 2009; Laschinger et al., 2010). The NAQ-R consists of 22 questions that focus on the varying aspects of bullying behaviors. Three categories emerge among these questions: work-related bullying, person-related bullying, and physically intimidating bullying. Questions are written in behavioral expressions and do not reference ‘‘harassment’’ or ‘‘bullying.’’ The questionnaire has a Cronbach’s ! of .92 (Einarsen et al., 2009; Laschinger et al., 2010). Bullying behaviors were examined using the 22 questions from the NAQ-R to measure exposure over the course of work within the university facilities. Response alternatives included: never, now and then, monthly, weekly, and daily. The investigators also utilized a survey created by Rosenstein and O’Daniel (2008) that assessed job performance. This survey was modified to meet the investigation goals and assimilate with the structure of the NAQ-R. Response alternatives were changed from ‘‘never, rarely, sometimes, frequent, and constant’’ to ‘‘never, now and then, monthly, weekly, and daily.’’ The original survey consisted of 12 questions. Two questions were added addressing ‘‘physical symptoms’’ and ‘‘absenteeism’’ to make a total of 14 questions. Another modification included replacing the question regarding ‘‘adverse events’’ with a question about ‘‘medical errors’’ as the investigators felt the original question was too broad. The survey concluded with an additional free-text option to allow respondents to voice any comments regarding the survey content or share personal experiences, thoughts, or concerns.
Reliability and Validity of Measures Factor analysis was performed to test if the scales measuring three types of bullying in the NAQ-R instrument were distinct from each other. The results of factor analysis are provided in Table 1, which shows that three clear factors emerge. Person-related bullying had 12 items (Cronbach’s ! = .95), work-related bullying had five items (Cronbach’s ! = .84), and physically intimidating bullying had two items (Cronbach’s ! = .66). A composite score for each scale was computed by adding the scores on items loading on the scale divided by the number of items. Similarly, factor analysis was employed to see if the two outcome variables are distinct from each other. The results are presented in Table 2. There are two clear factors. The factor on psychological/behavioral responses consisted of nine items (Cronbach’s ! = .94), and the factor on medical errors consisted of five items (Cronbach’s ! = .91). The composite variables were developed by adding the scores for the items loading on the factor divided by the number of items loading on the factor.
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psychological and behavioral responses was higher than the mean score of 1.79 for medical errors.
Results After examining the participating nurses’ demographic characteristics, it was determined that 1% of participants were less than 20 years old, 44% were between 21 and 39 years old, 50% were between 40 and 59 years old, and 5% were over 60 years old. There were 17% of nurses with less than 2 years of experience, 29% between 3 and 10 years, 16% between 11and 20 years, 22% between 21 and 30 years, and 16% with over 31 years of experience. Most nurses were women (91%). A significant number of nurse participants were employed at the main hospital (67%), followed by women’s and children’s hospital (27%), and orthopedic hospital (2%), with 4% of the participants not responding to this question. The descriptive statistics and zero-order correlations between the study variables are presented in Table 3. The mean scores for work-related and person-related bullying suggest that the extent of person-related bullying (mean = 2.28) was higher than work-related bullying (mean = 1.78). The extent of physically intimidating bullying was the lowest (mean = 1.26). Furthermore, the mean score of 2.14 for
Testing of the Hypothesized Model On the basis of a combination of multiple regressions and path analyses, the best-fitting path model was developed, which is presented in Figure 2. Physically intimidating bullying behavior was found rather uncommon and also did not show any significant relationship with either medical errors or psychological/behavioral responses. Thus, it was excluded from the model. When work-related and person-related bullying were regressed on medical errors, they showed significant standardized beta weights of .260 and .370, respectively (both coefficients significant at p G .001). However, when work-related and person-related bullying were regressed along with psychological and behavioral responses on medical errors, the standardized beta weight for work-related bullying was reduced to j.06, which is insignificant, and the standardized beta weight for person-related bullying declined from .370 to .251 (both significant at p G .001). This analysis suggests that the effect
Table 1
Factor analyses of bullying behaviors of the NAQ-R instrument Item
Factor 1 Factor 2 Factor 3 Mean score
Person-related bullying 1. Spreading of gossip and rumors about you .83 2. Being ignored or excluded .73 3. Having insulting or offensive remarks made about your personality or .83 attitudes or your private life 4. Hints of signals from others that you should quit your job .80 5. Repeated reminders of your errors or mistakes .82 6. Being ignored or facing a hostile reaction when you approach .73 7. Persistent criticism of your errors or mistakes .84 8. Practical jokes carried out by people you don’t get along with .65 9. Having allegations made against you .70 10. Being the subject of excessive teasing and sarcasm .63 11. Excessive monitoring of your work .65 12. Being ridiculed or humiliated in connection with your work .70 Work-related bullying 13. Being ordered to do work below your level of competence .17 14. Having your opinions ignored .47 15. Being given tasks with unreasonable deadlines .29 16. Being exposed to an unmanageable workload .12 17. Having key areas of responsibility removed or replaced with more .45 trivial or unpleasant task Physically intimidated bullying 18. Intimidating behaviors such as finger-pointing, invasion of .31 personal space, shoving, blocking your way 19. Threats of violence or physical abuse or actual abuse .17 Percent variance explained 38.65 Note. NAQ-R = Negative Acts Questionnaire-Revised.
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.17 .28 .11
.16 .17 .29
2.06 2.21 1.91
.13 .27 .30 .29 .21 .20 .31 .34 .42
.13 .01 .24 .06 .19 .28 .39 .11 .25
1.50 1.71 1.97 1.66 1.31 1.58 1.47 2.16 1.87
.73 .60 .77 .80 .65
.25 .26 .01 .09 .16
2.29 2.76 2.07 2.65 1.63
.29
.73
1.37
j.05 18.41
.85 10.39
1.16
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Table 2
Factor analyses of outcome variables Item
1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13. 14.
Factor 1
Psychological and behavioral responses How often have you experienced personal stress as a result of bullying behaviors? .90 How often have you experienced physical symptoms (nausea, gastrointestinal .81 upset, headaches) as a result of bullying behaviors? How often have you experienced frustration as a result of bullying behaviors? .86 How often have you experienced absenteeism as a result of bullying behaviors? .52 How often have you experienced loss of ability to concentrate as a result of .82 bullying behaviors? How often have you experienced reduced team collaboration as a result of .81 bullying behaviors? How often have you experienced reduced information transfer as a result of .78 bullying behaviors? How often have you experienced reduced communication as a result of .85 bullying behaviors? How often do you think there is a link between bullying behavior and the .65 following clinical outcome at your hospital: poor staff morale? Medical errors How often do you think there is a link between bullying behavior and the .25 following clinical outcome at your hospital: medication errors? How often do you think there is a link between bullying behavior and the .22 following clinical outcome at your hospital: medical errors? How often do you think there is a link between bullying behavior and the .28 following clinical outcome at your hospital: impaired patient safety? How often do you think there is a link between bullying behavior and the .43 following clinical outcome at your hospital: impaired quality? How often do you think there is a link between bullying behavior and the .20 following clinical outcome at your hospital: patient mortality? Variance explained 42.66
of work-related bullying on medical errors is mediated fully by psychological and behavioral responses and the effect of person-related bullying is partially mediated by psychological and behavioral responses. In summary, work-related bullying showed a highly significant positive relationship with psychological/behavioral responses but did not have any direct relationship with medical errors. Person-related bullying, on the other hand, showed significant positive relationships with both psychological/behavioral responses and medical errors. Additional analyses were performed to examine if bullying behavior differed between facilities and according to age and gender. Analysis of variance was performed to test the effects of gender and facilities, and simple regression analysis was performed to test the effect of age on bullying. The analysis suggested no significant differences of bullying between facilities, but significant differences in bullying behavior were observed for age and gender. Person-related bullying was negatively associated with age (t = j3.120, p G .001), and physically intimidating behavior was positively associated with age (t = 1.948, p G .05). Male nurses experienced significantly higher work-related bullying than female nurses
Factor 2
Mean score
.21 .21
2.25 1.84
.25 .21 .24
2.43 1.27 1.89
.30
2.29
.29
2.01
.26
2.27
.37
3.05
.80
1.66
.88
1.80
.86
1.93
.75
2.11
.74
1.43
27.98
(F = 3.393, p G .067), but there were no significant differences in person-related and physical bullying.
Discussion The results show that person-related and work-related bullying have a significant relationship with psychological/ behavioral responses and medical errors. The person-related bullying could be viewed as an informal bullying composing of behaviors such as gossip, practical jokes, or being excluded. The person-related behaviors could come from peer groups or cliques and may be fostered by organizational culture. Study participants commented in the open-ended question that bullying behaviors were more behind the scenes, showed lack of teamwork/cooperation, a ‘‘figure it out yourself’’ attitude, snarky comments, and a lot of negative gossips. Work-related bullying could be viewed as formal bullying including behaviors such as assignment of unmanageable workloads and deadlines. These are more likely to be driven from superiors and are supported by the structure of the organization. Multiple study participants commented that bullying behaviors derived from supervisors or management.
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Table 3
Means, standard deviations, and correlations of study variables
1. 2. 3. 4. 5.
Variable name
Mean
SD
1
2
3
4
5
Work-related bullying Person-related bullying Physical bullying Psychological and behavioral responses Medical errors
1.78 2.28 1.26 2.14 1.79
0.87 0.95 0.58 0.94 0.78
.84 .66* .52* .82* .51*
.95 .38* .68* .54*
.66 .46* .27*
.94 .61*
.91
Note. N = 241. The scales range from 1 = never to 5 = daily. Cronbach’s ! is provided in the italics along the diagonal. *p G .01.
A study participant commented that more and more tasks are added with zero recognition given and faults are pointed out by management whereas the good outcomes are ignored. Work-related bullying did not show a direct relationship with medical errors but showed an indirect relationship through psychological/behavioral responses. This could be explained utilizing the participant’s example; more and more tasks are given with no recognition. This may not directly impair the quality of care delivered, but lack of recognition could affect morale, which in turn affects quality of care. Study participants did not perceive physically intimidating bullying behaviors as related to psychological/behavioral responses or medical errors. As participants’ age increased, the amount of bullying reported decreased. This could be explained by normalization of person-related bullying as participants become accustomed to those behaviors, bullying behaviors become encultured, or alternatively actual bullying behaviors decline (Hutchinson et al., 2010). In terms of individual items constituting the three types of bullying behaviors, the prevalent person-related bullying behaviors included ‘‘being ignored or excluded’’ and ‘‘excessive monitoring of your work’’ (see Table 1). The prevalent
work-related bullying behaviors were ‘‘having your opinions ignored’’ and ‘‘being exposed to an unmanageable workload’’ (see Table 1), and the prevalent psychological/behavioral responses included ‘‘poor staff morale’’ and ‘‘feelings of frustration’’ (see Table 2). These results confirm that bullying behaviors are related to morale, job satisfaction, and diminished quality of care and are consistent with previous studies (Cleary et al., 2010; Felblinger, 2009; OlenderRusso, 2009; Vessey et al., 2009; Yildirim, 2009)
Relationship of Bullying With Gender, Age, and Facility Work-related bullying did not change with age/experience. This could be explained by staffing shortages resulting in high workloads, which potentially impact ability to meet deadlines, or being assigned work below competency levels. Person-related bullying is perceived higher with younger/ less experienced nurses and decreases as age/experience increases. This finding is consistent with the previous research. In this study, men experienced more work-related bullying. This can be explained because women dominate the nursing
Figure 2
The best-fitting empirical model showing relationships between bullying behaviors and psychological/behavioral responses and medical errors
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profession and men are the minority (Deltsidou, 2009). For example, Salin and Hoel (2013) observe that women tend to utilize social manipulation, social relationships, and social reputation as forms of bullying. Those behaviors align with peer-to-peer, person-related bullying. There was no significant difference in bullying behaviors or outcomes among the three locations studied. This can be explained because the three locations are within the same community and employees often float from one facility to the other. The locations are all part of a large organization with the same mission, vision, values, and leadership.
Implications for Practice The findings of this study suggests that the overall level of bullying behaviors at the university hospital system is not severe; however, there is a prevalence of person-related and work-related bullying that directly and indirectly impact behavioral/psychological responses and medical errors. Personrelated bullying is more common with a mean score of 2.28, whereas work-related bullying had a mean score of 1.78. A mean score of 2.0 would suggest bullying behaviors occur now and then. As the score rises to 3.0, the frequency of bullying behaviors increases to monthly. Mean scores above 3.0 would indicate a serious problem with bullying as the behaviors occurs weekly or daily. These study findings reinforce the necessity to identify bullying behaviors and implement prevention strategies in the workplace. Organization leaders hold the primary role to address workplace bullying behaviors. As leaders, they must set the example of how employees should conduct themselves within the workplace and with their coworkers. Their behaviors trickle down and impact organizational culture. An organization’s culture may contribute to continued bullying behaviors. Leadership should evaluate the current culture’s tolerance of bullying behaviors. Center (2011) provided a set of assessment questions to aid leadership in creation of a culture that does not tolerate bullying. Questions include the following: How are incidents handled when they occur? Are they ignored, indirectly teaching staff they are acceptable? Are incidents acknowledged as an opportunity for improvement and growth, empowering staff to confront the issues as quality improvement? How can these issues be addressed in team meetings? How is the incident investigated? Are there assumptions of individual blame, or are breakdowns considered a system issue requiring a system investigation? How many incidents of bullying behavior are tolerated before action is taken to change behavior? Utilizing these or similar questions to assess current practices and culture will help leadership determine what prevention strategies they must take to counter bullying. Person-related bullying includes gossip, being ignored, criticism, practical jokes, or teasing. Prevention should be
AprilYJune & 2015
focused on the bullying instigator, target, and culture. Conflict resolution is required to address and resolve poor behaviors as stated by Johnson (2011). Encouraging all employees to practice emotional intelligence, crucial conversations, and collaboration through sensitivity training, education about staff relationships, and team communication programs is essential (Cleary et al., 2010; Piper, 2006; Rosenstein & O’Daniel, 2008). Behaviors are taught and often passed down from mentors and experienced coworkers. In the freetext comments of the survey, study participants mentioned feeling intimidated by preceptors during orientation and that senior nurses were hesitant to teach new nurses. To prevent bullying behaviors becoming accepted in the organizational culture, it is important to modify orientation and mentoring of new employees to ensure behaviors are not being passed down (Center, 2011). Early education such as open discussion of bullying behaviors during orientation and continuous coaching will allow young professionals to develop skills required to collaborate, communicate, and be accepting of differences. Early introduction to workplace bullying will also eliminate norms that have developed regarding ‘‘hazing’’ and ‘‘rites of passage’’ (Center, 2011; Laschinger et al., 2010; Olender-Russo, 2009; Vessey et al., 2009). Improper reporting mechanisms have been found to be a huge barrier to successful implementation of workplace bullying initiatives. Study participants’ comments revealed that there was a fear of being reprimanded for reporting bullying behaviors and that the current reporting system served as a form of tattling on coworkers versus being a useful tool for process improvement. Clear and trustworthy mechanisms must be in place for employees to report bullying behaviors such as a reporting ‘‘hot-line’’ (Rosenstein & O’Daniel, 2008; Vessey et al., 2009). The human resources department needs to own the investigation and grievance procedures. It is vital that those involved with the investigation have no connection or regular interaction with the individuals involved (Hutchinson et al., 2010). Work-related bullying includes being ordered to complete work below one’s competence level, being given unreasonable deadlines, having one’s opinions ignored, and being given unmanageable workloads. Work-related bullying may be the product of staffing shortages, workplace design, policies, or structure of the organization. Examining workplace design and policies is important to discover if they are the fertile ground for bullying. Characteristics that contribute to bullying are a rigid, vertical organization structure, informal alliances and hierarchies, imbalance of power, job insecurity, and organizational wide restructuring and downsizing (Cleary et al., 2010; Hutchinson et al., 2010; Johnson, 2011; LaVan & Martin, 2008; Olender-Russo, 2009). Controlling, power-driven and rigid cultures do not encourage communication, group work, or collaboration (Khatri, Brown, & Hicks, 2009). Hierarchical workplaces create power imbalances that fuel bullying and dehumanize employees (Khatri, Baveja, Boren, & Mammo, 2006). It is
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important for organizations whose goal is to prevent and eliminate bullying to restructure their workplace design.
Limitations Participation was an important limitation in this research. Of the 1,078 nurses employed at a university hospital system in Mid-Missouri, 248 returned the survey. Of the 248 responses, 241 were complete and usable, leaving 837 nurses not participating. The reasons for the low response rate may be that the survey was distributed via email through nursing managers and supervisors. Surveys may have not been forwarded to staff especially by managers having bullying tendencies, surveys may have not been forwarded in a timely manner, reminders may have not been forwarded, or nurses may have not had private access to complete the survey. Subject sensitivity is a limitation. Bullying behaviors are highly underreported because of fear and mistrust. Those feelings may inhibit an individual from completing a survey. Reviewing the free-text comments from survey results revealed that nurses felt other people such as physicians, leadership, and patients’ families often act as bullies. Level of bullying may be higher if the study included other sources such as physicians and families of patients. Some nurses also expressed their opinions about the importance of this topic and recommended expanding the research to include other professions.
Conclusion The use of the NAQ-R and survey created by Rosenstein and O’Daniel are reliable tools to identify the existence of bullying, what type of behavior is experienced most frequently, who is likely to experience these behaviors, and the relationship to job performance. Findings from this study suggest that bullying behaviors exist and affect psychological/behavioral responses, such as stress and anxiety, and medical errors. Implications from bullying behaviors can be costly in the form of low morale, frustration, reduced collaboration, poor communication, and impaired quality. Health care organizations should identify bullying behaviors in their culture and organization and implement bullying prevention strategies to reduce bullying behaviors and their effects. Additional research is recommended after prevention strategies are implemented to evaluate success. References Brees, J., Mackey, J., & Martinko, M. (2013). An attributional perspective of aggression in organizations. Journal of Managerial Psychology, 28(3), 252Y272. Center, D. (2011). Mandates for patient safety: Are they enough to create a culture of civility in health care? The Journal of Continuing Education in Nursing, 42(1), 16Y17. Cleary, M., Hunt, G., & Horsfall, J. (2010). Identifying and addressing bullying in nursing. Mental Health Nursing, 31, 331Y335.
Deltsidou, A. (2009). Undergraduate nursing students’ level of assertiveness in Greece: A questionnaire survey. Nurse Education in Practice, 9(5), 322Y330. Einarsen, S., Hoel, H., & Notelaers, G. (2009). Measuring exposure to bullying and harassment at work: Validity, factor structure and psychometric properties of the Negative Acts Questionnaire-Revised. Work & Stress, 23(1), 24Y44. Felblinger, D. (2009). Bullying, incivility and disruptive behaviors in the healthcare setting: Identification, impact, and intervention. Frontiers of Health Services Management, 25(4), 13Y23. Hutchinson, M., Wilkes, L., Jackson, D., & Vickers, M. (2010). Integrating individual, work group and organizational factors: Testing a multidimensional model of bullying in the nursing workplace. Nursing Management, 18, 173Y181. Johnson, S. (2011). An ecological model of workplace bullying: A guide for intervention and research. Nursing Forum, 46(2), 55Y63. Khatri, N., Baveja, A., Boren, S., & Mammo, A. (2006). Medical errors and quality of care: From control to commitment. California Management Review, 48(3), 115Y141. Khatri, N., Brown, G., & Hicks, L. (2009). Moving from a blame culture to a just culture in health care. Health Care Management Review, 34(4), 312Y322. Laschinger, H., Grau, A., Finegan, J., & Wilk, P. (2010). New graduate nurses’ experiences of bullying and burnout in hospital settings. Advanced Nursing, 66(12), 2732Y2742. LaVan, H., & Martin, W. (2008). Bullying in the U.S. workplace: Normative and process-oriented ethical approaches. Business Ethics, 83, 147Y165. Lindy, C., & Schaefer, F. (2010). Negative workplace behaviors: An ethical dilemma for nurse managers. Nursing Management, 18, 285Y292. MacIntosh, J., Wuest, J., Gray, M., & Cronkhite, M. (2010). Workplace bullying in health care affects the meaning of work. Qualitative Health Research, 20(8), 1128Y1141. Olender-Russo, L. (2009). Creating a culture of regard: An antidote for workplace bullying. Creative Nursing, 15(2), 75Y81. Pearson, C., & Porath, C. (2009). The cost of bad behavior: How incivility is damaging your business and what to do about it. New York, NY: The Penguin Group. Piper, L. E. (2006). A theoretical model to address organizational human conflict and disruptive behavior in health care organizations. The Health Care Manager, 25(4), 315Y320. Read, E., & Laschinger, H. K. (2013). Correlates of new graduate nurses’ experiences of workplace mistreatment. The Journal of Nursing Administration, 43(4), 221Y228. Rodwell, J., & Demir, D. (2012). Psychological consequences of bullying for hospital and aged care nurses. International Nursing Review, 59, 539Y546. Rosenstein, A., & O’Daniel, M. (2008). Managing disruptive physician behavior. Neurology, 70, 1564Y1570. Salin, D., & Hoel, H. (2013). Workplace bullying as a gendered phenomenon. Managerial Psychology, 28(3), 235Y323. Szutenbach, M. P. (2013). Bullying in nurses: Roots, rationales, and remedies. Journal of Christian Nursing, 30(1), 16Y23. Vessey, J., Demarco, R., Gaffney, D., & Budin, W. (2009). Bullying of staff registered nurses in the workplace: A preliminary study for developing personal and organizational strategies for the transformation of hostile to health workplace environments. Professional Nursing, 25(5), 229Y306. Yildirim, D. (2009). Bullying among nurses and its effects. International Council of Nurses, 56(4), 504Y511.
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